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IPAP > EMED Phase 2 > Flashcards

EMED Phase 2 Flashcards

1
Q

? dz process causes the majority of ischemic heart dzs?

Criteria for resting, new and increasing angina

A

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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2
Q

After leaving the aorta, what does the LCA divide into and supply

What does the RCA supply

A

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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3
Q

What two factors determines the amount of coronary artery blood flow?

Exercised induced MI is usually the result of ? and leads to ? Dx

A

Diastolic duration
Peripheral vascular resistance

Fixed atherosclerotic lesions
Stable angina

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4
Q

What can cause atherosclerotic plaques to rupture?

The rupture of one of these causes ?

A 
Composition/shape
Shearing forces
Arterial tone
Perfusion pressure
Movement

Platelet release

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5
Q

What happens to the heart as the size of an infarct increases?

? is the main Sx of ischemic heart dz

A

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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6
Q

Angina is usually precipitated by ? 3 things

What can be done to differentiate angina and MI

A

Stress Exercise Cold

MI= little response to nitro

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7
Q

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

A

HTN DM Tobacco FamHx HyperCholesterol
>40y/o

Brady= inferior wall

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8
Q

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?

A

Bradycardia
New heart block

Late diastole S3 (overly compliant LV filling)

New systolic murmur= papillary dysfunction, MV leaflet flailing, VSD

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9
Q

The presence of ? in MI PE indicates dysfunction and/or left sided HF

What PE findings signify right sided HF

A

Rales

JVD
Hepato-Jugular reflex
Peripheral edema

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10
Q

Dx unstable angina is based on ?

What two parts of PT are non-Dx

A

Hx

ECG, BioMarkers

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11
Q

Define TIMI

A

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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12
Q

? is the best test for finding AMIs

Define STEMI

A

EKG

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

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13
Q

EKG showing ST elevation suggests ?

EKG showing ST depression suggests ?

What lead is used to ID RV infarction and ? caution is needed?

A

Transmural injury/infarct

Ischemia

V4R
Preload dependent= caution w /Nitro/BB

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14
Q

? EKG finding is ‘STEMI equivalent’?

5 true statements regarding reciprocal ST segment changes

A

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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15
Q

Where is the MC pacemaker lead location

How are MIs identified in these PTs

A

RV

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

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16
Q

Define Wellens

Combination of ? two results virtually excludes all MIs?

A

LAD stenosis causing V2/3 T-wave abnormality
Anterior MI pending <9 days

High sensitivity troponin + TIMI score <2

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17
Q

Troponin time frames

Define HEART Score

A

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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18
Q

What are the two STEMI reperfusion methods

Timelines for Tx

A

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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19
Q

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

A

Glycoprotein 2b/3a antagonists

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20
Q

STEMI Tx drugs

A

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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21
Q

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

A

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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22
Q

What is the preferred NSTEMI Tx method

What is the most common form of the preferred Tx method

A

PCI 90-120min of arrival

Coronary angioplasty w/ or w/out stents

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23
Q

How are PCI PTs prepped to have fewer adverse events in the next 6mon?

Fibrinolytic therapy act as ? and improve ? function

A

Antiplatelets: thienopyridines and G2b/3a inhibitors

Plasminogen activators
Improve LV function and mortality

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24
Q

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

A

<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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25
Q

? is the most catastrophic complication of fibrinolytic Tx

If STEMI PTs receive fibrinolytic Tx, need Tx for ? long

A

Intracranial bleeds

Full dose x 48hrs w/ UFH, Enoxaparin or Fondaparinux

26
Q

MOA of G2b/3a antagonists

MOA of ASA

A

Antiplatelets agent that interrupts platelet activation despite present agonist

Inhibits platelet aggregation from thromboxane A2 stimulation from arachidonic acid pathway

27
Q

All N/STEMI/unstable angina PTs need to have ? much ASA

When does ASA need to be substituted w/ Clopidogrel

A

> 162, preferably 325mg if naive of ASA

True ASA allergy
Active PUD

28
Q

Anti-platelet ADP antagonists

A

Prasurgel- irreversible receptor antagonist
C/i if Hx CVA, TIA, bleeding

Ticagrelor- reversible non-thienopyridine P2Y12 antagonist, eliminated in 72hrs

29
Q

ASA and anti-thrombin therapy plus ? improves CV out comes for PTs receiving fibrinolysis for STEMIs

When are G2b/3a a recommended therapy

A

Clopidogrel

Positive troponin
Likely to receive PCI

30
Q

UFH reduces the risk of AMI and death during the acute phase of ?

Why is UFH stopped after 48hrs of therapy

A

Unstable angina

Reduce risk for HIT

31
Q

? type of heparin combined w/ ASA and fibrinolysis improves STEMI outcomes

Nitroglycerin has what two benefits

A

Enoxaparin (LMWH)

Dilates vascular beds
Inhibit platelet aggregation

32
Q

What are 3 benefits of nitro use in PTs not treated w/ thrombolytics

IV nitro is tapered to ? when used and only for ? long

A

Reduced infarct size
Improved regional function
Dec CV complication rate

BP reduction
First 48hrs in STEMI, recurrent ischemia, CHF, HTN

33
Q

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

A

HOTN
Stop Nitro, fluids to correct BP

Volume dependent (preload)

34
Q

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

A

Sildenafil- 24hrs
Tadalafil- 48hrs

Anti-dysrhythmic, ischemic and HTN properties

Dec re-infarction rates, inc cardiogenic shock

35
Q

BBs may be used within the first 24hrs of an MI if PT has none of ? 4 things

A

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

36
Q

What medication can slow development of CHF during an MI and lowers mortality afterwards

