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Case Files EM Ch 1-3 > strep, MI, afib > Flashcards

strep, MI, afib Flashcards

1
Q

several features that make group A streptococcus more likely

A

age less than 15 years, fever, absence of cough, and the presence of tonsillar exudate

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2
Q

if the rapid test is negative

A

perform negative throat culture (gold standard) if positive, the patient should be notified and given penicillin therapy

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3
Q

viral etiologies of pharyngitis (most common cause)

A

rhinovirus, coronavirus, adenovirus, herpes simplex virus [HSV], influenza, parainfluenza, EBV and CMV [causing infectious mononucleosis], coxsackievirus [causing herpangina], HIV

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4
Q

bacterial etiologies of pharyngitis

A

GABS, group C streptococci, Arcanobacterium haemolyticum, meningococcal, gonococcal, diphteritic, chlamydial, Legionella, and Mycoplasma species

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5
Q

specific oropharynx conditions caused by bacterial organisms

A

peritonsillar abscess, epiglottitis, retropharyngeal abscess, Vincent angina, and Ludwig angina

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6
Q

other oropharnyx conditions

A

candidal pharyngitis, aphthous stomatitis, thyroiditis, and bullous erythema multiforme

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7
Q

think retropharnygeal abcess if ?

A

greater than 2-3mm of soft tissue between C2-3 and trachea
grea`ter than 21mm between lower cervical vertebrae
(deet from Peds ER)

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8
Q

Centor Criteria for Predicting Streptococcal Pharyngitis

A

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

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9
Q

what causes pharyngitis at a rate similar to GABS in young adults
if not treated causes ?

A

Fusobacterium necrophorum

Lemierre syndrome, a life-threatening suppurative complication.

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10
Q

rapid-antigen test (RAT) for GABS

A

80% to 90% sensitive and exceedingly specific when compared to throat cultures
-POC, results available in minutes, confirm negative RAT with throat cultures

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11
Q

Centor Criterial treatment algorithm

A

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

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12
Q

Centor Criterial treatment algorithm if no RAT available

A

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

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13
Q

nonsuppurative complications of GABS pharyngitis

A

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

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14
Q

Prevention of the ? complications of GABS pharyngitis remains perhaps the most compelling reason for antibiotic therapy, including:

A

suppurative complications: tonsillopharyngeal cellulitis, peritonsillar and retropharyngeal abscesses, sinusitis, meningitis, brain abscess, and streptococcal bacteremia

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15
Q

antibiotic of choice for GABS pharyngitis

A

PCN:
penicillin V 500-mg bid dosing for 10 days in adults
-all pts should get adequate analgesia and reassurance

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16
Q

abx for GABS if pt compliance is an issue..

A

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)

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17
Q

a controversial GABS treatment to decrease pain and swelling

A

dexamethasone 0.6 mg/kg up to 10 mg PO or IM.

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18
Q

life-threatening causes of sore throat (should be considered when a patient presents with “sore throat”)

A

acute epiglottitis, peritonsillar abscess, retropharyngeal abscess, and Ludwig angina less common: Vincent angina and diphtheria pharyngitis (highly infectious)
also mono and HIV

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19
Q

Management of the airway in complicated airway conditions sometimes necessitates ? because the pharynx and larynx may be edematous, distorted, or inflamed

A

emergency cricothyroidotomy

-safest method of surgically securing an airway in the ED.

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20
Q

Epiglottitis presentation/dx/tx

A

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

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21
Q

Retropharyngeal abscess presentation/dx/tx

A

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)

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22
Q

Ludwig angina presentation/dx/tx

A

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)

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23
Q

Peritonsillar abscess presentation/dx/tx

A

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)

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24
Q

? 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.

A

Glomerulonephritis

Rheumatic fever

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25
Q

immediate therapy for MI

A

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

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26
Q

indications for immediate reperfusion therapy for STEMI

A
  • 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
27
Q

typical EKG findings in NSTEMI and UA

A

Horizontal ST-segment depression
ECG findings change in accord with symptoms
Deep T-wave inversions

28
Q

EKG leads correlating with coronary artery and location

A 
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
29
Q

risk factors for CAD

A

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)

30
Q

TIMI risk score

A

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

31
Q

TIMI risk score interpretation

A

Risk of death, MI, or revascularization at 2 wk by score: 1, 5%; 2, 8%; 3, 13%; 4, 20%; 5, 26%; 6, 41%.

