L4: Cardiac, Vascular, and Pulmonary emergencies Flashcards
Classic angina history
Pressure, heaviness, tightness, fullness, or squeezing in the center or left of the chest
Precipitated by exertion
Relieved by rest
+/- Radiates to shoulder, arms, neck, jaw
Indicates ischemic event in coronary arteries
Angina equivalents for atypical presentation in women, elderly, diabetics
SOB N/V diaphoresis fatigue dizzy/lightheaded weak palpitations syncope
Angina labs
CBC CMP D-Dimer Lipids BNP Troponin \+/- CK-MB
Stable angina
Substernal chest pain 2-5 minutes
Symptoms are stable, resolve with rest
Unstable angina
Increasing severity/frequency/duration OR occurs at rest
ST depression or T inversion with normal troponin
NSTEMI
Non-occlusive thrombus, ischemia
ST depression or T inversion with elevated troponin
STEMI
Occlusive thrombus,
transmural infarction
ST elevation or new left bundle branch block or true posterior MI
Acute coronary syndrome encompasses
Unstable angina + MI
MI=NSTEMI, STEMI
Heart score
0-2 points based on criteria: Suspicious history ECG changes Age Number of risk factors Initial troponin value
TIMI score
Age > 65 >3 CAD risk factors Known CAD ASA use in past 7 days Severe Angina ECD changes Positive cardiac marker
What is a positive high-sensitivity troponin?
(+)= Acutely increased hs-cTn >100 ng/L
(+)= <100 ng/L but 2 hour delta >10ng/L
high-sensitivity troponin aka
hs-cTn Assay
How to rule out MI using cardiac enzymes
Negative enzymes 4-6 hours after symptom onset
Negative enzymes <4-6 hours after onset
repeated at 2 hours and still negative
When to do stress testing
ONLY if unsure of ACS
Stress echocardiogram
Can be done exercise or pharmacologic (dobutamine)
Radionucleotide Myocardial Perfusion Imaging
AKA nuclear stress test
Perfusion defect/ hypoperfusion visualization
During stress testing, monitor _____ and stop the test if _______
Monitor: BP, ECG changes, echo
Stop test: CP, SOB, ST changes, decreased BP, ventricular arrhythmias
Initial management for all Acute Coronary Syndrome patients
Aspirin + Analgesia
Stable angina diagnostics
No ECG changes
No enzyme elevation
(-) stress test (most)
Stable angina management
+/- Angiography for PCI interventions
Nitrates→ SL nitroglycerin PRN
Q5 min, >3 doses→ ER
Beta blockers
+/- CCB
Antiplatelet: ASA (81-325 mg), Clopidogrel, or combo
Prinzmetal’s angina aka
Variant angina
Vasospastic angina
Prinzmetal’s angina presentation
5-12 minute angina episodes
Usually at rest between midnight and early morning
Prinzmetal’s angina diagnostics
EKG→ ST elevation during episodes
Rule out MI→ serial cardiac enzymes
Holter monitor
Coronary angiography→ diagnostic
Prinzmetal’s angina management
Nitrates
CCBs
Contraindications to use of Nitrates
hypotension
RV infarct/inferior MI recent PDE5 inhibitors (sildenafil)
STEMI symptoms
Chest pain/heaviness/pressure
SOB, radiates to arm, neck, back
Weakness, fatigue, diaphoresis
N/V. Palpitations, dizziness, syncope
Management of a STEMI
ABCs Telemetry, IV access SL nitro, ASA 325 chewed Call Cardiology→ cath lab Percutaneous coronary intervention Extensive disease→ CABG
Your patient is having a STEMI but PCI isn’t available quickly….
if not available within 120 minutes, consider fibrinolytics
NSTEMI or UA management
ABCs
Telemetry, IV access
SL nitro
PCI, no fibrinolytics
When is PCI contradicted? What is the management in these cases for UA/NSTEMI?
Renal failure, sepsis, unstable patient medically manage with continuous IV heparin and ASA
Which parts of MONA (Morphine, Oxygen, Nitro, Aspirin) are being phased out, and why?
