2- CV and Pulm Emergencies Flashcards
1
Q
What diagnostic tests should be ordered for a pt presenting w/ chest pain?
A
ECG, CXR (2nd line), pulse ox, labs, echo
2
Q
Pt presents with pressure, heaviness, tightness, fullness, and sqeezing in the center/ left of his chest. He notes it is precipitated by exertion and relieved by rest. The sensation radiates to his shoulder, arms, neck/ jaw. What are you concerned for?
A
Angina
3
Q
What is indicated by angina?
A
Ischemic event
4
Q
What populations can present with abn sxs of angina?
(SOB, N/V, diaphoresis, fatigue, dizzy/ lightheaded, weak, palpitations, syncope)
A
Women, elderly, DM
5
Q
In what type of angina are sxs stable and resolve w rest?
A
Stable angina
6
Q
What type of angina increases in severity/ frequency/ duration OR occurs at rest?
A
Unstable angina
7
Q
What is defined as an MI with a non-occlusive thrombis and ischemia with elevated cardiac enzymes?
A
NSTEMI
8
Q
What is defined as an MI with occlusive thrombus or transmural infarction?
A
STEMI
9
Q
Male sex, > 55 yo, DM, hyperlipidemia, HTN, FH, tobacco use, obesity, and h/o atherosclerotic disease are RFs for what?
A
CAD
10
Q
What risk calculator is used almost exclusively because it is better at predicting risk of an adverse coronary even over a period of 6 weeks?
A
HEART score
(also can use TIMI score)
11
Q
What diagnostic tests should be ordered for CAD?
A
12-lead ECG- ST/ T wave changes
Cardiac enzymes- initial troponin
(others: stress testing, coronary angiography)
12
Q
What are the preferred tests for diagnosing ACS?
A
Troponin I and T
(T = high sensitivity troponin)
13
Q
Is a single set of negative biomarkers sufficient to r/o an ACS event?
A
Typically NO
14
Q
If pts have sxs for > 2 hours and their Trop T is negative, you can r/o what dx?
A
ACS
15
Q
What measure is a sensitive and specific determinant of myocardial injury but is unable to distinguish the etiology of the injury?
A
Troponin T- consider initial value + 2-hr delta value
16
Q
When can you r/o ACS with Troponin I?
A
3 values 6 hrs apart, if no rise by 3rd > r/o ACS
17
Q
Troponin T is beneficial bc it can rapidly r/o or rule in an MI and is able to ID more pts with ACS. What are 2 of its disadvantages?
A
Significnat % of pts with (-) values with the old assay will be elevated now
More elevated values in pts w/o ACS (a little too specific)
18
Q
Pt presents w CV concern. ECG shows ST depression or T inversion but does NOT have raised troponin. Likely dx?
A
Unstable angina
19
Q
Pt presents w CV concern. ECG shows ST depression or T inversion AND has raised troponin. Likely dx?
A
NSTEMI
20
Q
What are the diagnostic stress test options for CV sxs?
A
Stress echo- 1st line option is able to exercise
Nuclear- perfusion defect visualized
21
Q
Pt presents with substernal chest pain lasting 2-5 min only with activity and never at rest. There are no ECG changes/ enzyme elevation. Presumed dx?
A
Stable angina
22
Q
What is the medical management for stable angina?
A
Nitrates
Beta blockers
Antiplatelet meds
+/- CCB
23
Q
What is the dose for Nitrates given to a pt with stable angina?
A
SL nitro PRN for chest pain, q 5 min but no more than 3 doses w/i 15 min
24
Q
What are possibilites for antiplatelet meds in the tx of stable angina?
A
Aspirin (81- 325 mg daily), Plavix, combo
25
Prinzmetal angina is aka?
Variant angina
26
Pt presents with an episode of angina 5-15 min usually at rest and often between midnight and early morning. EKG shows ST elevation during chest pain episodes. Presumed dx?
