Cardiovascular

Question 1

Elevated Trops?

Answer 1

0.014 - normal
0.014- 0.1 - micro MI, myocarditis, heart failure, CKD, sepsis, hypertensive crisis, stroke, and SAH
0.1-1 - small to moderate MI, myocarditis, heart failure, OE, CKD, sepsis
1-10 - large MI, myocarditis, PE, critical illness
>10 - very large MI, myocarditis

Question 2

Causes of ST elevation

Answer 2

MI, Pericarditis, Benign Early Depolarization, Aortic Dissection, PE, electrolyte abnormalities

Question 3

Types of narrow complex tachycardia?

Answer 3

Narrow complex tachycardia = SVTs trigged above the ventricle and is using the septum to depolarize the ventricles so this is FAST conduction.
Sinus - lots of causes - nodal system intact, something making heart rate fast, vagus or circulation of sympathetic hormones
A.fib/Aflutter - nodal system intact but activated from other spots in the atria, SA signal doesn’t get through
AV N/RT - problem is with the AV node itself or accessory pathway causing a loop, but still going in the right direction

Question 4

Types of wide complex tachycardia?

Answer 4

Depolarization occurring outside of the septum in the ventricle itself - slow = wide complex.
Ventricular tachycardia - usually monomorphic
Torsades de Pointes - polymorphic

Things that slow down the conducting system = BBB (either left or right) wide is because half is fast and slow. This is a SVT but looks wide.

Question 5

Rule for LBBB vs RBBB

Answer 5

William
Morrow
V1 to V6

Thinking about the direction of travel of the vector to the V1 and V6 leads.

Question 6

Classes of anti-arrhythmics

Answer 6

Class 1: Na+ channel blocker - levels (A,B,C) Quinidine, Lidocaine, Propafenone
Class 2: metoprolol, propranolol - Beta blocker
Class 3: K+ channel blocker - amioderone
Class 4: Verapamil/ Diltazem - Ca++ blocker (nondipyramide)

Question 7

Anti-arrhythmics that act on the AV/SA nodes and should be avoided in wide complex?

Answer 7

CCBs and Beta-blockers, also avoid digitalis and adenosine

Question 8

When to follow up on an aortic aneurysm?

Answer 8

Follow up starting at 4.5cm, need to refer to specialist at 5cm

Question 9

Bradycardia, no P waves, double peaked Ts?

Answer 9

Junctional rhythm - rhythm not generated from the SA node but from AV

Question 10

Q waves, inverted Ts?

Answer 10

Both signs of previous MI/ myocardial ischemic changes

Question 11

What bleeds in trauma?

Answer 11

Spleen, kidney - floppy structures.

Question 12

What holds your blood in a trauma?

Answer 12

Abdomen (check Morrison pouch) 
Thigh (up to a litre) 
Pelvis (pouch of Douglas) 
Thorax (hemothorax) 
Retroperitoneal (back pain)

Question 13

Initial management of a shock?

Answer 13

Rule out trauma - every hole and tube or a finger (rectal, catheter, ETT, or sweep)
Try to get a GCS
Give saline, morphine for pain and Ancef
(Consider IVIG if strong tetanus concern, can give shot over the next few weeks)

SAMPLE
Check for subcutaneous emphysema
Flail chest, bowel sounds, Hbg, type and cross (if you know you are giving blood)
X-ray - cross table lateral to clear C-Spine (usually C1/2 and C6/7 fractured)
GET A URINE
Measure output

(Fill the tank, squeeze the tank, flog the heart)
Fluids, pressers, ionotropes)

Question 14

Most common sign of right heart failure?

Answer 14

Left heart failure

Question 15

Cor pulmonale

Answer 15

RH failure due most commonly to pulmonary HTN

Question 16

Low platelets - when do we need to anticoagulate?

Answer 16

Can start DVT prophylaxis around >100 platelets

Question 17

How much should you down with daily in CHF weights

Answer 17

1kg/day

Question 18

Wellen’s criteria?

Answer 18

Deep inverted T’s -sign of high grade t-wave inversion

Question 19

Duke’s criteria

Answer 19

For risk of endocarditis

Question 20

DDX for atypical heart failure

Answer 20

Vascular - ischemic, HTN, tachycardia induced cardiomyopathy (a.fib)
Infectious - post-viral/myocarditis, HIV, Chagas, TB (constrictive pericarditis)
Neoplastic - not so much
Drugs - alcohol, chemo (Doxyrubicin, herceptin), radiation can cause constrictive pericarditis, cocaine
Iatrogenic/ infiltrate/ idiopathic - amyloid/sarcoid, hemochromatosis,
Congenital - HOCM, peds stuff
Autoimmune - Giant cell myocarditis
Trauma - takotsubo (apical ballooning, stress related HF)
Endocrine/metabolic - thyroid dysfunction/ pheo/ Cushing’s/acromegaly

*VALVULAR

Question 21

Investigations for atypical HF

Answer 21

Viral serology, HIV, HX, SPEP, total protein, CXR, calcium, ECG (low voltage, bradycardia, iron studies - ferritin/saturation/ genetic test for hemochromatosis, cardiac MRI, Cardiac PET, hormone levels (TSH, ACTH)

Always: Trops, TSH, echo, Iron studies (ferritin)

Question 22

Triad of critical AS?

Answer 22

Dyspnea, syncope, angina

Question 23

The 4 Ds of vertebrobasilar TIA/ stroke

Answer 23

Dysphagia, Diplopia, Dysarthria, Drop attacks (dizziness)

Question 24

DDX for bradycardia

Answer 24

Meds, athletes, ACS (inferior), OSA, hyperK+, increased ICP (Cushing’s triad),

Question 25

No P waves, narrow QRS complex

Answer 25

From AV node (junctional rhythm)

Question 26

Causes of hyperkalemia

Answer 26

Insulin deficiency, decreasing kidney function, ARBS/ACE/Spironolactone, diet, constipation.

Question 27

Tx of HyperK+

Answer 27

Ca+ gluc (1-2g), Insulin (IV - regular, 10 units, with D50 - one amp), to stabilize the membrane and shift the potassium. Can give ++ ventolin, and give bicarbonate (if acidosis). Give fluids, and lasix at the same time (can work)

Don’t give CaCl - unless pt is coding. Causes soft tissue burns if IV goes interstitial.

Kayexalate. Longer term management.