Emergency Medicine Flashcards
When a man comes into the ED with dyspnea and palpitations, what is the first thing that should be done?
The patient should get an IV and be placed on cardiac and pulse oximetry
monitors.
Causes of Afib (5 Categories)
Cardiac - Hypertension (approximately 80% of cases), coronary artery disease,
cardiomyopathy, valvular heart disease, rheumatic heart disease, congenital
heart disease, myocardial infarction, pericarditis, myocarditis
Pulmonary - Pulmonary embolism, chronic obstructive pulmonary disease (COPD),
obstructive sleep apnea
Systemic disease - Hyperthyroidism, obesity, metabolic syndrome, inflammation
EToh - “Holiday heart syndrome”
Post op - Cardiac surgery, any surgery
Idiopathic Approximately 10% of AF
How does AF lead to poor perfusion of the limbs and the brain?
Acutely, the loss of the “atrial kick” leads to a reduction in cardiac output (CO) by as much as 15%.
Together with the rapid ventricular
response shortening the diastolic filling time, CO may be significantly reduced,
especially in those with already poor left ventricular function
Treatment options for stable patients with AF starts with?
What type of control is prioritized in the ED.?
Rate control and/or
rhythm control, with or without anticoagulation.
In the acute setting such as the emergency department, ventricular rate control is the single most important goal
of therapy.
Two groups of patients with AF who should not receive rate controlling agents.
unstable patients in whom the instability is presumed to be caused by the rhythm, (2) patients with Wolff-Parkinson-White (WPW) syndrome
Name 4 AV Nodal blocking agents
Why shouldnt patients with with WPW should not
receive any AV nodal blocking agents
What should they get instead?
Adenosine, Beta blockers, CCBs and Digoxin
It could lead to accelerated conduction down the accessory pathway and potentially induce ventricular fibrillation and
cardiac arrest.
Give them cardio-version
Drugs for rate control in AFib (x4)
Dilatizem, B-blockers, Digoxim and Amiodarone/Dronedarone
What is the risk of Hypotension with Diltiazem?
lowest risk of
hypotension because it has least negative
inotropic effect compared to other drugs
Why is role digoxin limited in the ED
of its slow onset of action, long half-life, and ineffectiveness
at rate control in the typical high sympathetic tone ED patient
Which drug for Rate Control in Afib has the highest risk of hypotension
Beta blockers - particularly in patients with borderline low blood pressure or poor LV function
What is the major causes of thromobogenesis post cardioversion
dislodging of an existing clot or the
formation of new clot caused by the “atrial stunning.”
Define the 48 hour rule
AF of less
than 48 hours duration does not generally require acute anticoagulation except
when the patient has mitral valve disease, severe left ventricle dysfunction, or prior history of embolic stroke.
Anticoagulation protocol prior to cardioversion with TEE (3 parts)
Screening transesophageal echocardiography
(TEE), if no clot, administer heparin or enoxaparin, get INR of 2-3 and proceed immediately to cardioversion
Warfarin in continue 3-4 weeks, post cardioversion in the context of atrial stunning
Which is the most effective types of cardioversion?
What factors make cardioversion less successful (x4)
Complications of DC Cardioversion
DC is more successful compared to chemical.
hypertension,
an enlarged left atrium, heart failure, or AF for more than a year.
bradycardia, ventricular tachycardia, ventricular stunning with hypotension
Drugs for Cardioversion
Class 1c? x2
Adverse Effects?
Contraindications?
Flecainide
(oral), Can lead to Dizziness and dyspnea; Contraindicated in CAD
Propafenone
(oral) can lead to dizziness, VT; Contraindicated in CAD
Drugs for Cardioversion
Class III? x4
Adverse Effects?
When are they preferred?
Dofetilide (oral) can lead to VT, torsade de pointes Preferred if any structural
heart disease is
present, especially
LV dysfunction
Amiodarone (oral or IV), can lead to Hypotension, bradycardia, pulmonary toxicity, hepatotoxity, hyper/hypothyroidism, photosensitivity, ataxia, peripheral neuropathy, blurry vision. Preferred if any structural heart disease is
present, especially
LV dysfunction
Ibutilide (IV), can lead to VT, torsade de pointes, Specifically for AF and
atrial flutter
Vernakalant (IV) can lead to Hypotension, bradycardia. Rapid conversion, low
proarrhythmic risk
How does Dabigatran compare to warfarin? Positives and Negatives?
