EMED Flashcards

1
Q

__ is the leading cause of death among US adults

___ causes this leading cause w/ ? predominant Sx

A

Ischemic heart dz

Coronary artery dz
Chest pain

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2
Q

High likelihood of short term risk of death in PTs w/ unstable angina

A
SHIPMATES BS
S3 
HOTN
Inc TnT
Prolonged
MR
Accelerating Sx frequency
Tachy/brady
Edema, pulmonary
ST >0.5mm

BBB
Sustained V-tach

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3
Q

Low likelihood of short term risk of death from PTs w/ unstable angina?

Left coronary artery divides into ? and ? to supply ?

A

Reproducible w/ palpation
New/inc angina
Stable EKG

LCX and LAD
LAD: main anterior/septal
LCX: some anterior/lateral

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4
Q

ACS may be caused by secondary reduction of blood flow due to ?

Atherosclerotic plaques develop because of ?

A

Disruption/erosion of plaques
Platelet aggregation at lesions
Coronary artery spasm
Microvascular dysfunction

Repetitive wall injury

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5
Q

What is the classic location for MI myocardial ischemia pain?

Angina pain can be precipitated by ? events and lasts ?

A

Substernal/L chest radiating to arm, neck, jaw

Stress Exercise Cold
<5min w/ rest/nitro

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6
Q

Acute myocardial ischemia usually presents w/ more prominent pain and Sxs including ?

? PTs are more likely to have atypical presentation of MI?

A

Diaphoresis Nausea SoB
w/ little response to Nitro

Female
Advanced age
DM

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7
Q

What are the traditional RFs for ACS/AMI?

These RFs are not useful in ? PT populations

A

DM Tobacco FamHx
Hypercholesterolemia
HTN

ED PTs >40y/o

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8
Q

? PE finding may be heard indicating a failing myocardium

The presence of a new ? is ominous and may indicated ?

A

S3- volume overload

New systolic murmur-
Papillary dysfunction
MV leaflet flail w/ MR
VSD

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9
Q

S3 heart sounds are heard normally during ? and can indicate ? failure

Presence of ? on PE is indicative of LV dysfunction and L-sdied HF

A

Early diastole
Systolic HF

Rales, S3 regardless

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10
Q

Define TIMI Score

What are the parts of it

A

Thrombosis in MI for unstable angina

Age: >65
Markers elevated
ECG depressions
RFs, 3 or more
Ischemic chest pain, 2 or more
Coronary stenosis >50%
ASA use <7days
Max- 7pts
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11
Q

What is the single best test to identify PTs w/ AMI in the ED

This test must be obtained and interpreted w/in ?min of presentation to ED

A

12 lead EKG

<10min

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12
Q

What is the ‘general’ definition of an STEMI

ST elevation suggests ? while depression suggests ?

A

ST elevation of 1mm or more in two contiguous leads w/ reciprocal changes

Ele: transmural injury/infarction
Dep: ischemia

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13
Q

What is the next step for suspected inferior wall AMI?

What finding is Dx

A

R sided EKG

ST elevation in V4R= RV infarction

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14
Q

PTs w/ RV infarction are ? dependent, be careful if using ?

Pts w/ non-Dx EKG but persistent Sxs have ? follow on test?

A

Pre-load dependent
Nitro/BBs

Repeat EKG

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15
Q

If reciprocal EKG changes are seen, ? does this indicate?

How does the height of ST elevations correlate to severity?

A
Larger area
Increased severity
Severe pump failure
Inc CV complications
Inc mortality

High= more extensive injury

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16
Q

What leads are used for posterior MIs?

What artery is involved w/ this type?

A

V7-9

Circumflex

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17
Q

LBBB criteria

What is the MC pacemaker lead location?

A

Elevation 1mm+, concordant
Elevation 5mm+, discordant
Depression 1mm+ V1-3

RV pacing

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18
Q

Where is Welens seen on EKG and what does it indicate

Why is this difficult to Dx

A

V2-3, possibly V1-4
LAD stenosis

T-waves present during pain free period
T-waves absent during painful episode

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19
Q

Wellen’s PTs are likely to develop ? type of MI

When are serum biomarkers not needed for Dx

When are these markers useful?

A

Anterior

Dx ST segment elevations

Non-Dx EKGs of NSTEMI
Risk stratification during N/STEMI and unstable angina

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20
Q

How can cardiac injury be differentiated between acute or chronic?

How long does it take for troponin to rise, peak and return to normal?

A

Delta troponin over 1-3hrs

3-12hrs
12-24hrs
5-14days

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21
Q

How are STEMI PTs Tx

They usually get ? three meds in the ED?

What medication is added to unstable angina, refractory NSTEMI or pre-PCI?

A

PCI w/in 90-120min
Fibrinolysis <30min of arrival

Anti platelet/thrombins and Nitrates

G-2b/3a antagonist

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22
Q

What are the 4 anti-platelet meds used during the Tx of STEMI?

