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ER > CV 2 > Flashcards

CV 2 Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

A female presents to the ED with chest and upper abdominal pain that started 40 minutes ago and rates it as an 8/10. It has not responded to antacids. The pain is aching, does not radiates, and no vomiting. She has no SOB & mentions a similar episode for 10 minutes earlier today. What diagnosis?

A

MI

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2
Q

What do you see on this ECG? What is it most consistent with?

A

ST depression (that’s greater than 1mm); T wave inversion in V5 & V6

Most consistent with Myocardial Ischemia

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3
Q

What is the major difference between UA & NSTEMI?

A

NSTEMI there are abnormal cardiac markers (troponins) that indicate cell necrosis.

With UA, no cell necrosis has occurred (yet)

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4
Q

What is the pathology behind UA or NSTEMI?

A

Complex coronary lesions, stenosis with plaque rupture, hemorrhage, or thrombus

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5
Q

What happens if you miss the diagnosis of an UA or an NSTEMI?

A

UA has a high risk of developing an MI

NSTEMI will progress to a larger MI/death

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6
Q

What are the major symptoms of UA or NSTEMI?

A

Substernal chest pain/discomfort at rest, that lasts longer than 10 minutes

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7
Q

What might you see on PE with UA or NSTEMI?

A

S4 gallop is common! Variables changes in LV function

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8
Q

So, what’s the criteria to diagnose NSTEMI?

A

ONE value (serial markers every 6-8 hours) >99th percentile of upper reference limit

* Classic curve of troponins: Starts slightly elevated, peaks, and comes back down

*Remember values that are elevated but not quite in the 99th percentile, you should be suspicious of (troponin should never be elevated)

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9
Q

What’s the one type of patient who might give you a false positive on troponins?

A

Those with chronic renal failure

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10
Q

What are some of the risk factors to UA or NSTEMI?

A

Older than 65

Prior coronary stenosis

ST seg deviation

2 or more angina episodes in prior 24 hours

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11
Q

You have a patient you are concerned has UA or NSTEMI, but their first biomarkers are negative, ECG is normal, what do you do?

A

Continuous monitoring, serial ECG’s, and serial troponins

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12
Q

If absolutely everything came back stone cold normal for 24 hours, what do you do with your patient who you were concerned about UA or NSTEMI?

A

Stress test/imaging

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13
Q

Your patient that you thought had an MI but was normal for 24 hours just had a stress test done and it came back positive for ischemia – what do you do? What if it had come back negative?

A

Positive à Cath lab (possible revascularization)

Negative à Discharge

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14
Q

Let’s say the patient you’re concerned about an MI has ST depression, positive troponins and still has chest pain – what do you do?

A

NTG (3 in the ED)

ASA (chew 325mg)

Start oral beta-blocker

Can add CCB

**SINCE THERE ARE ELEVATED TROPONINS ITS AN NSTEMI SOOOOO ADD:

Full Anticoag (LMWH)

Prasugrel or Trcagrelor

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15
Q

For our patient that has a NSTEMI, we have started her on all the appropriate meds, what do we do next?

A

Most NSTEMI’s should be considered for revascularization

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16
Q

What factors would favor revascularization?

A

Recurrent angina/ischemia, elevated troponins, ST depression on ECG, Develop CHF or EF (that’s less than .40), sustained VTach

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17
Q

A woman presents with 7 day history of 3/10 chest discomfort and SOB. She describes it as fullness. She has had increasing fatigue, but today she is very fatigued with increasing SOB at rest – what diagnosis?

A

Pericardial effusion (with possible tamponade)

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18
Q

What would we see on PE with pericardial effusion with compression – tamponade?

A

JVD, soft heart sounds but clear lungs, hypotensive –> varying BP’s

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19
Q

What do you see on this ECG?

A

Low voltage (in both limb and precordial leads) with flat T waves

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20
Q

When we see low voltage on ECG & we are concerned about pericardial effusion what diagnostic test must we order? What would we see?

A

Echo – RA/RV collapse in early diastole

Thus we would have to re-evaluate the BP to see if a drop of >10mmHg in systolic BP occurs with INSPIRATION

*If so, that indicates PULSUS PARADOXUS à CARDIAC TAMPONADE

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21
Q

What is cardiac tamponade?

A

Pericardial effusion elevates to a pressure causing compression of the heart.

Leads to progressive limitation of diastolic filling & is FATAL if not recognized and aggressively treated

22
Q

What 3 things are often associated with tamponade, what are they known as?

A

Beck’s triad = decline in arterial pressure,

elevation of systemic venous pressure, and quiet heart

23
Q

If we give someone with tamponade a small amount of IV fluid what would we expect to happen?