Prinzmetal angina (variant angina)
27
What is diagnostic for Prinzmetal angina?
Coronary angiography
28
What is the tx for Prinzmetal angina?
Nitrates and CCB
29
Prior to giving nitro, you should ask a pt what?
Ask if they have recently taken Sildenafil, Vardenafil or Tadalafil
30
Pt presents w/ chest pain, heaviness, pressure, with radiation to arm, neck, back, SOB, weakness/ fatigue, N/V, diaphoresis, palpitations, and dizziness/ syncope. What are you concerned for?
ACS
31
What is included in the initial management for STEMI?
ABCs, call cardiology, cardiac monitoring/ cath lab, IV access, SL nitro, aspirin 325mg (chewed), revascularization, BB
32
Is "MONA" recommended for initial ACS tx?
(morphine, oxygen, nitro, aspirin)
No- just nitro and aspirin
33
When should SL nitro be avoided in ACS pts? (6)
* SBP \< 90 or \> 30 below baseline
* Marked bradycardia (\< 50) or tachycardia (\> 100)
* Known/ suspected R ventricular infarction
* Pt took PDE5 inhibitor w/i 24-48 hrs
* Hypertrophic cardiomyopathy
* Severe aortic stenosis
34
The following are contraindications to what initial management of STEMI?
HF, cardiogenic shock, bradycardia/ heart block, reactive airway disease
BB
35
What revascularization is preferred in the initial management of STEMI?
PCI (percutaneous coronary intervention)- w/i 90 min
36
What revascularization is considered in the management of STEMI if extensive disease found?
CABG (bypass surgery)
37
What is gold standard for diagnosing CAD?
Coronary angiography
38
What are the 2 "PCI" interventions?
Angioplasty, stenting
39
In what management of STEMI does an inflated balloon compress plaque against artery walls?
Angioplasty
40
What type of stents are preferred in the management of STEMI due to lower risk of strent thrombosis?
Drug eluting stents (DES)
(base metal stents rarely used)
41
What are the factors when considering a coronary artery bypass graft (CABG)?
of occluded vessels, anatomic complexity of lesions, likelihood to have successful revascularization w/ PCI, co-morbidities
42
Initial management of NSTEMI is the same as STEMI with the exception of what?
No thrombolytics, PCI (if not c/i), if PCI c/i then medically manage with heparin continuous infusion + aspirin
43
What are c/i to PCI in management of NSTEMI?
Renal failure, sepsis, unstable pt
44
What are the more common peri-infarction emergencies? (period following MI)
Peri-infarction pericarditis (PIP), acute mitral regurgitation, Dressler's syndrome
(others: hemorrhage/ bleeding, arrhythmias, rupture of LV free wall or IV septum)
45
Pt presents 2-3 days post MI. On PE you note pericardial rub. Echo shows pericardial inflammation +/- effusion. What peri-infarction emergency are you concerned about?
Peri-infarction pericarditis
46
What is the tx for peri-infarction pericarditis?
Tylenol/ supportive (generally self-limited), ASA +/- cholchicine
47
What should be avoided in tx of peri-infarction pericarditis?
NSAIDS
48
Although pericarditis can occur post MI, what is important to note when evaluating this?
Can happen for many other reasons and tx depends on etiology
49
Pt presents with CP, tachypnea, and dyspnea. On PE you note **hypotension, JVD/ distended neck veins, and muffled heart sounds (Beck's triad)**. ECG shows sinus tachy. What are you concerned for?
Cardiac tamponade
50
What will CXR and echo show on a pt with cardiac tamponade?
CXR- enlarged cardiac silhouette
Echo- effusion w tamponade
51
What is tx for cardiac tamponade?
Drainage of pericardial effusion and subsequent monitoring
52
The following are all causes of what?
Ischemia to papillary muscle
LV dilation or true aneurysm
Papillary muscle or chordal rupture 2-7 days post ischemia
Acute mitral regurgitation
53
What will be noted on PE with acute mitral regurgitation?
