FINAL CARDS Flashcards
A pt presents with acute intracranial hemmorage, what is the approach to lowering the BP
If the BP is above 220, start lowering tx with IV infusion
If below 220 the lower BP to less than 140 (can cause harm)
A pt presents with acute (less than 72 hrs) with ischemic stroke
What is the BP lowering Tx approach
Does the pt qualify for thrombolytics?
Yes? Then lower BP to less than 185/100-110 in the first hour and before starting thrombolytics then maintain BP less than 180/105 for the first 24 hours.
No?
Is the SBP above 220?
No? Then restart pts BP medication
yes? Lower BP by 15% during the 1st 24hrs
What are the acyanotic congenital heart dz
VSD/ASD (without eisnmenger)
PFO
PDA
Coart
All these are L to R shunts (high pressure to low pressure)
What are the Cyanotic Congenital Heart Dz
Transpo of the Great vessels (incompatible with life)
Truncus Arteriosis ( basically an overriding aorta)
Hypoplastic L heart (pt never develops a left ventricle)
Tetralogy of fallout ( VSD +PS+RVH+Overriding Aorta)
Pentalogy of Fallot (tetra +ASD)
Total Anomolous Pulm Venous return
All are naturally R to L shunts
What are the common risk factors for Congeintal Heart Dz
Genetics Rubella exposure Alcohol while pregnant Multi fetal births DM HTN Connective Tissue Disorders Mood D/o Epilepsy Thyroid D/o
You are evaluating an infant and you heard a harsh systolic murmur over the left scapula or left shoulder
Think >?./
Coart of the aorta
These pts will have life long HTN problems
You are listening to lung sounds and you hear an ejection/ Systolic murmur at the LUSB that increases with inspiration, with a Wide Split S2
Think?
PS
What is the MC obstructive Heart Lesion in Children/ Infants
AS, Harsh sys ejection murmur that radiates to the carotids. Increases with expiration, and increases with hand grip
Where is the common site for Coart to occur
Adjacent to the Ductus Arteriosis
What is the Tx appraoch to Coart (congenital)
Surgical repair, ballon angio
Life long HTN tx
You hear a fixed wide S2 split, tat first is acyanotic and later develops cyanosis, and clubbing
Think what MC congenital HDz later found in adults
ASD
ASD is a L to R shunt that eventually develops RVH and eisnmerger syndrome leading to cyanosis
At what age does the PFO close
At 6 months
A new born presents with HF s/s , poor growths, and has an increased risk of infections,
You hear a pansystolic murmur at the LSB
Think
VSD
These pts present acyanotic and then later can develop eisnmerger syndrome and become cyanotic
Increased R Vent pressure lead to what looks like CHF with Edema in the periphery
O se the shunt reverse these pts has a large apical pulse and pulm congestion
With labored RR, grunting, rib contractions
CXR will show Cardiomegaly and prom pulm arteries
EKG LAE, LVH leading to RVH
What is the Treatment approach to VSD in infants
Is its small and AS/s then f/u at 8-10 weeks
Then again at 12 months
Most will spont. Recovery
If its large
Then Diet intervention 2 prevent wt gain
Dietetics, the ACEI, and SRGRY if PAP is greater than 50mmHg
pts with need ABX prophylaxis for dental and RR procedures for any produced with in 6 months of SRGICAL repair
You hear a continous machine like murmur In a new born, with Lower extremity cyanosis yet uppers are not
What natural pathway of circulation has not closed
PDA
Which normally closes at 1 wk
Leads to LHF to RHF to eisnmerger syndrome leading to LE cyanosis and UE acyanotic
Pt will also have a wide pulse pressure
Tx with SRGY ligation
What is the MC cyanotic Heart lesion
Tetralogy
What are the 4 findings in tetralogy
- VSD
- RVOO (PS)
- RVH
- Overriding aorta
- ASD? =pentalogy
PS leads to RVH leading to Eisnmerger through the VSD, and Cyanosis
Describe the murmur of PS
Sys ejection murmur at the LUSB
With a loud s2 sound
+/- systolic thrill
Prominent RV pulse
A mother says her baby gets cyanotic but then does a squat and is able to keep playing
What is this ?>
Text spell seen in tetralogy
Then squat increases SVR which increase LV pressure
Causing reversal of eisnmergers and reduces cyanosis
What are the later findings of tetralogy in infants
Poor feeding Tets spells Increase HR and BP Cyanosis Syncope Poor growth And late puberty
You see a “boot shaped” heart on CXR
With a right aortic arch
Think
Tetralogy
How do you Dx tetralogy
Gestalt and ECHO!
