EMED Flashcards
__ is the leading cause of death among US adults
___ causes this leading cause w/ ? predominant Sx
Ischemic heart dz
Coronary artery dz
Chest pain
High likelihood of short term risk of death in PTs w/ unstable angina
SHIPMATES BS S3 HOTN Inc TnT Prolonged MR Accelerating Sx frequency Tachy/brady Edema, pulmonary ST >0.5mm
BBB
Sustained V-tach
Low likelihood of short term risk of death from PTs w/ unstable angina?
Left coronary artery divides into ? and ? to supply ?
Reproducible w/ palpation
New/inc angina
Stable EKG
LCX and LAD
LAD: main anterior/septal
LCX: some anterior/lateral
ACS may be caused by secondary reduction of blood flow due to ?
Atherosclerotic plaques develop because of ?
Disruption/erosion of plaques
Platelet aggregation at lesions
Coronary artery spasm
Microvascular dysfunction
Repetitive wall injury
What is the classic location for MI myocardial ischemia pain?
Angina pain can be precipitated by ? events and lasts ?
Substernal/L chest radiating to arm, neck, jaw
Stress Exercise Cold
<5min w/ rest/nitro
Acute myocardial ischemia usually presents w/ more prominent pain and Sxs including ?
? PTs are more likely to have atypical presentation of MI?
Diaphoresis Nausea SoB
w/ little response to Nitro
Female
Advanced age
DM
What are the traditional RFs for ACS/AMI?
These RFs are not useful in ? PT populations
DM Tobacco FamHx
Hypercholesterolemia
HTN
ED PTs >40y/o
? PE finding may be heard indicating a failing myocardium
The presence of a new ? is ominous and may indicated ?
S3- volume overload
New systolic murmur-
Papillary dysfunction
MV leaflet flail w/ MR
VSD
S3 heart sounds are heard normally during ? and can indicate ? failure
Presence of ? on PE is indicative of LV dysfunction and L-sdied HF
Early diastole
Systolic HF
Rales, S3 regardless
Define TIMI Score
What are the parts of it
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
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
12 lead EKG
<10min
What is the ‘general’ definition of an STEMI
ST elevation suggests ? while depression suggests ?
ST elevation of 1mm or more in two contiguous leads w/ reciprocal changes
Ele: transmural injury/infarction
Dep: ischemia
What is the next step for suspected inferior wall AMI?
What finding is Dx
R sided EKG
ST elevation in V4R= RV infarction
PTs w/ RV infarction are ? dependent, be careful if using ?
Pts w/ non-Dx EKG but persistent Sxs have ? follow on test?
Pre-load dependent
Nitro/BBs
Repeat EKG
If reciprocal EKG changes are seen, ? does this indicate?
How does the height of ST elevations correlate to severity?
Larger area Increased severity Severe pump failure Inc CV complications Inc mortality
High= more extensive injury
What leads are used for posterior MIs?
What artery is involved w/ this type?
V7-9
Circumflex
LBBB criteria
What is the MC pacemaker lead location?
Elevation 1mm+, concordant
Elevation 5mm+, discordant
Depression 1mm+ V1-3
RV pacing
Where is Welens seen on EKG and what does it indicate
Why is this difficult to Dx
V2-3, possibly V1-4
LAD stenosis
T-waves present during pain free period
T-waves absent during painful episode
Wellen’s PTs are likely to develop ? type of MI
When are serum biomarkers not needed for Dx
When are these markers useful?
Anterior
Dx ST segment elevations
Non-Dx EKGs of NSTEMI
Risk stratification during N/STEMI and unstable angina
How can cardiac injury be differentiated between acute or chronic?
How long does it take for troponin to rise, peak and return to normal?
Delta troponin over 1-3hrs
3-12hrs
12-24hrs
5-14days
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?
PCI w/in 90-120min
Fibrinolysis <30min of arrival
Anti platelet/thrombins and Nitrates
G-2b/3a antagonist
What are the 4 anti-platelet meds used during the Tx of STEMI?
What 3 anti-thrombins are used?
Clopidogrel ASA Prasugrel
Ticagrelor
UFH Enoxaparin Fondaparinux
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?
Streptokinase
TARA-plase
Abciximab Tirofiban Eptifibatide
Nitro Morphine Metoprolol Atenolol
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
Refractory angina
Hemodynamic/electric instability
Inc risk for clinical events
PCI <2hrs
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
What is the recommended method to repurfsion NSTEMIs
What is the MC type of this method?
PCI w/in 90-120min
Coronary angioplasty
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
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
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
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
MOA of G2b/3a antagonists
MOA of ASA
Interrupts platelet activation
Inhibits platelet aggregation d/t thromboxane A2 stimulation mediated by arachidonic acid pathway
All unstable angina, N/STEMI PTs get ? med?
What is the alternative medication used but only if ?
325mg ASA
Clopidogrel
True allergy/active PUD
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
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
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
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
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
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
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
Anterior wall AMIs typically cause PTs to acquire ? dysrhythmia?
Why is this finding ominous?
Sinus tachy
Persistent sinus tachy= poor prognosis
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
? 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
? 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
New RBBB can occur MC in ? AMI
Previously stable PT that suddenly decompensates needs to have ? Dx r/o
Anteroseptal
Mechanical complication
? 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
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
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
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
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
? PT presentation suggests a possible inferior wall MI is present
How are these Dx
JVD/HOTN after giving Nitro
Echo/Nuclear imaging
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
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
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
Define HF
What are the cardinal manifestations of HF
Impaired ventricular filling or ejection of blood
Peripheral edema
Dyspnea and fatigue
Fluid retention
What is the counter regulatory response to HF
What are the 3 types of this response?
