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Emergency Medicine > Cardiac > Flashcards

Cardiac Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Discuss how to calculate heart rate on ECG

A
  • 300 divided by number of large squares between RR

- Count off by 300, 150, 100, 75, 60, 50, 43, 37

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2
Q

Discuss how to calculate heart rhythm

A
  • every P wave followed by QRS
  • every QRS wave preceded by P wave
  • P wave axis is normal at 0-90 degrees
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3
Q

Discuss how to calculate QRS axis

A

Inspect leads I and II
- QRS upward in both I and II then axis is normal (-30 to 90)
- if not then go to step 2
Inspect QRS in leads in I and aVF
- if positive in lead I and negative in aVF then left axis deviation (-30 to -90)
- If negative in lead I and positive in aVF then right axis deviation (90-180)
- if negative in both lead I and aVF then extreme right axis deviation (-90 to -180)

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4
Q

Discuss findings in P-wave

A
  • best visualized in lead II and V1
  • if P height >2.5mm in lead II and positive deflection >1mm tall and >1mm wide in V1 then RA enlargement
  • if P width >2.5mm in lead II and negative deflection >1mm deep and >1mm wide in V1 then LA enlargement
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5
Q

Discuss findings in Q wave

A 
Pathologic if width >1mm and depth >1/4 R wave and is due to previous myocardial ischemia
Inferior (RCA)
- Leads II, III and aVF
Anteroseptal (LAD)
- lead V1/V2
Anteroapical (LAD distal)
- lead V3/V4
Anterolateral (CFX)
- lead V5/V6, I and aVF
Posterior (RCA)
- V1/V2 tall R wave instead of Q
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6
Q

Discuss normal findings in QRS complex

A

Narrow QRS Complex (normal) Requires

  • electrical implese triggering depolarization at AV node
  • functional His-Purkinje system to conduct electrical impulse at equal and rapid pace
  • Cardiomyocyte able to transmit electrical impulse
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7
Q

Discuss wide QRS complex causes (>120ms or >3 squares)

A 
Premature Ventricular Complex
- wide QRS complex appear after certain number of normal beats
- no P wave before PVC
- only 1
Right Bundle Branch Block
- wide QRS with normal sinus rhythm
- RSR in V1, prominent S in V6 (bunny ears)
- prominent R wave in V1
- inverted T wave in V1/V2/V3/V4
Left Bundle Branch Block
- wide QRS with normal sinus rhythm
- broad notched R in V6 (W)
- Absent R and prominent S in V1
Pacemaker
Accessory Pathway
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8
Q

Discuss right and left ventricular hypertrophy

A 
Right Ventricular Hypertrophy
- R wave > S wave in V1/V2
- Right axis deviation
Left Ventricular Hypertrophy
- Sokolow-Lyon: R in V5 or V6 + S in V1 >35mm
- higher R wave in leads 1, aVL, V5, V6
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9
Q

Discuss ST segment pathology

A
  • elevation of 2 small squares right of J point (QRS) relative to baseline TP segment
    Reciprocal Leads
  • Lateral leads to inferior leads
  • Anterior leads to posterior leads
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10
Q

Discuss QT interval

A
  • calculated by QT duration in milliseconds / square root of RR
  • normal 350-450
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11
Q

Discuss junctional escape and ventricular escape rhythms

A

Junctional
- rate 40-60 bpm with no or negative P wave and normal QRS
Ventricular
- rate 20-40 bpm with no P wave, widened QRS with abnormal ST segment

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12
Q

Discuss 1st degree AV block

A
  • block at AV node
  • PR interval consistent length and prolonged >200ms
  • regular RR interval
  • 1 P wave to QRS
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13
Q

Discuss second degree AV block Mobitz Type 1 (Wenkebach)

A
  • block at AV node
  • P wave constant but PR interval progressively lengthens from one beat to the next until single QRS complex is absent after which PR interval returns to initial length and cycle repeats
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14
Q

