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IPAP > EMED EOR > Flashcards

EMED EOR Flashcards

1
Q

? is the leading cause of death among US adults

What is the etiology of this MC

What is the predominant Sx of this MC

A

Ischemic heart dz

CADz

Angina

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2
Q

Pts presenting w/ ? type of MI usually present w/ angina at rest

LAD supplies blood to ? parts of the heart

LCX supplies blood to ? parts of the heart

A

NSTEMI

Anterior, Septal

Anterior/Lateral wall

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3
Q

RCA supplies blood to ? parts of the heart

How does the AV conduction system receive blood

Posteromedial papillary muscles receive blood supply from ?

A

RV, inferior LV via right posterior descending artery

Atrioventricular branch of RCA and septal perforating branch of LAD

RCA

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4
Q

? two factors determine coronary artery blood flow

Exercise induced myocardial ischemia is usually d/t ?

What are the non-classic Sxs for ACS associated w/

A

Diastolic duration, Peripheral vascular resistance

Fixed atherosclerotic clots

Age Female DM

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5
Q

What causes atherosclerotic plaques to form

What causes them to rupture

What happens after they rupture

A

Repetitive vessel wall injury

Shape/composition
Force/pressure
Arterial movement

Platelet activation

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6
Q

Angina is precipitated by ? and lasts for ? long

What are the alleviating factors for angina

Traditional cardiac risk factors for CADz include ? but are not helpful for Pts older than ?

A

Exercise Stress Cold, <10min

Rest and Nitro

> 40y/o: DM Tobacco FamHx Hyper-cholesterol/tension

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7
Q

? rhythm is commonly seen in inferior wall MIs

What are two poor prognostic factors of an anterior MI

What other VS abnormality is associated w/ poor prognosis

A

Bradycardia

Bradycardia, New heart block

Extremes of BP

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8
Q

Define S3

Hearing this during an MI can indicate ?

Risk stratification/prediction tool for unstable angina mortality/decision making

A

Late diastole sound d/t filling of overly compliant LV

Systolic HF

TIMI:
AMERICA

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9
Q

Define STEMI

ST elevation suggests ? while ST depression suggests ?

? EKG finding is a STEMI equivalent

A

ST elevations ≥1mm in two contiguous leads w/ reciprocal changes

E: transmural injury/infarct
D: ischemia

New LBBB

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10
Q

Posterior MI occurs d/t lesion located ?

MC pacemaker lead location

How are AMIs identified in Pts w/ pacemakers

A

Circumflex

RV

ST elevation of 5mm in leads w/ negative QRS complexes in V1-3

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11
Q

How does Wellens appear on EKG

How are these findings seen on EKGs

Why is this so dangerous

A

Abnormal T-waves in V2-3 d/t LAD stenosis

T-waves present while pain free and normalize w/ pain

Anterior MI in 8-9 days

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12
Q

What two criteria combined together virtually exclude an AMI

Troponin rise, peak, normalizes time frame

Define the Heart Score

A

Serial troponins w/ TMI <2

R: 3-12hrs P: 12-24hrs, N: 5-14d

Risk stratification for major adverse cardiac events: 0-3 low, 4-7 mod, 8-10 high

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13
Q

PCI time frames

Fibrinolysis time frames

A

≤90min w/ PCI capability
≤120min w/ no PCI capability

<30min if PCI can’t be accomplished in time frame

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14
Q

STEMI antiplatelets

STEMI antithrombins

Fibrinolytic agents

A

Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor

UFH Enoxaparin Fondaparinux

Alteplase Streptokinase Tenecteplase Anistreplase Reteplase

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15
Q

STEMI G2b/3a inhibitors

STEMI Anti-Ischemic therapies

NSTEMI/UA Tx timelines

A

Tirofiban Eptifibatide Abciximab

Morphine Metorpolol Atenolol Nitro

<24hs unless hemodynamically unstable then <2hrs

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16
Q

NSTEMI antiplatelets

NSTEMI antithrombins

NSTEMI direct thrombin inhibitor

A

Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor

Heparin Enoxaparin Fondaparinux

Bivalirudin

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17
Q

STEMI G2b/3a inhibitors

STEMI Anti-Ischemic therapies

? is the MC PCI

A

Tirofiban Eptifibatide Abciximab

Metorpolol Atenolol Nitro

Coronary angioplasty

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18
Q

Coronary artery stents are made of ? and have ? meds used after placement to lower adverse events

Fibrinolytics are used for Tx ?

