CardioResp Flashcards
List the cardiac questions
Chest pain SOB Palpitations Dizziness/syncope Orthopnoea/PND Peripheral oedema
List modifiable and non modifiable risk factors for IHD
Modifiable: Hypertension Diabetes Obesity Hypercholesterolaemia Smoking Non modifiable: Age Gender Family history
List cardiac differentials for breathlessness
Acute - severe pulmonary oedema, MI, arrhythmia, pericardial disease with effusion
Chronic - LV dysfunction, valvular disease, arrhythmia, pericardial disease with effusion, coronary artery disease
Describe the NYHA classification of chronic heart failure
I - no limitation of physical activity, fatigue, breathlessness, palpitation
II - slight limitation of physical activity + angina
III - marked limitation of physical activity, moderate HF
IV - inability to carry out any physical activity without discomfort, severe HF
List differentials for chest pain
Cardiac - MI, angina, pericarditis Aortic dissection Lung/pleura - pneumothorax MSK - inflammation Oesophagus - GORD, gastritis
Explain ECG axis
aVL - -30 I - 0 II - +60 aVF - +90 III - +120 aVR - -150
How is an ECG calibrated?
Paper runs at 25 mm/s
One large square - 5mm = 0.2s
Five large squares = 1s (300/min)
Rate = 300/R-R
Describe the protocol for interpreting an ECG
- Machine in working order? 25mm/a
- Check correct person “12 lead ECG of…”
- Rate - regular (300/RR) or irregular (QRSs x 6)
- Rhythm - P wave preceded by QRS = sinus. AF = absent P waves, irregular. Atrial flutter = saw tooth P waves, block. VT = 120-180, broad QRS. VF/asystole = capture or fusion beats, concordance.
- Axis
- Intervals - PR, QRS complex, QT
- ST segment/T wave changes
- R wave progression
List the possible locations of ischaemia according to ECG changes
V1-V4 - anteroseptal, LAD V1-V6 - anteroapical, LAD V4-V6 - anterolateral, LAD V5-V6, I, aVL - lateral, circumflex II, III, aVF - inferior, circumflex, RCA V7-V9 - posterior, circumflex
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of aortic stenosis
Pale, sweaty, elderly Sinus rhythm, tachycardia, low BP Low volume, slow rising pulse Normal JVP Apex non displaced, pressure loaded Thrill Ejection systolic, crescendo decrescendo, radiates to carotid (LUB SH DUB)
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of aortic regurgitation
Corrigan’s, de Musset’s, quincke’s, pistol shot femoral
Normal pulse, wide pulse pressure
High volume, collapsing pulse
Normal JVP
Displaced, volume loaded thrill
No thrill
High pitched diastolic murmur, heard best at left sternal edge in expiration with patient leaning forward (LUB DUB SH)
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of tricuspid regurgitation
COPD/lung disease, elephant ears, pulsatile liver
Normal pulse and BP
JVP - giant V waves, sharp Y descent
Normal apex beat
Right ventricular heave
Pansystolic murmur at lower sternal edge, heard best in inspiration (LUB ZZZ DUB)
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of mitral stenosis
Mitral facies (malar flush)
AF
Normal or low volume pulse
Raised JVP
Non displaced, tapping (open snap) apex beat
Right ventricular heave
Rumbling, mid diastolic murmur, heard best with bell in expiration with patient rolled to left (LUB DUB RRR)
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of mitral regurgitation
Normal general appearance, connective tissue disorder, pulse (maybe AF), blood pressure and JVP
Displaced, volume loaded apex beat
Right ventricular heave, thrill (rare)
Pansystolic murmur radiates to axilla (LUB ZZZ DUB)
