Exam 1 Flashcards
basic vital signs
blood pressure, pulse, respiratory rate, temperature, pulse oximetry (and now pain)
when normal signs do not = hemodynamically stable state
acute blood and fluid loss
serious illness in infants
meds blunt response (elderly)
normal (adult) vital signs
BP: 90-120 / 60-80
HR: 60-100bpm
RR: 12-20
classification of blood pressure
normal: <120 and <80
pre-HNT: 120-139 or 80-89
HNT, stage 1: 140-159 or 90-100
HNT, stage 2: >160 or >100
children vitals - trends
BP is lower (80-110 systolic)
HR (80-100) and RR (15-30) higher
Note: infants even more dramatic
- BP: 70-90 systolic
- HR: 100-150
- RR: 25-50
causes of tachypnea
Pneumonia Asthma Exacerbation Heart failure Pulmonary embolism Anxiety Drug intoxication Metabolic Acidosis Lung Trauma, rib fx Pain
causes of bradypnea
Alcohol or drug overdose
Sedative or hypnotic medications
Impending respiratory failure
OSA/ Sleep apnea
best way to measure HR
apical rate (bottom left of heart) for 60 seconds
causes of tachycardia
Fluid or blood loss Anxiety Pain Sepsis Allergic Reaction Fever
causes of bradycardia
Medications
Drugs
Brain injury
Heart blocks
temperature
most accurate = rectal
oral is 0.6 C (1 F) lower than rectal
fever
not an illness - a clinical response (that of uncompfortable)
temperature: C to F conversions
37 = 98.6 F
38 C = 100.4 F
39 C = 102.2 F
40 C = 104 F
pulse oximetry
measures arterial hemoglobin (hgb) saturation
limits:
- hypoperfusion (below 80 mmHg systolic)
- hypothermia
- anemia: if Hct is
causes of low oxygenation
elevation
hypoventilation
probe not on correctly (see waveform)
V-Q mismatch: atelectasis, pneumonia, PE, ARDS, CHF
AHA BP technique
seated for 5 min w/ arm supported at heart level
appropriate cuff size (bladder nearly or completely encircle arm)
no smoking or caffeine for 30 min
two or more readings separated by 2 min should be average (more taken if differ by >5mmHg)
blood pressure cuff - repercussions of improper fit
too narrow: overestimates BP
too wide: underestimates BP
causes of hypotension
Acute blood or fluid loss Sepsis Anaphylaxis Medications, drug overdoses Fit people
causes of hypertension
Medication non-compliance Pain, anxiety (white coat syndrome) Poor cuff size Medical History: HTN, CAD, DM, renal insufficiency, Drugs : cocaine, meth, decongestant MAOI use with tyramine containing food (old anti-depressent) Pheochromocytoma (tumor) Renal Stenosis “Hypertensive Emergencies”
hypertensive urgency
symptomatic elevated BP without End Organ Damage
BP of >180/120 used to suggest treatment
hypertensive emergency
elevated BP with End Organ Damage, such as ARF, MI, CHF, SAH (subarachnoid hemorrhage), stroke, etc.
possible result of HTN emergency
Pulmonary Edema - crackles in lungs
Aortic dissection – ripping tearing CP to back
ACS (Acute Coronary Syndrome) – CP, EKG changes, elevated trop
Preeclampsia – protein in urine, HA, edema
Hypertensive Encephalopathy – mental status changes
Subarachnoid Hemorrhage – sudden, worst ever HA
Ischemic Stroke – neuro deficits
Renal Failure – decreased UOP, high creatinine
HTN emergency workup
guided by symptoms
EKG : ST segment changes, suggesting ischemia
UA : Hematuria, casts, proteinuria suggesting renal impairment
CXR : pulmonary edema c/w CHF;
Widened Mediastinum c/w Aortic dissection
Other studies: Electrolytes: elevated Cr, hyperkalemia Head CT: if concerned for stroke Upreg: preeclampsia Utox
HTN emergency - management
Immediate but careful reduction in BP - lower slowly (except aortic dissection and ischemic stroke)
Reduce MAP by no more than 10-20% in 1st hour
calculation MAP
MAP = [(2 x diastolic) + systolic] / 3
Usual 70-110
MAP of about 60 is needed to perfuse the coronary arteries, brain, kidneys
hypertensive urgency - treatment
Labetolol 200 mg po
Captopril 25 mg po
Nitroglycerin tab or spray
Clonidine .1-.2 mg PO
Note: clonidine drops BP quickly but can can cause quick rebound to HNT - ask when not to use
medications for HNT - general word roots
- olols: beta blockers (block receptors for epi / adrenaline so heart beats slower and less intensely, which vessels dilate)
- prils: ACE inhibitors (ACE converts Ang I to Ang II, which constricts muscles around blood vessels)
- zides: diuretics (inc. salt in urine which takes H20 with it, decreasing vol. of fluid in vessels)
severe HTN (asymptomatic)
Treat if BP>180-200/110-120
Diuretics: HCTZ, 25 mg PO qd
- uncomplicated HTN
B-blocker : metoprolol 50mg PO BID
- angina, Post MI, migraines, SVT (supraventricular tachycardia)
ACE Inhibitor: Lisinopril 10mg PO qd
- if HF, renal disease, stroke, DM
- starting medications
pain
an unpleasant sensory and emotional experience with actual or potential tissue damage or described in terms of such damage.
