4 CV and Pulmonary Emergencies Flashcards
1
Q
CP DDx - things that will kill you
A
ACS Aortic dissection PE Tension pneumothorax Pericardial tamponade Mediastinitis Esophageal rupture Perforated ulcer
2
Q
Less critical DDx for chest pain
A
Anxiety GERD Esophageal spasm PNA/pleurisy Costochondritis Rib fracture/contusion Herpes zoster Pericarditis/myocarditis Cholecystitis Pancreatitis
3
Q
Important associated symptom to ask about with CP patients
A
Sense of “impending doom”
4
Q
Dx tests to run for CP
A
ECG CXR Pulse ox Labs: CBC, CMP, D-dimer (maybe), lipids, BNP, cardiac enzymes Echo
5
Q
Classic presentation for angina
A
Pressure, heaviness, tightness, fullness, or squeezing in the center or left of the chest precipiatated by exertion and relieved by rest
Can radiate to shoulder, arms, neck, or jaw
6
Q
Angina is indicative os some type of _______ happening in the coronaries
A
Ischemic event
7
Q
Anginal equivalents are atypical presentations common in women, elderly, or diabetic patients
A
SOB N/V Diaphoresis Fatigue Dizziness/lightheadedness Weakness Palpitations Syncope
8
Q
Coronary Artery Disease (CAD) can be subdivided into…
A
Stable Angina (Sx transient, stable, and resolve with rest)
Acute Coronary Syndrome
• Unstable angina (inc severity/freq/duration OR occurs at rest)
• NSTEMI (non-occlusive thrombus —> ischemia with elevated cardiac enzymes)
• STEMI (occlusive thrombus, transmural infarction)
9
Q
Increasing severity/frequency/duration of anginal symptoms or symptoms occurring at rest
A
Unstable angina
10
Q
Myocardial infarction caused by a non-occlusive thrombus
A
NSTEMI
11
Q
Occlusive thrombus and transmural infarction
A
STEMI
12
Q
CAD risk factors
A
Male Age >55 DM HLD HTN Fam Hx of CAD Tobacco use Obesity Hx of MI, CVA/TIA, PAD
13
Q
What is the main risk calculator for CAD?
A
HEART score
How suspicious is the Hx for ACS (0-2 pt) ECG changes (0-2 pt) Age (0-2 pt) # of Risk factors (0-2 pt) Initial Troponin value (0-2)
Score of 0-3 send home
Score of 4-6 admit for observation
Score of 7-10 early invasive strategies
Also, TIMI score
14
Q
What Dx tests do you do FIRST for CAD?
A
12-lead ECG** Always always always
• resting ECG may be normal
• Look for ST-T wave changes
Cardiac enzymes
• Initial troponin, then trend
• Can’t r/o MI on a single test (esp if <4-6h since Sx onset)
Stress testing (if admitted but not STEMI - only if you’re unsure and the patient is stable)
Coronary angiography
15
Q
_______ is a sensitive and specific determinant of myocardial injury (though it can’t distinguish the etiology of the injury)
A
hs-cTn (high-sensitivity Troponin)
16
Q
Acutely elevated hs-cTn of _________ (or lower elevations with an associated 2-hour delta of _______) are indicative of an acute process causing myocardial injury
A
> 100ng/L
Or 2h Delta of >10ng/L
17
Q
Chronic elevations hs-cTn, particularly those w/o a changing pattern, are indicative of…
A
A more chronic process of myocardial injury
18
Q
Advantages of high sensitivity troponin
A
Rapid r/o or rule in for MI
ID more patients experiencing ACS
Emphasizes the Delta Troponin
Gender specific reference ranges
Reported in whole numbers
Specifies normal, INT, and abnormal ranges
19
Q
Disadvantages of high sensitivity troponin
A
A significant % of patients with (-) values with the old assay will be elevated now
More elevated values in patients without ACS (false positives)
Changes in management patterns
New documentation needs
20
Q
For regular troponin, we trend the value every _____
A
Q6 hours (for a total of 3 values)
21
Q
What are the different options for stress testing?
A
Stress echo (exercise vs pharmacological)
Radionucleotide myocardial perfusion imaging - can visualize areas of hypoperfusion
22
Q
Which type of stress test is preferred?
A
Exercise - IF they are able to exercise
If not - dobutamine
23
Q
During a stress test, what should you monitor?
A
BP, ECG changes, echo changes
Test is stopped if pt develops CP, SOB, ST changes, or has decreased BP or ventricular arrhythmias
24
Q
Medical management for stable angina
A
Nitrates (SL nitro PRN for CP) - can take q5 min but no more than 3 doses within 15 min
Beta blockers
+/- CCB
Anti-platelet meds (Aspirin, Plavix, or combo)
25
What is Prinzmetal Angina?
