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SD- ER pt 1 > CV Emergencies Lecture > Flashcards

CV Emergencies Lecture Flashcards

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1
Q

Pericarditis is pleuritic like central CP that worsens with ___________ and improves with ________

A

Worsens when pt is supine

Imroves with sitting

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2
Q

Pericarditis is aggravated by..

1.
2.
3.

A

Movement

Coughing

Swallowing

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3
Q

MC cause of pericarditis?

A

Viral!

(Coxsackie)

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4
Q

What will you hear during a lung exam in a pt with pericarditis

A

Friction Rub

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5
Q

3 Ps of pericarditis?

A

Position
Palpation
Pleuritic

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6
Q

Duration= hours to days

Quality= sharp

A

Pericarditis

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7
Q
  • *1. Viral**
    2. Uremia
    3. Radiation
    4. Autoimmune
    5. Drug induced
    6. Trauma
    7. Early post MI
    8. Neoplastic
A

causes of pericarditis

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8
Q

True or False..

other, less common causes of pericarditis, include:
TB, acute bacterial infections, fungal

A

True

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9
Q

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)

A

Pericarditis

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10
Q

All pericarditis pts should get what image, because there may be a small effusion

A

Echo-doppler

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11
Q

Tx of pericarditis..

A

Bedrest
NSAIDs

**avoid oral anticoagulation!

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12
Q

Mortality rate in diagnosed cases = 8%

Mortality rate in undiagnosed cases= 40-50%

A

PE

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13
Q

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

A

PE

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14
Q

97% will have at least 1 of the following:

Tachypnea
Dyspnea
Pleuritic CP

A

PE

*1/3 will have tachycardia

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15
Q

ST, NSST-T Changes on ECG

O2 may be decreased; repiratory alkalosis

CXR often normal

D-Dimer is non specific

A

PE

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16
Q

Image of choice for PE?

A

Helical (Spiral) CT Angiography

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17
Q

Pain (deep, visceral, crushing, heavy squeeze) longer than 30 mins
+
diaphoresis

..should be highly suspicious of?

A

MI

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18
Q

Can be caused by….

CAD
Plaque rupture
Occlusive thrombus
No perfusion of effected myocardium

A

MI

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19
Q

Atypical presentation of MIs are commonly seen in….

A

Elderly
Women
Diabetics

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20
Q

If a person is having an MI, is there pulse and BP high or low?

A

Can be either!

*usually depends on what type of MI they are having (location)

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21
Q

The sympathetic NS is stimulated, causing
increased pulse
increased HR

..usually seen in what type of MI?

A

Anterior MI

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22
Q

Parasymp NS is stimulated, casuing a
decreased pulse
decreased BP

..usually seen with what type of MI?

A

Inferior MI

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23
Q

An S3 heart sound during an MI indicates ______ dysfunction

A

LV

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24
Q

Transient MR murmur with an MI indicates _________ dysfunction

A

Papillary muscle

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25
Q

What dose of ASA is typically given to an MI pt?

A

160-325 mg

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26
Q

For a STEMI,

>2mm ST elevation in ________ leads
>1mm ST elevation in _____ leads in 2 adjacent (contiguous) leads

A

>2mm in precordial leads

>1mm in limb leads

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27
Q

3 drugs that can be used to treat MI pain

A

Nitro
Morphine
Beta blockers

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28
Q

dose= 0.4mg SL Q5 minutes (for up to 3 doses)

A

Nitro

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29
Q

Avoid nitro is systolic BP is below…

A

90 mmHg

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30
Q

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

A

Morphine sulfate

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31
Q

Cardiac ultrasound/doppler (echocardiogram) should be obtained in an MI pt within…

A

24 hours

*will show wall motion abnormalities of MI, EF, others.

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32
Q

Best way to treat/reperfuse an MI?

A

Pecutaneous Coronary Intervention (PCI)

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33
Q

Ideal goal= to keep ischemic time to under…..

A

120 mins!

(so from onset of symptoms to PCI time)

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34
Q

PCI is more complete in reperfusion of infarct artery and decreasing re-occulusion liklihood in comparison to what alternative tx method…

A

Fibrinolytics

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35
Q

If PCI is not available, what is MI tx?

A

Fibrinolytics

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36
Q

Start fibrinolysis within _______ minutes of onset of symptoms

A

30 mins

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37
Q

tPA, tenecteplase, reteplase

A

Fibrinolytic drugs

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38
Q
  • 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
A

Absolute/relative contraindications for fibrinolytics

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39
Q

After a thrombolytic is given to an MI pt who needs it, what needs to be done next?

