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