midterm - pt 1 (SOB + Chest Pain) Flashcards
Asthma triggers
-Environment: Pollen, dust mites, molds, animal dander, cockroaches
-URI (MC)
-Aspirin-exacerbated respiratory disease (AERD)
-some NSAIDs
-!!Cold environments
-Exercise
-GERD
-Emotional stress
-Hormonal fluxes: Pregnancy, menstrual cycle
-!!BB (even eye drops)
Asthma sx and tx
-worse at night
-sx during childhood
-family hx
-hx of allergic rhinitis/eczema
-tripoding
-speaking in phrases
->40 RR, >120 HR
-SpO2 <90%
-peak flow < 40-50% of predicted
-AMS/agitation
-SILENT CHEST ≠ Reassurance
-BAD sx:
-decrease expiratory flow
-air trapping -> PTX
-decrease venous return -> hypotension, pulsus paradoxus
-Initial tx:
->92%
-1-2L normal saline
-MDI +- spacer, nebulizer
-SABA- albuterol
-Anticholinergic- ipratropium bromide WITH SABA
-Steroids (except mild)
-Magnesium sulfate- severe/impending failure
-Discharge tx:
-albuterol MDI +/- steroids (5 days)
-consider ICS
BiPAP
-INDICATIONS:
-stay on for at least 72 hrs
-MC- pulmonary edema
-COPD exacerbation (respiratory acidosis)
-PNA- be careful of hypotension
-burns
-flail chest
-post op deterioration
-CONTRAINDICATION:
-AMS
-no gag reflex
-upper airway obstruction
-facial trauma, burns
-gastric distention -> abdominal compartment syndrome
-GI bleed
-aspiration pneumonia
-respiratory arrest
-anxiety/agitation
-severe hypotension/shock/arrythmias
COPD exacerbation
-hyperresonant chest
- Worsened SOB*
- Increased volume and purulence of sputum*
- Dyspnea
- Cough, wheezing, chest congestion
- Accessory muscle use
- Hyperresonant lungs
- Pursed lips
- Barrel chest
- Prolonged expiration
-sputum color change*
-etiology: viral (MC) or bacterial infection; BBs, allergens
-EKG- tachycardia, MAT, cardiac mimics (STEMI)
-X-ray- flat diaphragm, vertical heart, increase AP diameter, bullae, RVH, large pulmonary artery
-right HF -> edema/ascites/hepatomegaly/JVD
-1. nasal cannula -> BiPAP! helps relieve accessory muscle use, decreases MORTALITY, days in hospital (immediate relief) -> intubation
- Setting: TV 6-10, RR: 10-14, PEEP: 0-5, FiO2: 100%
-88-92%
- COPD pts have CHRONIC hypercapnia with normal pH (metabolic compensation)
-IV, monitor
-2. bronchodilators (beta agonist)- SABA
-3. steroids- mainstay but not fast
-4. antibiotics:
- Azithromycin = outpt
- Ceftriaxone - no pseudomonas
- Levofloxacin - pseudomonas
Acute CHF
-MC sx- dyspnea
-IV, vitals, monitor, ECG, CXR, POCUS
-POCUS-
-CXR- cardiomegaly, pulmonary edema, pleural effusion, kerley B lines, dilated vessels
-US- 3+ B-lines, EF, walls, IVC
-Tx:
-100% NRB -> !NIPPV! -> intubate
-!!Nitroglycerin = 1st line if w/o shock -> decrease pre/afterload
-IV diuretics
-IF SHOCK…
-BiPAP
-vasopressors- norepinephrine, dopamine
-MAP 65-80
-Inotropes- dobutamine
-fluids or diuretics depending
Understand the risk stratification scores for PE (Wells, or Geneva, and PERC)
-Risk stratification with:
-Well’s score (classic)
-OR
-Revised Geneva score (more objective)
-YEARS score (pregnancy)
-If low risk on well or geneva -> r/o PE with PERC score
Pulmonary embolism and DVT
-RF- trauma to LE or pelvis in last 3mo, malignancy, venous FB (central line, PPM)
-JVD, S3/4
-rales, wheezing, dullness to percussion, fremitus, dec breath sounds
-flank/upper abd pain -> pulmonary infarct/pleuritis
-ECG- tachy, RBBB, S1Q3T3, deep TWI V1-V4, rightward axis
-CXR- atelectasis, effusion, elevated hemidiaphragm, hampton hump, westermarks sign
-U/S- right heart strain -> D-sign -> shifts the LV making it D shaped
-Doppler US for DVT
-CTA!!- BEST TEST
-Pregnant/contrast allergy- V/Q scan -> PERFUSION SCAN ONLY -> ventilation w/o perfusion
-Tx:
-UNSTABLE- thrombolysis and/or embolectomy
-STABLE- anticoagulation for 3mo with DOAC (preferred) or bridge to warfarin with UFH/LMWH
* (i.e. when is heparin used versus thrombolytics)?