Describe the general appearance, pulse rate and rhythm, volume and character, internal jugular, apex beat, palpation and auscultation findings of a small VSD
Normal appearance, pulse, block pressure, JVP and apex beat
Thrill at lower left sternal edge
Loud, harsh pansystolic murmur (LUB ZZZ DUB)
List differentials of bradycardia on ECG
Sinus node disease, sinus bradycardia
AV block
Describe the different types of heart block
1st degree - widened PR
2nd degree:
Mobitz I/Wenkebach) - progressive lengthening until a dropped QRS = longer longer longer drop
Mobitz II - intermittent failure of AVN = Ps don’t get through
3rd degree/complete - no synchronisation between Ps and QRS
*escape rhythm will be regular
Define trifascicular block
Bundle branch block
Left axis deviation
Widened PR interval
List differentials of tachycardia on ECG
Narrow complex, regular - sinus tachycardia, SVT, AVRT, AVNRT, atrial flutter, atrial tachycardia
Narrow complex, irregular - AF
Broad complex, regular - antidromic AVRT, VT/BBB
Broad complex, irregular - AF, atrial flutter, pre excited AF, toursades de points
List management of tachycardia
Narrow complex - ABC, O2, IV access, fatal manouvres, adenosine 6mg, antiarrhythmic, DC cardioversion (if haemodynamically unstable)
Broad complex - ABC, arrest call if pulseless, amiodarone/lidocaine, K+/Mg2+ if needed, sedation, DC cardioversion
Define atrial fibrillation
Abnormal heart rhythm, irregular beating of atria
Absent P waves, irregularly irregular on ECG
List some risk factors for AF
Hypertension, valvular heart disease, coronary artery disease, cardiomyopathy
COPD, sleep apnoea, obesity
Excess alcohol, diabetes, thyrotoxicosis
Describe the types of AF
Paroxysmal - spontaneously back to normal <7 days
Persistent - back to normal with assistance/>7 days
Long standing persistent/permanent
List some signs and symptoms of AF
Asymptomatic, palpitations, angina, SOB, tachycardia, irregularly irregular pulse
Describe the management of AF
- Rhythm control - cardioversion (DC/amiodarone/procainamide)
- Rate control - B blockers (bisoprolol, metoprolol), CCB (diltiazem, verapamil), digoxin, amiodarone
- Thromboembolic prophylaxis - warfarin/NOAC
List contraindications of flecainide
Structural heart disease
IHD
What is the CHA2DS2VASC score and when is it used?
To determine if anticoagulation is necessary in AF Congestive heart failure = 1 Hypertension = 1 Age >75 = 2 Diabetes = 1 Stroke/TIA/thromboembolism history = 2 Vascular disease (peripheral artery disease, MI, plaque) = 1 Age 65-74 = 1 Sex female = 1
> 1 consider anticoagulation therapy
2 anticoagulation is recommended
Explain HASBLED score
HTN = 1 Abnormal liver or renal function = 1 Stroke = 1 Bleeding = 2 Labile INR = 1 Elderly = 1 Drugs - NSAIDS, alcohol = 1
What anticoagulation is used for thromboembolic prophylaxis in patients with AF
Warfarin - inhibits vitamin K dependent synthesis of clotting factors *INR monitoring, mechanical valve, moderate/severe mitral stenosis
Dabigatran - thrombin inhibitor
Rivaroxaban - factor Xa inhibitor
Apixaban - factor Xa inhibitor
List scoring systems used in a patient with AF
CHA2DS2VASC
HASBLED*
HEMORR2HAGES*
*bleeding risk
Define the Sokolow-Lyon voltage criteria for LVH
S wave in V1 + R wave in V5/6 = >35 mm or 3.5 large squares
Describe ECG changes of an MI
Acute - ST elevation
Recent - T wave inversion, pathological Q waves
Old - pathological Q waves remain
New onset LBBB
Describe ECG changes of a PE
s1, q3, t3
Large S wave in lead I