oligoanalgesia
inadequate pain control
clinical features of pain
physiologic: inc. BP, inc. HR, tachypnea, nausea, diaphoresis (sweating), and skin color changes (pale or flushed)
behavioral: crying, yelling, cursing, withdraw, posturing,
pain and vital signs
vital signs are no a reliable guide to pain relief
pain assessment - pneumonic
O: onset P: provoking factors (what makes worse or better) Q: quality (sharp, dull, constant) R: radiation (where it moves) S: severity T: time course
results of poor pain management
Unnecessary suffering Delayed healing Altered immune response Altered stress response Development of chronic pain
non-pharmacologic treatment for pain
heat/cold
immobilization/elevation
explanation/reassurance
distraction
narcotics - proper use
treatment of moderate to severe pain
- best known narcotics are opiates (derived form opium)
narcotics - things to consider when selecting
route of administration - surgery: NPO suitable initial dose frequency of administration side effects use in- vs. out-patient
routes for pain medications
IV: easy to titrate, rapid onset of action, no delayed respiratory depression
IM: intramuscular - not common in ER
SQ: subcutaneous
PO: oral - slow onset, NPO (?), N/V
IO: interosseous - into bone marrow (often tibia), fast onset, good option with collapsed peripheral veins or edema; can deliver all meds!
IN: intranasal -pain control, seizures, palliative care, opiate OD, good for kids, limited on dose (max 1 ml q nostril)
PR: per rectal
conversion: pounds to KGs
lbs/2.2 = kgs
lbs/2 - 10%(lbs/2) - kgs
conversion: KGs to pounds
kg x 2.2 = lbs
kgx2 + 10%(kgx2) = lbs
analgesic
pain killer
narcotics / opioids - administration route for specific meds
PO: oxycodone, hydrocodone, codeine, methadone, tramadol
Common IV: hydromorphone, fentanyl, morphine
- Note that most of these meds can be given IM and PO also
side effects of opioids
Nausea and vomiting (25%) Constipation Urinary retention Respiratory depression (more pronounced in IV) Sedation Miosis (pupil restriction) Pruritis (itching) Antitussive (rid cough), antidiarrheal
acute opiate withdrawal - symptoms
Mydriasis (pupil dilation), yawning, increased bowel sounds, piloerection (goose bumps), restlessness, plus flu like symptoms:
- n/v/d, abdominal cramping
- rhinorrhea, lacrimation (tears)
- myalgias, arthralgies, piloerection
acute opiate withdrawal - treatment
symptom management
may offer Clonidine (1-3 mg TID prn)
Janka’s PO pain med regimen
- Motrin 600-800 TID and/or Tylenol 1 g TID-QID
- can take OTC - Norco 5/325 or Percocet 5/325 1 tab QID prn, w/ colace, prune juice, metamucil; driving precautions
- Rarely –Dilaudid 2 mg QID prn +/- NSAIDs
- may be missing something if need to prescribe in ER
prescribed opiate abuse in CO
CO has 2nd highest rate of prescription painkiller abuse in nation
coloradopdmp.org - website that lists all controlled substances a person has been prescribed
drug seeking behavior - red flags
- Out of town
- Lost or stolen prescription
- ED visits on weekends or night
- Frequent ED visits (no follow up appointments)
- Unusual knowledge of controlled substances
- Request a specific drug
- Long list of drugs they are allergic to
- Do not permit a physical exam
- Create a sense of urgency
- Common complaints: dental pain, back pain
drug speaking behavior - management
Attempt to contact patient’s physician to confirm history
Confirm patient has provided a copy of a photo ID and SSN
Check the CO PDMP
Talk to the the patient about your concerns
procedural sedation
pharmacological state of profound sedation with maintenance of all protective reflexes, spontaneous ventilation is adequate and airway is maintained
procedural sedation - levels
Minimal: mild anxiolysis (antianxiety) or pain control
- ventilation, CV fx maintained; no cardiac monitoring needed
Moderate (“conscious sedation”): pt is sleepy but arousable to voice or light touch (eyes closed)
- GOAL FOR MOST ED procedural sedation
Deep: requires painful stimuli to evoke a purposeful response
- may require assistance to maintain airway, CV fx usually maintained
general anesthesia
Patients cannot maintain airway or airway reflexes
Requires support of airway, breathing and cardiovascular functions
NOT COMMON IN ER
procedural sedation - patient evaluation
History: last meal, allergies, substance use and abuse, major organ system abnormalities, previous anesthesia use and complications.
