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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
Q

What direct thrombin inhibitor is used during unstable angina/NSTEMI not used for STEMI Tx

What anti-ischemic therapy is NOT used for NSTEMI?

A

Bivalirudin

Atenolol

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26
Q

What is the recommended method to repurfsion NSTEMIs

What is the MC type of this method?

A

PCI w/in 90-120min

Coronary angioplasty

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27
Q

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?

A

Thienopyridines
G2b/3a inhibitors

In/Direct plasminogen activators

LV function

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28
Q

What criteria must be met to use fibrinolytics during NSTEMI Tx

This form of reperfusion is better started early for ? MIs in ? location

A

<12hrs from Sx onset
ECT w/ one ST elevation >1mm in two or more leads

Larger/anterior

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29
Q

After a failed fibrinolytic administration, rescue PCI is recommended for ? PTs

A

<75y/o

Severe HF/edema

Hemodynamic compromising ventricular arrhythmias

Mod/large area of myocardium at risk

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30
Q

What is the most catastrophic complication of fibrinolytic therapy?

If fibrinolytics are used in STEMI PTs, how are they used?

A

Intracranial bleeds

Full dose UFH/Enox/Fonda x 48hrs

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31
Q

MOA of G2b/3a antagonists

MOA of ASA

A

Interrupts platelet activation

Inhibits platelet aggregation d/t thromboxane A2 stimulation mediated by arachidonic acid pathway

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32
Q

All unstable angina, N/STEMI PTs get ? med?

What is the alternative medication used but only if ?

A

325mg ASA

Clopidogrel
True allergy/active PUD

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33
Q

What is the ADP receptor antagonist used in ACS

This med is c/i in ? PTs

What is the benefit of using this med?

A

Prasurgel- irreversible

Hx of CVA/TIA/bleeding

Effect gone w/in 3 days of d/c

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34
Q

Why is LMWH used in NSTEMI PTs more often?

STEMI PTs Tx w/ ASA and ? had better outcomes

A

Greater BioAvail
Lower protein binding
Longer t1/2
More reliable anticoag effect

Enoxaparin

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35
Q

Nitro provides ? benefits to ACS PTs

When Nitro is used in AMI PTs not Tx w/ thrombolytics, what are the 3 benefits?

A

Relaxes smooth muscles/dilation
Inhibits platelet aggregation

Reduces infarct size
Improves regional function
Dec rate of CV complications

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36
Q

If nitro is used in AMI PTs, titrate to ? not ?

Recommend using IV Nitro for first 24-48hrs for ? PTs

A

BP, not Sx resolution

STEMi and recurrent ischemia
CHF
HOTN

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37
Q

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 ?

A

Sildenafil- 24hrs
Tadalafil- 48hrs

S/Sxs of HF
Low CO
Risk for cardiogenic shock

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38
Q

What are the relative c/is to giving BBs?

What are the c/is to giving ACEIs within 24hrs

A

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
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39
Q

Of all the meds, what ones may be used during ACS that don’t improve mortality?

When would they be used?

A

CCBs

Verapamil/Diltiazem if:
Ongoing ischemia
A-fib w/out CHF
LV dysfunction
AV blocks
Absolute c/i to BBs
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40
Q

Anterior wall AMIs typically cause PTs to acquire ? dysrhythmia?

Why is this finding ominous?

A

Sinus tachy

Persistent sinus tachy= poor prognosis

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41
Q

PTs w/ SCT, Afib/flutter post MI are best Tx w/ ?

What type of acquired rhythm is not associated w/ an increased mortality

A

Direct current cardioversion

Sinus brady w/out HOTN

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42
Q

? med is used for sinus brady causing HOTN, ischemia, ventricular escape rhthyms or Sx AV blocks?

Anterior/inferior MIs can cause PTs to develop ?

A

Atropine

Complete heart blocks

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43
Q

? 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 ?

A

Junctional rhythms

AMI
Benign

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44
Q

New RBBB can occur MC in ? AMI

Previously stable PT that suddenly decompensates needs to have ? Dx r/o

A

Anteroseptal

Mechanical complication

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45
Q

? post-AMI complication can occur 1-5 days after and lead to tamponade/death

How does it present?