Q wave inversion in lead III
T wave inversion in lead III
Describe ECG changes in hyperkalaemia
Low flat P waves
Broad bizarre QRS
Slurring into ST segment
Tall tented T waves
List some causes of heart failure
IHD Non ischaemic dilated cardiomyopathy Hypertension Valvular disease Congenital heart disease Arrhythmias Anaemia Thyrotoxicosis Paget's Pericardial disease Right HF Alcohol/drugs e.g. chemotherapy
List pathophysiological changes in heart failure
Ventricular dilatation Myocyte hypertrophy ANP secretion Salt/water retention Sympathetic stimulation Peripheral vasoconstriction RAS/adrenergic activation
List signs and symptoms of heart failure
Left HF:
Fatigue, exertional dyspnoea, orthopnoea/PND, displaced apex beat, gallop rhythm, mitral regurgitation, lung crackles, pitting oedema
Right HF:
Fatigue, dyspnoea, anorexia/nausea, raised JVP (+/- V waves of tricuspid regurgitation), cardiomegaly, hepatic enlargement, ascites, pitting oedema
Explain the Framingham classification for diagnosis of heart failure
2 major OR 1 major + 2 minor
Major - PND, crepitations, S3 gallop, cardiomegaly, raised CVP, weight loss >4.5kg in 5 days in response to treatment, neck vein distension, acute pulmonary oedema, hepatojugular reflex
Minor - bilateral ankle oedema, dyspnoea on exertion, tachycardia, decreases in vital capacity by half, nocturnal cough, hepatomegaly, pleural effusion
Describe the management of heart failure
General - exercise, low salt diet, stop smoking
Medical - diuretics (furosemide, bumetinide, thiazides), ACEi/ARB, B blockers, spironolactone, inotropic agents (dopamine, dobutamine, digoxin), nitrates, anticoagulation
Non pharmacological - revascularisation, biventricular pacemaker/implantable cardioverter defibrillator, cardiac transplantation, left ventricular assist device/artificial heart
List signs of heart failure on CXR
Alveolar oedema (bat's wings) Kerley B lines Cardiomegaly Dilated prominent upper lobe vessels Pleural effusions
Describe the pathophysiology of atherosclerosis and how that leads to ACS
Injury –> lipoproteins oxidise and combine with macrophages –> foam cells –> cytokines –> fat/smooth muscle proliferation –> plaque –> rupture –> platelet aggregation/adhesion –> localised thrombus, vasoconstriction –> MI
List the initial management of a patient having an MI
Morphine 2.5-10mg IV + antiemetic (metoclopramide 10mg)
Oxygen
Nitrates (GTN 2 puffs sublingual)
Aspirin 300mg or prasugrel 60mg/ticagrelor 180mg
Further management - PCI/thrombolysis
List complications of a STEMI
Sudden death Pump failure/pericarditis Ruptured papillary muscles/septum Embolism Aneurysm/arrhythmias Dressler's syndrome
What medication and further advice should an ACS patient be discharged with
Aspirin ACEi B blockers (bisoprolol) Clopidogrel/prasugrel Statin (simvastatin) Address modifiable risk factors 1 month off work 4 weeks no driving (inform DVLA)
Describe the pathophysiology of infective endocarditis
Endothelial damage/damaged valve –> platelet/fibrin deposit (vegetation) –> bacteraemia –> adherence/colonisation = mitral/aortic regurgitation
Describe the clinical presentation of infective endocarditis
Heart murmur + fever Systemic infection Valvular/cardiac damage (murmur) Embolisation Immune vasculitis (Roth spots, splinter haemorrhages, janeway lesions, oslers nodes)
Explain the Duke’s criteria for infective endocarditis
2 major OR 1 major + 3 minor OR 5 minor