What is the immediate Tx approach to a baby with tetralogy
Place the knees againt the chest
Start O2
And give fluid bolus
May need to treat HF with morphine, propranolol/ esmolol and then SRGY
(With out SRGY 50% DIE)
What are the major bad outcomes of Tetrology
Pulm regurgition, RV enlargement, RV dysfunction
Aortic root dilation
High risk of developing infectious endocarditis
What is Blue Baby syndrome
Transposition of the Great Arteries
Not comparable with life unless there is a Shunt ( PDA or PFO)
Must give PGE1 to maintain patency of PDA or PFO (NSAIDS WILL CLOSE IT)
Then perform Baloon arterial septostomy (BAS)
You see “egg on a string” pattern on CXR of an infant
What is this?
Transposition of the Great Vessels
describe eisnmenger syndrome
R to L shunt initially
Leads to PULM HTN
Increased RV pressure
Leads to R to L shunt
And Cyanosis
Findings: Hypoxia Polycythemia Increased Thrombus (ESR) Stroke/ ACS
What is the Tx approach toe eisnmenger syndrome
Excercise restrictions and transplant
Mean age of death 37y/0
What are the H/Ts
Hypoxia Hypothermia HyperK HypoK Hypogl Hypovolemic High H+
Tamp Tension Pneumo Toxins Thrombus Pulm Thrombu Cardio
A pt is in cardiac arrest with a ph less than 7.4
What is the most immediate tx to correct acid base
Ventilate!
What is the step by step process to treat hyper K
Give calcium gluconate to stabilize the membrane then give insulin and D50W( if glucose is below 220)
What is a severe K level
Below 3.5 or above 5.5 (7)
What is Becks triad
Muffled Heart tones
JVD
HOTN
Signs of Tamp
Need to centesis
What is the reveresal agent for APAP
N-acetylcytine
What is the reversal method for asprin
Alkaline the blood/ urine
Supportive care
What is the reversal method for TCAs
Alky the urine and blood
Supportive care
What is the reveresal agent for Benzos
Flumazinil
What is the reversal agent for Opiates
Naloxone
What is the reversal agent for Methanol/ Ethenol
Fomepizol/ dialysis
What is the reversal method for BB
Glucagon, + pacing + inotropes
What is the reversal method to CCB
Glucagon, Pacing, and Inotropes
What is the reversal agent for digitalis
DIgibind and close monitoring
A pt presents with unilateral rise and fall of the chest
With absent lung sounds unilaterally
JVD and Tracy deviation of CXR
What is this?