Discuss 2nd degree AV block Mobitz Type 2

A
  • block at His-Purkinje system (more serious as it can lead to complete heart block)
  • No gradual lengthening of PR interval,
  • have no QRS after P wave which may persist for >2 beats
  • may also have widened QRS
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15
Q

Discuss 3rd degree AV block

A
  • P waves an QRS complexes are independent of eachother and match at constant pace
  • regular P to P distance
  • Regular QRS to QRS distance
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16
Q

Discuss sick sinus syndrome

A
  • Bradycardia - Tachycardia syndrome where have combination of bradycardia and SVT
  • severe bradycardia with paroxysmal tachycardia (AF)
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17
Q

Discuss the Categorization of tachycardia

A 
Narrow QRS (SVT)
- Constant RR Interval
    - AV node Independent
         - sinus tachycardia
         - atrial flutter
         - atrial tachycardia
    - AV node Dependent
         - AVNRT
         - AVRT
- Irregular RR internal
     - atrial fibrillation
     - atrial flutter
     - multi-focal atrial tachycardia
Wide QRS (VT or SVT)
- Monomorphic VT
- SVT with aberrancy
      - Bundle branch block
      - Pre-excitation
      - Pacemaker
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18
Q

Discuss multifocal atrial tachycardia

A 
- each QRS preceded by P wave but irregular rhythm with >3 different P wave morphology
Causes
- COPD leading to pulmonary hypertension
- impaired or hypertrophied atrium
- digoxin toxicity
- acute coronary syndrome
- Rheumatic heart disease
Treatment
- Vagal maneuver, adenosine
- Amiodarone
- If preserved heart function then beta blocker or CCB
- if impaired heart function then diltiazem
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19
Q

Discuss AV nodal re-entrant tachycardia (AVNRT)

A
  • heart rate around 180 bpm
  • P wave hidden in QRS and can be superimposed on end of QRS
  • hidden P wave at end of QRS as pseudo R in lead 1
    Presentation
  • palpitations
  • exercise tolerance low
    Treatment
  • cardioversion if unstable
  • vagal stimulation, adenosine 6mg IV
  • preserved heart function: BB (metoprolol 5mg IV), CCB or digoxin
  • impaired heart function: Digoxin, amiodarone, diltiazem 20mg IV over 2 min
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20
Q

Discuss AV re-entrant tachycardia (AVRT)

A
  • include wolfe-parkinson-white syndrome
    - short PR interval (<120ms) and prolonged QRS preceded by delta wave
  • orthodromic AVRT narrow QRS followed by retrograde inverted P wave
  • antidromic AVRT have wide QRS followed immediately by inverted P wave
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21
Q

Discuss atrial flutter

A
  • rate 150 bpm

- saw toothed P wave before each QRS best seen in II, III, aVF

22
Q

Discuss atrial fibrillation

A
  • irregularly irregular QRS complex
  • no discernible P wave
    Cause
  • ACS, CAD, CHF
  • valvular disease
  • PE
  • hyperthyroidism
    Management
  • control heart rate if >120 with Diltiazem 20mg IV, verapamil 2.5-5mg IV, metoprolol 5mg IV, amiodarone 150mg if narrow complex
  • control heart rate >120 with procainamide 30mg/min for wide complex
  • A fib <48hrs then cardiovert electrocically or with drugs
  • A fib >48hrs then three weeks of anticoagulants before and 4 weeks after cardioversion
    - will then require long term rate control with BB or CCB
23
Q

Discuss ventricular tachycardia

A
  • wide QRS usually at rate between 100-200bpm
    • QRS is discernible and organized
  • polymorphic VT where QRS continually change in shape and rate between beats
    • Torsades de Pointes sine wave QRS due to prolonged QTc
      Cause
  • ACS
  • PVC
  • prolonged QTc
    Management
  • stable can try procainamide 20-50mg/min (max 17mg/kg) before cardioversion
  • Unstable cardioversion
24
Q

