CARDIOVASCULAR EMERGENCIES Flashcards
What are the causes of cardiac ischemia chest pain?
Angina pectoris (atherosclerosis) Acute coronary artery syndrome (thrombosis)
If a patient’s chest pain is sharp and worse with inspiration, what type of pain is it?
Pleuritic chest pain
What are some big things we should keep on DDx from the cardiac system, when a patient presents with chest pain?
MI, Pericarditis, aortic dissection, mitral valve prolapse, and PE
What should we keep on our DDx from the pulmonary system in a patient with chest pain?
Pneumothorax, pulm HTN, pneumonia
What should we keep on our DDx from the neuromuscular system in a patient with chest pain?
Chest wall pain, costochontritis, herpers zoster, cervical disc disease, thoracic outlet syndrome
What should we keep on our DDx from the GI system in a patient with chest pain?
Esophageal spasm, GERD, PUD, pancreatitis, gallbladder
With what diagnosis is admission essential?
MI, unstable angina, PE, aortic dissection, and spontaneous pneumothorax
If a patient presents with intense, sharp, inspiratory chest pain that started yesterday and has gotten progressively worse. They also note pain is worse while lying flat - what diagnosis are you thinking? What should you be sure to ask the patient about their history?
Pericarditis Any recent illnesses?
The patient tells you that 2 weeks ago she had an upper respiratory infection, which further heightens your suspicion for pericarditis. What position is ideal for examining someone with pericarditis? What would you hear?
Sitting up, leaning forward, and blow out all air Hear → pericardial friction rub!
Besides a pericardial friction rub, what other sound goes through systole to diastole?
PDA
What will you see on EKG with pericarditis?
ST Elevation that is diffuse!
What do you see?
Diffuse ST elevation (remember most patients don’t infarct everywhere!)
What are the 3 P’s associated with pericarditis?
Position, Palpation, and Pleuritic
Besides laying down, what else aggravates pericarditis?
Movement, coughing, swallowing, and even a bump on the road
Besides pleuritic chest pain, how else can pericarditis present?
Can mimic an MI!!
What is the most common cause of pericarditis?
Viral – Coxsackie virus
What are other causes of pericarditis?
Uremia, radiation, Autoimmune diseases, and drug induced (hydralazine, procainamide, isoniazid, and PCN) Can also present = Early post MI (2nd or 3rd day) or delayed myocardial-pericardial injury syndromes (last post-MI [dressler’s syndrome] or post heart surgery [postpericardotomy syndrome])
You have heard the pericardial friction rub and have found diffuse ST segment elevation – what do you do next for pericarditis?
Echo! For pericardial effusion If present you will need to repeat in order to prove it has resolved
How do you treat pericarditis?
NSAIDs (should resolve in days to weeks)
What must you absolutely avoid in pericarditis (especially if there’s an effusion)?
Anticoagulants!! → can lead to cardiac tamponade and kill the patient AKA truly make sure it’s not an MI…
If a patient presents with acute aching, substernal chest pain with SOB. You learn she is on an OCP and pain started one hour ago. She is tachycardic but no murmurs, rubs of gallops, and lungs clear – what should you think?
Pulmonary Embolism!!
What labs should you order if you suspect a PE?
CBC, PTT, INR, and D-Dimer
What should we always remember about a d-dimer?
It’s elevated in the presence of thrombus = sensitive But not very specific…
What ECG findings would you see with a PE?
ST & NSST-T changes
What would a chest x-ray show with a PE?
Atelectasis, pleural effusion
You get your d-dimer results back and they are elevated in the patient you suspect has a PE, what do you do next?
Helical CT Angiography
If the Helical CTA comes back inconclusive for a PE, what should you do next?
DVT studies (LE U/S)
What are the rates of mortality if you miss the diagnosis of a PE?
40-50%
What are some of the major risk factors for a PE (and DVT)?
Stasis (pregnancy, bed rest, surgery, immobilization) Hypercoagulability (OCP!! And Factor V Leiden)
Let’s say that that the CTA identifies a large thrombus in the left pulmonary artery – what do you do next?
Full anticoagulation for MINIMUM 3-6 (more like 6) months
What are the options for full anticoagulation?