Tension Pneumo
ND the chest and then move up to a chest tube in necessary
A pt presents with new SOB and chest pain , narrow QRS and is TachyHR
Recently went on a long trip and is a cancer survivor
What is the approach to this reversible H/T
This is a PE
Wells criteria greater than 4, goes straight to CTPA
If CKD, pregnant or C/I then V/Q scan or US
(Remember Low risk PE, wells less than 4 get a D-dimer which if less than 400 excludes PE)
If you find a STEMI what do you do
SEND TO PCI SEND TO PCI SEND TO PCI with in 90 minutes or 120
What are the 4 types of syncope
Vasovagal
Cardiac cause
Ortho HOTN
Cardio pulm structure (Exertional/ Non)
A woman was at a baseball game and she stood up to cheer, she felt a warm sensation and passed out
The EMS said that her HR and BP are both low
What type of syncope is this
Vasovagal ( could have been ortho from the quick positional change, but look at the HR and BP they are both low, in Ortho HOTN the BP will go down but the HR will go up)
Describe carotid sinus induced syncope
Often in older men, shaving, or tight collars
Baro receptor stimulation lead se to increase pressure on CN IX and X leading to increase in parasympathetic tone and syncope
(Hr and BP will drop)
What are the key findings of BP in ortho HOTN
SBP drops by 20 or more
DBP drops by 10 or more over 5 min
What are the common meds that cause ortho HOTN
Alpha blockers or A2 agonist
BB blockers, CCB
How does Addison’s disease cause ortho HOTN
Primary adrenal insufficiency leads to decrease aldosterone production
Which leads to low NA retention and there for low water retention
What is the most common cause of syncope from cardiac cause
bradycardia (Sick Sinus syndrome, AVB or sinus Brady)
An elderly man passed out while watching Tv at home
What kind of syncope should be suspected
Cardiac nature
Af RVR? WPW, SVT? VTAc? Prolonged QTC?
Torsaded D Pointes
Or a pacer failure
A young athlete presents with syncope think
HOCM
Describe the murmur of AS
Systolic crescendo decrescendo murmur @ RUSB that rads to the carotids
Describe the murmur of MS
Diastolic murmur that radiates to the apex
Can also have LAE, or Pulm Edma
Describe PS
Systolic murmur heard at the LUSB with a split S2 and increases of inspiration
Describe TS
Diastolic murmur that radiates to the right best heard at the LLSB
What are the holosystolioc murmurs
TR, MR, And VSD
What are the non exertional causes of cardio plum syncope
NYHA C IV HF
Carbon monoxide
COPD exacerbation
What is the admission criteria for pts with syncope
MI! AAA Decomp CHF Valvular HDz Pulm HTN AVB (II-III) WPW Long QTC (eval/observe)
Or ANY SYNCOPE THAT OCCURED WHILE SITTING DOWN/ DRIVING/ Excercising
What is the Lab w/u for syncope
W/u to rule out anemia
HF (BNP)
Ischemia
Pregnancy
A pt just Presents with syncope what should you do
Get and EKG
R/o WPW, BBB, QTci, AVB
When would you put a syncope pt on a holler monitor, loop recorder, or event monitor
Holter if S/s are daily
Event if S/s are weekly
And Loop recorder if S/s are monthly
When should you use ECHO in a syncope pt
To r/o RVOO/ LVOO
And should be done prior to any stress testing
Before you stress test a syncope pt what must you do 1st
ECHO! To r/o RV/LVOO
If you think the pt had a SZR what should you do
Order CT or EEG
If you believe the pts syncope is due to HOTN what test Can be ordered
Tilts test
You hear a diastolic blowing murmur at the LUSB
What is this murmur
AR
A young woman presents with abd pain, plus syncope
Think
Ectopic pregnancy
An old male smoker presents with flank pain plus syncope think
AA dissection
A pt presents with severe sudden HA and syncope think
SAH
A woman present with syncope preceded by a prodrome of warmth/tingling N/V and sweaty
Think
Vasovagal syncope
A cancer pt presents with SOB and syncope think !
PE PE PE
What does CHESS mean for high risk w/u syncope pts
CHF Hematocrit <30 ECG ABNML SOB SBP<90
Pts with any of the above should be admitted and eval/tx
What is the ACLS clinical approach
- Scene safety
- Unresponsive? Active emergency+AED
- Breathing or not Breathing?
Yes? Monitor
No? 4. Pulses?
Yes =rescue breathing
No? 5? Start CPR
6? Shockable Rhythm?
You respond to a cardiac code and there is a shockable rtrhym
CPR is already started
What are the next steps
Rhythm is shockable (vTac/ PVfib) CPR already started (Shock) CPR x2 min (SHOCK+Epi 1mg +Advanced Airway) CPR (Shock +Amio 300/150 plus H/Ts?)
