Ch 7. Cardio & Resp Flashcards
What are the Major causes of syncope? (5)
- Vasovagal/reflex mediated - 21%
- Cardiac - 10%
- Orthostatic hypotension- 9%
- Medication related - 7%
- Neurologic - 4%
- Unknown - 37% (After ED investigation this is about 50-60%)
ECG findings of syncope? (8)
- Bradydysrhythmias
- Short QT
- Long QT
- Second/third-degree heart block
- Tachydysrhythmias - Ventricular tachycardia
- Brugada
- WPW
- ARVD
- S1Q3T3 or right heart strain (PE)
- Signs of ischemia
- Signs of tamponade
What cardiopulmonary diseases can cause syncope? (excluding dysrhythmias) -(8)
- Valvular heart disease - eg aortic stenosis, tricuspid stenosis, mitral stenosis
- Cardiomyopathy (hypertrophic)
- Pulmonary hypertension
- Congenital heart disease
- Myxoma
- Pericardial disease / tamponade
- Aortic dissection
- Aortic stenosis
- PE
- MI
What are the classic symptoms of severe aortic stenosis? (3)
- Syncope
- Angina
- Dyspnea (exertional)
Syncope red flags (5)
Syncope AND… syncope AND chest pain AND palpitations AND HA AND back pain etc
- Chest pain (MI, PE, aortic stenosis, aortic dissection)
- Palpitations (dysrhythmias)
- Shortness of breath (PE, CHF)
- Headache (subarachnoid hemorrhage)
- Abdominal or back pain (AAA, ectopic pregnancy)
- Sudden onset without any warning (dysrhythmias)
What are high risk features of syncope? I.E. Admit these syncope patients! (3)
- Abnormal ECG
- History of cardiac disease especially CHF
- Syncope during exercise or supine
- Age >65
- FHx early cardiac death
Treatment of shock refractory VF/VT (5)
- STOP epi (this is catecholamine surge – bad)
- Minimize interuptions in pulse checks
- Double defibrillation – two sets of pads on
- Esmolol 0.5mg/kg bolus, then 50mcg/kg/min infusion
- Consider amiodarone or lidocaine or procainamide
Signs/symptoms of infective endocarditis (5)
- Chest pain
2. Vitals: fever, tachycardia, hypotension, hypoxia - Heart failure
- New murmur
- Hematuria (60-70%)
- Splinter hemorrhage, Osler’s nodes, Janeway lesions, Roth spots (retina)
- Stroke
- The major DUKE criteria are BCx + endocarditis bug and positive ECHO
- * TEE is BETTER (>90% sens), but TTE is the first screening test * Rx. Ceftriaxone + Vanco
What is Lemierre’s syndrome (1)
- Septic venous thrombus of the internal jugular vein
Common Causes of Heart Failure (10)
- MI
- HTN
- Dysrhythmia – esp A Fib
- Valvular disease (Aortic, mitral, Prosthetic)
- Left ventricular outflow tract obstruction
- Cardiomyopathy (Hypertrophic, Dilated, Restrictive)
- Acquired cardiomyopathy (Toxin – EtOH, cocaine, doxorubicin, or Metabolic – thyrotoxicosis, myxedema)
- Myocarditis
- Restrictive pericarditis
- Cardiac tamponade
- Anemia
Risk factors for AHF (6)
- HTN
- Diabetes
- Valvular heart disease
- Advanced age
- Male sex
- Obesity
- Sympathomimetic use
NYHA Classification of Symptoms (4)
- Class I – No limitation on physical activity
- Class II – Slight limitation on physical activity usually with exertion (>2 flights of stairs)
- Class III – Marked limitations on physical activity usually with normal activity ( <2 flights of stairs)
- Class IV – Symptoms occur at rest
Difference between systolic and diastolic HF (2)
- Systolic is associated with a LVEF < 50% (results in afterload sensitivity)
- Diastolic if LVEF > 50% (results in preload sensitivity)
CXR findings in AHF (6)
- Vascular redistribution
- Kerley B lines
- Interstitial edema
- Peribronchial cuffing
- Cardiomegaly
- Pleural effusions
Most sensitive symptom of acute heart failure (1)
- Dyspnea on exertion (84%)
Most specific symptoms for AHF (3)
- Orthopnea
- Paroxysmal nocturnal dyspnea
- Peripheral edema
Precipitants of AHF (6)
- Nonadherance - either to medications or diet (increased salt or fluid intake)
- Renal failure (esp missed dialysis)
- Substance abuse (cocaine, meth, alcohol)
- Poorly controlled HTN
- Iatrogenic (new negative ionotropic med (BB, CCBs) or salt retaining drugs (NSAIDS, steroids)
- Tachyarrythmia induced – Such as A Fib or Pacemaker-mediated
Management of AHF (sBP > 140) (4)
- Oxygen to maintain sats > 95%
- Nitroglycerine (SL 0.4mg q1-5 mins prn OR IV NTG 20-400 mcg/min
- Loop diuretics (Lasix) in setting of volume overload (20-40mg IV, or 2X home dose)
- NIPPV
Criteria for massive and sub-massive PE (2)
- Massive = shocky patient not responsive to pressors (sBP<90, cardiac arrest,
- Sub-massive PE = right heart strain, + troponin
Treatment of the hypotensive PE patient (4)
- Preload – don’t fluid overload (250-500mL boluses)
- Correct pulmonary vasculature resistance (correct oxygenation, acidosis)
- Anticoagulate (heparin +/- TPA)
- NorEpi/Epi for forward flow
** Only intubate a PE if they are about to arrest or peri-arrest
** If you intubate keep PEEP low (<6) and TV low (6mL/kg)
Mechanisms of hypoxemia (5)
- Low inspired O2 (Carbon monoxide, altitude)
- Hypoventilation (hypoxemic respiratory failure) – associated with elevated CO2.
