cardio Flashcards
things to focus on in the PE -important stuff
General assessment of overall condition
Skin: open sores/rashes (any infection source)
Mouth/teeth (again infection source)
Lungs - esp if suspected heart failure
Swelling/ulcers in extremities
Pulses
Varicosities (particularly legs for conduit)
Cardiac exam: JVD, rub, murmur, S3 or S4
Scars on chest/legs- raditation causes scar tissue on the chest that can cause problems
Swelling in extremities
Basic abdominal/neuro exam
stress echo is used to look particularly at
coronary artery
transesophageal echo helps look at the
valves
carotid ULS is used for
helps to insure this individual is not going to have a stroke during surgery
ABI are used to tell you about
PID
troponin indicative of NSTEMI
> .05 suspect unstabel angina
Troponin 0.10 → 0.20
class I indications for coronary bypass
<50% left main coronary artery
>70% proximal LAD and Cx stenosis
multi-vessel disease in a asymptomatic ot because stents don’t last as long as graphs do
low risk for bypass
<4%
when would you take most meds until
when would you stop ACE/ARB/Metformin
Continue ASA, beta-blockers, non-nephrotoxic meds until surgery
Stop ACE/ARB/metformin ~48h prior
what is a special consideration and might need to stop these earlier
Stop anticoagulation - many kinds!
Each one is different for how long, usually 2-7 days
Sometimes need a heparin drip if critical stenosis which is stopped right before surgery
CABG
coronary artery bypass grafting
mortality for CABG if low or average risk
Summit is around 0.7% for low/average risk
LIMA
left internal mammarry artery
is used in CABG
also known as the internal thoracic artery
CABG use these vessels
LIMA
Greater saphenous vein for other grafts
some facilities use the radial artery
what is a on-pump
This may be performed either with the help of a heart-lung bypass machine (traditional CABG, performed via a thoracotomy),
on pump
on a beating heart (off-pump CABG, and minimally invasive direct CABG).
Intra-aortic balloon pump
can insert at the end of case if a pt is having a hard time coming off bypass
when the heart is pushing blood out it is deflated and when the heart is relaxed and filling it inflates so that blood can not come back into the aorta
when the balloon deflates it creates a vacuum decreasing after-load
this is left in for a couple days until the heart heals
inserted after cardiogenic shock as well as a bridge to surgery
what is dressler syndrome
what is the tx
Post-pericardiotomy syndrome
autoimmune febrile pericarditis or pleuritis that may occur 1–6 weeks following
Fever, malaise
Chest pain, with or without associated dyspnea
Tachycardia
Pericardial friction rub
2-4 weeks after surgery
seen with fever and plueritic chest pain
NSAIDs controversial postoperatively ‘
Usually give colchicine
heart arrhythmia seen as a complication of CABG
MCC
afibb MC?
peak on post opp day TWO
all pts are on telemetry
want the rate to be lower
might have them go on amioderone
complications of CABG
afibb
CVA
AKI
cardiac tamponade
med management post op
ASA, statin, and beta-blocker
Postoperative long-term treatment with antiplatelet drugs (e.g., 100 mg aspirin 1-0-0) is required to reduce the risk of subsequent myocardial ischemia!
typically discharge pt on day following CABG
Typically discharge patients on POD #4 or 5 barring complications
wound healing post op week 2
murmur of AS
Murmur: systolic crescendo-decrescendo vs holosystolic at right upper sternal border
average survival withou A-S t valve replacement
Average survival without valve replacement is 2-3 years once severe
Best heard in the 2nd right intercostal space
Valsalva and standing from squatting decreases or does not change the intensity of the murmur (in contrast to hypertrophic cardiomyopathy).
mneumonic for AS
SAD (syncope, angina, dyspnea)
mechanical valve replacement require
coumadin for life
not the case with a biprostehtic valve
TAVR
Transcatheter AVR (TAVR): patients with high surgical risk or contraindication
can deploy valve through the groin
much safer than surgical
medicare covers TAVR for medium to high risk pts
TAVR common complciations
higher need for pacemaker with TAVR
greater risk of heart block
common causes of aortic insufficiency
connective tissue disorder (marfans)
AI murmur
early diastolic
AI surgical indications
moderate to servere with reduced EF <50%
primary MR
MCC rheumatic heart disease especially in other parts of the world
secondary MR
CAD
surgical indications for MR
symptomatic and EF >30%
if <30% greater surgical risk
if asymptomatic but lower EF might consider surgery
replacing the valve vs repair
repairs last longer than
replacing the valve but with
endocaritits you have to replace the valve
MCC of mitral valve stenosis
Almost always from rheumatic fever
management of mitral valve stenosis
Often managed by Interventional Cardiology with percutaneous mitral balloon commissurotomy
might relpace valve
78yo male presents to ED with SOB and altered mental status, with PMH of COPD, liver cirrhosis, CHF, cocaine and EtOH abuse, and HTN
pulses paradoxus and sinus tach
EKG-pulses paradoxis
ECHO AND XRAY – cardiomegaly
–> pericardial effusion NEED >1CM effusion on echon for centisis
The fluid can be either bloody (e.g., following aortic dissection) or serous (usually idiopathic)
BECK’S triad
hypotension, muffled heart sounds, distended neck veins!
