EMED EOR Flashcards by brandon lovin

? 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

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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

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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

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? 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

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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

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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

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? 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

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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

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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

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Posterior MI occurs d/t lesion located ?

MC pacemaker lead location

How are AMIs identified in Pts w/ pacemakers

Circumflex

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

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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

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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

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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

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STEMI antiplatelets

STEMI antithrombins

Fibrinolytic agents

Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor

UFH Enoxaparin Fondaparinux

Alteplase Streptokinase Tenecteplase Anistreplase Reteplase

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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

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NSTEMI antiplatelets

NSTEMI antithrombins

NSTEMI direct thrombin inhibitor

Prasugrel <60in after PCI
ASA
Clopidogrel
Ticagrelor

Heparin Enoxaparin Fondaparinux

Bivalirudin

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STEMI G2b/3a inhibitors

STEMI Anti-Ischemic therapies

? is the MC PCI

Tirofiban Eptifibatide Abciximab

Metorpolol Atenolol Nitro

Coronary angioplasty

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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

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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

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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

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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

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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

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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

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? 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

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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