C + D placement notes Flashcards
fixed risk factors of stroke (7)
age; FH; previous stroke/TIA/MI/PVD; sickle cell anaemia; ehtnicity
modifiable risk factors of stroke (7)
drugs (blood thinners); cholesterol levels; diabetes; hypertension; high BMI; trauma; AF
examples of contraindications to thrombolysis (4)
recent major head trauma; INR >1.7; active bleeding; stroke/TIA in the last 6 months
Stroke/TIA driving rules
no driving for 4 weeks post event; inform DVLA if still have symptoms after 4 weeks for car and must inform DVLA regardless if HGVT liscence; no driving for 3 months if had multiple strokes/TIAs
how to distinguish stroke from bells palsy
bells - cant move entire half of face, complete droop (LMN lesion so affects innervation after they have been combined);
stroke - can move eyeybrows and up (stroke is UMN and top half of face is innervated by both sides of brain => still gets input from unaffected side)
what can cause bells palsy
dormant viral infection e.g. shingles (ramsey-hunt syndrome);
what is Todd’s palsy
a neurological condition experienced by individuals with epilepsy, in which a seizure is followed by a brief period of temporary paralysis. The paralysis may be partial or complete but usually occurs on just one side of the body; may also affect speech and vision
when should labetelol not be given in haemorragic stroke
if BP is already below 140/90 as lowering it further msy prevent adequate perfusion into the rest of the brain
what clotting factors does warfarin act on
2, 7, 9 10
INR formula
INR = prothrombin time of pt/standard prothrombin time
how is a high INR reversed
vit K (slow acting) and prothrombin CC (fast acting)
what is prothrombin time
a blood test that measures the time it takes for plasma to clot
in men, what associated symptom can be a warning sign for PVD
erectile dysfunction
what is iloprost
a vasodilator
where does temporal vision dessucate?
optic chasam
what thrombolytic agents can be used in limb ischaemia
Tissue plasminogen activator (e.g. alteplase); streptokinase
how to tell if ALI is caused by a thrombus or an embolism
thrombus - weak/no pulses in both limbs;
embolism - normal pulses in one limb but no pulse in the other (95% will be due to embolism from AF)
what sound form is normal on a doppler of blood vessels
triphasic
how long should you wait before giving antihypertensives to an ischaemic stroke patient
24-48 hrs
symptoms of AAA (3)
Abdominal pain
Back or loin pain
Distal embolisation producing limb ischaemia
other symptoms of AAA rupture
abdominal pain, back pain, syncope, or vomiting
most common type of AAA rupture
posteriorly into the retroperitoneal space
traid of AAA rupture
- flank or back pain
- hypotension
- pulsatile abdominal mass
when is surgury indicated for AAA
AAA >5.5cm in diameter, AAA expanding at >1cm/year, or a symptomatic AAA in a patient who is otherwise fit
how to calculate a pack year
packs of cigarettes a day (20 per pack) x number of years
how does T2DM affect aneurysms
causes calcification of bvs which protects from anueyrsms
symptoms of critical limb ischaemia
arises from chronic; rest pain, ulcers, gangrene, dry skin
symptoms of acute limb ischaemia
6 Ps - pain, pallor, pulselessness, parasthesia, poikilothermia; paralysis
treatment for acute limb ischaemia
emergency referal to vascular - Endovascular therapies: Percutaneous catheter-directed thrombolytic therapy; ercutaneous mechanical thrombus extraction
Surgical interventions:
Surgical thromboembolectomy;
Endarterectomy; Bypass surgery; Amputation if the limb is unsalvageable
management for moderate PAD
75mg clopi; 80mg atrovastatin
what changes to look for for signs of vascular disease
hair loss on limbs; symmetry; lipodermatosclerosis; spider veins; scars; ulcers; haemosiderin; oedema
what score is used to calculated DVT risk
well’s score; score of over 2 means DVT is likely
components of the wells score (9)
active cancer; paralysis; unilateral pitting oedema; previous DVT; bedridden for 3+ days or recent major surgery; calf swelling; whole leg swelling; dilated collaterals (not varicose veins); tenderness
features of varicose veins (9)
pain/ache; cramp; restless leg; fatigue; heaviness; itching; bleeding; phlebitis; discolouration
what causes ‘champagne bottle’ sign
localised chronic inflammation - acute phase proteins, break down of rbcs, fibristic scars, absent capillaries leading to hypoxia
what causes Hemosiderin
RBCs breaking down ad ferrous pigment leaking out of capillaries - due to blood pooling in legs bc it cant be pumped properly
chest pain differentials
STEMI; NSTEMI; stable angina; unstable angina (pain at rest); pneumonia; stomach ulcers; GORD; dissection
what factors affect the preload
venous return; gravity; muscle pump; pumping ability; volume; respiratory pump
what valve disease can cause AF?
