L4: Cardiac, Vascular, and Pulmonary emergencies Flashcards
1
Q
Classic angina history
A
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
2
Q
Angina equivalents for atypical presentation in women, elderly, diabetics
A
SOB N/V diaphoresis fatigue dizzy/lightheaded weak palpitations syncope
3
Q
Angina labs
A
CBC CMP D-Dimer Lipids BNP Troponin \+/- CK-MB
4
Q
Stable angina
A
Substernal chest pain 2-5 minutes
Symptoms are stable, resolve with rest
5
Q
Unstable angina
A
Increasing severity/frequency/duration OR occurs at rest
ST depression or T inversion with normal troponin
6
Q
NSTEMI
A
Non-occlusive thrombus, ischemia
ST depression or T inversion with elevated troponin
7
Q
STEMI
A
Occlusive thrombus,
transmural infarction
ST elevation or new left bundle branch block or true posterior MI
8
Q
Acute coronary syndrome encompasses
A
Unstable angina + MI
MI=NSTEMI, STEMI
9
Q
Heart score
A
0-2 points based on criteria: Suspicious history ECG changes Age Number of risk factors Initial troponin value
10
Q
TIMI score
A
Age > 65 >3 CAD risk factors Known CAD ASA use in past 7 days Severe Angina ECD changes Positive cardiac marker
11
Q
What is a positive high-sensitivity troponin?
A
(+)= Acutely increased hs-cTn >100 ng/L
(+)= <100 ng/L but 2 hour delta >10ng/L
12
Q
high-sensitivity troponin aka
A
hs-cTn Assay
13
Q
How to rule out MI using cardiac enzymes
A
Negative enzymes 4-6 hours after symptom onset
Negative enzymes <4-6 hours after onset
repeated at 2 hours and still negative
14
Q
When to do stress testing
A
ONLY if unsure of ACS
15
Q
Stress echocardiogram
A
Can be done exercise or pharmacologic (dobutamine)
16
Q
Radionucleotide Myocardial Perfusion Imaging
A
AKA nuclear stress test
Perfusion defect/ hypoperfusion visualization
17
Q
During stress testing, monitor _____ and stop the test if _______
A
Monitor: BP, ECG changes, echo
Stop test: CP, SOB, ST changes, decreased BP, ventricular arrhythmias
18
Q
Initial management for all Acute Coronary Syndrome patients
A
Aspirin + Analgesia
19
Q
Stable angina diagnostics
A
No ECG changes
No enzyme elevation
(-) stress test (most)
20
Q
Stable angina management
A
+/- Angiography for PCI interventions
Nitrates→ SL nitroglycerin PRN
Q5 min, >3 doses→ ER
Beta blockers
+/- CCB
Antiplatelet: ASA (81-325 mg), Clopidogrel, or combo
21
Q
Prinzmetal’s angina aka
A
Variant angina
Vasospastic angina
22
Q
Prinzmetal’s angina presentation
A
5-12 minute angina episodes
Usually at rest between midnight and early morning
23
Q
Prinzmetal’s angina diagnostics
A
EKG→ ST elevation during episodes
Rule out MI→ serial cardiac enzymes
Holter monitor
Coronary angiography→ diagnostic
24
Q
Prinzmetal’s angina management
A
Nitrates
CCBs
25
Contraindications to use of Nitrates
hypotension
| RV infarct/inferior MI recent PDE5 inhibitors (sildenafil)
26
STEMI symptoms
Chest pain/heaviness/pressure
SOB, radiates to arm, neck, back
Weakness, fatigue, diaphoresis
N/V. Palpitations, dizziness, syncope
27
Management of a STEMI
```
ABCs
Telemetry, IV access
SL nitro, ASA 325 chewed
Call Cardiology→ cath lab
Percutaneous coronary intervention
Extensive disease→ CABG
```
28
Your patient is having a STEMI but PCI isn't available quickly....
