ORALS - CARDIO Flashcards
INFERIOR STEMI CASE
**PPE / MOVID **
- PPE, People (resus team, RT, pre-alert cath lab)
- Location: >120min for transfer to PCI center (if community)
- Target O2 sat 90%
- bloodwork: Tnt/CK, VBG
- EKG/CXR
**EKG (STE: 2,3,AVF, STD: AVL) **
- Posterior STD - V1-V3, dom R V2, Tall R wave V1-V2 (15 lead ECG)
- RV infaract - STE V1 +/- STE 3>2 (R sided leads)
**MGMT **
- nitro spray q5min, morphine
- ASA 325mg PO chew
- ticagrelor 180mg PO / clopidogrel 300mg
- ensure no R sided => 0.4mg S/L
- PCI appropriate (within 120min): heparin 50-60U/kg IV bolus => infusion
- TNK appropriate dosing (>120min + CP less than 12H) enoxaparin 30mg IV and 1mg/kg SQ (door to needle 30min)
- TNK - 0.5mg/kg (40mg)
OTHER THERAPIES
morphine 2-4mg IV Q5-15min
cardioselective BB (metoprolol) within 24H
atorvastatin 80mg before PCI
k >3.5-4.5 and Mg >2
Hgb >80
FOLLOW UP QUESTIONS
- Contraindications (absolute)
Any prior ICH
Known structural abnormality including AVM or malignant
Ischemic stroke within the last 3 months but not last 4.5 hours
Suspected dissection
Significant closed head injury within the last 3 months
Intracranial or intraspinal surgery within the last 2 months
(relative)
AC therapy
Pregnancy
Non compressible vascular puncture
Major surgery in the last 3 weeks
Dementia
Active PUD - Signs of reperfusion post TNK
Resolution of CP
Decrease in STE by 50% in the worst lead in 90 mins
AIVR
T wave inversion
Increased PVC’s - Indications for transfer post TNK
Failed reperfusion
Immediately post admin in any case of cardiogenic shock
As part of usual protocol - ACS time goals:
**PCI CENTER **
=> Medical contact to dx 10min
=> door to activate cath 10min
=> Door to out of ED time 30min
=> Door to needle time 90min
**NON PCI CENTER **
=> Door to transfer 30min
=> door to thrombolytics 30min
=> transfer time 60min
=> door to needle 120min - Indications for rescue PCI post TNK
STE resolution 50%
ongoing chest pain
shock / heart failure
refractory arrythmia
CARDIAC ARREST CASE
- PPE/MOVID
resus team / RT
monitors / cardiac pads
2 large bore IVs, if unable to establish IOs - Pulse check => proceed down ACLS (PEA / VTach) algorithm
Shockable rhyhthm - defibrillate at 200J Q2miin at every pulse and rhythm check for shockable rhythms. - Ensure ongoing high quality CPR at a 30:2 ratio
=> Rate 100-120
=> compression depth 2inches
=> minimal interruptions
=> full recoil
=> rotation of compressors Q2min
intubate at 2nd cycle of ACLS and monitor ETCO2 - Administer medications per ACLS algorithm
epi 1mg IV Q3min
amiodarone 300mg then 150mg IV
**consider: **
lidocaine 1.5mg/kg IV
MgSO4 torsades
Atropine 1mg IV - Consider H+Ts and treat
hypothermia
hypovolemia
hyperkalemia
hypoxia
hydrogen ion
thrombosis
toxins
tension
tamponade - ROSC (ETCO2 >40, spontaenous arterial pressure)
repeat set of vitals
ECG
Hypotension with pressors with MAP >65
appropriate sedation
Temperature management for normothermia, monitor with rectal or esophageal probes
foley for ins/outs
Causes of pericardial effusion
- Pericarditis
- Infection
- SLE
- RA
- Uremia
- Radiation
- Mets
- Trauma
Complications of pericardiocentesis
- PTX
- HTX
- Cardiac puncture
- Coronary laceration
- Liver injury
- Dysrhythmia
- Infection
What is the pulsus paradoxus
decrease in systolic BP during inspiration more then 10mmHg
due to RV filling restricted by pericardial fluid in pericardial sac (decreases LV filling and stroke volume and SBP)
Causes
1. tamponade
2. PE
3. COPD
4. Asthma
5. Tension
6. constrictive pericarditis
Clinical findings of tamponade
pulsus paradoxus
electrical alternana
Beck’s triad (JVP, muffled heart sounds, hypotension)
low voltages
US: RA collapse in systole, RV collapse in diastole, non collapsible IVC