Failed fibrinolytic therapy is f/u w/ PCI for ? Pts

A

Steel: Thienopyridines, G2b/3a inhibitors

STEMI if Tx is <12hrs from Sx onset

Hemodynamic arrhythmias
<75 y/o in cardiogenic shock
Severe HF/Pulm edema
Large myocardium area

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19
Q

Most catastrophic complication arising from fibrinolytic therapy

C/i for performing therapy

A

Intracranial bleeds

Prior intracranial hemorrhage
Cerebral vascular lesions
Intracranial neoplasm
Ischemic stroke <3mon
Active bleeding
Suspected dissection/pericarditis
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20
Q

STEMI Pts who receive fibrinolytics should receive them for ? long

MOA of ASA

Alternate for Clopidogrel in ? two scenarios

A

UFH, Enoxaparin, Fondaparinux x48hrs

Inhibit platelet aggregation through thromboxane A2 stimulation by arachidonic acid pathway

True allergy, Active PUD

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21
Q

MOA and c/i for Prasugrel use

MOA for Ticagrelor use

? reduces the risk of AMI and death during acute phase of unstable angina

A

Irreversible platelet receptor antagonist; Prior CVA/TIA or pathological bleeding

Reversible P2Y12 receptor antagonist;

UFH

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22
Q

Benefit of using Nitro during AMI

How is this med titrated during use

Mose serious s/e of use

A

Dec infarct size, complications
Inc function

To BP, not Sxs

HOTN induce reflex tachycardia

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23
Q

Avoid Nitro for how long after Sildenafil or Tadalafil use

Benefit of using ACEI for AMI

Benefit of Mg for AMI

A

S: 24hrs, T: 48hrs

Dec LV dysfunction/dilation
Slow CHF development
Lower mortality

Vasodilation w/ antiplatelet activity while protecting myocytes from Ca influx

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24
Q

? class of med do not decrease mortality after AMI

When is this class used

A

CCBs

Verapamil/Diltiazem for Pts w/:
Ongoing ischemia
Afib w/ rapid ventricular rate
LV dysfunction
AV blocks
BB c/i
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25
Q

Ventricular septum ruptures are common after ? infarcts

Papillary ruptures are more common after ? infarcts

How do these sound on PE

A

Anterior wall/Three vessel dz

Inferior

MR

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26
Q

How is post-MI pericarditis Tx

? PE finding after Nitro use suggests an inferior MI

What is the most serious complication of a RV infarct

A

ASA or Colchicine

Inc JVD or HOTN

Shock

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27
Q

? lab marker is most specific for cocaine induced MI

How are these Pts Tx

What is c/i for them

A

Troponin

ASA Nitrate Benzos

BBs for first 24hrs

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28
Q

Four cardinal manifestations of HF

Where are A/B/C natriuretic peptides secreted from

What is their purpose

A

Fatigue Retention Edema Dyspnea

A: atria
B: ventricle
C: endothelium

Dec RAAS, Inc Na excretion

29
Q

? Sx of HF has the highest sensitivity

What 3 Sxs have the highest specificity

What CXR findings are most specific for Dx of HF

A

Dyspnea w/ exertion

Nocturnal dyspnea
Orthopnea
Edema

Congestion Megaly Edema

30
Q

What EKG finding has the highest indication of underlying HF

What four other conditions are associated w/ inc BNP levels

Why is Pulmonary US used first during HF work up

A

Afib

P-HTN PE Pneumonia
Sepsis Renal failure

Determine if pulmonary congestion is present (B-line- sonographic equivalent to Kerley B lines)

31
Q

What IVC measurements are indicative of inc central venous pressure

What is the final piece of the bedside US assessment

Keep O2 sats above ? during HF workup

A

Size >2cm, Collapsed <50%

Determine EF

> 95%

32
Q

? diuretic is used for HTN A-HF

Why do most ED Pts need IV routes of diuretics

? vasodilator used recombinant BNP in its formulation

A

Furosemide- inc water/Na excretion

Bowel wall edema prevents absorption

Nesiritide- used when Nitro ineffective or c/i

33
Q

Why would BBs be used in normotensive HF

S/e of Nitro

S/e of IV Nitro

A

Inc NorEpi levels contributing to myocardial hypertrophy

HOTN

HA, HOTN

34
Q

S/e of Nitroprusside

S/e of Loop diuretics

What are the high risk physiological markers in Pts w/ AHF

A

HOTN, Cyanide toxicity, Coronary steal

Dec K, Mg; Inc Uremia
Ototoxicity
Pre-renal azotemia

Renal dysfunction
Low BP/Na
Inc BNP/troponin

35
Q

Define Primary Cardiomyopathy

Define Secondary Cardiomyopathy

What are the top 3 MC forms of cardiac Dz

A

Dz involving myocardium

Heart dz associated w/ systemic d/os

Ischemic, HTN, Myopathies

36
Q

? med improves survival for Dilated Myopathy

When is HOCM murmur louder and not associated w/ maneuver

How much fluid is normally in the pericardium

A

Carvedilol

First sinus beat after PVC

50mL

37
Q

? is a distinguishing feature of pericarditis

What is the MC and most important PE finding

A

Referred pain to L trapezial ridge d/t diaphragm pleura inflammation

Friction rub w/ diaphragm

38
Q

What are the 4 EKG stages of pericarditis

A

PR Segment:

1: depressed in 2,3,aVF
2: iso/depressed
3: iso/depressed
4: isoelectric

ST Segment:
1: elevation in 1, V5-6
2-4: isoelectric

T-wave:

1: none
2: dec amplitude
3: inversion 1, V5-6
4: normal

39
Q

Two EKG findings of pericarditis induced effusion

What is the procedure of choice to detect, confirm and f/u on pericarditis and/or effusions

How is this Tx

A

Low voltage QRS, Electrical alternans

Echo

Ibuprofen a6-8 x 7-21days
Colchicine- prevent recurrence

40
Q

When/Why would pericarditis need to be admitted

Why would f/u Echo be needed

What are poor prognosis factors

A

Associated myocarditis

Sxs fail to resolve/reappear

Temp
Subacute onset
ImmSupp
PO anticoag use
Myocarditis
Effusion >2mm
41
Q

Top 3 MCC of non-traumatic cardiac tamponades

Cardiac tamponades cause ? JVD characteristic to be absent

Dx test of choice for tamponades

A

Met malignancy
Acute, idiopathic pericarditis
Uremia

Y-descent

Echo

42
Q

How are tamponades managed

What type of catheter can be used to drain fluid and prevent reaccumulation

When are Pts w/ tamponades admitted

A

Volume expansion then centesis

Pig tail

Dec access to medicine
Unstable
Emergent centesis performed

43
Q

? triad is used for Cardiac Tamponade

What are the 4 RFs for Aortic Dissections

What two drugs accelerate atherosclerotic process and inc risks

A

Beck Triad:
HOTN inc JVD Muffled heart

Bicuspid valve
Ehler Danlose
Marfans
FamHx of dissection

Cocaine, Amphetamine

44
Q

? surgical Hx indicates an increased risk for aortic dissection

What mechanisms allow a dissection to occur

When dissection occurs, blood flows between ? to form a false lumen

A

Cardiac surgery

Weak medial, Stressed intima

Intima, Adventitia

45
Q

Blood dissecting all the way through ? layer of aorta is nearly always fatal

Define Stanford Types

Define DeBakey Types

A

Adventitia

A: ascending B: descending

1: ascending, arch and descending
2: ascending
3: descending

46
Q

? predicts the initial Sxs of aortic dissection

? types of dissections more commonly have chest vs abdominal pain

Dissection near the carotid artery can present as ?

A

Site of intimal disruption

Chest: Stanford A
Ab: Standford B

Classic stroke

47
Q

Aortic dissection interrupting blood flow to spine results in ?

MC CXR findings of dissection

What is the image modality of choice

A

Paraplegia

Wide mediastinum, Abnormal aortic notch

Coronary CT angigraphyw/ and w/out contrast- triple r/o

48
Q

What image is as sens/spec as CT for aortic dissections

What is a relative c/i

What makes this form of evaluation difficult

A

TEE

Esophageal dz

Sound disrupted by air in trachea/left bronchi

49
Q

What short acting BBs are used for aortic dissections

What are the BP range goals

What meds are used after negative inotropes

A

Esmolol Propranolol Labetalol

SBP 120-30

BB/CCB then vasodilators (nitroprusside/nicardipine)