Hypotension and new murmur
54
What is the treatment for acute mitral regurgitation?
Emergent surgery
55
What is Dressler's syndrome and when does it develop?
Post-cardiac injury syndrome (PCIS), develops weeks to months post MI
56
Pt presents with pleuritic CP, fever, and malaise. On PE you note pericardial friction rub. Labs show leukocytosis and elevated ESR. CXR shows pleural and/ or pericardial effusion or pulmonary infiltrates. What are you concerned for?
Dressler's syndrome
57
What is the treatment for Dressler's syndrome?
NSAIDS (first line)
Corticosteroids or colchicine if refractory
58
What specific PE findings are consistent with endocarditis?
Janeway lesions, splinter hemorrhages, Osler nodes, Roth spots
59
Pt presents w fever, chills, cough, dyspnea, orthopnea, and fatigue. PE shows palatal, conjunctival or subungual petechiae, and heart murmur. What are you concerned for?
Endocarditis
(other PE findings: Janeway lesions, splinter hemorrhages, Osler nodes, Roth spots)
60
What is the protocol for labs if suspected endocarditis?
Blood cultures x 3 before abx, leukocytosis, elevated ESR
61
What will be seen on echo for a pt with endocarditis?
Vegetations on valves
(get TEE, then TTE if inconclusive)
62
The following are RFs a/w what CV condition?
Artificial heart valves, congenital heart defects, previous hx, damaged heart valves, IV drug use, poor dentition/ dental infection
Endocarditis
63
With respect to Duke's diagnosis criteria for endocarditis, how many criteria must be satisfied?
2 major OR
1 major + 3 minor OR
5 minor
64
What is the treatment for endocarditis?
Abx (vanco + ceftriaxone or gentamicin)
Surgery (if not resolved w/ abx)
65
Pt presents with dyspnea, fatigue, diaphoresis, early satiety, cough, orthopnea, PND, and edema. PE shows tachycardia/ tachypnea, rales, JVD, S3/4, LE edema, and ascites. What are you concerned for?
HF (acute exacerbation)
66
CXR showing cardiomegaly, cephalization, Kerly B lines, +/- pulm edema is concerning for what?
HF (acute exacerbation)
67
What is the first line tx for HF (acute exacerbation)?
Diuretics- Furosemide = 1st line
(others: IV access, control airway/ O2, telemetry, Na/ fluid restriction, strict I+Os, +/- inotrope, chronic HF meds)
68
What tx should be avoided in acute, unstable, or uncompensated HF?
BBs
69
What are the BP values for both hypertensive urgency AND hypertensive emergency?
SBP ≥ 180, DBP ≥ 120
70
What is the primary difference between hypertensive urgency and hypertensive emergency?
Hypertensive urgency = no end-organ damage
Hypertensive emergency = acute end organ damage (cerebrovascular, ophtho, cardiac, renal)
71
What are the more common primary causes of HTN urgency/ emergency?
New diagnosis of HTN, non-adherence to meds
72
What is most important in a hypertensive workup?
Assess for end-organ compromise (neuro, ophtho, CV, renal)
73
What is the tx for hypertensive urgency if they are an established hypertensive pt?
Rest + increase med dose, add med, adherence to Na restriction
74
What is the tx for hypertensive urgency if it is a new occurrence of HTN?
Rest + initiate anti-HTN tx
75
What is tx for hypertensive emergency?
Hospitalize, workup for causes, tx end-organ damage (not absolute BP), reduction of BP, once BP stable w/ IV therapy- transition to oral therapy
76
What are the guidelines for reduction of BP with HTN emergency?
Reduce MAP by 10-20% within 1 hour, then by additional 5-15% over next 23 hours
1st choice agent = IV labetolol
77
Elderly male smoker w/ CAD, emphysema, and renal impairment presetns to your office. He has substernal/ back/ neck pain, a "tearing" CP. What are you concerned for?
