Pages 1-10 Flashcards
Which words in ACS history make ACS LESS likely?
- Stabbing
- Pleuritic
- Positional
- Reproducible by palpation
Which words in ACS history make ACS MORE likely?
- Radiates to one shoulder or both shoulders or arms
2. Precipitated by exertion
Sensitivity of initial EKG of AMI?
20% to 60%
Is location of chest pain linked to region of ischemia?
No
*Patients with inferior MI more often have abdominal pain or GI symptoms than those with anterior infarct
What does pain for only seconds or recurrent pain lasting hours/days with indicative of?
Non cardiac etiology
What is chest pain reproducible on deep inspiration or with coughing associated with?
- PE
2. Costochondritis
What does chest pain alleviated by leaning forward suggest?
Pericarditis
What does chest pain aggravated by moving arm or neck suggest?
MSK pain
What does sublingual nitroglycerin cause when evaluating MI?
Relaxing coronary smooth muscle AND relaxation of esophageal muscle
Associated symptoms pointing to MI?
- Nausea
- Vomit
- Diaphoresis
What are the CAD risk factors?
- Family history
- Diabetes
- Increased cholesterol
- Smoking
- Hypertension
What are the TIMI risk factors of MI?
- Age of 65
- Greater than 3 CAD risk factors
- Known stenosis over 50%
- ST elevation over 0.5mm
- Use of ASA in last week
- Within 24 hours
- Increased biomarkers
Atypical presentations of ACS?
- Pain anywhere from umbilicus to neck and the back
- Sharp, burning (simulating gastric reflux)
- Diabetics elderly may have no chest pain at all
- . Women often present with fatigue, SOB and generalized weakness
Describe management of patients with ACS?
1. IV access 2 Beta-blockers to control the rate and BP 3. Cardiac monitor. 4. Morphine 5. Oxygen 6. Nitroglycerin - Caution in STEMIs to inferior leads/right heart 7. Aspirin
Utility of cardiac enzymes in chest pain?
Troponin I is fairly cardiac specific
Classic H/P of thoracic aortic dissection?
- 95% of patients with acute aortic dissection report chest pain, with back or interscapular pain
- Majority of patients appear to be in distress
- 50% hypertensive, often with a systolic blood pressure > 200.
Difference of type A and B aortic dissection?
Type A: if ascending aorta is involved
Type B: no involvement of ascending aorta
Ddx for aortic dissection?
- MI
- PE
- Aortic aneurysm
- Aortic regurgitation without dissection
- Stroke
What is difference in BP and pulses in the arms indicative of?
Dissection involving subclavian artery
- Difference of 20 mmHg is significant
If thoracic aortic dissection is suspected what actions should be promptly performed?
- Intubate if unstable
- 2 large bore IV’s
- Cardiac monitoring
- Obtain blood for CBC, CMP, trops, coags, type and cross
- EKG
- CXR
- Consult cardiothoracic surgery while diagnostic testing is underway if suspicion is strong
How to diagnose AA?
- CXR more helpful than the EKG
- Widened mediastinum seen in 60% - 55% - CT chest: has sensitivity of 83-98% and specificity of 87-100%
- TEE: often used in patients unstable to send for CT or with impaired renal function
Surgical management of type A and B thoracic aneurysm?
Type A: emergent surgery
Type B: surgical intervention in subacute or chronic phase
***Managed medically in acute setting as early surgical intervention associated w/ increased mortality
How to manage BP and rate in Type B
Systolic BP: maintained at 100-120 regardless of baseline
HR: below 60 unless evidence of malperfusion arises - - Beta-blockers are first line, specifically, esmolol because easily titratable to desired effect
- To maintain BP, a vasodilator such as nitroprusside, may be necessary
- A vasodilator should never be used without first starting a beta blocker: can cause a reflex tachycardia increasing aortic wall stress
- As pain can cause htn/tachycardia, narcotics such as morphine are often necessary
How are type A dissections surgically managed?
- Excision of intimal tear
- Removal of entry point into false lumen
- Reconstruction of aorta w/ possible aortic valve repair
Signs and symptoms of acute heart failure?
- Dyspnea: Most common
- Increasing exercise intolerance
- Orthopnea
- Paroxysmal nocturnal dyspnea: waking in middle of night w/ respiratory distress
- Weight gain due to fluid retention
Physical exam in acute heart failure?
- Respiratory distress
- Adventitious lung sounds in all fields
- Rales in dependent portions of the lungs
- Diffuse wheezing and bronchospasm
- S3: can be indicative of fluid overload
- S4: associated with diastolic heart failure with stiff, non-pliable ventricles
- Persistent tachycardia: can make hear sounds more difficult
- Tachypnia
- Hypoxia
What does BNP tell us in HF work up?
- Released as response to increased ventricular wall stress
- Patients w/ respiratory distress secondary to HF have elevated BNP greater than 500
Diagnosis of HF?