What 3 anti-thrombins are used?

A

Clopidogrel ASA Prasugrel
Ticagrelor

UFH Enoxaparin Fondaparinux

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23
Q

What are the 5 fibrinolytic agents used?

What are the names of the G2a/3b meds?

What are the 4 additional anti-ischemic meds may be used?

A

Streptokinase
TARA-plase

Abciximab Tirofiban Eptifibatide

Nitro Morphine Metoprolol Atenolol

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24
Q

The invasive Tx approach seen in STEMI Tx is only applied to NSTEMI PTs if ?

If unstable angina/NSTEMI are hemodynamically unstable, start invasive Tx strategies w/in ? time fram

A

Refractory angina
Hemodynamic/electric instability
Inc risk for clinical events

PCI <2hrs

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25
What direct thrombin inhibitor is used during unstable angina/NSTEMI not used for STEMI Tx What anti-ischemic therapy is NOT used for NSTEMI?
Bivalirudin Atenolol
26
What is the recommended method to repurfsion NSTEMIs What is the MC type of this method?
PCI w/in 90-120min Coronary angioplasty
27
What two meds may be added to PTs receiving coronary stents during PCI? What are fibrinolytics MOA during NSTEMI Tx Fibrinolytic therapy improves ? part of the heart in particular?
Thienopyridines G2b/3a inhibitors In/Direct plasminogen activators LV function
28
What criteria must be met to use fibrinolytics during NSTEMI Tx This form of reperfusion is better started early for ? MIs in ? location
<12hrs from Sx onset ECT w/ one ST elevation >1mm in two or more leads Larger/anterior
29
After a failed fibrinolytic administration, rescue PCI is recommended for ? PTs
<75y/o Severe HF/edema Hemodynamic compromising ventricular arrhythmias Mod/large area of myocardium at risk
30
What is the most catastrophic complication of fibrinolytic therapy? If fibrinolytics are used in STEMI PTs, how are they used?
Intracranial bleeds Full dose UFH/Enox/Fonda x 48hrs
31
MOA of G2b/3a antagonists MOA of ASA
Interrupts platelet activation Inhibits platelet aggregation d/t thromboxane A2 stimulation mediated by arachidonic acid pathway
32
All unstable angina, N/STEMI PTs get ? med? What is the alternative medication used but only if ?
325mg ASA Clopidogrel True allergy/active PUD
33
What is the ADP receptor antagonist used in ACS This med is c/i in ? PTs What is the benefit of using this med?
Prasurgel- irreversible Hx of CVA/TIA/bleeding Effect gone w/in 3 days of d/c
34
Why is LMWH used in NSTEMI PTs more often? STEMI PTs Tx w/ ASA and ? had better outcomes
Greater BioAvail Lower protein binding Longer t1/2 More reliable anticoag effect Enoxaparin
35
Nitro provides ? benefits to ACS PTs When Nitro is used in AMI PTs not Tx w/ thrombolytics, what are the 3 benefits?
Relaxes smooth muscles/dilation Inhibits platelet aggregation Reduces infarct size Improves regional function Dec rate of CV complications
36
If nitro is used in AMI PTs, titrate to ? not ? Recommend using IV Nitro for first 24-48hrs for ? PTs
BP, not Sx resolution STEMi and recurrent ischemia CHF HOTN
37
Don't use Nitro in PTs that have taken which phosphodiesterase inhibitors w/in ?hrs Start PO BBs in N/STEMI Pts w/in 24hrs as long as they don't have ?
Sildenafil- 24hrs Tadalafil- 48hrs S/Sxs of HF Low CO Risk for cardiogenic shock
38
What are the relative c/is to giving BBs? What are the c/is to giving ACEIs within 24hrs
2/3* block PR interval >0.24 sec Asthma Reactive airway dz ``` HOTN Bilateral renal stenosis RF Hx of cough Angioedema w/ past ACEI use ```
39
Of all the meds, what ones may be used during ACS that don't improve mortality? When would they be used?
CCBs ``` Verapamil/Diltiazem if: Ongoing ischemia A-fib w/out CHF LV dysfunction AV blocks Absolute c/i to BBs ```
40
Anterior wall AMIs typically cause PTs to acquire ? dysrhythmia? Why is this finding ominous?
Sinus tachy Persistent sinus tachy= poor prognosis
41
PTs w/ SCT, Afib/flutter post MI are best Tx w/ ? What type of acquired rhythm is not associated w/ an increased mortality
Direct current cardioversion Sinus brady w/out HOTN
42
? med is used for sinus brady causing HOTN, ischemia, ventricular escape rhthyms or Sx AV blocks? Anterior/inferior MIs can cause PTs to develop ?
Atropine Complete heart blocks
43
? type of rhythms are usually transient and seen w/in 48hrs of an infarct? Ventricular premature contractions are more common in PTs w/ ? and are ?
Junctional rhythms AMI Benign
44
New RBBB can occur MC in ? AMI Previously stable PT that suddenly decompensates needs to have ? Dx r/o
Anteroseptal Mechanical complication
45
? post-AMI complication can occur 1-5 days after and lead to tamponade/death How does it present?
Ventricular wall rupture HOTN/Tachy JVD Dec sounds Pulsus paradoxus
46
What is the DxTOC for ventricular free wall ruptures? How is a ruptured septum detected, Dx and Tx
Echo w/ surgical Tx New holo murmur Pain/dyspnea Doppler echo, surgery
47