AKA: Variant angina or vasospastic angina
Episode of Angina 5-15 min, usually at rest and often between midnight and early morning
26
What tests do you run for Prinzmetal Angina?
EKG: ST elevation (only during anginal episodes)
Serial cardiac enzymes needed to r/o MI
Holter monitor
Coronary angiography (diagnostic***)
27
Treatments for Prinzmetal angina
Nitrates and CCB
Don’t need a stent or antiplatelets b/c no thrombus)
28
What drug do you need to ask about BEFORE giving a patient nitroglycerin
VIAGRA
29
Initial management of a STEMI
```
ABCs
Cardiac monitoring (telemetry)
IV access
SL Nitro
Aspirin 325mg chewed
```
+/- beta blocker, unfractionated heparin
30
What was the old go-to treatment for STEMI?
MONA - Morphine Oxygen Nitro Aspirin
BUT, morphine inhibits antiplatelet absorption and increases mortality in STEMI patients
O2 use (when NOT assoc with hypoxia) suggested to increase early myocardial injury and increase infarct size
31
_________ is important to help improve outcomes in STEMIs
Door to PCI time
PCI = Percutaneous Coronary Intervention
If PCI not readily available within 120 min, consider fibrinolytics
If extensive disease, consider CABG
32
When should you consider fibrinolytics for STEMI?
If PCI not readily available within 120 min
33
Gold standard for diagnosing CAD
Coronary angiography
Catheter threaded through femoral vessels into heart to assess lumen of vessels
Dye injected and patency of vessels is seen via fluoroscopy
34
What are the two PCI interventions?
Angioplasty
| Stunting
35
What factors need to be considered for Coronary Artery Bypass Grafts (CABG)?
Number of vessels that are occluded (multi-vessel disease)
Large area of potentially ischemic myocardium
Anatomic complexity of lesions
Likelihood to have successful revascularization w/ PCI
Co-morbidities
36
Contraindications to PCI in cases of NSTEMI/UA
Renal failure
Sepsis
Unstable patient
37
Most cases of NSTEMI/UA can be managed...
Medically with heparin continuous infusion and aspirin
NO thrombolytics
38
What are the contraindications to nitro
Hypotension
RV infarction/inferior MI
Recent use of PDE5 inhibitors
39
What are Peri-infarction emergencies
Episodes that occur in the post-MI period
```
Peri-infarction pericarditis (PIP)
Acute mitral regurgitation
Dressler’s syndrome
Hemorrhage/bleeding
Arrhythmias (esp. bradycardia)
Rupture of LV free wall or intraventricular septum
```
40
Peri-infarction pericarditis usually occurs ______
Soon after MI (first 2-3 days)
Is transient
PE: pericardial rub
Echo: pericardial inflammation +.- effusion
41
How do you treat a peri-infarction pericarditis (PIP)
Supportive - generally self-limited
Usually just Tylenol - AVOID NSAIDs (b/c they are usually already anticoagulated)
ASA +/- colchicine
42
Other non-MI causes of acute pericarditis
```
Infectious
Radiation
POST-CARDIAC INJURY SYNDROME
Drugs/toxins
Metabolic
Malignancy
Collagen vascular disease
Immune-related
Idiopathic
```
43
How does Cardiac tamponade present?
CP, tachypnea, dyspnea
PE: sinus tachycardia, HYPOTENSION, JVD, pericardial rub, MUFFLED HEART SOUNDS, pulses paradoxes
ECG: sinus tachycardia, low voltage (electrical alternans)
CXR: enlarged cardiac silhouette
Echo: effusion with tamponade
44
What is Beck’s triad
HYPOtension
JVD
Muffled heart sounds
(= cardiac tamponade)
45
Treatment of cardiac tamponade
Drainage of pericardial effusion
Percutaneous (pericardiocentesis) or surgical
Subsequent monitoring:
• Continuous telemetry
• Frequent vital signs x 24-48 hours
• Repeat echo prior to discharge
46
Causes of acute mitral regurgitation
Ischemia to papillary muscle
LV dilation or true aneurysm
Papillary muscle or chordal rupture (usually 2-7 days after infarct)
47
How will acute mitral regurgitation present?
Hypotension and NEW MURMUR
Dx: TTE (or TEE if inconclusive TTE)
48
Treatment of acute mitral regurgitation
Emergent surgery - can become very unstable quickly
49
What is Dressler’s Syndrome
Post-cardiac injury syndrome (PCIS)
Develops weeks to months post-MI (unlike PIP, which is days) or cardiac surgery, trauma, or PE
Presents with pleuritic CP, fever, malaise
PE: pericardial friction rub
Labs: leukocytosis, elevated ESR
CXR: pleural and/or pericardial effusion or pulmonary infiltrates
50
Treatment for Dressler syndrome
NSAIDs
| Corticosteroids or colchicine if refractory
51
Extra-CV manifestations of endocarditis?
