Cardiac 2024 Flashcards
MI, AV blocks, congenital abnormalities, BBB, percarditis, ...
1
Q
Afib and Aflutter med tx
A
BB, CCB(diltiazem, verapamil).
Also for Afib- digoxin for allergy to BB and CCB
2
Q
EKG for afib and aflutter
A
sawtooth for flutter. smaller sawtooth in afib.
3
Q
1,2,3 degree heart blocks
A
1st: prolonged PR interval(>200), every p has a qrs
2nd: dropped qrs
Mobitz 1: prog lengthening PR w/ dropped qrs
Mobitz 2: same length PR w/ occ dropped qrs
3rd: AV dissociation
4
Q
Causes can be from fibrosis, increased vagal tone, drugs, CAD, nml variant, mitral valve surgeries,
* delay in conduction thru AV node
*poss electrolyte imbalance causes are what
A
1st degree AV block
hypokalemia and hypomagnesiumia
5
Q
1st degree AV block symptoms? What is a big risk of having this? tx?
A
Asymptomatic usually. 3 x risk for Afib, pacemaker if over 300 PR interval and symptomatic
6
Q
Wenkebach tx
A
Mobitz 1; usually no tx. Atropine for bradycardia and hypotension, maybe pacing.
7
Q
Causes can be from increased vagal tone, drugs, nml variant, mitral valve surgeries, MI, HYPERkalemia
A
mobitz 1, wenkeabach
8
Q
4 types of afib
A
- Paroxysmal: self terminating in 7 days, usually 24 hrs, +/- recurrent
- Persistent: fails to self terminate, lasts > 7 days. Requires termination.
- Permanent: persistent AF > 1 year- refractory to cardioversion.
- Lone: Paroxysmal, persistent, or permanent w/out evidence of heart disease.
9
Q
symptoms in unstable afib
A
due to hypoperfusion: HYPOtension, altered mental status, refractory CP
10
Q
tx for unstable afib and aflutter
A
direct synchronized cardioversion
11
Q
AV nodal blocking agents
A
BB, digoxin, CCB
12
Q
bradycardia related decreased perfusion symptoms
A
fatigue, dizziness, CP, syncope
-think second degree heart block, mobitz type 1 Wenckebach
13
Q
TX for symptomatic wenckebach, what if it is persistent?
tx for mobitz type 2
A
atropine; pacemaker;
type 2: atropine or temp pacing. Progression to type 3 is common so permanent pacemaker is definitive.
14
Q
AV block commonly at bundle of HIS
A
mobitz type 2
15
Q
AV block rarely seen in patients w/out structural heart disease: myocardial ischemia, myocardial fibrosis, myocarditits(LYME), endocarditis
A
mobitz type 2
16
Q
avoid atropine in what heart block
A
it can precipitate 3rd degree heart block
17
Q
No atrial impulses reach ventricles leading to escape rhythm. More P waves then QRS complexes
A
3rd degree heart block
18
Q
causes of 3rd degree heart block
A
INFERIOR wall infarction, AV node blocking agents, degeneration of conduction system
19
Q
which AV block often symptomatic? symptoms?
A
3rd degree. syncope, fatigue, CP, death
20
Q
tx of 3rd degree heart block
A
maybe dopamine or adrenaline.
For sure pacemaker
21
Q
Valves most affected in endocarditis
A
M>A>T>P
except IV drug use: tricuspid
22
Q
describe acute bacterial endocarditis
A
infection of normal valves with virulent organism (eg S. aureus)
23
Q
describe subacute bacterial endocarditis
A
indolent infection of abnormal valves with less virulent organism (eg s viridans)
24
Q
organisms with IV drug related endocarditis
A
most commonly s aureus(especially MRSA), pseudomonas, candida
25
describe prosthetic valve endocarditis
early(within 60 days): staph epidermis most common.
late: resembles native valve endocarditis.
