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.
Sudden cardiac arrest next steps
The most common cause of suddent cardiac arrest (out of hospital) is Vtach or Vfib due to actue MI or ischemia.
The most cirtical factor determingin overall patient survival is elapsed time to effective resucitation, this includes 3 things:
- CPR (chest compression only)
- Prompt rhythm analysis
- Early Defibrilation (for patients in shockable rhythm)
V-fib almost never terminates spontaneously, and early rhytm analysis and defibrillation are the only effective means to reestablish perfusing cardiac rhythm and imporve patient survial.
adenosien and dipyridamole MOA vs Dobutamine
Adenosine and dipyridamole = coronary artery dilators without increasing HR or BP.
Dobutamine - B-1 agonist. Increased HR and BP.
Blunt trauma - aortic injury vs myocardical contusion
after a fall from height or car accident
aortic injury - HTN / tachy and anxiety (very vague symptoms) must have high suspicion and do a CXR (BIT) will see mediastinal widening - this is the most sensitive test for blunt aortic injury. Deviation of the trachea or ng tuve to the right or depression of the left mainstem bronchus may alsob e seen.
If CXR and history arent giving the diangoinsi the CHest CT and angio are approriate.
Myocardial contusion may also result from blunt trauma - tachy, is also seen on CXR here you may see rib fracture - which commonly can lead to cardiac contusion.
Mediastinal widening is not seen in cardiac contusion.
Blunt chest injury - pulmonary contusion
pulmonary contusion is the most common finding after blunt chest injury - CXR reveals opacities caused by hemorrhage in the involved lung segments
Traumatic diaphragmatic rupture
On CXR will see herniation of abdominal contents (stomach, intestine, spleen) into the thorax
What is treatment for Torsades?
Hemodynamically unstable - Immediate Defibrilation.
Hemodynamically stable - Mag sulfate
What is treatment to terminate PSVT rhythm?
Adenosine
What is treatment for Atrial tach or Vtach?
Amiodarone - class 3 antiarrhythmic.
What is treatment for symptomatic sinus bradycardia or AVnodal block>
Atropine
holosystolic murmur at left lower sternal border?
vsd
grade 1 or 2 murmur - no follow up
Grade 3 or higher - echo
joint hypermobility pectus excavatum scoliosis high arched palate poor wound heeling abdominal and inguinal hernias
COL5A1 or COL5A2 mutations
Ehlers danlos
Join hypermobility
pectus excavatum
scoliosis
tall with long extremities
NO BRUSING problems
Lens / retinal detachment
FBN1 Mutation
Marfans
Acute pyelonephritis will be posititive for what on Urine Dipstick?
BOTH
nitrites - ecoli
esterase - Pyuria.
What are the two ways HOCM is caused?
Mutation in the Cardiac Myosin binding protein C gene
or
Mutation in the Cardiac Beta Myosin Heavy chain gene.
pain in right anterior thigh when which is worse when walking and a small PULSATLIE mass in the right groin area
Femoral Artery Aneurysm.
the pain is caused by the anneurysm compressing on the femoral nerve which is right next to the artery.
this is the 2nd most common peripheral artery aneurysm after popliteal aneurysm
Holosystolic mumur heard at the lower sternal border and increases with INSPIRATION
Tricuspid Regurg
What is the treatment for Left ventricular systolid dysfunction?
Reduced EF / signs of pulmon edema?
Loops + ACE-I or ARB
may add BB
what is treatment for idiopathic pulmonary hypertention?
Endothelin Receptor Antagonists - Bosentan
or
PDE5 inhibitors - Sildenafil
or
Prostanoids - Epoprostenol
which cardiac drug can cause the following side effects? fluid retention peripheral edema palpitations ortho static hypotension Drug induced lupus like syndrome
Hydralazine
Prego + New onset HTN + Proteinturia or end organ dagmage at 20 weeks gestation or later
PREECLAMPSIA
Preeclampsia + Seizure
Eclampsia
Treatment of Eclampsia = Mag Sulfate
The seizure itself abates after 3-4 minutes. The purpose of giving mag sulfate is to prevent further seizures.
after mag sulfate give something for blood pressure control (HMLN)
deliver the baby - expediant delivery. This is the only cure for eclampsia… delivery of the baby.
Intrauterine Fetal demise + Growth restriction + multiple limb fractures + hypoplastic thoracic cavity
Type 2 OSTEOGENESIS IMPERFECTA
AD disorder caused by defective systhenesis of TYPE 1 COLLAGEN.
type 2 is lethal. Most patients die inutero.
Macrocephaly + Frontal Bossing + Midface hypoplasia + genu varum + Limb Shortening + trident hand (large gap between ring and middle finger)
Achondroplasia.
Non lethal autosomal dominant bone dysplasia.
Early Diastolic high pitchted murmur
Water hammer pulse
Wide pulse pressure
Aortic Regurg
Widened pulse pressure - Increase SBP and decreased DBP
Abrupt carotid distension and collapse “pistol shot” femoral pulses
Back flow from aorta to LV –> increased LVEDV
LV initially compensates with ECCENTRIC hypertrophy –> Increased SV and CO
Eventually the LV dysfunction –> Decreased SV and CO –> heart failure
What is the most likely cause of nephrotic syndrome in a patient with Hep B?
Membranous nephropathy.
even if its a kid with nephrotic.. if that kid has hep b.. then its membranoous nephropathy as the most likely cause.
what are the most common causes of membranous nephropathy in adults?
FSGS and Membranous nephropathy
what are the most common causes of Nephritic syndrome in kdis?
PSGN and HUS
What are the most common causes of nephritic syndrome in adults?
IgA nephropathy
Membranous glomerulonephritis
and
crescentic clomerulonephritis
Neonate with meningitis has Seizure + Temporal lobe hemorrhage and edema + patchy areas of increased attenuation in the cerebral cortex
what is the most likely cause?
HSV
Fixed splitting of the 2nd heart sound + enlarged right atrium and ventricle on x-ray and prominent hilar or proximal pulmonary arterial vasculatrue
ASD.
Blood goes from left to right heart.. causing right heart to enlarge. Also right heart is now sending more blood to lungs –> increased pulmon vasculature.
Patient with NEW onset SHARP chest pain, that is worse with deep breathing (pleuritic), and pain with swallowing. Scratchy sound on auscultatoin (friction rub)
EKG shows diffuse PR DEPRESSION (due to inflammation of atrial myocardium) and Diffuse ST ELEVATION (due to inflammation of ventricular myocardium)
Viral Pericarditis.
What is the treatment for viral pericarditis?
NSAIDS + Colchicine - for viral or idiopathic
Colchicine is given because it decreases the rate of recurrent pericarditis in these patients.
Hemodialisis for non viral - patients with pericarditis and ESRD
Corticosteroids (prednisone) are only added after NSAIDS / Colchicine fail.
in a pregnant patient what 3 things are assessed at 24-28 weeks?
Hemoglobin / hematocrit
ANtibody screen if Rh(D) negative
50-g 1 hour GCT
middle aged woman with Lower abdominal pain, urinary frequency and urgency. Relife after urinating. Dysparenuria… all negative tests for bacteria.
Interstitial Cystitis AKA bladder pain syndrome.
Associated with pscyh issues - fibromyalgia
Treatment - behavioral modification
Child born with Thin, loose skin, thin umbilical cord, and wide/large anterior fontanel
Fetal Growth Restriction - children will characteristically present like that.
Cause can be maternal or placental.
after birth its important to send teh Placenta in for HISTOPATHOLOGIC examination to evaluate for the presence of infarction and or infection.