Youre responded to a Cardiac Code and the pt converts from a shockable rhythm to asystole
What is the next steps
Unshockbale Rhythms include asystole and PEA
CPR EPI CRP EPI CPR EPI
Until Rosc or death or conversion to Shockable
You just finished doing CPR and your pt is in ROSC
What are the next steps
- Ensure proper Aiway ( Intubate as needed)
- Maintain SPO2 above 94%
- Maintain PaCO2 within 35-45 (proper ventilation)
- If SBP is below 90 initiate fluids Or if MAP is below 65
(Use inotropes and pressers as appropriate) - Obtain 12 lead to eval for STEMI
(PCI within 90 min )
6.Maintain gl 70-110
Evaluate need for admission
You pt is in ROSC and can follow commands
What is the next step
Admit to ICU
Youre at the END of ROSC and your pt cannot follow commands what is the next step
Start TTM at 32-26*C
Obtain CT and EEG eval for stroke
What are the criteria for stable vs unstable Dx
HOTN
AMS
S/s Shock
CP or HF
What is the Brady Algorithm
Is HR below 50 and pt is S/s
- Stable or Unstable?
Stable= monitor and observe e
Unstable= Atropine 0.5 mg Q3-5min max dose 3mg - Transcutaneous Pacing
Or Rx pacing with Dopamine or EPI
What is the definitive Tx for symptomatic Brady HR
ICD (pacer)
What is ICD (pacer) criteria
Ej fx less than 35% Greater than 40 days s/p MI Greater than 1 year life expectancy NYHA class 4 Sustained VTACH Or Sustained VTACH with an EF <40%
A pt has unsustained VTACH but has an EJFx less than 40%
What is the Tx
ICD
What is the criteria for CRT
EF Fx lesss than 35% New LBBB with wide QRS 2* type I AVB is S/s All 2*type II All 3* AVB
What is the Tachy HR ACLS algorithm
- Asses pt
- Maintain O2 above 94 percent
- Monitor, EKG, IV
- Stable vs Unstable
Stable: Vagal
Look at H/Ts
If regular; Adenosine 6/12/12
Is irregular ask is there any chance of WPW
If no: CCB or BB (verapamil, Carvedilol)
If yes: procanimide
Unstable: (HOTN, CHF, SHOCK, CP, AMS)
-Cardiovert without delay
If narrow and regular: consider adenosine
(Then can consider dyrhtmics Amio, procanimde, sotalol)
- Narrow or Wide (Stable)
Narrow: BB or CCB if no evidence of WPW
Wide: and regular consider Adenosine
If irregular: Amioderne 150 or procanimide
What medication must be avoided in WPW
BB and CCB
How will antidromic RVT present
Wide complex tachycardia
How will orthodromic SVT present
narrow complex SVT
What is the DOC in Stable Monomorph vTac
Procanimide
What are the drugs that can be used as a pill in the pocket approach for Afib
Flecanide and propafenone
If a pt has SVT and is unstable what do we do
Cardiovert
+/- adenosine
What is the criteria to use rate vs rhythm controle
Rate: older pts
Rhythm: younger pts or if the S/s are intolerable or they are athletes
What is the appraoch with rate control
- In older pts with Afib 180-350 bpm
- Start anticoagulant (heparin, warfarin, Apixaban)
- BB or CCB
Metoprolol, Carvedilol
Verapamil or diltiazem
If s/s of HF : digoxin
- Evaluate a CHA2Ds2Vasc
To determine long term aniotcoag tx
A CHADVASC score great than what in men and women means we must start antiocoag tx
Greater than 2 in men and 3 in women
What are the anti coagulation options in Afib after a CHADVASC score is obtained