if not available within 120 minutes, consider fibrinolytics
29
NSTEMI or UA management
ABCs
Telemetry, IV access
SL nitro
PCI, no fibrinolytics
30
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
31
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
32
Gold standard for CAD
```
Coronary angiography
Threaded through femoral vessels to heart→ dye→ patency assessed via fluoroscopy:
Percutaneous Coronary Intervention
Angioplasty
Stenting
```
33
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
34
Peri-infarction Pericarditis
Occurs 2-3 days after MI, transient
Auscultate: Pericardial rub
Echo→ pericardial inflammation +/- effusion
35
Peri-infarction Pericarditis treatment
Supportive, self limited
Tylenol
ASA+/- colchicine
Avoid NSAIDs
36
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
```
37
Acute pericarditis: post-cardiac injury syndrome
MI
pericardiotomy
trauma
38
Acute pericarditis EKG
diffuse ST elevation on most beats
39
Symptoms of cardiac tamponade
CP, tachypnea, dyspnea
Sinus tachycardia, pericardial rub, pulsus paradoxus
Beck’s triad
40
Beck's triad (cardiac tamponade)
hypotension
JVD
muffled heart sounds
41
Cardiac tamponade diagnostics
EKG→ sinus tachycardia, low voltage, electrical alternanas
CXR→ enlarged cardiac silhouette
Echo→ effusion with tamponade
42
Cardiac tamponade tx
Drainage of pericardial effusion:
1. Percutaneous/pericardiocentesis
2. Surgical +/- pericardiectomy
Monitoring:
Telemetry
Vital signs x 24-48 hours
Repeat echo prior to discharge
43
Acute mitral regurgitation
Caused by ischemia to papillary muscle
LV dilation
true aneurysm
papillary muscle/choral rupture usually 2-7 days after infarct
44
Acute mitral regurgitation on physical exam
Hypotension
| New murmur
45
Acute mitral regurgitation diagnostics
Transthoracic echo
If inconclusive: Transesophageal Echo
46
Acute mitral regurgitation treatment
emergency surgery
47
Dressler's syndrome occurs
Weeks to months after MI, cardiac surgery, cardiac trauma, pulmonary embolism
48
Dressler's syndrome AKA
Post-cardiac injury syndrome
49
Dressler's syndrome presentation
Pleuritic chest pain, fever, malaise
| Pericardial friction rub
50
Dressler's syndrome diagnostics
Labs→ leukocytosis, elevated ESR
| CXR→ pleural and or pericardial effusion or pulmonary infiltrates
51
Dressler's syndrome tx
NSAIDS
| Refractory→ corticosteroids, colchicine
52
Endocarditis
Bacterial growth on heart valves
53
Risk of endocarditis
```
Artificial valves
Congenital heart defects
Damaged valves
IVDU
Poor dentition or infection
Past history of
```
54
Endocarditis signs/symptoms
```
SOB
fever
chills
chest pain
cough
orthopnea
fatigue
Janeway lesions (palms)
Osler nodes (DIP)
Splinter hemorrhage (nail beds)
Roth spots (retina)
```
55
Endocarditis diagnosis
Modified Duke Criteria:
2 major
1 major + 3 minor
5 minor
56
Endocarditis labs and imaging
Labs→ blood cultures x 3 before abx
Leukocytosis
Elevated ESR
Echo→ vegetation on valves
57
Endocarditis tx
Abx x 6 weeks
Empiric→ Vancomycin + Rocephen
Targeted→ blood culture results
Refractory→ surgery (½ of cases)
58
CHF presentation
```
SOB
fatigue
diaphoresis
cough
orthopnea
PND
early satiety
2+ bilateral LE edema
Crackles
tachypnea
tachycardia
JVD
S3/S4
```
59
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
60
Long term management of CHF
BB
ACEI
Diuretics
+/- digoxin
61
Beta blockers + CHF?
avoid beta blockers in acute, unstable, uncompensated failure
May be used for long term management
62
Hypertensive crisis is blood pressure....
SBP >180
| DBP >100
63
Hypertensive Urgency
no end organ damage
64
Hypertensive Emergency
acute end organ damage:
| Cerebrovascular, ophthalmologic, cardiac, renal
65
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
```
66
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
67
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
68
Established hypertension, hypertensive urgency treatment
Increase dose of current meds, add additional meds
| Adherence to sodium restriction
69
New diagnosis of hypertension, hypertensive urgency treatment
Blood pressure reduction over several hours
70
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
71
Most aortic aneurysms are...
abdominal (90%)
72
Classic patient with an aortic aneurysm
elderly male smoker
CAD
emphysema
+/- renal impairment
73
Thoracic aortic aneurysm presentation
```
Substernal back/neck pain
+/- dyspnea
stridor
cough
dysphagia
hoarseness
SVC syndrome
Most commonly “tearing chest pain”
```
74
How is aortic aneurysm diagnosed?
