cardiac emergency Flashcards
study of choice for AAA or dissection
TEE
Severe HTN in a patient with shock is what?
it is aortic dissection until proven otherwise!
fusiform aneurysm
shaped like a longer oval bulge
saccular aneurysm
shaped like a circular short bulge
most common aortic aneurysm site
abdominal (75%). Typically are infrarenal.
AAA definitiion
> 3 cm (normal is 2 cm). consider repair when > 5 cm
Risk factors for AAA
HTN, Men, > 60, smoking, atherosclerosis, CHD, Marfans, Ehlers-danlos, Syphilis infection, Takayasu arteritis, Trauma
Ruptured AAA triad
- abdominal pain
- hypotension
- pulsatile abdominal mass
symptoms of AAA
back and abdominal pain, severe and abrupt onset is most common sx. Symptoms of AAA regardless of size are considered urgent
Ascending TAA cause
used to be d/t syphilis infection, now is from CMN
CMN
cystic medial necrosis- disorder of large arteries, accumulation of basophilic substance. occurs in marinas and ehlers danlos syndrome
Ascending TAA sx
worrisome chest pain that is deep, diffuse and aching
Arch TAA sx
pain and compression of adjacent structures, dysphagia, dry cough, hoarseness, dyspnea
Descending TAA definition
distal to the left subclavian artery. Most are fusiform, from arteriosclerosis (may be saccular if d/t syphilis).
Type of TAA seen in deceleration injuries
descending TAA from torn ligament arteriosus. There will be different BP in the left vs right extremes and increased mediastinum on CXR
Type I T/AAA
ranges from the proximal descending aorta to the proximal abdominal aorta
Type II T/AAA
ranges from the proximal descending aorta to the infrarenal aorta (above the split). Largest span
type III T/AAA
ranges from the distal descending aorta to the infrarenal aorta
Type IV T/AAA
primarily abdominal aorta involvement only
Aortic dissection
there is a false lumen created. it is almost always fatal. Usually related to marfans, CMN, HTN and less commonly d/t arteriosclerosis
most common site for aortic dissection
ascending aorta, 2-5 cm above the aortic valve. These are also the most lethal.
signs and sxs of ascending aortic disection
abrupt onset of severe ripping back pain, discrepancy in pulses, +/- syncope, hemiplegia and LE paralysis.
signs and sxs of descending aortic dissection
sudden onset chest and back pain that starts between the scapula and radiates anteriorly
descending aortic dissection
more common in elderly with hx HTN.
management of aortic dissections
ascending are managed surgically. Descending, will try to lower BP with BB and other antihypertensives before surgery is considered because is typically higher risk in elderly and CHD hx. Will do surgery for descending if there is increasing aortic size, PE and worsening pain
diagnosis of aortic dissection
CXR is non-specific, will see widened mediastinum. CT is test of choice, will see two lumens. If pt is unstable and there is no time for CT, can get an US/TEE. Can get an ECG to r/o MI but this is not going to tell you anything about a dissection.
vitals goal in an aortic dissection
SBP: 100-140mmHg and HR
acute pericarditis
inflammation of the pericardium
Sxs of acute pericarditis
chest pain, pericardial fx rub, serial ECG changes, pleuritic chest pain that radiates to back and shoulders and pain improves with sitting up and leaning forward.
PE finding that is most important for acute pericarditis
a 3-component friction rub that is continuous over the left sternal border. If pt is holding their breath and the friction rub persists it is a pericardial friction rub (vs pleural friction rub)
CXR findings for acute pericarditis
CXR is overall nonspecific but may see water bottle sign
ECG findings in acute pericarditis
diffuse concave ST elevation or T wave inversion. May see PR depression.
treatment for acute pericarditis
need to find and treat the underlying cause, but can do Aspirin or ibuprofen or indomethacin x 7-14 days +/- steroid for refractory sxs
Becks triad
for cardiac tamponade. Includes increased JVD, Hypotension and decreased heart sounds
When to treat acute pericarditis inpatient
Fever, Subacute onset (over weeks), immunosupresion, trauma, anti coagulated, if aspirin/nsaid tx failed, if pericardial effusion is severe, and if there is elevated cardiac biomarkers or other sxs of CHF
Pericardial effusion
abnormal amount of fluid or infected fluid in the pericardial space.
Pericardial effusion sx
chest pain and pressure, may have palpitations and dyspnea, may have pulsus paradoxus, pericardial friction rub, Ewart sign, etc.
pulsus paradoxus
regular cardiac rhythm but decrease in SBP during inspiration
eWart sign
dullness to percussion beneath the angle of the left scapula
diagnosis of pericardial effusion
echo is test of choice. Will see water bottle shaped heart on CXR
Tx of pericardial effusion
If pt is unstable, give IVF NS and pericardiocentesis in ED. if pt is stable, still give IVF but send to cath lab for guided pericardiocentesis
cardiac tamponade
there is fluid in the pericardial sac that happens so quickly or is so severe that the heart cannot compensate and there is decreased CO
presentation of cardiac tamponade
Beck’s triad of JVD, Hypotension, and muffled heart sounds. May also have pulsus paradoxus and Kussmaul sign.
Kussmaul sign
paradoxical increase in venous dissension and pressure during inspiration
risk factors for acute heart failure
HTN, DM, Valvular heart disease, old age, male sex, obesisty
Dyspnea on exertion- what is on the top of your differential?