A

Ventricular wall rupture

HOTN/Tachy
JVD
Dec sounds
Pulsus paradoxus

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46
Q

What is the DxTOC for ventricular free wall ruptures?

How is a ruptured septum detected, Dx and Tx

A

Echo w/ surgical Tx

New holo murmur
Pain/dyspnea

Doppler echo, surgery

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47
Q

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/ ?

A

Anterior wall
Extensive/three vessel CADz

Inferior wall

Day 3-5 post-MI
Dyspnea, HF
New holo murmur w/ MR

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48
Q

PTs are more likely to develop pericarditis after ? type of MI

These PTs are more likely to develop ? than actual pericarditis

A

Transmural and delayed presentation

Pericardial effusion

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49
Q

How is post-MI pericarditis or Dresslers Tx

If PT develops Dresslers 2-10wks later, how do they present?

A

ASA or Colchicine
No Ibuprofen- interferes w/ ASA anti-platelet effect

Pain Fever Pleuropericarditis

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50
Q

? PT presentation suggests a possible inferior wall MI is present

How are these Dx

A

JVD/HOTN after giving Nitro

Echo/Nuclear imaging

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51
Q

What is the most serious complication that can occur from a RV infarct?

How are these types Tx

A

Shock

Maintain preload (NS)
Reduce RV after load
Inotropic support
Early repurfusion

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52
Q

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?

A

Abrupt vessel closure

Bare metal- more likely to re-stenose
Drug eluding- late stent thrombosis 9-12mon later after d/c Clopidogrel

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53
Q

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

A

Cardiac troponin

Benzo ASA Nitrate

BBs

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54
Q

Define HF

What are the cardinal manifestations of HF

A

Impaired ventricular filling or ejection of blood

Peripheral edema
Dyspnea and fatigue
Fluid retention

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55
Q

What is the counter regulatory response to HF

What are the 3 types of this response?

A

Natriuretic peptides

A- atrial
B: ventricle
C: endothelium

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56
Q

What two effects do natriuretic peptides produce?

PTs w/ acute HF and pulmonary edema may benefit from ? Tx to prevent intubation

A

Vasodilation
RAAS/SNS inhibition

BiPap

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57
Q

What are the 6 phenotypes of acute HF?

A

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

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58
Q

How do PTs w/ acute on chronic HF present

High output HF is distinguished by a normal ? and often caused by ?

A

Gradual Sxs and weight gain from days/wks

Normal EF
Anemia/Thyrotoxicosis

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59
Q

Define Systolic Dysfunction HF

Define Diastolic Dysfunction HF

This may be an early initiator of ? cascade

A

HF w/ reduced EF <50%
Impaired ventricle emptying

HF w/ preserved EF
Impaired ventricular relaxation (chronic HTN)

Ischemic

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60
Q

How is HF Dx

What is the most useful parameter for Dx?

A

Clinically w/ Hx and PE

Hx of HF

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61
Q

What are the RFs for HF

What Sx has the highest sensitivity for Dx?

What are the 3 most specific Sxs?

A

DM Obese Valve dz
HTN Age Male

Dyspnea

Paroxysmal nocturnal dyspnea
Orthopnea
Edema

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62
Q

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?

A

S3

Abdominojugular reflux
JVD

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63
Q

What component of a HF workup out performs all Dx tests available?

What lab result has the most similar accuracy?

A

Clinical gestalt

BNP

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64
Q

What CXR findings are most specific for a final Dx of acute HF?

What EKG finding has the highest likelihood ratio for Dx HF?

A

Venous congestion
Interstitial edema
Cardiomegaly

Afib

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65
Q

What 3 factors can affect biomarker levels?

Bedside cardiopulmonary US can be used to address ? 3 questions?

A

Mass Age Gender

Signs of pulm congestion
Sign of volume overload
Low/norm LV EF

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66
Q

Pulmonary US is first used to determine if pulmonary congestion is present by looking for ?

These findings are sonographic equivalent to ? on CXR

A

B-lines

Kerley-B linesW

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67
Q

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

A

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

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68
Q

What step is the final piece of the ED based bedside US?