Jane way lesions
Older nodes
Splinter hemorrhages
Roth spots
52
Presentation of endocarditis
Fever, chills, cough, dyspnea, ortho Pena, fatigue
PE: palatial, conjunctival, or subungual petechiae, splinter hemorrhages, Osler nodes, janeway lesions, Roth spots, pallor, splenomegaly, HEART MURMUR
53
What labs do you draw for suspected endocarditis?
Blood cultures x 3 before abx
Leukocytosis with elevated ESR can be seen on CBC
Echo will show VEGETATION ON VALVES (get TEE)
54
Risk factors for Endocarditis
```
Artificial heart valves
Congenital heart defects
Hx of endocarditis
Damaged heart valves
IVDU
Poor dentition/dental infection
```
55
Treatment for endocarditis
Abx (usually prolonged, ~6 weeks)
Vancomycin + Rocephin until C&S returns
If condition does not resolve with abx, surgery may be necessary in up to 50% of cases
56
How does heart failure present?
Dyspnea, fatigue, diaphoresis, early satiety, cough, orthopnea, PND, edema
PE: tachycardia, tachypnea, rales, JVD, S3/S4, LE edema, ascites
ECG: +/- arrhythmias, ischemia, heart block
57
What labs do you need to do for HF?
CBC, CMP, TSH, Cardiac enzymes, BNP
CXR —> cardiomegaly, cephalization, Kerley B lines +/- pulmonary edema
Echo: look at EF, valves, pericardium, wall motion abnormalities
58
How do you treat HF?
IV access, control airway (O2), telemetry
1st line med: Furosemide
Sodium and fluid restriction
Strict I&O, daily weights
+/- Inotrope
Chronic HF meds once stable - BB, ACE, Diuretics, +/- digoxin
59
What med should be avoided in acute, unstable, uncompensated heart failure?
Beta blockers!
60
Definition of hypertensive urgency?
SBP ≥ 180, DBP ≥120
NO end-organ damage
61
What is the definition of hypertension emergency
SBP≥180, DBP≥120
Associated with acute end-organ damage (CV, Opto, Cardiac, Renal)
62
95% of cases of elevated BP are...
Primary (essential) HTN
Includes new diagnosis of HTN and non-adherence of medications
63
Examples of secondary causes of HTN (only5% of cases)
```
Sleep apnea
Renal artery stenosis
Pheo
Coarctation of the aorta
Pseudotumor cerebri
Chronic steroid therapy
Cushing’s syndrome
Thyroid/parathyroid disease
Primary hyperaldosteronism
Pregnancy
```
64
How to workup a hypertensive episode
BP measured in both arms
```
Assess for end-organ compromise
• Neuro check
• Opto check
• CV check (JVP, crackles, murmur, asymmetrical pulses
• Renal
```
ECG
Labs (UA, UDS, CBC, CMP, card enzymes, TSH, urine metanephrines)
Imaging: +/- CXR, head CT, CTA chest and abdomen
65
Treatment for HTN urgency
Rest
Established HTN patients:
• Inc dose of current meds
• Add additional med
• Adherence to sodium restriction
New occurrence of HTN
• BP reduction over several hours
66
How to treat hypertensive emergency
Should be hospitalized (usually in the ICU)
Workup secondary HTN causes
Treat end-organ damage - not absolute BP
Reduction of BP ONLY by 20-25% within 1 hour (NOT TOO QUICK)
Good first choice agent is IV labetalol (short half life) or continuous infusion like Nicardipine
Once BP stable with IV therapy, transition to oral therapy
67
___ % of aortic aneurysms are thoracic and ___% are abdominal
10% thoracic, 90% abdominal
68
Most common presenting feature of a thoracic aortic aneurysm
“Tearing” chest pain
Substernal, back or neck pain +/- dyspnea, stridor, cough, Sx of SVC syndrome
69
Most common presentation of an abdominal aortic aneurysm
Pulsating abdominal mass +/- abdominal/back pain
If rupture - also assoc with hypotension/hemodynamics instability
70
Thoracic aortic aneurysm risk is determined by...
Size of aneurysm
Often found incidentally on CXR/CT and asymptomatic
Usually managed medically
71
Medical management of Thoracic aortic aneurysms
Aggressive BP and HR control (keep SBP <120, HR<60-80)
Beta blockers for symptoms
Serial imaging (CT, MRA at 6 months)
72
Surgical management of Thoracic Aortic Aneurysms
Can be open vs endovascular
Considered if symptomatic, rapid expansion (growth >0.5cm in 6 months) or if size >5cm
73
Abdominal aortic aneurysms are typically asymptomatic if...
