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
What are 4 TB meds. Complications (8)
RIPE 1. Rifampin - hepatitis 2. Isoniazid (INH) – hepatitis. B6 deficiency. Peripheral neuropathy. Seizures 3. Pyrazinamide - hepatitis 4. Ethambutol – hepatitis.
TB risk factors (6)
- HIV
- Immigrant
3. First Nations
4. Elderly (or very young) - Alcoholic
6. Homeless
7. IVDU - Healthcare worker
- Exposure to family member with known TB
What is the acceptable risk of PE to send somebody home? (1)
- < 1.4%, the “no-test threshold” * The risk of investigating past this gives you more harm than benefit. PERC negative gets <1.4%
What is the lifetime risk of cancer for a CT-chest in a 25yoF, 50yoF, 25yoM (3)
- CT-PE in a 25yo F = 1/400
2. CT-PE in a 50yo F = 1/1,000 - CT-PE in a 25yo M = 1/2,000 (low risk breast cancer)
Well’s rule for PE (7)
Suspect a DVT, Suspect another Dx less, HR, Immobilized, Prior Hx, coughing up blood because of cancer
1. Suspected DVT +3
2. Alternative diagnosis less likely than PE +3
3. HR >100 +1.5
4. Immobilized/surgery last 4 weeks +1.5
5. Previous DVT/PE +1.5
6. Hemoptysis +1
7. Malignancy (active) +1
Use a Well’s score of <4.5 = dimer and >4.5 = direct to CT
Well’s rule for DVT (8)
C4P4 1. Cancer 2. Calf swelling 3. Collateral superficial veins 4. Calf pitting edema 5. Pain to leg 6. Pitting edema to leg 7. Prev surgery/immobilized (4 weeks) 8. Prev DVT
PERC rule (8)
* Only use PERC if they are LOW RISK. Well’s <2 HAD CLOTS (8) 1. Hemoptyis 2. Age > 50 3. DVT/PE prev 4. Contraception (OCP) 5. Leg swelling 6. O2 sats <95% 7. Tachy >100 8. Surgery/trauma recently Sn = 97%, NPV 99.5%
Does fever decrease PE risk? (1)
Does travel increase DVT/PE risk? (1)
- Only if >39.2 is PE less likely. 10% or PE have a temp >38.0
2. Travel increases DVT risk if >6hours
What is a good negative likelihood ratio? (1)
- 0.1 is good. 0.2 is OK. 0.5 is useless
Describe the approach to PE diagnosis (3)
- Well’s for low risk or high risk
- If low risk, apply PERC: PERC negative you’re done.
- If wells high >4.5 then straight to CT
- If Wells low, use D-dimer
5. If Dimer +, CT scan
Treatment of PE (1), or PE with active cancer (1)
- Treatment of PE=LMWH+warfarin or DOAC
- PE with active cancer = LMWH
- Outpatient Tm=Low PESI score, no RV dysfunction on ECHO/CT, negative trop
Treatment of subsegmental PE if low risk or high risk (2)
- Clinical observation and US for proximal DVT if low risk of recurrence
- Anticoagulate if high VTE risk
* Good patients to send to anticoagulation clinic!
Does pregnancy increase your risk of VTE? (1)
- Not really. Mostly 3rd trimester/peripartum
Can you use PERC in pregnancy? (1)
Can you use a D-Dimer in pregnancy? (1)
Which imaging study do you use for PE in pregnancy (2)
- PERC in pregnancy? Yes in first trimester
- D-dimer in pregnancy? Maybe. Maybe in first trimester
Imaging study:
1. VQ preferred if normal CXR. VQ preferred first line - Leg Doppler first only if they have leg symptoms
- CT maybe first in very early pregnancy
What is the risk of imaging in pregnancy (1)
- VERY VERY VERY low. CXR is like 12 hours of walking around the earth
- A CT or VQ is very low, 0.1% of the allowed radiation during pregnancy
Who gets a VQ scan for PE? (2)
- Young patient
2. Normal CXR
Treatment of PE: provoked, unprovoked, cancer (3)
