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ED and Cards Flashcards

1
Q

What are the most common complications of HOCM?

A

arrhythmias
myocardial ischemia
sudden death

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2
Q

What is bicarb in metabolic acidosis?

A

low bicarb
can check if appropriately compensating with Winter’s formula
pCO2 = 1.5(HCO3) + 8
* body will never OVER compensate, must be a respiratory component

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3
Q

How to tx unstable angina or non-St elevation Mi inpt?

A

Admit to ICU/CCU, telemetry
repeat EKG, CPK-MB, troponin at 6 hr intervals
Enoxaparin (though use unfractionated heparin until after procedure if they are going to have one), IV metoprolol, statin oral

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4
Q

What is 3rd degree AV block?

A

no correlation between the p and qrs waves

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5
Q

How to work up pt with burns from fire?

A
  1. check carboxyhemoglobin level *carbon monoxide poisoning
  2. CXR
  3. CBC, electrolytes
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6
Q

What are EKG findings of V tach?

A
  1. wide QRS
  2. A-V dissociation
  3. ischemia findings
  4. can progress to V fib
  5. HR usually 100-180
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7
Q

How do you convert an unstable pt with v tach?

A

start synchronized cardioversion at 100J, then 200J, then 360J, then 360J, if continues - use meds also to stabilize (lidocaine, amiodarone)

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8
Q

What is the work up for a pt with a high fever on CCS of unkown origin?

A

blood cultures, chest xray, urinalysis

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9
Q

How to read an EKG?

A

rate (300-150-100-75-60)

rhythm

intervals (PR, QRS (<3 boxes), QT)

T waves

elevations/delta waves

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10
Q

How give stress ulcer prophylaxis?

A

For all criticall ill pts (ICU)
PPIs, H2 blockers, or sucralfate

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11
Q

What is long term management of hypertensive emergency?

A
  1. transfer to floor when symptoms resolve
  2. start oral meds - labetalol or enalapril
    *may beed 2-3 meds (should include diuretic)
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12
Q

How to work up claudication/peripheral vascular dz?

A

ankle/brachial pressure index (ABI) - do it with a duplex in lower extremities - if <1 = peripheral vascular dz

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13
Q

How do you manage CHF with systolic dysfunction after the pt is stabilized?

A
  1. ACE inhibitor
  2. once stable add beta blockers
  3. if can’t do ACE inhibitor use hydralazine plus isosorbide dinitrate
  4. if a fib - start with digoxin
  5. Spironolactone (if dyspnea at rest or minimum exertion)
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14
Q

How do you differentiate between unstable angina and acute MI?

A

need troponins and CK-MB

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15
Q

How to treat unstable a fib?

A

emergency cardioversion for pt with hypotension, AMS, or angina

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16
Q

What rhythm control meds can not be used in QT rolongation because they also prolong QT intervals and can lead to Torsades?

A

Sotalol, ibutilide, dofetilide

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17
Q

What options can you use for tx for pts with a fib from a rate control perspective?

A
  1. Calcium channel Blockers:

Diltiazem just as rapid as verapamil with less side effects

Verapamil (constipation), rapid effect, do not use in pts with low EF bc decr contractility

  1. Beta-blockes (metoprolol and esmolol) *safe in well controlled asthma and COPD
  2. Digoxin for rate control in pts with poor EF
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18
Q

what are the indications for thrombolytics in acute MI?

A
  1. w/in 12 hours of onset and no access to cath lab for angioplasty
  2. >1-2 mm ST elevation
  3. new left bundle branch block (must have an old EKG to compare)
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19
Q

What are the side effects of statins?

A

myositis and increase in CPK levels

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20
Q

Why are beta blockers contraindicated in anaphylaxis?

A

they block the action of epinephrine (which is one beta receptors)

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21
Q

What type of antibiotics are given in burn patients?

A

topical - silver sulfadiazine

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22
Q

How do you treat alcoholic hepatitis (incr. AST/ALT, PT, and bili)?

A

Steroids (but not if SBP/infection present)

pentoxyphyline - reduces heptorenal syndrome

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23
Q

What is schistocytes a sign of?

