Cardio and resp - from pass medicine Flashcards
Possible ECG features in WPW include: (4)
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway*
right axis deviation if left-sided accessory pathway*
Associations of WPW
HOCM (hypertrophic obstructive cardiomyopathy) mitral valve prolapse Ebstein's anomaly thyrotoxicosis secundum ASD
Management of WPW
definitive treatment: radiofrequency ablation of the accessory pathway
medical therapy: sotalol**, amiodarone, flecainide
in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with … axis deviation
left
A 51-year-old female presents to the Emergency Department following an episode of transient right sided weakness lasting 10-15 minutes. Examination reveals the patient to be in atrial fibrillation. If the patient remains in chronic atrial fibrillation what is the most suitable form of anticoagulation?
CHADS-VASc score = 3, so warfarin, target INR 2-3
If low risk (age <65 and no risk factors), what anticoagulation?
Aspirin 75mg-300mg/day
What does CHA2DS2-VASc stand for?
C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 A Age 65-74 years 1 S Sex (female) 1
Restrictive lung diseases
Pulmonary fibrosis Asbestosis Sarcoidosis Acute respiratory distress syndrome Infant respiratory distress syndrome Kyphoscoliosis Neuromuscular disorders
Obstructive lung diseases
Asthma
COPD
Bronchiectasis
Bronchiolitis obliterans
2 level PE Wells Score
Clinical feature Points
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
common bendroflumethiazide SE?
hypokalaemia
Hypokalaemia causes on ECG
U waves
small or absent T waves (occasionally inversion)
prolong PR and QT interval
ST depression
‘In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT’
Two main types of VT:
monomorphic VT: most commonly caused by myocardial infarction
polymorphic VT: A subtype of polymorphic VT is torsades de pointes which is precipitated by prolongation of the QT interval. The causes of a long QT interval are listed below
Management of VT?
Management
If the patient has adverse signs (systolic BP < 90 mmHg, chest pain, heart failure or rate > 150 beats/min) then immediate cardioversion is indicated. In the absence of such signs antiarrhythmics may be used. If these fail, then electrical cardioversion may be needed with synchronised DC shocks
Drug therapy
amiodarone: ideally administered through a central line
lidocaine: use with caution in severe left ventricular impairment
procainamide
A 72-year-old man presents with lethargy and palpitations for the past four or five days. On examination his pulse is 123 bpm irregularly irregular, blood pressure is 128/78 mmHg and his chest is clear. An ECG confirms atrial fibrillation. What is the appropriate drug to control his heart rate?
B-blocker. A number of factors including age and symptoms would favour a rate control strategy. The NICE guidelines suggest either a beta-blocker or a rate limiting calcium channel blocker (i.e. Not amlodipine) in this situation. Some clinicians would prefer to use a more cardio-selective beta-blocker such as bisoprolol, although this is not stipulated in current guidelines
Agents used to maintain sinus rhythm in patients with a history of atrial fibrillation
sotalol
amiodarone
flecainide
others (less commonly used in UK): disopyramide, dofetilide, procainamide, propafenone, quinidine
Management of a PRIMARY Pneumothorax
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
Secondary pneumothorax
Recommendations include:
If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
Iatrogenic pneumothorax -
recommendations include:
less likelihood of recurrence than spontaneous pneumothorax
majority will resolve with observation, if treatment is required then aspiration should be used
ventilated patients need chest drains, as may some patients with COPD
Left ventricular aneurysm
a patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound
Ischaemia of the papillary muscle
a patient is noted to have a new early-to-mid systolic murmur 10 days after being admitted for a myocardial infarction
Causes of respiratory alkalosis
pulmonary embolism anxiety leading to hyperventilation pregnancy salicylate poisoning (initial stages) CNS disorders e.g. stroke, subarachnoid haemorrhage, encephalitis altitude
Causes of respiratory acidosis
COPD opiate overdose obesity hypoventilation syndrome neuromuscular disease life-threatening asthma (decompensated) benzodiazepines overdose
Drugs CId in asthma?
beta-blockers
adenosine
Drugs CId in recent myocardial infarction?
metformin
sildenafil
sumatriptan
hydralazine
What soes pulsus paradoxus imply?
severe asthma
a 60-year-old man with a history of tuberculosis presents with dyspnoea and fatigue. On examination the JVP is elevated, there is a loud S3 and Kussmaul’s sign is positive. Hepatomegaly is also noted
- stereotypical Hx of?
constrictive pericarditis
Stereotypical Hx of left ventricular free wall rupture
a patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds
What SE do all these drugs have in common?
levodopa verapamil diltiazem isosorbide mononitrate bromocriptine amlodipine most diuretics (ACE inhibitors, thiazides and loop diuretics) atracurium
hypotension
2 drugs causing bronchospasm?
Bronchospasm
beta-blockers
adenosine
Side-effects of b-blockers?
bronchospasm
cold peripheries
fatigue
sleep disturbances, including nightmares
Contraindications to b-blockers
uncontrolled heart failure
asthma
sick sinus syndrome
concurrent verapamil use: may precipitate severe bradycardia
Indications for b-blockers?
angina post-myocardial infarction heart failure arrhythmias hypertension thyrotoxicosis migraine prophylaxis anxiety
pulse in mixed aortic valve disease?
pulsus bisferiens
pulse in PDA?
collapsing
Drugs predisposing to gluacoma?
corticosteroids
risk of thiazide diuretics for men?
impotence
Early diastolic murmur, high-pitched and ‘blowing’ in character (2)?
aortic regurgitation
Graham-Steel murmur (pulmonary regurgitation)
Mid-late diastolic murmur, ‘rumbling’ in character (2)?
mitral stenosis
Austin-Flint murmur (severe aortic regurgitation)
Lyme disease (Borrelia) effect on ECGs?
a prolonged PR interval
