CP chief complaint- EMERGENT conditions Flashcards
1
Q
TIMI heart score
A
age >65 known CAD >3 risk factors for CAD EKG abnormal \+ cardiac markers recent Aspirin use
2
Q
lung collapse
A
PNX
3
Q
PNX
A
air leaks into the space b/w chest wall and lung, making the lung collapse
4
Q
tall thin men with pleuritic CP, 20-40 years of age
A
Primary spontaneous PNX (lung collapse. idiopathic)
5
Q
Tension PNX
A
mediastinal structures are shifted to the side
positive air pressure pushes these structures all wonky
6
Q
Clinical sx:
Pleuritic CP, Unilateral, Non-exertional, Sudden, SOB
A
PNX (collapsed lung)
7
Q
Hyperresonance
Decreased fremitus
Decreased breath sounds
A
PNX
8
Q
Test of choice to diagnose PNX
A
CXR- upright view. Expiratory
9
Q
Tension PNX additional sx
A
Increased JVP
systemic Hypotension
Pulsus paradoxus (exag drop in BP w inspiration)
10
Q
what does JVP reflect?
Jugular venous pressure
A
Pressure in the Right Atrium
11
Q
Tension PNX always need
A
Needle aspiration then Chest tube
12
Q
Small PSP (primary spon PNX) vs Large PSP mgmt
A
small: Observe and supp O2
large: needle/cath aspiration vs chest tube or cath thoracostomy
13
Q
stable, Secondary Spon PNX (d/t underlying dz like COPD or Asthma)
A
Chest tube or catheter thorac
+ Admit
14
Q
Patient ed after PNX
A
Avoid pressure changes for at least 2 weeks
- high altitude
- smoking
- aircraft
- scuba diving
15
Q
Virchow’s triad
A
Risk for PE
- damage
- stasis
- hyper coagulability condition
16
Q
Classic triad of sudden onset
A
SOB
Pleuritic CP
Cough
signs of PE!!
17
Q
PE of someone with PE
A
Tachypnea
Tachycardic
Low grade fever (interesting)
often lung exam is normal
18
Q
PE of someone with MASSIVE PE
A
LOC
Hypotension
Pulseless electrical activity
19
Q
CXR of someone with PE
A
often normal!!
a normal CXR in the setting of hypoxia is highly suspicious for PE
20
Q
Most common abnormal finding in someone with PE
A
Atelectasis: partial lung collapse
21
Q
Most common EKG changes in someone with PE
A
Tachy
Nonspec ST/T changes
22
Q
Most specific EKG changes indicating PE
A
S1Q3T3
wide and deep S (the down part) in lead I
isolated Q and T wave inversion in lead III
23
Q
best test to confirm PE, but not diagnose
A
Helical (spiral) CT angiography
24
Q
When to use VQ scan to detect PE
A
Pregnant pt
increased Creatine
25
GOLD standard to diagnose PE
f sj,/vc22`bh,mmmv
26
GOLD standard to diagnose PE
Pulmonary angiography- BUT rarely performed bc. ordered if high suspicion and negative CT or VQ scan
27
Tx of PE if pt is hemoD stable
Anticoag-1st line
Heparin bridge + Warfarin or novel oral anticoag
28
Tx of PE if pt is hemoD stable and one of following 3 is present:
- Anticoag is contra-indicated (recent bleed, bleeding disorder)
- Anticoag doesn't work
- Right ventricle dysfx seen on echo (bc even super small clot can be fatal)
29
Tx of PE if pt is NOT STABLE
systolic <90, acute RV dysfx
Thrombolysis (meds) vs. Thrombectomy/ Embolectomy
30
if PE is unlikely, what do you order?
D-dimer, good at ruling OUT PE but not really at confirming presence, need to order more if +
31
if PE is likely, what do you order?
