CP chief complaint- EMERGENT conditions Flashcards
TIMI heart score
age >65 known CAD >3 risk factors for CAD EKG abnormal \+ cardiac markers recent Aspirin use
lung collapse
PNX
PNX
air leaks into the space b/w chest wall and lung, making the lung collapse
tall thin men with pleuritic CP, 20-40 years of age
Primary spontaneous PNX (lung collapse. idiopathic)
Tension PNX
mediastinal structures are shifted to the side
positive air pressure pushes these structures all wonky
Clinical sx:
Pleuritic CP, Unilateral, Non-exertional, Sudden, SOB
PNX (collapsed lung)
Hyperresonance
Decreased fremitus
Decreased breath sounds
PNX
Test of choice to diagnose PNX
CXR- upright view. Expiratory
Tension PNX additional sx
Increased JVP
systemic Hypotension
Pulsus paradoxus (exag drop in BP w inspiration)
what does JVP reflect?
Jugular venous pressure
Pressure in the Right Atrium
Tension PNX always need
Needle aspiration then Chest tube
Small PSP (primary spon PNX) vs Large PSP mgmt
small: Observe and supp O2
large: needle/cath aspiration vs chest tube or cath thoracostomy
stable, Secondary Spon PNX (d/t underlying dz like COPD or Asthma)
Chest tube or catheter thorac
+ Admit
Patient ed after PNX
Avoid pressure changes for at least 2 weeks
- high altitude
- smoking
- aircraft
- scuba diving
Virchow’s triad
Risk for PE
- damage
- stasis
- hyper coagulability condition
Classic triad of sudden onset
SOB
Pleuritic CP
Cough
signs of PE!!
PE of someone with PE
Tachypnea
Tachycardic
Low grade fever (interesting)
often lung exam is normal
PE of someone with MASSIVE PE
LOC
Hypotension
Pulseless electrical activity
CXR of someone with PE
often normal!!
a normal CXR in the setting of hypoxia is highly suspicious for PE
Most common abnormal finding in someone with PE
Atelectasis: partial lung collapse
Most common EKG changes in someone with PE
Tachy
Nonspec ST/T changes
Most specific EKG changes indicating PE
S1Q3T3
wide and deep S (the down part) in lead I
isolated Q and T wave inversion in lead III
best test to confirm PE, but not diagnose
Helical (spiral) CT angiography
When to use VQ scan to detect PE
Pregnant pt
increased Creatine
GOLD standard to diagnose PE
f sj,/vc22`bh,mmmv
GOLD standard to diagnose PE
Pulmonary angiography- BUT rarely performed bc. ordered if high suspicion and negative CT or VQ scan
Tx of PE if pt is hemoD stable
Anticoag-1st line
Heparin bridge + Warfarin or novel oral anticoag
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)
Tx of PE if pt is NOT STABLE
systolic <90, acute RV dysfx
Thrombolysis (meds) vs. Thrombectomy/ Embolectomy
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 +
if PE is likely, what do you order?
Helical CT scan
Wells Criteria for PE
3 points:
- clinical signs and sx of DVT
- PE is #1 dx or equally likely
- 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
Low prob of PE (Wells)
<2 points
High prob of PE (Wells)
> 6 points
consider CT Angiography
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
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
Pericardial effusion
Accum of fluid in pericardial sac
Same cause of Acute pericarditis- viral, idiopathic, cancer
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
Tx of Pericardial effusion
Treat underlying cause- i.e. the pericarditis
Large effusion may need Pericardiocentesis for sx relief (draining)
Cardiac Tamponade
an Effusion (fluid) is causing pressure on heart- messing up Filling –> decreased CO and shock
MEDICAL EMERGENCY
What is the more important factor for severity of Tamponade?
How quickly the fluid accumulates
Cause of tamponade
comp of Pericarditis or TRAUMA- like the ATV accident pt encounter
Most common nontraumatic cause- Cancer
Beck’s triad
Tamponade
Low BP (hypotension)
Muffled heart sounds
JVP
BECKS TRIAD: a/w Cardiac Tamponade
Other sx:
- pulsus paradoxus
- SOB
- fatigue
- periph edema
- shock
- cool extremities
Diagnosis of Tamponade
Echo: shows effusion + diastolic collapse of cardiac chambers
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
Epigastric pain- constant, boring, radiates to back
Pancreatitis
2 most common causes of Pancreatitis
Gallstones
Alcohol abuse
Phys Exam signs of Acute Pancreatitis
Epigastric pain
Tachycardia
Dec bowel sounds
Dehydration
Necrotizing hemorrhagic Pancreatitis
Cullen signs- belly button
Grey turner sign- flank
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
Which lab is most specific for Pancreatitis?
Lipase!!!