32
Q

workup of ACS include ?

A

a chest radiograph (CXR), complete blood count, chemistries, coagulation studies, and blood type

33
Q

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?

A

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

34
Q

first tx steps of MI

A

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

35
Q

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?

A

immediate reperfusion therapy
two ways to achieve reperfusion: primary PCI (angioplasty or stent placement) (best) and thrombolysis
120 minutes

36
Q

PCI is also used for ? Administration of ? prior to PCI reduces the risk of reinfarction

A

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

37
Q

therapies of proven benefit for MI

A 
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)
38
Q

Inferior MI frequently causes ? and ? that is transient and may respond to ?

A

AV node dysfunction and second-degree block

atropine

39
Q

a complication of anterior MI is ? which generally implies irreversible damage to the His-Purkinje system and is an indication for ?

A

heart block

transvenous pacing

40
Q

what are the most frequently encountered complications in the ED and prehospital setting, occurring in approximately 10% of cases?

A

MI-associated ventricular tachycardia and ventricular fibrillation (sudden death)

41
Q

another complication of inferior MI that presents with hypotension
diagnosis?
treatment?
what to avoid?

A

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

42
Q

Late complications of MI that tend to occur in the ICU hours-days later

A

LV free wall rupture causing tamponade, VSD, pericarditis, LV aneurysm, and thromboembolism

43
Q

In pts with symptomatic AF with RVR, an early priority in management will be to ?

A

slow the ventricular rate
(typical symptoms of palpitations and dyspnea can be alleviated through simple rate control)
i.e. diltiazem (CCB)

44
Q

diseases associated with afib

A

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%)

45
Q

afib is theorized to be caused by…

A

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

46
Q

what does the ventricular rate in a fib depend on?

what is it usually?

A

depends on the AV node’s ability to conduct the atrial depolarization and to recover from the previous conduction
100-160 bpm

47
Q

afib algorithm

A

http://casefiles.mhmedical.com.mwu.idm.oclc.org/ViewLarge.aspx?figid=104715593&gbosContainerID=70&gbosid=218340

48
Q

how to tx stable a fib pts

In the acute setting such as the ED what is the single most important goal of therapy?

A

rate control and/or rhythm control, with or without anticoagulation

ventricular rate control

49
Q

two groups of patients with AF who should NOT receive rate controlling agents

A

(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!

50
Q

Afib Patients who are hemodynamically unstable should get ?

A

immediate electrical cardioversion to restore sinus rhythm

51
Q

Without anticoagulation 4% to 5% of a fib patients will have a thromboembolic event in the first month following cardioversion either from ?

A

the dislodging of an existing clot or the formation of new clot caused by the “atrial stunning”

52
Q

the “48-hour rule” to guide anticoagulation in afib

A

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

53
Q

if uncomplicated pt presents to the ED less then 48 hrs after onset of a fib, safe to ?

A

cardiovert and send home

54
Q

patients presenting with AF of greater than 48 hours duration should be ?

A

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)

55
Q

two methods of cardioversion

which is more effective?

A

direct current (DC) cardioversion (more effective 73-90%, 50% (old)) and pharmacologic cardioversion (50-70%, 30% (old))

56
Q

The likelihood of a successful cardioversion for either method depends on ?

A

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

57
Q

synchonized DC cardioversion levels

A

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

58
Q

complications of DC cardioversion (15%)

A

bradycardia, ventricular tachycardia, ventricular stunning with hypotension

59
Q

meds used to cardiovert

A

Ic: flecainide, propafenone (flakes, purple phone, only in healthy hearts)
III: Dofetilide, amiodarone, Ibutilide, Vernakalant

60
Q

chronic afib tx

A 
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
61
Q

new oral anticoagulation agent that was shown to be superior to warfarin in the recent RE-LY trial

A

Dabigatran (Pradaxa)

reduces the rate of ischemic and hemorrhagic strokes, major bleeding, and overall mortality compared to warfarin

62
Q

ASA or plavix for afib stroke prevention?

A

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

63
Q

CHA2DS2VASc score

A 
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

64
Q

?% of new-onset AF will spontaneously convert to sinus rhythm.

Patients with AF have a ?x higher risk of stroke than the general population.

A

70%

2-3x

Case Files EM Ch 1-3 (1 decks)

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