Score greater than 2 (men) or 3 (women)
Dabigatran unless there is MS, prosethic valve, GFR is less than 30 or they are unstable
Unstable= IV heparin
MS, Prostethic Valve, or GFR <30= Warfarin
An Afib Pt with a CHADVASC score of 5 needs anticoagulant tx
They have a GFR <30
What is the Rx option
Warfarin
Describe rhythm control for Afib
- Must meet criteria for AFIB
- Start immediate anticoagulant
Onset less than 48hrs - Cardiovert
- Rx: Felcaninde, Amio/ Drenedrone, sotalol + Anticoagulant x 1 month
- CHADVASC score
Onset more than 48 hrs
- Anticoagulant x3 wks
- Cardio vert
- Rx: Rx: Felcaninde, Amio/ Drenedrone, sotalol + Anticoagulant x 1 month
A pt presents with Afib and needs to be Cardiovert immediately (*unstable )
What is the appraoch to cardio version for this pt
- Anticoagulant (iv heparin)
- TEE
- Cardiovert
- Rx: Felcaninde, Amio/ Drenedrone, sotalol + Anticoagulant x 1 month
Calc CHADVASC
What are the 4 types of shock
Cardiogenic
distributive
Hypovolemic
Obstructive
describe Cardiogenic shock
CHF
MI
Arrhythmia
S/s Cold clammy
S3 gallop
Crackles in lung fields
+JVP
INCREASED PCWP
INCREASED SVR
DECREASED CO
Tx: inotropes and diuretics
Describe Distributive shock
From sepsis, anaphylactic,
S/s warm, dry, bounding pulses, wide pulse pressure,
DECREASED PCWP
INCRESAED CO
VERY VERY DECREASED SVR
Tx: IVF/ Pressors
Define Hypovolemic Shock
From any acute fluid loss
3rd spacing/ BUrns
S.s cold clammy
DECREASED PCWP
DECREASED CO
INCREASED SVR
Tx: IVF or Blood if loss is greater than 30%
Define obstructive shock
Can be from Tamp, Tension Pnuemo
PE,
S/s Becks triad
INCREASED CVP
DECREADED PRELOAD
DECREASED CO
INCREASED SVR
Tx: relieve obstruction
Denise DO2
DO2 is delivery of O2 to the tissues
COxCaO2
Define C. Output
Sv x HR
Define CaCo2
Concentration of O2 on the Hgb
SaO2 x HbG amount
What are the major causes of Hypovolemia
Hemorrhage, GI bleed, Fistula drainage, DI, Hypergylcemia
Diuretics
What is the gen approach to treating shock
1,. Intubate early and tx O2
- Main Tina cvp> 8 with IVF (NS or LR)
- Maintain map >65 with pressors
- Maintained Hct greater than 30
- Main ting CO with inotropes PRN
- IV access with large bore IV
Remember SHOCK IS TISSUE LEVEL HYPOXIA! NOT HOTN
Describe neurogenic shock
Truama at T5 or above
S/s can last 6 weeks or longer (inflammation vs perm damage)
S/s HOTN, LOW HR, HEAT LOSS, dry skin, and poikilothermia
Tx with pressors as appropriate
Describe anaphylactic shock
Massive vasodilation from histamine responce (mast cells)
Increased cap permeability
Tx with EPI EPI EPI +/- bronchodilator’s PRN
IVF
What is SIRS criteria
A combination of any of the 2:
Temp greater than 38 or less than 36* C
HR greater than 90
RR greater than 30 or PaCO2 less than 32
WBC greater than 12,000 or less than 4,000
SIRS criteria + suspected infection think
Sepsis
SIRS criteria + EOD think
Severe sepsis
Severe Sepsis (Sirs +EOD) + refractory HOTN think
Septic SHock
Describe septic shock
Séquele of conditions that lead to increased coagulation, decreased fibrinolytics,
INCREASED CO with DECRESAED SVR
Hyperdynamic state
DECRESAED UOP
ACIDOSIS form retention and accumulation of lactic acid
Edema (periph perm.)