Lipase goes with Pancreatitis
LP
Why might you see Hypocalcemia with Pancreatitis?
necrotic fat binds to calcium, lowering the serum levels
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
Are Abx used in Pancreatitis?
Not routinely. Only if severe infected necrosis is seen- then broad spectrum like Imipenem may be used
Chronic Pancreatitis
Triad: (but only seen in 1/3 of these pts) hmm..
Calcifications
Steatorrhea
DM
Other sx of Chronic Pancreatiits
Weight loss
Epigastric pain
Then the triad: Calcifications, steatorrhea, DM
Imaging of Chronic Pancreatitis
Calcification seen on CT and X Ray
Pancreatic function testing
Fecal elastase (most sensitive and specific)
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
Pancreatic CA
Very bad prognosis
Usually head of pancreas involved
Adencarcinoma
sx of Pancreatic CA
Painless jaundice Weight loss PRURITIS Anorexia Dark urine Courvoiser's sign Trousseaus malignancy sign
Trousseaus malignancy sign
Migratory vein inflammation (phlebitis) associated with malignancy
(d/t pro-coag factors formed by CA cells)
Courvoiser’s sign
Palpable, NON tender, distended gallbladder (RUQ)
d/t common bile duct obstruction
Tx of Pancreatic CA
Whipple procedure (remove pancreas and duodenum) if CA is confined to the head or duodenal area
GI complaints that may cause CP and are CRITICAL
Esophageal rupture
Perf ulcer
Acute cholecystitis
Acute pancreatitis
Becks triad
Tamponade
Muffled heart sounds
JVD
Hypotension
Esoph rupture
Vomiting or straining prior to this happening
Excruciating retrosternal CP
CP d/t cocaine use
- promotes clots
- increases heart’s oxygen demand
- constricts hearts blood vessels
How long does CP last with Unstable Angina or MI?
greater than 15 minutes
CP lasts for days/weeks/months
probably NOT ischemic
Pleuritic CP
Pulmonary
Chest wall
Cardiac Tamponade
tearing, ripping, searing CP
Aortic dissection
Dull, heavy, tight, pressure, ache, squeezing CP
Ischemia !!!
Worse lying down, better with sitting up and leaning forward
Pericarditis
Relief with Nitro
Ischemic CP
Esophageal spasm
CP relieved with rest
Stable angina
Women
Diabetics
>65 YO
often have atypical presentations of CP
poorly localized
C/o Fatigue and SOB
can be indicative of ischemia for Women, Diabetic, or >65 YO
Anterior wall MI
V2-4
Lateral wall MI
I, avL, v5-6
Inferior wall MI
II, III, avF
Person has stemi, now what?
Anticoags
B-blockers
IV Nitro
Start PCI therapy OR Thrombolysis
Mgmt of STEMI
“SNAB”
B blocker
Nitrates
Antiplatelet: (ASA + Clopidogrel)
Statin
EKG changes if someone has Hyperkalemia
peaked T waves
CONTRA to using Thiazide diuretics
allergy to Sulfa
CONTRA to Nitro
Systolic <90 Tachy >100 Brady <50 Use of Viagra within 24 hrs Hypertrophic cardiac myopathy Severe aortic stenosis?
ACE-I and ARBs ultimately result in
Vasodilation
Amlodipine is what category of CCB?
Dihydro
good for HTN and Angina
Verapamil
Diltiazem are what type of CCB
Non-Dihydro
Rate control
Angina
Diff b/w unstable angina and NSTEMI/STEMI
unstable angina: reversible ischemia and NO INJURY
NSTEMI/STEMI: injury from ischemia has occured
Anterior MI means what coronary vessel is likely affected?
Left Anterior Descending
LAD
Lateral MI means what coronary vessel is likely affected?
Left Coronary Artery
LCA
“left goes with lateral”
Inferior MI means what coronary vessel is likely affected?
