Review

Question 1

Hyperkalemia –

Hypokalemia –

Answer 1

Hyperkalemia – peaked T waves; wide QRS and flattened p waves

Hypokalemia –tall U waves and flat T

Question 2

how do we name the expected compensation?

Answer 2

named for the expected compensation (respiratory/metabolic) and the pH (acidic/alkalotic

Question 3

If delta delta is higher or lower, then we have what?

Answer 3

a 3rd acid base disorder present

Question 4

Acute coronary syndrome is an umbrella term for

Answer 4

Unstable Angina, NSTEMI and STEMI

Question 5

If cardiac enzymes are elevated, you are dealing with ________

Answer 5

NSTEMI or STEMI

Question 6

If cardiac enzymes are elevated, you are dealing with either NSTEMI or STEMI. What can tell the difference between the 2?

Answer 6

EKG

Question 7

Unstable Angina indicates _______ without _____

Answer 7

ischemia w/o myocardial damage

Question 8

Pt presents with chest pain what do you do?

What is the inital steps in management of NSTEMI?

Answer 8

1. O2 is low saturation
2. Pain relief with opiate analgesia and nitro; ONLY IF PAIN
3. ASA
4. EKG
5. Cardiac enzymes and CMP (to check renal function)

Question 9

There’s no ST elevation or depression on EKG, what is the DDX?

Answer 9

1. NSTEMI: sudden decrease in myocardial BF d/t acute plaque rupture leading to partially occluding thrombosis
2. Unstable angina: ischemia that does not necrosis.

Question 10

What do you give a patient with NSTEMI or Unstable angina?

Answer 10

1. ASA; given to 100% of pts with CP
2. P2Y12-inhibitors (-grel)
3. Bblockers, ACE inhibitors, statins

Question 11

Cardiac enzymes come back positive, what is the diagnosis?

Answer 11

NSTEMI

Question 12

How do you fix the STEMI (DO NOT USE IN NSTEMI)?

Answer 12

Coronary angiography/PCI are THE first choice for treatment if can be given in 90 minutes. If no cath lab and if can transfer to a hospital within 120 minutes, do IT.

If this can’t be done, thrombolytic (fibronitic) therapy should be started and the patient should be sent to somewhere for PCI

This is harmful if ACS without ST segment elevation

Question 13

Class 1 Antiplatelet drugs (have to do them over and over again for a year) given for NSTEMI-STEMI

Answer 13

1. ASA
2. P2Y12- inhibitors

3- Glycoprotein 2a/3b-inhibitors (abciximan, tirofiban, eptifibitide) is used long-term, IF THE PT IS AT HIGH RISK FOR NSTEMI

Question 14

What is a class 3 drug that you should NOT use for NSTE-ACS?

Answer 14

Thrombolytics

Question 15

When do you give PCI (percutaneous intervention) to a patient with NSTE-ACS?

Answer 15

High-risk patient, then send to cath lab

High risk = ST Depression and high troponin

Question 16

How do you treat a low-risk and high-risk patient differently with NSTEMI-ACS?

Answer 16

Low risk (NL troponin and - ST depression): stress test

High risk (high troponin and + ST depression): PCI and cath lab

Question 17

How can we tell if patient with ACS is experiencing unstable angina?

Answer 17

NL levels of troponin

Question 18

_______ is dangerous in NSTE-ACS.

______ is the MOST important thing in STEMI?

Answer 18

thrombolytic/fibrinolytic therapy

reperfusion therapy

Question 19

How do you treat the patient long term?

Answer 19

1. Glycoprotein IIB/IIIA inhibitors are used for high risk NSTEMI
2. Patients should be on long term anticoagulation therapy when they leave the hospital – Heparin and LMW heparin
3. Beta blockers, statins and ACE inhibitors are used to treat comorbities

Question 20

what is the progression of changes in cardiac enzymes in pt with STEMI?

Answer 20

Initial cardiac enzymes may be NL.

Become + 4-6 hours later

Troponin may stay elevated for 5-7 days after STEM

Question 21

How do you treat STEMI?

Answer 21

1. Aspirin
2. PG2Y12 inhibitor (clopidrgel/ Ticagrelor)

If high risk: Gp2a/3b inhibitors

3. Reperfusion therapy: via coronary angiography & PCI or thrombolytics (if facility of Primary PCI is not available) d/t ST elevation

Only give thrombo if cannot do CA or PCI in a cath lab
PCI: door to ballon is 90 minutes
If no cath lab, but you can transfer pt to hospital in 120 minutes, DO IT

Question 22

what are absolute CI for thrombolytics in STEMI?

