CV Emergencies Lecture Flashcards
Pericarditis is pleuritic like central CP that worsens with ___________ and improves with ________
Worsens when pt is supine
Imroves with sitting
Pericarditis is aggravated by..
1.
2.
3.
Movement
Coughing
Swallowing
MC cause of pericarditis?
Viral!
(Coxsackie)
What will you hear during a lung exam in a pt with pericarditis
Friction Rub
3 Ps of pericarditis?
Position
Palpation
Pleuritic
Duration= hours to days
Quality= sharp
Pericarditis
- *1. Viral**
2. Uremia
3. Radiation
4. Autoimmune
5. Drug induced
6. Trauma
7. Early post MI
8. Neoplastic
causes of pericarditis
True or False..
other, less common causes of pericarditis, include:
TB, acute bacterial infections, fungal
True
ECG changes occur within hours of onset of pain
initial changes= diffuse ST segment elevation in ALL leads EXCEPT aVR and VI
later changes= normalization of ST elevation followed by T wave flattening and T wave inversion (this can be days or longer)
Pericarditis
All pericarditis pts should get what image, because there may be a small effusion
Echo-doppler
Tx of pericarditis..
Bedrest
NSAIDs
**avoid oral anticoagulation!
Mortality rate in diagnosed cases = 8%
Mortality rate in undiagnosed cases= 40-50%
PE
Risk factors:
Stasis (pregnancy, obesity, varicosity, bed rest, immobilization, surgery, incresed age)
Cardiac D/Os
Hypercoagulability (OCPs, polycythemia, Factor V Leiden, etc)
Trauma
Chemo
Smoking
PE
97% will have at least 1 of the following:
Tachypnea
Dyspnea
Pleuritic CP
PE
*1/3 will have tachycardia
ST, NSST-T Changes on ECG
O2 may be decreased; repiratory alkalosis
CXR often normal
D-Dimer is non specific
PE
Image of choice for PE?
Helical (Spiral) CT Angiography
Pain (deep, visceral, crushing, heavy squeeze) longer than 30 mins
+
diaphoresis
..should be highly suspicious of?
MI
Can be caused by….
CAD
Plaque rupture
Occlusive thrombus
No perfusion of effected myocardium
MI
Atypical presentation of MIs are commonly seen in….
Elderly
Women
Diabetics
If a person is having an MI, is there pulse and BP high or low?
Can be either!
*usually depends on what type of MI they are having (location)
The sympathetic NS is stimulated, causing
increased pulse
increased HR
..usually seen in what type of MI?
Anterior MI
Parasymp NS is stimulated, casuing a
decreased pulse
decreased BP
..usually seen with what type of MI?
Inferior MI
An S3 heart sound during an MI indicates ______ dysfunction
LV
Transient MR murmur with an MI indicates _________ dysfunction
Papillary muscle
What dose of ASA is typically given to an MI pt?
160-325 mg
For a STEMI,
>2mm ST elevation in ________ leads
>1mm ST elevation in _____ leads in 2 adjacent (contiguous) leads
>2mm in precordial leads
>1mm in limb leads
3 drugs that can be used to treat MI pain
Nitro
Morphine
Beta blockers
dose= 0.4mg SL Q5 minutes (for up to 3 doses)
Nitro
Avoid nitro is systolic BP is below…
90 mmHg
Very affective drug in anterior MIs
Can lead to venous pooling
dose= 2-5 mg IV. repeat if needed
if BP drops, elevate legs and give IVF
Morphine sulfate
Cardiac ultrasound/doppler (echocardiogram) should be obtained in an MI pt within…
24 hours
*will show wall motion abnormalities of MI, EF, others.
Best way to treat/reperfuse an MI?
Pecutaneous Coronary Intervention (PCI)
Ideal goal= to keep ischemic time to under…..
120 mins!
(so from onset of symptoms to PCI time)
PCI is more complete in reperfusion of infarct artery and decreasing re-occulusion liklihood in comparison to what alternative tx method…
Fibrinolytics
If PCI is not available, what is MI tx?
Fibrinolytics
Start fibrinolysis within _______ minutes of onset of symptoms
30 mins
tPA, tenecteplase, reteplase
Fibrinolytic drugs
- Hx of cerebrovascular hemorrhage
- Stroke within 1 year
- Marked HTN (S>180, D>110)
- Active internal bleeding
- Recent head trauma
- Recent major surgery (within 3 weeks)
- >65 yo
Absolute/relative contraindications for fibrinolytics
After a thrombolytic is given to an MI pt who needs it, what needs to be done next?