What is the initial approach to HF Tx

A

LV EF

Airway w/ goal of >95%

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69
Q

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?

A

Dobutamine NorEpi Dopamine

Nitro
IV Nitroprusside after >200mcg of Nitro

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70
Q

When Tx HTN acute HF, always start ? med prior to using ?

How are normotensive HF PTs Tx

A

Nitrates before diuretics (Furosemide)

Loop diuretics 40mg IV

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71
Q

What adverse outcome can occur when treating normotensive HF?

Ongoing congestion/dyspnea after administering loop diuretics indicates need for ?

A

HypoK/Ca/Mg
Ototoxicity, especially if using aminoglycoside ABX

Vasodilators

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72
Q

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?

A

Morphine

Ultrafiltration

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73
Q

What med is used for normotensive HF Tx when Nitro is ineffective or c/i

A

Nesiritide- recombinant human BNP

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74
Q

How to dose Furosemide

What are 5 high risk markers in ED PTs w/ HF associated w/ morbidity/mortality?

A

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

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75
Q

Define Primary Cardiomyopathies

Define Secondary Cardiomyopathies

As a group these make the the third MC form of ?

A

Dz involving myocardium

Heart dz w/ systemic d/os

Cardiac dz in US after coronary/ischemic and HTN heart dz

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76
Q

What is the second MC cause of sudden cardiac death in adolescents?

? is the MC form of cardiomyopathy

A

Hypertrophic cardiomyopathy

Dilated

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77
Q

Peripartum cardiomyopathy manifests as ?

What is the primary indication for heart transplants in the US?

A

Dilated cardiomyopathy

Idiopathic dilated cardiomyopathy

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78
Q

What are the hallmarks of dilated cardiomyopathy?

What can lead to valve dysfunction and incomplete closure?

A

LV/RV dysfunction w/ normal LV thickness

Annular dilation and papillary displacement

79
Q

Where are the holosytolic MR/TR heard in dilated cardiomyopathy?

What PE finding will be seen if tricuspid insufficiency is significant?

A

Apex/LLSB

Enlarged/pulsatile liver

80
Q

How is dilated cardiomyopathy Dx

What may be seen on CXR

A

Echo

PHTN
Inc ratio
Enlarged silhouette
Biventricular enlargement

81
Q

Dilated cardiomyopathy EKG will almost always show ? and two common findings include?

What two rhythm disturbances are commonly seen?

A

Abnormality
LCH and LA enlargement

Afib
Ventricular ectopy

82
Q

When is an echo indicated for dilated cardiomyopathy

How are these PTs Tx

A

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
Q

Non-compliant med/diet PTs presenting w/ dilated cardiomyopathy are Tx w/ ?

Define Hypertrophic Cardiomyopathy

A

IV diuretic/nitrates

Asymmetric LV/RV hypertrophy w/ septal involvement

84
Q

What are the Dx hallmarks of Hypertrophic Cardiomyopathy

What 3 components of heart function remain normal

A

Asymmetric septal hypertrophy and fiber disarray on echo

CO
EF
End Syst/Diastolic volumes

85
Q

What causes most of the Sxs in Hypertrophic Cardiomyopathy

Severity of this Dz is associated w/ ?

A

Impaired diastolic relaxation
Restricted LV filling

Inc age

86
Q

What is the most frequent initial complaint of Hypertrophic Cardiomyopathy

What are two frequent parts of the PTs Hx

A

Dyspnea on exertion due to exercise induced sinus tach

FamHx of massive heart attack/HF

87
Q

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?

A

Inc o2 demand limited by LV size

Precordial/retrosternal chest discomfort

Poor/variable response to Nitro

88
Q

Hypertrophic Cardiomyopathy PTs poorly tolerate ? rhythm

What other PE finding is common

A

Afib

Sustained apical impulse
Presystolic lift
S4

89
Q

Where is the ejection murmur of Hypertrophic Cardiomyopathy best hear?

What PE maneuvers can decrease the murmur?

