strep, MI, afib Flashcards
several features that make group A streptococcus more likely
age less than 15 years, fever, absence of cough, and the presence of tonsillar exudate
if the rapid test is negative
perform negative throat culture (gold standard) if positive, the patient should be notified and given penicillin therapy
viral etiologies of pharyngitis (most common cause)
rhinovirus, coronavirus, adenovirus, herpes simplex virus [HSV], influenza, parainfluenza, EBV and CMV [causing infectious mononucleosis], coxsackievirus [causing herpangina], HIV
bacterial etiologies of pharyngitis
GABS, group C streptococci, Arcanobacterium haemolyticum, meningococcal, gonococcal, diphteritic, chlamydial, Legionella, and Mycoplasma species
specific oropharynx conditions caused by bacterial organisms
peritonsillar abscess, epiglottitis, retropharyngeal abscess, Vincent angina, and Ludwig angina
other oropharnyx conditions
candidal pharyngitis, aphthous stomatitis, thyroiditis, and bullous erythema multiforme
think retropharnygeal abcess if ?
greater than 2-3mm of soft tissue between C2-3 and trachea
grea`ter than 21mm between lower cervical vertebrae
(deet from Peds ER)
Centor Criteria for Predicting Streptococcal Pharyngitis
Presence of tonsillar exudates: 1 point
Tender anterior cervical adenopathy: 1 point
Fever by history: 1 point
Absence of cough: 1 point
Age less than 15 y: add 1 point to total score
Age more than 45 y: subtract 1 point from total score
what causes pharyngitis at a rate similar to GABS in young adults
if not treated causes ?
Fusobacterium necrophorum
Lemierre syndrome, a life-threatening suppurative complication.
rapid-antigen test (RAT) for GABS
80% to 90% sensitive and exceedingly specific when compared to throat cultures
-POC, results available in minutes, confirm negative RAT with throat cultures
Centor Criterial treatment algorithm
4+ points: treat empirically
2-3 points: RAT, treat if positive, if negative withhold abx until throat culture
0-1 points: no abx or diagnostic tests
Centor Criterial treatment algorithm if no RAT available
3-4 points: tx empirically
2 points: culture, no empiric treatment (unless GABS outbreak, patient contact with many children, an immunocompromised patient, or a patient with recent exposure to someone with confirmed GABS)
0-1 points: no tests, no abx
nonsuppurative complications of GABS pharyngitis
rheumatic fever, streptococcal toxic shock syndrome, poststreptococcal glomerulonephritis, and PANDAS (pediatric autoimmune neuropsychiatric disorder associated with group A streptococci)
-controversial if antibiotic treatment for GABHS decreases incidence of these conditions as they are rare
Prevention of the ? complications of GABS pharyngitis remains perhaps the most compelling reason for antibiotic therapy, including:
suppurative complications: tonsillopharyngeal cellulitis, peritonsillar and retropharyngeal abscesses, sinusitis, meningitis, brain abscess, and streptococcal bacteremia
antibiotic of choice for GABS pharyngitis
PCN:
penicillin V 500-mg bid dosing for 10 days in adults
-all pts should get adequate analgesia and reassurance
abx for GABS if pt compliance is an issue..
a single IM shot of 600,000 units of penicillin G benzathine in patients weighing <27 kg (1.2 million units if patient weighs >27 kg)
a controversial GABS treatment to decrease pain and swelling
dexamethasone 0.6 mg/kg up to 10 mg PO or IM.
life-threatening causes of sore throat (should be considered when a patient presents with “sore throat”)
acute epiglottitis, peritonsillar abscess, retropharyngeal abscess, and Ludwig angina less common: Vincent angina and diphtheria pharyngitis (highly infectious)
also mono and HIV
Management of the airway in complicated airway conditions sometimes necessitates ? because the pharynx and larynx may be edematous, distorted, or inflamed
emergency cricothyroidotomy
-safest method of surgically securing an airway in the ED.
Epiglottitis presentation/dx/tx
Sudden onset of fever, drooling, tachypnea, stridor, toxic appearing
dx: Lateral cervical radiograph (thumb-printing sign)
tx: Urgent ENT consultation for airway management
Helium-O2 mixture
Cefuroxime antibiotic therapy
Retropharyngeal abscess presentation/dx/tx
Usually child or if adult (trauma)
Fever, sore throat, stiff neck, no trismus
dx: Lateral cervical radiograph or CT imaging
tx: Stabilize airway
Surgical drainage
Antibiotics (penicillin and metronidazole)
Ludwig angina presentation/dx/tx
Submaxillary, sublingual, or submental mass with elevation of tongue, jaw swelling, fever, chills, trismus
dx: Lateral cervical radiograph or CT imaging
tx: Stabilize airway
Surgical drainage
Antibiotics (penicillin and metronidazole)
Peritonsillar abscess presentation/dx/tx
Swelling in the peritonsillar region with uvula deviation, fever, sore throat, dysphagia, trismus
dx: Cervical radiograph or CT imaging
tx: Aspiration of the region with pus
Abscess drainage
Antibiotic therapy (penicillin and metronidazole)
? is a rare complication of GABS pharyngitis (but not GABS infections of other tissues) that is NOT clearly prevented by antibiotic therapy.
