CP

Question 1

Immediate care for suspected MI

Answer 1

ABCs, stabilization, resuscitation, IV, O2, monitors, ECG, +/- CXR

Question 2

ACS epidemiology

Answer 2

> 6 mil americans w/CAD500K deaths/yr in US from CAD>4 mil ED visits/yr for ACP$100B/yr

Question 3

ACS etiology

Answer 3

ischemia vs. fixed atheroslclerotic lesion vs. evolving plaque/thrombus vs. spasm

Question 4

ACS risk factors

Answer 4

smoking, HTN, DM, HL, age, FH (CAD age <55 1st degree relative), CAD, PVDcardiac risk factors = poor predictors of ACS in ED

Question 5

ACS PE

Answer 5

normal cardiopulmonary = most common. S3 in 15-20% of pts. w/MI, chest wall TTP in 15%

Question 6

cardiac markers

Answer 6

CK-MB = >90% sensitive for MI 5-6 hrs later, only 50% earlier. elevate @3-12 hrs, peak @18-24rs. trop = Tn-I similar to CK-MB but duration is 5-1 days. Tn-T is less sensitive but is an independent marker for CV risk

Question 7

ACS Tx

Answer 7

OH BATMANO2, heparin, BB, ASA, thrombolytic, morphine, anti-platelet, nitrates

Question 8

ASA

Answer 8

inhibits thromboxane A2, decreasing PLT aggregation

Question 9

nitrates

Answer 9

decrease preload and after load, increase coronary perfusion

Question 10

BB

Answer 10

decrease infarct size, CV complications, and mortality

Question 11

cocaine CP

Answer 11

6% have MI, 20-60% have transient ischemia, can be delayed hr-days. etiology: spasm, inc. O2 depend, clot formation, accelerated atherosclerosis w/LVH. Dx: Tn:I is better, ECG and CK-MD = worse. Tx: benzos. avoid BBs!

Question 12

aortic dissection epi

Answer 12

Stanford A involves ascending aorta (80%), B is descending only. inc. risk in pts >50 w/HTN, smoking. younger w/marfan’s, ehler-danlos, pregnancy. A mortality: 75% if untreated, 15-20 if Sx. B mortality: 32-36% regardless of surgery

Question 13

aortic dissection Hx

Answer 13

90% w/abrupt, severe pain in chest (A) or mid-back (B), “tearing” or “ripping,” dull or pressure-like, N/V + diaphoresis = common

Question 14

aortic dissection: carotids

Answer 14

stroke

Question 15

aortic dissection: spinal arteries

Answer 15

paraplegia

Question 16

aortic dissection: abdominal A/renal/iliac

Answer 16

abdominal/flank pain

Question 17

aortic dissection: coronaries

Answer 17

A insufficiency, pericardial effusion/tamponade

Question 18

aortic dissection: laryngeal nerve compression

Answer 18

hoarseness

Question 19

aortic dissection: tracheal compression

Answer 19

dyspnea/stridor/wheezing

Question 20

aortic dissection: esophageal compression

Answer 20

dysphagia

Question 21

aortic dissection: PE

Answer 21

abrupt tearing pain, N/V, diaphoresis, typically normal CV/pulm exam. AI murmur in ~20%, abn pulses in ~50%.

Question 22

aortic dissection: CXR

Answer 22

abn in ~85%, widened mediastinum, L peural effusion, indistinct aortic know, displaced calcified intima >6mm from outer aortic wall

Question 23

aortic dissection: Dx imaging

Answer 23

spiral CT vs. TII vs. aortogram

Question 24

aortic dissection: Tx

Answer 24

2 large bore IVs, monitors, T&C, ECG. drop BP to decrease the shear force on the intima, lower both ABP and LV contractility

Question 25

PE: epidemiology

Answer 25

650K cases/yr in US, 80-90% DVT source. mortality 2-10% w/Dx + Tx, 30% w/o.

Question 26

PE: presentation

Answer 26

classic triad in 20% = dyspnea, hemoptysis, pleuritic CP. pleuritic CP in 74%, dyspnea in 84%, RR > 16 in 92%, HR >100 in 44%

Question 27

PE: wells criteria

Answer 27

3 pts for suspected DVT or alt. Dx less likely, 1.5 for HR > 100, recent immobilization, previous DVT/PE, 1 for hemoptysis, malignancy. 3-6 pts = 20.5% chance of PE. >6 pts = 67% chance of PE.

Question 28

PE: ECG

Answer 28

often normal, w/>40% showing nonspecific ST+T wave abn. sinus tach most common. S1Q3R3 in 6%

Question 29

PE: CXR

Answer 29

nl in 30%, concerning in s/o dyspnea + hypoxemia w/o RAD. ATX in 50%, elevated hemidiaphragm in 40%

Question 30

hampton's hump

Answer 30

pleural-based wedge shaped infiltrate

Question 31

westermark sign

Answer 31

prox. dilated pulmonry artery w/abrupt cutoff

Question 32

PE: Tx

Answer 32

IV, O2, monitors. if high pre-test prob, anticoagulate 1st, then order study. heparin 80 U/kg iv bolus, 18 U/kr/hr iv drip

Question 33

spontaneous ptx: epidemiology

Answer 33

tall, thin males, 10-20% w/exertion w/rupture of blebs, Sx vary w/size + rate of progression

Question 34

spontaneous ptx: presentation

Answer 34

acute, pleuritic CP in 95%, dyspnea in 80%, dec. breath sounds in 85%, tachypnea in >24%, tachypnea >24 in 5%, hyperressonance in <30%

Question 35

spontaneous ptx: Dx

Answer 35

tension ptx: needs immediate decompression. non-tension ptx: upright PA CXR = 83% sensitive

Question 36

sponteneous ptx: Tx

Answer 36

tube thoracostomy using minicatheter or standard chest tube; catheter aspiration (single or sequential); observation x 6hrs w/repeat CXR

Question 37

esophageal rupture

Answer 37

last of "big 5" life-threatening causes of CP