EMED EOR Flashcards
? is the leading cause of death among US adults
What is the etiology of this MC
What is the predominant Sx of this MC
Ischemic heart dz
CADz
Angina
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
NSTEMI
Anterior, Septal
Anterior/Lateral wall
RCA supplies blood to ? parts of the heart
How does the AV conduction system receive blood
Posteromedial papillary muscles receive blood supply from ?
RV, inferior LV via right posterior descending artery
Atrioventricular branch of RCA and septal perforating branch of LAD
RCA
? 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/
Diastolic duration, Peripheral vascular resistance
Fixed atherosclerotic clots
Age Female DM
What causes atherosclerotic plaques to form
What causes them to rupture
What happens after they rupture
Repetitive vessel wall injury
Shape/composition
Force/pressure
Arterial movement
Platelet activation
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 ?
Exercise Stress Cold, <10min
Rest and Nitro
> 40y/o: DM Tobacco FamHx Hyper-cholesterol/tension
? 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
Bradycardia
Bradycardia, New heart block
Extremes of BP
Define S3
Hearing this during an MI can indicate ?
Risk stratification/prediction tool for unstable angina mortality/decision making
Late diastole sound d/t filling of overly compliant LV
Systolic HF
TIMI:
AMERICA
Define STEMI
ST elevation suggests ? while ST depression suggests ?
? EKG finding is a STEMI equivalent
ST elevations ≥1mm in two contiguous leads w/ reciprocal changes
E: transmural injury/infarct
D: ischemia
New LBBB
Posterior MI occurs d/t lesion located ?
MC pacemaker lead location
How are AMIs identified in Pts w/ pacemakers
Circumflex
RV
ST elevation of 5mm in leads w/ negative QRS complexes in V1-3
How does Wellens appear on EKG
How are these findings seen on EKGs
Why is this so dangerous
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
What two criteria combined together virtually exclude an AMI
Troponin rise, peak, normalizes time frame
Define the Heart Score
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
PCI time frames
Fibrinolysis time frames
≤90min w/ PCI capability
≤120min w/ no PCI capability
<30min if PCI can’t be accomplished in time frame
STEMI antiplatelets
STEMI antithrombins
Fibrinolytic agents
Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor
UFH Enoxaparin Fondaparinux
Alteplase Streptokinase Tenecteplase Anistreplase Reteplase
STEMI G2b/3a inhibitors
STEMI Anti-Ischemic therapies
NSTEMI/UA Tx timelines
Tirofiban Eptifibatide Abciximab
Morphine Metorpolol Atenolol Nitro
<24hs unless hemodynamically unstable then <2hrs
NSTEMI antiplatelets
NSTEMI antithrombins
NSTEMI direct thrombin inhibitor
Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor
Heparin Enoxaparin Fondaparinux
Bivalirudin
STEMI G2b/3a inhibitors
STEMI Anti-Ischemic therapies
? is the MC PCI
Tirofiban Eptifibatide Abciximab
Metorpolol Atenolol Nitro
Coronary angioplasty
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
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
Most catastrophic complication arising from fibrinolytic therapy
C/i for performing therapy
Intracranial bleeds
Prior intracranial hemorrhage Cerebral vascular lesions Intracranial neoplasm Ischemic stroke <3mon Active bleeding Suspected dissection/pericarditis
STEMI Pts who receive fibrinolytics should receive them for ? long
MOA of ASA
Alternate for Clopidogrel in ? two scenarios
UFH, Enoxaparin, Fondaparinux x48hrs
Inhibit platelet aggregation through thromboxane A2 stimulation by arachidonic acid pathway
True allergy, Active PUD
MOA and c/i for Prasugrel use
MOA for Ticagrelor use
? reduces the risk of AMI and death during acute phase of unstable angina
Irreversible platelet receptor antagonist; Prior CVA/TIA or pathological bleeding
Reversible P2Y12 receptor antagonist;
UFH
Benefit of using Nitro during AMI
How is this med titrated during use
Mose serious s/e of use
Dec infarct size, complications
Inc function
To BP, not Sxs
HOTN induce reflex tachycardia
Avoid Nitro for how long after Sildenafil or Tadalafil use
Benefit of using ACEI for AMI
Benefit of Mg for AMI
S: 24hrs, T: 48hrs
Dec LV dysfunction/dilation