PNA types
-strep pneumoniae- rusty sputum, lobar
-haemophilus influenzae- COPD, lobar
-staph aureus- post viral, IVDU, abscesses
-klebsiella pneumoniae- alcoholics, COPD, currant jelly sputum
-pseudomonas and enterobacter- HAP, CF, sickly sweet odor, abscesses
-anaerobes- foul smell, poor dentition, alcoholics, patchy, causes ABSCESSES
atypical: productive cough, pathchy interstitial
-Mycoplasma pneumoniae- bullous myringitis, walking PNA, young adults
-chlamydia pneumoniae: staccato cough, non-toxic appearing, conjunctivitis
-legionella pneumophilia- GI sx, air conditioning, water sources, older sickly men, diffuse inflitrations on both side, hyponatremia
immunocompromised:
-PCP: HIV
-TB: fever night sweats, hemoptysis, abscess
-histoplasmosis: mississippi river valley, hilar adenopathy
CURB-65 and PORT
-CURB-65: outpt vs inpt treatment
-Confusion
-Uremia (BUN >20)
-RR >30
-BP (<90/<60)
-age > 65
-PORT: risk stratification for PNA severity
-Demographics- age, sex, nursing home
-Comorbidities- neoplasia, chronic liver ds, CHF, CVA, renal ds
-Presentation- AMS, RR>30, SBP <90, temp <95 or >103, HR >125
-Labs/imaging- pH<7.35, BUN >30, sodium <130, glucose > 250, hematocrit <30, PaO2<60, pleural effusion
PNA tx
OUTPT- NO CO-MORBIDITIES (CHOOSE ONE):
-1. Amoxicillin
-2. Azithromycin
-3. Clarithromycin
-4. Doxycycline
OUTPT CO-MORBIDITIES (CHOOSE ONE):
-1a. Augmentin AND
-1b. Azithromycin Or Doxycycline
-2a. Cefpodoximeproxetil or Cefuroxime axetil AND
-2b. Azithromycin or Doxycycline
-3. Levofloxacin -> Monotherapy fluoroquinolone not first line recommendation!!!!