Physical Exam: airway, heart, lungs
Fasting preferred
Patients with severe cardiac or pulmonary problems are poor candidates
procedural sedation - monitoring
Hemodynamic: cardiac monitor, auto BP cuff ( q 5 min)
Respiratory/Airway: continuous pulse oximetry, suction equipment, supplemental O2, bag valve mask, end tidal CO2?
Level of consciousness
IV access, reversal agents, COR cart
Provider skill set: necessary if problems occur
predictors of difficult airway
Obesity with short neck
Reduced neck movement
Reduced TMJ movement
Receding mandible
Mallampati grading system scale: assess ease of intubation if needed
Mallampati grading system scale
Assess ease of intubation if needed:
- class 1: soft pallet, uvula, pillars visible
- class 2: soft palate and uvula visible
- class 3: soft palate and base of uvula
- class 4: only hard palate visible
NSAIDS - mechanism
Potent inflammatory action occurs through inhibition of prostaglandin synthesis at wound site by blocking COX enzymes (reducing inflammation, pain and fever)
- aka, inhibits COX-1 and COX-2
Note: also upsets GI (ulcers) and causes bleeding (anti-coag) since prostaglandins protect stomach and help with coagulation
discharge criteria (from ER)
Stable vital signs 30 min) No evidence of respiratory distress Minimal nausea (tolerate PO fluids) Ambulation equal to pre-procedure Alert, oriented, and able to retain discharge instructions Responsible person to watch patient
wound management - history questions
mechanism of injury - how happen (bite, blunt, penetrating) - potential for infection - how long ago tetanus status, meds, allergies, co-morbidities foreign body possibility - sensation of FB if hand injury: dominant hand, type of work
wound management - physical exam
document neurovascular function (injury to tendons, nerves, joint capsule, blood vessels)
- BEFORE anesthesia!
wound closure and suturing
typically do not close >8 hrs after injury (primary intention)
face/scalp/neck: up to 24 hours
bite wounds - animal or person
typically do no close (unless gaping or for cosmetic)
ABX: Augmentin
must call animal control (ask about rabies)
wound management - anticipatory guidance
begin to wash wound 1-2 days (impervious t water after 24-48 hrs)
remodeling lasts for up to 6 months (cannot predict scar at time of sutureing)
sunscreen will help scarring
mechanism of injury - 3 types
shear: simple dividing of tissue (sharp glass, knife); low energy force
- heal with good result
Compression: crushes skin against bone (stellate laceration)
- baseball bat, windshield
Tension: flap type laceration
- high energy forces with surrounding tissue devitalized and prone to infection
tetanus prophylaxis
Update if last Tetanus was > 10 years ago
If very dirty or high risk, consider updating if last dose 5-10 years ago
Tdap if adult; DTaP if pediatric
infection prevention
irrigation: high volume good
debridement: cut out fatty tissue and irregular edges
blood supply: higher = less infection
prep: clean would
prophylactic antibiotics in wound management
healthy patient do not require
Use in specific situations:
- wound in mouth, genitals, feet (w/ saliva, feces, vaginal secretions)
- delayed presentation
- immunosupressed pt (DM, steroids, renal insufficiency)
- bites of any kind
- cartilage (poor blood supply) or joints
- valvular heart disease
- contaminated woulds with soil and organic materials (wood)
rabies - most likely transmitters
wildlife (92% exposures): raccoons, skunks, bats, foxes)
domestic animals (8%): cats, dogs
internationally: stray dogs
never: small rodents (squirrels, chipmunks, rats, mice, etc.)
principles of wound care
inspect and examine
prep (baby soap and H2O) and anesthesia
wash/irrigate/debride
- note: clip, do not shave hair
hemostasis (stop blood)
- if pulsing, explore arterial injury (if close, hematoma will occur)
exploration - explore through full ROM in bloodless field (use instruments)
closure (type, material used)
dressing
care instructions
local anesthesia for wound care
Drug classes: amides
- most common class: lidocaine (1-2 hrs), bupivicaine (4-6 hrs)
Drug class: esters
- cocaine, procaine, tetracaine (eye drops)
Epinephrine: often added to local anesthetic
epinephrine - why added to local anesthetics
provides hemostasis
longer duration of action
slows systemic absorption thus decreasing potential toxicity
can use “more” (but may not need to)
Note: never use on fingers, toes, penis, nose, or ears (extremities)
epinephrine - where not to use
fingers, toes, penis, nose, or ears (extremities)
- can block only circulation and cut off blood
ways to limit pain on injection of local anesthetic
Anesthetic is acidic (low pH) = burns!
