May 30 Flashcards
What are the Big 6 for Chest Pain?
Squeeze: tamponade, tension pneumothorax
Starve: MI/UA, PE
Burst: esophageal rupture, aortic dissection
Chest Pain - other causes:
Myocarditis, pericarditis Chest wall pain syndromes GERD, spasm, PUD Pancreatitis, cholecystitis Pneumothorax, pneumonia, pluritis Psych: hyperventilation...
Most frequent critical chest pain dx?
MI
- time is muscle
- get EKG and CXR promptly
Why harsh HSM radiating to axilla in MI?
Papillary muscle ischemia
What 3 things does Dr. Sharpless want?
Story, risk factors, hard clinical findings
Aside from vitals, what tells me the pt is critically ill or hypo-refused?
Diaphoresis - sweating pt makes me sweaty Cool, clammy skin Poor capillary refill AMS Poor urine output
What are 4 anginal equivalents?
Substernal pressure/pain rad to left arm = classic
- dyspnea
- weakness
- syncope
- confusion
What are the top 6 MI risk factors?
- DM
- Hypercholesterolemia
- HTN
- Smoking
- Family history early CAD
- Age (Men>45, women>55)
How can you tell if systolic ejection murmur rad to carotids is severe?
Aortic Stenosis
- Parvus et tardus
- late peak in intensity of the murmur = tight
What order for eval Chest Pain?
EKG, CXR, telemetry
IV, O2, Pox
Troponin, CBC, BMP, Mg, PT/PTT
What is classic EKG changes in MI?
ST elevation >1mm in 2 contiguous leads
Describe 4 shapes of ST elevations:
Smile: you have chance not MI
Concave upward: often MI but others
Convex: huge risk MI (frown or elevated but flat)
Inferior wall MI: leads? worry?
II, III, AvF
- may be assoc w/ RV MI = NO nitrates
What are reciprocal leads for inferior wall?
I, L
What is an anterior wall MI?
V1-V4 - knock on the anterior door
What are reciprocal leads to anterior wall?
II, III, AvF
What is a lateral wall MI?
V5-6, I, L
How see posterior wall MI on EKG?
ST depression in V1-V4
- but also could be sub-endocardial infarct
What is Acute MI therapy?
Aspirin - 4x 81mg chewable - MOST important Nitroglycerin (sub-lingual + IV) Morphine Heparin (bolus + drip) Cardiology - ASAP
Chest pain + back pain = ?
Aortic Dissection
- abrupt, excruciating, tearing pain
What kind of murmur w/ aortic dissection?
Aortic regurg - proximal dissection
- dilation of aortic valve ring
- loss of commissural support of aortic valve
Risk factors for aortic dissection?
HTN
Bicuspid aortic valve
Marfan / Ehlers-Danlos
Pregnancy
What is common in proximal aortic dissections?
Aortic insufficiency (regurg)
Tests/imaging for aortic dissection?
EKG - usually normal
CXR - abnormal 80% of the time
What is the egg shell sign on CXR for aortic dissection?
Separation > 5mm of intimal calcium from outer aortic contour
How treat aortic dissection?
Lower BP to reduce sheer forces
- give BB esmolol - short acting
- can also give nitroprusside after the BB
Classic triad for PE?
TEST TEST TEST
Dyspnea - labored breathing
Hemoptysis
Pleuritic chest pain
What may suggest massive PE?
Vascular collapse
Types of PE?
Thrombus - emboli
Amniotic fluid - usu during labor
Fat embolism - long bone fx
Air embolism - iatrogenic
Rick factors for PE?
Prior DVT/PE Lupus anticoagulant Protein C/S deficiency Central lines, surgery, cast/immobilization Cancers (ovarian/colon) Pregnancy, high dose estrogens IBD - Crohn's (often decreased C/S)
What hear on auscultation with a PE?
Wide split S2
- pipe is obstructed, takes more time to get all blood through pulmonary valve so it closes after aortic
What is Virchow’s triad?
Venous stasis
Hypercoagulability
Endothelial injury
Low pulse ox + normal pulmonary exam…
PE
CXR findings for PE
Westermark’s cut-off sign
- following a vessel and it just cuts off
Hamptom’s hump
Two main scans for PE?
V/Q scan
CT scan w/ contrast - so need good kidneys
How treat PE?
IV heparin bolus + drip (or lovenox)
Give tPA if:
- shock + PE
- PE + right heart failure