Major - positive blood culture (typical organism in 2 separate cultures/persistently +ve blood cultures), endocardium involved (positive echo/new valvular regurgitation)
Minor - predisposition, fever >38C, vascular/immunological signs, positive blood culture, positive echo
Describe the pathophysiology and causes of pericarditis
Inflamed pericardium –> leukocytes–> vascularisation –> constructive/effusion (tamponade)
Causes - viral, TB, idiopathic, bacteria, MI/dressler’s, renal failure, RA/sarcoid/SLE
List signs, symptoms and treatment of pericarditis
Sharp, central chest pain Worse on inspiration Radiates to left shoulder Eased by sitting forward \+/- dyspnoea \+/- fever Increased heart rate, respiratory rate Pericardial friction rub/knock Kussmaul's sogn Pulsus paradoxus Treatment - treat cause, bed rest, oral NSAIDs/corticosteroid, pericardial window, pericardiectomy
What are Kussmaul’s sign, pulsus paradoxus and beck’s triad
Kussmaul’s sign - JVP raises paradoxically with inspiration
Pulsus paradoxus - systolic pressure weakens in inspiration by >10mmHg
Beck’s triad - raised JVP, low BP, muffled heart sounds
Describe the management of pericardial effusion/cardiac tamponade
medical emergency
ABC, IV access, ECG, bloods
Pericardiocentesis –> drain
(Insert needle at level of xiphisternum, aim for tip of left scapula, aspirate continuously)
Describe ECG changes of pericarditis
Saddle ST elevation –> T wave flattening –> T wave inversion
Describe different types of oxygen devices that provide supplemental oxygen
Nasal cannulae:
Non acute situations or mild hypoxia
Deliver 24-40%
Flow rate 1-4L/min
Simple face mask:
Step up from nasal cannulae but not fixed FiO2
Delivers 30-40%
Flow rate 5-10L/min
Venturi mask:
Delivers 24-60% (24 blue 2-4L, 28 white 4-6L, 35 yellow 8-10L, 40 red 10-12L, 60 green 12-15L)
Non rebreather (reservoir) mask:
Acutely unwell patients
Delivers 85-90%
Flow rate 15L/min
NIV (CPAP/BiPAP):
CPAP for sleep apnoea, HF, acute PE
BiPAP for COPD, atelectasis, ARDS
Invasive ventilation:
Used in intensive care, theatre
Delivers 100%
Describe different severities of asthma in an acute setting
Mild - no features of severe, PEFR >75%
Moderate - no features of severe, PEFR 50-75%
Severe - PEFR 33-50%, cannot complete sentences in one breath, HR >110, RR >25
Life threatening - PEFR <33%, sats <92% or ABG pO2 <8kPa, cyanosis, poor respiratory effort, near or full silent chest, exhaustion, confusion, low BP, arrhythmia, normal pCO2
Near fatal - high pCO2
Describe the management of asthma
Chronic:
BTS guidelines - SABA –> ICS –> +LABA –> increase dose ICS /+LTRA or theophylline –> increase dose ICS /+LTRA or LAMA –> oral steroid
Emergency:
ABCDE, O2, ABG if sats <92%
5mg neb. salbutamol
40mg oral prednisolone STAT or IV hydrocortisone
500 micrograms neb. ipratropium bromide (severe)
ITU/anaesthetist, IV aminophylline or salbutamol (life threatening/near fatal)
Describe the pathophysiology of COPD
Mucous gland hyperplasia
Loss of cilia function
Emphysema
Chronic inflammation
Fibrosis of small airways
Chronic bronchitis = cough/sputum production on most days for 3 months of 2 consecutive years
Emphysema = enlarged air spaces distal to terminal bronchioles with destruction of alveolar walls
Describe the management of COPD
Stable:
Smoking cessation, pulmonary rehabilitation, diet, vaccinations, antimuscarinic/B2 agonist, steroids
(Infective) exacerbation:
ABCDE, O2 via Venturi mask, salbutamol nebs/ipratropium bromide, steroid 30 mg STAT then OD, antibiotics, CXR, consider NIV or ITU referral
What are the requirements for LTOT?
