EMED Phase 2 Flashcards
? dz process causes the majority of ischemic heart dzs?
Criteria for resting, new and increasing angina
Atherosclerosis
Rest: >20min
New: <2blocks, <1 flight of stairs
Increasing: previous dx now limiting activity <2 blocks or <1 flight of stairs
After leaving the aorta, what does the LCA divide into and supply
What does the RCA supply
LCX- lateral, some anterior heart
LAD- anterior/septal heart, RBB, posterior LBB
RV, AV conduction, septal perforating branch of LAD, RBB, posterior LBB, posterior/medial papillary muscles
What two factors determines the amount of coronary artery blood flow?
Exercised induced MI is usually the result of ? and leads to ? Dx
Diastolic duration
Peripheral vascular resistance
Fixed atherosclerotic lesions
Stable angina
What can cause atherosclerotic plaques to rupture?
The rupture of one of these causes ?
Composition/shape Shearing forces Arterial tone Perfusion pressure Movement
Platelet release
What happens to the heart as the size of an infarct increases?
? is the main Sx of ischemic heart dz
Dec LV function= dec CO, SV, BP
Inc LV end diastolic/systolic pressure
L atria/pulmonary capillary pressure increases- HF/pulm edema
Chest pain/discomfort
Angina is usually precipitated by ? 3 things
What can be done to differentiate angina and MI
Stress Exercise Cold
MI= little response to nitro
What are the traditional RFs for CAD that are not useful for assessing ED PTs older than ?
PTs having MI and bradycardia usually have ? type
HTN DM Tobacco FamHx HyperCholesterol
>40y/o
Brady= inferior wall
In the setting of an anterior wall MI, what are two poor prognostic findings
What heart sound may be heard during MIs?
What is an ominous sign in these PTs and what can is signal?
Bradycardia
New heart block
Late diastole S3 (overly compliant LV filling)
New systolic murmur= papillary dysfunction, MV leaflet flailing, VSD
The presence of ? in MI PE indicates dysfunction and/or left sided HF
What PE findings signify right sided HF
Rales
JVD
Hepato-Jugular reflex
Peripheral edema
Dx unstable angina is based on ?
What two parts of PT are non-Dx
Hx
ECG, BioMarkers
Define TIMI
Thrombosis in Myocardial Infarction for Unstable Angina, stratified risk for 14d risk of mortality
Age: >65y/o Markers, elevated EKG ST deviation RFs for CADz, 3 or more Ischemia pain, 2 or more anginal events <24hrs Coronary stenosis 50% or more ASA <7d
Max of 7pts
? is the best test for finding AMIs
Define STEMI
EKG
ST elevation of 1mm or more w/ reciprocal changes in two contiguous leads
EKG showing ST elevation suggests ?
EKG showing ST depression suggests ?
What lead is used to ID RV infarction and ? caution is needed?
Transmural injury/infarct
Ischemia
V4R
Preload dependent= caution w /Nitro/BB
? EKG finding is ‘STEMI equivalent’?
5 true statements regarding reciprocal ST segment changes
New LBBB-
Anterior division: LAD, Q1S3
Posterior division: RAD, S1Q3
Larger injury area Inc severity of CADz Severity of pump failure Higher likelihood of CV complications Inc mortality
Where is the MC pacemaker lead location
How are MIs identified in these PTs
RV
ST elevation >5mm in leads w/ normally negative QRS complexes
Define Wellens
Combination of ? two results virtually excludes all MIs?
LAD stenosis causing V2/3 T-wave abnormality
Anterior MI pending <9 days
High sensitivity troponin + TIMI score <2
Troponin time frames
Define HEART Score
Rise: 3-12hrs
Peak: 12-24hrs
Norm: 5-14 days
Risk stratification for major adverse cardiac event
Hx ECG Age RFs Total
What are the two STEMI reperfusion methods
Timelines for Tx
Percutaneous Coronary Intervention (mechanical)
Fibrinolytics w/ anti-platelet/thrombin (pharm)
<90min for PCI capable
<120min for non-PCI capable, fibrinolysis <30min of ED arrival
PTs w/ unstable angina or NSTEMI refractory to antiplatelet, antithrombins and nitrates may benefit from ? additional therapy
Glycoprotein 2b/3a antagonists
STEMI Tx drugs
Anti-p:
Prasugrel ASA Clopidogrel Ticagrelor
Anti-T:
UFH Enoxaparin Fondaparinux
Fibrinolytics:
Streptokinase Tenecte/Anistre/Alte/Reteplase
G2b/3a:
Abciximab Tirofiban Eptifibatide
Anti-Ischemics:
Nitro Morphine Aten/Metoprolol
When are the STEMI Tx protocols carried over for NSTEMI Txs
Unstable angina/NSTEMI PTs that are hymodynamically unstable need to have ? invasive Tx strategies performed w/in ? time
Refractory angina
Hymodynamic/electrical instability
Inc risk for clinical events
<2hrs Anti-platelet/thrombin Direct thrombin inhibitors G2b/3a Nitro/Aten/Metoprolol
What is the preferred NSTEMI Tx method
What is the most common form of the preferred Tx method
PCI 90-120min of arrival
Coronary angioplasty w/ or w/out stents
How are PCI PTs prepped to have fewer adverse events in the next 6mon?