When are these meds given

A

ACEI- reduce LV dysfunction/dilation

STEMI: <24hrs
UA/NSTEMI: pulm congestion, LVEF <40% and no HOTN/Cis

37
Q

How does Mg help limit the size of an infarct

A

Dilation
Antiplatelet
Suppressed automaticity
Myocyte protection from Ca influx of re-perfusion

38
Q

What benefits do CCBs offer during MIs

Why would Verapamil or Diltizaem be used

A

Anti-anginal/HTN
Vasodilation

Ongoing ischemia
A-Fib w/out CHF
LV dysfunction
AV blocks
BB are c/i
39
Q

? type of persistent arrhythmia is a poor prognosis after anterior MI

? type of arrhythmia is usually seen but transient

A

Sinus Tachy

A-fib
Junctional rhythms

40
Q

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

A

Direct cardioversion

Sinus brady w/out HOTN

41
Q

How is sinus brady post-MI Tx

This medication is also used for the Tx of ?

A

Atropine

Sx AV blocks

42
Q

Where does the AV conduction system receive it’s blood supply

Anterior MIs w/ ? EKG finding have a poor prognosis

A

AV branch of the RCA
Septal perforating branch of LAD

Complete blocks

43
Q

RBBB can happen in AMIs MC w/ ?

These are associated with inc ? and ?

What has higher mortality than RBBBs

A

Anteroseptal AMI

Inc mortality
Complete AV blocks

New LBBBs

44
Q

Mortality from AMIs increase as what two risk factors increase?

Previously stable AMI PTs that rapidly decompensate needs to have ? Dx considered

A

Dec CO
Inc pulm congestion

Torn/rupture infarct tissue (ventral wall rupture day 1-5) leading to tamponade (HOTN + Tachy)

45
Q

How is ventral wall rupture best Dx and Tx

Septal wall ruptures are most likely to occur in ? PTs and are Dx by ?

A

Dx: echo
Tx: surgery

Anterior MI/CADz (3 vessels)
New holosystolic murmur
Doppler echo

46
Q

What type of myocardium rupture is more common w/ inferior MIs

How will these PTs present

A

Pappillary muscle on day 3-5

Acute dyspnea
Inc HF
Pulmonary edema
MR holosystolic murmur

47
Q

Pericarditis after MIs is more common in ? PTs

These PTs will have pain w/ ? and relieved by ?

A

Transmural
Delayed presentation

Pain w/ inspiration
Relief w/ leaning forward

48
Q

How is pericarditis/Dresslers after an MI Tx

Why can’t ibuprofen be used

A

PO ASA 650mg q4-6hrs
Colchicine 0.6mg q12hrs

Interferes w/ ASA anti-platelet effects
Thins myocardial scar

49
Q

Isolated RV infarct is identified w/ ? EKG lead

What PE findings are suggestive

How is this type Dx

A

V4R

JVD or HOTN w/ Nitro

Echo
Nuclear imaging

50
Q

What is the most serious complication that can occur from RV infarction

How are these types of MIs Tx

A

Shock

Maintain preload
Reduce RV after load
Inotropic support of RV
Reperfusion

51
Q

Since inferior MIs aren’t Tx w/ Nitro/Morphine, what are they Tx w/

What are post-PCI presentations indicative of

A

Fluid, 1-2L then inotropic support

Bare metal- restenose short term
Drug eluding- late stent thrombosis after stopping Clopidogrel 9-12mon later

52
Q

How are cocaine induced MIs Tx

What is c/i

A

ASA Nitrates Benzos

BBs

53
Q

What are the 3 neuroanatomic categories of abdominal pain?

A

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

54
Q

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

A 
Extremes of age
Rapid onset of severe pain
Abnormal VS
Dehydrated
Visceral involvement evidence

30-40%
Tachycardia

55
Q

If intra-abdominal bleeding is suspected but VS are normal, what is the next step?

What labs are ordered for PTs w/ abdominal pain

A

Obtain orthostatic vitals

CBC CMP Clotting Type/Screen (cross match if hemorrhage suspected or transfusion anticipated)

56
Q

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?

A

Visualization of enlarged aorta

Mild-Mod: delayed/atypical
Sev: opportunistic

57
Q

What lab result is the most important measure of immune competency

SBO will have ? types of sounds on PE

A

CD4 count, >200= less likely to have opportunistic infxn

Hyperactive

58
Q

What PE finding is necessary for a Dx of peritonitis

What trifecta supplies enough evidence for Dx confirmation of peritonitis

A

Rebound tenderness

Rigidity
Referred tenderness
Pain w/ coughing

59
Q

Grouping pain, vomiting and rigidity can mean ? 4 Dxs

Grouping, pain, vomiting, and distension can mean 2 Dxs

A

Pancreatitis
Diabetic gastric paresis
DKA
Incarcerated hernia

Bowel obstruction
Cecal volvulus

60
Q

Grouping pain with or without vomiting can indicate ? 4 Dxs

What test is ordered for suspected pancreatitis if lipase is not available?

A

Acute Diverticulitis
Torsion (adnexa, testicle)
Mesenteric ischemia
MI

Amylase

61
Q

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

A

US

Cholescintigraphy

62
Q

How much radiation exposure occurs from a CT scan

Stopped on Abd Pain

A

10x of plain abdominal x-rays

Slide 48

IPAP (212 decks)

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