Cardio-Respiratory Flashcards
Protein levels in transudate and exudative fluid
Transudate <25 g/L
Exudate >35g/L
Kussmaul’s sign
Kussmaul’s sign is a paradoxical rise in jugular venous pressure on inspiration
is usually indicative of limited right ventricular filling due to right heart dysfunction
Which wave should a DC shock be synchronised with?
R wave
Central venous wave form
a wave
c
x descent
v wave
y descent
Atrial systole (end diastole)
Isovolumetric contraction (early systole)
Rapid ventricular ejection (mid systole)
Ventricular ejection and isovolumetric relaxation (late systole)
Early ventricular diastole
Indications for starting NIV in COPD?
pH < 7.35
pCO2 > 6.5
RR > 23
CPAP starting pressure
5-10
BiPAP initial pressures for COPD
EPAP - 3 (higher if known OSA)
IPAP - 15 (20 if pH < 7.25)
FEV1/FVC ratio that indicates COPD?
<0.7
Pattern on ECG showing PE (In leads I-III)
S1, Q3, T3
Prolonged QTC in:
Women
Men
460
440
Pulse in AS
Pulse pressure
Slow rising
Narrow
Causes of acute AR
Aortic dissection
IE
Ruptured aortic valve leaflet
Pulse in AR
Pulse pressure
Water hammer
Widened
Where is AR best heard
3rd intercostal space on the left in expiration
Adverse features in arrhythmias
Shock
HF
Myocardial ischaemia
Syncope
MR murmur =
pansystolic
Dose for atropine
500mcg every 3-5 mins to a total of 3mg
Management of Mobitz type 2 HB with bradycardia
Treat as if adverse features ie 500mcg of atropine every 3-5 mins to a total of 3mg
How to manage tachycardia with adverse features
Synchronised cardioversion
How many J do you start at for synchronised cardioversion in a broad complex tachycardia
120-150J
How many J do you start at for synchronised cardioversion in a narrow complex tachycardia
70 - 120J
Pad position in AFib/flutter when doing synchronised cardioversion
AP
If cardioversion fails what drug can be given in tachycardia
300mg amiodarone over 10-20mins and reattempt
Regular broad complex tachycardia (VT) without adverse features, treatment
Amiodarone
Regular narrow complex tachycardia with BBB without adverse features, treatment
Treat as narrow complex if bundle branch already known
Irregular broad complex tachycardia (most likely AF with bundle branch block) treatment
Treat as irregular narrow complex (AF)
ECG features of atrial fibrillation in WPW
Rate > 200 bpm
Irregular rhythm, with extremely high rates in some places — up to 300 bpm (this is too rapid to be conducted via the AV node)
Wide QRS complexes due to abnormal ventricular depolarisation via AP
Subtle beat-to-beat variation in QRS morphology
Axis remains stable, unlike Polymorphic VT
Torsade de pointes management
Stop all QT prolonging drugs and give magnesium 2g over 10 mins
When not to give adenosine in narrow complex tachycardia
Atrial flutter
4 things that make a bradycardia at high risk of asystole
Recent asystole
Mobitz type II
Complete heart block with broad QRS
Ventricular pause >3 secs
Stable patient with WPW + AF
Unstable
Procainamide
Cardioversion
How to recognise an aortic regurgitation murmur
Diastolic
Soft, blowing
L. sternal edge
Heard best on expiration
Recognising TR
Soft pansystolic murmur, left sternal edge, heard best on inspiration, 3rd heart sound
High risk characteristics of a patient with a pneumothorax
Haemodynamic compromise
Significant hypoxia
Bilateral
Underlying lung disease
>50 + w/ smoking hx
Haemopneumothorax
Inability to complete sentences in one breath = what severity of asthma
Severe
Moderate adult asthma exacerbation
PEFR more than 50–75% best or predicted (at least 50% best or predicted in children) and normal speech, with no features of acute severe or life-threatening asthma.