Profound HOTN and Hypoxia
What are bad lactate and BUN # in septic shock
Lactate greater than 4 is bad
BUN above 16 is bad (sometimes above 12 is bad)
What is the Tx to septic shock
- IVF (2-3 liters) with NS or LR , maybe even blood
Prevent hypothermia
And Coagulation
Maintain map greater than 65
Start TPN within 24 hrs
RX: Epi w/ 6-10 L NS/LR
Or 2-4 L of blood
If refractory HOTN start steroids
Glucose goal is greater than 250
PPI for PUD prevention
What is the infusion criteria for Blood products
HBG less than 7
Or less than 8 with active bleed
Or less than 9 with cardiogenic shock
&7,8,9
If persistant HOTN persists despite IV fluids for 1-2 hours in shock
What is the next step
IV steroids
Define elevated BP
SBP 120-129
DBP less than 80
Define STAGE I HTN
SBP 130-139
DBP 80-89
Define Stage II HTN
Greater than 140/90
Define primary HTN
Common
Silent killer
Leads to MI, Stroke, Aneurysms
Increased Risk with Age Inactivity DM Obesity (Insulin increases Na retention) Smoking FMHX And Diet/ ETOH consumption
What renin level is primary HTN
Low Renin STATE
Describe white coat HTN
Increased HTN in the office with out HTN at home
Describe masked HTN
NML blood pressure in the office with HTN at home
Define Isolated SBP
SBP greater than 120
With DBP less than 80
Define Isolated DBP HTN
SBP lesss than 120
DBP greater than 80
Define secondary HTN
Drug resistant HTN on 3 medications or controlled on 4
Acute onset
Onset less than 30 years old
COntrolled HTN that is not uncontrolled acutely
EOD
Malignant Hyperthermia
Diaostiolic HTN with age greater than 65
Any Hypokalemia state that has HTN
A pt Presesnt with abdominal mass on PE and skin pallor, has frequent UTIs and has refractive HTN
Think
Renal Parynchal Dz
Order Renal US
A pt presents with abdominal systolic bruits, and resistant HTN, that is abrupt onset and getting harder to control,
+flash pulm edema
Think ?
renovasulr Dz
(Young women, older men)
(Fibromuscular hyperplasia)
Order Renal duplex U/s or abdominal CT, MRA
Confirm with a bilateral era al arterial angiography
A pt presents with Afib and refractive HTN, with Hypokalemia, and muscle aches, +/- OSA, and a FMHx of early onset stroke
Think
Primary Aldosteronism 2nd HTN
Order Plasma aldosterone level
Or Sodium loading test
A pt presents with marked obesity and a poor mallanpati score
With resistant HTN
Think
OSA
Calculate epworth scale and order sleep study
A pt presente with fine tremor, Tachy hr, and acute abdominal pain
With resistant HTN
Think
DRUG OR ETOH abuse
NSAIDS, caffeine, cocaine, cyclosporine, tacrolimus clonidine withdrawal
Order drug test
A pt priests with skin stigma tat of neurofibromatiosis with Ortho HOTN
With resitsntat HTN
With palpations, sweating, and HA
Think?
PHEO
Order metanephrines
And CCT of the Abd and pelvis
A pt presents with moon face, truncal obesity, and hirstuisn
With refractory HTN
Think
Cushing’s syndrome
Order dexamethasone test or 24 hr free cortisol
A pt presents with delayed ankle reflex, preiorbital puffiness, and source skin, that is dry, and has cold Intolernce
With refrac HTN
Think
Hypothyroidism
Order T3/T4 TSH
A pt presents with lid lag, fine tremor and warm moist skin, with heat intolerance, insomina and wt loss
Has refrac HTN
Think
Hyperthyroidism
Order TSH, FT4 and Radioactive Uptake scans
A 229 yr old pt presentes with refrac HTN
Has BP greater in up extremities and lower in the LE
Has a continous murmur heard across the upper back
Think
Coart undiagnosed or repaired
Order Echo
And Thoracic/ Abdominla CT angio or MRA
A pt prestent with Refrac HTN and an elevated calcium
Think
Primary Hyper Parathyroid ism
Order a serum calcium and PTH
A pt presents with signs of masculinization with hypertension and Hypokalemia,
Think
Congenital Adrenal Hyperplasia
order Aldosterone to see if low
Elevated 11 beta oh or elevated deoxycortisone
A pt prestent with early onset HTN, with hypo or hyper kalemia, also has arrhythmia (flat T waves) and low aldosterone and renin state
With refractory HTN
Think
Mineral corticoide excess
What labs should be ordered in an acromegaly pt iwth refrac HTN
HGH and IGF1
What antidepressants can lead to refrac HTN 2nd HTN
Duloxetine and Venlafaxine
Switch to an SSRI
A pt has Stage I HTN and a ASCVD risk less than 10%.
