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NAC > Cardio & Resp > Flashcards

Cardio & Resp Flashcards

1
Q

STEMI Mx

A
  • 12 lead ECG within 10 mins, repeat q10-15mins if non-diagnostic but suspect (ST elevations or new LBBB)
  • ABCs - O2 > 90%
  • 325mg aspirin (chewable or rectal) + clopidogrel 300mg (if <75yo) OR ticagrelor
  • 3 sublingual nitro tablets q5mins or spray (no right sided MI or PDE-i)
  • morphine 2-4mg IV q5-15mins
  • metop 25mg (if no HF or brady or asthma)
  • troponins, electrolytes, Hct/Hb, coags
  • start anticoag (for PCI start UFH, for fibrino start enoxaparin)
  • start high intensity statin - atorva 80mg

*reperfusion
PCI - if within 120mins of med contact
fibrinolysis - if >120mins, <12hrs & no c/i

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2
Q

NSTEMI Mx

A
  • ECG - ST depressions or deep T-wave inversions without Q waves (12 lead ECG within 10 mins, repeat q10-15mins if non-diagnostic)
  • ABCs - O2 > 90%
  • 325mg aspirin (chewable or rectal) + clopidogrel 300mg (if <75yo) OR ticagrelor
  • 3 sublingual nitro tablets q5mins or spray (no right sided MI or PDE-i)
  • morphine 2-4mg IV q5-15mins
  • metop 25mg (if no HF or brady or asthma)
  • troponins, electrolytes, Hct/Hb, coags
  • start anticoag (for PCI start UFH, for fibrino start enoxaprin)
  • revascularization - coronary angio & PCI
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3
Q

Fibrinolysis contraindications

A
  • history of intracranial bleed, AVM, intracranial malignancy
  • ischemic stroke in last 3 months
  • symptoms of aortic dissection
  • active bleed
  • closed head or facial trauma in last 3 months
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4
Q

Which populations have atypical presentations of MI

A

women
elderly
diabetics

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5
Q

nitrate c/i

A

PDE-i in last 24 hours
right sided MI

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6
Q

CAD atherosclerosis questions

A

cold hands & feet
numbness and tingling in feet
ED
angina
pain with eating
CP (angina)
fatigue
palpitations
CHF (swelling)

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7
Q

types of coronary artery disease

A
  1. obstructive (plaque)
  2. non-obstructive (vasospasm or endothelial dysfunction)
  3. arterial dissection (tear blocks blood flow)
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8
Q

Investigations for CAD

A
  1. coronary angio
  2. coronary calcium scan (CT to assess plaque buildup)
  3. Echo (structure)
  4. EKG (electrical activity)
  5. Stress test
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9
Q

Coronary calcium scores

A
  • CT to assess calcium buildup in plaque in coronary walls (can show CAD b4 symptoms and help decide med use)
  • Higher score = higher risk of MI
  • 0-400 score
  • often done if strong FHx of early CAD, intermediate risk of MI (not high or low), risk is uncertain
  • not used for general CAD screening
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10
Q

CAD Management

A
  1. lifestyle mods & cardiac rehab
  2. anti-coag (afib), anti-HTN, statins, nitrates
  3. procedures - PCI, CABG
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11
Q

Aortic dissection sx & ix

A
  • sudden onset tearing CP/abdo pain radiating to back (especially Type A)
  • pulse deficit (>20 b/w arms)
  • heart murmur (can involve aortic regurg)
  • FND (stroke)
  • hypotension (esp ascending - cardiac tamponade, AR, MI, hemothorax)
  • syncope (often tamponade)

Ix:
- ECG (r/o MI)
- chest x-ray (widening of aortic silhouette & unexplained effusion)
- chest CTA or MRA angiography, TEE (can e done bedside)
- d-dimer?
- labs: CBC, lytes, trop, coag, type & crossmatch, LDH

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12
Q

Types of aortic dissections

A

Type A: ascending aorta
- AR, ACS, tamponade, hemothorax, FND , upper pulse diff

Type B: descending thoracic/thoracoabdominal distal to subclavian artery
* posterior chest/upper back pain & abdo
* visceral ischemia, renal insuff, lower ext ischemia, FND (spinal ischemia)

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13
Q

Aortic dissection mx

A

Ascending: surgical ER & ER surgical consult, control pain, BP management, catheter (monitor output)

Descending with ischemia: aortic stent grafting or surgery

Descending without ischmiea: ICU for medical mx & serial aortic ix

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14
Q

Pericarditis sx

A

etiology: often idiopathic - viral, AI, bacterial, malig
* pleuritic chest pain relieved sitting up & fwd (ausculatate while leaning way fwd)
* pericardial friction rub
* ECG (diffuse ST elevation & PR depression)
* pericardial effusion

suspect this if pt has fever, unexplained pericardial effusion/cardiomegaly

*ask about flu like sx, meds (TB), surgery or MI hx, CKD, TB, AI

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15
Q

Pericarditis ix & mx

A

IX:
* * friction rub on ausc leaning fwd
* ECG (diffuse ST elevations)
* labs: CBC, CRP, trop, consider etiology (viral, AI titers, HIV Hep C testing) etc
* chest-xray
* echo (effusion)

