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Emergency Med > cardiac emergency > Flashcards

cardiac emergency Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

study of choice for AAA or dissection

A

TEE

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2
Q

Severe HTN in a patient with shock is what?

A

it is aortic dissection until proven otherwise!

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3
Q

fusiform aneurysm

A

shaped like a longer oval bulge

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4
Q

saccular aneurysm

A

shaped like a circular short bulge

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5
Q

most common aortic aneurysm site

A

abdominal (75%). Typically are infrarenal.

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6
Q

AAA definitiion

A

> 3 cm (normal is 2 cm). consider repair when > 5 cm

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7
Q

Risk factors for AAA

A

HTN, Men, > 60, smoking, atherosclerosis, CHD, Marfans, Ehlers-danlos, Syphilis infection, Takayasu arteritis, Trauma

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8
Q

Ruptured AAA triad

A
  1. abdominal pain
  2. hypotension
  3. pulsatile abdominal mass
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9
Q

symptoms of AAA

A

back and abdominal pain, severe and abrupt onset is most common sx. Symptoms of AAA regardless of size are considered urgent

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10
Q

Ascending TAA cause

A

used to be d/t syphilis infection, now is from CMN

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11
Q

CMN

A

cystic medial necrosis- disorder of large arteries, accumulation of basophilic substance. occurs in marinas and ehlers danlos syndrome

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12
Q

Ascending TAA sx

A

worrisome chest pain that is deep, diffuse and aching

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13
Q

Arch TAA sx

A

pain and compression of adjacent structures, dysphagia, dry cough, hoarseness, dyspnea

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14
Q

Descending TAA definition

A

distal to the left subclavian artery. Most are fusiform, from arteriosclerosis (may be saccular if d/t syphilis).

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15
Q

Type of TAA seen in deceleration injuries

A

descending TAA from torn ligament arteriosus. There will be different BP in the left vs right extremes and increased mediastinum on CXR

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16
Q

Type I T/AAA

A

ranges from the proximal descending aorta to the proximal abdominal aorta

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17
Q

Type II T/AAA

A

ranges from the proximal descending aorta to the infrarenal aorta (above the split). Largest span

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18
Q

type III T/AAA

A

ranges from the distal descending aorta to the infrarenal aorta

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19
Q

Type IV T/AAA

A

primarily abdominal aorta involvement only

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20
Q

Aortic dissection

A

there is a false lumen created. it is almost always fatal. Usually related to marfans, CMN, HTN and less commonly d/t arteriosclerosis

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21
Q

most common site for aortic dissection

A

ascending aorta, 2-5 cm above the aortic valve. These are also the most lethal.

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22
Q

signs and sxs of ascending aortic disection

A

abrupt onset of severe ripping back pain, discrepancy in pulses, +/- syncope, hemiplegia and LE paralysis.

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23
Q

signs and sxs of descending aortic dissection

A

sudden onset chest and back pain that starts between the scapula and radiates anteriorly

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24
Q

descending aortic dissection

A

more common in elderly with hx HTN.

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25
Q

management of aortic dissections

A

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

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26
Q

diagnosis of aortic dissection

A

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.

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27
Q

vitals goal in an aortic dissection

A

SBP: 100-140mmHg and HR

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28
Q

acute pericarditis

A

inflammation of the pericardium

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29
Q

Sxs of acute pericarditis

A

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.

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30
Q

PE finding that is most important for acute pericarditis

A

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)

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31
Q

CXR findings for acute pericarditis

A

CXR is overall nonspecific but may see water bottle sign

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32
Q

ECG findings in acute pericarditis

A

diffuse concave ST elevation or T wave inversion. May see PR depression.

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33
Q

treatment for acute pericarditis

A

need to find and treat the underlying cause, but can do Aspirin or ibuprofen or indomethacin x 7-14 days +/- steroid for refractory sxs

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34
Q

Becks triad

A

for cardiac tamponade. Includes increased JVD, Hypotension and decreased heart sounds

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35
Q

When to treat acute pericarditis inpatient

A

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

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36
Q

Pericardial effusion

A

abnormal amount of fluid or infected fluid in the pericardial space.

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37
Q

Pericardial effusion sx

A

chest pain and pressure, may have palpitations and dyspnea, may have pulsus paradoxus, pericardial friction rub, Ewart sign, etc.

38
Q

pulsus paradoxus

A

regular cardiac rhythm but decrease in SBP during inspiration

39
Q

eWart sign

A

dullness to percussion beneath the angle of the left scapula

40
Q

diagnosis of pericardial effusion

A

echo is test of choice. Will see water bottle shaped heart on CXR

41
Q

Tx of pericardial effusion

A

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

42
Q

cardiac tamponade

A

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

43
Q

presentation of cardiac tamponade

A

Beck’s triad of JVD, Hypotension, and muffled heart sounds. May also have pulsus paradoxus and Kussmaul sign.

44
Q

Kussmaul sign

A

paradoxical increase in venous dissension and pressure during inspiration

45
Q

risk factors for acute heart failure

A

HTN, DM, Valvular heart disease, old age, male sex, obesisty

46
Q

Dyspnea on exertion- what is on the top of your differential?

A

Heart failure. DOE is the one sx with the highest sensitivity for HF

47
Q

The most specific sx of HF

A

paroxysmal nocturnal dyspnea, orthopnea, and edema

48
Q

PE findings for HF

A

S3 extra heart sound, abdominojugular reflex, and JVD.