What is the tx approach
Goal for their BP is less than 130/80
Unless they are old then only SBP <130
Start non pharm Tx (dash diet or excerise)
And 1 Rx drug
F/u 1 month
If at goal F/u in 3-6 months
If not at goal increase Tx
A pt has stage II HTN
What is the Tx approach
Start on 2 Rx meds
F/u in 1 month
A pt only has elevated HTN, that is not Isolated DBP
What is the tx approach
Non pharm intervention (DASH diet and excercise) F/U in 3-6 months
What are the 1st line medications for lowering BP in the non acute setting
Thiazides (must monitor K and Na)
ACE/ARBS (must monitor for hyper K)
CCB (amlodipe, Verapamil, dilatizem)
If a pt has HTN and HF what is the BP lowering DOC
Furosemide
If a pt has HTN and CKD what is the BP lowering dieruetic of choice
Furosemide
If a pt has primary hyper aldosteronism
And has HTN
What is the BP lowering DOC
Pt will present with muscle cramps/ fatigue, and have low potassium levels
Rx: Spirinolactone
What are the DOC for HTN in HFREF
BB (Carvedilol, bisprolol, and metoprolol)
If a pr has CKD and HTN what is the Tx approach
BP goal is 130/80 or less
Is there albuminuria?
>300
ACE is first line
If Ace intolerant then ARB
What is the Tx approach to a pt with Stable Ischemic HDz and HTN
BP goal is less than 130/80
1st line is a BB + ACE /ARB
If they have CP then add a CCB (amlodipine)
What are tehe pregnancy/ HTN drugs
Methyldopa
Labetalol
Nifedipine
What is the approach to a pt with HTN emergency
BP is greater than 180/120 with evidence of EOD
1 admit to the ICU
- Is there a PHEO, preclampsia, or AA discretion?
Eclampsia or PHEO= Lower BP to less than 140 in 1st hour (Nicaridpine)
If AA discretion= lower to less than 120 in first hour
If none of the above is present then lower BP by 25 % in 1st hour then to 160/100 in 2-6 hours then to NML within 24 hrs
A pt prestns with a BP 180/100, bust has no evidence of EOD
What is the approach
Restart oral medication
What is the appraoch to a pt with HTN and ischemic stroke
Is the Pt a candidate for fibrinolytics ?
Yes?
Lower BP to 180/110 before starting fibrinolytics
Then to 180/110 for the first 24 hours
How many blood pressure readings do you need to Dx HTN
at least 2 separate measurements on at least 2 separate occasions are necessary to diagnose a patient with hypertension.
What is the BP goal for pts older than 65
SBP less than 130
A pt with Stage II HTN and Ischemic HT Dz should ge t what specific BB
Carvedilol, metoprolol or Metoprolol
A pt has HTN with HEpEF
What are the appropriate medications for Tx the HTN
for HFpEF, any combination of two 1st agents would be appropriate (thiazide, CCB, ACE-I or ARB)
if a patient has stage 2 HTN with primary hyperaldosteronism. What Rx should be started
spironolactone should be started in combination with one other 1st line agent (thiazide, CCB, ACE-I or ARB)
Pts on thiazide diuretic are at risk of what electo abNML
HypoNa+ and Hypo K+
What are the three main renal parenchyma Dz
Diabetic nephropathy
Glomelurlos Nephritis
Polyscytic Kidney
Will presten with an abdominal mass, frequent UTI
Hematuria, anagelsia abuse, elevated serum cr.