A

microangiopathic hemolytic anemia (red blood cells being ripped apart in small vessels)

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24
Q

Who gets cardioversion in vtach?

A

hypotension, mental status chages, CHF, chest pain

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25
Q

When shoudl you intubate a burn pt?

A

airway compromise (stridor)

severely altered mental status

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26
Q

What is the next step in a fib tx if rate and rhythm control don’t work?

A

ablation

*50% effective

*if 2+ CHAD2S score - anticoagulation is on anticoagulation forever

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27
Q

How do you manage HOCM once stable/dx?

A
  1. beta blocker or calcium channel blocker (Verapamil)
  2. may need implantable defibrillator (based on septum size)
  3. avoid extreme exertional activity
  4. surgical fixes: can infuse alcohol to reduce thickness of septum, surgical myomectomy
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28
Q

What is 1st degree AV block?

A

increased PR interval

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29
Q

How do you surgically tx mitral stenosis?

A

balloon valvuloplasty or valvular replacement

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30
Q

How do you w/u and manage sudden, symptomatic bradycardia?

A
  1. EKG
  2. Atropine
  3. IV fluids
    stop beta blockers, nitrates, calcium channel blockers when hypotensive
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31
Q

What is the long term management of dyslipidemia?

A
  1. statin (high intensity - rosuvastatin, atorvastatin, bring down by 50%, mod intensity reduces by 30-50%)
  2. limit fats in diet
  3. exercise (don’t start intense exercise at same time as statin/stagger it)
  4. LFTs (AST, ALT, bilirubin) q3-6 months
  5. repeat LDL, Triglycerides, cholesterol levels in 6 wks, then f/u with levels q6-12 months
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32
Q

How do you tx aspirin (salicylate) overdose?

A
  1. always give activated charcoal (on CCS for toxicology)
  2. supportive care (IV hydration)
  3. IV bicarbonate to alkalinize the urine to increase drug excretion (check urine pH and give until urine pH is > 7.5)
  4. psych consult
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33
Q

What is f/u management for acute exacerbation of CHF?

A
  1. transfer to floor when MI excluded and hypoxia improved
  2. ECHO when sent to floor
  3. dobutamine if symptomatic after use of nitrates/furosemide)
  4. add beta-blockers after stable
  5. add spironolactone if pt is symptomatic at rest/min exertion
  6. if still symptomatic after all of this - digoxin
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34
Q

How to manage V tach?

A

DC cardioversion (unstable), lidocaine or amiodarone (stable), check electrolytes and correct

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35
Q

What is the different between epidural and subdural hematoma?

A

epidural (convex) - breif period of being well
subdural (lenticular)

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36
Q

What electrolytes can cause QT prolongation?

A

HypoK

HyopMag

HypoCa

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37
Q

How do you manage CHF with diastolic dysfunction after the pt is stabilized?

A
  1. Beta blockers
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38
Q

What is the most common arrythmia?

A

atrial fibrillation

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39
Q

What type of hypersensitivity reaction is anaphylaxis?

A

Type 1

Anaphylaxis and atopic

IgE cross linking and immediate release of histamine and bradykinin - increase permeability of capillaries, vasodilation, and bronchoconstriction

delayed response due to production of leukotrienes

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40
Q

What risk factor makes you more likely to get acetaminophen toxicity?

A

chronic alcohol use (due to increase in P450 acitvation (increase toxic metabolite production) and poor nutrition (decreased glutathione production)

*only 4g per day can lead to acetaminophen toxicity (vs 10-15g/day for other people)

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41
Q

How to control pain in burn patients?

A

IV morphine drip or PCA pump, or hydromorphone

*if renal failure - use fentanyl

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42
Q

What blood pressure medicine should be used in hypertensive emergency?

A
  1. Labetalol
    *oral and IV, very safe even in pregnancy
  2. Nitroprusside (only in ICU)
    *cyanide poisoning
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43
Q

What is type 3 hypersensitivity?

A

Immune complex mediated

complexes activate complement which attract neutrophils releasing lysosomal enzymes

ex: SLE, polyarteritis nodosa, post-strep glomerulonephritis

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44
Q

What are thrombolytics used in acute MI?