Sodium bicarbonate 1:10 (shelf life 1 week)
Warming the solution
Size of the needle (smaller)
Injecting slowly
Use of a topical anesthetic
Ice on wound (especially helpful in kids)
wound irrigation
volume is key: more is better (min: 250cc, ave: 1 liter, 100cc/cm of wound length)
moderate pressure (except loose tissue = low pressure) - 18 gauge IV cath w/ 30-60 cc syringe - can use pulse evac if dirty
Do not irrigate puncture wounds - SOAK
use isotonic solution (saline) or tap water
types of wound closure
primary intention
secondary intention
tertiary intention
primary intention
surgical repair with initial reapproximation of tissue layers
typically do not close >8 hrs after injury
face/scalp/neck: up to 24 hours
secondary intention
epithelialization and growth from base
used in ulcerations, abscess cavities, avulsions, punctures, bite wounds
also used in wounds >8 hrs since injury
tertiary intention
delayed primary closure - surgical closure in 3-5 days after injury (only if no signs of infection)
used of high velocity wounds, contaminated wounds, old wounds, stab wounds
will lessen scarring and heal faster
terms for describing layers of skin - how deep wound is
epidermis - outermost dermis subcutaneous tissue (hypodermis) superficial fascia muscle layer deep fascia
prepping wound - hair removal / debridement
after cleaning (baby soap and H20)
- clip, do not shave, hair
- never clip eye lashes or brows
Debridement (all devitalized or necrotic tissue should be removed)
- improves vascularity
- reduces infection
sutures - types, size, needle
absorbable: vicryl, chromic, gut
non-absorbable: ethilon, prolene, silk
size: inverse relationship (6.0 smaller than 2.0)
needle: reverse cutting needed used in ER (allows smooth, atraumatic penetration of touch skin and fascia)
- tapered needles used on soft tissue (or when smallest hole is needed)
absorbable sutures - tensile strength and time to dissolve
Vicryl: has 2-4 weeks of tensile strength, can take 2+ months to dissolve
Plain Gut: 7-10 days of tensile strength; up to 90 d. to absorb
Fast Absorbing Gut: 5-7 days of strength, absorbs in 3-4 weeks
suture sizes for different areas of body
face: 6-0
trunk: 3-0, 4-0
extremities: 4-0
- 5-0 on hands, toes
scalp: 4-0 (or staples)
alternatives to sutures
staples: good for scalp
steri strips: older people with fragile skin, kids, used to anchor would on fragile skin
dermabond: glue (needleless wound repair)
- do not use deep
- best used on low tension wounds (avoid hands, feet, joints)
- do not use on places requiring frequent washing
- DO NOT USE topical antibiotics after closure
goals of suturing
minimize tension, evert edges, symmetrical alignment, good wound prep, homeostasis to allow full visualization of injury
wound care - what to tell patients
apply topical ABX ointment after lac repair and BID for 3-5 days (except Durabond)
dressing left on for 24 hours; after that removed and left open to air
clean wound: 50-50% H20 and water around wound edges or baby soap and H20
no soaking (swimming or hot tub)
timing of suture removal (if applicable)
signs of infection
avoid sun exposure (sunscreen for 6 mo)
wound care - special concerns
Lip: vermillion border Oral: thru and thru Hand lacerations: FB, joint/tendon Eyelid lacerations: lacrimal system Nose: septal hematoma Ear: dressing is key Puncture wounds: pseudomonas Hand lacs: fight bite Cheek lacs: facial nerve
puncture wounds
do not close: heal to secondary intention
plantar wounds (bottom of foot): tx with Cipro to cover for pseudomonas (esp if went through shoe)
remove FB
soak - do not aggressively irrigate
hand lacerations - special considerations
examine in position of injury and through full ROM (in bloodless field)
consider flight bite
x-ray for foreign body
PE: motor and sensory distally, perfusion/cap refill
- tendon involvement = referral
ear lacerations - special considerations
use small (6-0) non absorbable sutures to close skin
cartilage only approximated
dressing is key: form into ear crevasses so no blood accumulation and distortion
lip lacerations - special considerations
look for intraoral / thru and thru
look for dental injury
throw 1st stitch to approximate vermillion border (if involved)
if not, begin on mucosal aspect then repair orbicularis oris
ABX: PCN or clindamycin
eyelid lacerations - special considerations
when to refer:
- inner surface of lid
- lid margins
- lacrimal duct involvement (plastics referral)
- ptosis involvement (eyelid)
- tarsal plate involvement (on each lid - muscle attachment)
nasal laceration
look for (and drain) septal hematoma - bloody pouch
align skin surrounding nasal canals
mucosal involvement: close with absorbable
facial lacerations
parotid gland: must ensure duct potency into oropharynx
facial nerve: motor control of most of muscles of facial expression; taste to anterior 2/3 of tongue