? is an exceedingly rare complication of GABS pharyngitis that CAN be prevented by antibiotic therapy.
Glomerulonephritis
Rheumatic fever
immediate therapy for MI
ASA, O2, sublingual nitro (think mONA BasH)
Depending on the result of the ECG:
+/-emergency reperfusion therapy, such as thrombolysis
+/- IV B-blockers, IV nitroglycerin, LMWH, and additional antiplatelet agents, such as clopidogrel
indications for immediate reperfusion therapy for STEMI
- ST elevation greater than 1 mV (1 mm) in 2 contiguous leads and more than 12 h since pain onset
- LBBB not known to be old with a history suggestive of acute MI
- ST elevations in posterior leads (V7, V8, V9) or ST depression in V1-V3 with a prominent R wave and upright T wave suggestive of posterior STEMI
typical EKG findings in NSTEMI and UA
Horizontal ST-segment depression
ECG findings change in accord with symptoms
Deep T-wave inversions
EKG leads correlating with coronary artery and location
LAD Anteroseptal V1, V2, V3 LAD Anterior V2-V4 LCA Lateral I, aVL, V4-V6 RCA Inferior II, III, aVF RCA Right ventricular V4R (also II, III, aVF) RCA, LCA Posterior R waves in V1, V2
risk factors for CAD
DM, Hypercholesterolemia; HDL less than 40 mg/dL
Current tobacco use, HTN
Age (male older than 45 y; female +55 y or premature menopause)
Family history of premature CHD (MI or sudden death before age 55 y in male first-degree relative; before 65 y in female first-degree relative)
Sympathomimetics (cocaine, amphetamines)
Rheumatologic conditions (RA, SLE)
TIMI risk score
Age +65 y
Prior documented coronary artery stenosis +50%
Three or more CHD risk factors
Use of aspirin in the preceding 7 d
Two or more anginal events in the preceding 24 h
ST-segment deviation (transient elevation or persistent depression)
Increased cardiac markers
TIMI risk score interpretation
Risk of death, MI, or revascularization at 2 wk by score: 1, 5%; 2, 8%; 3, 13%; 4, 20%; 5, 26%; 6, 41%.
workup of ACS include ?
a chest radiograph (CXR), complete blood count, chemistries, coagulation studies, and blood type
cardiac markers?
best one: Troponin I is extremely sensitive and specific for cardiac damage; thus an elevated level confirms infarction whereas a normal level at ? hours after the onset of pain excludes infarction.
Important limitations of cardiac markers?
myoglobin, CKMB, and troponin
8 to 12 hours
levels remain normal in unstable angina and serum elevations are delayed 4 to 12 hours after infarction
first tx steps of MI
immediately given aspirin to chew (162 mg dose is common)
also oxygen, sublingual nitroglycerin, which decreases wall tension and myocardial oxygen demand, and morphine sulfate
When the ECG reveals STEMI and symptoms have been present for less than 12 hours, ? is indicated
methods ?
total ischemic time should be limited to less than?
immediate reperfusion therapy
two ways to achieve reperfusion: primary PCI (angioplasty or stent placement) (best) and thrombolysis
120 minutes
PCI is also used for ? Administration of ? prior to PCI reduces the risk of reinfarction
STEMI complicated by cardiogenic shock, when there is a contraindication to thrombolysis, and in cases where thrombolysis fails to restore perfusion (rescue PCI)
LMWH and a glycoprotein IIB/IIIA inhibitor
therapies of proven benefit for MI
Aspirin (162 mg, chewed immediately, then continued daily for life) Primary PCI (angioplasty or stenting the blocked artery) Thrombolysis (if primary PCI not available; most regimens require heparin therapy) β-blockers (immediate IV use and started orally within 24 h; if no contraindications then continued daily) ACE-inh (started within 1-3 d, continued for life) Cholesterol-lowering drugs (started within 1-3 d and continued daily for life) Enoxaparin (dosage given prior to thrombolysis or PCI, for patients less than 75 y of age) Clopidogrel (75 mg daily with or without reperfusion therapy)
Inferior MI frequently causes ? and ? that is transient and may respond to ?
AV node dysfunction and second-degree block
atropine
a complication of anterior MI is ? which generally implies irreversible damage to the His-Purkinje system and is an indication for ?
heart block
transvenous pacing
what are the most frequently encountered complications in the ED and prehospital setting, occurring in approximately 10% of cases?