26
PE of endocarditis around body
* Persistent fever
* new onset murmur or worsening of an existing murmur
S: splinter hemmorhages
O: Osler nodes (hands/feet) painful
R: roth spots (eye)
J: Janeway lesions (hands/feet/ashtray)
27
3 biggest causes of endocarditis
IV drugs/needles, valve replacement surg, dental visits
28
6 organisms of endocarditis
staph aureus
strep viridans
staph epidermis
enterococcus
HACEK
strep bovis
29
describe staph aureus in endocarditis
most common cause of acute endocarditis, rapidly progressive, affects NORMAL valves. also common in pts with IV drug use (esp MRSA)
30
describe strept viridans in endocarditis
most common cause of subacute infective endocarditis; affects DAMAGED valves. part of oral flora(dental procedures)
31
describe staph epidermis in endocarditis
most common in early prostetic valve endocarditis, especially within 60 days of the procedure
32
describe enterococcus in endocarditis
seen especially in men over 50 years old with recent history of GI or genitourinary procedure
33
describe HACEK in endocarditis
Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella, Enterococci; all gram neg and hard to culture. Suspect these in endocarditis and neg blood cultures
34
describe strep bovis in endocarditis
especially in patients with colon cancer or UC
35
endocarditis blood cultures
3 sets at least 1 hour apart;
labs: leukocytosis, anemia(microchromic, normocytic), increased ESR/rheumatoid factor
36
left vs right sided emboli from heart
left to other organs(brain, kidney, spleen, heart)
right to lungs
37
imaging for endocarditis
Get TTE first (transesophageal echocardiogram more sensitive than TTE)
38
endocarditis, DUKE criteria
2 major OR 1 major with 3 minor, OR 5 minor
39
describe major criteria (DUKE)
1. sustained bacteremia with 2 pos blood cultures by organism known to cause endocarditis
2. endocardial involvement: + echo and new valvular regurgitation(AR or MR)
40
describe minor criteria (DUKE)
1. predisposing condition
2. fevers>38 degrees or 100.4
3. vascular and embolic phenomena(janeway, septic arterial or pulmonary emboli, ICH)
4. immunologic phenomena: oslers nodes, roth spots, +RF, acute glomerulonephritis
5. + blood culture not meeting major criteria
6. + echo not meeting major criteria (worsening existing murmur)
41
refractory CHF, persisent or refractory infection, invasive infection, prostetic valve, recurrent systemic emboli, fungal infections
indications for surgery for endocarditis
42
empiric endocarditis tx: native valve
* anti staph PCN: (nafcillin, oxacillin) plus ceftriaxone 4-6 weeks or gentamycin (aminoglycocides only 2 weeks)
* vanco if needed due to allergy
43
empiric endocarditis tx: prosthetic valve
vanco plus gentamicin plus rifampin
44
empiric endocarditis tx: fungal
amphotericin B for 6-8 weeks, often will need surgery
45
great gram positive coverage
PCN and Vanco
46
great gram neg coverage
gentamicin, ceftriaxone
47
Prophylaxis for which procedures to prevent endocarditis
dental, respiratory, and procedures involving infected skin/musculoskeletal tissues
48
Prophylaxis medications to prevent endocarditis
amox 2 gms 30-60 min before procedure
clinda 600 mg if PCN allergic
Macrolides or cephalexin are other options
49
4 things to ask if bradycardic pulse
Hypotension, AMS, refractory CP, acute heart failure
50
bradycardic med tx and exception
atropine 1st line; next is epi infusion or dopamine infusion, pacing
**exception is 3rd heart block- must pace then permanent pacemaker
51
When left side of the heart malfunctions, what happens?
blood will get backed up in the lungs, you get SOB, body does not get O2 rich blood to the body(fatigue), kidneys getting too little blood(doesn't make enough urine causing fluid build up in the body[legs]
52
When right side of the heart malfunctions, what happens?
blood gets backed up from tissues in the body[swelling in feet/LL], sluggish flow of blood and heart failure can lead to blood clots forming in heart, leading to clots in brain to cause a stroke OR clots in legs can travel to lungs
53
what is a cardiac arrest?