A

LLSB or Apex w/out carotid radiation

Squat Grips Leg elevations

90
Q

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

A

Inc murmur, Inc murmur

Inc murmur, Inc murmur

Dec, Dec

Dec, Inc

Dec, Dec

91
Q

What is the characteristic Echo finding when Dx hypertrophic cardiomyopathy

What is the mainstay of Tx for these PTs

A

Disproportionate septal hypertrophy

BBs

92
Q

What are the two layers of the pericardium

The space between the layers holds ?L of fluid

A

Visceral- serous/loos over epicardium
Parietal- dense collagenous sac

50mL

93
Q

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

A

L trap

Inflamed diaphragm pleura

Pericardial friction rub w/ diaphragm on LLSB/apex w/ PT sitting/leaning fwd

94
Q

What are the 4 stages of serial EKGs during acute pericarditis

A

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
Q

What will be seen on EKG if a pericardial effusion develops during pericarditis?

What is the DxTOC for pericarditis and it’s effusion

A

Low voltage QRS
Electrical alternans

Echo

96
Q

Anterior RV contacts w/ ?
Posterior LV contacts w/ ?

Although most cases are idiopathic and presumed viral, how are pericarditis Tx

A

Chest wall
Posterior pericardium/adjacent pleura

NSAIDs
Ibuprofen preferred
Cochicine

97
Q

When would a PT w/ pericarditis need to be admitted

Why would repeat echos be needed?

A

Myocarditis

Sxs fail to resolve/reappear
New Sxs appear

98
Q

What are poor prognosis indicators for pericarditis

PTs w/ these indicators or ? should be admitted

A 
Subacute onset over wks
Temp >100.4
ImmSupp
Myocarditis
Hx of PO Anticoag use
Large effusions >20mm

Enlarged silhouette

99
Q

What are the top 3 MC causes of non-traumatic cardiac tamponades?

What is the lowest likely cause?

A

Metastatic malignancy
Acute idiopathic pericarditis
Uremia

Anticoagulant hemorrhage

100
Q

PT w/ non-traumatic tamponade MC complain of ?

What PE finding may also be felt suggesting this Dx

A

Dyspnea at rest/exertion

Dropped beats on peripheral pulses during inspiration

101
Q

How much pressure separates true tamponade from restricted cardiac filling?

What may be present but is not Dx

A

> 10mmHg

Pulsus paradoxus

102
Q

What may be seen on PE in the neck of PT w/ tamponade?

What may be seen on abdominal exam?

A

JVD w/ absent Y-descent

RUQ tenderness from hepatic venous congestion

103
Q

What is the classic but uncommon EKG finding for tamponade?

What is the DxToC?

A

Electrical alternans

Echo

104
Q

In addition to large pericardial fluid, typical echo findings that describe a tamponade include ? four comments

A

RA compression

RV diastolic collapse

Abnormal TV/MV variation

Dilated IVC w/ lack of inspiration collapse

105
Q

When to post-Tx tamponade PTs need to be admitted?

What is Becks Triad that may be present

A

Hemodynamically unstable
Emergent pericardiocentesis
Insufficient social situation to provide emergency care

HOTN
Muffled sounds
JVD

106
Q

How does an aortic dissection begin?

Difference between Stanford and DeBaeky systems

A

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
Q

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?

A

Radiation tear between scapula
Sense of doom

A: anterior chest
B: abdominal

Type A

108
Q

What might be seen on PE of an aortic dissection?

What can cause a PTs Sxs to resolve and be mis-Dx?

A 
HTN
Aortic murmur
Dysphagia Hoarseness 
Pulse deficits radial/femoral
Horners

Dissection ruptures into true aortic lumen

109
Q

What are the 4 factors of mis-Dx an aortic dissection

What is the MC CXR abnormality

A

PT walks in
Non-enlarged mediastinum
Absent pulse difference
Non-specific Sxs

Wide mediastinum
Abnormal aortic contour

110
Q

What is the image of choice for Dx of aortic dissection

If properly trained, what image is just as good?

A

CT w/ and w/out contrast
CT Triple r/o- CADz, PE and Dissection

TEE

111
Q

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?