Full anticoagulation with unfractionated Heparin or LMW Heparin
(goal PTT=50-75 secs)
Post PCI stent, what treatment needs to be established?
Long term ASA use
If a PCI center is not readily available (artery open in 120 mins), but is reachable by transfer
..what can you give in the mean time?
Fibrinolytics
(PCI follows)
Risks of giving fibrinolytics before PCI?
If PCI done too early, before thrombolytic wears off, there is an increased risk of bleeding
Spontaneous tear in intima of aorta allows blood to dissect into media, separating aortic wall
Aortic Dissection
Associated with long standing, poorly controlled HTN-
repetitive torque to ascending/descending aortic wall
Aortic dissection
Which type…
Dissection starts in aortic arch proximal to L subclavian artery
Type A Dissection
Which type…
Dissection starts in proximal descending aorta beyond the subclavian artery
Type B Dissection
Severe CP often radiating to/down back
HTN usually present
ECG= LVH common; NSST-T changes; ischemia if coronaries are involved
Aortic dissection
Image of choice for an aortic dissection?
Multiplanar CT
Must decrease BP ASAP!
target SBP= 100-110 mmHg
Give Beta blockers!
(Labetalol, Esmolol)
Aortic dissection tx
Target SBP for an aortic dissection pt?
100-110 mmHg
What type of dissection DEFINITElY requires surgery?
Type A
What type of dissection…
Requires urgent surgical repair if there is an arterial branch occlusion or a progressive dissection
BUT
If pt stabilizes and dissection does NOT invove branch arteries, CAN do surgery or can just medically treat BP and get annual CT scans
Type B dissection
How do you distinguish between unstable angina (UA) and a NSTEMI?
NSTEMI will have abnormal cardiac markers (CK, MB, troponins) that indicate cell necrosis
*no cell necrosis in UA
If UA is left untreated, what are they are high risk for developing?
MI in the following days/weeks
If NSTEMI is left untreated, what can happen?
Progression to larger MI/death
ECG abnormal 50% of time:
ST depression
T wave inversion
(signs of ischemia)
Unstable angina
NSTEMI
Pain at rest
Prolonged >10 mins
Substernal CP
Radiation
Nausea, dyspnea, diaphoresis
UA/NSTEMI
*women and elderly present different
For a CP pt, you should get an EKG within…
10 mins
Serial cardiac markers should be checked every…
6-8 hours
>65
At least 2 risk factors for CHD
Prior coronary stenosis
ST segment deviation on presenting ECG
2+ anginal episodes in 24 hours
ASA in the last 7 days
Elevated cardiac markers
TIMI Risk Score
(risk factors for adverse events)
Why might you see an ECG with low voltage?
Fluid present (ie tamponade with effusion)
COPD (increased air surrounding heart)
Obesity
If troponins and ECG are negative for a CP (possible UA) pt, what should you do within the next 24-48 hours?
Stress test/imaging
*if + for ischemia= refer. possible cath
*if - for ischemia, discharge
Tx for NSTEMI/UA pts
ASA**
Beta blockers
UFH,LMW Heparin
(CCB can be used 3rd line or alternative to Beta blockers if contraindicated)
NSTEMI pt with….
*Recurren Angina/ischemia
*Elevated troponins
*ST depression
*CHF or EF <0.40
*Sustained vtach
*PCI within last 6 mo
*Prior CABG
Should favor Cath/revascularization
Increase in pericardial fluid, increasing intrapericardial pressure, resulting in compression of the heart
*limitation of ventricular diastolic filling, leading to decreased stroke volume and cardiac output
Cardiac tamponade
Marked elevation and equilibration of LV and RV
LA and RA pressures elevated
Marked decrease in cardiac output
***RA and RV collapse seen on echo
Cardiac tamponade
- decreased arterial pressure
- increased systemic venous pressure
- quiet heart
Beck’s Triad
seen with cardiac tamponade
- Hypotension
- Distended neck veins
- Distant heart sounds
Beck’s triad (Cardiac Tamponade)
Cardiac output is very _____ sensitive
Volume
Intrapericardial pressure is markedly increased
RV and LV volumes diminshed
inspiration results in a decreased LV volume, resulting in a systolic BP drop >10 mm
Pulsus Paradoxus
Increased venous return
Slight increase RV volume
Slight decrease LV volume
RV output increases, LV output decreases
minimal drop in systolic BP (2-4 mm)
what NORMALLY occurs with inspiration
pulsus paradoxus is an exaggeration of this
Pulsus paradoxus can be seen with cardiac tamponade
true or false?
true
Diagnostic image of choice for cardiac tamponade?