Helical CT scan
32
Wells Criteria for PE
3 points:
- clinical signs and sx of DVT
- PE is #1 dx or equally likely
1. 5 points:
- HR >100 bpm
- have been immobile at least 3d OR surgery in prev 4 wks
- previous DVT/PE
1 point added:
- hemoptysis (bloody cough)
- Cancer
33
Low prob of PE (Wells)
<2 points
34
High prob of PE (Wells)
>6 points
consider CT Angiography
35
PERC criteria to rule out PE
If pt is low risk and meets all 8, no need to get any testing
If pt is low risk but does not meet all criteria, D-dimer is indicated
36
PERC Criteria
```
Younger than 50
HR <100
Ox sat >95%
No hemoptysis
No estrogen use
No prior DVT/PE
No unilateral leg swelling
No surgery/trauma req hosp in recent 4 wks
```
37
Pericardial effusion
Accum of fluid in pericardial sac
| Same cause of Acute pericarditis- viral, idiopathic, cancer
38
EKG changes assoc with Pericardial Effusion
Electrical alternans- alternating amplitudes of QRS complex bc heart is swaying around in all of the fluid
Low QRS voltage
39
Tx of Pericardial effusion
Treat underlying cause- i.e. the pericarditis
Large effusion may need Pericardiocentesis for sx relief (draining)
40
Cardiac Tamponade
an Effusion (fluid) is causing pressure on heart- messing up Filling --> decreased CO and shock
MEDICAL EMERGENCY
41
What is the more important factor for severity of Tamponade?
How quickly the fluid accumulates
42
Cause of tamponade
comp of Pericarditis or TRAUMA- like the ATV accident pt encounter
Most common nontraumatic cause- Cancer
43
Beck's triad
Tamponade
44
Low BP (hypotension)
Muffled heart sounds
JVP
BECKS TRIAD: a/w Cardiac Tamponade
Other sx:
- pulsus paradoxus
- SOB
- fatigue
- periph edema
- shock
- cool extremities
45
Diagnosis of Tamponade
Echo: shows effusion + diastolic collapse of cardiac chambers
46
Tx of Tamponade
REMEMBER IT'S a MEDICAL EMERGENCY
Immediate Pericardiocentesis to remove pressure
Volume resusc and pressure support if needed , Pericardial window if recurrent
47
Epigastric pain- constant, boring, radiates to back
Pancreatitis
48
2 most common causes of Pancreatitis
Gallstones
| Alcohol abuse
49
Phys Exam signs of Acute Pancreatitis
Epigastric pain
Tachycardia
Dec bowel sounds
Dehydration
50
Necrotizing hemorrhagic Pancreatitis
Cullen signs- belly button
| Grey turner sign- flank
51
Diagnostic criteria for Pancreatitis
Acute onset epigastric abd pain --> radiating to back
Elevated LIPASE or AMYLASE 3x normal
Imaging
but if first two are present, don't need the 3rd
52
Which lab is most specific for Pancreatitis?
Lipase!!!
Lipase goes with Pancreatitis
LP
53
Why might you see Hypocalcemia with Pancreatitis?
necrotic fat binds to calcium, lowering the serum levels
54
Tx of Pancreatitis
"Rest the pancreas"
Actually, 90% recover in 3-7 days with only supportive care
NPO, high volume IVF (lactated ringer), Pain meds
55
Are Abx used in Pancreatitis?
Not routinely. Only if severe infected necrosis is seen- then broad spectrum like Imipenem may be used
56
Chronic Pancreatitis
Triad: (but only seen in 1/3 of these pts) hmm..
