Cardio ER Flashcards
What is the most common cause of ischemic heart dz
Atherosclerosis of coronary arteries
Risk factors of CAD
Age >50, Family Hx, Male, smoker, Htn, Hyperlipidemia, DM
Presentation of stable angina
CP lasting 5-10 mins
Relieved by rest and SL nitro
Treat a stable angina in ER
1) Cardiac work up
2) ASA
3) O2
4) Nitrates if needed
5) Follow up in office
EKG, Troponin, and CXR findings in Stable angina
EKG-unchanged
Troponin- neg
CXR- neg
Presentation of unstable angina
1) New exertional CP
2) Someone with previous stale CAD that now has angina a rest and no relief with nitro
Work up unstable angina
Cardiac work up, ASA, O2, nitrates, Admit to tele to have angiogram scheduled, Cardiac consult, BB, Heparin drip, CCB
What does a cardiac work up consist of
Troponin EKG CXR CBC CMP
What do my EKG, Troponin and CXR show in unstable angina?
1) EKG- ST depressions at time of pain, and normal with no pain
2) Troponin- sligh elevation
3) CXR- normal
What is unstable angina a precursor for?
MI
What is variant angina
Coronary artery vasospasm
What will EKG show in variant angina at the time of pain
ST elevations
What will the troponin show in variant angina
Negative
Treat my variant angina
Go home
I have cp while waling up the stairs at school. By the time I have sat down in my seat for a few minutes the pain subsides . If I were in your ED would you admit me?
No- Stable angina
I woke up last night at 2am with intense CP, I rushed to the ED and the pain had subsided when I got there and my EKG and biomarkers are negative. What should you do for me
Refer to cardiology - Variant angina
I am having severe substernal crushing CP. My EKG shows ST elevations in II and III. Help Me!!
Straight to Cath lab in <90 mins-STEMI
I have had CP in the past, but it has always resolved. This time I have taken my nitro and rested, but the pain has not been relieved. My EKG shows ST depressions, but my serial troponins are negative. What is my most likely diagnosis
Unstable Angina
How long does typical CP last for an MI
15-30 mins
In an MI do I respond to nitro
Nope
Describe typical CP in an MI
severe, crushing substernal pain
Associated symptoms with MI
SOB, Diaphoresis, N/V
Elderly presentation of MI
Weakness and CP
DM presentation of MI
Diaphoretic, holding chest, but no CP
Women presentation of CP
SOB, easy fatigability
How many patients will die of V. Fib arrest due to MI in ED
1 in 5
What is a Q wave
Old, transmural infarction
What do ST elevations mean?
Transmural ischemia
What do T wave inversions mean
Ischemia
What do ST depressions mean?
Ischemia
How long does it take to see a rise in troponin
3-6 hours
Can you have an elevated troponin without an MI?
Of course. Renal dz is the most common
I have typical CP that is not relieved with nitro or rest. My EKG is normal, but my troponin is elevated? Help me!!
1) Oxygen
2) Aspirin 325 chewed
3) Nitro
4) Morphine
5) Anticoagulation
6) BB/rate control
What is cardiogenic shock characterized by
depression of myocardial contractility, decreased Cardiac output
What are risk factors for cardiogenic shock
Elderly, female, impaired EF, Extensive infarct
How to patients with Cardiogenic shock present
Ill, Tachy, lethargic, hypotensive, JVD, crackles or rales
Drug you give me for Cardiogenic shock
PRESSORS- dopamine
What should you not give me if I am hypotensive in cardiogenic shock
beta blockers
If I am having cardiogenic shock due to AMI what do you do for me
PCI or balloon pump until you can get to PCI
I did some coke what drug is contraindicated in me
beta blockers
What does dresslers syndrome consist of
Pericarditis, Fever, leukocytosis, pericardial or pleural effusion (Friction rub)
How long after a heart attack can you get dresslers syndrome
1-6 weeks
How do you manage my dresslers syndrome
Supportive care- admit
What is contraindicated if I have dresslers syndrome
Anticoagulant- can cause hemorrhage or tamponade
I have JVD, Pitting edema, and clear lungs - what do I have
Isolated Right heart failure
I have crackles, rales and orthopnea, but no JVD or pitting edema- what do I have
Isolated LEft heart failure
I have JVD, piting edema, orthopnea, crackes and rales- what do I have
Combined right and left HF
Causes of Right heart failure
Acute:MI or PE
Chronic: pulm stenosis, COPD, pulm Htn, Left sided