- Provoked = 3 months
2. Unprovoked = 6 months (or lifetime) - Cancer = LMWH 3-6months then warfarin until cancer is cured OR Edoxaban!
*Send to anticoagulation clinic for FU
Treatment of PE treatment failure (PE despite compliant with warfarin or DOAC) (1)
- LMWH (if on LMWH increase dose 25%)
What score can you use to risk stratify PE (1)
- PESI (Pulmonary embolism severity index)
Algorithm for DVT workup (3)
- Start with your Well’s DVT score
1. Low PTP: negative D-Dimer or negative US = you’re done
2. Mod PTP: negative D-Dimer or 2 negative US 7days apart
3. High PTP: negative D-Dimer and US or negative USx2
Treatment of DVT (2)
- Anticoagulate (same as PE) – warfarin or DOAC
2. Calf veins and no risk of propagation – watch it
A massive DVT with a blue/purple/cyanotic leg (1)
- Phlegmasia cerulea dolens
* Talk to vascular immediately
Treatment of superficial thrombophlebitis (2)
- US for high risk patients 2. Anticoagulate if very high risk, otherwise supportive treatment
Signs/symptoms that increase the likelihood of ACS (5)
- CP radiating right > bilaterally > left
- Diaphoresis
- N+V
- Exertional pain
- Pain similar to previous MI
What is the STEMI complication? (5)
- STEMI + hypotension =
- STEMI + elevated JVD =
- STEMI + hypotension and crackles =
- STEMI + new systolic murmur =
- STEMI + pulse deficit in left arm =
- STEMI + hypotension = cardiogenic shock
- STEMI + elevated JVD = right sided failure
- STEMI + hypotension and crackles = left sided failure
- STEMI + new systolic murmur = VSD, acute valvular insuffiency
- STEMI + pulse deficit in left arm = aortic dissectio
How do you do troponin testing in Calgary (3)
- 0hour, >3hours since max symptoms, trop <5 = RULED OUT
2. 0hour >52 = RULED IN - 0hour 6-51 = Do a delta 2 hour, 2 hour delta >10 = RULED IN, 2 hour <4 = RULED OUT, 2 hour
4-10=do another trop in 1 hour.
What is in the HEART score (5)
1. History – concerning or not 2. EKG – normal or non-specific 3. Age (<44, 45-64, >65) 4. Risk factors (T2DM, smoker, HTN, HL, FHx, Obese) 5. Trop (normal or elevated >14)
EKG findings for PE (6)
- Sinus tachycardia (44%)
- Non-specific ST changes (ST-elevation, ST-depression, TWI - 50%)
- RV strain pattern (TWI V1-4, Inferior leads - 34%)
- Complete / Incomplete RBBB (18%)
- RAD (16%)
- Dominant R wave in V1
- P pulmonale (peaked P wave lead II)
- S1Q3T3 (20%)
- Atrial tachyarrhythmia (Afib, Flutter, MAT - 8%)
What are the indications for thrombolysis in PE? (3)
- Acute PE + pulseless
- Acute PE + profound bradycardia and shock
- Acute PE + sustained hypotension (sBP <90 x 15 mins despite inotropes)
- Consider: acute submassive PE (sBP >90 and RV dysfunction)
RV dysfunction: RV dilation on echo/CT, BNP>500, elevated trop, ECG changes
The two best tests for myocarditis (2)
- ECG (95-100% abnormal)
2. CXR (60% abnormal)
3. Trop in adults
*Also respiratory distress, lethargy, fever, WOB
Auto-immune pericarditis 1-2 weeks out from MI (1)
- Dressler’s syndrome
How do you know if an inferior MI involves the right ventricle? (4)
- STe III > II
- STe V1 > V2
- STd in V2 (not V1)
- Tall R wave in V1
- Do an RV lead to check
* There is a much higher mortality with RV MI. More hypotension. More arrhythmia’s
* *Beware nitroglycerin! Treat hypotension with fluid. Fill the tank
When to suspect Legionnaires’ disease (Legionella Pneumonia) (3)
- Looks clinically identical to CAP. Consider testing in immunocompromised patients, or significant exposure – often contaminated water in large outbreaks
1. GI Sx (N+V+D)
2. Hyponatremia
3. Elevated liver enzymes
4. Immunocompromised (old, alcoholic, T2DM, IVDU, renal disease)
5. Exposure to a large outbreak – cruise ship, apartment, nursing home - Do a Legionella urinary antigen, or Legionella sputum PCR (best)
What is diffuse alveolar hemorrhage syndrome, and how do you treat it? (2)
- Hemoptysis, anemia, SOB, diffuse alveolar infiltrates
* Often caused by vasculitis (Wegener’s, Goodpasture’s, HSP, glomerulonephritis, APLA), but also PE, DIC, mitral regurg, HIB, endocarditis, infections
* *CXR shows patchy alveolar opacification, CT shows ground-glass - Rx ABCs, IV methylpred 500mg Q6H, and PLEX
DDx wide complex tachycardia (4)
- VTACH VTACH VTACH
- SVT with aberrancy
- Flutter with aberrancy
- Sinus tach with aberrancy
DDx bradycardia (5)
- Sinus bradycardia
- Junctional rhythm
- Hyperkalemia
- Hypothyroid
- BB, CCB, Dig, Clonidine
STEMI DDx (8)
- STEMI (ischemia)
- Pericarditis/myocarditis
- Hyperkalemia / hypercalcemia
- ICH
- Benign early repol
- Ventricular aneurysm
- LBBB / paced rhythm
- Brugada syndrome
- Hypothermia
- PE
- Takotsubo/vasospasm
ST-depression DDx (5)
- Ischemia (NSTEMI)
- Reciprocal changes
- Posterior STEMI
- Digoxin
- RBBB/LBBB
- Hypokalemia
Approach to AV-nodal re-entry tachycardia (2)
- If its narrow and regular = orthodromic WPW = block the AV node
- If its wide and irregular = antidromic (antichrist) WPW = shock
DDx wide complex tachycardia (4)
- VTACH VTACH VTACH (monomorphic or polymorphic)
- SVT with aberrancy
- Flutter with aberrancy
- Sinus tach with aberrancy
- TOX: hyperkalemia, Na+ channel blocker (cocaine, TCA, anticholinergic)
- AFib WPW
- Pacemaker tachycardia
What makes a wide-complex tachy more like to be V-Tach (5)
- PMHx: Hx of MI, structural heart disease
- Extreme axis deviation
- Wide QRS
- Concordance in precordial leads (V1-6)
- AV dissociation (P waves marching through, capture beats, fusion beats) – 100% specificity to rule in VT!