Calcifications
Steatorrhea
DM
57
Other sx of Chronic Pancreatiits
Weight loss
Epigastric pain
Then the triad: Calcifications, steatorrhea, DM
58
Imaging of Chronic Pancreatitis
Calcification seen on CT and X Ray
59
Pancreatic function testing
Fecal elastase (most sensitive and specific)
60
Tx of Chronic Panceatitis
```
Stop drinking, Pain meds
Low fat diet
Vit supp
Oral enzyme replacement
Remove only if pain doesn't stop despite meds
```
61
Pancreatic CA
Very bad prognosis
Usually head of pancreas involved
Adencarcinoma
62
sx of Pancreatic CA
```
Painless jaundice
Weight loss
PRURITIS
Anorexia
Dark urine
Courvoiser's sign
Trousseaus malignancy sign
```
63
Trousseaus malignancy sign
Migratory vein inflammation (phlebitis) associated with malignancy
(d/t pro-coag factors formed by CA cells)
64
Courvoiser's sign
Palpable, NON tender, distended gallbladder (RUQ)
| d/t common bile duct obstruction
65
Tx of Pancreatic CA
Whipple procedure (remove pancreas and duodenum) if CA is confined to the head or duodenal area
66
GI complaints that may cause CP and are CRITICAL
Esophageal rupture
Perf ulcer
Acute cholecystitis
Acute pancreatitis
67
Becks triad
Tamponade
Muffled heart sounds
JVD
Hypotension
68
Esoph rupture
Vomiting or straining prior to this happening
Excruciating retrosternal CP
69
CP d/t cocaine use
- promotes clots
- increases heart's oxygen demand
- constricts hearts blood vessels
70
How long does CP last with Unstable Angina or MI?
greater than 15 minutes
71
CP lasts for days/weeks/months
probably NOT ischemic
72
Pleuritic CP
Pulmonary
Chest wall
Cardiac Tamponade
73
tearing, ripping, searing CP
Aortic dissection
74
Dull, heavy, tight, pressure, ache, squeezing CP
Ischemia !!!
75
Worse lying down, better with sitting up and leaning forward
Pericarditis
76
Relief with Nitro
Ischemic CP
| Esophageal spasm
77
CP relieved with rest
Stable angina
78
Women
Diabetics
>65 YO
often have atypical presentations of CP
poorly localized
79
C/o Fatigue and SOB
can be indicative of ischemia for Women, Diabetic, or >65 YO
80
Anterior wall MI
V2-4
81
Lateral wall MI
I, avL, v5-6
82
Inferior wall MI
II, III, avF
83
Person has stemi, now what?
Anticoags
B-blockers
IV Nitro
Start PCI therapy OR Thrombolysis
84
Mgmt of STEMI
"SNAB"
B blocker
Nitrates
Antiplatelet: (ASA + Clopidogrel)
Statin
85
EKG changes if someone has Hyperkalemia
peaked T waves
86
CONTRA to using Thiazide diuretics
allergy to Sulfa
87
CONTRA to Nitro
```
Systolic <90
Tachy >100
Brady <50
Use of Viagra within 24 hrs
Hypertrophic cardiac myopathy
Severe aortic stenosis?
```
88
ACE-I and ARBs ultimately result in
Vasodilation
89
Amlodipine is what category of CCB?
Dihydro
good for HTN and Angina
90
Verapamil
| Diltiazem are what type of CCB
Non-Dihydro
Rate control
Angina
91
Diff b/w unstable angina and NSTEMI/STEMI
unstable angina: reversible ischemia and NO INJURY
NSTEMI/STEMI: injury from ischemia has occured
92
Anterior MI means what coronary vessel is likely affected?
Left Anterior Descending
| LAD
93
Lateral MI means what coronary vessel is likely affected?
Left Coronary Artery
LCA
"left goes with lateral"
94
Inferior MI means what coronary vessel is likely affected?