A

tPA
streptokinase

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45
Q

What are the 3 things that can give you AST/ALT in the 1000s?

A
  1. medications (acetaminophen, methotrexate, RIPE, amiodarone)
  2. Viral hepatitis (A, B, very rarely C)
  3. Ischemic liver (after event like v fib/MI)
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46
Q

What genetic syndrome is associated with aortic stenosis?

A

Turner Syndrome

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47
Q

Labs to check for alcoholics

A

Electrolytes, blood alchol level, serum magnesium, ABG, AU, blood cultures, LP (if altered mental status)

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48
Q

What usually causes myocardial ST segment elevation vs depression?

A

ST seg elevation - infarction
ST seg depression - ischemia, or posterior wall MI

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49
Q

What are EKG findings of R ventricular hypertrophy?

A

R in V1 > 7 mm

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50
Q

Who gets started on a statin?

A
  1. anyone with clinical CV disease
  2. LDL > 190
  3. person 40-75 yo w/ DM and LDL 70-189 w/o clinical CV disease
  4. people with/o clinical CV disease or DM who are 40-75 yo with LDL 70-189 w/ a 10 y CV dz risk >7.4% (framingham risk score)
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51
Q

How to work up a pt with a symptomatic tachycardia?

A

EKG, pulse ox, fluids if hypotensive

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52
Q

How do you initially manage hypertensive emergency?

A
  1. EKG
  2. BUN/Cr, CBC
  3. IV labetolol, nutroprusside, or enalaprilat
  4. oxygen and pulse ox
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53
Q

What is the differential for MI?

A

unstable angina
Acute MI
dissecting aortic aneurysm
pericarditis
esophageal spasms
PE
musculoskeletal pain
pancreatitis
pneumothorax

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54
Q

Who should receive hyperbaric oxygen for pts with carbon monoxide poisoning?

A
  1. carboxyhemoglobin >25%
  2. altered mental status
  3. angina
  4. pregnancy with carboxyhemoglobin > 15%
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55
Q

What non-cardiac drugs also block Ca channels and can cause QT prolongation?

A

macrolides, fluoroquinolones, antipsychotics (haloperidol), methadone

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56
Q

What cardiac drugs should not be used in HOCM?

A

digoxin
nitrates *causes decr venous return and increased obstruction
vasodilators
ACE inhibitors *incr peripheral resistance

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57
Q

How to manage emergent atrial fibrillation?

A

IV diltiazem (or verapamil) (CCB)

admit to telemetry unit

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58
Q

What is the difference between action potentials in your heart nodal cells vs the non-nodal cells?

A

In non-nodal cells, the depolarization is mediated by Na channels (rapid) (then Ca and K come in)

In nodal cells (SA and AV), the depolarization is mediated by Ca channels (slow until meets the threshold, then faster Ca channels open).

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59
Q

What are the most common post MI complications?

A

arrhythmia (most common in first 3 days)
valvular dysfunction/rupture (3-5 days)
cardiogenic shock
aneurysm formation (delayed)
mural thrombus (at anytime)
myocardial rupture (3-5 days)
conduction defects

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60
Q

How to work up dyspnea with exertion and abnormal cardiac exam in outpt office?

A
  1. pulse ox, oxygen
  2. EKG, CXR, ECHO
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61
Q

How to long can it take for respiratory failure to develop in a burn victim?

A

6-24 hours

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62
Q

How to work up unstable angina (transient chest pain at rest or worsening pain with exercise)?

A

aspirin, nitroglycerin, morphine
EKG
CXR
CK-MB and troponin to differentiate bewteen MI and unstable angina

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63
Q

Pre-surgery labs

A

CBC, PT, Type and Cross

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64
Q

How do you cardiovert a pt who has been in a fib for less than 48hrs?

A

Usually will cardiovert on their own. But if they don’t, start heparin drip and cardiovert. then go on anticoagulation for weeks.

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65
Q

What is the long term management after acute MI?

A

beta-blockeres and statins
ACE inhibitors if EF is low (<40%) or sig. anterior wall MI (V1-V4)
Clopidogrel, prasugrel, or ticagrelor for severeal months if a stent is placed

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66
Q

What makes the heart beat faster (mechanism) and slower?