Non smoker
PaO2 <7.3kPa or <8kPa if cor pulmonale
16 hours/day
Describe different severities of COPD
All FVC <0.7 Stage 1 Mild - FEV1 >80% predicted Stage 2 Moderate - FEV1 50-79% predicted Stage 3 Severe - FEV1 30-49% predicted Stage 4 Very Severe - FEV1 <30% predicted
List likely organisms for different types of pneumonia
CAP - streptococcus pneumoniae, haemophilis influenza, mycoplasma pneumoniae, staph. aureus, legionella, moraxella catarrhalis, chlamydia
HAP - G-be enterobacteria, staph. aureus, pseudomonas, klebsiella, bacteroides
Aspiration - orophangeal anaerobes
Immunocompromised - pneumocystis jiroveci, strep. pneumoniae, h. influenzae, s. aureus, m. catarrhalis, m. pneumoniae
Explain a scoring system used to determine severity of pneumonia
CURB-65 Confusion <8 in abbreviated mental test Urea >7 mmol/L RR >30/min BP <90 systolic +/- 60 diastolic >65 years old
0-1 = home treatment 2 = hospital therapy 3 = Severe, consider ITU
Describe management of pneumonia
ABC - pO2 >8.0 +/- sats >94%, IV fluids, VTE prophylaxis, analgesia
Antibiotics according to local guidelines
Mild - oral amox (500mg/8h)
Moderate - oral amox (500mg/8h) + clarithromycin (500mg/12h)
Severe - IV co-amox (1.2g/8h) + clarithromycin (500mg/12h)
HAP - aminoglycoside + 3rd gen cephalosporin IV
Aspiration - cephalosporin + metronidazole IV
List some causes of non resolving pneumonia and some other complications
Complications - respiratory failure, hypotension, AF, pleural effusion, empyema, lung abscess, septicaemia, pericarditis, myocarditis, jaundice Host immunocompromised Antibiotic - dose too low Organism - resistance Second diagnosis - PE, cancer
List some clinical features of TB
Fever, night sweats, malaise, weight loss
Respiratory - cough, sputum, haemoptysis, pleural effusion
Non respiratory - erythema nodosum, lymphadenopathy, arthralgia, pericardial effusion, meningitis
Describe treatment for TB including monitoring required and important ADRs
Check patient’s weight
Rifampicin, isoniazid, pyrazinamide, ethambutol - 2 months
Rifampicin, isoniazid - 4 months
Monitor LFTs, visual acuity, counsel re contraception
ADRs:
Rifampicin - hepatitis, orange secretions, no OCP
Isoniazid - hepatitis, peripheral neuropathy, psychosis
Pyrazinamide - hepatitis, optic neuritis, vomiting, arthralgia
Ethambutol - retrobulbar neuritis
List clinical features of pleural effusion and investigations done on pleural aspirate
Dyspnoea, pleuritic chest pain, decreased lung expansion, decreased breath sounds, stony dull to percussion, bronchial breathing, tracheal deviation away
USS guided pleural aspiration - protein, pH, LDH, glucose, amylase
List some causes of pleural effusion
Transudate - HF, cirrhosis, hypoalbuminaemia (nephrotic syndrome, peritoneal dialysis), hypothyroidism, mitral stenosis, PE, constrictive pericarditis, SCV obstruction
Exudate - malignancy, infection (TB, HIV), inflammatory (RA, pancreatitis, dressler’s), yellow nail syndrome, fungal infections, drugs
What is Light’s criteria?