Right coronary artery
| RCA
95
Acute tx for Unstable Angina and NSTEMI
Early invasive OR meds
96
Acute tx for STEMI
START REPERFUSION is priority
97
Meds for STEMI
Anticoags: ASA + plavix
B-blocker: Atenolol
IV Nitro
Statin: Atorvastatin
and REPERFUSION
98
Meds for UA/NSTEMI
Anticoags: ASA + plavix
B-blocker: Atenolol or Metoprolol
IV Nitro
Statin: Atorvastatin
maybe ACE-I if high risk for another event
99
4 things in mgmt of UA, STEMI, NSTEMI
| add reperfusion if STEMI
B-blocker
Nitro
Anticoag
Statin
100
Commonly used b-blockers in ACS
Atenolol
| Metoprolol
101
Commonly used ACE-I in HTN, Diabetic nephropathy, and CKD
Lisinopril
102
Non-dihydro CCBs affect
the HEART more
used for rate
(Verapamil, Diltiazem)
103
Dihydro CCBs affect
the vessels more
used for HTN
(Amlodipine)
104
both types of CCB can be used for
Angina
105
When should you NOT use Dihydro (affecting the periph vessels) i.e. Amlodipine, Felodipine, or Nifedipine
in ACUTE MI
heart attack!! Don't use CCB
106
Tx of HTN in pregnancy
Nifedipine (a dihydro CCB)
| Methyldopa
107
Initial therapy for ACS
Nitrates
| B-blockers
108
Left Heart Failure
Congestion of pulmonary system
- SOB
- fatigue
- hypoxia
- cough w frothy
- orthopnea
109
Right Heart Failure
Congestion of peripheral tissues
- weight gain (d/t dependent edema)
- ascites
- increased JVD
- anorexia, GI distress, weight loss
- hepatomegaly
- impaired liver fx
110
SOB, sweaty, tachypnea, tachycardic, rales, crackles, S3 or S4
Left Heart Failure
111
Periph edema
RUQ pain/discomfort
JVD
Ascited
Right Heart Failure
112
With Systolic HF, will likely see an Ejection Fraction
<40%
113
Normal Ejection Fraction
>50-55 %
114
Dilated Left ventricle means
Systolic dysfx
115
Left ventricle hypertrophy
Diastolic dysfx
116
CXR shows:
- Cardiomegaly
- Cephalization of vessels
- Kerley B lines
- Pleural effusions
HEART FAILURE, dawg
117
Stress EKG is contra-indicated when
ANY ACUTE EVENT
something that's already stressing out the heart
118
Labs to order
```
Cardiac enzymes- trop and CK-MB
CBC
CMP
Glucose
LFT
BNP
```
119
BNP is very useful in:
ruling OUT Heart Failure
<100
120
Treatment order for HF
Diuretic
ACE-I
Then, if tolerating, add B-blocker
121
ARDS
Acute Respiratory Distress Syndrome
potentially fatal complication of HF
122
Workup for Acute Decomp Heart Failure
```
EKG
CXR
Pulse ox
Arterial blood gas
CBC
Electrolytes
Renal/liver
Cardiac markers
BNP
Echo
```
123
Hypertrophic cardiomyopathy
Sudden death
Young athletes
Diastolic
Thick L ventricle wall
124
Dilated cardiomyopathy
MOST COMMON TYPE
Enlargement of all chambers
Systolic dysfx
125
Restrictive cardiomyopathy
Rigid vent walls
Diastolic
(least common type)
126
Cardiomyopathy
| definition
Heart is not working well but NOT DUE TO: cad, htn, valve dz, chd
But, its Structurally or Functionally jacked up still
127
Dilated cardiomyopathy
SOB, fatigue, CP
Abd pain
Periph edema
```
PE:
S3 gallop
Mitral/tricuspid REGURGITATION murmur
JVP
Crackles
```
128
What causes Dilated cardiomyopathy?
Idiopathic usually
+ a bunch of possible others (genetic, infection, alc, drugs, endocrine, diet)
129
If Dilated Cardiomyopathy is infectious, most likely
VIRAL if in the US
130
Gold standard for dx of Infectious Dilated Cardiomyopathy
Endomyocardial biopsy
131
Tx for Dilated Cardiomyopathy
ACE-I
Diuretics
B-blockers
Digoxin maybe
Anti-arrhythmics
Anticoags
Implantable defibrillator
Cardiac transplant
132
1st line tx for Symptomatic Dilated Cardiomyopathy
ACE-I
133
Leading cause of Sudden Cardiac Death in young people
Hypertrophic Cardiomyopathy
a DIASTOLIC filling abnormality
134
What causes Hypertrophic Cardiomyopathy?