Heart has stopped pumping blood effectively due to an electrical issue, brain not getting enough O2, person unconscious, may not be breathing or breathing abnormally
54
Beck's triad
B E C
B: big jugular vein distention
E: extreme low BP (hypotension) C: can't hear heart sounds, distant muffled heart sounds
**Cardiac tamponade
55
5 initial symptoms of hypoxemia
restless & confusion, dizziness (syncope), fatigue, SOB, tachycardia
56
first sign of decreased cardiac output
tachycardia
57
pulses paradoxes
think cardiac tamponade;
systolic drop by 10mmhg upon respiration;
pulse pressure gets closer due to heart being compressed (systolic minus diastolic)
58
what tests to get for cardiac tamponade?
** echo: pericardial effusion and diastolic collapse of cardiac chambers (swinging heart)
1st, EKG: short and uneven qrs complexes , electrical alternans
- cardiac cath shows all pressures in chambers to be equal
59
- EKG: short and uneven qrs complexes , electrical alternans
cardiac tamponade
60
cardiac tamponade 6 symptoms
dyspnea, fatigue, peripheral edema, shock, reflex tachycardia, cool extremities
61
dyspnea, fatigue, peripheral edema, shock, reflex tachycardia, cool extremities
cardiac tamponade symptoms
62
Normal inspiration causes ___ pressure and pulls ___ into the___, the ___ ventricle ____, and this ______ affect left heart volume at all.
negative, pulls blood in the heart, the right ventricle expands and this does not affect left heart volume.
63
In tamponade, extra volume pushes ______ to the left and causing 3 things
interventricular septum to the left,
1. less left ventricular diastolic volume
2. lower stroke volume
3. lower systolic BP during inspiration
64
In tamponade, what happens to the atria
The atria can't distend enough to accomodate VENOUS blood so blood backs up and you see JVP
65
electrical alternans
QRS complexes have different heights, think tamponade
66
What is cardiogenic shock?
Heart's fault that pt is in shock.
inadequate tissue perfusion causing low cardiac output with increased systemic vascular resistance. Often systolic in nature.
67
difference between cardiogenic shock and hypovolemic shock
cardiogenic produces increased respiratory effort/distress, hypovolemic does not.
68
3 main Causes of cardiogenic shock
MI, heart failure(CHF), lethal rhythm
69
signs in cardiogenic shock
hypoTN, rales(blood backed up in lungs), JVD(heart failure), increased RR, decreased sp02(hypoxia)
70
myocarditis, valve dysfunction, congenital heart ds, cardiomyopathy, arrhythmias, MI
etiologies of cardiogenic shock
71
hypoTN, rales, JVD, increased RR, decreased sp02
signs in cardiogenic shock
72
symptoms in cardiogenic shock
CP, dyspnea, cold extremities with delayed capillary refill
73
increased pulmonary capillary wedge pressure(>15mmHg)
cardiogenic shock
74
cardiogenic shock and pulmonary capillary wedge pressure
increased pulmonary capillary wedge pressure(>15mmHg)
75
Vaso constriction or dilation in cardiogenic shock
vasoconstriction- increased SVR
76
Which shock do you do not give large amounts of fluid
cardiogenic shock
77
Tx of cardiogenic shock
O2, ISOtonic fluids(avoid aggressive IV fluid tx); inotropic support to increase myocardial contractility and CO:
1. dobutamine: positive inotrope
2. epi: positive inotrope and vasoconstrictor
3. Amrinone: may be used if refractory, positive inotrope
intraaortic balloon pump support
78
describe these meds:
1. dobutamine
2. epi
3. Amrinone
1. dobutamine: positive inotrope
2. epi: positive inotrope and vasoconstrictor
3. Amrinone: may be used if refractory, positive inotrope
79
Foramen Ovale
Shunts 2/3 of oxygenated blood from right atrium directly into the left atrium. Remaining 1/3 passes into right ventricle. Most of the remaining 1/3 goes through the right ventricle and gets pumped into the pulm artery.