Answer 22

1. Prev hemorrhagic stroke
2. Other strokes
3. Intracranial neoplasms
4. recent head trauma
5. Active internal bleeding (not menstruation)
6. Suspected aortic dissection
7. ANY bleeding

Question 23

1 treatment for STEMI?

Answer 23

SEND TO CATH LAB

Question 24

Post MI complications (5)

Answer 24

Post infarct ischemia

Arrhythmia

Right ventricular infarction

Mechanical complications

Myocardial dysfunction

Question 25

Post MI Ischemia can occur when? Tx?

Answer 25

1. After thrombolytic therapy for STEMI 2. After medically treating a NSTEMI. Treat with vigorous medical therapy. If refractory, undergo early aniography and revascularization

Question 26

What arrythmias can occur after a MI?

Answer 26

1. Sinus bradycardia (MCC in inferior MI) 2. Supraventricular tachycardia, including a-fib 3. Conduction disturbances 4. Ventricular arrhythmias

Question 27

AV node supplied by _______

Answer 27

RCA

Question 28

Post-MI, patient has 1st degree AV block 2nd degree AV block Complete AV block describe them

Answer 28

- 1st degree AV block: most common and no treatment - 2nd degree AV block: only treat if symptom - Complete AV block: most common in an inferior MI. If occurs with an anterior MI => worse.

Question 29

complete AV block is most common in an ____ MI and worse with an _____ MI? What is the treatment?

Answer 29

inferior anterior = worse bc sign of BAD infarction Permenant pacing

Question 30

What is the most comon conduction abnormality in the first few hours after MI and how is it treated?

Answer 30

Ventricular arrythmia (VT/VF) if hemodynamically signifiant: defibrillate Stable: antiarrhythmic meds + amiodrone

Question 31

how do you treat RV infarction, which occurs in 1/3 of all inferior MIs.

Answer 31

IV fluids - AVOID VASODILATORS (NG) - DO NOT REDUCE PRELOAD

Question 32

Right ventricular infarcts (RV infarcts) presents with what sx?

Answer 32

1. HypoTN with NL LV function 2. High JVP 3. Clear lungs

Question 33

How are LV/RV infarcts different?

Answer 33

RV infarcts RV infarcts will have clear lungs Dx by: ST elevation in the right sided anterior leads LV infarcts LV infarcts do NOT have clear lungs Dx: ST elevation in the left sided anterior leads

Question 34

A pt with recent MI presents with systolic BP <90. They have cold extremities, decreased urine output and are confused; what are you thinking?

Answer 34

Cardiogenic shock - these patients will not respond with fluid resucitation - give inotropic support (DA, dobutamine, NE) - poor prognosis

Question 35

NAME THAT SHOCK should be considered for urgent coronary angiography, revascularization and possible placement of intra-aortic balloon pump.

Answer 35

cardiogenic shock

Question 36

NAME THAT SHOCK Echocardiagram should be taken and will show function of the LV is moderately - severely reduced.

Answer 36

Cardiogenic shock

Question 37

• Essentials of Diagnosis in a patient with shock (4)

Answer 37

Hypotension (low BP) Tachycardia Oliguria Altered mental status (confusion)

Question 38

Name that shock Blood loss or dehydration causes decreased intravascular volume. To treat, we replete the intravascular volume

Answer 38

hypovolemic shock

Question 39

NAME THAT SHOCK! Shock caused by [cardiac tamponade, tension pneumothorax and massive PE] that is treated by treating underlying cause

Answer 39

Obstructive shock

Question 40

NAME THAT SHOCK A category of shocks, where the most common in septic shock!

Answer 40

distributive

Question 41

NAME THAT SHOCK! Shock most commonly caused by gram (-/+) organism where hypotension does NOT respond to fluid. Systolic BP are < 100mmHg, serum lactate levels are high (> 2mmol/L) and requires vasopressors to keep MAP above 65mmHg.

Answer 41

SEPTIC SHOCK

Question 42

NAME THAT SHOCK! Type of shock treated by fluids + ABX + hope for the best!

Answer 42

septic shock