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3. E Med & Surgery > 2- CV and Pulm Emergencies > Flashcards

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

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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

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3
Q

What is indicated by angina?

A

Ischemic event

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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

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5
Q

In what type of angina are sxs stable and resolve w rest?

A

Stable angina

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6
Q

What type of angina increases in severity/ frequency/ duration OR occurs at rest?

A

Unstable angina

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7
Q

What is defined as an MI with a non-occlusive thrombis and ischemia with elevated cardiac enzymes?

A

NSTEMI

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8
Q

What is defined as an MI with occlusive thrombus or transmural infarction?

A

STEMI

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9
Q

Male sex, > 55 yo, DM, hyperlipidemia, HTN, FH, tobacco use, obesity, and h/o atherosclerotic disease are RFs for what?

A

CAD

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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)

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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)

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12
Q

What are the preferred tests for diagnosing ACS?

A

Troponin I and T

(T = high sensitivity troponin)

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13
Q

Is a single set of negative biomarkers sufficient to r/o an ACS event?

A

Typically NO

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14
Q

If pts have sxs for > 2 hours and their Trop T is negative, you can r/o what dx?

A

ACS

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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

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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

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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)

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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

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19
Q

Pt presents w CV concern. ECG shows ST depression or T inversion AND has raised troponin. Likely dx?

A

NSTEMI

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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

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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

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22
Q

What is the medical management for stable angina?

A

Nitrates

Beta blockers

Antiplatelet meds

+/- CCB

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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

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24
Q

What are possibilites for antiplatelet meds in the tx of stable angina?

A

Aspirin (81- 325 mg daily), Plavix, combo

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25
Q

Prinzmetal angina is aka?

A

Variant angina

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26
Q

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?

A

Prinzmetal angina (variant angina)

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27
Q

What is diagnostic for Prinzmetal angina?

A

Coronary angiography

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28
Q

What is the tx for Prinzmetal angina?

A

Nitrates and CCB

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29
Q

Prior to giving nitro, you should ask a pt what?

A

Ask if they have recently taken Sildenafil, Vardenafil or Tadalafil

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30
Q

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?

A

ACS

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31
Q

What is included in the initial management for STEMI?

A

ABCs, call cardiology, cardiac monitoring/ cath lab, IV access, SL nitro, aspirin 325mg (chewed), revascularization, BB

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32
Q

Is “MONA” recommended for initial ACS tx?

(morphine, oxygen, nitro, aspirin)

A

No- just nitro and aspirin

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33
Q

When should SL nitro be avoided in ACS pts? (6)

A
  • 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
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34
Q

The following are contraindications to what initial management of STEMI?

HF, cardiogenic shock, bradycardia/ heart block, reactive airway disease

A

BB

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35
Q

What revascularization is preferred in the initial management of STEMI?

A

PCI (percutaneous coronary intervention)- w/i 90 min

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36
Q

What revascularization is considered in the management of STEMI if extensive disease found?

A

CABG (bypass surgery)

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37
Q

What is gold standard for diagnosing CAD?

A

Coronary angiography

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38
Q

What are the 2 “PCI” interventions?

A

Angioplasty, stenting

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39
Q

In what management of STEMI does an inflated balloon compress plaque against artery walls?

A

Angioplasty

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40
Q

What type of stents are preferred in the management of STEMI due to lower risk of strent thrombosis?

A

Drug eluting stents (DES)

(base metal stents rarely used)

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41
Q

What are the factors when considering a coronary artery bypass graft (CABG)?

A

of occluded vessels, anatomic complexity of lesions, likelihood to have successful revascularization w/ PCI, co-morbidities

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42
Q

Initial management of NSTEMI is the same as STEMI with the exception of what?

A

No thrombolytics, PCI (if not c/i), if PCI c/i then medically manage with heparin continuous infusion + aspirin

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43
Q

What are c/i to PCI in management of NSTEMI?

A

Renal failure, sepsis, unstable pt

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44
Q

What are the more common peri-infarction emergencies? (period following MI)

A

Peri-infarction pericarditis (PIP), acute mitral regurgitation, Dressler’s syndrome

(others: hemorrhage/ bleeding, arrhythmias, rupture of LV free wall or IV septum)

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45
Q

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?

A

Peri-infarction pericarditis

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46
Q

What is the tx for peri-infarction pericarditis?

A

Tylenol/ supportive (generally self-limited), ASA +/- cholchicine

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47
Q

What should be avoided in tx of peri-infarction pericarditis?

A

NSAIDS

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48
Q

Although pericarditis can occur post MI, what is important to note when evaluating this?