Rupture of the interventricular septum is more common after ? type of AMI Papillary muscle ruptures are more common w/ ? type of MI and present w/ ?
Anterior wall Extensive/three vessel CADz Inferior wall Day 3-5 post-MI Dyspnea, HF New holo murmur w/ MR
48
PTs are more likely to develop pericarditis after ? type of MI These PTs are more likely to develop ? than actual pericarditis
Transmural and delayed presentation Pericardial effusion
49
How is post-MI pericarditis or Dresslers Tx If PT develops Dresslers 2-10wks later, how do they present?
ASA or Colchicine No Ibuprofen- interferes w/ ASA anti-platelet effect Pain Fever Pleuropericarditis
50
? PT presentation suggests a possible inferior wall MI is present How are these Dx
JVD/HOTN after giving Nitro Echo/Nuclear imaging
51
What is the most serious complication that can occur from a RV infarct? How are these types Tx
Shock Maintain preload (NS) Reduce RV after load Inotropic support Early repurfusion
52
Post-PCI PT presenting w/ chest pain has ? Dx until proven other wise What is the more likely and less likely cause for their presentation?
Abrupt vessel closure Bare metal- more likely to re-stenose Drug eluding- late stent thrombosis 9-12mon later after d/c Clopidogrel
53
What is the most sensitivity biomarker for cocaine induced MI? What three drugs are used as mainstay Tx ? are c/i for the first 24hrs
Cardiac troponin Benzo ASA Nitrate BBs
54
# Define HF What are the cardinal manifestations of HF
Impaired ventricular filling or ejection of blood Peripheral edema Dyspnea and fatigue Fluid retention
55
What is the counter regulatory response to HF What are the 3 types of this response?
Natriuretic peptides A- atrial B: ventricle C: endothelium
56
What two effects do natriuretic peptides produce? PTs w/ acute HF and pulmonary edema may benefit from ? Tx to prevent intubation
Vasodilation RAAS/SNS inhibition BiPap
57
What are the 6 phenotypes of acute HF?
HTN HF: SBP >140 Pulm Edema: distress, rales Cardiogenic shock: SBP <90, hypoperfusion Acute on Chronic: S/Sxs of AHF but BP <140 and >90 High Output: tachy, warm, congested Right HF: low output w/ JVD, megaly and HOTN
58
How do PTs w/ acute on chronic HF present High output HF is distinguished by a normal ? and often caused by ?
Gradual Sxs and weight gain from days/wks Normal EF Anemia/Thyrotoxicosis
59
# Define Systolic Dysfunction HF Define Diastolic Dysfunction HF This may be an early initiator of ? cascade
HF w/ reduced EF <50% Impaired ventricle emptying HF w/ preserved EF Impaired ventricular relaxation (chronic HTN) Ischemic
60
How is HF Dx What is the most useful parameter for Dx?
Clinically w/ Hx and PE Hx of HF
61
What are the RFs for HF What Sx has the highest sensitivity for Dx? What are the 3 most specific Sxs?
DM Obese Valve dz HTN Age Male Dyspnea Paroxysmal nocturnal dyspnea Orthopnea Edema
62
On PE, what finding has the highest likelihood ratio for acute HF? What are the only other two findings that have a high likelihood ratio over 5?
S3 Abdominojugular reflux JVD
63
What component of a HF workup out performs all Dx tests available? What lab result has the most similar accuracy?
Clinical gestalt BNP
64
What CXR findings are most specific for a final Dx of acute HF? What EKG finding has the highest likelihood ratio for Dx HF?
Venous congestion Interstitial edema Cardiomegaly Afib
65
What 3 factors can affect biomarker levels? Bedside cardiopulmonary US can be used to address ? 3 questions?
Mass Age Gender Signs of pulm congestion Sign of volume overload Low/norm LV EF
66
Pulmonary US is first used to determine if pulmonary congestion is present by looking for ? These findings are sonographic equivalent to ? on CXR
B-lines Kerley-B linesW
67
What pulmonary US finding is pathologic and highly specific for alveolar/interstitial edema? Because these findings can be found in numerous other conditions, what f/u test is needed
More than two b-lines on any sonographic window Elevated central venous pressure as marker for R hear congestion IVC >2cm/collapse index <50% indicates elevated pressure
68
What step is the final piece of the ED based bedside US? What is the initial approach to HF Tx
LV EF Airway w/ goal of >95%
69
Acute HF w/ HOTN is Tx w/ ? meds How are PTs w/ acute HF and HTN Tx and what is added if further load reduction is needed?
Dobutamine NorEpi Dopamine Nitro IV Nitroprusside after >200mcg of Nitro
70
When Tx HTN acute HF, always start ? med prior to using ? How are normotensive HF PTs Tx
Nitrates before diuretics (Furosemide) Loop diuretics 40mg IV
71
What adverse outcome can occur when treating normotensive HF? Ongoing congestion/dyspnea after administering loop diuretics indicates need for ?
HypoK/Ca/Mg Ototoxicity, especially if using aminoglycoside ABX Vasodilators
72
What medication can be used for congestion and anxiety while Tx normotensive HF? If diuretic and medical strategies fail, what procedure is used and especially good for lowering water/Na?
Morphine Ultrafiltration
73
What med is used for normotensive HF Tx when Nitro is ineffective or c/i
