CVS

Question 1

Clinical approach to “sympathetic crashing acute pulmonary edema”

Answer 1

1) Nitrates (hydralazine is also an option, but it is less titratable and less predictable)
2) PEEP/NIPPV
3) Diuretics (IV Lasix)
4) Beta blocker (if HR > 150)
5) Transition to long-term antihypertensive (ie. labetalol and hydralazine)

Question 2

Clinical approach to “symptomatic bradycardia”

Answer 2

1) Atropine
2) Pacing (Transcutaneous or TVP)
3) Chronotropy (epinephrine, dopamine, isoproterenol)
4) Calcium (if secondary to hyper-kalemia)
5) Insulin (for beta blocker/CCB overdose)

Question 3

how to manipulate pulmonary vascular resistance to “unload the right ventricle”

Answer 3

1. maintain SpO2 >92% (Hypoxic pulmonary vasoconstriction is to be avoided)
2. Avoid excessive PEEP. PPV/PEEP is transmitted to the pulmonary circulation, adds to afterload. Unless patient is refractory hypoxemia d/t ARDS and needs to be oxygenated
3. Avoidance of hypercapnea. CO2 increases pulmonary arterial pressure and RV afterload
4. Pulmonary vasodilators (nitric oxide, prostacycline, bosentan, sildenafil, milrinone, levosimendan)

Question 4

Target electrolyte levels in the setting on an AMI

Answer 4

1. iCa+ > 1.0 mmol/L (Low serum calcium is independently correlated with LV systolic dysfunction in CAD patients with and without AMI)
2. K+ 3.5-4.5 mmol/L (in setting of ACS, hypokalemia defined as potassium levels <3.5 is associated with ventricular arrhythmias)
3. Mg+ >1.0 mmol/L (low serum Mg levels may be associated with cardiac arrhythmias and sudden death. Magnesium has antiarrhythmic effects)

Question 5

NSTEMI treatment pathway

Answer 5

1. “Dual anti platelet therapy” (ASA + P2Y12 inhibitors)
2. Statin therapy (atorvastatin)
3. Beta blockade (metoprolol)
4. Nitrates (NTG)
5. Systemic anticoagulation (heparin/LMWH)
6. Maintain normoxia (SpO2 >90%)
7. Optimize electrolytes (target normal range)

Question 6

treatment pathway for tamponade

Answer 6

1. Optimize preload with a fluid bolus (remember that tamponade is OBSTRUCTIVE and not cardiogenic shock. obstructive shock patients are preload dependent d/t elevated RV afterload
2. Augment rate: Allow tachycardia (in your CO equation your preload/afterload/contractility are all fucked so if you want to maintain MAP you’ll have to keep the HR a little bit higher)
3. Improve Forward flow: Levophed (if they are in shock you’ll have to support their hemodynamics with vasopressors. levy is 1st line)
4. Remove effusion: pericardiocentesis

Question 7

CO goals in aortic stenosis

Answer 7

1. preload high (force blood through the tiny little hole)
2. afterload normal
   3.HR low (prevent pulmonary edema/back flow)
3. contractility high (force blood out)

Question 8

CO goals acute aortic regurgitation and acute mitral regurgitation

Answer 8

1. afterload low
2. HR high (dont allow backfill)
3. contractility high (force blood out)
4. PPV or Intubation

Question 9

CO goals acute mitral stenosis

Answer 9

1. preload normal (Phenylephrine or vasopressin)
2. afterload normal
3. HR low (prevent pulmonary edema/back flow) [Esmolol or amiodarone]
4. contractility normal

Question 10

CO goals aortic stenosis

Answer 10

1. give fluids/Avoid preload-decreasing drugs
2. Vasopressors for cardiogenic shock (Phenylephrine or vasopressin)
3. sensitive to both bradyarrhythmia and tachydysrhythmias (Treat both aggressively)