A

Epi/NE activate B receptors than incr cAMP, which causes repolarization to happen faster in the nodal cells and that incr HR

Actylcholine decreased cAMP and slows repolarization to decr HR (parasympathetic)

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67
Q

What is this rhythm?

A

V fib

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68
Q

How to work up possible acute MI?

A
  1. aspirin
  2. nitroglycerin (unless contraindicated - hypotensive, murmur, or Hypertrophic obstructive cardiomyopathy)
  3. morphine (relax the pt)
  4. EKG - st elevation
  5. CK-MB (takes 4 hrs to elevate after MI and peaks at 12-18 hrs and lasts 2-3 days)
  6. troponin (any elevation = damage, stays elevated for 1-2 wks)
  7. CXR
  8. pulse ox
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69
Q

When do you see Kerley B lines on CXR?

A

pulmonary edema

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70
Q

Initial labs in a pt with A fib?

A

Thyroid function tests (look for thyrotoxicosis)

Cardiac enxymes

ECHO

ABG

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71
Q

What is Type 2 hypersensitivity?

A

Cytotoxic IgM, IgG bind to fixed antigen

complement mediated lysis - NK cells

ex: autoimmune hemolytic anemia, rheumatic fever, goodpasture’s syndrome, bullous pemphigoid, ITP

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72
Q

What are the common causes of death in the initial period after a 2nd or 3rd degree burn?

A

hypovolemic shock, infection, airway injury

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73
Q

S4 gallup

A

“a STIFF heart”

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74
Q

How do you tx peripheral vascular dz/claudication?

A
  1. stop smoking
  2. aspirin and other antiplatelet drugs such as clopidogrel for severe dz
  3. graded exercise program
  4. meticulous foot care
  5. Cilostazol (antiplatelet and vasodilator)
  6. statins if LDL >100
  7. possible revascularization with angioplasty/surgery
    1. ACI inhibitors for HTN
  9. follow at 1 month intervals to coach on exercise/lifestyle and ABIs q3-6 months
75
Q

Why do we do an unsynchronized shock in v fib?

A

bc a synchronized shock is coordinated with ventricular contraction, but there is no ventricular contraction in v fib - so it has to be unsynchronized

76
Q

Triad of opiod intoxication

A

respiratory depression, miosis (pinpoint pupils), depressed mental status

77
Q

How to treat stable a fib?

A

rate control with AV nodal blocking agent (diltiazem or verapamil)

78
Q

What is a common side effect of amiodarone?

A

pulmonary fibrosis, thyroid disorders, and corneal deposits (all long term use)

79
Q

When a pt with syncope has a murmur, what are the top 3 diagnoses to think of?

A

aortic stenosis
HOCM
mitral stenosis

80
Q

How do manage hypertensive emergency after intial stabilization?

A
  1. head CT
  2. CXR
  3. conitnue IV antihypertensive (labetolol, nitroprusside, enalaprilat)
  4. transfer to ICU
  5. reduce BP by 1/3 but not <95 mm Hg Diastolic
81
Q

How do you treat cardiac tamponade?

A

needle decompression (50-100 ml)

82
Q

What are next steps management of an acute MI after the initial w/u?

A

clopidogrel oral (antiplatelet)
metoprolol, statin, ace inhibitor (lisinopril) if EF is decreased
angioplasty
repeat CK-MB and troponin (4 hrs), EKG in 15-30 mins

83
Q

How does digoxin work for afib?

A

Increases contractilty by increasing amount of Ca in the cell for depolarization of the nodal cells, but then it also stimulates the vagus nerce to increase parasympathetic drive and decreases RESTING heart rate only

84
Q

How do you use the CHADS2 score?

A

To determine anticoagulation in non-valvular a-fib…(valvular a fib all need anticoagulation)

C - CHF (1pt)

H - HTN (1pt)

A is for age >75 (1pt)

D is for DM (1 pt)

S is for stroke or TIA (2pt)

score of 0-1 aspirin

score of 2+ anticoagulant (Warfarin, dabigatran, rivaroxaban, abixaban) and will need to stay on it forever

85
Q

What is the treatment for Torsades?