Natriuretic peptides
A- atrial
B: ventricle
C: endothelium
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
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
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
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
How is HF Dx
What is the most useful parameter for Dx?
Clinically w/ Hx and PE
Hx of HF
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
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
What component of a HF workup out performs all Dx tests available?
What lab result has the most similar accuracy?
Clinical gestalt
BNP
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
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
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
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
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%
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
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
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
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
What med is used for normotensive HF Tx when Nitro is ineffective or c/i
Nesiritide- recombinant human BNP
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
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
What is the second MC cause of sudden cardiac death in adolescents?
? is the MC form of cardiomyopathy
Hypertrophic cardiomyopathy
Dilated
Peripartum cardiomyopathy manifests as ?
What is the primary indication for heart transplants in the US?
Dilated cardiomyopathy
Idiopathic dilated cardiomyopathy
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
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
How is dilated cardiomyopathy Dx
What may be seen on CXR
Echo
PHTN
Inc ratio
Enlarged silhouette
Biventricular enlargement
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
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
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
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
What causes most of the Sxs in Hypertrophic Cardiomyopathy
Severity of this Dz is associated w/ ?
Impaired diastolic relaxation
Restricted LV filling
Inc age
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
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
Hypertrophic Cardiomyopathy PTs poorly tolerate ? rhythm
What other PE finding is common
Afib
Sustained apical impulse
Presystolic lift
S4
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
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
What is the characteristic Echo finding when Dx hypertrophic cardiomyopathy
What is the mainstay of Tx for these PTs
Disproportionate septal hypertrophy
BBs
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
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
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
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
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
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
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
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
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
How much pressure separates true tamponade from restricted cardiac filling?
What may be present but is not Dx
> 10mmHg
Pulsus paradoxus
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
What is the classic but uncommon EKG finding for tamponade?
What is the DxToC?
Electrical alternans
Echo
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
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
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
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
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
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
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
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
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
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
Define Platypnea
What causes this condition?
Dyspnea upright
Loss of ab muscle tone Intracardiac shunting (patent foramen ovale)
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
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%
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
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
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
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
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
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
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
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
Hypercapnia causes an increase of ?
Extreme hypercapnia can lead to cardiovascular collapse at levels above ?
Inc ICP- HA Confusion Lethargy
PaCO2 >100
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
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
What causes cyanosis?
How is this determined?
Inc amount of reduced DeoxyHgb/Hb derivatives
Absolute amount of deoxygenated Hb in blood
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
Cyanosis become visible when levels reach ?
What two areas of the body are sensitive for central cyanosis
Deoxygenated Hb >5g
Tongue
Buccal mucosa
What meds can cause pseudo cyanosis?
What heavy metals can cause it?
Chlorpromazine
Amiodarone
Minocycline
Nicroandil
Gold/Silver
How does pseudocyanosis present
Lips/membranes are normal
Abnormal skin color doesn’t blanch w/ pressure
Discoloration more intense in sun-expsoed areas
Methemoglobinemia will always have PulsOx of ? regardless of Tx
Carboxyhemoglobinemia will have ? reading on PulsOx
80-85%
Higher percentage of O2 saturation
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)
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
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
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
PTs need to avoid flying for ? days after PTx Tx
Why?
7-14d
Boyles law: inc elevation inc gas volume
Define Pneumonia
This is the __ leading cause of death in older adults
Infection of alveoli
8th
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
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
What PTs are at higher risk for pneumococcal pneumonia
Elder/<2y/o
Day care kids
HIV/Sickle cell
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
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
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
How is Legionella Dx
Chlamydia pneumonia is linked w/ ? delayed presentation
Urine Ag test
Adult onset pneumonia
? form of atypical pneumonia occurs year round
How does this present?
Mycoplasma w/ epidemics q4-8yrs
Retrosternal chest pain
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
What is the MC cause of pneumonia in alcoholics?
? is one of the most serious non-OB infections
Strep Pneumo
CAP
? 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
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
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
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
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
? 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
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
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
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
What meds are used in preferential sequence for asthma attacks?
Beta agonists
Anticholinergics
Glucocorticoids
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
What drug can be added to albuterol during asthma treatment?
What steroids are given upon d/c
Ipratropium
Prednisone
Prednisolone for Peds
To be d/c after asthmatic event PEFR should be above?
If below ?, admit
> 70%
<40%
When is IV Mg added to asthma Tx
What sedative may be usd to dec Noradrenaline uptake?
FEV1 <25%
Ketamine
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
Dx of COPD encompasses ? Dx
This is #3 of ?
Chronic bronchitis
Emphysema
Bronchiectasis
Asthma
3rd leading cause of death
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
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
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
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
? 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
? 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
Respiratory failure in COPD is measured at ?
When is respiratory acidosis expected?
PaO2 <60
SaO2 <90
PcO2 >44
COPD PTs taking ? med need to have their levels measured
Acute COPD SaO2 goals
Theophyline
88-92%
PaO2 60-70mmHg
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
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
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
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
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
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
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
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
Where do PE PTs complain of their chest pain?
Between clavicles/costal margin
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
DVTs in ? locations are more likely to cause thrombophlebitis
What causes Homans sign
Calf/saphenous veins
Pain from DVT w/ passive foot dorsiflexion
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
What is the most EKG manifestation of PT w/ PE
What is the first step in VTE Dx
S1Q3T3
Estimate pre-test probability
How long does D-dimer remain in blood
What is the MC imaging modality for PE
t1/2 x 8hrs x 3days
CT angiography
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
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
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
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
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
When is surgical embolectomy considered for Tx
Young PT w/ large proximal PE w/ HOTN