Nesiritide- recombinant human BNP
74
How to dose Furosemide What are 5 high risk markers in ED PTs w/ HF associated w/ morbidity/mortality?
No Hx of use: 20-40mg IVP Hx of use: total daily dose x 1-2.5, divide in half and give IV bolus q12hrs Renal dysfunction Low BP/Na Elevated BNP/troponin
75
# Define Primary Cardiomyopathies Define Secondary Cardiomyopathies As a group these make the the third MC form of ?
Dz involving myocardium Heart dz w/ systemic d/os Cardiac dz in US after coronary/ischemic and HTN heart dz
76
What is the second MC cause of sudden cardiac death in adolescents? ? is the MC form of cardiomyopathy
Hypertrophic cardiomyopathy Dilated
77
Peripartum cardiomyopathy manifests as ? What is the primary indication for heart transplants in the US?
Dilated cardiomyopathy Idiopathic dilated cardiomyopathy
78
What are the hallmarks of dilated cardiomyopathy? What can lead to valve dysfunction and incomplete closure?
LV/RV dysfunction w/ normal LV thickness Annular dilation and papillary displacement
79
Where are the holosytolic MR/TR heard in dilated cardiomyopathy? What PE finding will be seen if tricuspid insufficiency is significant?
Apex/LLSB Enlarged/pulsatile liver
80
How is dilated cardiomyopathy Dx What may be seen on CXR
Echo PHTN Inc ratio Enlarged silhouette Biventricular enlargement
81
Dilated cardiomyopathy EKG will almost always show ? and two common findings include? What two rhythm disturbances are commonly seen?
Abnormality LCH and LA enlargement Afib Ventricular ectopy
82
When is an echo indicated for dilated cardiomyopathy How are these PTs Tx
Cause of HF uncertain Exclude correctable causes of HF EF R/o other complications ACEIs/ARBs- Carvedilol Cardiac resynchronization Amiodarone/implanted defib if complex ventricular ectopy
83
Non-compliant med/diet PTs presenting w/ dilated cardiomyopathy are Tx w/ ? Define Hypertrophic Cardiomyopathy
IV diuretic/nitrates Asymmetric LV/RV hypertrophy w/ septal involvement
84
What are the Dx hallmarks of Hypertrophic Cardiomyopathy What 3 components of heart function remain normal
Asymmetric septal hypertrophy and fiber disarray on echo CO EF End Syst/Diastolic volumes
85
What causes most of the Sxs in Hypertrophic Cardiomyopathy Severity of this Dz is associated w/ ?
Impaired diastolic relaxation Restricted LV filling Inc age
86
What is the most frequent initial complaint of Hypertrophic Cardiomyopathy What are two frequent parts of the PTs Hx
Dyspnea on exertion due to exercise induced sinus tach FamHx of massive heart attack/HF
87
Why do PTs w/ hypertrophic cardiomyopathy have chest pain? What angina pectoris/atypical presentations can they also have? What will their response be once in the ED?
Inc o2 demand limited by LV size Precordial/retrosternal chest discomfort Poor/variable response to Nitro
88
Hypertrophic Cardiomyopathy PTs poorly tolerate ? rhythm What other PE finding is common
Afib Sustained apical impulse Presystolic lift S4
89
Where is the ejection murmur of Hypertrophic Cardiomyopathy best hear? What PE maneuvers can decrease the murmur?
LLSB or Apex w/out carotid radiation Squat Grips Leg elevations
90
Valsalva does ? to hypertrophic cardiomyopathy and MVP Standing does ? to hypertrophic cardiomyopathy and MVP Passive leg raise does ? to hypertrophic cardiomyopathy and MVP Grips does ? to hypertrophic cardiomyopathy and MVP Squats does ? to hypertrophic cardiomyopathy and MVP
Inc murmur, Inc murmur Inc murmur, Inc murmur Dec, Dec Dec, Inc Dec, Dec
91
What is the characteristic Echo finding when Dx hypertrophic cardiomyopathy What is the mainstay of Tx for these PTs
Disproportionate septal hypertrophy BBs
92
What are the two layers of the pericardium The space between the layers holds ?L of fluid
Visceral- serous/loos over epicardium Parietal- dense collagenous sac 50mL
93
Normal pain of pericarditis including sharp/stabbing restrosternal pain can also radiate to ? Why does this radiation occur? What is the MC and important PE finding for Dx
L trap Inflamed diaphragm pleura Pericardial friction rub w/ diaphragm on LLSB/apex w/ PT sitting/leaning fwd
94
What are the 4 stages of serial EKGs during acute pericarditis
1 (acute): PR depressions 2, aVF, V4-6 ST elevation 1 V5-6 2: PR iso/depressed, ST returns to isoelectric line, dec T-wave amplitude 3: PR iso/depressed, ST isoelectric, T wave inversion 1 V5-6 4: PR/ST isoelectric, T wave normal
95
What will be seen on EKG if a pericardial effusion develops during pericarditis? What is the DxTOC for pericarditis and it's effusion
Low voltage QRS Electrical alternans Echo
96
Anterior RV contacts w/ ? Posterior LV contacts w/ ? Although most cases are idiopathic and presumed viral, how are pericarditis Tx
Chest wall Posterior pericardium/adjacent pleura NSAIDs Ibuprofen preferred Cochicine
97
When would a PT w/ pericarditis need to be admitted Why would repeat echos be needed?
Myocarditis Sxs fail to resolve/reappear New Sxs appear
98