Thoracic aortic aneurysm
78
Elderly male smoker w/ CAD, emphysema, and renal impairment presetns to your office. He has a pulsating abd mass, and abd/ back pain. What are you concerned for?
Abd aortic aneurysm
(if rupture, + hypotension/ hemodynamic instability)
79
Is a thoracic aortic aneurysm or abd aortic anerysm more common?
Abd
80
What will CXR show with thoracic aortic aneurysm (even if asx)?
Widened mediastinum
81
How is a thoracic aortic aneurysm typically managed?
Aggressive BP and HR control- keep SBP \< 120 and HR \< 60-80
82
When should a thoracic aortic anueysm be surgically managed?
Symptomatic, rapid expansion (growth \> 0.5cm in 6 mos), \> 5.0cm
83
What is the management for AAA if asx and \< 5.5cm?
Observation and RF mod, US every 6 mos- 1 yr
84
What are possible complications a/w AAA?
Rupture (high morbidity/ mortality), aneurysm thrombosis, thromboembolism (can lead to acute limb ischemia)
85
When should an AAA be surgically managed?
Asx ≥ 5cm, rapidly expanding (growth \> 0.5cm in 6 mos), a/w peripheral arterial aneurysm or PAD
86
What is defined as an emergent condition in which the inner layer of the aorta tears and blood surges through the tear causing the rest of the aorta layers to dissect?
Aortic dissection
(fatal if blood filled channel ruptures through outside aortic wall)
87
Pt presents with "ripping" or "tearing" CP radiating to the back. PE shows signs of hemodynamic compromise. What are you concerned for?
Thoracic aortic dissection
88
Pt presents with severe back, abd, or flank pain + hypotension and shock. PE shows signs of hemodynamic compromise. What are you concerned for?
Abdominal aortic dissection
89
The following are RFs for what emergency?
Uncontrolled HTN, atherosclerosis, pre-existinc aortic aneurysm, bicuspid aortic valve, aortic coarctation, CT disease, cocaine use, pregnancym male gender, advanced age
Aortic dissection
90
Management of aortic dissection depends on what?
The type (ascending vs descending)
91
What is the management for acute ascending thoracic dissection (type A)?
Cardiac surgical emergency
92
What is the management for descending thoacic aortic dissection (type B)?
Managed medically
93
It is important to rapidly distinguish between an ascending and descending aortic dissection. How is this done?
CTA (inital screening if pt stable)
Multiplanar TEE (if pt unstable)
94
What is the inital management for aortic dissection if pt is unstable or there is airway compromise?
Intubate (bedside TEE) and emergency surgery consult
95
What is the initial management for aortic dissection if stable?
Admit, surgical consult, morphine for pain control, BP control with IV beta blocker (Esmolol), CT
96
What are the ideal BP and HR parameters for a stable pt with aortic dissection?
SBP \< 100-120
HR \< 60
97
What is defined as a sudden decrease in limb perfusion that causes a potential threat to limb viability and can present as new/ worsening claudication to paralysis?
Acute limb ischemia
98
Acute limb ischemia due to a sudden, dramatic onset is due to what?
Embolus
99
Acute limb ischemia due to gradual onset is due to what?
Thrombosis
100
What are the 6 P's a/w acute limb ischemia?
Pain, pulselessness, pallor, paresthesias, paralysis, poikilothermia
101
What is important for PE of a pt with acute limb ischemia?
Bilateral neuro exam (sensation, strength, pulses)
Doppler for PT/ DP, ABI (\< 0.4 = significant ischemia)
102
What imaging is utilized for acute limb ischemia?
Vascular imaging (CTA/ MRA with contrast)
103
With acute limb ischemia, threatened limbs require what?
Immediate surgical revascularization (intraoperative arteriography)
Consult vascular surgery ASAP
104
What is included in the initial management of acute limb ischemia?
