Cardio

Question 0

ST segment

Answer 0

Segment in between the QRS complex and the next T wave

To detect ST elevations measure against end of T to next P wave

Question 1

How to diagnose STEMI?

Answer 1

at least 1 mm ST elevation in 2 or more contiguous leads
must be at least 2 mm in leads v1-v3
Or a new LBBB

Question 2

STEMI: EKG mimics

Answer 2

Pericarditis/myocarditis - recent rad tx, fever
Benign early depolarization - young healthy male
Left ventricular hypertrophy - hypertension
Pacemaker - paced
HyperK - renal failure
Coronary vasospasm - cocaine and oth stimulants
Aneurysm - prior MI, usually assoc with q waves

Question 3

Define ACS

Answer 3

Umbrella term encompasses
Unstable angina and
Acute MI

Question 4

What percentage of pts presenting to adult ED with chest pain have ACS?

Answer 4

15%

One third of those will have an acute MI and the remainder unstable angina

Question 5

Angina: duration of symptoms

Answer 5

typically <10 mins
occasionally lasting 10 - 20 mins
usually improves w/in 2 - 5 mins after REST or NITROglycerin

Question 6

What % of pts experiencing an acute MI have NO pain?

Answer 6

27. 4% men
28. 5% women

Up to half of pts w/ unstable angina present with atypical symptoms

Prognosis is worse at time of infarction in pts with atypical symptoms (fatigue, malaise, vague discomfort)

Question 7

Bradycardia in acute MI

Answer 7

May occur in inferior MI

Poor prognostic indicator in anterior MI (heart block is also a poor prognostic indicator)

Question 8

EKG w/in _____ mins of pt w/ CP presenting to ED

Answer 8

10 mins

Question 9

J point

Answer 9

H

Question 10

Goal hospital to balloon time

Answer 10

90 mins

Question 11

Risk of intracranial hemorrhage with fibrinolytic tx in acute MI

Answer 11

0.5-1%

Question 12

Goal hospital to needle time (fibrinolytic tx) in acute MI

Answer 12

30 mins

To administer thrombocytes if no cath lab available

Question 14

Clopidogrel in acute MI

Answer 14

Plavix

The addition of clopidogrel to aspirin and antithrombin therapy improves cardiovascular outcomes in patients receiving FIBRINOLYSIS for STEMI

Question 14

Cocaine induced CP

Answer 14

6% will have an MI
Normal CP work-up

1. ASA, NTG, O2
2. Benzos
   - Consider Phentolamine or CCB (in benzo non responders)
3. Consider NaHOC3 for Ventricular Arrhythmias immediately following cocaine use
   - reverses cocaine induced QRS prolongation by Na channel blockade

Labetalol?
Theoretical contra-indication B-blocker 2nd to unopposed alpha

May discharge after: 9-12 hour period of ECG’s and serial troponins, if both are negative.
NEJM 2/03; n=334; outcome of zero events at 30 days if no more cocaine

Question 15

Diltiazem

Answer 15

CCB

A fib,

Question 16

Commotio cordis

Answer 16

Primary electrical event resulting in induction of Vfib
Due to blow occurring 10-30ms before peak of T wave

Often results from innocent-appearing chest wall blow
Usually insufficient to cause damage to ribs, sternum, or heart

Second most common cause of death in young athletes

Question 17

MCC of death in young athletes?

Answer 17

HOCM

Question 18

Cocaine induced CP

Answer 18

6% will have an MI
Normal CP work-up

1. ASA, NTG, O2
2. Benzos
   - Consider Phentolamine or CCB (in benzo non responders)
3. Consider NaHCO3 for Ventricular Arrhythmias immediately following cocaine use
   - reverses cocaine induced QRS prolongation by Na channel blockade

Labetalol?
Theoretical contra-indication B-blocker 2nd to unopposed alpha

May discharge after: 9-12 hour period of ECG’s and serial troponins, if both are negative.
NEJM 2/03; n=334; outcome of zero events at 30 days if no more cocaine

Question 19

Cocaine induced CP

Answer 19

6% will have an MI
Normal CP work-up

1. ASA, NTG, O2
2. Benzos
   - Consider Phentolamine or CCB (in benzo non responders)
3. Consider NaHOC3 for Ventricular Arrhythmias immediately following cocaine use
   - reverses cocaine induced QRS prolongation by Na channel blockade