Heparin (have to closely monitor PTT for 5-7 days) LMWH (without need to monitor for 5-7 days) → Warfarin Or dabigatran, rivaroxaban, and apixaban
What is the goal range for INR for PE?
2-3
A patient presents with severe substernal chest pain radiating to the left arm that started 30 minutes ago. You ask about any abdominal pain or changes and he mentions having indigestion/belching for the past few weeks – what diagnosis are you thinking?
MI!!
What would you hear on PE with an MI? What position is it best heard in?
Instead of lub-dub you now hear Blub-dub = S4 gallop! (occurs right before S1) Heard best with patient lying on their side
If a patient has high cholesterol what might you notice on their face?
Xanthelasma
What do you see on this ECG?
ST segment elevation V2-V6 & pathological Q waves are presenting
If you see ST segment elevation in V2-V6, what part of the heart is the MI occurring in?
Anteriolateral MI
In general, how does a STEMI present?
With deep, crushing, heavy, squeezing, almost burning chest pain That’s more severe than angina type pain
Where can the pain of an MI radiate too? What is it often mistaken for?
Arms, neck, jaw Often mistaken for indigestion
What causes an MI?
CAD, plaque rupture or an occlusive thrombus, which leads to no perfusion in effected myocardium
What must we always remember about females and diabetics with MI’s?
Atypical presentations → often painless
What should we always look for in the neck of a patient with chest pain?
Look for JVD and palpate the carotids
If a patient presents to the ED with deep, crushing, chest pain, what happens initially?
Triage, check O2 sat, IV fluids/draw labs, give ASA or sl NTG, get an ECG within minutes of arrival!!
What is the diagnostic criteria of an MI on ECG?
Greater than or equal to 2mm of ST elevation or greater than 1mm of ST elevation in 2 adjacent leads
How do we treat the chest pain of an MI?
NTG, Morphine sulfate, and Beta-blockers
What labs do we order when we suspect an MI?
CBC, cardiac markers (serial troponins), INR, PTT, electrolytes, Cr, BUN, Mg, glucose, and lipids May also want to get an Echo
What strategies can we utilize to reperfuse a patient with an MI?
Acute PCI – must be “door to balloon” in under 90 minutes The absolute latest would be 120 minutes Otherwise: Fibrinolysis (tPA) – must initiate within 30 minutes from the onset of sxs
What are the problems with each reperfusion technique?
PCI is not always available at every hospital Fibrinolysis has a major risk of bleeding
What are absolute contraindications to tPA?
Hx of cerebrovascular hemorrhage, prior stoke (within 1 year), HTM greater than 180/110, active bleeding, and recent head trauma or recent surgery
Everyone after a STEMI must be be on what drug long term?
ASA
What if we are in a remote area and PCI is not available?
Can give fibrinolytic agent to transport patient. PCI must be performed 3-6 hours later.
A patient presents with tearing, unrelenting chest pain that is radiating to the mid back – what diagnosis?
Aortic dissection
What type of murmur might you hear with an aortic dissection?
High pitched holosystolic (MR murmur)
What imaging should you order with an aortic dissection? What would you see?
Echo – LVH with a decreased EF CT of chest/abdomen
If a CT reveals an aortic dissection that extends from below the left subclavian artery down towards the abdominal aorta – what type is it?
Type B Aortic Dissection
If an aortic dissection is before the right subclavian artery and begins in the aortic arch, what type is it?
Type A Aortic Dissection
What is the pathology behind an aortic dissection?
Spontaneous tear in intima of aorta allows blood to dissect into media – separating the aortic wall. Associated with long standing, poorly controlled HTN
How do we initially treat an aortic dissection?
MUST LOWER BP ASAP – Use Beta Blockers!! (just beware if patient has COPD)
What types of Beta Blockers can we use IV to treat an aortic dissection?
Labetalol or Esmolol (can add nitroprusside if needed)
What type of aortic dissection must undergo surgery?
Type A MUST If Type B dissects into the arterial branch occlusion or progressive dissection = urgent surgical repair. Otherwise, if patient stabilizes use medical Rx to keep BP near 100mmHg
