FINAL Flashcards
ASD
-secundum- MC -> percutaneous
-primum
-sinus venousus
-split S2
-elective surgery from 2-5yo
VSD
-hypertrophy of LV and LA
-holosystolic -> increase if small
-membranous, infundibular, muscular, AVSD
-shunt determined by pulmonary artery pressure
-afterload reducers and diuretics
-endocarditis prophylaxis
AVSD
-down syndrome
-splitting of S2
-cardiomegaly on CXR
-tx- surgery in infancy
-pulm banding if premature of <5kg
PDA
-F>M
-RUBELLA
-bounding arterial pulses
-widen pulse pressure
-enlarged heart
-machine like murmur
-tx- indomethacin for premature
-surgery if doesnt close -> ligation + division or vascular coil
aortic stenosis
-supravalvular = williams
-systolic pressure gradient >10mmHg
-mild- 0-25 = 2.5cm jet
-moderate- 25-50
-severe- 50-75
-critical- >75
-tx:
-surgery- resting gradient of 60-80
-subaortic stenosis 40-60 bc rapidly progressive
-balloon- standard of care for KIDS
-AVR- standard for ADULTS
pulmonary stenosis
-if PFO -> R->L -> cyanosis
-Noonan’s syndrome
-mild/asymp- <30
-mod-sev- 30-60; >60
-tx- balloon valvuloplasty
coarctation of the aorta
-turners, M>F
-bicuspid 70%
-dx- BP, doppler echo, imaging (scallop, “3”), cardiomegaly
-CHILD:
-UE>LE BP
-tinnitus, epistaxis, HA
-decrease pulse in LE
-SEVERE- acidosis, shock, HF
-tx- PDE1 for PDA -> surgery
-ADULTS:
-aortic/brain aneurysm/dissection
-CHF, CAD, HTN
-claudication
-F/U- MRI, BP, doppler echo, CAD -> 1-2 years
-tx- balloon angio
Tetralogy of fallot
-MC cyanotic
-VSD, RV hypertrophy, RVOTO, overriding aorta
-severity depends on RVOTO
-tet spells- squat to increase SVR -> AVOID ACE
-dx- boot shaped heart, RAD on ECG, echo
-fu- QRS >180ms, ventricular arrythmia!!, afib, pulm insufficiency, HF -> ECHO and MRI
-sudden death from ventricular arryhtmia possible
-tx-
-PDE1
-surgery within the first year
-palliative- blalock-thomas-tanssig shunt (surgery not possible early)
-surgery- patch VSD, resect RVOTO
truncus arteriosus
-failure of neural crest cells to migrate to bubus cordis
-DiGeorge syndrome
-tx- surgery
transposition of the great vessels- D-type
-RF- mom with diabetes
-dx- echo, CXR -> egg on string
-2 closed systems -> YOU NEED A PDA, VSD, or ASD
-RVH, LV atrophy
-tx- PDE1 for PDA, balloon to open PFO
-surgery within 2 weeks:
-arterial switch
-atrial switch (mustards)
-post op- pacemaker, CHF, transplant, TVR
-bradycardia and atrial dysrhythmia MC
transposition of the great vessels- L type
-aorta to the left
-“Congenitally corrected”
-asymptomatic until adult -> valves give out
-Progressive Heart Failure
-Arrhythmias:
-Sudden cardiac death
-AV block
-Atrial arrhythmias
-Severe AV (tricuspid) regurgitation – TVR:
-Difficult to image using conventional ECHO.
-MRI becoming test of choice for RV function (NOT ECHO)!!!!!