Anticoagulation, close monitoring, surgery when worsens
105
What is defined as acute, sudden onset of intestinal hypoperfusion?
Acute mesenteric ischemia
106
Elderly pt with hx of afib presents with severe abd pain, out of proportion to PE. Labs show elevated serum lactate. What emergency are you concerned about?
Acute embolic occlusion (acute mesenteric ischemia)
107
Pt with hx of PAD presents with chronic post-prandial abd pain, food aversion, weight loss, and hematochezia. Labs show elevated serum lactate. What are you concerned for?
Mesenteric thrombosis
108
What is the diagnostic imaging of choice for acute mesenteric ischemia?
CTA
109
What is the treatment for acute mesenteric ischemia?
Systemic anticoagulation and pain management
110
What medical emergency most often occurs in lower extremities and pelvis and is a/w Virchow's triad?
(Virchow's triad = endothelial damage, hypercoaguability, stasis)
DVT
111
What is Virchow's triad?
Endothelial damage, hypercoaguability, stasis
112
Pt presents with swelling, pain/ discomfort, edema on his L leg. PE shows erythema, warmth and swelling. Labs show elevated D-dimer. What is the test of choice for suspected dx?
Suspected dx = DVT
Dx test of choice = duplex US
113
What is the treatment for DVT?
Anticoagulation
114
Pt presents with **acute onset CP, dyspnea**, cough, hemoptysis, and syncope. Hx of endothelial damange, hypercoaguability, and stasis. PE shows tachypnea, **tachycardia, hypoxia**. What are you concerned for?
PE
115
Eval of pt with chest sxs presents in the ER. Labs show elevated D-dimer. ECG shows sinus tachycardia with S1 Q3 T3 pattern. CXR shows Hampton's hump and Westermark sign (although both rare). What is suspected dx and what is gold standard dx test?
PE, pulmonary CTA = gold standard
116
How are D-dimer and Well's criteria used to assess a pt with possible PE?
* Low or mod pretest probability for PE (Wells) + neg D-dimer = no further workup
* Pos D-dimer = further workup
* If high pretest probability for PE (Wells) = do not need D-dimer, further workup necessary
117
What is the tx for PE?
Supplemental O2, IV access, cardiac monitoring, anticoagulation
(anticoag: UNF heparin, LMWH, warfarin, NOAC)
118
What is defined as any breech of the lung surface or chest wall allowing air to enter the pleural cavity, causing the lung to collapse?
Pneumothorax
119
In what population is a primary pneumothorax most common?
| (can also have secondary)
Tall, young males
120
What forms due to a 1-way valve where air can enter the pleural space upon inspiration but not leave an dis cost commonly due to trauma?
Tension pneumothorax = MED EMERGENCY
(a/w tracheal dev, hemodynamic instability)
121
How is pneumothorax diagnosed?
CXR
122
What is the tx for pneumothorax?
* If mild, resolve on its own, if \<15-20% lung involvement, observe and repeat CXR in 24-48 hrs
* Tube thoracostomy if sx
* Tension pneumothorax = needle decompression then chest tube placement
123
What condition is characterized by paroxysmal attacks of reversible bronchospasm, mucous plugging, and inflammation of tracheobronchial tree?
Asthma
124
Pt presents with SOB, wheezing, cough, respiratory distress, use of accessory muscles/ nasal flaring. What is suspected dx and should you still be concerned if they have a "quiet" chest?
Asthma
YES (complete airway obstruction)
125
Tx fo asthma?
**Airway, O2**
B2 agonist SVNs (Albuterol)
Steroids (PO prednisone or IV solu-medrol)
Nebulized anticholinergics (Atrovent)
IV magnesium (severe exacerbations and not responsive to therapy)
126
What is defined as refractory asthma attack that doesn't respond to initial therapy with bronchodilators, is a medical emergency, and typically requires ICU admission?
Status asthmaticus