Right coronary artery
RCA
Acute tx for Unstable Angina and NSTEMI
Early invasive OR meds
Acute tx for STEMI
START REPERFUSION is priority
Meds for STEMI
Anticoags: ASA + plavix
B-blocker: Atenolol
IV Nitro
Statin: Atorvastatin
and REPERFUSION
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
4 things in mgmt of UA, STEMI, NSTEMI
add reperfusion if STEMI
B-blocker
Nitro
Anticoag
Statin
Commonly used b-blockers in ACS
Atenolol
Metoprolol
Commonly used ACE-I in HTN, Diabetic nephropathy, and CKD
Lisinopril
Non-dihydro CCBs affect
the HEART more
used for rate
(Verapamil, Diltiazem)
Dihydro CCBs affect
the vessels more
used for HTN
(Amlodipine)
both types of CCB can be used for
Angina
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
Tx of HTN in pregnancy
Nifedipine (a dihydro CCB)
Methyldopa
Initial therapy for ACS
Nitrates
B-blockers
Left Heart Failure
Congestion of pulmonary system
- SOB
- fatigue
- hypoxia
- cough w frothy
- orthopnea
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
SOB, sweaty, tachypnea, tachycardic, rales, crackles, S3 or S4
Left Heart Failure
Periph edema
RUQ pain/discomfort
JVD
Ascited
Right Heart Failure
With Systolic HF, will likely see an Ejection Fraction
<40%
Normal Ejection Fraction
> 50-55 %
Dilated Left ventricle means
Systolic dysfx
Left ventricle hypertrophy
Diastolic dysfx
CXR shows:
- Cardiomegaly
- Cephalization of vessels
- Kerley B lines
- Pleural effusions
HEART FAILURE, dawg
Stress EKG is contra-indicated when
ANY ACUTE EVENT
something that’s already stressing out the heart
Labs to order
Cardiac enzymes- trop and CK-MB CBC CMP Glucose LFT BNP
BNP is very useful in:
ruling OUT Heart Failure
<100
Treatment order for HF
Diuretic
ACE-I
Then, if tolerating, add B-blocker
ARDS
Acute Respiratory Distress Syndrome
potentially fatal complication of HF
Workup for Acute Decomp Heart Failure
EKG CXR Pulse ox Arterial blood gas CBC Electrolytes Renal/liver Cardiac markers BNP Echo
Hypertrophic cardiomyopathy
Sudden death
Young athletes
Diastolic
Thick L ventricle wall
Dilated cardiomyopathy
MOST COMMON TYPE
Enlargement of all chambers
Systolic dysfx
Restrictive cardiomyopathy
Rigid vent walls
Diastolic
(least common type)
Cardiomyopathy
definition
Heart is not working well but NOT DUE TO: cad, htn, valve dz, chd
But, its Structurally or Functionally jacked up still
Dilated cardiomyopathy
SOB, fatigue, CP
Abd pain
Periph edema
PE: S3 gallop Mitral/tricuspid REGURGITATION murmur JVP Crackles
What causes Dilated cardiomyopathy?
Idiopathic usually
+ a bunch of possible others (genetic, infection, alc, drugs, endocrine, diet)
If Dilated Cardiomyopathy is infectious, most likely
VIRAL if in the US
Gold standard for dx of Infectious Dilated Cardiomyopathy
Endomyocardial biopsy
Tx for Dilated Cardiomyopathy
ACE-I
Diuretics
B-blockers
Digoxin maybe
Anti-arrhythmics
Anticoags
Implantable defibrillator
Cardiac transplant
1st line tx for Symptomatic Dilated Cardiomyopathy
ACE-I
Leading cause of Sudden Cardiac Death in young people
Hypertrophic Cardiomyopathy
a DIASTOLIC filling abnormality
What causes Hypertrophic Cardiomyopathy?
FAMILIAL
aut dominant
Sx of Hypertrophic Cardiomyopathy
often NOTHING, sudden death
if sx: exertional SOB, fatigue, pre-syncope, palpitations
S4 associated with
Hypertrophic Cardiomyopathy
sudden death
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
Dihydro CCBs (act more on VESSELS)
Amlodipine
Nifedipine
Non-Dihydro CCBs
act more on HEART
Verapamil
Diltiazem
Rigid Cardiomyopathy
Diastolic dysfx bc the walls are rigid and can’t fill properly
Most common cause of RESTRICTIVE CARDIOLMYOPATHY
Amyloidosis protein infiltrating the heart
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!!!
S3 gallop should prompt you to think about
Restrictive Cardiomyopathy
and this is not seen in Constrictive Pericarditis
Other sx of Restrictive Cardiomyopathy
Edema Abd disc Ascites Syncope CP SOB
S3 gallop
JVP
Kussmaul
Possible Regurgitation murmur
Periorbital Purpura (w/ heart failure) is pathgnomic
“racoon eyes”
“panda eyes”
a late finding for Cardiac Amyloidosis (a cause of Restrictive CM)
What will be enlarged in Restrictive CM?
Both Atria
Tx for Restrictive CM
Underlying cause
Low dose LOOP DIURETICS
Heart transplant
Poor prog :(
1st line tx for Symptomatic Restrictive CM
Loop diuretics
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
Takubostu CM
Trop and BNP will be elevated
EKG shows STE
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
Cardiac Ausc exam
Firm pressure
Light pressure
Firm:
Light:
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
JVD
atrial pressure
indic of volume overload
esp in right side of heart
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
Leaning fwd heart exam
good for Aortic or Pulmonic REGURGITATION murmurs
bringing base closer to chest wall
Homans sign
pt sitting on table, pull toes up in dorsiflexion
is it painful in the calf?
testing for phlebitis (inf of veins)
Allen test
occlude Radial and ulnar arteries
pt make tight fist
then open hand
release pressure of ULNAR artery (pinky)
does BF return?
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