Slow CHF development
Lower mortality
Vasodilation w/ antiplatelet activity while protecting myocytes from Ca influx
? class of med do not decrease mortality after AMI
When is this class used
CCBs
Verapamil/Diltiazem for Pts w/: Ongoing ischemia Afib w/ rapid ventricular rate LV dysfunction AV blocks BB c/i
Ventricular septum ruptures are common after ? infarcts
Papillary ruptures are more common after ? infarcts
How do these sound on PE
Anterior wall/Three vessel dz
Inferior
MR
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
ASA or Colchicine
Inc JVD or HOTN
Shock
? lab marker is most specific for cocaine induced MI
How are these Pts Tx
What is c/i for them
Troponin
ASA Nitrate Benzos
BBs for first 24hrs
Four cardinal manifestations of HF
Where are A/B/C natriuretic peptides secreted from
What is their purpose
Fatigue Retention Edema Dyspnea
A: atria
B: ventricle
C: endothelium
Dec RAAS, Inc Na excretion
? Sx of HF has the highest sensitivity
What 3 Sxs have the highest specificity
What CXR findings are most specific for Dx of HF
Dyspnea w/ exertion
Nocturnal dyspnea
Orthopnea
Edema
Congestion Megaly Edema
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
Afib
P-HTN PE Pneumonia
Sepsis Renal failure
Determine if pulmonary congestion is present (B-line- sonographic equivalent to Kerley B lines)
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
Size >2cm, Collapsed <50%
Determine EF
> 95%
? diuretic is used for HTN A-HF
Why do most ED Pts need IV routes of diuretics
? vasodilator used recombinant BNP in its formulation
Furosemide- inc water/Na excretion
Bowel wall edema prevents absorption
Nesiritide- used when Nitro ineffective or c/i
Why would BBs be used in normotensive HF
S/e of Nitro
S/e of IV Nitro
Inc NorEpi levels contributing to myocardial hypertrophy
HOTN
HA, HOTN
S/e of Nitroprusside
S/e of Loop diuretics
What are the high risk physiological markers in Pts w/ AHF
HOTN, Cyanide toxicity, Coronary steal
Dec K, Mg; Inc Uremia
Ototoxicity
Pre-renal azotemia
Renal dysfunction
Low BP/Na
Inc BNP/troponin
Define Primary Cardiomyopathy
Define Secondary Cardiomyopathy
What are the top 3 MC forms of cardiac Dz
Dz involving myocardium
Heart dz associated w/ systemic d/os
Ischemic, HTN, Myopathies
? med improves survival for Dilated Myopathy
When is HOCM murmur louder and not associated w/ maneuver
How much fluid is normally in the pericardium
Carvedilol
First sinus beat after PVC
50mL
? is a distinguishing feature of pericarditis
What is the MC and most important PE finding
Referred pain to L trapezial ridge d/t diaphragm pleura inflammation
Friction rub w/ diaphragm
What are the 4 EKG stages of pericarditis
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
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
Low voltage QRS, Electrical alternans
Echo
Ibuprofen a6-8 x 7-21days
Colchicine- prevent recurrence
When/Why would pericarditis need to be admitted
Why would f/u Echo be needed
What are poor prognosis factors
Associated myocarditis
Sxs fail to resolve/reappear
Temp Subacute onset ImmSupp PO anticoag use Myocarditis Effusion >2mm
Top 3 MCC of non-traumatic cardiac tamponades
Cardiac tamponades cause ? JVD characteristic to be absent
Dx test of choice for tamponades
Met malignancy
Acute, idiopathic pericarditis
Uremia
Y-descent
Echo
How are tamponades managed
What type of catheter can be used to drain fluid and prevent reaccumulation
When are Pts w/ tamponades admitted
Volume expansion then centesis
Pig tail
Dec access to medicine
Unstable
Emergent centesis performed
? triad is used for Cardiac Tamponade
What are the 4 RFs for Aortic Dissections
What two drugs accelerate atherosclerotic process and inc risks
Beck Triad:
HOTN inc JVD Muffled heart
Bicuspid valve
Ehler Danlose
Marfans
FamHx of dissection
Cocaine, Amphetamine
? 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
Cardiac surgery
Weak medial, Stressed intima
Intima, Adventitia
Blood dissecting all the way through ? layer of aorta is nearly always fatal
Define Stanford Types
Define DeBakey Types
Adventitia
A: ascending B: descending
1: ascending, arch and descending
2: ascending
3: descending
? 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 ?