tricuspid atresia
-need a ASD and VSD
-RV atrophy + dilation
-dx- echo
-tx:
-PDE1
-inotropes, ventilation, O2
-surgery:
-norwood-neonate
-glenn- 3-6mo
-fontan- 2-3yrs -> atrial arrythmia, HF, polycythemia (too late at this step)
ebstein anomaly
-RA hypertrophy
-atrialization of RV- sail like tricuspid valve
-TR -> cyanosis if TR -> R->L shunt -> PFO
-CXR- significant cardiomegaly (box)
-RF- lithium
-ECG- WPW
-in an adult -> cyanosis due to TR going through ASD (NOT pulm HTN)
-tx- surgery for significant TR and sx
hypoplastic left heart syndrome
-NEED ASD + PDA
-LV hypoplasia
-MV and AV atresia or stenosis
-40-40 club PO2:PCO2
-dx- echo
-tx:
-PGE1
-surgery:
-norwood
-glenn
-fontan
eisenmenger complications and tx
-coagulopathy
-gout
-clubbing
-brain abscesses
-cerebral microemboli
-airway hemorrhage -> esp if higher altitude
-microcytosis -> stroke
-EPO high
-polycythemia -> phlebtomy for >65% hct and sx or preop
-r/o correctable ds
-once dx -> dont do aggressive testing -> can be fatal
-diuretics, O2
-definitive- transplant
-prostacyclin to delay but $$
CABG indications and vessel
-2- triple vessel ds with sx
-left main stem (>50%)
-LAD (>70%) w/ 2 or 3 vessel ds
-failed medical therapy
-thrombosis or stent restenosis post PTCA
-emergent from cathlab- dissection
-failed graft
-DM2 + multivessel ds
-disabling angina despite tx
-with or without cardiopulmonary bypass
-left internal mammary
-radial artery- allens test
-venous: great saphenous, small saphenous
CABG technique
-thoracotomy via midline
-bypass
-arrest heart
-anastomose distal to stenosis
-complications- postpericardiotomy syndrome- autoimmune febrile pericarditis or pleuritis 1-6wks
-post op acute mediastinitis
-infection, dehiscence, osteomylelitis
aortic insufficiency
-LV dilation/hypertrophy
-increase systolic pressure (SV) and decrease diastolic pressure (EF) -> increase pulse pressure -> hyperdynamic circulation
-bobbing of head, uvula
-quinckes sign- capillary in fingers
-pistol shots over femoral artery
-waterhammer, corrigans
-dx- echo, cath, decrescendo diastolic murmur L sternal border
-causes- aortic root dilation, infective endocarditis, RF, bicuspid
-tx- replace if symptoms
-if asymptomatic and <50% EF -> surgery
-pig for older >70
-mechanical for young <60yo
-if aortic root is >45mm -> root repair
mitral stenosis
-RF
-pulmonary edema, afib, dilated LA
-dx- echo, cath
-diastolic rumble
-anticoagulation with vitamin K antagonist (warfarin, INR 2.5) if afib
-Surgical tx: open commissurotomy (separate) but if leaflets are calcified or degree of fusion is too great then replacement
mitral regurgitation
-mitral prolapse
-dx- echo/cath
-holosystolic murmur from apex to axilla
-biphasic p waves
-afib, enlargement of atrial appendage
-tx-
-HF management- diuretics, ACEi, BB
-surgery -> repair > replacement
aortic dissection
-causes- chronic HTN, deceleration, coarctation, aneurysm, bicuspid aortic valve (turners)
-MC- ascending (type A)
-type B- descending only
-can cause cardiac tamponade, aortic insufficiency, compress kidney and arm arteries
-weak distal pulses
-neck pain
-diff in left and right arm BP
-dx-
-ECG
-CXR- widened aorta
-TEE- unstable
-CT- stable- gold standard
-tx:
-type A- surgery with graft!! or stent
-type B- BB and nitroprusside
-NO THOMBOLYTICS
-BP: goal 100-120
-vaspressors for hypotension (not catecholamines)
-IV BB, cardiazem (Diltiazem), clevidipine (cleviprex)
-vasodilator (IV sodium nitroprusside) for HTN
-morphine
aortic aneurysm
-RF: smoking, male, hx, athero
-infrarenal MC
-lower back pain
-blue toe syndrome
-livedo reticularis
-decrease ABI
-dx- US -> CTA
-SYMPTOMATIC STABLE GET CTA FIRST
->3cm - confirms
-stable- 3-5.4 -> BB, smoking cessation
-4-4.9 repeat US every year
-5-5.4 repeat US every 6mo
->5.5 (5 for women) on CTA -> surgery
->.5cm in a year