A

Full anticoagulation with unfractionated Heparin or LMW Heparin

(goal PTT=50-75 secs)

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40
Q

Post PCI stent, what treatment needs to be established?

A

Long term ASA use

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41
Q

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?

A

Fibrinolytics

(PCI follows)

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42
Q

Risks of giving fibrinolytics before PCI?

A

If PCI done too early, before thrombolytic wears off, there is an increased risk of bleeding

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43
Q

Spontaneous tear in intima of aorta allows blood to dissect into media, separating aortic wall

A

Aortic Dissection

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44
Q

Associated with long standing, poorly controlled HTN-
repetitive torque to ascending/descending aortic wall

A

Aortic dissection

45
Q

Which type…

Dissection starts in aortic arch proximal to L subclavian artery

A

Type A Dissection

46
Q

Which type…

Dissection starts in proximal descending aorta beyond the subclavian artery

A

Type B Dissection

47
Q

Severe CP often radiating to/down back
HTN usually present

ECG= LVH common; NSST-T changes; ischemia if coronaries are involved

A

Aortic dissection

48
Q

Image of choice for an aortic dissection?

A

Multiplanar CT

49
Q

Must decrease BP ASAP!

target SBP= 100-110 mmHg

Give Beta blockers!
(Labetalol, Esmolol)

A

Aortic dissection tx

50
Q

Target SBP for an aortic dissection pt?

A

100-110 mmHg

51
Q

What type of dissection DEFINITElY requires surgery?

A

Type A

52
Q

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

A

Type B dissection

53
Q

How do you distinguish between unstable angina (UA) and a NSTEMI?

A

NSTEMI will have abnormal cardiac markers (CK, MB, troponins) that indicate cell necrosis

*no cell necrosis in UA

54
Q

If UA is left untreated, what are they are high risk for developing?

A

MI in the following days/weeks

55
Q

If NSTEMI is left untreated, what can happen?

A

Progression to larger MI/death

56
Q

ECG abnormal 50% of time:

ST depression
T wave inversion
(signs of ischemia)

A

Unstable angina
NSTEMI

57
Q

Pain at rest
Prolonged >10 mins
Substernal CP
Radiation

Nausea, dyspnea, diaphoresis

A

UA/NSTEMI

*women and elderly present different

58
Q

For a CP pt, you should get an EKG within…

A

10 mins

59
Q

Serial cardiac markers should be checked every…

A

6-8 hours

60
Q

>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

A

TIMI Risk Score

(risk factors for adverse events)

61
Q

Why might you see an ECG with low voltage?

A

Fluid present (ie tamponade with effusion)
COPD (increased air surrounding heart)
Obesity

62
Q

If troponins and ECG are negative for a CP (possible UA) pt, what should you do within the next 24-48 hours?

A

Stress test/imaging

*if + for ischemia= refer. possible cath
*if - for ischemia, discharge

63
Q

Tx for NSTEMI/UA pts

A

ASA**
Beta blockers
UFH,LMW Heparin

(CCB can be used 3rd line or alternative to Beta blockers if contraindicated)

64
Q

NSTEMI pt with….

*Recurren Angina/ischemia
*Elevated troponins
*ST depression
*CHF or EF <0.40
*Sustained vtach
*PCI within last 6 mo
*Prior CABG

A

Should favor Cath/revascularization

65
Q

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

A

Cardiac tamponade

66
Q

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

A

Cardiac tamponade

67
Q
  1. decreased arterial pressure
  2. increased systemic venous pressure
  3. quiet heart
A

Beck’s Triad

seen with cardiac tamponade

68
Q
  1. Hypotension
  2. Distended neck veins
  3. Distant heart sounds
A

Beck’s triad (Cardiac Tamponade)

69
Q

Cardiac output is very _____ sensitive

A

Volume

70
Q

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

A

Pulsus Paradoxus

71
Q

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)

A

what NORMALLY occurs with inspiration

pulsus paradoxus is an exaggeration of this

72
Q

Pulsus paradoxus can be seen with cardiac tamponade

true or false?

A

true

73
Q

Diagnostic image of choice for cardiac tamponade?

A

Echocardiogram

74
Q

Tx for cardiac tamponade?