- Right to left shunt (doesn’t improve with applied oxygen)
- VQ mismatch (PE, pneumonia, ARDS)
- Diffusion impairment (interstitial lung disease, ARDS)
Components of the PRAM score (5)
- Suprasternal indrawing
- Scalene retractions
- Wheeze
- Air entry (decreased)
- O2 sats (less than 93
) * PRAM is then score 0-4 (mild), 5-8 (moderate), 9-12 (severe)
Asthma treatment (moderate) (3)
- Ventolin with MDI+spacer <20kg 5 puffs, >20kg 10 puffs Q20MIN x3 (Or Ventolin via neb 5mL)
- Ipratropium with MDI+spacer 5 puffs Q20MIN x3 * After one hour reassess and continue with Ventolin Q20min or Q30min Q1H etc
- Dexamethasone 0.3mg/kg PO (Max 10mg)
Severe asthma treatment options (6)
- Ventolin
- Atrovent (iptratropium)
3.Dexamethasone/methylprednisolone 2mg/kg max 80mg - MgSO4 25mg/kg (max 2g IV)
- EPI IV or IM
- IV Ventolin
- Inhaled anaesthetic
- Inhaled nitrous oxide
- NIPPV
Signs of impending respiratory failure in pneumonia/COPD (5)
- Accessory muscle use
- Altered mental status
- Paradoxical breathing
- Diaphoresis
5. Silent chest
Three cardinal symptoms of COPD exacerbation (3)
- Increased dyspnea
- Increased sputum production
- Increased sputum purulence
* You need 2/3 symptoms to diagnose AE-COPD*
Treatment of AE-COPD (5)
- Ventolin (MDI or neb) – Ventolin neb 5mg inhaled continuous
2. Atrovent (ipratropium) – Atrovent neb 5mg inhaled continuous - Prednisone 50mg PO x3-5d or solumedrol 125mg IV
- Magnesium 2g IV
- BiPAP – highly effective for COPD!
- Doxy, Clavulin, Levofloxacin, Ceftriax + Azithro, 5 days
Ventilation strategy in COPD (3)
- Use a large ETT (8 or bigger)
- Low tidal volumes (4-5mL/kg)
- Low vent rates (10 per minute)
- Long I:E ratio
DDx of hemoptysis (8)
*Bronchiectasis, bronchitis, bronchogenic carcinoma, tB *
1. Bronchiectasis or bronchitis
2. Malignancy (bronchogenic carcinoma)
3. Vascular (vasculitis, AVM)
4. Pneumonia, lung abscess, fungal infection
5. TB
6. PE
7. CHF
8. Valvular heart disease
9. Trauma, foreign body
10. Aorto-tracheal fistula after aneurysm repair
*Consider hemoptysis as blood-streaked or massive hemoptysis
**Also consider oropharynx and epistaxis and GI sources.
Definition of massive hemoptysis? (1) Vascular etiology of hemoptysis? (1) Approach to massive hemoptysis (3)
- Hemoptysis = 100mL /hr (or about 1 cup)
- Etiology = bronchial circulation (1% of blood flow in the lungs, but 90% of cases because it is a high flow system. The pulmonary arteries are very low pressure.
Approach to hemoptysis:
1. Secure airway – biggest tube possible - Bleeding lung down ?maybe
- Selective mainstem intubation of the non-affected lung
- Reverse anti-coagulation
- Urgent bronch, angiography and embolization, surgery, ECMO
Define Hospital acquired pneumonia (1)
- Patient has extensive healthcare contact: IV chemo, nursing home, hospitalized in the last 90 days, dialysis
* Higher risk for Staph aureus, Klebsiella, pseudomonas
Rx. Ceftriaxone + Azithro. Or Levofloxacin if outpatient
MRSA drug coverage (6)
1. Doxycycline 2. Septra 3. Vanco 4. Cipro 5. Linezolid 6. Clindamycin
Three physiological targets to treat in aortic dissection (3)
- TREAT PAIN! (Fentanyl, Hydromorphone)
- HR target < 60
- sBP target < 110
Differential diagnosis for cavitary lung lesion (5)
- Klebsiella pneumoniae
- Staph pyogenes
3. TB - Aspiration pneumonia
- Bronchogenic carcinoma
- MAC
7. Wegener’s granulomatosis - Bullae
- Pulmonary infarctions
Differential diagnosis for mediastinal lymphadenopathy (3)
- Lymphoma
- Sarcoidosis (bilateral, symmetrical)
- TB
Complications of TB (6)
- Pneumonia
- Empyema
- Sepsis (military TB)
4. Peritoneal TB - Hepatosplenomegaly
6. Prostatitis - Epididymitis/orchitis
- Adrenal insufficiency
- TB osteomyelitis
10. Meningitis