Cardiac Emergencies Flashcards
pleuritic-like central chest pain that worsens when patient is supine & improves with sitting
aggravated by movement, coughing, swalllowing
pericarditis
Most common cause of pericarditis
coxsackie
other causes of pericarditis
uremia-untreated or w/ dialysis
early post MI (often on 2nd or 3rd day)
neoplastic disease (lung, breast, lymphoma, Hodgkins, leukemia)
PE for pericarditis
friction rub
what are the 3 P’s of pericarditis
position
palpation
pleuritic pain
location of pericarditis
retrosternal or towards cardiac apex
EKG for pericarditis
diffuse ST segment elevation
(in limb leads & precordial leads)
Management for pericarditis
bed rest until pain & fever resolved
NSAIDs
**oral anticoagulants should be avoided**
what is the mortality rate of undiagnoses pulmonary embolisms?
40-50% mortality rate
risk factors for pulmonary embolism
stasis
cardiac disorders
hypercoagulability (OCP, V Leiden factor)
trauma
chemo
smoking
S/S for pulmonary embolism
97% will have at least 1 of the following:
tachypnea, dyspnea, pleuritic chest pain
1/3 will also have tachycardia
elevated in presence of thrombus (97% sensitivity) but not specific (45%)
plasma D-dimer
how is a pulmonary embolism diagnosed?
helical (spiral) CT angiography
TX for pulmonary embolism
full anticoagulation for min. 3-6 months or longer
unfractionated heparin
risks: bleeding, thrombocytopenia
low molecular weight heparin
warfarin
deep, visceral, crushing, heaving, squeezing
+/- burning
radiation: arms, neck jaw
STEMI
STEMI might be mistaken for what?
indigestion
What populations are more likely to present with atypical symptoms of a MI?
elderly
women
diabetics (painless MI)
acute TX for STEMI
NTG
morhpine sulfate
Beta-blockers
want to relieve pain to reduce stress & anxiety
ultimately, what needs to be done with a STEMI?
PCI
major difference between unstable agina & NSTEMI
NSTEMI: abnormal cardiac markers that indicated cell necrosis
UA: no cell necrosis has occured (yet)
high risk of deeloping MI in following days/weeks
unstable angina
progression to larger MI/death
NSTEMI
EKG for NSTEMI/UA
ST depression
TW inversion
what is the lab criteria for NSTEMI
at least one value (serial markers every 6-8hrs) > 99th percentile of upper reference limit
risk factors for adverse events (TIMI risk score)
(for NSTEMI & UA)
age > 65 yrs
at least 2 risk factors for CHD
prior coronary stenosis
ST seg deviation (or deep TW inversion)
2 or more anginal episodes in prior 24 hrs
use of ASA in prior 7 days
elevated serum cardiac biomarkers
if 6-7 factors, risk of adverse outcome is 41%
What should we do if everything is negative for a NSTEMI/UA work up?
proceed to stress test/imaging within 24-48 hrs
management for ongoing ischemia (NSTEMI or UA)
anti-ischemia rx: NTG, ASA, beta-blockers
Ca blockders- 3rd line rx
all patients- ASA (prasugrel or ticagrelor added to ASA w/ NSTEMI)
LMW heparin-started on admission
spontaneous tear in intima of aorta allows blood to dissect into media-separating aortic wall
aortic dissection
what is aortic dissection associated with?
long standing, poorly controlled HTN
(repetitive torque to ascending/descending aortic wall)
dissection starts in aortic arch proximal to left subclavian artery
Type A
dissection starts in proximal descending aorta beyond subclavian artery
Type B
which type of aortic dissection needs surgery & is a huge operation
Type A
S/S of aortic dissection
severe chest pain often raidating to/down back
HTN usually present
imaging for aortic dissection
multiplanar CT
TX for aortic dissection
must lower BP asap
(beta blockers)
accumulation of fluid in paricardial cavity
pericardial effusion
causes of pericardial effusion
pericarditis
uremia
cardiac trauma
what symptoms usually accompany pericardial effusion
cough & dyspnea
chest pressure
hiccups
abdominal fullness
what diagnostics are used to determine the extent of cardiac effusion
CXR or echocardiography
EKG for pericardial effusion
low QRS voltage
electrical alternans is pathognomonic of effusion
TX of pericardial effusion
pericardiocentesis is necessary to relieve fluid accumulation
how are recurrent effusions treated?