MS + MR
cardio reasons for collapse
postural hypotension; MI; AS; bradycardia; tachycardia
non cardio reasons for collapse (6)
resp - PE;
neuro - vaso-vagal syncope; stroke/TIA
endo - diabetes (hypoglycaemia)
misc - Micturition syncope (while urinating), cough syncope
what does the coronary sinus do
drains the coronary arteries
what does the right circumflex artery supply
conduction tissue; right side of heart - RA +RV
what does the left circumflex arty supply
left atrium and the posterior-lateral aspect of the left ventricle
what does the left anterior descending artery supply (4)
most of the interventricular septum; the anterior, lateral, and apical wall of the left ventricle; most of the right and left bundle branches; anterior papillary muscle of the mitral valve
where is the SAN located
junction of the vena cava + RA
what is the dicrotic notch
a prominent and distinctive feature of the pressure waveform in the central arteries. It is universally used to demarcate the end of systole and the beginning of diastole in these arteries
high output cardiac failure CO and BP
vasodilation occurs meaning vasc resistance is low and so CO is high but BP is low
3 neuro systems that regulate BP
- vasomotor centre in the medulla - incre symp stimulation -> smooth muscle contraction -> incr resistance -> incre afterload -> BP (e.g. when standing up);
- higher brain centres e.g. hypothal, cerebral cortex - stimulated by changes in temp, size, pH etc.;
- baroreceptors (in carotid sinus and aortic arch)/ chemo receptors (aortic/carotid bodies) - symp/parasymp stimulation when activated
examples of vasodilators and how they work (2)
kinins - similar to histamine but acts only on visceral smooth muscle;
atria-natrietic peptide- increased release in resposne to atria stretch, decreases aldosterone release
examples of vasoconstrictors
adrenaline, NA
where are renin and angiotensin released from
renin - kidney
angiotensin - liver
why is bloodflow autoregulation required
to make sure blood flow is constant and organ receive what they need
what is an arrhythmia (electrically)
disorder of production/conduction of an impulse
how to distinguish AF from AVRT/AVRNT
AF is has an irregularly irregular rythm; AVRNT/AVRT, regular and p waves may be visible
what is a left anterior fasicular block
something interfering with your heartbeat’s signal when it gets to the left anterior fascicle of your heart’s left bundle branch - makes your heart’s left ventricle contract later than your heart’s right ventricle
when may normal variant sinus arrhythmia occur
during breathing in
how many large seconds are in a large ECG square
0.2 (200ms)
for there to be 1 degree heart block, how many squares long must the PR interval be?