50
Q

When are aortic dissections more likely to occur during pregnancy

? is the 2nd MCC of unexpected, non-traumatic death

What causes this MC to develop

A

3rd-T or Post-partum

PE

Blood clot d/t coagulation exceeds fibrinolysis removal

51
Q

? types of DVTs cause scarring and poor valve function

These allow ? syndrome to eventually develop

What are the two reasons Pts die from PEs

A

Femoral, Iliofemoral

Post-Thrombotic- varicose veins, pain, swelling, hyperpigmentation

Near total occlusion= PEA
Asystole= ischemia to His-Purkinge

52
Q

Pts that survive large PEs tend to have ? dysfunction for life

Most to least risk for PE from joint immobilization

What combo has the greatest risk

A

Right heart

Hip Knee Ankle Shoulder Elbow

Hip and knee w/ non-weight bearing

53
Q

What are the highest risk surgeries to cause PEs

? does cancer change the risk for clots

? types of cancers are particularly thrombogenic

A

Joint replacement
Abdominal to remove Ca
Brain/Cord surgery w/ neuro deficits

Undifferentiated/larger burdern= higher risk

Adenocarcinoma
Glioblastoma
Metastatic melanoma
Lymphoma
Multiple myeloma
54
Q

Cancers arising from ? organ are notoriously high risks for PEs

? types of cancer have minimal risk for VTE

VTE risk is high during the induction phase of chemo, especially if ? is used

A

Pancreatic
Stomach
Ovarian
Renal cell

Localized breast
Cervical
Prostate
Non-melanomatous skin (SCC/BCC) w/out chemo Txs

L-asparaginase
Bolus Fluorouracil/Tamoxifen

55
Q

Concomintent use of ? med increases risk for VTEs

Who are more likely to have recurrent VTEs

What is not an independent RF for VTEs

A

RBC growth factors (EPO)

Men when d-dimer remains inc’d

Smoking

56
Q

Age and risk for VTE

Obesity risk for VTE

Pregnancy risk

A

50-80y/o

<35kg

Post-partum > pregnancy

57
Q

Bed rest becomes VTE RF after ?

Long distance travel becomes VTE RF after ?

When are stroke Pts at highest risk

A

> 72hrs

> 6hrs

First month after

58
Q

? hormone increased VTE RFs

? is the classic PE pain

Leg pain of ? location/size suspects DVTs

A

Estrogen

Between clavicle and costal margins that inc w/ cough/breathing

≥2cm difference 10cm below tibial tubercle

59
Q

How do upper extremity DVTs present

? types of clots are more likely to cause thrombophlebitis

What PE sign may be present

A

Hand/finger swelling

Calf, Saphenous vein

Homan- pain w/ passive dorsiflexion

60
Q

Define Phlegmasia Cerulea Dolens

Define Phlegmasia alba dolens

? VS findings suggest a PE

A

Swollen, painful and dusky/blue d/t DVT

Swollen, painful and pale/white d/t DVT

Hypoxemia, Dyspnea w/ clear lungs

61
Q

When is an EKG more specific for PEs

What three findings may be seen

Well’s Score for PE

A

RV systolic pressure exceeds 40mmHg

T-wave inversion V1-4
In/Complete RBBB
S1Q3T3

Suspected PE/Ald Dx less likely- 3
HR >100, Prior DVT, Immobilization <4wks- 1.5
Active Ca, Hemoptysis- 1

62
Q

Well’s Score for DVT

A

asldkfj

63
Q

? is the best test used to exclude DVTs

? is the imaging test of choice for DVTs

What veins can be assess w/ this image of choice

A

D-dimer: fibrin clots degraded by plasmin

Venous US w/ 7.5 MHz probe

Saphenous Tibial Peroneal veins

64
Q

DVT r/o and Dx flow chart

A 
<1pt/low score: D-dimer
Neg: DVT was r/o
Pos= US
-US: r/o
\+US: Tx DVT
Mod/High probability= US:
\+US: Tx DVT
-US: D-dimer
-: DVT r/o
\+: repeat US in 7d
65
Q

How are DVTs Tx once found

How are DVTs Tx if Cerulea Dolens is present

A

UFH/LMWH

Anticoagulate, place limb at neutral, consult for catheter directed thrombolysis

No emergency transfer unavailable w/in 6hrs:
Systemic fibrinolytics

Warfarin needs LMWH x 5d

66
Q

? is the only medication approved for use during DVT and PE

Stopped on

Define Syncope

Syncopes are MCC by ?

A

Rivaroxaban

Slide 370

Transient loss of consciousness w/ loss of postural tone

Vasovagal (brady/hypo)- prodrome of dizzy, nausea, pallor, diaphoresis and dec vision

67
Q

What can cause situational syncope

When is a Dx of Carotid Sinus Hypersensitivity considered

What are posterior circulation deficits associated w/ brain stem ischemia/vertebrobasilar insufficiency

A

Autonomic reflex from urination, defecation, coughing

Recurrent syncope w/ negative cardiac workup

Diplopia, Vertigo, Focal neuro deficit, Nausea

68
Q

What is the MC condition mistaken for syncope

Four characteristics that point away from syncope

What PE finding suggests Subclavian Steal as cause of syncope

A

Seizure

Postictal state, Tongue bite, Incontinence, Epileptic aura

UE BP differs >20mmHg

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