suture removal recommendations
Face: 3-5 days Scalp: 7-10 days Hands: 7-10 days Feet: 7-10 days Extremities: 7-14 days (joints) Trunk: 7-10 days
note: leaving sutures in too long = scar
lacerations - when to refer
Patient request Foreign bodies Deep Structure involvement Time constraints Eye lid considerations Level of comfort
foreign bodies
x-ray finds glass, metal, gravel >2mm
if pt feels FB sensation, take good look
organic material (soil, wood, clay) more likely to become infected
regional blocks: advantages over infiltration
No tissue distortion Avoids infiltrating highly sensitive areas (palm) Longer duration of anesthesia Smaller amount of anesthetic needed Abrasion cleaning Fracture analgesia
regional blocks (or any anesthesia) - precautions
use sterile technique
- alcohol swab anesthetic you are using (if already opened)
- prep area before injecting
regional blocks for facial anesthesia
supraorbital nerve: whole forehead
supratrochlear nerve (side of nose)
infraorbital nerve: under eye to top of lip
mental nerve: bottom lip and chin
Note: all line up with pupil
Note: rub tissue following injection to spread anesthesia
supraorbital nerve block
blocks forehead
Procedure: inject into SQ space just superior to eyebrow in line with pupil to medial brow
infraorbital nerve block
blocks lower eye lid, medial check, side of nose, upper lip
Procedure: inject mucosa above first maxillary pre-molar (tooth behind canine); angle up towards infraorbital notch under eye
mental nerve block
blocks labial mucosa, gingiva, and lower lip down chin
Procedure: inject into mucosal fold at canine/first premolar
abscesses
difficult to get good anesthesia
use hemostat and Q-tios to get pus out
use packing to keep wound open for drainage (remove in 48 hours)
suturing - general tips
facial sutures: 2-3mm from wound edge, 3-5 mm apart
Other body parts: 3-4 mm form wound edge, 5-10 mm apart
Note: always begin suturing distal to you and suture towards you
simple interrupted stitch
technique: gather more tissue at base than at surface; eversion key; enter at 90 degree angle
- # of ties = size of material
when used: standard wound closure (low tension and not too deep)
subcutaneous / buried stitch
technique: enter at mid dermis and exit at dermal/epidermal junction; then enter dermal/epidermal junction and exit mid dermis
- avoid placing in adipose tissue
- know it deep (bottom of stitch)
when used: gaping wounds
running suture
technique: simple interrupted at one end and tie knot (only cut short end), continue stitching along wound.
- to tie off: leave loop of suture and tie as if tying with two ends (pull loop through)
when used: in hurry with long, strait wound
horizontal mattress
technique: take big bite (1 cm from edge) and out other side. On same size, go down 1 cm and re-enter, taking another big bite (tie off on original entering side)
- add simple interrupted stitches and, when done, pull out horizontal mattress
when used: temporary placement w/ high tension repair to approximate edges; wounds with increased tension (fascia and over joints)
vertical mattress
technique: take big bite (1 cm from wound edge); reverse needle and go back through 1-2 mm from wound edge) - tie off on original side
- typically continue with these same sutures along wound (may add few simple interrupted)
- risk: too much tension = strangulation, maceration, infection
when used: excess, lax skin (all in one - avoid a layered closure)
chest pain differential - cardiac
angina/MI
aortic dissection (ripping pain through back)
pericarditis/tamponade
chest pain differential - pulmonary
pneumonia/bronchitis
pulmonary embolism
pleurisy (inflammation of pleura - membranes of pleural cavity)
pneumothorax/pneumomediastinum
chest pain differential - neuro/psych
Thoracic outlet syndrome (compression of nerves, arteries, or veins form lower neck to armpit)
Herpes Zoster (shingles)
Anxiety
Radiculopathy (pinched or compressed nerves)
chest pain differential - MSK
costochondritis
rib trauma
rib Strain/ coughing
- nonspecific
chest pain differential - GI
PUD (peptic ulcer disease)/gastritis cholecystitis (gallbladder) pancreatitis (radiates to back / alcoholic) peritonitis GERD/spasm esophageal rupture
chest pain differential - life-threatening conditions
Ischemia/ MI Aortic Dissection Pericardial Tamponade Pulmonary Embolism Esophageal Rupture
Chest pain - history / initial evaluation
ABC’s (airway, breathing, circulation)
History: associated sxs, medications, tx w/ meds, similar or previous episodes, recent trauma
Pain characteristics (OPQRST)
Chest pain - physical exam
Pulmonary:
- chest wall tenderness (MI, MSK)
- rales (LV dysfunction, pneumothorax)
Cardiac:
- new murmur
- Hamman’s crunch
Vascular:
- carotid or femoral bruits
- equal pulses
Abdominal:
- tenderness (cholecystitis, pancreatitis, etc.)