A

GIve Magnesium!

Can also try lidocaine, then unsynchronized cardioversion

86
Q

How to follow pts with acetaminophen toxciity?

A

repeat acetaminophen levels after 4 hours - more accurate.

*follow LFTs and coags: if increase in PT and signs of hepatic encephalopathy - need liver transplant

87
Q

What is the best drug to treat hypertension in a diabetic?

A

ACE inhibitors

88
Q

What condition most commonly leads to a fib?

A

chronic HTN

*but mitral regurg/stenosis can cause it, so can MI, drugs (cocaine)

89
Q

3 principles to manage a fib?

A
  1. rate control HR <110 at rest *this is better than rhythm control in general
  2. anticoagulation
  3. rhythm control (DC cardioversion, chemical cardioversion - amiodarone, sotalol, flecainide)
90
Q

What are some considerations when deciding to convert someone out of a fib?

A

rate vs rythmm control

rate - usually better, will need to be on long term maintenance drug

long term success of maintaining rnormal sinus rhythm is less if the arrhythmia has been there a long time or if left atria is enlarged

91
Q

How do you tx patients with a fib if you choose to do rhythm control?

A

Amiodarone!

*best option for maintaining rhythm after conversion when there is systolic dysfunction

Only one other option in pts with low EF - dofetilide

92
Q

How do you treat carbon monoxide poisoning?

A

100% oxygen

93
Q

How do you tx delirium tremens?

A

benzodiazepines (life saving!)
- chlordiazepoxide 50-100 mg q4-6 hrs, diazepam, lorazepam, or phenobarbital
IV thiamine and folic acid
Fluids
replete Mg

94
Q

What is type 4 hypersensitivity?

A

Delayed (T-cell mediated)

sensitized T lymphocytes encounter antigen which leads to macrophage activation

*only type of hypersensitivity rxn that doesn’t involve antibodies

es: multiple sclerosis, Giullain-Barre, graft-vs-host, PPD, contact dermatitis

95
Q

What is a common side effect of lidocaine?

A

confusion, esp in elderly

96
Q

How to treat supraventricular tachycardia?

A

carotid sinus massage

adenosine

97
Q

What EKG signs would be expected in aortic stenosis?

A

left ventricular hypertrophy

98
Q

How do you treat cyanide toxicity from nitroprusside use?

A

sodium thiosulfate and stop nutroprusside

99
Q

How do you cardiovert a stable pt who has been in a fib for more than 48 hours.

A

*TEE is looking for clots, if you find one - don’t cardiovert, go on heparin and anticoagulaiton

100
Q

How to work up acetaminophen toxicity (pt with N/V, RUQ tenderness)?

A

CBC, lytes, LFTs, PT, amylase, lipase, abdominal U/S

tox labs - aspirin level, acetaminophen level

101
Q

What are common causes of V tach?

A
  1. electrolyte abnormalities
    - hypoMg, HypoCa, Hyper/hypoK
  2. TCA overdose
102
Q

What are the side effects of amiodarone?

A

causes QT prolongation - but doesn’t lead to torsades

ataxia, nausea, thyroid effects, hepatitis, cirrhosis, corneal deposits, cough, constipation, momry and sleep disturbance

103
Q

What is the murmur of aortic stenosis?

A

systolic murmur on URSB, radiates to carotids and is worse with leg raise/squatting (increasing venous return) and better with valsalva (decreasing venous return)

104
Q

What is an EKG sign of cardiac tamponade?

A

varying size of QRS wave - means heart is freely moving in the chest wall

105
Q

What is the most common presenting symptom of HOCM?

A

dyspnea

106
Q

How do you give furosemide in pulmonary edema due to CHF?

A

give furosemide every 20 minutes until pt is making enough urine

107
Q

What kind of CT do you get for head trauma (looking for blood)?

A

Non contrast head CT

108
Q

How does dobutamine work?

A

positive inotrope - increases contractility and this helps empty the lungs by improving heart function

109
Q

What does adenosine do?

A

slows conduction through the AV node and can help figure out what is happening in SVT

110
Q

What are reasons a pt might get pushed into congestive heart failure?