+ reduces the rate of
ischemic and hemorrhagic strokes, major bleeding, and overall mortality compared
to warfarin. does not require INR monitoring, is less susceptible to diet and drug interactions
- higher cost, twice daily dosing, need for adjustment in patients with renal failure,
lack of an antidote, and lack of long-term safety data
If some one can not take warfarin or dabigatran, what might you recommend for antiplatlet therapy
Antiplatelet therapy consists of aspirin 75 to 325 mg daily, clopidogrel 75 mg
daily, or both together, knowing its not as good as the other two drugs.
Process for evaluation person with palpitations +/- hypotension
Labs?
ABCs, Stabilize if need be History, including medications and habits, a complete head-to-toe examination, 12-lead ECG, Lytes and CXR
Maybe a DrugScreen or drug level, or TSH
How do you tell the difference between VT and SVT with aberrancy.
What do you do if you cant tell the difference.
Demographics:
VT - ≥50, history of coronary artery disease or congestive heart failure, history
of VT, atrioventricular dissociation, fusion beats, QRS >0.14 second, extreme
left axis deviation, and precordial concordance (QRS complexes either all positive or all negative).
SVT w/ ab - ≤35, history of SVT, preceding ectopic P waves with
QRS complexes, QRS
Sinus tachycardia
ECG findings and treatment?
Atrial rate 100-160 bpm.
1:1 conduction.
Normal sinus P waves and PR intervals
Treat underlying cause
Atrioventricular nodal reentrant
tachycardia (AVNRT)
ECG findings (P waves?) and treatment?
P wave usually buried in QRS complex. 1:1 conduction. Often preceded by premature junctional or atrial contraction.
Rarely >225 bpm
If stable, consider vagal
maneuvers, adenosine, calciumchannel
blockers or β-blockers
Atrioventricular reentrant
tachycardia (AVRT)
ECG findings (P waves?) and treatment?
Inverted retrograde P waves
after QRS complex. Retrograde reentry involving
bypass tract.
consider vagal maneuvers, adenosine, calciumchannel
blockers or β-blockers
Atrial flutter.
ECG findings (P waves?), response to vagal maneuvers? treatment?
Atrial rate 250-350 bpm.
“Sawtooth” flutter wave (best seen in II, III, aVF, V1-V2). 2:1 conduction common (although
may be any ratio)
Will not convert to sinus with vagal maneuvers or adenosine
calcium channel
blockers, β-blockers.
Treat underlying cause
Junctional tachycardia
Patholophysiology? and Causes (5x)
increased automaticity in the AV node coupled with decreased automaticity in the sinus node.
Digoxin toxicity (= the classic cause of AJR) Beta-agonist, Myocardial ischaemia, Myocarditis, Cardiac surgery
Junctional tachycardia
ECG findings (P waves?), response to vagal maneuvers? treatment?
Inverted P wave before or after QRS or buried in QRS
complex. Rate >100 bpm
Will not convert to sinus with vagal maneuvers or adenosine. If stable, consider diltiazem, β-blockers. Treat underlying
cause
Ventricular tachycardia
ECG findings (P waves?),treatment?
Wide QRS-complex
Dissociated P wave (if present). 100-250 bpm
If stable, consider amiodarone,
procainamide, or sotalol.
Lidocaine as second-line agent
Antidromic AVRT
ECG findings (P waves?),treatment?
Retrograde P waves may or may not be visible, may be obscured by ventricle depoilarization
Avoid β-blockers, calcium channel blockers, and adenosine
Narrow complex tachycardia
with aberrancy
ECG findings (P waves?, QRS? Axis),treatment?
Preceding ectopic P waves with
QRS complexes.
QRS usually
Pharm therapy for non sustained VTach (lasting less than 30 secs
None. F/u with Cardiologist for workup for structural or congenital heart disease. e
Treatment of Hypovolemic Shock in DM type 1, Adults vs Kids
Maintainence fluids?
Adults with clinical shock should receive an initial
2-L bolus of normal saline with frequent reassessment. In children, shock is treated
with boluses of 20 mL/kg of normal saline.
continue an infusion of half normal
saline at two to three times maintenance
An insulin dose DM type 1
For how long?
0.1 U/kg/h (5-10 U/h in the adult) is adequate for almost all clinical situations.
when the serum glucose falls to 200 to 300 mg/dL and the person’s anion gap is normal.
If the initial serum K is normal or low in DKA then…..
Potassium replacement can be started immediately.