tx of pericardial effusion
Typically surgical approach is subxiphoid pericardial window
Leave pericardial drain in place until drainage slows
need this if you have less than 1cm of
what determines the tx of tamponade
unstable—> pericardicentesis
hemodynamically stable–> pericardial window
Pericardial window
an incision in the peridardium is made that allows continual drainage from the pericardial space into the pleural cavity to prevent a cardiac tamponade
Commonly indicated for effusion due to underyling malignancy
Hemodynamic monitoring
presentation of AD
It commonly occurs in hypertensive males between the 4th and 6th decade. Patients complain of a sudden onset and severe pain radiating into the thorax, back, or abdomen. Initial chest x-ray shows a widened mediastinum.
diagnostic imaging in AD
The diagnosis is confirmed with a contrast-enhanced CT in stable patients and transesophageal echocardiography in unstable patients.
what determines tx of AD
type A is the emergency
(ascending)
type B is less urgent
(descending still getting blood flow)
tear of the intima media adventitia
surgical tx of AD
takes like 7 hours
Open surgery with a polyester graft implantation
Possibly, endovascular treatment: aortic stent implantation (only in type B dissections and if the operative risk is too high)
other than HTN what is common etiology of AD
HTN Pregnancy Cocaine Chest trauma Iatrogenic Syphilitic aortitis Arteriosclerosis HLD Smoking Many congenital factors, including connective tissue disorders
type B AD management
Target value of the systolic blood pressure is ∼ 90–120 mm Hg
IV labetalol, esmolol, or propanolol (best initial )
Followed by IV sodium nitroprusside (vasodilator)
MC locations of AD
~2.2 cm above the aortic root
Distal to the left subclavian artery
Aortic arch
Pneumomediastinum (or mediastinal emphysema)
air can be seen
throughout
even in the neck
check for crepitus in a young man that presentes with SOB
coughing –> ruptured alveoli–> eep
tx of Pneumomediastinum
Treatment is usually observation
Esophageal injuries more commonly require intervention or close following
Mallory-Weiss syndrome:
longitudinal laceration at the GE junction
non-transmural
Often from varices, portal HTN
Hematemesis, melena, dizzy, abd pain
Upper endoscopy (really a GI thing)
Boerhaave syndrome
esophageal rupture from force or trauma
True surgical emergency
Mortality of 35-40%
triad of boerhaave
Mackler triad of
chest pain,
vomiting,
and subcutaneous emphysema
mallory weiss presentations
Patients typically present with a history of
epigastric pain and
hematemesis.
diagnostic of mallory weiss
Esophagogastroduodenoscopy
chest xray for booerhaves
what stage of lung cancer can you use lobectomy & mediastinal lymph node
Stages I/II
Stage IIIA lung cancer mgnmt
: potentially resectable disease: multimodality
Stage IV lung cancer mgnmt
Stage IV: chemotherapy
MC sxs of lung cancer
Cough Chest pain Shortness of breath Hemoptysis Wheezing Dysphagia/Hoarseness Recurring infections such as bronchitis and pneumonia Weight loss and loss of appetite Fatigue
Metastatic signs and symptoms:
NEW bone or joint pain
neuro sxs
mets to brain
85% of all lung cancers are
NSCLC
NSCLC is
NSCLC comprises a number of cancer types, including peripheral adenocarcinoma and central squamous cell carcinoma.
VATS
video assisted thorascopy
Can be used for a bunch of things
classifications of pleural effusion
classified as transudative
due to congestive heart failure, liver cirrhosis
exudative
pneumonia, malignancies, PE), depending on the underlying cause.
presentation of pleural effusion
Typically presents
with dyspnea and a dry cough.
tx of plerual effusion usually involves
Typically recommend ultrasound-guided thoracentesis (most often by Interventional Radiology) with pleural fluid analysis if it’s the first time
pleaural fluid serum LDH in trans vs exudative
<2/3 Upper LMN
= trans
> 2/3 upper LMN is exudative
cylothorax
lymph filling up the lung
somatostatin and octreotide
tension ptx presentation
Hypotension
hypoxia
chest pain
dyspnea
Catamenial ptx:
endometrial tissue in the plura
(rare) women 30-40yo, within 48h of menstruation, right-sided
Thought to be from endometriosis of the pleura
pleurodesis
mechanical or talc
can basically cause the lung to stick to the wall
tx of ptx usually involves
VATS with bleb resection
chest tubes on xray should be
inside the wall
pleura vac
never take a chest tube off of this!
direct communication to the lung and will introduce air if taken off
NEVER CONNECT CHEST TUBE TO WALL SUCTION can cause lung to herniate
connect it the the pleruavac
if you need to change the pleuravac clamp it first
heimlick valve
can be used if pt wants to go home
chest tubes should always be set to
If a chest tube is on suction, it is connected to a canister, on CONTINUOUS suction (not intermittent), usually -20cm H2O
water seal means …
Water seal” means off suction because there is a column of water that “seals” the end of the chest tube system (don’t want air getting back in, it’s a closed system
water or suction