A

Pericardiocentesis
IVF to increase preload

75
Q

Pericardectomy and pericardotomy are necessary in 25% for…

A

recurrent tamponade

76
Q

Acute MI or severe ischemia
Progression of HF
Acute HF superimposed on chronic HF
Acute volume overload of LV

A

can all cause acute pulmonary edema

77
Q

D/C of meds
Excessive Na intake
Myocardial ischemia
Tachyarrhythmias
Intercurrent infection

A

Precipitating factors of acute pulmonary edema

78
Q

Severe dyspnea***
+/- pink, frothy sputum
Cool extremities, cyanosis
Diaphoresis
Anxious, restless, unable to breath

JVD***

A

Acute pulmonary edema

79
Q 
Lungs= diffuse crackles, rales, wheezing
Heart= tachy, S3

“butterfly” pattern of alveolar edema on CXR

A

Acute pulmonary edema

80
Q

Tx for acute pulmonary edema?

A

O2!
Morphine
IV diuretics (Furosemide)

81
Q

Drug that helps acute pulmonary edema because..

venodilator, decreases PCW/LA pressure
Decreases anxiety

A

Morphine

82
Q

Can be paroxysmal or persistent

95% of the time, is seen with underlying cardiac or pulmonary pathology

often called “holiday heart”

A

A fib

83
Q

Atrial depolarization 400-600/min

A

A fib

84
Q

If new/untreated, ventricular tachycardia

120-180 bpm

A

A fib

85
Q

What is the first priority in an A fib pt?

A

Examine hemodynamic stability

*most patients will be stable
****if not stable, DC cardioversion

(pulse, BP, symptoms)

86
Q

Risk of thromboemboli in A fib if ongoing for longer than…

A

48-72 hours

87
Q

If A fib pt is hemodynamcally stable (most are), what is the initial goal and how do we achieve it?

A

Rate control!

with IV diltiazem

88
Q

If A fib is present for >48-72 hours, must fully anticoagulate for how long before attempting cardioversion?

A

3 weeks

89
Q

Cardioversion to NSR + drug rx to maintain NSR

*this increases CO

A

Rhythm control of a fib

90
Q

Leave in A fib, control ventricular rate + anticoagulate (warfarin)

A

Rate control of A fib

91
Q

Ibutilide can be used for rapid conversion of recent onset…

A

A fib and A flutter

92
Q

Asymptomatic pt with BP >220/120 mmHg

High BP (>200/110) with optic disc edema or progressive target organ (kidneys, heart) complications

Perioperative HTN

A

Hypertensive Urgencies

93
Q

Warrant BP lowering within a few hours

A

HTN urgencies

94
Q

Warrant substantial BP lowering within 1 hour to avoid severe morbidity or death

(BP often very elevated..DBP>130mmHg)

A

HTN emergencies

95
Q

Hypetensive encephalopathy
Hypertensive nephropathy
Malignant HTN

A

Hypertensive emergencies

96
Q

HA
Irritability
Confusion
Altered mental status (cerebrovascular spasm)

A

Hypertensive encephalopathy

97
Q

Hematuria
Proteinuria
Progressive kidney dysfunction (arteriolar necrosis and intimal hyperplasia)

A

Hypertensive nephropathy

98
Q

Encephalopathy or nephropathy
PLUS
papilledema!

predisposes to progressive renal dysfunction if not rapidly fixed

A

Malignant HTN

99
Q

↑↑BP with:

Intracranial hemorrhage

Aortic dissection

Pre-eclampsia/eclampsia

Unstable angina

Acute MI

A

Hypertensive emergencies

100
Q

DO NOT use meds to lower BP unless greater than..

A

200/100

101
Q

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

A

2 hours

102
Q

Nicardipine and Clevipine are two potent CCBs that are used for

A

HTN emergencies

(Nicardipine=1st line)

103
Q

___% of abdominal aneurysms are below renal arteries

A

75

104
Q

Palpable, pulsatile, non tender mass

abdominal ultrasound allowes for accurate dimension measures

A

AAA

105
Q

>60 yo with risk factors for AAA:

  • family hx of AAA
  • presence of PAD/atherosclerosis
  • presence of peripheral artery aneurysms
A

Screen with ultrasound for AAA

106
Q

AAA >6.5 cm

A

SURGERY always!!

107
Q

AAA >5 cm

A

probable surgery

108
Q

AAA >5 cm has a 20-40% rupture chance over…

A

5 years

SD- ER pt 1 (8 decks)

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