What are poor prognosis indicators for pericarditis PTs w/ these indicators or ? should be admitted
``` Subacute onset over wks Temp >100.4 ImmSupp Myocarditis Hx of PO Anticoag use Large effusions >20mm ``` Enlarged silhouette
99
What are the top 3 MC causes of non-traumatic cardiac tamponades? What is the lowest likely cause?
Metastatic malignancy Acute idiopathic pericarditis Uremia Anticoagulant hemorrhage
100
PT w/ non-traumatic tamponade MC complain of ? What PE finding may also be felt suggesting this Dx
Dyspnea at rest/exertion Dropped beats on peripheral pulses during inspiration
101
How much pressure separates true tamponade from restricted cardiac filling? What may be present but is not Dx
>10mmHg Pulsus paradoxus
102
What may be seen on PE in the neck of PT w/ tamponade? What may be seen on abdominal exam?
JVD w/ absent Y-descent RUQ tenderness from hepatic venous congestion
103
What is the classic but uncommon EKG finding for tamponade? What is the DxToC?
Electrical alternans Echo
104
In addition to large pericardial fluid, typical echo findings that describe a tamponade include ? four comments
RA compression RV diastolic collapse Abnormal TV/MV variation Dilated IVC w/ lack of inspiration collapse
105
When to post-Tx tamponade PTs need to be admitted? What is Becks Triad that may be present
Hemodynamically unstable Emergent pericardiocentesis Insufficient social situation to provide emergency care HOTN Muffled sounds JVD
106
How does an aortic dissection begin? Difference between Stanford and DeBaeky systems
Intima integrity violated, allows blood in between intimal/adventitia layer ``` Stanford A: ascending Stanford B: descending DeBakey 1: both asc/descend DeBakey 2: only ascending Debakey 3: only descending ```
107
What is the classic onset of aortic dissection? Stanford Type A usually had ? pain while B had ? pain What type can involve coronary arteries and present w/ neuro Sxs?
Radiation tear between scapula Sense of doom A: anterior chest B: abdominal Type A
108
What might be seen on PE of an aortic dissection? What can cause a PTs Sxs to resolve and be mis-Dx?
``` HTN Aortic murmur Dysphagia Hoarseness Pulse deficits radial/femoral Horners ``` Dissection ruptures into true aortic lumen
109
What are the 4 factors of mis-Dx an aortic dissection What is the MC CXR abnormality
PT walks in Non-enlarged mediastinum Absent pulse difference Non-specific Sxs Wide mediastinum Abnormal aortic contour
110
What is the image of choice for Dx of aortic dissection If properly trained, what image is just as good?
CT w/ and w/out contrast CT Triple r/o- CADz, PE and Dissection TEE
111
What is the relative c/i to doing TEE for assessment of the aorta What meds are preferred for BP control after dissection What are the BP goals to achieve?
Known esophageal Dz Short BBs- PLE preferred Nitropursside/Nicardipine 120-130/100-120
112
When are aortic dissection more likely during pregnancy? Define Dyspnea What is it usually caused by
3rd-T/Post-partum Subjective feeling of difficult/labored breathing Pulm/Cardiac Dz
113
Orthopnea is MC due to ? but can also be due to ? Define Trepopnea What can cause this
LV failure Diaphragm paralysis/COPD Dyspnea associated w/ recumbent positions Post-pneumonectomy Unilateral diaphragm paralysis Ball-valve airway obstruction
114
# Define Platypnea What causes this condition?
Dyspnea upright ``` Loss of ab muscle tone Intracardiac shunting (patent foramen ovale) ```
115
What are the MC causes of dyspnea What are the most immediately life threatening?
``` Obstructive airway dz Decompensated HF Ischemic heart dz Pneumonia Psychogenic ``` ``` Upper airway obstruction Tension PTx PE Neuro weakness Fat embolism ```
116
What bedside test can be done to Dx dyspnea resulting from COPD What are the Tx goals for PTs w/ dyspnea?
Bedside spirometric analysis Partial pressure >60mmHG SaO2 >90%
117
What is the difference between Hypoxia and Hypoxemia What is the limit for the definition of Hypoxemia
Xia- insufficient delivery of O2 to tissues Xemia- abnormal low arterial O2 tension PaO2 <60mmHg
118
What is the MC cause of hypoxia? What is the hallmark of a R to L shunt causing hypoxemia
Alveolar hypoxia Lack of O2 inc after supplemental O2
119
What are the 3 acute compensatory reactions to hypoxemia What are the two chronic compensatory mechanisms?
Inc ventilation Pulm aterial constriction Inc symphathetic tone Inc RBC mass Dec tissue o2 demands
120
How does hypoxia manifest in the CNS? What finding/lab result is not used as an indicator of hypoxemia
Somnolence HA Agitation Coma Seizure Cyanosis
121
What are two situations that a pulse-ox could over estimate O2 saturation? Regardless of the cause of hypoxemia, the goal of Tx should be to keep PaO2 above ?
Methemoglobin Carboxyhemoglobin >60mmHg
122
Except for PTs w/ ?, arterial oxygenation responds to supplemental O2 Hypercapnia is exclusively caused by ? and define as ? limit
R to L shunts Alveolar hypoventilation PaCO2 >45mmHg
123
Having numerous etiologies, hypercapnia will never be produced by ? alone How is hypercapnia produced