Discuss ventricular fibrillation

A
  • chaotic irregular appearence without discrete QRS waveform
    Management
  • Shock first with 200J if biphasic or 360J if monophasic
  • High quality CPR for 2 minutes
  • Shock
  • CPR
  • Epinephrine 1mg IV after first or second shock and repeat Q3-5min
    - can use vasopressin 40u IV as alternate to epi
  • Amiodarone 300mg IV bolus
25
Q

Differentiate between SVT with aberrancy and SVT

A

SVT with Aberrancy
- QRS morphology same as when in sinus rhythm
- responds to vagal stimulation
SVT
- history of prior MI or heart failure
- no relatonship between P waves and QRS complexes
- Concordance of QRS complexes in chest leads

26
Q

Discuss pulseless electrical activity

A 
ECG
- rhythm displaying organized electrical activity but without pulse
Cause (5H's and 5T's)
- Hypovolemia
- Hypoxia
- Hydrogen ion-acidosis
- Hyper/hypokalemia
- Hypothermia
- Tablets (Overdose)
- Tamponade
- Tension pneumothorax
- Thrombosis coronary
- Thrombosis pulmonary
27
Q

Discuss the causes of heart block and treatment

A

Cause
- vasovagal event
- Acute inferior MI (RCA) in 1st Degree and Type 1
- Acute MI (LDA) in 3rd degree and Type 2
Treatment
- if no serious signs and 1st degree or type 1 then observe
- if no serious signs and type 2 or 3rd degree then transcutaneous pacing
- if severe signs then atropine 0.5mg q3-5min
- transcutaneous pacing or dopamine 2-10mcg/kg/min or epi 2-10mcg/min

28
Q

Discuss the typical findings for angina and the CCS classification

A

Angina has all 3 of:
- Retrosternal chest pain that radiate to shoulder/jaw/arm
- Provoked by exertion or emotional stres
- Improves with rest or nitroglycerin
CCS Classification
- CCS1: No limitation to activity; angina only with strenuous activity
- CCS2: Slight limitation to activity; angina with normal activity
- CCS3: Marked limitations to ordinary activity: angina with walking or climbing stairs
- CCS4: Angina at rest

29
Q

Discuss the presentation, exam, and management of stable angina

A 
Presentation
- typical angina <20 minutes
Exam
- Dyskinetic apical pulse
- S4
- Mitra regurgitation
Management
- Smoking cessation
- nitrates
- Beta blocker
- Aspirin
- Statin
30
Q

Discuss the differences between STEMI, NSTEMI and unstable angina

A

Unstable Angina
- severe and prolonged angina >20 with no ECG changes or cardiac enzyme changes
NSTEMI
- severe and prolonged angina >20 minutes with no ECG changes but elevation in cardiac enzymes
STEMI
- severe and prolonged angina >20 minutes with ECG and cardiac enzyme changes

31
Q

List the stratification for treatment for NSTEMI

A 
High risk (TIMI 5-7, ST shift)
- Heparin
- GP IIb/IIIa inhibitor with clopidegrel
- B blocker
- Early catheterization
Intermediate Risk (TIMI 3-4, normal ECG)
- heparin
- Clopidegrel
- Observation
Low Risk (Time <=2)
- Beta blocker
- Early follow up
32
Q

List the Major Risk Factors for Ischemic Heart Disease

A

Major

  • History of cardiovascular disease
  • older age
  • male
  • Dyslipidemia
  • Smoking
  • Diabetes
  • Hypertension
  • Family Hx (male <55, female <65)
33
Q

Discuss the presentation, investigations and management for Acute coronary syndrome

A

Presentation
- cresendo pattern with increased frequency, intensity and duration of chest pain
- angina at rest without provocation
- new onset severe angion (CCS3) without previous angina
- diaphoresis
- shortness of breath
- nausea
Investigations
- ECG
- inferior (RCA) II, III, aVF
- lateral (LCA, left circumflex) I, aVL, V5, V6
- lateral (LAD) V5, V6
- anterior (LAD) V1, V2, V3, V4
- troponon I at presentation and 6&9 hrs later
- if negative at 6 hrs then rules out infarction
Management
- supplemental oxygen
- anti-platelets (ASA 160 and ticagrelor 180/clopidogreal 600mg)
- anti-thrombin (heparin50-70units/kg 4000U)
- vessels opened by PCI or tPA
- PCA if within 90 minutes to cath lab of first medical contact
- tPa dose 30mg <60kg, 35mg 60-69kg, 40mg 70-79kg, 45mg 80-89kg, or 50mg >90kg
- Symptomatic
- morphine
- nitroglycerin (unless inferior infarct noted due to risk of decrease preload and cardiovascular collapse)