Neuro:
- AMS (altered mental status)
- focal defects
Derm:
- vesicular rash (herpes zoster)
MI - characteristics on physical exam
chest pain to palpation (15%)
Hammans Crunch
heard on cardiac exam (w/ stethoscope) - crunching, rasping sound, synchronous with the heartbeat; heard over the precordium; produced by the heart beating against air-filled tissues.
occurs with: pneumediastinum/pneumopericardium or esophageal rupture
cardiac risk factors - non modifiable
family hx
gender (male)
age (>45 male, >55 female)
Note: be sure to ask about in hx, but although predictive of CAD in asymptomatic pts, poor predictor of AMI in ED
cardiac risk factors - modifiable (7 major)
HTN Smoking Hyperlipidemia Diabetes Obesity (cocaine)
Note: be sure to ask about in hx, but although predictive of CAD in asymptomatic pts, poor predictor of AMI in ED
Acute Coronary Syndrome (ACS)
Ranges from angina to MI
- Occluded vessels can cause anginal pain with exertion (relieve with rest or NTG - nitroglycerin)
- Plaque rupture can lead to total vessel occlusion/ Acute Myocardial Infarction
- spectrum of clinical presentations
Range: Stable Angina, Unstable Angina, NSTEMI, STEMI
vessel changes with coronary syndrome
plaque grown into vessel walls (not build up on inside of lumen)
- so, plaque rupture is more likely to cause MI than stenosis
classical MI symptoms
substernal chest pain/pressure diaphoresis (sweating) nausea dyspnea (SOB) radiation to arm/jaw exertional
Lasting <2min or >24 hours is less likely to be ischemic
atypical MI symptoms
palpitations nausea SOB epigastric pain weakness fatigue
more common in women and diabetics; up to 50% of people with unstable angina may have atypical sxs and no chest pain
ACS - 4 sxs that are specific
Diaphoresis
Vomiting (not nausea)
Exertional chest pain
Radiating pain to the back or right arm
Note: just good to know this (possibly not tested)
stable angina
predictable pattern of chest pain/pressure/squeezing that occurs with exertion and relieved with rest or Nitroglycerin
- lasts 5-15 min
- occurs in known CAD
- normal condition (stable)
Note: PE, labs, CXR, EKG all normal in stable angina
unstable angina
new onset, change in severity, duration, frequency of the normal angina
Note: PE, labs, CXR, EKG all normal in unstable angina
NSTEMI (non-ST elevation MI)
worsening or changing symptoms, with myocardial damage
- see troponin elevation
STEMI (ST elevation MI)
worsening or changing symptoms, with myocardial damage
- see troponin elevation and EKG changes
chest pain: diagnostic tests
EKG: perform w/in 10 min of arrival (normal does not guarantee no MI)
CXR: heart size, pneumomediastinum, pulm. congestion, free air)
Labs: troponin, LFTs/lipase, D dimer, CBC, BMP
Additional studies:
- chest CT or V/Q scan: r/o PE
- abd CT: r/o aortic dissection
- cardiac US/echo: heart failure
EKG changes indicative of MI
T wave inversion
ST elevation
Significant Q waves
risks for cholecystitis - 4 Fs
forty
fat
female
fertile
D dimer
a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis (fibrin degradation product)
- helps to dx or rule out thrombosis (blood clot) or dx DIC (disseminated intravascular coagulation)
cardiac markers
troponin: rises w/in 1.5-3 hrs of injury (for acute MI)
- 3 hour repeat troponin to r/o acute MI or risk stratify
CK-MB, myoglobin: not relevant in ED
troponin v. stress test
troponin are for acute MI
stress tests are for CAD
present to ED w/ chest pain - initial treatment and medications
Note: there are algorithms for this (UTD)
IV, pulse ox, monito, EKG (in 10 min)
- Oxygen is sat < 90%
Aspirin (160-325mg, po/pr)
- only thing shown to reduce mortality!