A

Known esophageal Dz

Short BBs- PLE preferred
Nitropursside/Nicardipine

120-130/100-120

112
Q

When are aortic dissection more likely during pregnancy?

Define Dyspnea

What is it usually caused by

A

3rd-T/Post-partum

Subjective feeling of difficult/labored breathing

Pulm/Cardiac Dz

113
Q

Orthopnea is MC due to ? but can also be due to ?

Define Trepopnea

What can cause this

A

LV failure
Diaphragm paralysis/COPD

Dyspnea associated w/ recumbent positions

Post-pneumonectomy
Unilateral diaphragm paralysis
Ball-valve airway obstruction

114
Q

Define Platypnea

What causes this condition?

A

Dyspnea upright

Loss of ab muscle tone
Intracardiac shunting (patent foramen ovale)
115
Q

What are the MC causes of dyspnea

What are the most immediately life threatening?

A 
Obstructive airway dz
Decompensated HF
Ischemic heart dz
Pneumonia
Psychogenic
Upper airway obstruction
Tension PTx
PE
Neuro weakness
Fat embolism
116
Q

What bedside test can be done to Dx dyspnea resulting from COPD

What are the Tx goals for PTs w/ dyspnea?

A

Bedside spirometric analysis

Partial pressure >60mmHG
SaO2 >90%

117
Q

What is the difference between Hypoxia and Hypoxemia

What is the limit for the definition of Hypoxemia

A

Xia- insufficient delivery of O2 to tissues
Xemia- abnormal low arterial O2 tension

PaO2 <60mmHg

118
Q

What is the MC cause of hypoxia?

What is the hallmark of a R to L shunt causing hypoxemia

A

Alveolar hypoxia

Lack of O2 inc after supplemental O2

119
Q

What are the 3 acute compensatory reactions to hypoxemia

What are the two chronic compensatory mechanisms?

A

Inc ventilation
Pulm aterial constriction
Inc symphathetic tone

Inc RBC mass
Dec tissue o2 demands

120
Q

How does hypoxia manifest in the CNS?

What finding/lab result is not used as an indicator of hypoxemia

A

Somnolence HA Agitation Coma Seizure

Cyanosis

121
Q

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 ?

A

Methemoglobin
Carboxyhemoglobin

> 60mmHg

122
Q

Except for PTs w/ ?, arterial oxygenation responds to supplemental O2

Hypercapnia is exclusively caused by ? and define as ? limit

A

R to L shunts

Alveolar hypoventilation
PaCO2 >45mmHg

123
Q

Having numerous etiologies, hypercapnia will never be produced by ? alone

How is hypercapnia produced

A

Inc CO2 production

Portion of tidal volume remains in dead space
Alveolar volume= tidal - dead

124
Q

Medullary chemoreceptors stimulate ? and ? in response to inc CO2 levels

What are two reasons respiratory drive would be decreased?

A

Respiratory rate
Tidal volume

CNS lesion
Toxic depression

125
Q

Hypercapnia causes an increase of ?

Extreme hypercapnia can lead to cardiovascular collapse at levels above ?

A

Inc ICP- HA Confusion Lethargy

PaCO2 >100

126
Q

How is hypercapnia Dx

What is the relation between BiCarb and CO2 increase during acute hypercapnia?

What is the relation in chronic hypercapnia

A

ABG
End tidal CO2

BiCarb +1 per 10 mmHg CO2

BiCarab +3 per 10mmHg

127
Q

How is hypercapnia Tx

When do these PTs need to be admitted

A

Increasing minute ventilation

New acidosis
CNS Sxs
Neuromuscular Dz
COPD w/ worse hypercapnia/added respiratory acidosis

128
Q

What causes cyanosis?

How is this determined?

A

Inc amount of reduced DeoxyHgb/Hb derivatives

Absolute amount of deoxygenated Hb in blood

129
Q

What are the two categories of cyanosis

How are these two categories related?

A

Central: mucus membranes/tongue cyanosis from dec pulmonary oxygenation

Peripheral: fingers/extremities from constriction and dec peripheral flow

All central result in peripheral

130
Q

Cyanosis become visible when levels reach ?