A

BP will go up for a short period of time since CO is extremely Volume Sensitive

24
Q

How do we treat cardiac tamponade?

A

Pericardiocentesis

25
Q

A patient presents to the ED with severe SOB that awoke him abruptly from sleep. He denies any form of chest pain. He has a history of an MI 1 year ago and has not been compliant with his medications. His O2 sat is 90% and he is becoming more anxious with more difficulty breathing - what diagnosis?

A

acute pulmonary edema

26
Q

What might you find on PE with acute pulmonary edema?

A

Crackles & rales

Apical holosystolic murmur (mitral regurg) & S3 gallop

JVD

27
Q

What diagnostic test should you get with acute pulmonary edema?

A

ECG

CXR – vascular redistribution, alveolar edema in a “butterfly” pattern, with Kerly B lines

BNP – elevated (due to increased filling pressures)

28
Q

How do we treat acute pulmonary edema?

A

This is a medical emergency!!!

Give O2!

Morphine sulfate (venodilator & reflex withdrawal of sympathetic NS)

IV diuretics

Nitrates (especially if elevated BP) to decrease preload

29
Q

A patient presents to the ER with a racing heart and palpitations for the past 5 hours. He denies any SOB. On PE his BP 155/90 and his rhythm is irregular at 150bpm – what diagnosis?

A

Atrial Fibrillation

30
Q

What do you see on this EKG?

A

Afib

31
Q

In Afib, how might the pulses vary between over the heart and radial?

A

Radial will be less because the heart hasn’t filled enough to create an appropriate output

32
Q

What is our first priority when we have a patient in AFib?

A

Assess hemodynamic stability (BP, P, and sxs)

33
Q

If a patient is not stable and in Afib – what do you do?

A

Cardioversion

34
Q

If a patient in stable and in Afib – what do you do next?

A

Echo – to look for underlying cardiac or pulmonary precipitating factors

Figure out how long it has been present for

Control their rate with Diltiazem

35
Q

What happens if you learn the person’s Afib has been present for >48 hours?

A

You must fully anticoagulated for 3 weeks before cardioversion

36
Q

If a patient has persistent/recurrent Afib how do you manage them?

A

Rhythm control (cardiovert + meds or ablation)

Rate control (leave in afib & anticoag)

37
Q

What medication can you give for rapid conversion of recent onset Afib or Aflutter?

A

Ibutilide

38
Q

A patient comes to the ED with severe HA & Nausea. She has also been confused. Hx of HTN & dyslipidemia but stopped all meds when she lost her job. She also smokes 2ppd. Her current BP is 230/130 – what diagnosis?

A

HTN Emergency!

39
Q

What do you look for on PE with HTN Emergencies?

A

EYES! – Arteriolar narrowing, A/V nicking, disc margins & papilledema

40
Q

What labs do you want to check with HTN Emergencies?

A

Kidney’s (UA for protein)

Along with CBC, INR, PTT, and Lytes

41
Q

If a patient is asymptomatic with high BP – how would we treat them?

A

Do not require emergent Rx

42
Q

BTW, what is considered high BP?

A

Greater than 200/110

43
Q

What’s the difference between a HTN urgency & HTN Emergency?

A

Urgency = Lower BP within a few hours (no more than 25% within 2 hours)

Emergency = Lower BP within 1 hour (to avoid HTN encephalopathy, nephropathy)

44
Q

What do we need to make sure of when we suspect a HTN urgency?

A

It’s not an MI

45
Q

What meds are 1st line for HTN Emergencies?

A

Nicardipine or Clevipine

46
Q

What other meds can you use of a htn emergency?

A

Labetolol, Esmolol, IV NTG

47
Q

A patient brought in by EMS developed acute abdominal pain 25 minutes ago. Hx includes CHD, HTN, and PAD & he’s a heavy smoker. In route to the ED he becomes progressively hypotensive. He’s given fluids & his BP drops near 60mmHg (systolic) – what diagnosis are you thinking?

A

Aortic aneurysm

48
Q

What could have been seen on PE for this patient long ago to prevent his current state of aortic aneurysm?

A

Pulsatile aortic mass in the stomach

49
Q

What do we monitor AA’s with to make sure they’re not expanding too much?

A

Ultrasound

50
Q

Who should be screened with an ultrasound for AAA’s?

A

Male smokers over 60 who…

  • Have a family history of AAA
  • Presence of PAD/atherosclerosis
  • Presence of peripheral artery aneurysms
51
Q

If a patient is asymptomatic when do we stent the aorta to prevent AAA?

A

Always do surgery if greater than 6.5cm

Probably surgery if greater than 5 cm

ER (10 decks)

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