80
ductus arteriosus
shunts blood from the pulm artery directly into the aorta(systemic circulation), bypassing fetal lungs
81
as baby takes its first breath, what happens
left side pressure becomes > right side pressure, promoting closure of openings
82
prostaglandins and PDA and ductus arteriosus
1. to close PDA, give a prostaglandin inhibitor (IV indomethacin or Ibuprofen)
2. To keep ductus arteriosus open, administer a prostaglandin
83
Left to right congenital heart disease
most common
1. VSD, most common
2. ASD
3. PDA
84
Eisenmenger syndrome
lt to right shunt eventually develops into a right to left shunt
85
4 types of VSD
1. perimembranous, most common, hole in LV outflow tract near tricuspid
2. muscular: swiss cheese pattern
3. inlet(posterior): located posterior to septal leaflet of tricuspid valve
4. supracristal(outlet): beneath pulmonic valve. May have aortic valve insuffiency.
86
87
symptoms of moderate VSD
excessive sweating or fatigue, especially during feeds, lack of adequate growth, frequent respiratory infections
88
excessive sweating or fatigue, especially during feeds, lack of adequate growth, frequent respiratory infections
symptoms of moderate VSD
89
symptoms of large VSD
severe sx. No pressure differences between ventricles.
90
High pitch harsh holosystolic murmur best heard at LL sternal border.
May be associated with a thrill or diastolic rumble at the mitral area
VSD
91
VSD heart sound
High pitch harsh holosystolic murmur best heard at LL sternal border.
May be associated with a thrill or diastolic rumble at the mitral area
92
smaller VSDs heart sound
usually louder and associated with more palpable thrills then larger ones
93
testing for VSD
echo preferred over cath.
94
ECG and CXR in VSD
ECG: LVH.
CXR: may be nml, show left atrial enlargement or RVH.
95
When to repair large VSD
at 2 years to prevent pulm HTN
96
4 types of ASD, most common
1. ostium secundum 80%
2. ostium primum(assoc with mitral valve abn)
3. sinus venosus
4. coronary sinus
97
1. ostium secundum 80%
2. ostium primum(assoc with mitral valve abn)
3. sinus venosus
4. coronary sinus
ASD
98
1. perimembranous, most common, hole in LV outflow tract near tricuspid
2. muscular: swiss cheese pattern
3. inlet(posterior): located posterior to septal leaflet of tricuspid valve
4. supracristal(outlet): beneath pulmonic valve. May have aortic valve insuffiency.
VSD
99
ASD symptoms occur when usually
around 30 years old
100
symptoms of ASD in infants and young children
recurrent resp infection, failure to thrive, exertional dyspnea
101
recurrent resp infection, failure to thrive, exertional dyspnea
symptoms of ASD in infants and young children
102
symptoms of ASD in adolescents and young adults
exertional dyspnea, easy fatigability, palpitations, atrial arrhythmias, syncope, heart failure
103
paradoxical emboli
stroke from venous clots, think ASD
104
exertional dyspnea, easy fatigability, palpitations, atrial arrhythmias, syncope, heart failure
symptoms of ASD in adolescents and young adults
105
murmur with ASD
systolic murmur best heard at left sternal border; fixed S2 splitting
106
systolic murmur best heard at left sternal border, fixed S2 splitting
ASD
107
crochetage sign
notching of peak of r wave in inferior leads, think ASD
108
ECG in ASD
incomplete RBBB. echo best test.