Labetalol?
Theoretical contra-indication B-blocker 2nd to unopposed alpha

May discharge after: 9-12 hour period of ECG’s and serial troponins, if both are negative.
NEJM 2/03; n=334; outcome of zero events at 30 days if no more cocaine

Question 20

Commotio cordis

Answer 20

Primary electrical event resulting in induction of V Fib
occurs after a blunt blow to the chest in a pt who does not have any structural heart disease

must occur at the upstroke of the T to cause V Fib

Often results from innocent-appearing chest wall blow
Usually insufficient to cause damage to ribs, sternum, or heart

Second most common cause of death in young athletes

Question 21

EKG finding highly specific for pericarditis

Answer 21

PR depression

Will also see ST elevations

Question 22

Parkland burn formula

Answer 22

4% x BSA x wt in kg = L in 24 hours

Give 1/2 over first 8 hrs
Next 1/2 over next 16 hours

Maintain UOP of 50cc/hr?

Question 23

Burns

Answer 23

1st deg - sensation intact, red, swollen, epidermis? intact - no blisters

2nd deg - blistering, exudate, sensation intact

3rd deg - charred, leathery, dermal injury, sensation not intact

4th degree charred to bone

Question 24

Torsades: tx?

Answer 24

IV MgSO4

Question 25

8 classic findings on CXR in Ao dissection

Answer 25

``` Widened mediastinum Blurred Ao knob Ao calcifications Deviation of trachea to the right Apical cap? Pleural effusion ```

Question 26

Ao outflow track on US

Answer 26

<4 cm

Question 27

What med to start first in dissection

Answer 27

Esmolol

Question 28

How much blood to remove on pericardioscentesis to relieve tamponade?

Answer 28

? mls

Question 29

asymptomatic HTN

Answer 29

start oral antihypertensive if bp >200/120 | PCP f/u in 1 week

Question 30

HTN in pregnancy

Answer 30

ACEI contraindicated start labetalol or hydralazine

Question 31

HTN emergency

Answer 31

administer parenteral agents, with goal of therapy to decrease the MAP by 25% w/in 1 hour then to 160/110 within the next 6 hours

Question 32

low molecular weight heparins

Answer 32

lovenox safe in pregnancy, but *unfracionated heparin is the preferred anticoagulant during the third trimester; its infusion can be stopped quickly and it has a more predictable reversal response to protamine sulfate if labor begins

Question 33

brugada syndrome

Answer 33

autosomal dominant 90% males 30s-40s yo syncope or sudden death need tele admission for defibrillator placement incomplete RBBB with j-point and st-segment elevations in leads V1-V3

Question 34

sgarbossa criteria

Answer 34

st segment elevation measuring > or equal to 1 mm concordant with the QRS in any lead st segment depression measuring > or equal to 1 mm in any of the V1 through V3 leads Discordant ST segment elevation measuring > or equal to 5 mm only needs to occur in one lead

Question 35

EKG predictors of reperfusion in acute MI

Answer 35

early T wave inversions can be highly specific markers for reperfusion an accelerated idioventricular rhythm 60-120 beats per min is also highly specific for reperfusion - benign don't supress it

Question 36

ekg in true posterior infarct

Answer 36

R>S waves in V1 and V2 with upright T waves | ST depression in V1-V2

Question 37

occluded vessel in inferior MI

Answer 37

ST elevations II, III, aVF 80% right coronary 20% circumflex

Question 38

occluded vessel in right ventricular infarct

Answer 38

ST elevation in V1 and II, III and aVT always right coronary

Question 39

occluded vessel in anterior MI

Answer 39

ST elevation V1, V2 and V3 left anterior descending (LAD) coronary artery

Question 40

dressler's syndrome

Answer 40

pericarditis 2-8 weeks post-MI - probably a continuum with earlier pericarditis (pericarditis can be seen 1-7 days post transmural MI) fever, leukocytosis, friction rub, pericardial and pleural effusions tx NSAIDS and steroids

Question 41

examples of high output heart failure

Answer 41

``` thyrotoxicosis anemia av fistula beriberi paget's disease of the bone ```

Question 42

what happens withen a pt with EBV is treated with ampicillin or amoxicillin

Answer 42

maculopapular rash