Question 11

ACS treatment pathway

Answer 11

1. Dual antiplatelet therapy (Aspirin + P2Y12 inhibitor)
2. Anticoagulant (UFH/enoxaparin/fondaparinux)
3. Oxygen (sats >94%)
4. Rate control (Metoprolol)
5. Analgesia (NTG, opioids)
6. Statin therapy
7. Reperfusion (TnK or PCI)
8. Angiotensin-converting enzyme inhibitors
9. Optimize electrolytes (target normal range)

Question 12

PULMONARY EDEMA + SHOCK (“wet and cold” Cardiogenic Shock) treatment algorithm

Answer 12

1. IV/O2/Monitor
2. Differentiating the shock (pump failure vs mechanical complications)
3. optimize the MAP (Norepinephrine +/-
   Inotropic agent)
4. “fix the lungs” (CPAP/NIPPV/Intubation)
5. differentiate + optimize volume status (fluid bolus vs lasix)
6. consider inotrope for HFrEF/shitty contractility (dobutamine/epi)
7. treat underlying etiology
8. mechanical circulatory support

Question 13

treatment goals for acute cardiogenic shock

Answer 13

1. Address the underlying cause of shock
2. If shock is from pump failure, patients are frequently extravascularly fluid-overloaded but intravascularly volume-depleted
3. Fluid challenges in 250-mL isotonic crystalloid boluses with frequent re-assessment of intravascular volume status
4. if patient is still hypotensive post fluids, start an adrenergic agonist (norepinephrine)
5. Dobutamine is a good option for inotropy when the primary mechanism of shock is poor cardiac contractility. Patients may still require levo for hemodynamic support

Question 14

treatment goals for Hypertensive acute decompensated HF

Answer 14

1. Treatment should be targeted to afterload and preload reduction
2. Afterload can be reduced with a number of medicines, including nitrates and ACE inhibitors
3. Nitrates are first line, with NTG being the most common
4. loop Diuretics can be used in intravascularly volume-overloaded patients for preload reduction (Lasix)
5. Check and replenish electrolytes, particularly magnesium and potassium (arrhythmias)

Question 15

treatment for cardiogenic shock patients who are “warm and wet”

Answer 15

1. Fix lungs (CPAP/BIPAP)
2. Fix perfusion (Norepinephrine +/- inotrope)
3. Determine volume status and address

Question 16

Acute HF treatment goals

Answer 16

1. fix the lungs (O2 vs NIPPV vs Tube them)
2. optimize perfusion (Levo support?)
3. optimize volume status (fill the tank vs diurese)
4. optimize contractility (inotrope? electrolytes?)
5. treat underlying etiology (cath lab?)
6. consider mechanical circulatory support (does this dude need IABP/ECMO/LVAD)

Question 17

hemodynamic strategies and targets in aortic dissection

Answer 17

1. HR <60
2. SPB <120 mm Hg
3. art line for accurate titration of antihypertensives
4. If BP differs between arms on NIBP use the extremity/value with the higher BP
5. Labetalol IV 10-20 mg bolus over 2 min, then 20-80 mg bolus q10-15 min to a max of 300 mg, or initiate labetalol infusion at 0.5-2 mg/min, titrate up by 0.5 mg/min every 10 min to a max of 10 mg/min.
   might have to stack hydralazine on top of your labetalol to hit the alpha reduction

Question 18

Treatment for Post Cardiac Arrest

Answer 18

1. Labs, EKG, POCUS, Imaging
2. If MI then MI management, consider abx if infiltrates on CXR, replace magnesium as needed
3. TTM, Video EEG, Avoid long acting sedatives (propofol prefered)
   Analgesia/antipyretic package:
   1,000 mg acetaminophen PO q6hr scheduled.
   Buspirone 30 mg PO q8hr-q12hr.
   Ketamine infusion 0.1-0.3 mg/hr is helpful for both analgesia and shivering.
4. Finding the cause of the cardiac arrest is the most important thing.
5. Hemodynamic targets as per normal