34
Q

List the TIMI score

A
  • age >65
  • > 3 cardiac risk factors
  • known CAD or stenosis >50%
  • aspirin use within 7 days
  • severe angina >=2 episodes within 24hrs
  • ECG ST changes (elevation or depression >0.5mm)
  • elevated cardiac markers
35
Q

Discuss the pathophysiology and risk factors for aortic dissection

A 
Pathophysiology
- tear in intimal layer where blood flow tears and continus to dissect intimal layer
- lead to rupture of aorta, clot in false lumen which can travel downward and lead to acute ischemia, or cardiac tamponade
Risk Factors
- Hypertension
- Connective tissue disease 
- bicuspid aortic valve
- aortic co-arctation
- valve replacement
- CABG
- Smoking
36
Q

Discuss the presentation and management of aortic dissection

A

Presentation
- abrupt onset and hemodynamically unstable
- sharp tearing chest pain radiating to the back
- 40% immediate mortality with 1% risk of mortality per hour for next 48hrs
- discrepancy in blood pressure (>20-30mmHg) between two arms
- weak one sided pulse
- aortic regurgitation
Investigation
- CXR show wide mediastinum
- CT angiography
Management
- ABC with IV medication to lower blood pressure
- Type A involve ascending aorta and require surgery
- Type B no involvement of ascending aorta and can be treated with IV labetalol to lower blood pressure

37
Q

Discuss the pathophysiology and risk factors for pericarditis

A 
Pathophysiology
- Inflammation of the pericardium
- tamponade when pericardial effusion constricts the heart leading to cardiogenic shock
Risk Factors
- recent upper respiratory infection
38
Q

Discuss the presentation and management of pericarditis

A

Presentation
- sharp pleuritic chest pain at central or left chest which is worse when lying down
- pulsus paradoxus (decrease in BP by >10 with inspiration) with tamponade
- decreased heart sounds and pericardial friction rub
Investigations
- diffuse ST elevation and PR depression
Management
- aspirin, NSAID, steroids if refractory for pericarditis
- pericardiocentesis for effusion or tamponade

39
Q

Discuss the pathophysiology and risk factors for a pulmonary embolism

A

Pathophysiology
- clot in deep leg veins which travels to the lungs
- leads to dead space ventilation and hypoxemia
- increased pulmonary vascular resistance causing right ventricular strain
Risk Factors (Virchow’s triad)
- Stasis: immobilization
- Hypercoaguable states: inherited thrombotic disorder, malignancy, inflammatory disorders, pregnancy or OCP
- Endothelial injury

40
Q

Discuss the presentation and management of pulmonary embolus

A

Presentation
- Pain on one side of chest that is worse with inspiration
- dyspnea, cough, syncope, hemoptysis and palpitation
- increase JVP, peripheral edema
- DVT signs
Investigations
- Wells criteria
- CXR band atelectasis decrease volume on one side
- ECG: right ventricular strain (inverted T wave and ST depression in V1-V4), RBBB, S1Q3T3
- d-dimer positive
- CT pulmonary angiography
Management
- massive PE resulting in cardiovascular compromise then tPA
- stable then low molecular weight heparin and bridge to warfarin

41
Q

List the Wells criteria for PE

A
  • Active Cancer
  • Hemoptysis
  • Recent immobilization or surgery +1.5
  • Tachycardia (>100bpm) +1.5
  • Past Hx of DVT or PE +1.5
  • Signs or symptoms of DVT +3
  • No alternative diagnosis more like +3
    >4 then high risk and go right to CTPA
  • <4 do D-Dimer first and then if positive move to CTPA
42
Q