Fibrinolytic therapy act as ? and improve ? function
Antiplatelets: thienopyridines and G2b/3a inhibitors
Plasminogen activators
Improve LV function and mortality
When is fibrinolytic therapy indicated for STEMI PTs as a a reperfusion Tx method
This Tx choice is particularly beneficial for ? types of MIs
If this Tx fails, rescue PCI is recommended for PTs w/ ? criteria
<12hrs from Sxs and EKG w/ 1mm ST elevation in 2 leads
Larger/anterior infarctions
Cardiogenic shock <75y/o
HF/Pulm edema
Hemodynamically compromising ventricular arrhythmias
Failed fibrinolytic therapy and mod/large amount of myocardium at risk
? is the most catastrophic complication of fibrinolytic Tx
If STEMI PTs receive fibrinolytic Tx, need Tx for ? long
Intracranial bleeds
Full dose x 48hrs w/ UFH, Enoxaparin or Fondaparinux
MOA of G2b/3a antagonists
MOA of ASA
Antiplatelets agent that interrupts platelet activation despite present agonist
Inhibits platelet aggregation from thromboxane A2 stimulation from arachidonic acid pathway
All N/STEMI/unstable angina PTs need to have ? much ASA
When does ASA need to be substituted w/ Clopidogrel
> 162, preferably 325mg if naive of ASA
True ASA allergy
Active PUD
Anti-platelet ADP antagonists
Prasurgel- irreversible receptor antagonist
C/i if Hx CVA, TIA, bleeding
Ticagrelor- reversible non-thienopyridine P2Y12 antagonist, eliminated in 72hrs
ASA and anti-thrombin therapy plus ? improves CV out comes for PTs receiving fibrinolysis for STEMIs
When are G2b/3a a recommended therapy
Clopidogrel
Positive troponin
Likely to receive PCI
UFH reduces the risk of AMI and death during the acute phase of ?
Why is UFH stopped after 48hrs of therapy
Unstable angina
Reduce risk for HIT
? type of heparin combined w/ ASA and fibrinolysis improves STEMI outcomes
Nitroglycerin has what two benefits
Enoxaparin (LMWH)
Dilates vascular beds
Inhibit platelet aggregation
What are 3 benefits of nitro use in PTs not treated w/ thrombolytics
IV nitro is tapered to ? when used and only for ? long
Reduced infarct size
Improved regional function
Dec CV complication rate
BP reduction
First 48hrs in STEMI, recurrent ischemia, CHF, HTN
What is the most serious side effect of Nitro use for AMI and how is this corrected
Why is the use of Nitro done cautiously in inferior MIs
HOTN
Stop Nitro, fluids to correct BP
Volume dependent (preload)
Ntiro use needs to be avoided in PTs that have used ? PPD inhibitors w/in ? time frame
BBs during MIs offer ? 3 benefits?
Why is Metoprolol used
Sildenafil- 24hrs
Tadalafil- 48hrs
Anti-dysrhythmic, ischemic and HTN properties
Dec re-infarction rates, inc cardiogenic shock
BBs may be used within the first 24hrs of an MI if PT has none of ? 4 things
Signs of HF
Low CO
Risk for cardiogenic shock (>70y/o, <120SBP, >110/<60HR, no STEMI Sxs
C/is: PR interval >0.24sec, 2/3 blocks, asthma/airway dz
What medication can slow development of CHF during an MI and lowers mortality afterwards
When are these meds given
ACEI- reduce LV dysfunction/dilation
STEMI: <24hrs
UA/NSTEMI: pulm congestion, LVEF <40% and no HOTN/Cis
How does Mg help limit the size of an infarct
Dilation
Antiplatelet
Suppressed automaticity
Myocyte protection from Ca influx of re-perfusion
What benefits do CCBs offer during MIs
Why would Verapamil or Diltizaem be used
Anti-anginal/HTN
Vasodilation
Ongoing ischemia A-Fib w/out CHF LV dysfunction AV blocks BB are c/i
? type of persistent arrhythmia is a poor prognosis after anterior MI
? type of arrhythmia is usually seen but transient
Sinus Tachy
A-fib
Junctional rhythms
Post-MI PTs w/ SVT, AFib or Flutter w/out hemodynamic compromise are best treated by ?
What type of arrhythmia has not bee correlated to increased mortality
Direct cardioversion
Sinus brady w/out HOTN
How is sinus brady post-MI Tx
This medication is also used for the Tx of ?
