Elkins Notes and Miscellaneous - Exam 1 Flashcards
**What is the EKG finding that leads to STEMI dx? What is the exception to the rule?
New or presumed new ST elevation of ≥ 1 mm in 2 anatomically contiguous leads
The exception to this rule is in V2 and V3 where the following must be seen
≥ 2 mm in men
≥1.5 mm in women
What are the EKG findings associated with NSTEMI?
New or presumed new horizontal or down-sloping ST depression ≥ 0.5 mm in two anatomically contiguous leads
AND/OR
T wave inversion ≥0.1 1 mm in two anatomically contiguous leads with prominent R wave or R/S ratio >1
Draw the EKG heart lead chart
Based on troponin levels, when can an AMI be safely ruled out? How long does troponin stay elevated?
if negative in low risk patients after 6-12 hours of chest pain onset AMI can safely be ruled out
7-10 days
What is the initial management for ACS?
cardiac monitoring
IV line (2 large bore)
oxygen if less than 95%
ASA 160-325mg CHEWED
NTG
What is the MOA of nitro?
Nitroglycerin reduces left ventricular afterload through arterial dilation as well as preload through venous dilation
What should you do in an ACS event and the chest pain returns or continues after 2 NTG? Give SBP values
If chest pain returns or continues and SBP >100 mm Hg, start IV nitroglycerin at 10 μg/min and increase by 5 μg/min every 3–5 minutes until SBP falls by 10% or chest pain is relieved. Keep SBP above 90 mmHg.
What are the CI to NTG?
severe aortic stenosis
hypertrophic cardiomyopathy
suspected right ventricular infarct (inferior STEMI with elevation in V1)
hypotension (SBP <90 or > 30 mmHg below baseline)
marked bradycardia or tachycardia
phosphodiesterase 5 inhibitor in last 24 hours (eg, sildenafil)
What are the alternative options for NTG if the BP remains elevated?
clevidipine, nicardipine, metoprolol or esmolol
What is the NSTEMI/UA conservative management approach? invasive management? _____ will be started within 24 hours
Cardiac Monitoring
IV line placement
O2 if applicable
ASA initial dose chewed
NTG
Morphine (if applicable)
ASA ongoing daily dose
Clopidogrel (antiplatelet)
LMWH (anticoagulant) conservative approach
Heparin if considering PCI
PO beta blocker
_____ is the goal reperfusion time if the facility has PCI. Non-PCI
90 minutes
120 minutes
When is tPA indicated?
STEMI only
**Indication: unable to get to PCI within 120 minutes of “first medical contact” with symptoms that have been present < 12 hours
When are BB recommended in a STEMI? What are the CI? What 2 drugs specifically?
IV beta-blockers are recommended at time of presentation for STEMI if patient is undergoing PCI and has SBP > 120mmHg without contraindications
congestive heart failure (CHF), bradycardia, conduction blocks, and hypotension.
metoprolol or atenolol
Where do 90% of all dissections occur?
in the right lateral wall of the proximal ascending aorta
What are the risk factors for an aortic dissection?
male sex
age over 50 years
poorly controlled hypertension
cocaine or amphetamine use
a bicuspid aortic valve or prior aortic valve replacement
CT disorders: Marfan’s syndrome and Ehlers-Danlos syndrome
pregnancy
What is the BP like in aortic dissection?
BP varies from hypotensive to normotensive to hypertensive
_____ is a diastolic murmur often found with aortic dissection. Describe it?
Aortic regurgitation
soft, high-pitched, early diastolic decrescendo murmur heard best at the 3rd intercostal space on the left (Erb’s point) on end expiration, with the patient sitting up and leaning forward
What type of dissection is associated with cardiac tamponade?
ascending aortic dissections
if dimer is _____ in aortic dissection there is a 97% sensitivity that a dissection is not present
< 500 ng/mL
What is the ADD-RS assessment tool? When is it used? Score 0-1 what should you do? score 2-3?
aortic dissection detection risk score
to determine risk for an aortic dissection
0-1 order d-dimer
2-3 straight to CTA
What is the management summary in aortic dissection?
resuscitate as needed
cardiovascular consult!!
2 IV access and cardiac monitoring
reduce BP and HR: 100-120 and HR less 60, use esmolol or labetalol
vasodilator if BP not controlled: IV nicardipine, clevidipine, nitroglycerin, or nitroprusside
fentanyl for pain control
What labs would you want to order in pericarditis?
CBC, BMP, ESR, CRP, troponin, BNP
What is the tx for pericarditis if the pt cannot have NSAID or recent MI?
glucocorticoids
What are the indications for admission for pericarditis?
temperature >38°C (100.4°F)
subacute onset over weeks
immunosuppression
history of oral anticoagulant use
associated myocarditis (elevated cardiac biomarkers, symptoms of heart failure)
failure to respond to therapy with NSAIDs after 1 week of therapy
a large pericardial effusion (an echo-free space >20 mm)
cardiac tamponade
uremic pericarditis (renal failure)
hemodynamic compromise
What are 3 etiologies of SAH?
aneurysm, AV malformations, trauma
Can you have +meningeal signs in SAH?