Severe adult asthma exacerbation
PEFR 33–50% best or predicted
OR respiratory rate of at least 25/min
or pulse rate of at least 110/min
or inability to complete sentences in one breath
or accessory muscle use
Life-threatening adult asthma severity
PEFR less than 33% best or predicted
or oxygen saturation of less than 92%
OR NORMAL CO2
or altered consciousness
or exhaustion
or cardiac arrhythmia
or hypotension
or cyanosis
or poor respiratory effort
or silent chest
or confusion
What on an ECG is suggestive of a posterior STEMI ?
ST depression and upright TW in V1-3
What ECG finding is most suggestive of an NSTEMI
TWI in V2
First line treatment in a hypertensive emergency due to pheochromocytoma
Phentolamine (alpha blocker)
Define malignant hypertension
Hypertensive emergency with retinopathy grade III / IV
Define hypertensive emergency
A hypertensive emergency is severe hypertension (often defined as systolic blood pressure (BP) ≥ 180 mm Hg and/or diastolic blood pressure ≥ 120 mm Hg) with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys).
First line tx for malignant hypertension, hypertensive encephalopathy or ICH
Labetalol
Hypertensive emergency + MI 1st line tx
GTN + esmolol
Esmolol decreases HR
GTN reduces pre-load and cardiac output, so increasing coronary blood flow
Hypertensive emergency + APO 1st line tx
GTN or clevidipine
Hypertensive emergency + AKI 1st line tx
Fenoldopam
Decreases afterload and increases renal perfusion
Most common organism causing pneumonia
Streptococcus pneumoniae
ST elevation in V1 - V2
Myocardial area
Vessel
Septal
Proximal LAD
ST elevation in V3 - V4
Myocardial area
Vessel
Anterior
LAD
ST elevation in V5 - V6, I, aVL
Myocardial area
Vessel
Lateral
Left circumflex
ST elevation in V1-4
Myocardial area
Vessel
Anteroseptal
LAD
ST elevation in V3 - V6, I, aVL (R: II, III, aVF)
Myocardial area
Vessel
Anterolateral
LAD or left circumflex
ST elevation in II, III, aVF (R: I, aVL)
Myocardial area
Vessel
Inferior
RCA
ST elevation in R: V1 - V3 (P: V7 - V9)
Myocardial area
Vessel
Posterior
RCA or left circumflex
What denotes near fatal asthma
Raised pCO2 and or requring mechanical ventilation with increased pressures
Malar flush is seen in ?
Mitral stenosis
Variant angina
Coronary artery spasm
Often at rest
Relieved by GTN
After how many hrs is STEMI medically managed (ie no reperfusion therapies)
12 hrs
When is thrombolysis offered instead of PCI
Can’t get to PCI centre within 120 mins
First line DAPT in STEMI having PCI
Except over what age
Aspirin + Prasugrel
except in age over 75 due to bleeding risk / benefit
If cocaine user presents with CP and ECG changes (even if symptoms resolving), how to treat
Treat as an NSTEMI
Why is GTN contraindicated in an Inferior STEMI
Due to poor RV function, become preload dependent, GTN reduced preload
Why inferior STEMI most likely to get HB
Right coronary supplies the SA and AV node
Early complication of anterior STEMI
LV dysfunction and pulmonary oedema
Pericarditis ecg changes
1) diffuse ST elevation and/or PR depression, 2) normalization of ST- and PR-segments, 3) diffuse T-wave inversions with isoelectric ST-segments, and 4) normalization of the ECG.
Most specific test for HF
BNP, if <100 NOT YOUR HEART
Drug that will aggrevate HF
NSAIDs
Why might an early diastolic murmur be found in aortic dissection?
Stanford A, impacts on the root
Aortic regurgitation
Where is beta blockers contraindicated for AF
Anyone with airway issues e.g. COPD / asthma
Insulin dependent diabetics
PVD
When is flecanide contraindicated in AF
What is used instead for chemical cardioversion
Not had an echo
Any known structural heart disease
Amiodarone
Classic hypothermia ECG change
J wave
Microorganism in sub acute IE
Strep viridans (from the mouth)
settles on abnormal valves
Valve targeted by Staph. areus causing IE (via IVDU usually)
Tricuspid
Any murmur loader on inspiration is on which side?