What two areas of the body are sensitive for central cyanosis

A

Deoxygenated Hb >5g

Tongue
Buccal mucosa

131
Q

What meds can cause pseudo cyanosis?

What heavy metals can cause it?

A

Chlorpromazine
Amiodarone
Minocycline
Nicroandil

Gold/Silver

132
Q

How does pseudocyanosis present

A

Lips/membranes are normal
Abnormal skin color doesn’t blanch w/ pressure
Discoloration more intense in sun-expsoed areas

133
Q

Methemoglobinemia will always have PulsOx of ? regardless of Tx

Carboxyhemoglobinemia will have ? reading on PulsOx

A

80-85%

Higher percentage of O2 saturation

134
Q

Give O2 to all PTs w/ central cyanosis, failure to improve suggests ? 3 things

What part of the chest is under a negative pressure?

A

Shock
Abnormal Hgb
Pseudocyanosis

Pleural space- (-5 - -8)

135
Q

How much pressure from TPtx before visible sign will be seen?

What is the clinical hallmarks of SPTx?

What is the MC physical finding

A

> 15-20mmHg decreases venous return

Tracheal deviation
Hyper resonance
HOTN
Dyspnea

Sinus tachy

136
Q

What is the initial test for TPtx

What is done if PT can’t assume position for this test

A

PA CXR

Deep sulcus sign
Profound lateral angle

137
Q

What is the ED Tx foal for TPtx

What is the criteria for a PT to have PTx and be stable

A

Eliminate intrapleural air
Needle-D/thoracostomy

RR <24
No dyspnea at rest
Pulse 60-120
Normal BP
PaO2 >90%
No hemothorax
138
Q

PTs need to avoid flying for ? days after PTx Tx

Why?

A

7-14d

Boyles law: inc elevation inc gas volume

139
Q

Define Pneumonia

This is the __ leading cause of death in older adults

A

Infection of alveoli

8th

140
Q

What two microbes can cause pneumonia via hematogenous seeding

What PTs are most at risk for pneumonia

A

Staph A
Strep pneumo

Aspiration
Impaired mucociliary clearance
Bacteremia risk

141
Q

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?

A

Pneumococcus

Mycoplasma
Chlamydia
Legionella

Strep pneumo
Legionella

142
Q

What PTs are at higher risk for pneumococcal pneumonia

A

Elder/<2y/o
Day care kids
HIV/Sickle cell

143
Q

What PTs are at higher risk for pneumococcal pneumonia

How is pneumococcal pneumonia Tx

A

Elder/<2y/o
Day care kids
HIV/Sickle cell

Admitted: 3rd Gen cephalosporin and macrolide
OutPT: Macrolide

144
Q

PT w/ pneumonia after viral illness suggests ?

What population is Pseudomonas pneumonia more likely to infect

A

Staph A pneumonia

Prolonged hospitalization
Broad ABX/high steroids
Structural lung dz
Nursing home residents

145
Q

How do H Influenzae and Moraxella look different on CXR?

How are atypical pneumonias Tx

A

HI: multi-lobar infiltrates
MC: diffuse infiltrates

No cell wall=
Macrolides
Respiratory fluoroquinolones

146
Q

How is Legionella Dx

Chlamydia pneumonia is linked w/ ? delayed presentation

A

Urine Ag test

Adult onset pneumonia

147
Q

? form of atypical pneumonia occurs year round

How does this present?

A

Mycoplasma w/ epidemics q4-8yrs

Retrosternal chest pain

148
Q

What atypical is a rare cause of pneumonia in the US

How is this atypical Tx

A

Q fever: C burnetti in dried urine

Doxy
Respiratory fluoroquinolone

149
Q

What is the MC cause of pneumonia in alcoholics?

? is one of the most serious non-OB infections

A

Strep Pneumo

CAP

150
Q

? 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?

A

P jiroveci

Pneumonia

Influenza

151
Q

What are the 3 MC microbes causing nursing home pneumonia

___Dx accounts for 75% of hospitalized HIV PTs

A

Strep pneumo
Gram-neg bacilli
H Influenza

CAP bacterial pneumonia

152
Q

What is the MC cause of pneumonia in HIV PTs

What oppotunistic infections are seen as CD4 counts decrease?