Discuss the discharge criteria for PE

A 
PE Severity Index
- age >80
- Hx of Cancer
- Hx of Heart Failure or chronic lung disease
- Tachycardia >100
- Hypotension where SBP <100
- Hypoxia <90%
High risk if >=1
43
Q

Discuss esophageal rupture

A 
Risk Factors
- severe vomiting 
- recent upper endoscopic procedure
Presentation
- severe retching followed by extreme retrosternal chest pain
- odynophagia
- neck pain
- dysphonia
- dyspnea
- Fever
Investigations
- leukocytosis
- CXR pneumo-mediastinum, free peritoneal air, subcutaneous emphysema
- CT Chest
Management
- NPO
- IV Abx (Ceftriaxone and Flagyl)
- IV PPI
- Drainage
- Surgery
44
Q

Discuss the presentation of vasovagal syncope

A 
Trigger
- fear, pain
- coughing, swallowing
- urinating
Presentation
- pre-syncopal symptoms (lightheadedness, dizziness, pallor, nausea)
- last for seconds to minutes
- abrupt recovery
45
Q

Discuss the presentation of orthostatic syncope

A

Trigger
- lying to sitting
- sitting to standing
- previous blood loss, hypovolemia, or autonomic neuropathy
Presentation
- No prodrome and last seconds to minutes
- Abrupt recovery
- Postural hypotension (sys drop by 20, dia drop by 10, HR increase by 30)
- hypovolemia

46
Q

Discuss the presentation of cardiac syncope

A 
Trigger
- exertional
- have history of cardiac disease or sudden cardiac death in family
Presentation
- have chest pain, palpittions, SOB
- lasts <30 seconds
- abrupt recovery
- Abnormal cardiac exam or ECG
47
Q

Discuss the San Fransisco Syncope Rule

A

Admitted if any of the following

  • Acute decompensated heart failure
  • shortness of breath
  • systolic BP <90
  • abnormal ECG
  • hemotocrit <30
48
Q

Discuss the presentation and management of septic shock

A

Presentation
- warm shock so have tachycardia and increase pulse pressure (SBP-DBP)
- fever
- infectious symptoms
Diagnosis
- Systemic Inflammatory Response Syndrome >=2
- Temperature <36 or >38
- HR >90
- RR >20 or PaCO2 <32
- WBC <4 or >12
- sepsis when SIRS + source of infection
- septic shock when sepsis + SBP <90 refractory to fluids
Management
- Abx
- large volume IV crystalloid 3-5L
- if inadequate response (MAP <65 after 2L) then pRBC or vasopressor (dopamine or norepinephrine)

49
Q

Discuss the presentation and management of hypovolemic shock

A

Presentation
- cold shock so tachycardia and decreased pulse pressure
- Decreased JVP, dry mucous membranes, dry axilla, decreased skin tugor
Management
- large volume crystalloids
- pRBCs if bleeding

50
Q

Discuss the presentation and management of obstructive shock

A 
Etiology
- tension pneumothorax
- cardiac tamponade 
- pulmonary embolism
Presentation
- cold shock
- increased JVP and peripheral edema
Management
- large volume IV crystalloid 
- relieve obstruction
51
Q

Discuss the presentation and management of cardiogenic shock

A 
Etiology
- ACS
- Arrhythmia
- Valvular pathology
Presentation
- Cold shock
- increased JVP, peripheral edema
Management
- small IV boluses of crystalloids (250-500) with monitoring of RR (as have risk for pulmonary edema)
- vasopressors
52
Q

Discuss the management for shock

A 
- ABC
IMOPH
- IV
- Monitors (ECG, pulse, foley)
- Oxygen
- Pressure
- 
Fluids
- IV crystalloid fluids
- if inadequate response after 2L require vasopressors
Investigations
- CBC
- electrolytes
- glucose
- lactate
- creatinine, BUN
- LFT
- INR
- CK
- Troponin
- ECG
- urinalysis
- CXR

Emergency Medicine (8 decks)

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