Right
Electrolyte abnormality leading to torsades
Hypocalcaemia
Hypokalaemia
Causes of a +ve V1
Posterior infarct
RBBB
Normal in children and young adults.
Right Ventricular Hypertrophy (RVH) …
Right Bundle Branch Block (RBBB)
Posterior Myocardial Infarction (ST elevation in Leads V7, V8, V9)
Wolff-Parkinson-White (WPW) Type A.
Incorrect lead placement (e.g. V1 and V3 reversed)
Dextrocardia.
Most common SVT in young patients
AV node re-entrant tachycardia
4 situations where asystole is at increased risk:
Recent asytole
Mobitz type 2
Complete HB with broad QRS
Ventricular pauses > 3 secs
Average peak flow in men and women
600
450
Chest drain size for pneumothorax
8-14
High risk in context of pneumothorax
Haemodynamic instability
Hypoxia
Bilateral
Underlyinh lung disease
50+ w/ significant smoking hx
Haemopneumothorax
When is a DOAC contrainidicated in diagnosed PE
Cancer
Anti phospholipid
Haemodynamic instability
Renal impairement
FEV1/FVC ratio in restrictive lung disease
High FEV1/FVC ratio
Which lung conditions need an increase I:E when ventilating
Obstructive, to get rid of CO2
Criteria for the diagnosis of ARDS
Onset within 1 week
Bilateral opacities on CXR
Ratio of PaO2/FiO2 of <300 on PEEP 5 or CPAP 5
Loading dose of aminophylline (IV)
Maintenance
5mg/kg over 10-20 mins
maintenance infusion of 0.5 mg/kg/hour
Blood gas finding at altitude
Respiratory alkalosis
The typical ECG features of WPW in sinus rhythm are:
Shortened PR (<120 ms)
Delta wave (slurring of the initial rise in the QRS complex)
Widening of the QRS complex (>110 ms)
How to identify type A WPW
Predominantly positive delta wave and QRS in the precordial leads, can resemble RBBB in V1
How to identify type B WPW
The delta wave and QRS complex are predominantly negative in leads V1 and V2 and positive in the other praecordial leads, resembling LBBB
Bivalirudin
specific and reversible direct thrombin inhibitor (DTI). NICE recommends it as a possible treatment for adults with STEMI who are having percutaneous coronary intervention.
Recognised risk factors for aortic dissection include:
Hypertension
Atherosclerosis
Aortic coarctation
Sympathomimetic drug use, e.g. cocaine
Marfan syndrome
Ehlers-Danlos syndrome
Turner’s syndrome
Tertiary syphilis
Pre-existing aortic aneurysm
Wellens syndrome
is a pattern of deeply inverted or biphasic T waves in V2-3, which is highly specific for critical stenosis of the left anterior descending artery (LAD).
Tietze’s syndrome
is a rare disorder that causes localized pain and tenderness in one or more of the upper four ribs.
Fixed rate block can be due to what (2)
Mobitz I or Mobitz II atrioventricular block.
How to determine the cause for a fixed rate block
QRS narrow - type 1
QRS wide - type 2
Contra-indications to the use of adenosine include:
2nd or 3rd degree AV block
Sick sinus syndrome
Long QT syndrome
Severe hypotension
Decompensated heart failure
Chronic obstructive lung disease
Asthma
Where does the electrical activity in AF usually originate from
The disorganised electrical activity in AF usually originates at the root of the pulmonary veins.
How to recognise subendocardial ischaemia
Which artery is affected
ST depression in leads V2-V6, I, II and aVF
ST elevation in aVR
Left main coronary
Three beta-blockers licensed for use in chronic heart failure
bisoprolol, carvedilol and nebivolol.
When is glucagon recommended in bradycardia?