A
  1. not taking meds
  2. ischemia
  3. arrythmia (afib, doesn’t get extra help from atrium anymore)
111
Q

When does hepatotxocity occur in acetaminophen toxicity?

A

peak injury 72-96 hrs after ingestion

*watch them!

112
Q

S3 gallup

A

“I’M re-laxed”

113
Q

What is 2nd degree AV block?

A

*only heart block that causes arrythmias

  1. wenkebach - increasing PR interval until a beat is dropped
  2. all PR intervals are the same, but they are increased and lead to dropped beats?
114
Q

Who needs hemodialysis in salicylate overdose?

A
  1. persistent acidosis with pH <7.1
  2. initial salicylate levels >160 mg/dL or > 130 mg/dL after 6 hrs
  3. coma/seizuers
  4. renal failure
  5. congestive heart failure
115
Q

What can cause complete heart block?

A

Meds (B-blockers, CCB, digoxin)
Myocarditis (viral or lyme dz)
MI (especially inferior wall)
aging and fibrosis of the conduction system (Most common)

116
Q

What are good options for smoking cessation?

A

varenicline, bupropion (if also have depression)

117
Q

How to evaluate for cardiac tamponade?

A

CXR - shows dark halo around the heart
assess pulsus paradoxicus (drop in BP with inhalation >10 mm Hg)
ECHO

118
Q

Why is it important to give beta blockers in CHF?

A
  1. reduces oxygen consumption of the heart
  2. anti-arrythmic and anti-ischemic (which is MCC death in CHF)
119
Q

Do we shock patients in asystole?

A

no!

CPR and epinephrine

120
Q

How do you tx cocaine-induced hypertensive crisis?

A

(alpha blocker) phentolamine
*DO NOT USE beta blocker

121
Q

Who requires a Head CT before an LP?

A

altered mental status, papiledema, sz, immunocompromised

122
Q

What are cannon “a waves?”

A

When there is a wave in the jugular veins bc the tricuspid valve is close when the atrium is contracting

123
Q

What type of heart dysfunction is HOCM?

A

diastolic - issue is that heart chambers are small and can’t fill up
*use beta blockers!

124
Q

What is the most important side effect when using nitroprusside to lower blood pressure (vaso dilator)

A

acute cyanide toxicity (esp in setting of renal failure)

125
Q

How do you initially treat syncope with abnormal cardiac exam?

A
  1. EKG, Tele bed in hospital
  2. ECHO, troponin
126
Q

What is Wernicke Syndrome?

A

thiamine deficiency (seen in alcholics)
confusion, ataxia, mand ophthalmoplegia (weakness or paralysis of one or more extraocular muscles)
reversible with thiamine treatment

127
Q

Who gets pleuritic chest pain?

A

PE, pneumothorax, pneumonia, pericarditis

(pain that is worse with inspiration)

128
Q

How to monitor patients with anaphylaxis after initial treatment?

A

montior for 6-8 hours due to possibilty of late second reaction

129
Q

What type of cardiac exam is typical of hypertrophic cardiomyopathy?

A

prominent apical impoulse, S4 gallup, 2/6 harsh systolic ejection murmur at LLSB that is worse with valsalva (decr venous return) and improves with squatting (incr venous return and relieves outflow tract obstruction from HOCM)

130
Q

How to work up “fluttering” or “palpitations?”

A

EKG

*if EKG is normal - do a Holter monitor

131
Q

What 3 meds should any pt with acute altered mental status of unclear etiology receive?

A

Naloxone
thiamine
dextrose

132
Q

What premeds do you use with cardioversion?

A

diazepam or midazolam if you have time

133
Q

How do you stress test in a pt who can not do an exercise stress test?

A

use dipyridamole thallium test

134
Q

What is long term management for pts with unstable angina/non ST elevation MI?

A

aspirin + second anti-platelet (clopidogrel) if underwent angioplasty or had MI
statin, beta-blockers, and ace inhibitors
*can stop ACE inhibitor at 6 wks if f/u ECHO shows EF > 40%

135
Q

What arrythmia can occur with low magnesium (alcholics)?

A

Torsades

136
Q

Ddx for a pt with fever, altered mental status, tremor?