What is the single most common underlying cause of DKA in young people
UTIs
SIRS Criteria (4 parts)
At least 2 of the following
Temperature >38°C or 20 breaths per minute or Paco2 12,000 cells/mL or 10% bands
Definition of severe sepsis (8 Points)
Sepsis in conjunction with at least one sign of organ failure or
hypoperfusion, such as lactic acidosis (lactate ≥4 mmol/L), oliguria (urine output
≤0.5 mL/kg for 1 hour), abrupt change in mental status, mottled skin or delayed
capillary refill, thrombocytopenia (platelets ≤ 100,000 cells/mL) or disseminated
intravascular coagulation, or acute lung injury/acute respiratory distress syndrome
Definitions of septic Shock
Multiorgan Dysfunction Syndrome?
Severe sepsis with hypotension (or requirement of vasoactive
agents, eg, dopamine or norepinephrine) despite adequate fluid resuscitation in the
form of a 20- to 40-cc/kg bolus
MODS is the far end of the spectrum that begins with SIRS. It is defined as dysfunction of two or more organ systems such that homeostasis cannot be maintained without intervention.
Common Pathogens causing infection of unknown source.
Empiric Antibiotic Recommendations?
Escherichia coli, Staphylococcus aureus, Streptococcus pneumoniae, Enterococcus spp, Klebsiella spp, Pseudomonas aeruginosa
Vancomycin plus antipseudomonal penicillin (eg, piperacillin/tazobactam) Or antipseudomonal cephalosporin (eg, ceftazadine, cefepime) plus fluoroquinolone (eg, levofloxacin, ciprofloxacin) Or aminoglycoside (eg, gentamicin, amikacin)
Common Pathogens causing Pneumonia
Empiric Antibiotic Recommendations?
Streptococcus pneumoniae, Mycoplasma pneumoniae, Haemophilus influenza,, Chlamydophila pneumoniae, Legionella
Antipseudomonal cephalosporin (eg, ceftazadine, cefepime), plus macrolide (eg, azithromycin Or fluoroquinolone (eg, levofloxacin, moxifloxacin)
Common Pathogens causing UTI
Empiric Antibiotic Recommendations?
Escherichia coli, Klebsiella spp
Enterococcus spp
Fluoroquinolone (eg, levofloxacin)
Or third-generation cephalosporin
(eg, ceftriaxone)
Empiric Therapy for an Abdominal infection
Ampicillin ( if Listeria is suspected)
plus
Cefazolin, cefuroxime, ceftriaxone,
cefotaxime, ciprofloxacin, or levoflox-
acin,
plus
metronidazole
How do Infants and the elderly present with sepsis differently than adults and adolescents?
What other nonspecific sign can one look for?
they may present
with hypothermia rather than hyperthermia, leukopenia rather than leukocytosis,
and they may not be able to mount a tachycardia (as in elderly patients on β- or
calcium-channel blockers) or they may have a tachycardia attributed to other
causes (as in anxious infants
vomiting, fatigue, behavioral changes—should prompt concern
for sepsis
Parts of the Sepsis Bundle for a patient coming into the ED. Access? Labs? Imaging? Drugs?
How Quickly should Abx be started in the context of sepsis.
cardiac and pulse-oxygenation monitor and ECG, nasal canula or facemask should be titrated to keep oxygen saturation >93%
Access: two large-bore, peripheral IVs with 20 to 40 mL/kg (2-4 L in adults) crystalloid unless, they have heart or renal failure
Labs: Lactic acid, CBC, CMP, Blood cultures from two sites, Urinalysis with culture, Pregnancy test in women of childbearing age
Imaging: CXR
Drugs: Broad-spectrum intravenous antibiotics
Broad-spectrum intravenous antibiotics should be started rapidly —ideally after
the cultures have been drawn, but antibiotic infusion should not be delayed if cultures cannot be obtained in a timely fashion (
What is goal-directed therapy (EGDT) and whne should it be initiated? (2 criteria)
Early Goal-Directed Therapy
If the patient continues to be hypotensive or has a lactate level greater than 4 mmol/dL or has other signs of continued hypoperfusion,
then early goal-directed therapy (EGDT) should be initiated.
Goal 1 of EGDT: central venous pressure (CVP) at… what if mechanically ventilated?
How often can you give saline to option this goal?
8-12 mm Hg
> 12 mm Hg if mechanically ventilated
500 cc of normal saline can be bolused every
15 to 30 minutes until the CVP goal is met.