Inc CO2 production Portion of tidal volume remains in dead space Alveolar volume= tidal - dead
124
Medullary chemoreceptors stimulate ? and ? in response to inc CO2 levels What are two reasons respiratory drive would be decreased?
Respiratory rate Tidal volume CNS lesion Toxic depression
125
Hypercapnia causes an increase of ? Extreme hypercapnia can lead to cardiovascular collapse at levels above ?
Inc ICP- HA Confusion Lethargy PaCO2 >100
126
How is hypercapnia Dx What is the relation between BiCarb and CO2 increase during acute hypercapnia? What is the relation in chronic hypercapnia
ABG End tidal CO2 BiCarb +1 per 10 mmHg CO2 BiCarab +3 per 10mmHg
127
How is hypercapnia Tx When do these PTs need to be admitted
Increasing minute ventilation New acidosis CNS Sxs Neuromuscular Dz COPD w/ worse hypercapnia/added respiratory acidosis
128
What causes cyanosis? How is this determined?
Inc amount of reduced DeoxyHgb/Hb derivatives Absolute amount of deoxygenated Hb in blood
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What are the two categories of cyanosis How are these two categories related?
Central: mucus membranes/tongue cyanosis from dec pulmonary oxygenation Peripheral: fingers/extremities from constriction and dec peripheral flow All central result in peripheral
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Cyanosis become visible when levels reach ? What two areas of the body are sensitive for central cyanosis
Deoxygenated Hb >5g Tongue Buccal mucosa
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What meds can cause pseudo cyanosis? What heavy metals can cause it?
Chlorpromazine Amiodarone Minocycline Nicroandil Gold/Silver
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How does pseudocyanosis present
Lips/membranes are normal Abnormal skin color doesn't blanch w/ pressure Discoloration more intense in sun-expsoed areas
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Methemoglobinemia will always have PulsOx of ? regardless of Tx Carboxyhemoglobinemia will have ? reading on PulsOx
80-85% Higher percentage of O2 saturation
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Give O2 to all PTs w/ central cyanosis, failure to improve suggests ? 3 things What part of the chest is under a negative pressure?
Shock Abnormal Hgb Pseudocyanosis Pleural space- (-5 - -8)
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How much pressure from TPtx before visible sign will be seen? What is the clinical hallmarks of SPTx? What is the MC physical finding
>15-20mmHg decreases venous return Tracheal deviation Hyper resonance HOTN Dyspnea Sinus tachy
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What is the initial test for TPtx What is done if PT can't assume position for this test
PA CXR Deep sulcus sign Profound lateral angle
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What is the ED Tx foal for TPtx What is the criteria for a PT to have PTx and be stable
Eliminate intrapleural air Needle-D/thoracostomy ``` RR <24 No dyspnea at rest Pulse 60-120 Normal BP PaO2 >90% No hemothorax ```
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PTs need to avoid flying for ? days after PTx Tx Why?
7-14d Boyles law: inc elevation inc gas volume
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# Define Pneumonia This is the __ leading cause of death in older adults
Infection of alveoli 8th
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What two microbes can cause pneumonia via hematogenous seeding What PTs are most at risk for pneumonia
Staph A Strep pneumo Aspiration Impaired mucociliary clearance Bacteremia risk
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What microbe is the MC cause of CAP What 3 atypical are most likely to be seen? What two microbes cause the most severe CAP?
Pneumococcus Mycoplasma Chlamydia Legionella Strep pneumo Legionella
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What PTs are at higher risk for pneumococcal pneumonia
Elder/<2y/o Day care kids HIV/Sickle cell
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What PTs are at higher risk for pneumococcal pneumonia How is pneumococcal pneumonia Tx
Elder/<2y/o Day care kids HIV/Sickle cell Admitted: 3rd Gen cephalosporin and macrolide OutPT: Macrolide
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PT w/ pneumonia after viral illness suggests ? What population is Pseudomonas pneumonia more likely to infect
Staph A pneumonia Prolonged hospitalization Broad ABX/high steroids Structural lung dz Nursing home residents
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How do H Influenzae and Moraxella look different on CXR? How are atypical pneumonias Tx
HI: multi-lobar infiltrates MC: diffuse infiltrates No cell wall= Macrolides Respiratory fluoroquinolones
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How is Legionella Dx Chlamydia pneumonia is linked w/ ? delayed presentation
Urine Ag test Adult onset pneumonia