A

delirium tremens, alcholic hallucinosis, acute intoxication, acute schizophrenia, bacterial meningitis, subdural hematoma

137
Q

Why do pts with aortic stenosis get angina?

A

bc the coraonaries aren’t being filled enough and that causes the ischemia

138
Q

If pt has scleroderma and malignant hypertension how do you treat this pt?

A

ACE inihbitors

139
Q

What drugs can be used for anticoagulation?

A

Warafin (goal INR 2-3)

Dabigatran: oral direct thrombin inhibitor

Rivaroxaban, abixaban: oral factor Xa inhibitor

140
Q

What type of murmur is heard with mitral stenosis?

A

diastolic murmur at LLSB , worse with squatting/leg raising (increased venous return) and better with valsalva (less venous return)
*most common valvular issue after rheumatic fever

141
Q

How to w/u CHF with shortness of breath?

A

sit pt upright, EKG, Oxygen and pulse ox, furosemide IV, nitroglycerin IV (relieve pulmonary congestion with vasodilation), ECHO, CXR, ABG, CK-MB, Troponins, BNP, go ICU

142
Q

How do you tx claudication that is worsening?

A

arteriography if considering surgical revascularization

143
Q

What are the 2 types of heart failure?

A

systolic (EF < 45%)
diastolic (EF >45%)

144
Q

What labs do you see in alcoholic hepatitis?

A

AST: ALT 2:1

AST will never be over 500, usually 100-200

145
Q

What are goal urine outputs for kids and adults?

A

adults - 0.5 cc/hr

children - 1 cc/hr

146
Q

How to manage mitral valave stenosis?

A
  1. left heart catheterization (to characterize the stenosis)
  2. salt restriction (trying to decrease fluid to improve the heart function)
  3. diuretics (trying to decrease fluid to improve the heart function)
  4. surgical repair when valve is <1 cm wide
147
Q

What is the most common cause of death in burns victims?

A

carbon monoxide poisoning

148
Q

What is the follow up and management after you cardiovert and stabilize a pt?

A

stay in ICU, CCU
continue amiodarone
do stress test once the pt is stable
consult cardiology, ECHO (r/u structural causes)
consider automatic implanatble cardioverter defirbillator placement
metoprolol

149
Q

How to manage aortic stenosis?

A 
ECHO to eval valve diameter
if symptomatic (chest pain, fainting), transcatheter aortic valve repair or open valve replacement if undergoing heart surgery for other reasons (CABG)
150
Q

Who should have a pacemaker placed?

A
  1. symptomatic bradycardia
  2. type 2 or 3rd degree AV block
151
Q

What is the better ECHO for evaluating mitral stenosis?

A

TEE rather than TTE

152
Q

What is the concern in Mitral stenosis when the atria gets dilated? (EKG notched P wave or biphasic p wave)

A

a fib - may need anticoagulation (warfarin) and digoxin if they are experience with a fib

153
Q

How to you anticoagulant after a stent placement?

A

aspirin and a second anti-platelet drug like clopidogrel, prasugrel, or ticagrelor for 1 year

154
Q

What does multifocal atrial tachycardia look like on EKG?

A

multiple p wave morphologies (originating from different places in the atrium)

155
Q

tx of intracranial hemorrhage?

A

intubation and hyperventilation (pCO2 of 25-30 mmHg)
IV mannitol
neurosurg consult for surgical evacuation of hematoma
maintain systolic BP > 100 mmHg

156
Q

How to treat acetaminophen toxicity?

A

IV acetylcysteine *helpful up to 24 hours by replacing glutathione stores

charcoal administration

157
Q

Follow up management for cardiac tamponade?

A

continue IV NS
pericardiocentesis with needle
possible placement of pericardial window
surgical consult
transfer to ICU

158
Q

What are risk factors for coronary artery dz?

A

DM, peripheral vascular dz, HTN, smoking tobacco, hyperlipidemia, HDL <40, first degree relative with MI/heart dz (male <55, women <65)

159
Q

What do you always check in addition to acetaminophen level when worried about overdose?

A

aspirin level

160
Q

Should you anticoagulate an elderly person with a fib who has a fall risk?