Goal 2 of EGDT mean arterial pressure at….
what can you use to obtain to this goal, if fluids arent working?
greater than 65 mm Hg
vasopressors should be initiated, with either norepinephrine or dopamine
Goal 3 of EGDT: central venous oxygen saturation at …..
what does it mean when the o2 sat is less than 70 percent
How can you correct this issue? What it that does not work
greater than 70%:
the tissues are extracting as much oxygen as possible from the blood, and therefore that tissue demand is not being met
Transfusing packed red blood cells to a hematocrit ≥30%. If that does not work, dobutamine infusion should be started to
boost cardiac output.
Glucose is reccommended to be at what level in sepsis?
A patient’s glucose goals should be between 140 and 180 mg/dL.
When should platlets be be started in a patient with DIC. Other medications?
platelets may be given if the platelet count is
Complications associated with sepsis 5 systems
Cardiac failure ALI and ARDS DIC (disseminated intravascular coagulation) Hepatic failure Renal failure
Shock is divided into three stages….
Compensated, progressive, and irreversible.
How does the body get to progressive shock?
What happens to blood in low flow states?
What fluid shift occur in context to progressive shock?
Arterial pressure falls. This leads to
cardiac depression from decreased coronary blood flow, and, in turn, further decreases
arterial pressure.
In the microvasculature,
low blood flow causes the blood to sludge, amplifying the inadequate delivery of oxygen
to the tissues.
Ischemia results in increased microvascular permeability, and
large quantities of fluid and protein move from the intravascular space to the extravascular
compartment, which exacerbates the already decreased intravascular volume
What is the definition of irreversible shock?
any therapeutic
efforts become futile. Despite transiently elevated arterial pressures and cardiac output,
the body is unable to recover, and death becomes inevitable.
Where are the five sources of bleeding one should focus on in a trauma patient?
Labs to be obtained in the context of Hemorrhagic shock.
1) external
bleeding (eg, scalp/extremity lacerations); (2) thorax (eg, hemothorax, aortic injury);
(3) peritoneal cavity (eg, solid organ lacerations, large vessel injury); (4) pelvis/
retroperitoneum (eg, pelvic fracture); and (5) soft-tissue compartments (eg, longbone fractures)
hemoglobin, hematocrit, base deficit, and lactate levels.
When is a blood transfusion indicated for a trauma patient? (x 2 reasons)
Other blood products?
A blood transfusion is indicated if the patient persists in shock despite the rapid infusion of 2 to 3 L of crystalloid solution, or if the patient has had such severe
blood loss that cardiovascular collapse is imminent.
Crystalloids, fresh-frozen
plasma (FFP), and/or platelets may need to be transfused if massive blood volumes
have been given. Transfusion protocols differ by institution regarding the ratio of
FFP to platelets to PRBCs that should be administered.
Definition of pemissive hypotension and why do we think it is effective?
blood pressure is allowed to remain low (mean arterial pressures of
60-70 mm Hg or a systolic blood pressure of 80-90 mm Hg).
Permissive hypotension
is thought to be effective in hemorrhagic shock because it is thought that post-hemorrhage, the artificially increased blood pressure by aggressive fluid
resuscitation may disrupt endogenous clot formation and promote further bleeding
What effects can large amount of crystalloid have on outcomes.
crystalloid is often administered at room temperature, which is actually colder than the body temperature and can result in hypothermia.
also dilute the endogenous clotting factors and erythrocyte concentration, resulting in poorer control of bleeding and also
diminished oxygen carrying capacity
Contraindications to permissive hypotension.
patients with traumatic brain injuries who require maintenance of their cerebral perfusion pressure; patients with a history
of hypertension, congestive heart failure, or coronary artery disease, in whom
hypotension will be poorly tolerated and may produce other medical problems
such as strokes or myocardial infarctions.
What type of excess is necessary for a patient with pentrating trauma.
1) large-bore IV access at two sites
Complications of penetrating Chest injuries?
Signs and symptoms
Further Studies/ Interventions? (Imaging and Procedures)
Pericardial effusion/tamponade
Pneumothorax or hemothorax
Distant heart sounds, hypotension, JVD Decreased breath sounds, low oxygen saturation, hypotension
CXR may detect air or fluid in the pleural cavity. FAST is sensitive in detecting fluid within the pericardial sac ED ultrasound is useful in detecting an occult pneumothorax Chest tube thoracostomy may yield a rush of air or blood