> 1 (0.2s)
how many little squares wide is a wide complex QRS
6
what does a carotid massage stimulate?
vagus nerve (via baroreceptros)
what arrhythmias are irregularly irregular
mobitz II; 2:1/3:1 AV block
RA enlargement ECG
peaked P wave (P pulmonale) with amplitude: > 2.5 mm in the inferior leads (II, III and AVF)
what do bifid p waves indicate
result from slight asynchrony between right and left atrial depolarisation
when is a Q wave pathological
depth is >25% the height of R
digoxin toxicity ECG
downsloping, depressed ST segment
hyperkalaemia ECG
tall T wave (>5mm in chest and >10mm in limb)
what is sgarbossa’s criteria and what is it used for
used to identify an infarction on an ECG in someone with LBBB - Concordant ST elevation ≥ 1 mm in ≥ 1 lead;
Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3;
Proportionally excessive discordant ST elevation in ≥ 1 lead anywhere
what can cause a fall in CO (with low preload)
hypotension; bleeding out; dehydration i.e. low blood volume
what can cause a fall in CO (high preload)
heart failure
what occurs in shock
metabolic demands are not met
what are the shockable rhythms
pulseless VT; VF
what rhythms are non-shockable
asystole; pulseless electrical activity (PEA)
non-shockable rhythms management
asytole - CPR, adrenaline, other drugs;
PEA - check pulse, CPR -> continue this cycle
VF ECG features
polymorphic QRS, features unidentifiable
defib steps
- call for help;
- ABCDE - give O2, start CPR;
- place defib pads on (R mid clavicular, L mid-auxillary);
- stop CPR and remove O2 - check rythm;
- restart CPR and ask everyone else to stand clear - charge pads;
- stop CPR, make sure everyone is clear (no touching bed, no sudden movement etc.)
- deliver shock;
- immediately restart CPR + O2
what is the main cause of pericarditis
Coxsackie B virus
when is VT considered to be caused by an MI
if it occurs within 12hrs of MI
ACS scorates
S- central
O- acute
C- crushing
R- neck, jaw, tongue, arms
A- SOB, diaphoresis (sweating), anxiety, nausea
T- depends on severity
E- possibly relieved w GTN
S- severe
what scores are used to assess complexity and mortality risk in ACS
SYNTAX and GRACE score
what is dressler’s syndrome
pericarditis
what inflammatory markers indicate papillary muscle rupture
macrophages and granulation tissue
what valve disease has a displaced apex sound
MR
effect of squatting on ejection systolic murmurs
AS - murmur is worse
HOCM - murmur is improved (due to increased BP)
with and NSTEMI what tool is used to decide what intervention should be done
GRACE score
management for first time/unknown cause of AF
cardioversion (otherwise rate and rhythm)
what may need to be done alongside rhythm control of AF
anticoagulation - as still in AF just not tachy
at what point in the cardiac cycle should a CT angiogram be taken
diastole (low and stable HR)
symptoms of HF (8)
SOB (exertional, PND, orthopnea); decreased exercise tolerance; syncope; fatigue; weight loss; cardiac wheeze (due to pulmonary oedema); sputum production (pink/frothy)
signs of HF (9) on examination
raised JVP; gallop/tachycardia; pitting oedema; cyanosis; muffled heart sounds (pulmonary oedema); bibasal crackles (PO); valve disorders; HTN; ascites
what can be given for pain in palliative HF pts (5)
diamorphine; oramorph; paracetamol; TENS machine; acupuncture
examples of SSRIs
Citalopram; Fluoxetine
what side effect can rosuvastatin cause
rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood which can damage brain, kidneys etc.)
what are key differentiating symptoms for a SAH
thunderclap/smack to back of head headache; one eye non responsive to light
what is Leriche syndrome
aortoiliac occlusive disease
what is the leriche triad
erectile dysfunction; absent femoral pulses; buttock claudication
why is atherosclerosis less common in veins and capillaries
blood is flowing at a much lower pressure - less damage = less inflammation and built up of plaque material
what can be given for low BP in cardiogenic shock
IV GTN
what is cardiogenic shock
inability of the heart of pump blood to meet the demands of the body
what is Angioedema a side effect of
ACEi
what drugs class if given for migraines
BBs
symptoms of digoxin toxicity
nausea, vomiting, diarrhoea, abdominal pain, or anorexia; weakness, confusion; disturbances of colour vision with a tendency to perceive yellow halos around objects (xanthopsia)
what is carcinoid syndrome
collection of symptoms some people with a neuroendocrine tumour may have - may affect the heart, especially the valves