NON-SEVERE INPATIENT:
-beta-lactam- Ceftriaxone IV OR Ampicillin + sulbactam (Unasyn) OR cefotaxime PLUS Azithromycin
-OR monotherapy- fluoroquinolone: Levofloxacin
SEVERE: beta lactam (ceftriaxone) + atypical coverage (azithro/doxy) + MRSA coverage (vanco/linozolid)
-IF PSEUDOMONAS- piperacillin-tazobactam or cefepime
-atypical coverage (always)- azithromycin or doxycycline
-PLUS MRSA- vancomycin or linezolid if post-influenza, IV drug use,
- PCP = TMP/SMX
pneumothorax
-CXR upright- collapse usually at apex, deep sulcus sign if severe
-CXR supine- deep sulcus sign- air goes anteriorly and basally
-POCUS- pleural slide -> ants on log and M-Mode (Seashore)
-M-mode barcode -> BAD, no slide
-Tx:
-small (simple)- <20% or apical <1-2cm from chest wall -> observation w/ 100% nasal O2 -> repeat CXR in 6 hrs
-Large/symptomatic- chest tube
-Tension- >20% -> needle decompression in 2nd ICS MCL -> chest tube 5th ICS anterior axillary line
asthma vs COPD vs CHF
6 you cant miss chest pain
-ACS
-PE
-dissection
-tension ptx
-tamponade
-esophageal rupture
Typical vs atypical sx, UA/NSTEMI/STEMI
-UNSTABLE ANGINA:
-negative troponins
-nonspecific ECG
-tx with meds and consider cath in 1-2 days
-NSTEMI:
-ECG- ischemia
-positive cardiac enzymes
-tx medically and cath within 1-2 days
-STEMI:
-ECG- ST elevations
-positive positive enzymes
-STAT tx
-atypical- elderly, female, DM
-short term pain
-pain with movement
-24 hour pain
-RF- >40yo, HIV + HAART
posterior MI
-reciprocal changes in anterior leads (V1-V3) -> depressions
-V7-V9- ST elevation
-tall R waves
-no nitro for posterior and inferior! infarcts
-RV dysfunction
-brady
ACS management
-ABCs, IV, monitoring, serial ECG (10), CXR, troponin (30)
-O2 if <90%
-!Nitroglycerin- ↓ preload
-Avoid w/ sildenafil in past 24-48 hrs
-ANTIPLATELETS:
-!Aspirin 162-325mg -> Reduces mortality by 23%
-P2Y12 inhibitor:
-ASAP or at the time of PCI
-Clopidogrel (Plavix)
-ASA+ clopidogrel -> reduce MACE in pts with NSTEMI
-Ticagrelor (Brilinta)- ?better than clopidogrel-> but higher chance of bleeding
-Prasugrel (Effient)
-ANTICOAGULANTS:
-LMWH/UFH- controversial
-STEMI getting PCI: UFH
-STEMI getting fibrinolysis: LMWH, UFH, or Fondaparinux
-BB and statins- start but not in ER
PCI VS Thrombolytics
-!!PCI- within 90 minutes
-120 for non-PCI facilities
-Sx <12 hrs, Sx 12-24 hrs with ongoing ischemia, or if signs of cardiogenic shock and severe acute HF regardless of time
-!!Thrombolytic tx within 30 mins
-Inferior to PCI
-Best reduction in M&M if within 12 hrs of sx
-4 agents: Tenecteplase (tPA), reteplase, alteplase
-Transfer to PCI facility after!!!!
tPA contraindications
-ABSOLUTE
-PCI immediately available
-History of !intracranial hemorrhage!
-Known !intracranial neoplasm or vascular lesions!
-Intracranial or intraspinal surgery within !3 months!
-Active internal bleeding (except menses) or known bleeding disorder
-!Embolic stroke within 3 months! (exception: embolic stroke within 3 hours)
-Suspected !aortic dissection!
-Significant facial or head trauma within !3 months!
-RELATIVE
-Uncontrolled severe hypertension(>180 systolic, >110 diastolic)!!!