A

Can happen for many other reasons and tx depends on etiology

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49
Q

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?

A

Cardiac tamponade

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50
Q

What will CXR and echo show on a pt with cardiac tamponade?

A

CXR- enlarged cardiac silhouette

Echo- effusion w tamponade

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51
Q

What is tx for cardiac tamponade?

A

Drainage of pericardial effusion and subsequent monitoring

52
Q

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

A

Acute mitral regurgitation

53
Q

What will be noted on PE with acute mitral regurgitation?

A

Hypotension and new murmur

54
Q

What is the treatment for acute mitral regurgitation?

A

Emergent surgery

55
Q

What is Dressler’s syndrome and when does it develop?

A

Post-cardiac injury syndrome (PCIS), develops weeks to months post MI

56
Q

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?

A

Dressler’s syndrome

57
Q

What is the treatment for Dressler’s syndrome?

A

NSAIDS (first line)

Corticosteroids or colchicine if refractory

58
Q

What specific PE findings are consistent with endocarditis?

A

Janeway lesions, splinter hemorrhages, Osler nodes, Roth spots

59
Q

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?

A

Endocarditis

(other PE findings: Janeway lesions, splinter hemorrhages, Osler nodes, Roth spots)

60
Q

What is the protocol for labs if suspected endocarditis?

A

Blood cultures x 3 before abx, leukocytosis, elevated ESR

61
Q

What will be seen on echo for a pt with endocarditis?

A

Vegetations on valves

(get TEE, then TTE if inconclusive)

62
Q

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

A

Endocarditis

63
Q

With respect to Duke’s diagnosis criteria for endocarditis, how many criteria must be satisfied?

A

2 major OR

1 major + 3 minor OR

5 minor

64
Q

What is the treatment for endocarditis?

A

Abx (vanco + ceftriaxone or gentamicin)

Surgery (if not resolved w/ abx)

65
Q

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?

A

HF (acute exacerbation)

66
Q

CXR showing cardiomegaly, cephalization, Kerly B lines, +/- pulm edema is concerning for what?

A

HF (acute exacerbation)

67
Q

What is the first line tx for HF (acute exacerbation)?

A

Diuretics- Furosemide = 1st line

(others: IV access, control airway/ O2, telemetry, Na/ fluid restriction, strict I+Os, +/- inotrope, chronic HF meds)

68
Q

What tx should be avoided in acute, unstable, or uncompensated HF?

A

BBs

69
Q

What are the BP values for both hypertensive urgency AND hypertensive emergency?

A

SBP ≥ 180, DBP ≥ 120

70
Q

What is the primary difference between hypertensive urgency and hypertensive emergency?

A

Hypertensive urgency = no end-organ damage

Hypertensive emergency = acute end organ damage (cerebrovascular, ophtho, cardiac, renal)

71
Q

What are the more common primary causes of HTN urgency/ emergency?

A

New diagnosis of HTN, non-adherence to meds

72
Q

What is most important in a hypertensive workup?

A

Assess for end-organ compromise (neuro, ophtho, CV, renal)

73
Q

What is the tx for hypertensive urgency if they are an established hypertensive pt?

A

Rest + increase med dose, add med, adherence to Na restriction

74
Q

What is the tx for hypertensive urgency if it is a new occurrence of HTN?

A

Rest + initiate anti-HTN tx

75
Q

What is tx for hypertensive emergency?

A

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
Q

What are the guidelines for reduction of BP with HTN emergency?

A

Reduce MAP by 10-20% within 1 hour, then by additional 5-15% over next 23 hours

1st choice agent = IV labetolol

77
Q

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?

A

Thoracic aortic aneurysm

78
Q

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?

A

Abd aortic aneurysm

(if rupture, + hypotension/ hemodynamic instability)

79
Q

Is a thoracic aortic aneurysm or abd aortic anerysm more common?

A

Abd

80
Q

What will CXR show with thoracic aortic aneurysm (even if asx)?

A

Widened mediastinum

81
Q

How is a thoracic aortic aneurysm typically managed?

A

Aggressive BP and HR control- keep SBP < 120 and HR < 60-80

82
Q

When should a thoracic aortic anueysm be surgically managed?

A

Symptomatic, rapid expansion (growth > 0.5cm in 6 mos), > 5.0cm

83
Q

What is the management for AAA if asx and < 5.5cm?

A

Observation and RF mod, US every 6 mos- 1 yr

84
Q

What are possible complications a/w AAA?