A

Strep Pneumo

> 800: bacterial
250-500: M tuberculosis, Crypto, Histo
<200: Pneumocystitis

153
Q

How is pneumonia Tx on outpatient basis?

A

Macrolide (Clarith/Azith)
Respiratory fluroquinolone
Tetracycline (Doxy)-2nd choice

Erythromycin- sunburn
Clarithromcin- metal taste
Azithromycin- 1/day dose

154
Q

PTs admitted for pneumonia w/ Pseudomonas Risk are given ? ABX

What two are added for HAP coverage?

A

Piper/Tazo + Cipro/Aztreo + Moxi/Levofloxacin

Vanc or LInezolid

155
Q

? is the MC chronic dz of childhood

What is the pathophysiologic hallmark of this chronic Dz

A

Asthma

Reduced diameter due to contractions, congestion, edema and secretions

156
Q

Asthma PT w/ silent chest and no wheeze means ?

What are the 7 asthma mimickers

A

Severe airflow obstruction

Cardiac asthma- HF
UA obstruction
Multiple PE
Aspiration
Tumor/bronchial obstruction
Interstitial lung dz
Vocal cord dysfunction
157
Q

Asthma PT w/ silent chest and no wheeze means ?

What are the 7 asthma mimickers

A

Severe airflow obstruction

Cardiac asthma- HF
UA obstruction
Multiple PE
Aspiration
Tumor/bronchial obstruction
Interstitial lung dz
Vocal cord dysfunction
158
Q

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?

A

FEV1 and PEFR

PEFR

Repeat FEV1 or PEFR after 1hr of Tx

159
Q

What meds are used in preferential sequence for asthma attacks?

A

Beta agonists
Anticholinergics
Glucocorticoids

160
Q

Why are B agonists used in asthma

What is the MC s/e

A

B1- inc rate/force of contraction
B2- inc dilation

Skeletal muscle tremors

161
Q

What drug can be added to albuterol during asthma treatment?

What steroids are given upon d/c

A

Ipratropium

Prednisone
Prednisolone for Peds

162
Q

To be d/c after asthmatic event PEFR should be above?

If below ?, admit

A

> 70%

<40%

163
Q

When is IV Mg added to asthma Tx

What sedative may be usd to dec Noradrenaline uptake?

A

FEV1 <25%

Ketamine

164
Q

When asthma PTs are d/c from ER what are they Rx’d?

A

PO meds
Inhaler
CCS
Short B-agonists

Peak flow meter
F/u and action plan

165
Q

Dx of COPD encompasses ? Dx

This is #3 of ?

A

Chronic bronchitis
Emphysema
Bronchiectasis
Asthma

3rd leading cause of death

166
Q

What are the 4 stages of COPD

What are the hallmark Sxs

A

Mild: FEV >80
Mod: 50-79
Sev: 30-49
VSev: <30

Dyspnea Cough Sputum

167
Q

In early stages of COPD, what do ABG results look like?

What are the clinical signs of severe COPD

A

Mod hypoxemia w/out hypercapnia

Secondary polycythemia: facial vascular engorgement
Hypercarbia- tremor, confusion

168
Q

BNP levels below ? supports a Dx of COPD and not HF

? therapy reduces COPD mortality

What are the goals of this therapy

A

<100

O2

PaO2 >60
SaO2 >90 at rest

169
Q

What criteria are needed to place COPD PT on O2

PaO2 levels between ? is when PHTN, Cor Pulmonale or Polycythemia present

A

PaO2 <55
SaO2 <88%

56-59mmHG

170
Q

? meds are give to COPD Pts

When are inhaled CCS’ recommended

A

Long acting B2 agonists w/ anticholinergics

Documented spirometric response
FEV1 <50%
Recurrent exacerbations needing ABC/systemic CCS

171
Q

? drug can COPD PTs w/ mild GOLD stages take to decrease exacerbation?

What can trigger an acute COPD exacerbation?

A

Azithromycin

Hypoxia
Cold weather
BBs
Narcotics
Sedatives
172
Q

Respiratory failure in COPD is measured at ?