Risk determined on size of aneurysm, can be asymptomatic, incidental finding
CXR/CT→ widened mediastinum
75
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
76
When to surgically manage a thoracic aortic aneurysm
symptomatic
>5.0 cm
rapid expansion >.5 cm in 6 months
77
Abdominal aortic aneurysm presentation
Pulsating abdominal mass +/- abdominal/back pain
Complications→ rupture, aneurysm thrombosis, thromboembolism
If ruptured→ hypotension, hemodynamic instability
78
When to observe an abdominal aortic aneurysm
Asymptomatic <5.5 cm→ surveillance, risk factor modification, ultrasound q6-12 months
79
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
80
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
81
At risk for aortic dissection
```
uncontrolled HTN
Atherosclerosis
pre-existing aortic aneurysm
bicuspid aortic valve
aortic coarctation
Marfan’s
Cocaine
Pregnancy
male
age
```
82
Thoracic aortic dissection presentation
Ripping/tearing chest pain radiating to the back
| Signs of hemodynamic compromise
83
Abdominal aortic dissection presentation
Severe back/abdominal/flank pain + hypotension, shock
| Signs of hemodynamic compromise
84
Stable aortic dissection imaging
CT angiography
85
Unstable aortic dissection imaging
multiplanar transesophageal echo
86
For an Unstable aortic dissection
always intubate
87
Acute ascending thoracic dissection (type A) treatment
Cardiac surgical emergency
88
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
89
De Bakey Type I
Aortic aneurysm
| Originate in ascending aorta, propagates to aortic arch or beyond
90
De Bakey Type II
Aortic aneurysm
| Originates in and is confined to the ascending aorta
91
De Bakey Type III
Aortic aneurysm
| Originates in the descending aorta, can extend in either direction but more commonly distally
92
*Standford Type A*
Aortic aneurysm
| All dissections involving the ascending aorta regardless of site of origin
93
*Standford Type B*
Aortic aneurysm
| All dissections not involving the ascending aorta
94
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
95
Acute limb ischemia
Sudden decrease in limb perfusion→ threat to limb liability
96
Acute mesenteric ischemia
Acute, sudden onset of intestinal hypoperfusion
97
Acute limb ischemia presentation
```
Ischemic rest pain
Gangrene
Hours to days
New/worsening claudication, paralysis
*6 P’s*
```
98
Acute mesenteric ischemia presentation
Acute embolic occlusion:
Elderly
afib
severe abdominal pain
```
Mesenteric thrombosis:
PAD
chronic postprandial pain
food aversion
weight loss
+/- hematochezia
```
99
Embolus vs thrombosis
| acute arterial occlusion
Embolus→ sudden, dramatic onset
| Thrombosis→ gradual
100
6 P's of acute limb ischemia
```
pain
pulselessness
pallor
paresthesias
paralysis
poikilothermia
```
101
Diagnosis of acute limb ischemia
Bilateral neuro exam→ sensation, strength
Pulses→ Doppler posterior tibialis, dorsalis pedis
Ankle brachial index (ABI)
102
Diagnosis of acute mesenteric ischemia
CT angiography (imaging of choice)
KUB→ diagnose complications, but can’t diagnose ischemia
103
Initial management of all acute limb ischemia
Anticoagulation
Close monitoring
Exam worsens→ surgery
104
Management of acute limb ischemia if the limb is viable
Anticoagulate, then do CTA
| MRA→ monitor progression
105
Management of acute limb ischemia if the limb is threatened
Immediate surgical revascularization→ intraoperative arteriography
106
acute mesenteric ischemia management
Systemic anticoagulation
Pain management
+/- angioplasty with stent
Peritoneal signs→ +/- exploratory laparotomy
107
DVT risk factors
```
Virchow’s triad
Recent surgery
Prolonged bed rest
Oral contraceptives
Hormone replacement therapy
Factor V leiden
Recent trip
Malignancy
```
108
Virchow's triad
stasis of blood flow
endothelial injury
hypercoagulability
109
DVT presentation
Lower extremities or pelvis > upper extremities
Swelling, pain/discomfort
Unilateral edema
Erythema, warmth
110
DVT diagnosis
Duplex ultrasound (test of choice)
Venography
Elevated D-Dimer
111
DVT management
Anticoagulation:
Low molecular weight heparin (Lovenox)
Warfarin+heparin bridge
New oral anticoagulants
112
DVT prevention in bedridden patients
Elevate foot of bed
Leg exercises, compression hose
High risk→ anticoagulation
113
DVT perioperative or travel prevention
Early or frequent ambulation
| Leg exercises, compression hose
114
Risk factors for pulmonary embolism
the same as for DVT
115
Pulmonary embolism presentation
```
Acute onset Chest pain or SOB
Cough
Hemoptysis
Syncope
Tachypnea
Tachycardia Hypoxia
+/- unilateral extremity edema
```
116
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
117
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
118
Diagnostic interventions for pulmonary embolism according to Well's criteria
0-4 pts→ PE unlikely→ D-dimer
>4 pts→ PE likely→ CTA
119
Well's criteria risk based on points:
Low <2 pts
Intermediate 2-6 pts
High risk >6 pts
120
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
```
121
Tension pneumothorax
one-way valve, air can enter pleural space during inspiration but can’t exit
122
Who gets a primary/spontaneous pneumothorax?
Tall, young males
123
Who gets a secondary pneumothorax?
COPD
CF
Pneumonia
Malignancy
124
Who gets a tension pneumothorax?
Trauma
125
CXR of tension pneumothorax
tracheal deviation
| hemodynamic instability