- contraindications: bleeding ulcer, anaphylaxis
Pain control: morphine or fentanyl
Nitrates (NTG)
- sublingual q 5 min x 3
- if pain relieved, nitropaste to chest
- if no pain relief or labile BP, start drip
- contraindicated: hypotensive (BP<90 systolic, HR<50) or RV infarct
nitroglycerin (NTG) treatment - chest pain or suspicion of MI
sublingual q 5 min x 3
- if pain relieved, nitropaste to chest
- if no pain relief or labile BP (fluctuates from normal to high); start drip
Contraindicated: hypotensive (BP<90 systolic, HR<50) or RV infarct
If patient is have an (N)STEMI (based on EKG, troponin levels, etc.) - additional treatment
percutaneous coronary interventions (PCI) - stent
- door to “balloon time” is 90/120 min of ED arrival (120 min if not PCI capable facility and transport needed)
thrombolysis (“-ases”) w/in 30 minutes if not PCI center (can’t balloon)
thrombolytics for acute MI
clotbusters (“-ases”)
- tPA, Streptokinase (SK) , tenecteplase(TNKase), reteplase (rPA)
successful reperfusion rates between 60-80%
main complication is bleeding (rare but often fatal b/c intercerebrayl hemorrhage = ICH)
PCI (Percutaneous Coronary Intervention)
gold standard for acute MI (NSTEMI or STEMI)
- preferred to thrombolytics if available
- door-to-balloon time is ideally within 90 minutes
aka: balloon angioplasty, stenting
chest pain presents to ER - where patient should go from there
telemetry (admit and watch): concerning hx. w/ no ST elevation, pain free, normal troponin
Cardiac ICU: actue MI, ongoing pain, elevated troponin, NTG drip
home (low risks patients):
- low HEART score (0-3)
- two negative troponin, 3 hrs apart
- single lab troponin negative 6 hrs from onset of sx w/ constant pain
once you send for a troponin in ER > opened door to potential cardiac disease - what’s appropriate follow-up
must initiate provocative testing within 72 hours (in outpatient setting)
- stress tests
various stress tests
performed in outpatient setting to assess myocardial health
Treadmill: least expensive, most available, but lowest sensitivity (68%)
Stress echo: no radiation, better sensitivity (80%)
Nuclear Stress Testing: (myocardial perfusion imaging) highly accurate, but radiation, takes longer
chest pain presents to ER (diagnostic tests performed) - risks scores that help to decide next steps
HEART: more appropriate for ED patients (low risk = discharge home = score 0-3)
TIMI: simple but poor predictive value for ED (low risk = score of 0-1)
- used by PCP and cardiac docs
Both: mdcalc.com
HEART score
risk score used to determine if patient should be sent home, admit for clinical observation, or early invasive strategies performed following presentation to ER with chest pain
- 0-3: d/c home for out patient f/u
- 4-6: consider admit
- 7-10: admit and diagnostics
Takes into account:
- History
- EKG
- Age
- Cardiac Risk Factors
- Troponin
Allows for clinical gestalt (judgement)
GI cocktail
mix of medications that can be given to receive chest pain possibly due to indigestion
- caution: can make an MI feel better, so caution if think pt should be admitted (possibly do not want to take away sxs)
cocaine chest pain - basics and what to avoid
stimulatory: leads to vasoconstriction, inc. platelet aggregation, atherosclerosis
- MI occurs in 6% of abusers w/ chest pain
Tx: benzodiazepine (combat agitation, HNT, tachycardia)
AVOID beta blockers > leads to unopposed alpha agonist effect and worsening vasoconstriction
cardiogenic shock
insufficient cardiac output to meet metabolic demands of the tissues
Hypoperfusion = hypotension, tachy or brady-cardia, cool mottled skin, altered mental status, oliguria (dec. urine output)
Emergency!!
left-sided heart failure - sxs
pulmonary edema, frothy sputum, orthopnea (SOB when flat), dyspnea on exertion
systolic dysfunction: EF<40%
right-sided heart failure - sxs
dependent edema, hepatic enlargement, JVD
usually result of left-sided failure
heart failure - CXR findings and labs
cephalization: dilated upper lung vessels
Kerley B lines: horizontal lines of congestion at bases of lungs
overall: pulmonary congestion
Labs: BNP (brain natriuretic peptide)
heart failure - ER treatment
sit up, give O2, nitroglycerin
small amounts of fluid, treat dysrhythmias or electrolyte balance
send for Eco / ADMIT
pulmonary embolism - classic triad of sxs
chest pain, dyspnea, hemoptysis (coughing up blood)
virchows triad
factors thought to contribute to thrombosis
hypercoagulable state venous stasis (or turbulence) endothelial injury: from HNT, etc.