Echocardiogram
Tx for cardiac tamponade?
Pericardiocentesis
IVF to increase preload
Pericardectomy and pericardotomy are necessary in 25% for…
recurrent tamponade
Acute MI or severe ischemia
Progression of HF
Acute HF superimposed on chronic HF
Acute volume overload of LV
can all cause acute pulmonary edema
D/C of meds
Excessive Na intake
Myocardial ischemia
Tachyarrhythmias
Intercurrent infection
Precipitating factors of acute pulmonary edema
Severe dyspnea***
+/- pink, frothy sputum
Cool extremities, cyanosis
Diaphoresis
Anxious, restless, unable to breath
JVD***
Acute pulmonary edema
Lungs= diffuse crackles, rales, wheezing Heart= tachy, S3
“butterfly” pattern of alveolar edema on CXR
Acute pulmonary edema
Tx for acute pulmonary edema?
O2!
Morphine
IV diuretics (Furosemide)
Drug that helps acute pulmonary edema because..
venodilator, decreases PCW/LA pressure
Decreases anxiety
Morphine
Can be paroxysmal or persistent
95% of the time, is seen with underlying cardiac or pulmonary pathology
often called “holiday heart”
A fib
Atrial depolarization 400-600/min
A fib
If new/untreated, ventricular tachycardia
120-180 bpm
A fib
What is the first priority in an A fib pt?
Examine hemodynamic stability
*most patients will be stable
****if not stable, DC cardioversion
(pulse, BP, symptoms)
Risk of thromboemboli in A fib if ongoing for longer than…
48-72 hours
If A fib pt is hemodynamcally stable (most are), what is the initial goal and how do we achieve it?
Rate control!
with IV diltiazem
If A fib is present for >48-72 hours, must fully anticoagulate for how long before attempting cardioversion?
3 weeks
Cardioversion to NSR + drug rx to maintain NSR
*this increases CO
Rhythm control of a fib
Leave in A fib, control ventricular rate + anticoagulate (warfarin)
Rate control of A fib
Ibutilide can be used for rapid conversion of recent onset…
A fib and A flutter
Asymptomatic pt with BP >220/120 mmHg
High BP (>200/110) with optic disc edema or progressive target organ (kidneys, heart) complications
Perioperative HTN
Hypertensive Urgencies
Warrant BP lowering within a few hours
HTN urgencies
Warrant substantial BP lowering within 1 hour to avoid severe morbidity or death
(BP often very elevated..DBP>130mmHg)
HTN emergencies
Hypetensive encephalopathy
Hypertensive nephropathy
Malignant HTN
Hypertensive emergencies
HA
Irritability
Confusion
Altered mental status (cerebrovascular spasm)
Hypertensive encephalopathy
Hematuria
Proteinuria
Progressive kidney dysfunction (arteriolar necrosis and intimal hyperplasia)
Hypertensive nephropathy
Encephalopathy or nephropathy
PLUS
papilledema!
predisposes to progressive renal dysfunction if not rapidly fixed
Malignant HTN
↑↑BP with:
Intracranial hemorrhage
Aortic dissection
Pre-eclampsia/eclampsia
Unstable angina
Acute MI
Hypertensive emergencies
DO NOT use meds to lower BP unless greater than..
200/100
In a HTN emergency,
goal is to lower BP by 25% within ___ hours, then more gradual lowering (over 2-6 hours) to a BP ~160/100
2 hours
Nicardipine and Clevipine are two potent CCBs that are used for
HTN emergencies
(Nicardipine=1st line)
___% of abdominal aneurysms are below renal arteries
75
Palpable, pulsatile, non tender mass
abdominal ultrasound allowes for accurate dimension measures
AAA
>60 yo with risk factors for AAA:
- family hx of AAA
- presence of PAD/atherosclerosis
- presence of peripheral artery aneurysms
Screen with ultrasound for AAA
AAA >6.5 cm
SURGERY always!!
AAA >5 cm
probable surgery
AAA >5 cm has a 20-40% rupture chance over…
5 years
