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Emergency > Chest Pain > Flashcards

Chest Pain Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

When is morphine contraindicated?

A

In patients with respiratory depression/failure

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2
Q

Agent of choice for patients with hyperkalemia and EKG changes?

A

Calcium gluconate

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3
Q

Drug for SVT?

A
  1. Adenosine (short acting AV blocking agent)

2. Vagal maneuvers

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4
Q

What drugs are commonly used for wide complex V-tach?

A
  1. Amiodarone
  2. Sotalol
  3. Procainamide
  4. Lidocaine (2nd line)
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5
Q

First line treatment for decompensated CHF with pulmonary edema?

A

NTG. Is a preload reducer (increase venous capacitance).

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6
Q

When do patient’s with a-fib need anti-coagulation (time frame)?

A

> 48h or unknown duration

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7
Q

What drug (which is sometimes used for rate control in a-fib) is contraindicated for a-fib if a patient has symptoms of CHF?

A

B-blocker b/c of effect on intropy.

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8
Q

Relative contraindications to t-PA?

A
  1. Systolic > 180
  2. Current anticoagulation
  3. Major surgery within 3w
  4. PUD
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9
Q

Absolute contraindications to t-PA?

A
  1. Previous hemorrhagic stroke
  2. Intracranial neoplasm
  3. Active internal bleeding (including menses)
  4. Suspected aortic dissection or pericarditis
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10
Q

6 T’s

A
  1. Toxins
  2. Tamponade
  3. Tension pneumo
  4. Thrombosis (coronary)
  5. Thrombosis (pulmonary)
  6. Pulmonary
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11
Q

5 H’s

A
  1. Hypovolemia
  2. Hypoxia
  3. Hydrogen ions
  4. Hyper/hypokalemia
  5. Hypothermia
    * 6. Hypoglycemia
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12
Q

How effective is glucagon for food bolus?

A

50%. Upper GI if unsuccessful.

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13
Q

Drugs contraindicated for WPW?

A
  1. B-blockers
  2. CCB

Both promote conduction solely through accessory pathway

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14
Q

What is the common 1st line agent to abort WPW?

A

Procainamide

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15
Q

EKG findings in WPW BESIDES 𝛿 wave?

A
  1. Short PR (100ms)
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16
Q

Treatment for non-complicated pericarditis?

A

NSAIDs (colchicine)

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17
Q

Which valve is most often infected with IVD?

A

Tricuspid.

  1. Patients might have hemoptysis
  2. Blood cultures positive 98% of time
  3. Cover for S. Aureus and Strep
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18
Q

What might you see on EKG with dissection?

A
  1. Ischemia (if involves coronary arteries)
  2. Low voltage
  3. Electrical alternans
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19
Q

Classic physical exam finding with Boerhaves?

A
  1. Mediastinal or cervical emphysema
  2. Hamman sign (crunching on auscultation)
  3. Possible lateral displacement of mediastinal pleura on CXR
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20
Q

Plan for small pneumothorax in healthy patient (

A
  1. Observe 6h
  2. Repeat CXR. If no increase, discharge home.
  3. 24h follow up
  4. No air travel or underwater activities until fully healed
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21
Q

Hypocalcemia EKG changes

A

hypO=lOng QT

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22
Q

Hypercalcemia EKG changes

A

hypeR=shorRt QT

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23
Q

Hypokalemia EKG changes

A
  1. T-wave flattening
  2. ST depression
  3. U-waves
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24
Q

EKG changes with hyperkalemia besides peaked T-waves

A
  1. Loss of P-waves
  2. Widened QRS
  3. Sine waves –> V-fib
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25
Q

Most common agent for rate control for a-fib?

A

Diltiazem

Go directly to cardioversion if unstable

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26
Q

t-PA indication for PE?

A
  1. Sustained hypotension = Massive PE + hemodynamic collape

2. PTs who lose pulses or have profound bradycardia

27
Q

First EKG finding in MI (not just ischemia)?

A

Hyperacute T-waves

28
Q

How long do Q-waves typically take to develop?

A

8-12 hours after occlusion

29
Q

What trial confirmed the use of aspirin in AMI?

A

ISIS-2 trial (shows it independently reduces mortality)

NTG, heparin, CCBs, and lidocaine have no proven mortality benefits

30
Q

Door-to-balloon time goal?

A

90m

31
Q

Where are two places to look for a posterior MI on EKG?

A
  1. ST depression in V1-V3

2. ST elevation in V7-V9

32
Q

In patients with confirmed MI, how often can you make the call based on the first EKG?