If the bradycardia is caused by beta-blockers or calcium-channel blockers
Decubitus angina
generally occurs in patients with congestive cardiac failure and severe coronary artery disease. As the patient lies down the increased intravascular volume places strain on the heart and triggers chest pain episodes.
Definitive treatment for brugada
insertion of an implantable cardioverter-defibrillator (ICD)
At what creatinine level is fondaparinux contraindicated in NSTEMI
creatinine above 265 micromoles per litre
Lown-Ganong-Levine syndrome, ECG findings
Sinus rhythm with a very short PR
Narrow QRS complexes
Absence of a slurred upstroke (delta wave)
Initial dose of adenosine in heart transplant patients
3mg
True Trifascicular Block
Right bundle branch block
Left axis deviation (Left anterior fascicular block)
Third degree heart block
Incomplete trifascicular block”
Right bundle branch block
Left axis deviation (= left anterior fascicular block)
First degree AV block
bifascicular block - two patterns
RBBB + LAFB
or
LBBB + RAFB
Aminophylline maintenance infusion
infusion of 500-700 mcg/kg/hour
Antibiotic therapy in whooping cough
Macrolide antibiotics are used first-line:
Clarithromycin for babies aged less than 1 month
Azithromycin or clarithromycin for children aged 1 month or older and for non-pregnant adults
Erythromycin for pregnant women.
They just reduce the length of infectivity
When is Oral Fluid Testing (OFT) recommended in whooping cough
Child 2-16 yrs old, cough for 14 days or more
At least 1yr after the vaccine
Optimal plasma therapeutic range for theophylline
10-20mg/L
When is an XR indicated in asthma?
Suspected pneumomediastinum
Suspected consolidation
Life-threatening asthma
Failure to respond to treatment satisfactorily
Requirement of ventilation
Chlamydia psittica antibiotic choice
tetracycline or doxycycline for 2-3 weeks
The borders are of the safe triangle for inserting a chest drain are:
Base of the axilla
Lateral border of latissimus dorsi
Lateral border of pectoralis major
5th intercostal space
How long after an aminophylline dose should a level be taken?
4-6hrs
Gold-standard investigation for the confirmation of a case of Legionnaires’ disease?
Isolation and culture from a sputum sample
Cavitating upper lobe pneumonia may indicate
Klebsiella pneumoniae
Criteria for antibiotic prophylaxis for whooping cough
Onset of disease in the index case is within the preceding 21 days and;
There is a close contact in one of the two priority groups
Group 1. At increased risk of severe or complicated infection (vulnerable)
Infants under one year who have received less than three doses of pertussis vaccine
Group 2. At increased risk of transmitting the infection to individuals in Group 1:
Pregnant women at greater than 32-weeks gestation
Healthcare workers working with infants and pregnant women
Individuals working with infants too young to be vaccinated (<4 months old)
Individuals sharing a household with infants too young to be vaccinated (<4 months old)
Q fever
Highly infectious zoonotic infection caused by Coxiella burnetti.
It is most commonly seen as an occupational disease affecting farmers, slaughterhouse workers and animal researchers.
Treatment for Q fever
2 weeks of oral doxy
Löfgren’s syndrome is described as being a triad of:
Bilateral hilar lymphadenopathy on chest X-ray
Erythema nodosum
Arthralgia (particularly affecting the ankles)
It is a type of sarcoidoisis
What type of cancers are pancoasts tumours usually?
Non small cell cancers
What predicts the 24-hour risk of critical respiratory illness in patients admitted from ED with COVID-19.
qCSI
True posterior infarct, which artery is impacted?
Posterior interventricular artery
Cocaine chest pain management
Treat as an NSTEMI/STEMI as per ECG
Indication for CPAP in pulmonary oedema
Severe dyspnoea and acidaemia
Indication for invasive ventilation in pulmonary oedema
Respiratory failure or reduced consciousness / physical exhaustion
AF but stable management
<48hr hx
>48hrs
Rhythm or rate control
Rate control
Causes of torsades de pointes
Congenital (Inherited long QT syndrome)
Drugs:
Antiarrhythmic agents, such as quinidine, sotalol, dofetilide, and ibutilide
Antidepressants
Antivirals and antifungals
Macrolides, such as erythromycin and clarithromycin
Fluoroquinolones
Antimalarials
Electrolytes - Low levels of potassium (hypokalemia) or magnesium (hypomagnesemia) can increase the risk of torsades de pointe
When should therapeutic pleural aspiration be stopped?