<5.5cm - observation and U/S every 6 months to year
74
Complications of a AAA
Rupture (high morbidity and mortality
Aneurysm thrombosis
Thromboembolism —> acute limb ischemia
75
When do you do surgical management of a AAA?
Asymptomatic AAA ≥5cm
Rapidly expanding AAA (growth >0.5cm in 6 months)
Associated with peripheral arterial aneurysm or PAD
76
Emergent condition in which the inner layer of the aorta tears, blood then surges through the tear, causing the rest of the layers to dissect
Aortic dissection
If the blood filled channel ruptures through the outside aortic wall, it’s often fatal
77
Sx of aortic dissection
Thoracic - “ripping” or “tearing” chest pain radiating to the back
Abdominal: severe back, abdominal, or flank pain + hypotension and shock
Both: signs of hemodynamics compromise
78
Risk factors for aortic dissection
```
Uncontrolled HTN
Atherosclerosis
Pre-existing aortic aneurysm
Bicuspid aortic valve
Aortic coarctation
Connective tissue disease (Marfan)
Cocaine use
Pregnancy
Male gender, advanced age
```
79
What is a Type A aortic dissection
Acute ascending thoracic dissection - CARDIAC SURGICAL EMERGENCY
80
What is a Type B aortic dissection
Descending thoracic aortic dissection - managed medically if hemodynamically stable and w/o end-organ complications
81
How to distinguish between Type A and Type B aortic dissections quickly
CT angiography - initial screening study in hemodynamically stable patient
Multiplanar TEE if hemodynamically UNstable
82
Initial management of aortic dissection
If unstable or airway compromise:
• Intubate
• Bedside TEE
• Emergent vascular surgery consult
```
Otherwise:
• Admit to ICU, consult vascular surgery
• Pain control (morphine)
• BP control (SBP 100-120, HR<60) IV beta blocker (esmolol)
• CT
```
83
What are the Six P’s of acute limb ischemia
```
Pain
Pulselessness
Pallor
Paresthesias
Paralysis
Poikilothermia
```
84
How do you assess neuro in cases of acute limb ischemia?
Assess sensation
Assess strength
Pulses
• Doppler for PT, DP
• Ankle-bronchial index (<0.4 indicates significant ischemia)
85
What imaging should you do for acute limb ischemia?
CTA, MRA
Performed in patients with viable limbs (anticoagulation prior and monitor progression)
Threatened limbs require immediate surgical revascularization (intraoperative arteriography)
86
Initial management of acute limb ischemia
Anticoagulation, close monitoring, surgery as soon as the exam worsens
Consult vascular surgery ASAP
87
Acute, sudden onset of intestinal hypoperfusion
Acute mesenteric ischemia
Can be due to acute embolic occlusion (esp elderly patient with a fib) or severe abd pain out of proportion to PE) or Mesenteric thrombosis (may be chronic - with PAD)
88
Chronic post-prandial pain, food aversion, weight loss +/- hematochezia
Mesenteric thrombosis
Typically with known PAD
89
What imaging do you do for acute mesenteric ischemia?
CT Angiography is test of choice
KUB may be useful to ID related complications (but doesn’t Dx ischemia)
90
Treatment for acute mesenteric ischemia
Systemic anticoagulation and pain management
+/- angioplasty with stent
+/- exploratory laparotomy if peritoneal signs
91
Risk factors for DVT
```
Recent surgery
Prolonged bed rest
Oral contraceptives
Hormone replacement therapy
Factor V Leiden, hypercoagulable states
Recent trip
Malignancy
```
92
What is Virchow’s triad?
Risk factors for DVT
Endothelial damage
Hypercoagulability
Stasis
93
Test of choice for DVT
Duplex ultrasound
94
Treatment for DVT
Anticoagulation (Lovenox or Heparin bridge to warfarin, possible NOACs)
Prevention in bedridden patients
Prevention in perioperative patients and travelers
95
Presentation of Pulmonary Embolism
Pleuritic CP, dyspnea, cough, hemoptysis, syncope
PE: tachypnea, TACHYCARDIA, HYPOXIA, +/- unilateral extremity edema
96
What is the rare ECG pattern they talk about for PE?
S1Q3T3
But usually you’ll just see sinus tachycardia
97
Buzzwords for PE CXR findings
Hampton’s hump
| Westermark sign
98
Gold standard for diagnosing PE
Pulmonary angiography (CTA)
Can also do V/Q scan if CTA contraindicated
LE Doppler U/S to evaluate for concurrent DVT
99
What is the name of the criteria used to asses for risk of PE?
Well’s criteria
100
How do you treat PE?
Supplemental O2
IV access
Cardiac monitoring
ANTICOAGULATION
Consider also: thrombolytics, IVC filter, embolectomy if very severe