large cardiac sillhouette on CXR
BRADYCARDIA CASE
- PPE/MOVID
resus team / RT - Monitors
cardiac pads
if HD unstable, transcutaneous pacing (anterior - posterior pad placement) - Bloodwork
think of causes: Trop/CK, lytes, tox screen - Medications (if stable)
atropine 0.5mg-1mg Q3-5min
epi 0.1mcg/kg/min
dopamine 5mcg/kg/min
isoproterenol (B1)
Calcium - Electricitiy
continue with transcutaneous pacing
TVP insertion
follow up questions
1. ddx for bradycardia
Meds (PACED)
=> Propranolol, poppies, physostigmine
=> Anti-arrh, anticholinesterase
=> CCB, clonidine
=> Ethanol
=> dixogin
Toxin (digitalis), organophosphates
**Lytes **(hyperK)
Ischemia
ICP
- Complications with TVP insertion
**associated with cordis insertion: **
carotid puncture
PTX
infection
thrombophlebitis
**associated with pacing wire insertion: **
RV rupture
dysrhythmias
failure to capture
- Sites of TVP insertion
Right IJ
Femoral
Subclavian
Brachial
TORSADES CASE
- PPE/MOVID
resus team, RT, 2nd ERP
ensure pulse
review drug list (stop any QTC prolonging drugs) - mgmt
magnesium 4g IV / 1h then infusion
monitor mg levels
correct hypokalemia
consider lidocaine 1.5mg/kg load then 1mg/min - electricity
defibrillation - increase HR (for acquired)
overdrive pacing
isoproterenol (B agonist) 2-10mcg/min
epinephrine
follow up questions
- List causes of torsades
**Congenital: **
Jarvell lange nielson
romano ward
MVP
sporadic
**Non congenital: **
hypoMg, hypoK, hypoCa
ICH
Hypothermia
Hypothyroidism
meds - sotolol/procainamide/amio, lithium, haldol, olanzapine, benadryl
VT/VF Storm CASE
- PPE/MOVID
resus team, RT, 2nd ERP, pre-alert cardiac ICU
bloodwork - TNT/CK, tox screen - Mgmt
NE or phenyl (no beta, sympathetic drive) for hypotension
amiodarone
MgSO4 2-4g IV
Consider:
esmolol
anesthesia - stellate ganglion block
ECMO - Treat underlying cause
revascularization
ICD
ICD interrogation
follow up questions
1. What is the definition of VT/VF storm:
Sustained VT or >3 VF requiring intervention in 24H
- List common triggers of VT/VF storm:
acute MI
CHF
Electrolytes - hypoK, hypoMg
Meds - sympathomimetics
Med non adherence
Thyrotoxicosis
Sepsis
AFIB RVR CASE
- PPE/MOVID
resus team, RT
place on cardiac-resp monitors and cardiac pads
bloodwork - incuding septic w/o, TSH TNT/CK - Afib w CHF
If stable
=> lasix
=> nitro spray 0.5mg Q5min x3
=> 02 titrate >92% (NP => NRB => BIPAP)
refractory or unstable => trial sync cardioversion
if C/I to cardioversion = amiodarone - Consult
cardiology
AFIB alone MGMT
stable vs unstable
anticoagulation status
Anticoagulation status?
- if anticoagulated 1) synchronized cardioversion 200J 2) cardioversion with procainamide 15mg/kg IV
- if not anticoagulated (can do above if):
HD unstable
NVAF less than 12H, no recent stroke / TIA (6mos)
NVAF 12-48H and CHADS2 0-1
*RECALL - CHADS2 is age 75
need 3 weeks of AC prior to cardioversion
any VAF
NAVF less than 12H and recent stroke
NVAF 12-48H and CHADS >2
NVAF >48H
Post cardioversion continue anticoagulation based on CHADS65 positive OR CVA
CAD or arterial vascular disease - ASA
- apixaban 5mg BID / 2.5mg BID (if bad kidneys)
- Rivaroxaban 20mg daily
HEART FAILURE CASE
- PPE/MOVID
resus team, RT
bloodwork - TSH, Trop/CK
Exam - volume status - Management
BIPAP
MAP optimization
- reduce afterload in HTN (nitro)
- hypotension (NE, epi for inotropy)
- Vasopressin (pulm HTN)
Volume status
- diuretics (IV lasix)
- consider fluid challenge if 1) no AKI 2) no pulm congestion on US 3) overall picture is hypovolemia
Inotrope
- dobutamine 5mcg/kg/min - Cause (ddx)
arrythmia
revascularization / ischemia
valvular problem
toxin clearance
thyroid disease - Do not
treat sinus tachy
give diltiazem / CCB
BB
fix mild hyponatremia
delay bipap
