EMED Phase 2 Flashcards by brandon lovin

? 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

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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

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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

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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

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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

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Angina is usually precipitated by ? 3 things

What can be done to differentiate angina and MI

Stress Exercise Cold

MI= little response to nitro

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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

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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

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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

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Dx unstable angina is based on ?

What two parts of PT are non-Dx

ECG, BioMarkers

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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

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? is the best test for finding AMIs

Define STEMI

EKG

ST elevation of 1mm or more w/ reciprocal changes in two contiguous leads

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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

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? 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

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Where is the MC pacemaker lead location

How are MIs identified in these PTs

ST elevation >5mm in leads w/ normally negative QRS complexes

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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

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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

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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

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PTs w/ unstable angina or NSTEMI refractory to antiplatelet, antithrombins and nitrates may benefit from ? additional therapy

Glycoprotein 2b/3a antagonists

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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

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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

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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

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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

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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

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? 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 Slide 48