49
Q

Acute heart failure CXR findings

A

Pulmonary venous congestion, cardiomegaly, and interstitial edema

50
Q

Pulmonary US findings for HF

A

Sonographic B lines- more than 2 lines in a window is specific for alveolar and interstitial edema

51
Q

Hypertensive HF tx

A

give O2 to get SpO2 > 95%, Nitroglycerin SL, IV nitroprusside if BP still high after nitroglycerine, and IV Furosemide (loop diuretic)

52
Q

Normotensive HF Tx

A

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

53
Q

Admission criteria for Acute HF

A

+ troponin, BUN > 40, Cr > 3, Na 32 at time of arrival, poor perfusion, and if vasoactive meds still being titrated

54
Q

Hypertensive emergency BP

A

> 180/120

55
Q

end organ damage targets of hypertensive emergency

A

brain, heart, aorta, kidney, eye

56
Q

biggest risk with hypertensive emergency

A

development of subarachnoid hemorrhage, followed by ischemic stoke.

57
Q

chest pain, back pain, Unequal BP in UE, and abnormal CT angio of chest

A

think acute aortic disection

58
Q

SOB, with interstitial edema on chest XR

A

think acute pulmonary edema

59
Q

Chest pain, N/V and sweating with changes on ECG and elevated cardiac biomarkers

A

think acute MI

60
Q

Chest pain, N/V, sweating

A

could be MI or acute coronary syndrome. ACS is a clinical diagnosis

61
Q

abdominal bruit with elevated Cr and proteinuria

A

think acute renal failure

62
Q

Seizures with proteinuria, hemolysis, elevated liver enzyme levels and low plt. counts

A

think Eclampsia

63
Q

Blurred vision, retinal hemorrhages

A

tonk hypertensive retinopathy

64
Q

AMS, N/V, HA, papilledema

A

think hypertensive encephalopathy

65
Q

HA, focal neuro defects, RBC on LP

A

think subarachnoid hemorrhage

66
Q

HA, new neuro defects and abnormal head CT

A

think intracranial hemorrhage

67
Q

New neuron defects and abnormal Ct of brain

A

think acute ischemic stroke

68
Q

Bleeding that is unresponsive to pressure

A

think acute perioperative HTN

69
Q

anxiety, palpitations, tachycardia, sweating

A

sympathetic crisis- look for pheochromocytoma or drug use

70
Q

HTN emergency tx

A

reduce BP acutely by 20% using IV labetalol bolus, Nitroglycerine if HF or ACS, and or Nicardipine CCB for neuro HTN

71
Q

Hypertensive urgency

A

elevated BP without acute target organ dysfunction. BP still > 180/120. Reduce BP slowly, over days-weeks

72
Q

Criteria for AMI

A

must have at least 2: (criteria are not used in ED)
1. Hx of characteristic chest pain

  1. evolutionary ECG changes
  2. Elevation of cardiac enzymes
73
Q

Classic AMI

A

Retrosternal, epigastric Chest pain or tightness that may radiate, SOB, sweating, N/V

74
Q

Most typical presentation of AMI

A

an atypical presentation

75
Q

Presentation of Chest pain in the ED

A

First in w/u is 12 lead ECG. Second is get CBC, Chem 7, blood gas, etc. Ultimately will most likely admit the pt

76
Q

AMI enzymes

A

Myoglobin peaks first at 9-12 hrs, then Troponin-I at 12-16 hrs and lastly CK-MB at 12-24 hrs

77
Q

Observation for AMI, when do you draw troponin I and T?

A

at 0, 1, 3, 6 and 9 hrs

78
Q

Observation for AMI, when do you get ECGs?

A

get serial ECGS over 9 hrs

79
Q

Observation for AMI, and labs and ECG are negative

A

send for an echo

80
Q

Observation for AMI, all tests are normal

A

send for a graded stress test

81
Q

the only times you do not give nitrates in Chest pain/ AMI pts

A

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

82
Q

when and who should receive BB for AMI

A

Not given in the ED anymore. only given 24 hrs s/p even as long as there are no RF for cariogenic shock

83
Q

Pt comes in with Chest pain/AMI- what is the best thing you can do?

A

Give Aspirin! 325 mg is the best dose, or 2 baby aspirin in the field works too.

84
Q

the only times aspirin is not given for AMI

A

Pt has a legitimate anaphylaxis allergy to aspirin or an Actively bleeding peptic ulcer. If this is the case, give Plavix.

85
Q

Which is more important, choosing the right thrombolytic or giving it as fast as possible?

A

Giving it fast is more important than type given

86
Q

Eligibility criteria for receiving a thrombolytic

A

STEMI, Chest pain, and EKG changes.

87
Q

What else should be given to STEMI pts who have received a fibrinolytic?

A

they get full dose anticoagulants for 48 hours. This could be unfractionated heparin, enooxaparin, etc. Subq enoxaparin may be better than heparin (ESSENCE trial)

88
Q

C/I for thrombolytics

A

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

89
Q

When should a thrombolytic be given

A

if pt cannot get PCI must give thrombolytic within 30 mins

90
Q

what is the magic time for PCI?

A

90-120 minutes from arrival to ED

Emergency Med (10 decks)

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