Causes of Left heart failure
Infarct
Most common symptoms of CHF
SOB, DOE
On exam of left CHF what heart sound can be heard
S3
What are the CXR findings seen in CHF
Interstitial pulmonary edema
Kerly B lines
Treat my CHF exacerbation in the ER
1) IVLasix
2) Bipap
3) Vasodilators (nitro)
4) Positive inotropes
5) Morphine
I am hypertensive in a CHF exacerbation treat me
Nitropureside
I am hypotensive in a CHF exacerbation treat me
Pressors
Cannot give lasix or nitro
How many patients with infective endocarditis will have a murmur
90%
MCC and valve of acute endocarditis
Staph tricuspid
MCC in IVDA
Staph
MCC in normal people
Strep viridians
MCC valves infected in subacute
Aortic +Mitral
Major criteria of Jones criteria
1) Positive blood culture
2) Evidence of endocardial involvment
Minor criteria of Jones criteria
1) Predisposition
2) Fever >38
3) Vascular phenomena
4) Immunologic phenomena
5) Microbiological evidence
6) Echo
Endocarditis is diagnosed by what
need 2 major or 1 major and 3 minor from jones criteria
How many blood cx do you need for an endocarditis patient
3
Emperic tx of endocarditis
IV Pen G or ceftriaxone
IF MRSA-vanco
What is myocarditis
Inflammation of the heart muscle
MCC of myocarditis
Viral
I am febrile, with tachycardia out of proportion to fever with a pleural rub,– what lab value of mine will be elevated?
CK-MB
ESR
I have ST elevations in V1-V6
Pericarditis
I have CP that is better with leaning forward
Pericarditis
MCC of pericarditis
Idiopathic
Tx of pericarditis
3 weeks of NSAIDS, get echo
Becks triad
Hypotension, Kussmals sign, pulsus paradoxis
What is Kussmals sign
JVD with inspiration
What is pulsus paradoxis
drop on pulse with inspiration
I have muffled heart sounds and hypotension treat me
Emergent pericardiocentesis
I have breast cancer and I just took a long plane ride to see my new grandchild. Now I am presenting to your ER with sudden onset SOB- Work up for me
High risk- CTA
I am a healthy 23 year old male with sudden onset cp – work me up for PE
Low risk- D dimer
What percentage of people diagnosed with PE have a predisposing factor
90%
Most common finding on EKG for PE
Tachycardia
Most specific finding on EKG for PE
S1Q3T3
What is the “Gold standard” for PE diagnosis
pulmonary angiography
What is the “gold standard” for DVT diagnosis
Venogram
When do you do a V/Q scan
Allergic to dye
Elevated Bun/Cr
Treat my stable PE
Heparin bolus then drip
Admit
Convert to coumadin
What must you do before starting anticoagulation
guaiac
Therapeutic INR for coumadin
2.5
PT is used to monitor what
Heparin
Treat my unstable PE
Embolectomy or TPA
Does Lovenox work for PE…what about DVT
No, Yes
What is a hypertensive Urgency
BP >115 diastolic
What is a hypertensive Emergency
BP>115 with signs of end organ damage
What is end organ damage?
Blurred vision, elevated troponin, HA, renal problems, CP
What is malignant hypertension
Htn emergency +papilledema
Treat my Htn emergency
Nitropresside
How fast should you lower my bp?
Not more than 25-30% in the first hour, return to baseline within 24-48 hrs
I have sharp tearing pain that radiates up into my shoulder blades– what will my CXR look like and what other imaging should you get
1) Mediastinum widening
2) CTA of chest, abdomen and pelvis with IV contrast
What is the “gold standard” for Aortic aneurysms
Aortography
My aortic aneurysm involves the ascending aorta- do i need surgery
Yes- I have type A in stanford classification
My aortic aneurysm does not involve the ascending aorta- do i need surgery
No- mange me medically - I have type B in stanford classifications
I have a pulsiile abdominal mass and right hip pain- what should you do
Call vascular NOW
Manage my dissecting aneurysm
IV Esmolol (lower BP)
Prep for OR
2 large Bore IV
Name 2 signs of retroperitoneal bleeding
Cullen, grey turners
What is another cause of retroperitoneal bleeding
Coumadin
I am 85 and experiencing abdominal pain after eating with a syncopal event- what diagnostic test will you get, and which is the “gold standard”
1) CT of the abdomen with IV contrast
2) Arteriography
Treat my messinteric ischemia if the CT detected a thrombus
Heparin drip
Treat my messinteric ischemia if no thrombus
Admit, NPO and bowel rest
What are the 6 P’s
pain, pallor, paralysis, pulselessness, paresthesias, and polar (for cold).