-endovascular aneurysm repair (EVAR)- stent graft
-open- bentall and elephant trunk
cardiac surgery complications
-10 days on vent = 10% chance of VAP
-stroke
-pericardial tamponade
-afib- 25%
-sternal wound infection
-post op MI / acute graft closure
catheters
-CENTRAL VENOUS
-if peripheral is unavail
-ionotropes, vasopressors, vasodilating
-TPN
-monitoring central venous pressure
-access for pulmonary artery catheter - swan ganz
-ARTERIAL
-continuous BP monitor
-ABG
-PULMONARY ARTERY CATHETER
-hemodynamic monitor in unstable pts
-guidance of fluid management
-mixed venous sampling
-preop assess prior to cardiac surgery
-assess right heart pressure and pulm HTN
ejection fraction
Normal EF: 55-70%
Borderline EF: 50-55%
Reduced EF: <50%
Severely Reduced EF: <35%
-<35- defib
-preserve- diastolic HF
-low- systolic HF
venous waves
-increase A wave in PS, pHTN, tricuspid stenosis
-C and V combine in tricuspid regurgitation
-increase V in TR
-X and Y gets deeper with constrictive pericarditis
-Y gets shallow with pericardial tamponade
nutrition
-12-25 /kg first 7-10 days
-less calories is better (used to be 30)
-refeeding syndrome- arrythmia from increase electrolytes
-high carbs -> high CO2 -> acidosis
-80% of wt for obese
-CC of tube feed = CC of water
-1.2-2 /kg = protein -> higher for burns, obesity, trauma and lower for renal
-EN = PN
-mixed-oil lipid injectable emulsions (olive oil, triglycerides, oils) or 100% soybean oil lipid injectable emulsions in first week (PN)
-fish oil- or non-fish oil-containing lipid injectable emulsions be provided to pts who are candidates for PN within first week
enteral nutrition
-first line
-initial- 50ml/hr
-increase by 25 ml/hr q 4-8hr until target
-complication:
-aspiration
-perforation
-resp failure
oxygen-hemoglobin dissociation curve
-LEFT SHIFT
-increase affinity for O2
-decrease CO2
-decrease H+
-decrease 2,3DPG
-decrease temp
-HbF
RIGHT SHIFT
-decrease affinity for O2
-increase CO2
-increase H+
-increase 2,3 DPG
-increase temp
-EX. exercise
anion gap
-Na - (Cl + HCO3)
-<12 is normal
-anion gap acidosis- MUDPILES- methanol, uremia, DKA, propylene glycol, INH, lactic acidosis, ethylene glycol, salicylates
-GOLD MARK- ethylene/propylene Glycol, Oxoproline, L/D lactate, Methanol, ASA, renal failure, Ketoacidosis
coagulation
-10a causes prothrombin -> thrombin
-thrombin causes fibrinogen -> fibrin
-heparin + enoxaparin inhibit thrombin
-you need Ca for all of this to work -> supplement
-FFP- coagulation factors
-cryo- fibrinogen -> clots
-platelets, FFP, desmopressin -> increase strength of clots (MA)
-lysis in 30 -> tranexamic acid (TXA) or aminocalproic acid to increase clot stability
transfusion
-1 PRBC, 1 FFP, platelet, Ca, blood warmer
-thrombosis if too much cryo, FFP, platelets
heparin induced thrombocytopenia
-MC with UFH (5%) >LMWH (1%)
-heparin > enoxaparin
TYPE 1
-non immune response
-mild drop in platelets >100,000
-1-2 days after start of heparin- returns to normal when you stop it
-usually no clinical consequence
TYPE 2
-immune mediated
-antibody against heparin platelet factor 4 complex -> bind to Fc receptor -> activates platelet -> white clots
-life/limb threatening condition
-leads to thrombocytopenia, arterial, and venous thromboses
-thrombotic sequelae:
-venous:arterial thrombosis -> 4:1
-DVT (50%), PE (25%), acute limb ischemia (10-20%), warfarin assoc venous limb gangrene (5-10%), acute thrombotic stroke or MI (3-5%)
-50% risk of thrombosis over 30 days if no tx
-thrombotic tendency exist for at least 40 days after stopping
-overall risk - 38-76%
-4-14 days after starting heparin (take into consideration of other recent hospitalizations)
-as soon as 10 hrs after re-exposure to heparin
-has occurred 3-4 days after cessation of heparin