A pt presesnt with HypoK, Hyper Na+
And HTN with Met Alky
Think
hyperaldostro
What type of HTN does Hyperparathyroidsim lead to
It’s a cause of 2nd HTN and leads to Isolated Systolic HTN
What kind of HTN does Hypothyroidsm lead to
2nd HTN
With increased renal retention of Na+
So elevated DBP
What kind of HTN does Hyperparathyroidsm lead to
2nd HTN with hypercalcemia that leads to increased Peripehrl resistant
How does Birth Control raise BP
Positve effect on angiotensinogen
What is the perferred HTN emergency Rx in ACS
Nitro
What is the Major ADE of Sodium Nitroprusside
Cyanide Toxic
What is the preferred Rx for HTN emergency in preeclampsia
Hydralazine
How should enalaprit be used in HTN emergency
Indicated for high renin HTN Emergency
Contraindications: pregnancy, renal artery stenosis, angioedema, renal insufficiency, hyperkalemia
What are the perferred Rx for HTN emergency Rx with PHEO
nicardipine
What is the preferred Rx in HTN emergency for abdominal Dissection
Esmolol
What is the perferred Rx in HTN emergency due to cocaine
Phentolamine
What are the indications for an ICD
NYHA 2-3 with EF ≤35%
(> 40 days after MI)
NYHA 4
Survivor of Sustained VT Cardiac Syncope
Non-Sustained VT Cardiac Syncope with EF ≤40%
All require > 1 year life expectancy!
A continuous machine like murmur best heard of the pulmonic area
Is what
PDA
What is always the 1st step in evaluating syncope
EKG!
Pts with VTACH that fail Cath ablation should get what intervention
ICD
What is always the best 1st answer in unstable tachycardia with a pulse
Synch Cardioversion
What is always the best answer in Stable Narrow complex Tachycardia
Vagal and adenosine
How will posterior wall MIs always present
Tall R wav with St depression in V1 V2 or V3
With St elevations in II, III, AVF
A pt has a heart score of 1-3
What is the approach to Tx
Dc home and encourage PCM follow up
A pt has a Heart score greater than 3 and a timi of 1-2
What is the appraoch
Non invasive stress testing
If the heart score and time score is greater than 3 with a grace over 140
What is the appraoch
12 hour procedure time
OMI+MONA+BASHC
If grace is 109 but not over 140 then 72 hours
What would make a pt high risk with ah heart score greater than 3 that would require 2 hr invasive angio?
Cardiogenic shock LV dysfunction or HF Persistnet angina Mitral regurgitation New VSD Sustained VTACH
What is an adequate UOP
Greater tahn 0.5 ml/kg/hr
What is the lactate goal in Shock
Less than 4
If a pt has Hf and is warm and dry what is the tx
Out pt diuretics
Hf that is warm and wet
What is the tx
Inpt furosemide
Hf that is cold and dry
What is the Tx
ICU inotropes
HF that is Cold and wet
What is the tx
Inotropes + diuretics, + vasodilators
If a pt is not making urine what is the necessary intervention
Hemmofiltariotn
If a hf pt does not respond to inoptrops what is the solution
Mechanical intervention IABP LVAD ect
Pulm embolism can lead to what acid base
Resp Alky
What does mud piles stand for
Methanol Uremia DKA Propylene Isoniazid/ iron Lactic Acidosis Ethylene Salicylic acid
If a pt has low Albumin how is the Anion gap corrected
Corrected AG (CAG) = AG +2.5 (4-Albumin)
Example if AG is 12 and Albumin is 2
Corrected AG = 12 + 2.5(4-2) = 17
If CAG is high for the patient, look for cause: MUDPILES
Aortic stenosis effects the S2 sound how
Paradoxical split that is eliminated on inspiration
What murmur presents with a fixed S2 split
ASD
Wha are the two criteria to surgical correct a VSD
HF or PAP greater than 50
You hear an continous machine like murmur
What other finding would accompany this Murmur
Widend pulse pressure
this is a PDA