FAMILIAL
| aut dominant
135
Sx of Hypertrophic Cardiomyopathy
often NOTHING, sudden death
if sx: exertional SOB, fatigue, pre-syncope, palpitations
136
S4 associated with
Hypertrophic Cardiomyopathy
sudden death
137
Tx for Hypertrophic Cardiomyop
If A-sx: nothing, just monitor
If Sx: B-blockers or (non-dihydro) CCBs, i.e. Verapamil or Diltiazem
May need Surgery if refractory to meds
138
Dihydro CCBs (act more on VESSELS)
Amlodipine
| Nifedipine
139
Non-Dihydro CCBs
| act more on HEART
Verapamil
| Diltiazem
140
Rigid Cardiomyopathy
Diastolic dysfx bc the walls are rigid and can't fill properly
141
Most common cause of RESTRICTIVE CARDIOLMYOPATHY
Amyloidosis protein infiltrating the heart
142
Restrictive Cardiomyopathy can sometimes be confused with Constrictive Pericarditis.
How should we tell them apart?
Pericarditis: hx of prev pericarditis, trauma, cardiac surgery, CA, etc
Restrictive CM: rare, often underlying dz progress slowly until sx show, then rapid decline
S3 GALLOP!!!
143
S3 gallop should prompt you to think about
Restrictive Cardiomyopathy
| and this is not seen in Constrictive Pericarditis
144
Other sx of Restrictive Cardiomyopathy
```
Edema
Abd disc
Ascites
Syncope
CP
SOB
```
S3 gallop
JVP
Kussmaul
Possible Regurgitation murmur
145
Periorbital Purpura (w/ heart failure) is pathgnomic
"racoon eyes"
"panda eyes"
a late finding for Cardiac Amyloidosis (a cause of Restrictive CM)
146
What will be enlarged in Restrictive CM?
Both Atria
147
Tx for Restrictive CM
Underlying cause
Low dose LOOP DIURETICS
Heart transplant
Poor prog :(
148
1st line tx for Symptomatic Restrictive CM
Loop diuretics
149
Takubostu CM
Presents just like an MI, so treat just like an MI
Stabilize pt
Cath lab
at d/c: ASA, beta blocker, ACE-I until heart recovers
150
Takubostu CM
Trop and BNP will be elevated
EKG shows STE
151
What is Takubsto?
"broken heart syndrome"
TEMPORARY systolic and diastolic dysfx but in the ABSENCE of CAD
trigger: emotional or physical stress, often post-menopausal WOMEN
152
Cardiac Ausc exam
Firm pressure
Light pressure
Firm:
Light:
153
Pulses to check on cardiac exam:
Ausc AND palpate:
- Carotid
- Abd Aorta
- Renal (just listen)
Just palpate:
- Brachial
- Radial
- Iliac
- Femoral
- Post tib
- Dorsalis pedis
154
JVD
| atrial pressure
indic of volume overload
esp in right side of heart
155
Hepatojug reflux
check for R side fluid overload
apply pressure to LIVER in RUQ, and observe the JVP.
If it increased with this, suggests VOLUME overload
156
Leaning fwd heart exam
good for Aortic or Pulmonic REGURGITATION murmurs
bringing base closer to chest wall
157
Homans sign
pt sitting on table, pull toes up in dorsiflexion
is it painful in the calf?
testing for phlebitis (inf of veins)
158
Allen test
occlude Radial and ulnar arteries
pt make tight fist
then open hand
release pressure of ULNAR artery (pinky)
does BF return?
159
When to perform Allen test
prior to radial artery puncture
want to make sure ULNAR ARTERY is patent and can take over when the radial artery is punctured