pulmonary embolism - CXR findings
hampton’s hump: wedge shaped opacification suggesting infarct distal to emboli
westermark’s sign: dilation of pulmonary vessels proximal to embolism
hampton’s hump
CXR finding: wedge shaped opacification suggesting infarct distal to emboli
- pulmonary embolism
Westermark’s sign
CXR finding: dilation of pulmonary vessels proximal to embolism w/ collapse of distal vessels
- pulmonary embolism
Homan’s sign
pain w/ squeeze of calf - positive result significant for DVT
phlegmasi cerculea dolens
cyanotic limb due to swelling - positive result significant for DVT
Stanford Type A
classification for aortic dissection: involves ascending aorta (even if also involves descending)
Stanford Type B
classification for aortic dissection: dissection beyond brachiocephalic trunk
cardiac tamponade
blood or fluid in pericardium prevents heart ventricles from expanding fully; excess pressure province heart from working properly
- Beck’s triad: distant heart sounds, hypotension, JVD
- pulsus paradoxus: on exam, detect beats on cardiac auscultation during inspiration that cannot be palpated on radial pulse
- electrical alterans: on EKG - alternating QRS axis
Beck’s triad
distant heart sounds, hypotension, JVD
significant for cardiac tamponade
pulsus paradoxus
on exam, detect beats on cardiac auscultation during inspiration that cannot be palpated on radial pulse
significant for cardiac tamponade
electrical alterans
on EKG - alternating QRS axis
significant for cardiac tamponade
Dresslers Syndrome
pericarditis following MI, surgery or trauma
immune system response after damage to heart muscle (occurs within 1st week after surgery)
Boorhave’s Syndrome
esophageal rupture
- air where it should not be (Hamman’s crunch)
- retching (dry-heaving), vomiting (blood)
- ETOH abuse or ulcer
Hamman’s crunch
crackles that correlate with heart beat (heard on auscultation); heart beating against air-filled tissues (air where it should not be)
happens with:
- esophageal rupture
- pneumomediastinum
- pneumopericardium
acetaminophen
tylenol, non-narcotic, mild or moderate pain
peds 15mg/kg (max adult 4g/day)
analgesia only (no anti-inflammatory or anti platelet)
can use in children <6mo
NSAIDS - Ibuprofen (mortrin, advil) and naproxen (aleve)
non-narcotic, mild or moderate pain, anti-inflammatory, anti-pyretic
peds 10mg/kg (max adult 2400mg/day)
inhibit COX-1 and COX-2 (prostaglandin) synthesis
avoid: kids <6mo, 3rd trimester preg
Ketorolac / Toradol
non-narcotic, IV version of highly effective NSAID
good for renal colic (abd pain caused by kidney stones), migraines
aspirin
use: dec risk of non-fatal MIs, cancer
avoid in children and adolescents (Reyes - brain and liver swelling) and 3rd trimester preg
hydrocodone
oral, narcotic, mild to moderate pain
used in conbo w/ tylenol (Norco, vicodin) or Ibuprofen (vicoprofen)
less potents than oxycodone
fewer side effects than codeine
codeine
oral, narcotic
usually combined w/ aspirin or tylenol
metabolism issues: rapid and poor
great anti-tussive
tramadol
oral, narcotic
good for chronic pain (fibromyalgia)
morphine sulfate
narcotic by which all others compared, IV
3rd fastest of morphine, hydromorphone, and fentanyl
- onset: 5-10min; duration 2-6 hrs
hypotension and pruritis
hydromorphone (Dilaudid)
opioid (narcotic), stronger than morphine sulfate w/ less pruritis, nausea, hypotension
2nd fastest of morphine, hydromorphone, and fentanyl
- onset 3-5 min IV; duration 2-4 hrs
note: great bioavailability when given orally
fentanyl
opioid (synthetic narcotic), 100x more potent than morphine
Fastest of morphine, hydromorphone, and fentanyl (fentanyl = FAST)
- onset 1 min, duration 30-min
Often combined with Versed for “conscious sedation”
comes in many forms: lolli-pop, transdermal patch, IN
Caution: glottic wall rigidity
Reversal agent: Naloxone
conscious sedation
fentanyl with versed
narcotic reversal agents
methadone: used for managing opioid addiction (fatal arrhythmias, QT prolongation)
Suboxone: contains buprenorphine and naloxone; used for managing opioid addiction (ST and LT replacement therapy
Naloxone: opioid antagonist that “kills high” + rapid withdrawal sxs if misuse
Clonidine
can be used for acute opiate withdraw (mainly do sxs managment)
Versed
benzodiazepine
respiratory and CV depression
onset 1 min, lasts 1 hour