MI-associated ventricular tachycardia and ventricular fibrillation (sudden death)
another complication of inferior MI that presents with hypotension
diagnosis?
treatment?
what to avoid?
right ventricular infarction
diagnosis confirmed by ST elevation in lead V4 on a right-sided ECG
primary treatment is aggressive volume loading
avoid nitro and high-dose morphine
Late complications of MI that tend to occur in the ICU hours-days later
LV free wall rupture causing tamponade, VSD, pericarditis, LV aneurysm, and thromboembolism
In pts with symptomatic AF with RVR, an early priority in management will be to ?
slow the ventricular rate
(typical symptoms of palpitations and dyspnea can be alleviated through simple rate control)
i.e. diltiazem (CCB)
diseases associated with afib
HTN, CAD, CM, valvular HD, rheumatic HD, congenital, MI, pericarditis, myocarditis
PE, COPD, OSA
hyperthyroidism, obesity, metabolic syndrome, inflammation
cardiac/any surgery
“holiday heart” (binge etOH)
lone afib (10%)
afib is theorized to be caused by…
complex interaction between triggers for AF and abnormal atrial myocardium that has multiple reentrant circuits or automatic foci outside the SA node–>rapid electrical activity in the atria–>disorganized and ineffective atrial contractions
the rapid atrial electrical activity is also conducted through the AV node leading to an irregular ventricular response
what does the ventricular rate in a fib depend on?
what is it usually?
depends on the AV node’s ability to conduct the atrial depolarization and to recover from the previous conduction
100-160 bpm
afib algorithm
http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104715593&gbosContainerID=70&gbosid=218340
how to tx stable a fib pts
In the acute setting such as the ED what is the single most important goal of therapy?
rate control and/or rhythm control, with or without anticoagulation
ventricular rate control
two groups of patients with AF who should NOT receive rate controlling agents
(1) unstable patients in whom the instability is presumed to be caused by the rhythm
(2) patients with Wolff-Parkinson-White (WPW) syndrome (any AV nodal blocking agents can lead to accelerated conduction down the accessory pathway and potentially induce vfib)-
should get immediate electrical cardioversion!
Afib Patients who are hemodynamically unstable should get ?
immediate electrical cardioversion to restore sinus rhythm
Without anticoagulation 4% to 5% of a fib patients will have a thromboembolic event in the first month following cardioversion either from ?
the dislodging of an existing clot or the formation of new clot caused by the “atrial stunning”
the “48-hour rule” to guide anticoagulation in afib
afib less than 48 hours duration does not generally require acute anticoagulation except when the patient has mitral valve disease, severe LV dysfunction, or prior history of embolic stroke
if uncomplicated pt presents to the ED less then 48 hrs after onset of a fib, safe to ?
cardiovert and send home
patients presenting with AF of greater than 48 hours duration should be ?
anticoagulated prior to cardioversion:
warfarin for 3-4 wks goal INR 2-3 then cardiovert
OR screen with TEE and if no clots give the combination of heparin/enoxaparin (LMWH) then cardiovert (quicker)
with both, give warfarin for 3-4 wks post-cardioversion (INR 2-3)
two methods of cardioversion
which is more effective?
direct current (DC) cardioversion (more effective 73-90%, 50% (old)) and pharmacologic cardioversion (50-70%, 30% (old))
The likelihood of a successful cardioversion for either method depends on ?
the characteristics of the patient, the etiology of the AF, and, most importantly, the duration of the AF:
New-onset AF will spontaneously convert in about 70% of cases, whereas cases of AF with a longer duration and dilated atria may prove refractory to all attempts at cardioversion
synchonized DC cardioversion levels
100-360 J (most patients require ≥200 J), for AF <24 h: start with 100 J; biphasic conversion offers a better success rate and fewer complications and achieves conversion at 50% of monophasic levels
complications of DC cardioversion (15%)
bradycardia, ventricular tachycardia, ventricular stunning with hypotension
meds used to cardiovert
Ic: flecainide, propafenone (flakes, purple phone, only in healthy hearts)
III: Dofetilide, amiodarone, Ibutilide, Vernakalant
chronic afib tx
amiodarone, propafenone, dronedarone (like amio but no iodine, less effective, ^mort in class IV HF) if refractory to meds + symptomatic AF may use radiofrequency catheter ablation
new oral anticoagulation agent that was shown to be superior to warfarin in the recent RE-LY trial
Dabigatran (Pradaxa)
reduces the rate of ischemic and hemorrhagic strokes, major bleeding, and overall mortality compared to warfarin
ASA or plavix for afib stroke prevention?
ASA, clopidogrel, and ASA + clopidogrel are all less effective in preventing stroke than warfarin, but pts who need anticoagulation but cannot take warfarin or dabigatran, the combo of clopidogrel + ASA is more effective than ASA alone
CHA2DS2VASc score
CHF hx - 1 HTN hx - 1 Age 65-74 - 1; 75+ - 2 DM - 1 Stroke/TIA/TE hx - 2 Vasc diz hx - 1 Sex, female - 1
0: low risk, no therapy better than ASA
1: low/moderate, consider warfarin/dabigatran over ASA
2+: moderate/high, should anticoagulate with warfarin or dabigatran
?% of new-onset AF will spontaneously convert to sinus rhythm.
Patients with AF have a ?x higher risk of stroke than the general population.
70%
2-3x
