9 - CHF

Question 1

Acute heart failure can manifest in 2 ways:

Answer 1

1) Acute pulmonary edema

2) Acute MI–>cardiogenic shock

Question 2

Increased pressure inside heart chambers cause contractility to increase or decrease? What is this law called?

Answer 2

Increase, Frank-Starling

Question 3

Causes of HF:

Answer 3

1) MI
2) htn (this is only rapid in pre-eclampsia)
3) dysrhythmia
4) “itis” (pericard, myocard, endocard)
5) dissection
6) cardiac tamp
7) valve disorder
8) PE
9) cardiomyopathy
10) high output heart failure

Question 4

What are some examples of high output heart failure?

Answer 4

1) anemia
2) Beriberi
3) Paget’s
4) thyrotoxicosis
5) AV fistula

Question 5

In systolic heart failure, EF will be < _____%

Answer 5

40

Question 6

What will the body do to compensate for low CO?

Answer 6

Increase Renin and Angiotensin to increase fluid volume

Question 7

The heart has an inability to relax. This is called ______heart failure

Answer 7

diastolic

Question 8

What are some causes of diastolic HF?

Answer 8

LVH, htn, CAD

Question 9

Would you want to diurese pts with diastolic HF?

Answer 9

NO! The problem is with back up in preload, you need to increase fluid volume and give vasodilators

Question 10

Patient has SOB, cough, weakness, orthopnea, PND, fatigue, JVD. Do you suspect right or left sided failure?

Answer 10

left (mixed b/c it’s also causing right heart failure)

Question 11

What are the right sided heart failure symptoms

Answer 11

peripheral edema
RUQ pain
JVD
hepatojugular reflex

Question 12

Most common cause of right heart failure

Answer 12

left HF

Question 13

Labs to dx HF in ED:

Answer 13

LFT (end organ damage)
BNP
cardiac enzymes

Question 14

How do you treat hypotensive HR?

Answer 14

Inotropes, fluids. worst prognosis

Question 15

heart sound specific to CHF

Answer 15

S3

Question 16

why can you expect liver tenderness/pain/megaly?

Answer 16

backflow and engorgement into liver from backup in vena cava

Question 17

what’s are some fun findings on CXR is common with CHF?

Answer 17

Kerley B lines and cephalization (vertical lines), big heart, pleural effusion, big vena cava

Question 18

What rule of thumb are you using for ventilation of CHF patients?

Answer 18

Mild-Mod: Conscious and cooperative–non-invasive

Mod-Severe: AMS or unstable–intubation

Question 19

Reduce preload with

Answer 19

nitrates and diuretics

Question 20

Reduce afterload with

Answer 20

ntg

ACE inhibitors

Question 21

Inoptropes

Answer 21

dobutamine, dopamine

Question 22

pain control

Answer 22

morphine which will also vasodilate

Question 23

dilation of arterial wall

Answer 23

aneurysm

Question 24

AAA that is concerning will be > ___cm

Answer 24

3, monitor

Question 25

AAA that should be considered for repair is > ____cm

Answer 25

5 (also repair if pt is symptomatic)

Question 26

What is the red flag complaints for AAA?

Answer 26

back pain + abd pain

Question 27

What is the classic triad of AAA?

Answer 27

1) back pain + abd pain
2) pulsatile mass
3) hypotension

Question 28

Cullen’s sign is __________ and Grey-Turner sign is ________. Both are extremely alarming for what?

Answer 28

umbilical, flank, AAA rupture

Question 29

Dx AAA

Answer 29

1) CXR is 65% sensitive, but NOT specific (can’t r/o)
2) US is 90% sensitive but can’t r/o
3) CT w/ is gold standard***

Question 30

Tx for AAA?

Answer 30

1) rupture suspected? emergent repair
2) >5cm? elective repair
3) 3-5cm? close monitoring

Question 31

what lethal problem mimics many other “chest pain” complaints?

Answer 31

dissection

Question 32

what are the 3 layers of the aortic wall?

Answer 32

inside vessel out: intima, media, adventitia

Question 33

Dissection dissects through what layers?

Answer 33

intima and media

Question 34

most dissections are ascending, descending, or localized to the arch?

Answer 34

ascending 60%
descending 30%
arch 10%

Question 35

Patient c/o back pain, diaphoresis, n/v, syncope, what is leading DDx

Answer 35

dissection, must rule this out first!!

Question 36

Common exam findings in dissection

Answer 36

MI (dissects at coronary vessels), syncope, neuro deficit

Question 37

EKG findings in dissection

Answer 37

normal, or may show inferior MI

Question 38

Dx test of choice for dissection

Answer 38

CTA –will show aortic dilation, false lumen, etc

Question 39

Tx of dissection

Answer 39

1) pain control–Fentanyl (only enough to take edge off, you need to monitor)
2) decrease pressure to 100
3) minimize shear pressure (lower HR <60)***
So #1 is BB–Esmolol that primarily targets HR
4) sx repair