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? form of atypical pneumonia occurs year round How does this present?
Mycoplasma w/ epidemics q4-8yrs Retrosternal chest pain
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What atypical is a rare cause of pneumonia in the US How is this atypical Tx
Q fever: C burnetti in dried urine Doxy Respiratory fluoroquinolone
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What is the MC cause of pneumonia in alcoholics? ? is one of the most serious non-OB infections
Strep Pneumo CAP
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? is the MC cause of AIDS related death in pregnant PTs What is the MC serious elderly infection? What is the MC serious viral infection?
P jiroveci Pneumonia Influenza
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What are the 3 MC microbes causing nursing home pneumonia ___Dx accounts for 75% of hospitalized HIV PTs
Strep pneumo Gram-neg bacilli H Influenza CAP bacterial pneumonia
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What is the MC cause of pneumonia in HIV PTs What oppotunistic infections are seen as CD4 counts decrease?
Strep Pneumo >800: bacterial 250-500: M tuberculosis, Crypto, Histo <200: Pneumocystitis
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How is pneumonia Tx on outpatient basis?
Macrolide (Clarith/Azith) Respiratory fluroquinolone Tetracycline (Doxy)-2nd choice Erythromycin- sunburn Clarithromcin- metal taste Azithromycin- 1/day dose
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PTs admitted for pneumonia w/ Pseudomonas Risk are given ? ABX What two are added for HAP coverage?
Piper/Tazo + Cipro/Aztreo + Moxi/Levofloxacin Vanc or LInezolid
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? is the MC chronic dz of childhood What is the pathophysiologic hallmark of this chronic Dz
Asthma Reduced diameter due to contractions, congestion, edema and secretions
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Asthma PT w/ silent chest and no wheeze means ? What are the 7 asthma mimickers
Severe airflow obstruction ``` Cardiac asthma- HF UA obstruction Multiple PE Aspiration Tumor/bronchial obstruction Interstitial lung dz Vocal cord dysfunction ```
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Asthma PT w/ silent chest and no wheeze means ? What are the 7 asthma mimickers
Severe airflow obstruction ``` Cardiac asthma- HF UA obstruction Multiple PE Aspiration Tumor/bronchial obstruction Interstitial lung dz Vocal cord dysfunction ```
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How is the severity of asthma measured What is used to monitor the progress of Tx What is the best predictor of need to admit?
FEV1 and PEFR PEFR Repeat FEV1 or PEFR after 1hr of Tx
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What meds are used in preferential sequence for asthma attacks?
Beta agonists Anticholinergics Glucocorticoids
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Why are B agonists used in asthma What is the MC s/e
B1- inc rate/force of contraction B2- inc dilation Skeletal muscle tremors
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What drug can be added to albuterol during asthma treatment? What steroids are given upon d/c
Ipratropium Prednisone Prednisolone for Peds
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To be d/c after asthmatic event PEFR should be above? If below ?, admit
>70% <40%
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When is IV Mg added to asthma Tx What sedative may be usd to dec Noradrenaline uptake?
FEV1 <25% Ketamine
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When asthma PTs are d/c from ER what are they Rx'd?
PO meds Inhaler CCS Short B-agonists Peak flow meter F/u and action plan
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Dx of COPD encompasses ? Dx This is #3 of ?
Chronic bronchitis Emphysema Bronchiectasis Asthma 3rd leading cause of death
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What are the 4 stages of COPD What are the hallmark Sxs
Mild: FEV >80 Mod: 50-79 Sev: 30-49 VSev: <30 Dyspnea Cough Sputum
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In early stages of COPD, what do ABG results look like? What are the clinical signs of severe COPD
Mod hypoxemia w/out hypercapnia Secondary polycythemia: facial vascular engorgement Hypercarbia- tremor, confusion
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BNP levels below ? supports a Dx of COPD and not HF ? therapy reduces COPD mortality What are the goals of this therapy
<100 O2 PaO2 >60 SaO2 >90 at rest
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What criteria are needed to place COPD PT on O2 PaO2 levels between ? is when PHTN, Cor Pulmonale or Polycythemia present
PaO2 <55 SaO2 <88% 56-59mmHG
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? meds are give to COPD Pts When are inhaled CCS' recommended
Long acting B2 agonists w/ anticholinergics Documented spirometric response FEV1 <50% Recurrent exacerbations needing ABC/systemic CCS