When is respiratory acidosis expected?

A

PaO2 <60
SaO2 <90

PcO2 >44

173
Q

COPD PTs taking ? med need to have their levels measured

Acute COPD SaO2 goals

A

Theophyline

88-92%
PaO2 60-70mmHg

174
Q

MC adverse effect of using CCS in acute COPD Tx

These PTs need ABX to cover ? 3 microbes that cause exacerbations

A

Hyperglycemia

Strep pneumo
H Influenza
M catarrhalis

175
Q

Initial ABX Tx for acute COPD exacerbations include ?

What PTs are at higher relapse w/in the next 2wks after an ED visit

A

Azithromycin Doxy Augmentin

5 or more ED visits/yr
Activity limitations
Initial RR
PO CCS prior to ED arrival

176
Q

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

A

Home O2
Bronchodilator Tx
Short course PO CCS
F/u appt w/ PCM <7days

PE

177
Q

Normal healthy PTs won’t have Sxs of PE until ?

Define Postthrombotic Syndrome

A

20% occlusion

Pooling blood on leg vein valves causing pain, ulcer, hyper pigmentation and swelling

178
Q

How do PEs lead to death

Define Chornic Thromboembolic PHTN

A

PEA
Asystole from ischemic affect on His/Purkinje system

Post-PE PT w/ pulmonary obstructions leading to lung damage, dyspnea and PHTN

179
Q

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

A

> 8hrs

Abdominal to remove Ca
Joint replacements
Brain/spinal cord

180
Q

What is NOT a risk factor for VTEs

What are the hallmarks of a PE

What is the 2nd MC Sx

A

Smoking

Dyspnea
ECG changes
CXR w/ DDx

Chest pain w/ pleuritic features

181
Q

Where do PE PTs complain of their chest pain?

Define Paradoxical Embolism Syndrome

What is an atypical manifestation

A

Between clavicles/costal margin

PE shifting sides and causing stroke

Myelopathy- numbness below waist

182
Q

Where do PE PTs complain of their chest pain?

A

Between clavicles/costal margin

183
Q

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

A

Split S2 or S3

> 2cm difference between legs 10cm below tibial tubercle

Hand/finger swelling

184
Q

DVTs in ? locations are more likely to cause thrombophlebitis

What causes Homans sign

A

Calf/saphenous veins

Pain from DVT w/ passive foot dorsiflexion

185
Q

What PE findings suggest presence of a PE

Define Westermark and Hampton hump

A

Hypoxemia/dyspnea w/ clear lungs on PE and imaging

West: complete lobar obstruction
Hamp: peripheral dome shape

186
Q

What is the most EKG manifestation of PT w/ PE

What is the first step in VTE Dx

A

S1Q3T3

Estimate pre-test probability

187
Q

How long does D-dimer remain in blood

What is the MC imaging modality for PE

A

t1/2 x 8hrs x 3days

CT angiography

188
Q

What test has nearly 100% success at excluding PEs

What is the imaging test of choice in DVTs

A

VQ scans

Venous US w/ 7.5MHz probe

189
Q

What drug is used for initial Tx of VTE

How are VTEs causin Phelgmasia Cerulea Dolens Tx

A

Heparin- UFH/LMWH

Anticoags
Neutral position limb
Remove any constriction
No transfer avail x6hrs= fibrinolytics

190
Q

How is VTE associated localized thrombophlebitis Tx

What is used if extensive veins involvement is present?

A

NSAIDs
Topical diclofenac gel
No need of anticoag

Full dose anticoag

191
Q

How are PTs w/ VTEs and receiving warfarin managed?

What drug can be used for DVT and PE

A

LMWH until prothrombin time is prolonged and x 5days

Rivaroxaban

192
Q

What are the 3 categories of PEs

A

Massive:
SBP <90 x 15min
SBP <100 w/ HTN Hx
>40% reduction of SBP

Submassive:
near/normal BP

All others= Less Severe

193
Q

When is surgical embolectomy considered for Tx

A

Young PT w/ large proximal PE w/ HOTN

IPAP (212 decks)

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