The procedure should be stopped when no more fluid or air can be aspirated, the patient develops symptoms of cough or chest discomfort or 2.5litres has been withdrawn.
Loading dose for theophylline
Maintenance infusion for theophylline
5 mg/kg over 20 minutes
0.5mg/kg/hr
Commonest mechanical complication of STEMI
Mitral regurg
Ventricular septal rupture murmur
Pan systolic murmur
If the patient is unstable and you deliver three shocks to them without success
administer amiodarone 300mg IV over 10-20 minutes and repeat synchronised DC shock (ensure maximum recommended shock level is given)
Three most common causes of a regular narrow complex tachycardia:
Sinus tachycardia
Atrial Flutter
Re-entrant SVT
Formula for determining max sinus HR
220 - age
Incremental doses in adenosine for SVT
6 -> 12 -> 18
Clinical risk stratification tool that can aid decision-making and workup in patients where acute aortic dissection is suspected.
The Aortic Dissection Detection Risk Score (ADD-RS)
MAP reduction aim in hypertensive emergencies
A progressive lowering of BP is indicated in hypertensive emergencies, aiming for an initial reduction in MAP* of ~25% over an hour.
Which valve disorders (2) are contraindications to using nitrates in angina
Aortic stenosis and mitral stenosis
The DeBakey Classification
Type 1-4 classification of aortic dissections
Definitive treatment for brugada syndrome?
implantable cardioverter-defibrillator
Rate-limiting calcium channel blocker (2)
Diltiazem / Verapamil
Prosthetic valve endocarditis blind therapy
Non prosthetic valve IE
vancomycin, rifampicin and low-dose gentamicin
Amox and low dose gent
Which type of treatment does atrial flutter respond LESS well to?
Atrial flutter generally responds less well to drug treatment than atrial fibrillation.
When flecanide is given as rhythm control in atrial flutter what should be prescribed alongside it?
Beta blocker or rate controlling calcium channel blocker
Hypertensive encephalopathy, what is used when labetalol is contraindicated?
Nircandipine
Abx for infective endocarditis caused by…
Staphylococci e.g. Staphylococcus aureus
Flucloxacillin (plus rifampicin and low-dose gentamicin in prosthetic valve endocarditis)
Abx for infective endocarditis caused by…
Streptococci e.g. Streptococcus viridans
Benzylpenicillin alone if fully-sensitive
Abx for infective endocarditis caused by…
Enterococci e.g. Enterococcus faecalis
Amoxicillin plus low-dose gentamicin
Abx for infective endocarditis caused by…
‘HACEK’ microorganisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella spp.)
Amoxicillin plus low-dose gentamicin
Valve most commonly affected by IE
Mitral
Then Aortic
Then combined
The following conditions are associated with a widely split S2:
Deep inspiration
Right bundle branch block
Prolonged right ventricular systole (e.g. pulmonary stenosis, P.E.)
Severe mitral regurgitation
Atrial septal defect (fixed splitting, doesn’t vary with respiration)
What supplies sensory supply to the pericardium?
Phrenic nerve
SVT, asthmatic, alternative to adenosine?
Verapamil
When is immediate initiation of NIV appropriate in acute pulmonary oedema?
Acidosis and dyspnoea
The following are contra-indications to the use of amiodarone:
Severe conduction disturbances (unless pacemaker fitted)
Sinus node disease (unless pacemaker fitted)
Iodine sensitivity
Sino-atrial heart block (except in cardiac arrest)
Sinus bradycardia (except in cardiac arrest)
Thyroid dysfunction
In which heart valve disorders is GTN contraindicated?
Mitral and aortic stenosis
