Cardiology Flashcards
Treatment of BB over dose
Presentation - Bradycardia, AV block, hypotension, diffuse wheezing (B2 blockade)
Intoxication with digoxin, CCBs and cholinergics would all cause similar symptoms.. but wheezing is most likely in BB toxicity.
Treatment:
- secure airway
- IV fluids
- ATROPINE!! IV
If Atropine doesnt work:
4. IV Glucagon –> increases intracellular CAMP and treats both BB and CCB toxicity.
Why cant u give dobutamine?
Dobutamine is positvely inotropic which would hlep in this case. HOwever it also causes vasodilation, which would worsen the hypotension.. so its contraindicated here.
Digoxin toxicity
Fatigue, anorexia, nausea, blurred fision, disturbed color perception, cardiac arrhytmias
Give Digoxin- specific antioboidy (Fab)
cocaine toxicity - chest pain treatment
1st line - supplemental oxygen and Benzos - for blood pressure and anxiety
Nitroglycerin and CCB for pain - vasodilate - decrease cocaine induced coronoary artery vasoconstriction
Aspirin - cocaine is prothrombogenic.. aspirin retards that process
BB are CONTRAINDICated = unopposed alpha.
What diagnostic marker has the highest sensitivity for CHF?
Bilateral lung crackles elevated JVP Lower extremity edema 3rd heart sound Elevated BNP
BNP = 90% sensitivity.
BNP is a natriuretic hormone released from ventricular myoctyes in patients with CHF in response to high ventricular filling pressures
The rest of the signs are specific for CHF. Their absence however should not be used to rule out CHF because they may or may not be present.
Aortic stenosis causes
> 70 = age related senile calcific aortic stenosis
<70 in developed countries = MCC is bicuspid aortic valve
Rheumatic disease also causes aortic stenosis (more so in developing countries)
Aortic stenosis - harsh ejection murmur at the right upper sternal border with radiation to the carotids. Crescendo - decrescendo murmur)
HOw can you differentiate HOCM and AS murmur?
they sound the exact same.
Locations are different.
HOCM - lower left sternal border
AS - 2nd right ICS
STEMI Management
- O2
- Nitrates ( do not give with hypotension, Right ventricular infarction or severe aortic stenosis)
- Antiplatelet therapy = Aspirin + Copidogrel (unelss they getting cath)
- Anticoagulation - unfractioned heparin / LMWH or Bivalirudin (direct thrombin inhibitor)
- BB (Contraindicated in CHF, and bradycardia)
- PCI (within 90 mins)
- Statins - ASAP
Cardiac tamponade presentation, diagnosis and treatment
Elevated JVP, hypotension, CLEAR LUNGS
MAT - Echo
EKG - will show electrical alternans (varying amplitude of Peaks) because heart is floating around in the pericardial sac.
Best therapy - immediate pericardiocentesis
After rapid deceleration blunt chest trauma how should aortic injury be assessed?
Once stabilized with airway, breathing and circulation.. patients should be assessed with an upright CXR.
Findings on CXR suggesting aortic injury - widended mediastinum, large left-sided hemothorax, deviation of the mediastinum to the right and disruption of the normal aortic contour.
Confirm diagnosis with CT scanning.
Tx = emergent operative repair.
Where are burr cells seen?
Burr cells (AKA echniocytes) - are spiculated RBCs with serrated edges that can be seen in liver disease and ESRD.
Howell-Jolly Bodies
Small black pellets in RBCs - seen in patients with splenectomy or functional asplenia.
Not seen in healthy individuals - a normal spleen removes howell jolly bodies
Target cells
Central density surrounded by pallor - seen in hemoglobinopathies (thalassemias) or Chronic liver disease (especially obstructive liver disease)
what is treatment for stable angina?
there are 3 main drugs BBs, CCBs, and Nitrates.
BB = first line therapy - work by decreasing myocardial oxygen demand by decreasing contractility (inotropic) and heart rate (chronotropic)
CCBs = 2 types (non dihydropyridine and dihydropyridine)
Non-dihydropyridine are 1st line alternatives when there is a contraindication to BBs. (verapimil / diltiazem)
Dihydrpiridine can be used - they work in 2 ways.