A

Rupture (high morbidity/ mortality), aneurysm thrombosis, thromboembolism (can lead to acute limb ischemia)

85
Q

When should an AAA be surgically managed?

A

Asx ≥ 5cm, rapidly expanding (growth > 0.5cm in 6 mos), a/w peripheral arterial aneurysm or PAD

86
Q

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?

A

Aortic dissection

(fatal if blood filled channel ruptures through outside aortic wall)

87
Q

Pt presents with “ripping” or “tearing” CP radiating to the back. PE shows signs of hemodynamic compromise. What are you concerned for?

A

Thoracic aortic dissection

88
Q

Pt presents with severe back, abd, or flank pain + hypotension and shock. PE shows signs of hemodynamic compromise. What are you concerned for?

A

Abdominal aortic dissection

89
Q

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

A

Aortic dissection

90
Q

Management of aortic dissection depends on what?

A

The type (ascending vs descending)

91
Q

What is the management for acute ascending thoracic dissection (type A)?

A

Cardiac surgical emergency

92
Q

What is the management for descending thoacic aortic dissection (type B)?

A

Managed medically

93
Q

It is important to rapidly distinguish between an ascending and descending aortic dissection. How is this done?

A

CTA (inital screening if pt stable)

Multiplanar TEE (if pt unstable)

94
Q

What is the inital management for aortic dissection if pt is unstable or there is airway compromise?

A

Intubate (bedside TEE) and emergency surgery consult

95
Q

What is the initial management for aortic dissection if stable?

A

Admit, surgical consult, morphine for pain control, BP control with IV beta blocker (Esmolol), CT

96
Q

What are the ideal BP and HR parameters for a stable pt with aortic dissection?

A

SBP < 100-120

HR < 60

97
Q

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?

A

Acute limb ischemia

98
Q

Acute limb ischemia due to a sudden, dramatic onset is due to what?

A

Embolus

99
Q

Acute limb ischemia due to gradual onset is due to what?

A

Thrombosis

100
Q

What are the 6 P’s a/w acute limb ischemia?

A

Pain, pulselessness, pallor, paresthesias, paralysis, poikilothermia

101
Q

What is important for PE of a pt with acute limb ischemia?

A

Bilateral neuro exam (sensation, strength, pulses)

Doppler for PT/ DP, ABI (< 0.4 = significant ischemia)

102
Q

What imaging is utilized for acute limb ischemia?

A

Vascular imaging (CTA/ MRA with contrast)

103
Q

With acute limb ischemia, threatened limbs require what?

A

Immediate surgical revascularization (intraoperative arteriography)

Consult vascular surgery ASAP

104
Q

What is included in the initial management of acute limb ischemia?

A

Anticoagulation, close monitoring, surgery when worsens

105
Q

What is defined as acute, sudden onset of intestinal hypoperfusion?

A

Acute mesenteric ischemia

106
Q

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?

A

Acute embolic occlusion (acute mesenteric ischemia)

107
Q

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?

A

Mesenteric thrombosis

108
Q

What is the diagnostic imaging of choice for acute mesenteric ischemia?

A

CTA

109
Q

What is the treatment for acute mesenteric ischemia?

A

Systemic anticoagulation and pain management

110
Q

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)

A

DVT

111
Q

What is Virchow’s triad?

A

Endothelial damage, hypercoaguability, stasis

112
Q

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?

A

Suspected dx = DVT

Dx test of choice = duplex US

113
Q

What is the treatment for DVT?

A

Anticoagulation

114
Q

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?

A

PE

115
Q

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?

A

PE, pulmonary CTA = gold standard

116
Q

How are D-dimer and Well’s criteria used to assess a pt with possible PE?

A
  • 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
Q

What is the tx for PE?

A

Supplemental O2, IV access, cardiac monitoring, anticoagulation

(anticoag: UNF heparin, LMWH, warfarin, NOAC)

118
Q

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?

A

Pneumothorax

119
Q

In what population is a primary pneumothorax most common?

(can also have secondary)

A

Tall, young males

120
Q

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?

A

Tension pneumothorax = MED EMERGENCY

(a/w tracheal dev, hemodynamic instability)

121
Q

How is pneumothorax diagnosed?

A

CXR

122
Q

What is the tx for pneumothorax?

A
  • 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
Q

What condition is characterized by paroxysmal attacks of reversible bronchospasm, mucous plugging, and inflammation of tracheobronchial tree?

A

Asthma

124
Q

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?

A

Asthma

YES (complete airway obstruction)

125
Q

Tx fo asthma?

A

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
Q

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?

A

Status asthmaticus

3. E Med & Surgery (19 decks)

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