A

50% of initial EKGs are nondiagnostic in patients with eventual MI

33
Q

What leads might show a lateral MI other than V4-V6?

A

I and aVL

34
Q

Besides ASA and NTG, what drugs will MI likely need?

A
  1. Heparin or Lovenox
  2. Clopidgrel (GP IIB/IIIA inhibitor)

Both reduce the risk of reinfarction

35
Q

How long after diagnosis of MI can thrombolysis still be used?

A

Up to 12h

36
Q

What is TIMI risk score used for?

A

Estimates mortality for patients with unstable angina and non-ST elevation MI

37
Q

What drugs are avoided in the acute setting of MI that are generally given long term?

A

Β-blockers

There is risk of cardiogenic shock

38
Q

What are the most common ED and pre-hospital complications of MI?

A

V-tach and V-fib

39
Q

If a patient with anterior MI has bradyarrhythmia, what needs to be done?

A

Indicates heart block 2/2 damage to His-Purkinje system

Needs transvenous pacing

40
Q

What might you see in an inferior MI that hits the AV node?

A

Second-degree heart block that is transient and may respond to atropine

41
Q

What should be avoided in patients with a right sided MI?

A

NTG and high-dose morphine as it can lead to hypotension

42
Q

What are some late complications of MI?

A
  1. Free wall rupture
  2. VSD
  3. Pericarditis
  4. Aneurysm
  5. Thromboembolism
43
Q

Explain why “AF begets more AF”

A

Underlying low levels of tachycardia lead to global cardiomyopathy and thus more AF

44
Q

Which two patients with AF should NOT receive rate controlling agents?

A
  1. Patients with WPW

2. Hemodynamically unstable

45
Q

Why is diltiazem DOC for a-fib RVR?

A

Low risk of hypotension (because of minimal inotropic effect)

46
Q

What are your two options for anticoagulation for a-fib > 48 hours?

A
  1. Coumadin 4w, (INR 2-3), cardiovert, coumadin 4w

2. TEE, hep or lovenox, cardiovert, coumadin 4w

47
Q

What is better for cardioverson AC or DC?

A

DC

48
Q

What is the biggest factor for determining if cardioversion will be successful in a-fib?

A

Duration of AF

49
Q

Why aren’t most patients with AF put on antiarrhythmics after cardioversion to prevent recurrence?

A

The drugs have toxicity and some are proarrhythmic

50
Q

If a patient with AF must be put on an antiarrhythmic, what is commonly used?

A
  1. Amiodarone
  2. Propafenone
  3. Dronedarone (fewer side effects but less effective)
51
Q

What trial showed that rate control + anticoagulation was better than rhythm control for AF?

A

AFFIRM

52
Q

What is CHAD2 used for?

A

Estimates stroke risk in patients with AF

53
Q

What are parameters for CHAD2?

A
  1. CHF
  2. HTN
  3. Age > 75
  4. DM
  5. Stroke or TIA (2 points)
54
Q

What anticoagulant might be better than coumadin for AF based on RE-LY trial?

A

Dabigatran (Pradaxa)

Reduces rate of ischemic and hemorrhagic stroke, major bleeding, and overall mortality

55
Q

In a patient with AF that needs anticoagulation but can’t take warfarin, what should be used?

A

ASA + Clopidogrel

56
Q

What are the two forms of D-dimer tests?

A
  1. ELISA (more accurate)

2. Whole blood immunoagglutination test

57
Q

A d-dimer might be falsely negative if clot is how old?

A

> 72 hours

58
Q

What test should you use for a pregnant patient with suspected PE?

A

V/Q most likely. One author recommends using the perfusion scan but not the ventilation scan.

59
Q

How many patients with untreated proximal DVT will develop PE?

A

60%

60
Q

What patients with DVT might been thrombolysis?

A

Extensive DVT that involves iliac and femoral veins

61
Q

What are unusual presentations of PE?

A
  1. Seizure
  2. Syncope
  3. Abdominal pain
  4. High fever
  5. Productive cough
  6. Adult onset asthma
  7. New SVT
  8. Hiccups
62
Q

PERC criteria applies to who?

A

Patients that are low risk (which can be determined with Wells criteria)

63
Q

What two CXR signs might you see with PE?

A
  1. Westermark sign (peripheral lung vasoconstriction)

2. Hamptom hump (wedge-shaped density associated with infarction)

64
Q

What are the “classic” findings of PE on EKG?

A
  1. S in I
  2. Q in III
  3. Flipped T in III

Emergency (23 decks)

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