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? drug can COPD PTs w/ mild GOLD stages take to decrease exacerbation? What can trigger an acute COPD exacerbation?
Azithromycin ``` Hypoxia Cold weather BBs Narcotics Sedatives ```
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Respiratory failure in COPD is measured at ? When is respiratory acidosis expected?
PaO2 <60 SaO2 <90 PcO2 >44
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COPD PTs taking ? med need to have their levels measured Acute COPD SaO2 goals
Theophyline 88-92% PaO2 60-70mmHg
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MC adverse effect of using CCS in acute COPD Tx These PTs need ABX to cover ? 3 microbes that cause exacerbations
Hyperglycemia Strep pneumo H Influenza M catarrhalis
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Initial ABX Tx for acute COPD exacerbations include ? What PTs are at higher relapse w/in the next 2wks after an ED visit
Azithromycin Doxy Augmentin 5 or more ED visits/yr Activity limitations Initial RR PO CCS prior to ED arrival
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When d/c COPD PTs from ED after acute exacerbation, what 4 things need to be arranged ? is the 2nd leading cause of sudden unexpected non-traumatic death
Home O2 Bronchodilator Tx Short course PO CCS F/u appt w/ PCM <7days PE
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Normal healthy PTs won't have Sxs of PE until ? Define Postthrombotic Syndrome
20% occlusion Pooling blood on leg vein valves causing pain, ulcer, hyper pigmentation and swelling
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How do PEs lead to death Define Chornic Thromboembolic PHTN
PEA Asystole from ischemic affect on His/Purkinje system Post-PE PT w/ pulmonary obstructions leading to lung damage, dyspnea and PHTN
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How long does it take for VTE risks to increase after whole body immobility? What types of surgeries have the highest risk for VTE development
>8hrs Abdominal to remove Ca Joint replacements Brain/spinal cord
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What is NOT a risk factor for VTEs What are the hallmarks of a PE What is the 2nd MC Sx
Smoking Dyspnea ECG changes CXR w/ DDx Chest pain w/ pleuritic features
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Where do PE PTs complain of their chest pain? Define Paradoxical Embolism Syndrome What is an atypical manifestation
Between clavicles/costal margin PE shifting sides and causing stroke Myelopathy- numbness below waist
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Where do PE PTs complain of their chest pain?
Between clavicles/costal margin
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What might be heard on PE during PE What PE finding indicated likelihood of a DVT What do PTs complain of if DVT is in arm of catheter
Split S2 or S3 >2cm difference between legs 10cm below tibial tubercle Hand/finger swelling
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DVTs in ? locations are more likely to cause thrombophlebitis What causes Homans sign
Calf/saphenous veins Pain from DVT w/ passive foot dorsiflexion
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What PE findings suggest presence of a PE Define Westermark and Hampton hump
Hypoxemia/dyspnea w/ clear lungs on PE and imaging West: complete lobar obstruction Hamp: peripheral dome shape
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What is the most EKG manifestation of PT w/ PE What is the first step in VTE Dx
S1Q3T3 Estimate pre-test probability
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How long does D-dimer remain in blood What is the MC imaging modality for PE
t1/2 x 8hrs x 3days CT angiography
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What test has nearly 100% success at excluding PEs What is the imaging test of choice in DVTs
VQ scans Venous US w/ 7.5MHz probe
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What drug is used for initial Tx of VTE How are VTEs causin Phelgmasia Cerulea Dolens Tx
Heparin- UFH/LMWH Anticoags Neutral position limb Remove any constriction No transfer avail x6hrs= fibrinolytics
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How is VTE associated localized thrombophlebitis Tx What is used if extensive veins involvement is present?
NSAIDs Topical diclofenac gel No need of anticoag Full dose anticoag
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How are PTs w/ VTEs and receiving warfarin managed? What drug can be used for DVT and PE
LMWH until prothrombin time is prolonged and x 5days Rivaroxaban
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What are the 3 categories of PEs
Massive: SBP <90 x 15min SBP <100 w/ HTN Hx >40% reduction of SBP Submassive: near/normal BP All others= Less Severe
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When is surgical embolectomy considered for Tx
Young PT w/ large proximal PE w/ HOTN