MX:
- NSAIDS ibuprofen/aspirin/ketorolac (use until complete resolution of sx for 24h) + colchicine (3months) + PPI
- only use steroids if c/i to NSAIDS (RF or pregnancy)
- should respond to tx within 1-2 weeks & monitor CRP weekly
- restrict activity until improved
- *if develops pericardial effusion causing tamponade - pericardiocentesis

*if not improving, r/o TB, bacterial, AI, cancers

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16
Q

Pericarditis medical tx

A

NSAIDS + PPI + Colcichine (3mo)

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17
Q

Tension pneumo mx

A
  • resusc (ABCs), O2, pain meds
  • unstable: needle decompression and hear air gush (14 or 16G needle into 2nd ICS MCL) & chest tube thoracostomy (water seal) + x-ray for position
  • admission

*insert needle over upper border of rib (vasculature and nerves run along bottomside of rib)

18
Q

Post MI pericarditis

A

Dressler’s syndrome (give aspirin + colchicine)

19
Q

Key history questions for pericarditis

A

*ask about flu like sx, meds (TB), surgery or MI hx, CKD, TB, AI

20
Q

Heart failure classes:

A
  • LVEF <40: reduced EF (ischemic & dilated myopathies)
  • 40-50 = mid range EF
  • LVEF > 50: pEF (HOCM)
  • valvular stenosis or regurg
  • PHTN
  • cardiac tamponade, constrictive pericarditis
  • high output heart failure

NYHA CLASS

21
Q

HF symptoms

A
  • excess fluid: SOB, orthopnea, edema, hepatic pain, abdo ascites (elevated JVD >3cm, pulm edema rales and LL edema)
  • reduced c/o which activates RAAS: fatigue, weak
22
Q

HF investigations

A
  1. ECG
  2. labs - BNP, troponins, CBC, lytes, BUN & Cr, LFTs (hepatic cong), fasting sugar
  3. x-ray - cardiomegaly, pleural effusions (blunting of CP angle)
  4. echo
  5. can do PFTs to r/o COPD
23
Q

Swelling differentials

A

HF
Renal failure
Liver failure
Meds (CCB)
DVT

24
Q

Acute HF decompensation mx:

A

LMNOP
* Lasix
* Morphine
* Nitrates
* O2> 90, consider NIV if in distress
* Position and NIV
* don’t start BB during acute, but if they are already on try to keep them on this

LT mx:
*should be on an ACE/ARB or now ARNIs (candesartan & sacubitril)
* spironolactone
* BB
* SGLT2 (dapagliflozin, empagliflozin)
* Digoxin if nothing else is working

25
Q

NYHA Scale

A

1 - ordinary activity = no sx
2 - ordinary activity = sx
3 - less than ordinary activity (showering, dressing, making bed) = sx but comfortable at rest
4 - sx at rest

26
Q

HF exam findings

A

displaced apical impulse
S3 and S4
Pulmonic accentutation P2
Mitral regurg (pan systolic murmur)
inspiratory basilar crackles that don’t clear with cough
dull to percussion and diminishe dsounds at base
non-tender pitting edema
large pulsatile liver
abdo swelling and ascites
increased JVD

27
Q

Dig Toxicity Sx & Mx

A
  • vtach, vfib, AV block
  • hyperkalemia
  • N/V/D/confusion/yellow vision
  • electrolyte abnorm
  • if severe, admit & correct electrolyte abnorm
  • give dig immune Fab if arrhythmias or hyperkalemia
  • temporary pacemaker if HB
28
Q

Asthma diagnosis

A

sx: SOB, wheeze, tightness, cough worse at night, FHX

PFTs - FEV1/FVC <70% w bronchodilator reversal >12% (after 20 mins), methacholine challenge

XRAY - r/o cancer or infection

29
Q

Asthma outpatient mx

A

Education (env control, avoid triggers, asthma action plan, technique & priming inhaler, peak flow meter) and check spirometry yearly

Technique - breathe out fully, breathe in fully & hold 10 sec, out –> shake puffer & wait 1 min before next puff (prime by spraying 4 puffs if new or >2weeks since use)

Inhalers:
- <2x/week: salbutamol 1-2puffs q4-6h PRN
- >2x/week (not daily): salb qid + low dose ICS 1 puff bid (Flovent)
- daily: LABA + med dose ICS (combo - Advair mod dose or Symbicort high dose)
- still uncontrolled: add LABA, LRTA, high dose ICS, oral steroids, consider omalizumab (anti IgE if >12yo)

If using SABA > 4x/day, >2x/week, 1night/week or 2nights/month –> increase

COMBOS:
- Advair (250mg steroid + LABA)
- Symbicort (400mg + LABA)

30
Q

What are your ICS Asthma inhalers called?