pericardial window
marked elevation & equilibrium of LV & RV diastolic pressures
marked decreas in CO
cardiac tamponade
what happens to the RA & RC in early diastole in cardiac tamponade & can be seen on echo
RA & RV collapse
beck’s triad
(cardiac tamponade)
decline in arterial pressure
elevation of systemic venous pressure
quiet heart
what is pulsus paradoxus
marked exaggeration of normal process
systolic BP drop > 10mmHg
diagnostic tool for cardiac tamponade
echocardiogram
what treatment may be life saving in cardiac tamponade?
pericardiocentesis
precipitating factors:
discontinuation of meds
excessive salt intake
myocardial ischemia
tachyarrhythmia
intercurrent infecion
acute pulmonary edema
is acute pulmonary edema a medical emergency?
yes
S/S of acute pulmonary edema
severe dyspnea
+/- pink/frothy sputum
may have cool extremities
cyanosis & diaphoresis
anxious/restless
unable to breath sitting
CXR for acute pulmonary edema
lungs-
vscular redistribution
interstitial &/or alveolar edema
“butterfly” pattern of alveolar edema
TX for acute pulmonary edema
- supplemental O2
- morphine sulfate
- IV diuretics
- nitrates
are most patients asymptomatic or symptomatic with high BP?
most are asymptomatic & do not require emergent Rx
hypertensive urgency
warrant BP lowering within a few hours
hypertensive emergencies
warrant substantial BP lowering within 1 hours to avoid severe morbidity or death
S/S of hyptensive encephalopathy
HA
irritability
confusion
altered MS
S/S of hypertensive nephropathy
hematuria
proteinuria
progressive kidney dysfunction
malignant HTN
encephalopathy or nephropathy + papilledema
We don’t use meds to lower BP unles it is greater than what?
Why?
> 200/110
brain will auto-regulate perfusion
What is our goal with decreasing BP?
decreased BP by nore more that 25% within 2 hours
then more gradual lowering (2-6 hrs) to BP ~ 160/100
management for hyptensive emergencies
IV nicardipine & clevipine
IV NTG, labetalol, esmolol….
dilation of a segment of a blood vessel
abdominal or thoracic
aortic aneurysm
abdominal aneurysms
75% are ______ renal arteries
below
PE for aortic aneurysms
abdominal aneurysms often palpable-
pulsatile, non-tender mass
want can accurately measure dimensions of AA’s & is useful for serial follow up of small AA’s
abdominal ultrasound
who do we screen for aortic aneurysms?
male smokers
> 60 yrs old w/ risk factors
what are the risk factors for AAA?
FH of AAA
presence of PAD/atherosclerosis
presence of peripheral artery aneurysms
risk of rupture for AAA
(over 5 yrs)
< 5cm- 1-2% over 5 years
> 5cm- 20-40% over 5 years
Tx of AA
operative excision w/ graft replacement for rapidly expanding AA’s or those with symptoms
what do we do for asymptomatic AA’s?
surgery always if > 6.5cm
probably surgery if > 5cm
what can precipitate atrial fib/flutter
emotional stress
use of stimulants
following surgery
w/ acute ETOH intoxication (“holidary heart”)
with A fib/flutter, what do we do if the patient is not hemodynamically stable?
DC cardioversion
If A fib is stable, what is our initial goal?
How do achieve this goal?
rate control is intial goal
IV diltiazem or IV beta-blocker
What must we do if A fib is present > 48-72 hrs?
must fully anticoagulate
PR interval > 0.20 seconds
first degree AV block
progressive lengthening of PR interval until drop of QRS complex
mobitz type I
(Wenkebach)
P waves followed by aburpt dorp of 1 or more QRS complexes
**without PR prolongation
mobitz type II
complete disocciation of atria & ventricles
atrial rate usually 60-100
ventricular rate usually 30-40
third degree AV block
3 or more consecutive ventricular premature beats
ventricular tachycardia
TX for unstable ventricular tachycardia
synchronized cardioversion
TX for pulseless V tach
defib & CPR
no effective pumping action
without intervention → death
sudden unconsciouness
ventricular fibrillation
V tach with QRS twisting around the baseline
torsades de pointes
TX of torsades de pointes
IV magnesium
correction of electrolyte abnormalities