* Assess old ECG’s for the presence of a previous LBBB or RBBB
Treatment of Torsades de Pointes (2)
- DC Cardioversion 200J biphasic
- Magnesium 2g IV slow push (or over 10 min), then 2g over 1 hour.
- Overdrive pacing to avoid bradycardia (rate 100)
Describe the landmark for a median nerve block (1), ulnar nerve block (1), sub-mental nerve block (1)
- Proximal wrist crease, just lateral to palmaris longus tendon, infiltrate 5mL deep to flexor retinaculum
- Ulnar nerve block proximal wrist crease, just ulnar to the flexor carpi ulnaris tendon
- Sub-mental nerve block – aim for the mental foramen, from the fold in the buccal mucosa, 4th-5th tooth from midline
CURB-65 score (5)
- Confusion
- Uremia >7
- Resp rate >30
- sBP <90
- Age >65
DDx ST-elevation in aVR?
- Left main
- pLAD
- Triple vessel
- Massive cardiac ischemia (dissection, post-arrest, severe anemia, massive PE)
- SVT/LBBB/LVH with strain
- Hypo or hyperkalemia
- Sodium channel blockade
Procainamide dosing, and when to stop infusion (2)
- 20mg/min for 30 mins
2. STOP: max dose (17mg/kg), QRS lengthens 50%, hypotension
Bugs involved in COPD (3)
- Strep pneumo
- H flu
- M. Catarrhalis
- Viruses
- Atypicals (Mycoplasma, Chlamydia)
- Pseudomonas *End-stage COPD. Frequent exacerbations, recent hospitalization, severe Dz
The CHESS pneumonic for high-risk of death after syncope (5)
- CHF
- Hematocrit <30
- ECG abnormality
- Shortness of breath
- Systolic BP <90
(3) types of cardiomyopathy
- Dilated (most common – CHF). Heart tries to compensate for poor contraction so it gets bigger
- Restrictive – fibrosis or infiltration of the heart muscle or pericardium.
- Hypertrophic – young patient that gets exercise induced chest pain/dyspnea/syncope. Often from septal hypertrophy. ECG with dagger Q waves. Rx beta blockers
Treatment of stable and unstable V-Tach (2)
- Stable = Procainamide
- Unstable = Shock
* But still probably shock anyone that has known heart disease/ischemic disease/LV dysfunction
Treatment of monomorphic VT and polymorphic VT (2)?
- Monomorphic VT (often from a prev infarct scar) – Rx Procainamide
- Polymorphic VT (often from prev ischemia) – Rx amiodarone
DDx stridor (6)
- Stridor: typically caused by extra-thoracic airway obstruction.
1. Nasal (polyp, foreign body)
2. Foreign body aspiration
3. Mass (airway, larynx, trachea
4. Epiglottitis
5. Croup
6. Tonsillitis
7. Retropharyngeal abscess
8. Vocal cord paralysis, vocal cord dysfunction
What is the NBG pacemaker code? (3)
*Only the first 3 matter to EM
1. Chamber paced
2. Chamber sensed
3. Response to event
(DDD is dual chamber paced, dual sensed, Dual inhibit/trigger - paces both chambers if too slow)
(VVI is ventricle paced, ventricle sensed, and inhibits - paces, but will not pace if it senses a beat)
What does applying a magnet do to a pacemaker (1)?
- A magnet puts a pacemaker into asynchronous mode (DOO). It will pace, but will only pace and will not sense or inhibit.
Causes of pacemaker malfunction (2 categories)
- Failure to capture - battery depletion, lead fracture/misplacement, electrolyte/metabolic derangement
- Failure to sense - lead displacement, lead fracture, low voltage complexes can’t be sensed