A

ORANGE: Flovent (fluticasone propionate) - 125mcg, 250mcg, 500mcg

BROWN: Pulmicort (budesonide) - 100mcg, 200mcg, 400mcg

PURPLE: ADVAIR (LABA-ICS COMBO)

WHITE & RED: SYMBICORT (COMBO)

31
Q

Inhaler colours

A

Blue: salbutamol (SABA) & salmeterol (LABA)

Green: Atrovent (SAMA)

Orange: Flovent (ICS)

Brown: Pulmicort (ICS)

Purple: Combo Advair

White/red: Symbicort combo

Singulair: tablets
Spiriva: handheld (COPD) - LAMA

32
Q

ER Asthma Attack Mx

A

SOB, diaphoretic, dyspneic, tachypneic (RR > 30), HR > 120, SpO2 <90%, tripod, PEF < 50%, difficulty talking, cyanotic, reduced consciousness, absent breath sounds, bradycardia & hypotensive = ER!!!

  • Assess ABCs (ABG, peak flow, intubate?)
  • O2 > 94%
  • Brochodilators (albuterol) q20mins x 3 (can continue every 1-4hrs as needed) - nebulized or MDi with spacer (4-8puffs q20min)
  • Steroid (40-60mg po pred or IV) qd for 5-7d
  • for severe, add on ipratropium to SABA
  • Fluids
  • If unresponsive - Mg (2g over 20mins), ICU, consider other causes (anaphylaxis, foreign body etc)
  • discharge w inhalers, 5d steroids, fu with GP in 5 days, safety plan (return if inhaler use <2h, sx)
33
Q

Asthma history

A

EVENT - OCD, meds, symptoms, 911, admitted, intubated, discharge meds?

Asthma HX (recently increase puffer times, attacks at night)

Triggers
- infections, meds (aspirin, BB), exercise, cold air, pollen/dust, GERD
- indoor - smoke, pets, fabrics, perfume, for, mold, construction
- stress
- ask occupation

PMH & FH

34
Q

Meds that can worsen asthma

A

Beta-blockers (non-specific) & aspirin

Ace can cause a cough

35
Q

COPDE Mx

A

Increased SOB, purulence, volume

Ix:
- ABG, chest x-ray, labs (CBC, lytes, BUN Cr, troponin, BNP, influenza testing), ECG

  • Mx ABCs (if dec LOC & ABG - consider ventilation) & get ABG
  • O2 88-92 (check ABG and titrate oxygen accordingly)
  • nebulized broncho (albuterol + ipratropium q1hr x 3)
  • 60 mg steroids x 5d (PO or iV)
  • antibiotics if 2/3 criteria (if no pseudo RF, do ceft 1g IV or levo 500mg IV; if pseudo - piptazo 4.5g IV or cefepime or ceftaz)
  • can consider anti-viral therapy

Antibiotics (DOUBLE CHECK THIS)
- outpt: levo 750mg PO q24h x 5d or amox 1000mg PO tid /clarithro 500mg PO bid
- inpt/immuno/group home: azithro 500mg IV q24h x 5d + ceft 1g IV q24h
- pseudo sens or recent Ab/Cx piptaz 3.375g IV q6h
- MRSA Vanc 1g IV q24h

Discharge:
- inhalers
- 5d course steroids
- antibiotics
- post rehab for exercise tolerance
- O2 if needed (PaO2 < 55 or cor pulm with <60)
- vaccines
- smoking cessation

36
Q

COPDE Antibiotic Protocol

A
  • outpt: levo 750mg PO q24h x 5d or amox 1000mg PO tid /clarithro 500mg PO bid
  • inpt/immuno/group home: azithro 500mg IV q24h x 5d + ceft 1g IV q24h
  • pseudo sens or recent Ab/Cx piptaz 3.375g IV q6h
  • MRSA Vanc 1g IV q24h
37
Q

Inhaler mx for COPD

A

Short acting Ventolin (q6h PRN) & Atrovent (1-2 q6h)

Long acting bronchodilator
- LABA (Serevent) +/- Atrovent
- LACA (Spiriva) –> stop atrovent (both cholinergic)

ICS- LABA combos:
- Advair
- Symbicort

38
Q

Asthma classifications

A
  • intermittent (<2/week)
  • mild persistant (>2x but <daily)
  • moderate persistant (daily)
  • severe persistant (multiple x a day)

Well controlled, not well controlled, very poorly controlled

39
Q

Inhaler technique

A

https://www.cdc.gov/asthma/caring/?CDC_AAref_Val=https://www.cdc.gov/asthma/inhaler_video/default.htm

40
Q

SABA inhaler dosage for asthma

A
  • Usual dose: 2 inhalations every 4 to 6 hours as needed
  • Acute exacerbation at home: 2 to 4 inhalations, can be repeated every 20 minutes for a total of 3 doses, then as directed◊
  • Acute care setting: 4 to 8 inhalations every 20 minutes for 3 doses§, then taper depending on response to therapy

NAC (6 decks)

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