Morphine→ inhibits absorption of platelet meds, associated with increased mortality
Oxygen→ use when not associated with hypoxia may increase early myocardial injury and increase infarct size
Gold standard for CAD
Coronary angiography Threaded through femoral vessels to heart→ dye→ patency assessed via fluoroscopy: Percutaneous Coronary Intervention Angioplasty Stenting
Indications for Coronary Artery Bypass Graft
Multi-vessel disease, large area of potentially ischemic myocardium
Anatomic complexity of lesions
Likelihood of successful revascularization with PCI
Comorbidities
Peri-infarction Pericarditis
Occurs 2-3 days after MI, transient
Auscultate: Pericardial rub
Echo→ pericardial inflammation +/- effusion
Peri-infarction Pericarditis treatment
Supportive, self limited
Tylenol
ASA+/- colchicine
Avoid NSAIDs
Acute Pericarditis which ISN’T post-cardiac injury syndrome
Infectious radiation drugs toxins uremia myxedema ovarian hyperstimulation syndrome breast/lung cancer hodgkin lymphoma mesothelioma collagen vascular disease, immune-related idiopathic
Acute pericarditis: post-cardiac injury syndrome
MI
pericardiotomy
trauma
Acute pericarditis EKG
diffuse ST elevation on most beats
Symptoms of cardiac tamponade
CP, tachypnea, dyspnea
Sinus tachycardia, pericardial rub, pulsus paradoxus
Beck’s triad
Beck’s triad (cardiac tamponade)
hypotension
JVD
muffled heart sounds
Cardiac tamponade diagnostics
EKG→ sinus tachycardia, low voltage, electrical alternanas
CXR→ enlarged cardiac silhouette
Echo→ effusion with tamponade
Cardiac tamponade tx
Drainage of pericardial effusion:
- Percutaneous/pericardiocentesis
- Surgical +/- pericardiectomy
Monitoring:
Telemetry
Vital signs x 24-48 hours
Repeat echo prior to discharge
Acute mitral regurgitation
Caused by ischemia to papillary muscle
LV dilation
true aneurysm
papillary muscle/choral rupture usually 2-7 days after infarct
Acute mitral regurgitation on physical exam
Hypotension
New murmur
Acute mitral regurgitation diagnostics
Transthoracic echo
If inconclusive: Transesophageal Echo
Acute mitral regurgitation treatment
emergency surgery
Dressler’s syndrome occurs
Weeks to months after MI, cardiac surgery, cardiac trauma, pulmonary embolism
Dressler’s syndrome AKA
Post-cardiac injury syndrome
Dressler’s syndrome presentation
Pleuritic chest pain, fever, malaise
Pericardial friction rub
Dressler’s syndrome diagnostics
Labs→ leukocytosis, elevated ESR
CXR→ pleural and or pericardial effusion or pulmonary infiltrates
Dressler’s syndrome tx
NSAIDS
Refractory→ corticosteroids, colchicine
Endocarditis
Bacterial growth on heart valves
Risk of endocarditis
Artificial valves Congenital heart defects Damaged valves IVDU Poor dentition or infection Past history of
Endocarditis signs/symptoms
SOB fever chills chest pain cough orthopnea fatigue Janeway lesions (palms) Osler nodes (DIP) Splinter hemorrhage (nail beds) Roth spots (retina)
Endocarditis diagnosis
Modified Duke Criteria:
2 major
1 major + 3 minor
5 minor
Endocarditis labs and imaging
Labs→ blood cultures x 3 before abx
Leukocytosis
Elevated ESR
Echo→ vegetation on valves
Endocarditis tx
Abx x 6 weeks
Empiric→ Vancomycin + Rocephen
Targeted→ blood culture results
Refractory→ surgery (½ of cases)
CHF presentation
SOB fatigue diaphoresis cough orthopnea PND early satiety 2+ bilateral LE edema Crackles tachypnea tachycardia JVD S3/S4
Acute, ED management of CHF
Echo→ look at ejection fraction, valves, pericardium, wall motion abnormalities
IV access, control airway, O2, telemetry
Furosemide
Sodium + fluid restriction
Strict I+O, daily weights
+/- Inotrope
Long term management of CHF
BB
ACEI
Diuretics
+/- digoxin
Beta blockers + CHF?
avoid beta blockers in acute, unstable, uncompensated failure
May be used for long term management
Hypertensive crisis is blood pressure….