- EKG: evaluates if cardiac ischemia is etiology
- CK
- CK-MB / troponin
- CMP
- BUN/Creatinine: determine if there’s a component of renal failure
- May be cause or may exacerbate fluid retention/overload - CBC: determines if anemia/thrombocytopenia may be contributing
- BNP
- CXR
Leading cause of systolic heart failure?
MI and subsequent infarc is leading cause
What does BNP tell us in HF?
- Determines presence of pulmonary congestion/edema
- Evaluates presence of cardiomegaly
- Pleural effusions and Kerley B lines
Treatment of HF?
- Oxygen
- CPAP or BiPAP: in moderate/severe resp distress
- Nitrates: to decrease preload, oxygen consumption and SVR
- Net result increases CO allowing heart to pump more efficiently - Loop diuretics: if evidence of fluid overload w/ JVD and other
* Many patients presenting with HF are euvolemic and will become hypotensive with diuretic therapy.
Only therapy in HF demonstrating decreased morbidity and mortality in moderate/severe respiratory distress?
CPAP or BiPAP
- Has reduced need for intubation and ventilation in a significant portion of the population
Management in HF with signs of hypotension and cardiogenic shock?
- Inotropic medications: Levophed, dopamine and other peripheral vasoconstrictors to support BP
What are the rule out criteria for PE?
- Age less than 50
- Pulse less than 100
- Sats > 95% on RA
- No hemoptysis
- No exogenous estrogen
- No history of venous TE
- No surgery or trauma w/in 4 weeks
- No unilateral leg swelling
- No active cancer
Management of PE?
- Either unfractionated heparin or LMWH
- May be started before imaging confirmation in patients with high pre-test probability
- Admission for anticoagulation
Contraindications to anticoagulation?
- Active bleeding: cerebral or GI
2. Previous reaction to Generally patients with PE
How to manage PE if anticoagulation cannot be used?
IVC filter
How dose the heparin bridge work?
Warfarin has a theoretical transient hypercoagulable effect so patients placed on heparin until Coumadin reaches a therapeutic level
What is therapeutic level of warfarin?
INR 2-3
“AKA Coumadin”
Utility if thrombolytics in PE?
Controversial and may be indicated in setting of a massive PE with significant cardiopulmonary compromise or submassive PE w/ evidence of right heart strain
What is the normal PR?
0.12 - 0.20s
Diagnostic Criteria LBBB?
- QRS duration of 120 ms or greater
- Dominant S wave in V1
- Broad monophasic R wave in lateral leads
- Absence of Q waves in lateral leads
- Prolonged R wave peak time > 60ms in left precordial leads
Normal QRS interval?
0.08 - .10 seconds
Which are the lateral leads?
- I
- aVL
- V5-V6
Diagnostic Criteria RBBB?
- Broad QRS > 120 ms
- RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
- Wide, slurred S wave in the lateral leads (I, aVL, V5-6)
Diagnosis of RAE on EKG?
- P wave amplitude greater than 2.5 mm in II
and/or
greater than 1.5 mm in V1
Diagnosis of LAE on EKG?
- P wave duration greater than 0.12s in lead II
2. Notched P wave in limb leads
How to find LVH on EKG?
S wave depth in V1 + tallest R wave height in V5-V6 greater than 35
What does ST depression indicate?
Ischemia or NSTEMI
Greater 1 mm is more specific and conveys a worse prognosis.
Greater than 2 mm in 3 leads associated with high probability NSTEMI and predicts significant mortality
What does inferior STEMI look like?
- ST elevation in leads II, III and aVF
- Progressive Q waves in II, III and aVF
- Reciprocal ST depression in aVL
Which are inferior leads?
II, III and aVF
What happens if nitrates given in RV infarcts?
Preload sensitive and develop severe hypotension in response to nitrates or other preload-reducing agents
- Treated with fluid loading
Signs of right ventricular STEMI?
- ST elevation in V1
- ST elevation in lead III greater than lead II: III more rightward facing than II
- Combination of ST elevation in V1 and ST depression in V2 is highly specific for right ventricular MI
Which are posterior leads?
V1-V3
How to recognize SVT?
Regular tachycardic rate with narrow QRS
How to recognize Multifocal Atrial Tachycardia?
- Irregularly irregular
2. P waves with different morphologies
Initial management of a patient in respiratory distress?
- Oxygen
- Monitor and pulse oximeter
- IV access
- EKG
- CXR
Different sources of oxygen and the percentage of oxygen they provide?
- Nasal cannula at 2-3 L/min, FiO2 26%
- Non rebreather at 15 L/min, FiO2 40-60%
- Bag valve mask at 15 L/min, FiO2 90%
DDx for respiratory distress?
- Asthma/COPD/CHF exacerbation
- ACS
- Pulmonary edema
- Pneumonia
- Pulmonary Embolism
- Tension Pneumothorax
- Pericardial tamponade
- Anaphylaxis
- Upper airway obstruction