Site of intimal disruption
Chest: Stanford A
Ab: Standford B
Classic stroke
Aortic dissection interrupting blood flow to spine results in ?
MC CXR findings of dissection
What is the image modality of choice
Paraplegia
Wide mediastinum, Abnormal aortic notch
Coronary CT angigraphyw/ and w/out contrast- triple r/o
What image is as sens/spec as CT for aortic dissections
What is a relative c/i
What makes this form of evaluation difficult
TEE
Esophageal dz
Sound disrupted by air in trachea/left bronchi
What short acting BBs are used for aortic dissections
What are the BP range goals
What meds are used after negative inotropes
Esmolol Propranolol Labetalol
SBP 120-30
BB/CCB then vasodilators (nitroprusside/nicardipine)
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
3rd-T or Post-partum
PE
Blood clot d/t coagulation exceeds fibrinolysis removal
? types of DVTs cause scarring and poor valve function
These allow ? syndrome to eventually develop
What are the two reasons Pts die from PEs
Femoral, Iliofemoral
Post-Thrombotic- varicose veins, pain, swelling, hyperpigmentation
Near total occlusion= PEA
Asystole= ischemia to His-Purkinge
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
Right heart
Hip Knee Ankle Shoulder Elbow
Hip and knee w/ non-weight bearing
What are the highest risk surgeries to cause PEs
? does cancer change the risk for clots
? types of cancers are particularly thrombogenic
Joint replacement
Abdominal to remove Ca
Brain/Cord surgery w/ neuro deficits
Undifferentiated/larger burdern= higher risk
Adenocarcinoma Glioblastoma Metastatic melanoma Lymphoma Multiple myeloma
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
Pancreatic
Stomach
Ovarian
Renal cell
Localized breast
Cervical
Prostate
Non-melanomatous skin (SCC/BCC) w/out chemo Txs
L-asparaginase
Bolus Fluorouracil/Tamoxifen
Concomintent use of ? med increases risk for VTEs
Who are more likely to have recurrent VTEs
What is not an independent RF for VTEs
RBC growth factors (EPO)
Men when d-dimer remains inc’d
Smoking
Age and risk for VTE
Obesity risk for VTE
Pregnancy risk
50-80y/o
<35kg
Post-partum > pregnancy
Bed rest becomes VTE RF after ?
Long distance travel becomes VTE RF after ?
When are stroke Pts at highest risk
> 72hrs
> 6hrs
First month after
? hormone increased VTE RFs
? is the classic PE pain
Leg pain of ? location/size suspects DVTs
Estrogen
Between clavicle and costal margins that inc w/ cough/breathing
≥2cm difference 10cm below tibial tubercle
How do upper extremity DVTs present
? types of clots are more likely to cause thrombophlebitis
What PE sign may be present
Hand/finger swelling
Calf, Saphenous vein
Homan- pain w/ passive dorsiflexion
Define Phlegmasia Cerulea Dolens
Define Phlegmasia alba dolens
? VS findings suggest a PE
Swollen, painful and dusky/blue d/t DVT
Swollen, painful and pale/white d/t DVT
Hypoxemia, Dyspnea w/ clear lungs
When is an EKG more specific for PEs
What three findings may be seen
Well’s Score for PE
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
Well’s Score for DVT
asldkfj
? 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
D-dimer: fibrin clots degraded by plasmin
Venous US w/ 7.5 MHz probe
Saphenous Tibial Peroneal veins
DVT r/o and Dx flow chart
<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
How are DVTs Tx once found
How are DVTs Tx if Cerulea Dolens is present
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
? is the only medication approved for use during DVT and PE
Stopped on
Define Syncope
Syncopes are MCC by ?
Rivaroxaban
Slide 370
Transient loss of consciousness w/ loss of postural tone
Vasovagal (brady/hypo)- prodrome of dizzy, nausea, pallor, diaphoresis and dec vision
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
Autonomic reflex from urination, defecation, coughing
Recurrent syncope w/ negative cardiac workup
Diplopia, Vertigo, Focal neuro deficit, Nausea
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
Seizure
Postictal state, Tongue bite, Incontinence, Epileptic aura
UE BP differs >20mmHg