SBP >180
DBP >100
Hypertensive Urgency
no end organ damage
Hypertensive Emergency
acute end organ damage:
Cerebrovascular, ophthalmologic, cardiac, renal
Possible secondary causes of hypertension
Sleep apnea Renal artery stenosis Pheochromocytoma Coarctation of the aorta Pseudotumor cerebri Chronic steroid therapy Cushing’s syndrome Thyroid or parathyroid disease Primary hyperaldosteronism Pregnancy
Hypertensive crisis workup
BP in both arms
ECG
Labs→ UA, urine drug screen, CBC, CMP, cardiac enzymes, TSH, urine metanephrines
Imaging→ +/- CXR, heart CT, CTA chest + abdomen
Assess for end-organ compromise
Assess for end-organ compromise in hypertensive crisis by system
Neurologic→ LOC, visual fields, focal motor/sensory deficits
Ophthalmologic→ fundoscopic exam: retinal hemorrhages, papilledema, AV nicking
Cardiovascular→ elevated JVP, lung crackles, murmur, asymmetrical pulses
Renal→ urine output, BUN/Cr
Established hypertension, hypertensive urgency treatment
Increase dose of current meds, add additional meds
Adherence to sodium restriction
New diagnosis of hypertension, hypertensive urgency treatment
Blood pressure reduction over several hours
Hypertensive Emergency tx
Hospitalize→ ICU
Workup secondary causes
Treat end organ damage (not BP)
Reduction of BP→ slow
Reduce mean arterial pressure by 20-25% in 1 hour
IV labetalol or continuous Nicardipine infusions (easier to titrate)
Transition to oral therapy→ once stabilized
Most aortic aneurysms are…
abdominal (90%)
Classic patient with an aortic aneurysm
elderly male smoker
CAD
emphysema
+/- renal impairment
Thoracic aortic aneurysm presentation
Substernal back/neck pain \+/- dyspnea stridor cough dysphagia hoarseness SVC syndrome Most commonly “tearing chest pain”
How is aortic aneurysm diagnosed?
Risk determined on size of aneurysm, can be asymptomatic, incidental finding
CXR/CT→ widened mediastinum
Medical management of a thoracic aortic aneurysm
Aggressive BP + HR control→ Beta blockers
SBP<120, HR 60-80
Serial Imaging, CT, MRA at 6 months
When to surgically manage a thoracic aortic aneurysm
symptomatic
>5.0 cm
rapid expansion >.5 cm in 6 months
Abdominal aortic aneurysm presentation
Pulsating abdominal mass +/- abdominal/back pain
Complications→ rupture, aneurysm thrombosis, thromboembolism
If ruptured→ hypotension, hemodynamic instability
When to observe an abdominal aortic aneurysm
Asymptomatic <5.5 cm→ surveillance, risk factor modification, ultrasound q6-12 months
When to do surgery for an abdominal aortic aneurysm
> 5.0 cm
rapid expansion >.5 cm in 6 months
associated with peripheral arterial aneurysm or PAD
Aortic dissection
Inner layer of the aorta tears, blood surges through the tear→ rest of aorta layer dissect
Rupture through the outside aortic wall→ fatal
At risk for aortic dissection
uncontrolled HTN Atherosclerosis pre-existing aortic aneurysm bicuspid aortic valve aortic coarctation Marfan’s Cocaine Pregnancy male age
Thoracic aortic dissection presentation
Ripping/tearing chest pain radiating to the back
Signs of hemodynamic compromise
Abdominal aortic dissection presentation
Severe back/abdominal/flank pain + hypotension, shock
Signs of hemodynamic compromise
Stable aortic dissection imaging
CT angiography
Unstable aortic dissection imaging
multiplanar transesophageal echo
For an Unstable aortic dissection
always intubate
Acute ascending thoracic dissection (type A) treatment
Cardiac surgical emergency
Descending thoracic aortic dissection (type B)
Managed medically if stable, no end-organ complications
Admit to ICU, consult vascular surgery
Morphine,
IV Esmolol→ SBP 100-120, HR<60
De Bakey Type I
Aortic aneurysm
Originate in ascending aorta, propagates to aortic arch or beyond
De Bakey Type II
Aortic aneurysm
Originates in and is confined to the ascending aorta
De Bakey Type III
Aortic aneurysm
Originates in the descending aorta, can extend in either direction but more commonly distally
Standford Type A
Aortic aneurysm
All dissections involving the ascending aorta regardless of site of origin
Standford Type B
Aortic aneurysm
All dissections not involving the ascending aorta