Increase myocardial oxygen supply - coronary vasodilation
Decreaase Myocardial oxygen demand through systemic vasodilation (and thus a decrease in afterload)!!
Nitrates - dilation of venous capacitance vessles anda reduction in cardiac preload. The result is a redcution in Left ventricular wall stress (relieves the pain) and reduced myocardial oxygen demand.
Coarctation of the aorta
Thickening of the tunica media near the junction of the ductus arteriosus and aortic arch
systolic ejection murmur at the left interscapular area.
PDA
how do you keep the duct open? Prostaglandin E2 and LOW O2 tension
How do you close PDA duct? NSAIDS
continous - Machine like murmur
wide pulse pressure - bounding pulses.
elevated BNP in the infant
ECHO = MAT and diagnostic.
Diagnosis based on clincial presentation and ECHO.
Keep open with indomethacin if baby needs it.. like transposition of great vessels.
Isolated systolic hypertension
Important cause of HTN in elderly. Caused by increased stiffness or decreased elasticity of the arteiral wall. It is associated with an increase in cardiovascular morbidity andmortality.
will see very high Systolic BP >140 and a normal diastolic BP <90. (very high pulse pressure).
Manage the same as Hypertension - lifestyle modifications and pharmacologic therapy.
AAA rupture and expansion risk factors
Main risk factors are: Older age (>60) cigarette smoking family history of AAA white race Atherosclerosis
The ones that determine expansion and rupture risk:
Large diameter
Rate of expansion
Current cigarette smoking.
Surprisingly- HTN has a weak association with AAA formation , expansion and rupture. Treatment with BBs or ACE-I does not slow expansion
Diabetics actually have a lower risk of getting AAA (even though they have higher risk of atherosclerosis and cardiovascular disease)
DVT vs Arterial Emboli
Arterial = 6 Ps Pain - acute and suddenly painful Pallor Parestheisas PULSELESSNESS Poikilothermia (cool extermity) Parlysis (due to nerve ischemia)
DVT: Pain (pain is dull and achey) Swelling Tenderness NO PULSELESSNESS In venous thromus!
Leriche Syndrome
arterial occulsuion at the bifurcation of the aorta into the common iliac arteries (AORTOILIAC OCCLUSION), TRIAD OF:
- Bilateral hip, thigh, and buttock claudication
- Absent or dminished femoral pulses and symetric atrophy of lower extremities due to chornic ischemia
- Impotence - almost always present in men with this conditions. If there is no impotenence.. then leriche syndrome is not the diagnosis!
AAA
Abdominal CT (with contrast) in patients who are symptomatic and hemodynamically stable.
Symptomatic - meaning pain radiating to back, abdominal pain, flank pain etc.
in symptomatic or ruptured - you will see severe pain , hypotension and a pulsatile mass
Abdominal Ultrasound: once in a life screening in men who are:
between 65-75 yo
smoked ever
Serial imaging is done in patients who have an AAA < 5cm
Treatment:
stop smoking.
surgical repair in the following:
ruptured
symptomatic but not ruptured
anneurysms >5.5cm!!!
Aortic Dissection Risk factor, diagnosis and treatment
Highest risk factor = Elevated BP
Marfans
Cocaine Use
Clinical features=
sharp, tearing chest or back pain
>20 mm Hg variation in systolic BP between arms
Diagnosis:
BIT -CXR
Confirm with CTA
If theyre unstable just go to OR
For stable - aggressively bring down BP - IV BB / CCB
Marfans and Ehlers danlos are both inheritied connective tissue disorders characterised by degeneration and weakening of themedial layer of the aortic wall. Patietns with these conditios have predisposition to BOTH aortic aneurysms and aortic dissection.
Marfans is responsible for almsot 50% of aortic dissectoins in pateints >40.
In patients greater than 60 marfans is an uncommon cause
Diastolic vs Systolic Murmur next steps
Diastolic and continuous murmurs are usually due to an underlying pathologic cause. Their presence should prompt further evaluation = Transthoracic ECHO!!
Mid-systolic murmurs in young, asymptomatic adults - do not require further evaluation.
Digoxin toxicity and next steps
Digoxin toxicity - nausea, vomiting, diarrhea, vision changes, arrhythmia
Next steps:
get digoxin level
EKG - identify any life threatening arrhytmias
PT/INR - rule out coagulopathies.
