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Flashcards in Finals Medicine Surgery Deck (496)
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Hyperkalemia on ECG
(4 features)

Tall tented T wave
QRS a complex broaden
PR prolonged
P wave flattened

1

Managing hyper kalmia

10ml 10% calcium chloride/gluconate over 5-10 min
Insulin/glucose infusion
Salbutamol
Calcium resinous
Identify and manage underlying cause

2

Wolf Parkinson white syndrome

Delta wave (characteristic slurred up slope)
(Pre-excited AF sometimes)
PR short
(Accessory pathway: bundle of Kent)

3

ECG changes of ACS (chronological)

Normal
Peaked T wave
ST segment elevation
Q wave formation and loss of R wave (anterior chest leads)
T wave inversion

4

4 criteria for STEMI/Emergency re perfusion

2 mm ST elevation in 2 or more contiguous chest leads
1 mm ST elevation in 2 or more limb leads of same territory
New LBBB or LBBB in clinical MI
True posterior MI

5

RV hypertrophy on ECG

R axis deviation
Dominant R wave in lead V1
Inverted T waves spreading from right side of the heart

6

Axis deviation

Look at I and avF
If away from each other then L axis deviation
If towards each other then R axis deviation if both positive then normal

7

IE bacteria

Strep
Staph
HACEK
The HACEK organisms are a group of fastidious Gram-negative bacteria that are an unusual cause infective endocarditis (IE), which is an inflammation of the heart due to bacterial infection.[1] HACEK is an abbreviation of the initials of the genera of this group of bacteria: Haemophilus, Aggregatibacter (previously Actinobacillus), Cardiobacterium, Eikenella corrodens, Kingella.[1] The HACEK organisms are a normal part of the human flora, living in the oral-pharyngeal region.[2]

8

Causes of dominant R wave in V1/V2

Posterior MI
PE
RBBB
RVH

DUchenne muscular dystrophy
Dectrocardia
WPW

9

Why is it important to diagnose posterior MI?

Posterior MI can cause back pressure and raise JVP.
Usually when we see JVP elevation, we tend to give diuretics because we think it's R heart failure. However diuretics can be fatal for posterior MI as we're decreasing the preload, ie stretching... (Sterling law)

10

Mesenteric ischemia (classic triad)

GI emptying
Abdo pain
Underlying cardiac disease

11

JVP waves

http://youtu.be/cLETr8qmXPQ

12

How to differentiate a jugular venous pulse from the carotid pulse

JVP:
Not palpable.
Obliterated by pressure.
Characterised by a double waveform.
Variable with respiration - it decreases with inspiration.
Enhanced by the hepatojugular reflux

13

Waveforms of JVP

Waves[2][3][4]
a - presystolic; produced by right atrial contraction.
c - bulging of the tricuspid valve into the right atrium during ventricular systole (isovolumic phase).
v - occurs in late systole; increased blood in the right atrium from venous return.
Descents
x - a combination of atrial relaxation, downward movement of the tricuspid valve and ventricular systole.
y - the tricuspid valve opens and blood flows into the right ventricle.
The a and v waves can be identified by timing the double waveform with the opposite carotid pulse. The a wave will occur just before the pulse and the v wave occurs towards the end of the pulse. Distinguishing the c wave, x and y descents is an almost impossible task.

14

Causes of raised jugular venous pressure

Heart failure.
Constrictive pericarditis (JVP increases on inspiration - called Kussmaul's sign).
Cardiac tamponade.
Fluid overload, eg renal disease.
Superior vena cava obstruction (no pulsation).

15

Abnormalities of jugular venous pressure

Abnormalities of the a wave: disappears in atrial fibrillation.

Large a waves occur in any cause of right ventricular hypertrophy (pulmonary hypertension and pulmonary stenosis) and tricuspid stenosis.

Extra large a waves (called cannon waves) in complete heart block and ventricular tachycardia.

Prominent v waves

Tricuspid regurgitation - called cv or v waves and occurring at the same time as systole (a combination of v wave and loss of x descent); there may be earlobe movement.

Slow y descent
Tricuspid stenosis.
Right atrial myxoma.

Steep y descent
Right ventricular failure.
Constrictive pericarditis.
Tricuspid regurgitation.
(The last two conditions have a rapid rise and fall of the JVP - called Friedreich's sign.)

16

Austin-flint murmur

soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet.(in similar way to MS)

17

AR signs

large-volume, 'collapsing' pulse also known as: Watson's water hammer pulse

Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
low diastolic and increased pulse pressure

de Musset's sign (head nodding in time with the heart beat)

Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich Quincke)

Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery; named for Ludwig Traube)

Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

18

Drugs not to be used in severe AS

Nitrates (risk of syncope)

19

TAVI

Transcatheter aortic valve implantation

20

AF definition

Uncoordinated and disordered contraction of atria at fast rate which leads to initiation of ventricular contraction through the AV node at varying intervals... Thus leading to an irregularly irregular pulse

21

NY Heart Association classification of HF

I Cardiac disease, but no symptoms and no limitation in ordinary physical activity, e.g. shortness of breath when walking, climbing stairs etc.

II Mild symptoms (mild shortness of breath and/or angina) and slight limitation during ordinary activity.

III Marked limitation in activity due to symptoms, even during less-than-ordinary activity, e.g. walking short distances (20–100 m).
Comfortable only at rest.

IV Severe limitations. Experiences symptoms even while at rest. Mostly bedbound patients.

22

What sign is pathognomic of HF?

3rd heart sound

23

Most common causes of HF in UK

CAD
HTN
Alcohol
Valvular disease

24

Lifestyle modifications in HF?

Smoking
Alcohol
Salt intake
Limit fluid intake (<2L)

25

TTT of HF

ACEI/ARB
Betablockers
Spironolactone/eplerenone

Diuretics for fluid overload but don't impact prognosis

26

Other ttt for HF

Revascularisation if CAD
Bi ventricular pacemaker /defibrillator if dysynchrony
Transplantation
LVAD

27

Symptoms of IE

Lethargy
Fever
Night sweats

Less common:
New heart failure
Embolic phenomena (stroke)

28

IE on examination

New murmur
Splenomegaly
Embolic phenomena (splinter hges, osler's nodes, janeway lesions, petechiae

Evidence of aetiology: IVDA, infected cannula, recent surgery

29

Ix in IE

3 blood cultures (different sites / different times)
Echo (find vegetation)
Baseline blood test (CRP)
ECG
Urine (hematuria)