Used if pleural fluid protein is 25-35g/L
Fluid is an exudate if:
Pleural fluid/serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH is 2/3 upper limit of normal
List signs, symptoms and management of a pneumothorax
Asymptomatic, sudden onset dyspnoea, pleuritic chest pain
Decreased lung expansion, hyperresonance to percussion, decreased breath sounds, trachea deviated away (tension)
Management:
BTS guidelines - O2, aspirate, chest drain
If tension (medical emergency) - large bore needle with saline syringe in 2nd intercostal space MCL, chest drain
List risk factors for a PE
Recent surgery (abdo, pelvic, hip, knee) Thrombophilia e.g. antiphospholipid syndrome Leg fracture Prolonged bed rest, decreased mobility Malignancy (breast, prostate, pelvis) Pregnancy/post partum/OCP/HRT Previous PE
List clinical features, treatment and prevention of PE
Clinical features - acute breathlessness, pleuritic chest pain, haemoptysis, dizziness, syncope, pyrexia, cyanosis, high RR/HR, low BP, raised JVP, pleural rub, pleural effusion, DVT signs
Treatment - anticoagulation (LMWH) until INR >2, start warfarin (for 3 months), thrombolysis
Prevention - compression stockings, heparin, early mobilisation, stop OCP/HRT pre-op
List some risk factors, clinical features and complications of lung cancer
Risk factors - high smoking pack years, increased age (>40), FH of lung history, carcinogen exposure
Clinical features - cough, haemoptysis, dyspnoea, chest pain, anorexia, weight loss, cachexia, anaemia, clubbing, lymphadenopathy, consolidation, collapse, pleural effusion, bone tenderness, hepatomegaly (mets)
Complications - SVC obstruction, Horner’s syndrome, paraneoplastic syndrome (high Ca, SIADH, Cushing’s/Addison’s)
Describe the TNM staging for NSCLC
Primary tumour (T)
Tx malignant cells in bronchial secretions, no other evidence of tumour
TIS - carcinoma in situ
T0 - none evident
T1 - <3cm, in lobar or more distal airway
T2 - >3cm and >2cm distal to carina or any size if pleural involvement or obstructive pneumonitis extending to hilum but not all the lung
T3 - involves chest wall, diaphragm, mediastinal pleura, pericardium, or <2cm from but not at carina. T >7cm diameter and nodules in same lobe
T4 - involves mediastinum, heart, great vessels, trachea, oesophagus, vertebral body, carina, malignant effusion or nodules in another lobe
Regional nodes (N)
N0 - none involved (after mediastinoscopy)
N1 - peribronchial and/or ipsilateral hilum
N2 - ipsilateral mediastinum or subcarinal
N3 - contralateral mediastinum or hilum, scalene or supraclavicular
Distant metastasis (M)
M0 - none
M1a - nodule in other lung, pleural lesions or malignant effusions
M1b - distant metastases present
What is obstructive sleep apnoea? How is it diagnosed and managed?
Intermittent closure/collapse of pharyngeal airway –> apnoeic episodes terminated by partial arousal
>15 episodes in 1 hour
Epworth Sleepiness Scale score >9
Polysomnography
Treatment - weight loss, no evening alcohol, mandibular advancement devices, pharyngeal surgery, CPAP, gastroplasty, tracheostomy
When should an ABG measurement be considered
Unexpected deterioration in an ill patient
Acute exacerbation of a chronic chest condition
Impaired consciousness or impaired respiratory effort
Signs of CO2 retention (bounding pulse, drowsy, tremor, headache)
Cyanosis, confusion, visual hallucinations
Validate measurements from pulse oximetry
List causes of bilateral hilar lymphadenopathy on CXR
Sarcoidosis
Infection (TB, mycoplasma)
Malignancy (lymphoma, carcinoma, mediastinal tumours)
Organic dust disease (silicosis, berylliosis)
Extrinsic allergic alveolitis
List differentials of granulomatous disease
Infections - TB, leprosy, syphillis, cat scratch fever, schistosomiasis
Autoimmune - primary biliary cirrhosis, granulomatous orchitis
Vasculitis - GCA, polyarteritis nodosa, takayasu’s arteritis, Wegener’s granulomatosis
Idiopathic - Crohn’s disease, de Quervain’s thyroiditis, sarcoidosis
List differentials for a nodule in the lung on a CXR
Malignancy (primary/secondary) Abscesses Granuloma Carcinoid tumour Arterio-venous malformation Encysted effusion (fluid, blood, pus) Cyst Foreign body Skin tumour (seborrhoeic wart)
List some causes of an upper lobe infection
Aspergillosis
TB
Klebsiella
Staph. aureus