Atropine
Sx AV blocks
Where does the AV conduction system receive it’s blood supply
Anterior MIs w/ ? EKG finding have a poor prognosis
AV branch of the RCA
Septal perforating branch of LAD
Complete blocks
RBBB can happen in AMIs MC w/ ?
These are associated with inc ? and ?
What has higher mortality than RBBBs
Anteroseptal AMI
Inc mortality
Complete AV blocks
New LBBBs
Mortality from AMIs increase as what two risk factors increase?
Previously stable AMI PTs that rapidly decompensate needs to have ? Dx considered
Dec CO
Inc pulm congestion
Torn/rupture infarct tissue (ventral wall rupture day 1-5) leading to tamponade (HOTN + Tachy)
How is ventral wall rupture best Dx and Tx
Septal wall ruptures are most likely to occur in ? PTs and are Dx by ?
Dx: echo
Tx: surgery
Anterior MI/CADz (3 vessels)
New holosystolic murmur
Doppler echo
What type of myocardium rupture is more common w/ inferior MIs
How will these PTs present
Pappillary muscle on day 3-5
Acute dyspnea
Inc HF
Pulmonary edema
MR holosystolic murmur
Pericarditis after MIs is more common in ? PTs
These PTs will have pain w/ ? and relieved by ?
Transmural
Delayed presentation
Pain w/ inspiration
Relief w/ leaning forward
How is pericarditis/Dresslers after an MI Tx
Why can’t ibuprofen be used
PO ASA 650mg q4-6hrs
Colchicine 0.6mg q12hrs
Interferes w/ ASA anti-platelet effects
Thins myocardial scar
Isolated RV infarct is identified w/ ? EKG lead
What PE findings are suggestive
How is this type Dx
V4R
JVD or HOTN w/ Nitro
Echo
Nuclear imaging
What is the most serious complication that can occur from RV infarction
How are these types of MIs Tx
Shock
Maintain preload
Reduce RV after load
Inotropic support of RV
Reperfusion
Since inferior MIs aren’t Tx w/ Nitro/Morphine, what are they Tx w/
What are post-PCI presentations indicative of
Fluid, 1-2L then inotropic support
Bare metal- restenose short term
Drug eluding- late stent thrombosis after stopping Clopidogrel 9-12mon later
How are cocaine induced MIs Tx
What is c/i
ASA Nitrates Benzos
BBs
What are the 3 neuroanatomic categories of abdominal pain?
Visceral- obstruction, ischemia, inflammation from unmyelinated fibers innervating walls/capsules, localized to level of spinal cord
Parietal- irritated myelinated fibers innervating peritoneum of anterior abdominal wall via afferent signals, localized to dermatome= immobile, rebound pain
Referred- same side as affected area, ureter obstruction- ipsilateral testicular pain
What are the 5 red flags of abdominal pain
If intra-abdominal hemorrhage is present, SBP wont change until ? blood loss so using ? is more useful to assess
Extremes of age Rapid onset of severe pain Abnormal VS Dehydrated Visceral involvement evidence
30-40%
Tachycardia
If intra-abdominal bleeding is suspected but VS are normal, what is the next step?
What labs are ordered for PTs w/ abdominal pain
Obtain orthostatic vitals
CBC CMP Clotting Type/Screen (cross match if hemorrhage suspected or transfusion anticipated)
What PE finding is used as ‘de facto’ evidence of leakage/rupture leading to circulatory collapse
How do PTs w/ mild-mod and severe immune compromise present w/ diseases?
Visualization of enlarged aorta
Mild-Mod: delayed/atypical
Sev: opportunistic
What lab result is the most important measure of immune competency
SBO will have ? types of sounds on PE
CD4 count, >200= less likely to have opportunistic infxn
Hyperactive
What PE finding is necessary for a Dx of peritonitis
What trifecta supplies enough evidence for Dx confirmation of peritonitis
Rebound tenderness
Rigidity
Referred tenderness
Pain w/ coughing
Grouping pain, vomiting and rigidity can mean ? 4 Dxs
Grouping, pain, vomiting, and distension can mean 2 Dxs
Pancreatitis
Diabetic gastric paresis
DKA
Incarcerated hernia
Bowel obstruction
Cecal volvulus
Grouping pain with or without vomiting can indicate ? 4 Dxs
What test is ordered for suspected pancreatitis if lipase is not available?
Acute Diverticulitis
Torsion (adnexa, testicle)
Mesenteric ischemia
MI
Amylase
Preferred imaging modality for biliary tract
What is the next step if US is normal but high suspicion for cholecystitis or biliary dyskinesia is present
US
Cholescintigraphy
How much radiation exposure occurs from a CT scan
Stopped on Abd Pain
10x of plain abdominal x-rays
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