A

YES!

Would have to fall daily to increase risk for intracranial bleed on warfarin.

161
Q

How to initially tx burn victims?

A
  1. 100% oxygen if elevated carboxyhemoglobin
  2. fluid resuscitation 4ml/kg/% BSA burned (Ringer’s lactate, plasmalyte)
  3. prevent infection with topical antibiotics
  4. enteral nutrition
  5. intubation if significant respiratory injury
162
Q

What is the mechanism for increasing contractility in the heart?

A

protein kinase A leads to increase in both intracellular and extraculular Ca availability which makes depolarization happen faster in nodal cells.

*this is what CCBs target to slow the heart (why they decr contractility)

163
Q

What are EKG findings of L ventricular hypertrophy?

A

S in V1 or V2 + R in V5 > 35 mm

164
Q

What are contraindications to thrombolytics?

A
  1. GI bleed
  2. intracranial hemorrhage
  3. recent surgery
  4. aortic dissection
  5. any active internal bleeding
  6. relative contraindications: BP >180/110, active ulcers, recent head trauma, pregnancy
165
Q

What electrolyte can be low in alcoholics?

A

Magnesium, replete!

166
Q

How to treat a fib with mitral stenosis?

A

digoxin
may also use a beta blocker to slow heart rate and increase ventricular filling time

167
Q

Which valve can you balloon (aortic or mitral)?

A

Mitral - caused by fibrosis
*CANNOT valve aortic bc caused by calcification and will just break apart

168
Q

How does spironolactone work?

A

inhibits renin-angiotensin system (diuretic) and lowers mortality in syslotic dysfunction

169
Q

When do you use rhythm control in pts with a fib?

A

If the pt can’t tolerate rate control.

170
Q

How to initially manage anaphylaxis?

A
  1. pulse ox, oxygen

stridor = intubate

  1. epinephrine
  2. IV NS
  3. diphenhydramine
  4. IV steroids
  5. albuterol if wheezing

*unstable - dyspnea, stridor, hypotension

171
Q

How to treat pts with v fib?

A

CPR

DC unsynchronized cardioversion (360 J)

CPR (don’t check pulse)

check rhythm

repeat defibrillation at 360 J

CPR

IV access - epinephrine or vasopressin q5 mins

check rhythm

Defibrillate

CPR

Amiodarone

check rhythm

Defibrillate

172
Q

who should get glycoprotein 2b/3a?

A

anyone who is going to go for cardiac catheritization in acute MI

173
Q

What 3 conditions do we use unsynchronized defibrillation?

A

V fib

Pulseless ventricular tachycardia

Torsades de pointes

174
Q

How to interpret chest xrays?

A

AP (portable) or PA (in radiology)

rotation

penetration - should see spine all the way down to diaphragm

check diaphragms/pleural effusions/air/even diaphragm

Cardiac silhouette (should be less than 50%)

Bones - rib fx or metastatic dz

Lung parenchyma

175
Q

What is seen here and what is the most likely dz?

A

hyperinflation, flat diaphragms, darkening of lung fields, elongated heart

COPD

176
Q

What is the dz and what findings do you see?

A

pneumonia - lobar

177
Q

How to tx lobar pneumonia?

A

ceftriaxone + azithrmycin

or

flouroquinolone

178
Q

What do we see here and what is on the ddx?

A

fine lacy appearance, diffuse in all lobes, reticular pattern

atypical pneumonia, viral pneumonia, or interstitial lung dz

179
Q

What chest xray findings are present in CHF?

A

increased flow in apices “cephalization”

cardiomegaly

pleural effusion

kerley B lines (fluid in interlobular septum)

180
Q

What always must be done after you put in a line or tube in a pt?

A

xray to check position!

181
Q

What is the correct position of the endotracheal tune?1

A

1-2 cm above carina

182
Q

What is the correct position for a central line?

A

tip of the line at the junction of the SVC and the right atrium (at the point where the right main stem bronchus is seen)

*not in the atrium

183
Q

What type of xray should you get if you are worried about abdominal perforation?

A

chest xray

(KUBs don’t always include the top of the diaphragm)

Step 3 (15 decks)

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