-Prolonged cardiopulmonary resuscitation (>10minutes) or recent surgery (<3 weeks) or non-compressible vascular puncture
-Recent internal bleeding or active peptic ulcer disease
-Pregnancy
-Current anticoagulation with high international normalized ratio (INR)
-For streptokinase: prior exposure to the drug or history of allergic reaction
pericarditis ECG and tx
-fever, malaise
-lasts 2-4wks
-pulsus paradoxus
-can have pericardial effusion
-ECG:
-Diffuse STE (not in V1 or aVR, that makes pericarditis unlikely)
-<1 week- widespread ST elevation and PR depression -> aVR and V1- ST depression and PR elevation
-stage 2- normal
-stage 3- widespread T wave inversion
-4- normal
-spodicks sign- downsloping TP segments in 2, V4-V6
-Tx:
-NSAIDs , ASA or steroids
brugada
-inherited arrhythmia -> sudden death
-adults
-incidental
-syncope
-VT, VF
-ST elevation >2mm in >1 of V1-V3 followed by neg T wave
wellens syndrome
-unstable angina
-strongly associated with proximal stenosis of LAD
-Pts walk around with these
-often found incidentally or during a pain-free period
-troponins are often normal (or only slightly elevated)
-High risk for large anterior wall acute MI
-As soon as its dx -> interventional cardiologist consulted for definitive tx with cardiac catheterization with PCI
-ECG- deep wide symmetrical T wave inversion in V2-V3
sgarbossa’s criteria
-In pts with LBBB or VENTRICULAR PACED RHYTHYM
-can be difficult to dx an infarct (bc T-wave inversions are expected)
-can help dx infarction in setting of LBBB
esophageal rupture
-RF- alcoholic, iatrogenic, vomiting, coughing, childbirth, seizures, weightlifting, Ca, trauma, caustic, FB
-MACKLER TRIAD (Boerhaave):
-vomiting followed by
-severe retrosternal chest pain
-subcutaneous emphysema
-neck/thoracic pain, SOB, abdominal pain (if lower), fever
-crepitus- Hamman’s crunch
-diaphoretic
-reduced breath sounds on side of perforation
-DX:
-cervical XRAY- subq emphysema
-chest XRAY- pneumomediastinum, pneumopericardium, PTX, pleural effusion, widened mediastinum, subdiaphragmatic air
-CT esophagram with water soluble contrast (gastrografin)- TEST OF CHOICE- -Extravasated contrast/air, Free air/fluid, wall thickening, Pneumomediastinum, Pneumopericardium, PTX, Widened mediastinum
-TX:
-ABCDE
-NPO
-broad spectrum IV antibiotics
-IV analgesic
-IV PPI
-parenteral nutrition
-cardiothoracic surgical consult
aortic dissection
-widen mediastinum
-aortic insufficiency murmur
-pulse deficit
-can cause tamponade
-Dx:
-CT angiography- IV contrast
-Tx:
-Stanford A - Emergency SURGERY (CT surgery)
-Stanford B - Endovascular stenting and Medical management
-!GOAL: HR < 60 & SBP <120
-HR is more important -> every beat pumps more blood into it
-IV agents
-!!First line: BB!!!!!
-!Esmolol
-Labetolol
-Nicardipine
-Vasodilators (2nd line)
-Nitroprusside
-No nitrates by themselves! -> Reflex tachycardia
myocarditis
-assoc with pericarditis
-usually viral cause -> cruzii aka CHAGAS MCC)
-drugs, toxins, immune, idiopathic
-myalgias, joint pain
-chest pain
-HF sx
-fever, tachy
-dysrhythmias
-sudden death
tamponade
-Becks triad- muffled heart sounds, JVD, hypotension
-pulsus paradoxus
-CXR- water bottle heart (chronic) -> normal if acute
-300ml until you see on CXR
-ECG- low voltage, electrical alternans
-US- swinging heart, effusion, RV diastolic collapse!!!
-Acute tamponade tx:
-ABCs, IV, monitor, ECG, O2
-FLUIDS! -> preload dependent (avoid ventilation bc of this)
-Emergent pericardiocentesis- unstable
-stable- guided pericardiocentesis or pericardial window
endocarditis: presentation diagnosis treatment
-s. aureus > viridians strep > HAECK
-FEVER! ( FUO + new heart murmur????? Think this)
-NEW murmur***
- HF
-glomerulonephritis
-osler nodes- painful nodules on fingers
-roth spots
-janeway lesions- painless spots on palms
Dx:
-Echo- vegetation, abscess, new regurgitation, dehiscence of prosthetic valves
-TEE
-Blood culture
-Duke criteria
Tx:
- ED: abx for 6 wks
- Native valve: NO IV drug use - vancomycin and cefazolin
- Native valve: IV drug use, sepsis - vancomycin + CEFEPIME (antipseudomonal)
- Prosthetic valve: vancomycin + GENTAMYCIN + cefepime; SURGERY