YES!
(+) meningeal signs may develop several hours after the bleed due to an aseptic meningitis caused by the breakdown of the blood products within the CSF
_____ is the preferred imaging option in SAH. What time frame?
CT w/o because of the blood proteins that are picked up on CT started to break down after 6 hours. Within 6 hours is best
What are the 6 Ottawa SAH rules?
- s/s of neck pain or stiffness
- 40+ years old
- witnessed LOC
- onset with exertion
- thunderclap HA
- limited neck flexion on exam
any of the 6 require further investigation
When is a LP used in SAH?
head CT is negative but suspicion for SAH is still high
pt presents AFTER the 6 hour mark
What is the next step in SAH if suspicion remains high but CT and LP are both negative?
CT angiogram, MRA, MRI, or four-vessel cerebral angiogram may be considered
What is the goal BP for SAH? What BP medications?
No optimal target has been defined - a SBP < 160 (MAP <110) reduces risk of rebleeding
labetalol, nicardipine, clevidipine or enalapril
In an SAH once BP is controlled, consider converting the agent to _____ within 48 hours
nimodipine (CCB)
When do you tx hypoglycemia in SAH? What is the goal BS range?
hypoglycemia - treat if BS <60 mg/dL
hyperglycemia - treat if BS is >180 mg/dL to a goal of between 140-180 mg/dL
What is the tx for GCA with and without vision loss?
No vision disturbance: oral prednisone 60 mg-> follow up with ophth within 1 week
Visual loss - admit for high dose IV steroids (methylprednisolone 250 mg IV q6h) and bx in the hospital
Where is the MC location for TN?
MC location V2 or V3 of the trigeminal nerve
What is the tx for an acute attack of TN in the ED?
IV Phenytoin over 5–10 minutes, may abort an acute attack
What is the black box warning for IV phenytoin?
risk of hypertension and cardiac arrhythmias (BLACK BOX) if administered rapidly (more than 50mg/min in adults)
What is the first line therapy to induce remission for TN? What population is this NOT indicated for? Why?
carbamazepine(Tegratol) 100 mg BID
avoid in patients of Asian ancestry due to risk of SJS and TEN
What is the alternative remission therapy for TN? Who do they need to f/u with?
lamotrigine (Lamictal)
PCP or neurology
What are the historical red flags for meningitis?
Recent exposure to similar illness
Recent illness or antibiotic treatment
Recent travel to areas with endemic disease
Penetrating head trauma
CSF otorrhea or CSF rhinorrhea
Cochlear implant devices
Recent neurosurgical procedures
What neurosurgery is most often associated with meningitis?
most often a ventriculoperitoneal (VP) shunt
_____ should be ordered if considered for a viral meningitis?
CSF PCR amplification
What is the initial management for all menigitis?
supportive therapy: protect agitated patients from self-injury, monitor for seizures
symptomatic therapy: analgesics, antipyretics
IV fluids
What is the empiric regimen for suspected bacterial meningitis? What is the timeframe goal? What if the pt is less than 1 month old?
dexamethasone pretreat 0-20 minutes prior to abx
ceftriaxone (Rocephin) PLUS vancomycin
- sub cefotaxime in infants due to displacing bilirubin from albumin binding sites
Acyclovir - until viral etiologies are ruled out
When should you add on ampicillin in bacterial meningitis? doxy?
ampicillin (<1 month and >50 years old, immunocompromised patients)
tick borne dz
When should you add on metronidazole in bacterial meningitis?
metronidazole (associated otitis, sinusitis, mastoiditis, brain abscess)
What is the MC etiology for viral men? Which viruses require tx? What is the tx?
enteroviruses
HSV, VZV, HIV
acyclovir
What is the Glasgow Coma Scale?
What is the MC etiology of encephalitis?
herpesviruses (HSV, VZV, EBV)
What will MRI/CT of HSV encephalitis show?
abnormalities on imaging reflective of the areas of inflammation
What is the management of enchaphlitis? What is the timeframe goal for tx?
supportive with symptom control
seizures - IV lorazepam - secondary prevention to be considered ( not primary prevention)
order neuro checks
Empiric abx as in meningitis until dx is confirmed
Empiric antiviral (IV acyclovir) - goal 30 minutes after arrival
if HSV or severe VZV/EBV are suspected
What is the abx of choice for a brain abscess that arose from odontogenic source?
IV PCN G
What is the abx of choice for a brain abscess that arose from neurosx source?
vancomycin PLUS ceftazidime
What is the abx of choice for a brain abscess that arose from all other sources?
Cefotaxime (alt. ceftriaxone) PLUS metronidazole