Heart failure. DOE is the one sx with the highest sensitivity for HF
The most specific sx of HF
paroxysmal nocturnal dyspnea, orthopnea, and edema
PE findings for HF
S3 extra heart sound, abdominojugular reflex, and JVD.
Acute heart failure CXR findings
Pulmonary venous congestion, cardiomegaly, and interstitial edema
Pulmonary US findings for HF
Sonographic B lines- more than 2 lines in a window is specific for alveolar and interstitial edema
Hypertensive HF tx
give O2 to get SpO2 > 95%, Nitroglycerin SL, IV nitroprusside if BP still high after nitroglycerine, and IV Furosemide (loop diuretic)
Normotensive HF Tx
Give furosemide IV. If pt is already normally taking loop diuretic, take the normal daily dose x 2.5/2= IV bolus given every 12 hr
Admission criteria for Acute HF
+ troponin, BUN > 40, Cr > 3, Na 32 at time of arrival, poor perfusion, and if vasoactive meds still being titrated
Hypertensive emergency BP
> 180/120
end organ damage targets of hypertensive emergency
brain, heart, aorta, kidney, eye
biggest risk with hypertensive emergency
development of subarachnoid hemorrhage, followed by ischemic stoke.
chest pain, back pain, Unequal BP in UE, and abnormal CT angio of chest
think acute aortic disection
SOB, with interstitial edema on chest XR
think acute pulmonary edema
Chest pain, N/V and sweating with changes on ECG and elevated cardiac biomarkers
think acute MI
Chest pain, N/V, sweating
could be MI or acute coronary syndrome. ACS is a clinical diagnosis
abdominal bruit with elevated Cr and proteinuria
think acute renal failure
Seizures with proteinuria, hemolysis, elevated liver enzyme levels and low plt. counts
think Eclampsia
Blurred vision, retinal hemorrhages
tonk hypertensive retinopathy
AMS, N/V, HA, papilledema
think hypertensive encephalopathy
HA, focal neuro defects, RBC on LP
think subarachnoid hemorrhage
HA, new neuro defects and abnormal head CT
think intracranial hemorrhage
New neuron defects and abnormal Ct of brain
think acute ischemic stroke
Bleeding that is unresponsive to pressure
think acute perioperative HTN
anxiety, palpitations, tachycardia, sweating
sympathetic crisis- look for pheochromocytoma or drug use
HTN emergency tx
reduce BP acutely by 20% using IV labetalol bolus, Nitroglycerine if HF or ACS, and or Nicardipine CCB for neuro HTN
Hypertensive urgency
elevated BP without acute target organ dysfunction. BP still > 180/120. Reduce BP slowly, over days-weeks
Criteria for AMI
must have at least 2: (criteria are not used in ED)
1. Hx of characteristic chest pain
- evolutionary ECG changes
- Elevation of cardiac enzymes
Classic AMI
Retrosternal, epigastric Chest pain or tightness that may radiate, SOB, sweating, N/V
Most typical presentation of AMI
an atypical presentation
Presentation of Chest pain in the ED
First in w/u is 12 lead ECG. Second is get CBC, Chem 7, blood gas, etc. Ultimately will most likely admit the pt
AMI enzymes
Myoglobin peaks first at 9-12 hrs, then Troponin-I at 12-16 hrs and lastly CK-MB at 12-24 hrs
Observation for AMI, when do you draw troponin I and T?
at 0, 1, 3, 6 and 9 hrs
Observation for AMI, when do you get ECGs?
get serial ECGS over 9 hrs
Observation for AMI, and labs and ECG are negative
send for an echo
Observation for AMI, all tests are normal
send for a graded stress test
the only times you do not give nitrates in Chest pain/ AMI pts
if taken sildenafil in past 24 hrs or tadalafil in past 48 hrs, if Right Ventricular involvement is suspected. Use of BB is not a c/i for nitrates
when and who should receive BB for AMI
Not given in the ED anymore. only given 24 hrs s/p even as long as there are no RF for cariogenic shock
Pt comes in with Chest pain/AMI- what is the best thing you can do?
Give Aspirin! 325 mg is the best dose, or 2 baby aspirin in the field works too.
the only times aspirin is not given for AMI
Pt has a legitimate anaphylaxis allergy to aspirin or an Actively bleeding peptic ulcer. If this is the case, give Plavix.
Which is more important, choosing the right thrombolytic or giving it as fast as possible?
Giving it fast is more important than type given
Eligibility criteria for receiving a thrombolytic
STEMI, Chest pain, and EKG changes.
What else should be given to STEMI pts who have received a fibrinolytic?
they get full dose anticoagulants for 48 hours. This could be unfractionated heparin, enooxaparin, etc. Subq enoxaparin may be better than heparin (ESSENCE trial)
C/I for thrombolytics
Stroke within last 6 months, recent head trauma, surgery or any other trauma in past 2 weeks, Recent ulcer or GI bleed, Hypertensive emergency, CPR > 10 mins, if suspect aortic dissection, cariogenic shock, and if pericarditis
When should a thrombolytic be given
if pt cannot get PCI must give thrombolytic within 30 mins
what is the magic time for PCI?
90-120 minutes from arrival to ED