Causes of acute arterial occlusion
Embolus: Cardiac: Afib, MI, endocarditis, valvular disease, prosthetic valves Arterial: Aneurysm, atherosclerotic plaque
Paradoxical embolus
Thrombosis: Vascular grafts atherosclerosis aneurysm entrapment syndrome hypercoagulable state low flow state
Trauma
Blunt, penetrating, iatrogenic
Acute limb ischemia
Sudden decrease in limb perfusion→ threat to limb liability
Acute mesenteric ischemia
Acute, sudden onset of intestinal hypoperfusion
Acute limb ischemia presentation
Ischemic rest pain Gangrene Hours to days New/worsening claudication, paralysis *6 P’s*
Acute mesenteric ischemia presentation
Acute embolic occlusion:
Elderly
afib
severe abdominal pain
Mesenteric thrombosis: PAD chronic postprandial pain food aversion weight loss \+/- hematochezia
Embolus vs thrombosis
acute arterial occlusion
Embolus→ sudden, dramatic onset
Thrombosis→ gradual
6 P’s of acute limb ischemia
pain pulselessness pallor paresthesias paralysis poikilothermia
Diagnosis of acute limb ischemia
Bilateral neuro exam→ sensation, strength
Pulses→ Doppler posterior tibialis, dorsalis pedis
Ankle brachial index (ABI)
Diagnosis of acute mesenteric ischemia
CT angiography (imaging of choice)
KUB→ diagnose complications, but can’t diagnose ischemia
Initial management of all acute limb ischemia
Anticoagulation
Close monitoring
Exam worsens→ surgery
Management of acute limb ischemia if the limb is viable
Anticoagulate, then do CTA
MRA→ monitor progression
Management of acute limb ischemia if the limb is threatened
Immediate surgical revascularization→ intraoperative arteriography
acute mesenteric ischemia management
Systemic anticoagulation
Pain management
+/- angioplasty with stent
Peritoneal signs→ +/- exploratory laparotomy
DVT risk factors
Virchow’s triad Recent surgery Prolonged bed rest Oral contraceptives Hormone replacement therapy Factor V leiden Recent trip Malignancy
Virchow’s triad
stasis of blood flow
endothelial injury
hypercoagulability
DVT presentation
Lower extremities or pelvis > upper extremities
Swelling, pain/discomfort
Unilateral edema
Erythema, warmth
DVT diagnosis
Duplex ultrasound (test of choice)
Venography
Elevated D-Dimer
DVT management
Anticoagulation:
Low molecular weight heparin (Lovenox)
Warfarin+heparin bridge
New oral anticoagulants
DVT prevention in bedridden patients
Elevate foot of bed
Leg exercises, compression hose
High risk→ anticoagulation
DVT perioperative or travel prevention
Early or frequent ambulation
Leg exercises, compression hose
Risk factors for pulmonary embolism
the same as for DVT
Pulmonary embolism presentation
Acute onset Chest pain or SOB Cough Hemoptysis Syncope Tachypnea Tachycardia Hypoxia \+/- unilateral extremity edema
Pulmonary embolism diagnosis
Elevated D-dimer
ECG→ sinus tachycardia, S1 Q3 T3 (rare)
CXR→ usually normal
Rare: hampton’s hump, westermark sign
Pulmonary angiography CTA (gold standard)
CTA contraindicated→ V/Q perfusion scan→ high, low, intermediate probability
LE doppler→ evaluate for DVT
Pulmonary embolism management
O2, IV access, Cardiac monitoring
Anticoagulation:
Unfractionated heparin, MWH, warfarin, rivaroxaban, pradaxa
Stabilizes, prevents migration, prevents additional thrombi
Risk: minor/major bleeding
+/- thrombolytics, IVC filter, embolectomy
Diagnostic interventions for pulmonary embolism according to Well’s criteria
0-4 pts→ PE unlikely→ D-dimer
> 4 pts→ PE likely→ CTA
Well’s criteria risk based on points:
Low <2 pts
Intermediate 2-6 pts
High risk >6 pts
Well’s criteria
3 points: signs/symptoms of DVT 3 points: PE is most likely diagnosis 1.5 points: tachycardia >100 bpm 1.5 points: Immobilization/surgery in last month 1.5 points: Prior DVT/PE 1 point: Hemoptysis 1 point: Active malignancy
Tension pneumothorax
one-way valve, air can enter pleural space during inspiration but can’t exit
Who gets a primary/spontaneous pneumothorax?
Tall, young males
Who gets a secondary pneumothorax?
COPD
CF
Pneumonia
Malignancy
Who gets a tension pneumothorax?
Trauma
CXR of tension pneumothorax
tracheal deviation
hemodynamic instability