What is the work up for extremity ischemia
1) Bedside doppler
2) CT with run off
What is the treatment for confirmed extremity ischemia
1) Heparin drip
2) Call vascular
What is virchows triad
1) stasis of blood flow
2) endothelial injury
3) hypercoagulability
I just had an IV in and now I have redness, tenderness along that vein. what test do I need. and if that test is negative what do you do with me
Doppler- warmth, elevation, NSAIDS
If I have a positive doppler of a superficial thrombophlebitis what do you do with me
Out patient follow up- can communicate with outside
What is the Sign of pain with dorsiflexion of the foot, and what does it indicate
Homans sign- DVT
I have unilateral pain and edema of my right leg- what test should you do
Doppler
I have a positive doppler fir a DVT with no PE symptoms- treat me!
Lovenox with bridging to coumadin
I have elevated venous pressure in my upper body –why?
Malignancy- Lung cancer (70%)
Management of SVC
Supportive- O2, Diuretics, steroids, head elevation
Syncope with a prodrome
Psychogenic or neurogenic
Syncope without prodrome
Cardiac
Work up of syncope
Work up what you think it is
Work up of syncope
Work up what you think it is
Work up of syncope
Work up what you think it is
What can cause High output CHF
Anemia or thyroxicosis
What can cause High output CHF
Anemia or thyroxicosis
What can cause High output CHF
Anemia or thyroxicosis
I have unilateral sharp stabbing pain in the temporal region of my head- what do you do with me?
Temporal arteritis-> High dose prednisone 60mg
Biopsy to temporal artery
I have unilateral sharp stabbing pain in the temporal region of my head- what do you do with me?
Temporal arteritis-> High dose prednisone 60mg
Biopsy to temporal artery
I have unilateral sharp stabbing pain in the temporal region of my head- what do you do with me?
Temporal arteritis-> High dose prednisone 60mg
Biopsy to temporal artery
What test is elevated in temporal arteritis
ESR>50
What test is elevated in temporal arteritis
ESR>50
What test is elevated in temporal arteritis
ESR>50
I have sinus bradycardia treat me
1) IV atropine (Up to 2 doses)
2) If Atropine doesn’t work - pace
3) Call cardio- may have pacer placed
I have sinus bradycardia treat me
1) IV atropine (Up to 2 doses)
2) If Atropine doesn’t work - pace
3) Call cardio- may have pacer placed
I have sinus bradycardia treat me
1) IV atropine (Up to 2 doses)
2) If Atropine doesn’t work - pace
3) Call cardio- may have pacer placed
I have A fib treat me
1) IV Cadizem
2) Cardiovert
I have A fib treat me
1) IV Cadizem
2) Cardiovert
I have A fib treat me
1) IV Cadizem
2) Cardiovert
Before you cardiovert what test must you have
TEE
Before you cardiovert what test must you have
TEE
Before you cardiovert what test must you have
TEE
If you have new onset A fib can you cardiovert
yes if less than 48 hours
If you have new onset A fib can you cardiovert
yes if less than 48 hours
If you have new onset A fib can you cardiovert
yes if less than 48 hours
Treat my SVT
1) Increase vagal tone
2) Adenosine (up to 3 doses)
3) IV vardizem or BB
Treat my SVT
1) Increase vagal tone
2) Adenosine (up to 3 doses)
3) IV vardizem or BB
Treat my SVT
1) Increase vagal tone
2) Adenosine (up to 3 doses)
3) IV vardizem or BB
Treat my unstable V tac
cardiovert
Treat my unstable V tac
cardiovert
Treat my unstable V tac
cardiovert
Treat my stable V tac
IV antiarrhythmic
Treat my stable V tac
IV antiarrhythmic
Treat my stable V tac
IV antiarrhythmic
Treat my V fib
1) CPR
2) Shock
3) CPR
4) Rhythm/pulse chek
5) Shock
6) Epi
7) CPR
8) Rhythm/pulse check
9)
Treat my V fib
1) CPR
2) Shock
3) CPR
4) Rhythm/pulse chek
5) Shock
6) Epi
7) CPR
8) Rhythm/pulse check
9)
Treat my V fib
1) CPR
2) Shock
3) CPR
4) Rhythm/pulse chek
5) Shock
6) Epi
7) CPR
8) Rhythm/pulse check
9)