109
PDA located where
descending thoracic aorta and main pulm artery
110
PDA closes when
2-3 weeks
111
PDA common in who
premature births
112
How does blood move in a PDA
from aorta shunted to pulmonary vasculature
113
cyanosis lower half of body
eismengers syndrome in PDA
114
Symptoms in PDA; murmur
usually asymptomatic.
continuous machine like murmur loud at pulmonic area(left upper sternal border); wide pulse pressures(bounding peripheral pulses), loud S2
115
usually asymptomatic.
continuous machine like murmur loud at pulmonic area(left upper sternal border); wide pulse pressures(bounding peripheral pulses), loud S2
PDA
116
child has poor feeding, wt loss, frequent lower resp tract infections, pulm congestion, infective endocarditis
PDA
117
PDA if they are symptomatic
child has poor feeding, wt loss, frequent lower resp tract infections, pulm congestion, infective endocarditis
118
prostaglandins can keep what open
PDA
119
EKG in PDA
LVH, left atrial enlargement.
echo best test
120
R to L shunts
1. Tet of fallot(most common cyanotic shunt)
121
4 abn of tet of fallot
1. RV outflow obstruction
2. RVH
3. large unrestrictive VSD
4.OVERIDING AORTA
122
Cyanosis at birth
tet of fallot
123
older kid symptoms of tet of fallot
exertional dyspnea, cyanosis worsens with age
tet spells
124
tet spells
agitation, cyanosis, rapid shallow breathing from hypoxemia- blood bypassing lungs and entering aorta;
squatting decreases right to left shunting, improving oxygenation
in infants, relieved by putting knees to chest
125
tet of fallot murmur
harsh systolic murmur at left mid to upper sternal border(VSD), right ventricular heave
126
harsh systolic murmur at left mid to upper sternal border(VSD), right ventricular heave
tet of fallot
127
boot shaped heart on CXR
tet of fallot
echo best test.
128
transposition of great arteries definition
Discordance b/t aorta and pulm trunk (the aorta arises from the RV and the pulm trunk arises from the LV
129
What is the most common cyanotic heart disease presenting in the neonatal period(dextro)?
transposition of great arteries
130
Dextro-TGA
Dextro-TGA: most common. Aorta arises from the RV and the pulm artery from the LV, leading to 2 parallel circuits. The systemic circuit sends systemic deoxygenated blood back to the systemic circulation. The pulm circuit sends oxygenated pulm venous blood back to the lungs. Prior to surgical correction, survival is dependent upon the presence of shunts b/t right and left circulation.
131
Levo-TGA
Levo-TGA: cyanotic. Rt atrium sends blood to the morphologic LV, which is on the right side physically. This morphologic LV sends blood to the pulm system. The LA sends blood to morphologic RV located on the left side. The morphologic RV sends blood to the systemic circulation.
132
symptoms of TGA
severe cyanosis and tachypnea within the first 30 days of life not affected by exertion or the use of oxygen.
133
Egg on a string on CXR
TGA
134
ECG and CXR TGA
ECG: nml or rt axis deviation or RVH.
CXR: egg on a string
135
gold standard for TGA
cardiac cath; echo primary means of diagnosis.
136
Hallmarks of congenital heart disease.
1. 70% have bicuspid aortic valve
2. continuous machine like murmur, loudest where
3. boot shaped heart on cxr
4. widely fixed, split S2, does it vary with respirations?
5. Bounding pulses, wide pulse pressure
1. COA
2. PDA, pulmonic
3. Tet of fallot
4. ASD, no
5. PDA
137
Hallmarks of congenital heart disease.
6. rib notching on cxr, "3"sign
7. Systolic ejection murmur, heard best at pulmonic area
8. MC cyanotic heart disease overall
9. Suspect in a child with 2 year HTN, bilateral LE claudication
10. May develop stroke due to paradoxical emboli
1. COA
2. ASD
3. Tet of fallot
4. COA
5. ASD
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