-platelets count decrease to >50% of what it was on admission after 4 days -> particularly if they got unfractionated and LMWH
HIT dx and tx
-consider in anyone with unexplained drop in platelets
-<150,000 or 50% decrease while on heparin
-dx is CLINICAL
-do not wait for lab test results to start tx
-tx:
-d/c ALL HEPARIN (LMWH and flushes, catheters)
-treat immediately
-do NOT wait for lab results
-begin direct thrombin inhibitor -> lepirudin (refludan) or argatroban (acova)
-DTI- dont prolong PT and PTT
-do NOT use warfarin as substitute -> may actually worsen
-continue direct thrombin inhibitor until platelets are normal and need for IV anticoagulation has resolved
-overlap DTI with warfarin for at least 3-5 days
-warfarin start when pt is stable and platelets >100,000 and the DTI is therapeutic
-MONITOR- aPTT or factor 10a
-check every 2-4 hrs until its 1.5-2.5x normal
-check at least daily thereafter
disseminated intravascular coagulation (DIC)
-thrombin generation, fibrinolytic activation, inhibitor consumption
AND
-end organ damage
-clot and lyse -> bleed everywhere
-cause- neuro trauma, burns, infection/sepsis (gram neg), amniotic fluid embolism, cancer
-dx- schistocytes and low platelets
-high PT/PTT
-low fibrinogen
-high d-dimer, thrombin time
-high Cr, LDH (organs)
-tx- underlying cause
-replace factors
-coagulation inhibitors
-platelets transfusions
wounds
-class 1- clean - hernia
-class 2- clean contaminated - elective chole, GI
-class 2- clean contaminated- colorectal surgery
-class 3- contaminated- penetrating trauma, enterotomy
-class 4- dirty- perf diverticulitis, nec fascitis
hypo/hypernatremia
-135-145
-HYPERNATREMIA
-dehydration
-tx- hypotonic solution - D5W or hypotonic saline
-acute- decrease by 1-2/hr
-chronic- decrease by .5/hr
-max 10/day
-HYPONATREMIA
-pontine myelinosis if >25 for 24-48hrs
-limit to 10/day
-cerebral edema
-hypertonic saline -> NOT sodium bicarb
hyper/hypokalemia
-HYPERKALEMIA
-peak t wave
-high LDH
-cause- high WBC, high platelets, cell death (rhabdo, burns, tumor lysis), hypoaldosterone
-CaCl2 10% - 1amp
-Sodium bicarb - 1amp
-D50 and insulin 10u
-beta 2 agonist nebulizer
-kayexalate
-sodium zirconium cyclosilicate
-dialysis
-HYPOKALEMIA
-(K you want - K you have / Cr) x 100 = K you need to replete
-10/hr via IV
-NEED MG TO GIVE K
hyper/hypo calcemia
-HYPERCALEMIA
-nephrolithiasis
-constipation
-GI effects
-arrythmia
-tx- calcitonin, bisphosphonates, denosumab
-diuretics
-HYPOCALEMIA
-prolonged QTC interval
-tetany
-paresthesias
-seizure
-chvostek sign
-trousseau sign- carpal
-tx-
-IV calcium gluconate (severe)
-oral for mild - ca citrate/carbonate
-CHECK MG
hypo/hypermagnesemia
HYPOMAGNESEMIA
-energy, muscle, protein low
-cause- diet, diuretics, massive diarrhea, resus, burns, pancreatitis, SIADH, hyperaldosteronism
-arrythmia -> POST OP AFIB GIVE MG!!!!!!!!
-4.2-4.5 POST OP
-hyperreflexia, seizure
-torsades
-tx-
-magnesium sulfate IV
-rate of 2g/hr
-emergency 2g/5mins
HYPERMAGNESEMIA
-hypothyroid, adrenal insuff, antacid abuse, renal insuff, iatrogenic
-weak, hyporeflexia, paralysis of muscles
-EKG- AV block and prolonged QT and PR
-HYPOTENSION- give in eclampsia
-tx-
-normal saline
-IV calcium gluconate for acute
-loop diuretic
-DIALYSIS
hyper/hypophosphatemia
HYPOPHOSPHATEMIA
-hyperalimentation (after starving), DKA, malabsorption, phosphate binding antacids, alkalosis, hemodialysis, hyperparathyroid
-refeeding syndrome
-HEAD TRAUMA
-myocardial depression bc low ATP -> cardiac arrest
-oxyhemo curve shift to left
-anorexia
-bone pain
-hemolysis
-diaphragm stops working bc no ATP -> cant take off vent
-tx:
-PO replacement (neutrophos) or
-IV KPhos or NaPhos
-keep phosphorous x calcium ration <60
-GIVE MG AT SAME TIME
HYPOPHOSPHATEMIA
-renal insuff, hypoaparathyroid
-metastatic calcification
-tx:
-restriction of phosphate binding antacid (amphogel)
