Tintinellis EMED Ph 2 Flashcards
Cardiogenic Shock MC results from ?
These are more likely to occur from ? type of injury
What causes coronary artery hypoperfusion to occur
LV infarct induced pump failure leading to decreased tissue perfusion despite adequate volume avail in circulation
STEMI- leading cause of death in PTs w/ AMI
Lack of systemic resistance= dec DBP
Why does pulmonary edema occur during cardiogenic shock
Augmenting ? can improve coronary artery perfusion
What is the risk of this augmentation
Inc after load/dysfunction increases LV end diastolic pressure
Vasoconstriction
Dec CO
Why does cardiogenic shock induce systemic vasodilation
Euvolemic cardiogenic shock occurs subacutely in ? Pts
Finding of diaphoresis on these Pts indicates ?
Triggers systemic inflammatory response= inc NO w/ negative inotropic effects
Heart failure
Activation of sympathetic nervous system
Shock is indicated by SBP <90 or a MAP below ?
? type of view on E-FAST is used for suspected tamponades/effusions
Pericardial effusion and aortic root bigger than ? suggest ascending aortic dissection
<65mmHg
Sub-costal 4 chamber view
> 3cm
? is the most important definitive intervention for acute ischemia related cardiogenic shock
Add O2 to keep sats above ?
What issue happens after intubation w/ pos-pressure ventilation and how is this countered
Emergent revascularization via PCI/CABG
> 91%
Dec preload and CO= worsened HOTN;
Fluid bolus
How is HOTN during cardiogenic shock Tx
How is congestion w/out HOTN Tx
What is the nest step if these meds fail to correct the shock
Vasopressor- Dopamine, NorEpi
Inotrope- Dobutamine: inc contractility; if SBP <70: NorEpi
Intra-aortic balloon pump/assist device
Pts taking BBs and suffering from cardiogenic shock may not have appropriate response to dobuatmine, in which case ? med is used
Acute HF management is improved by ? therapies
? new medication is FDA approved for use but does not improve outcomes
Milrinone- selective phosphodiesterase 3 inhibitor
BB ACEI Resynch therapy Spironolactone
Nesiritide
What are the 3 cardinal Sxs of HF
MI induced reduction of CO causes the neurohormonal release of ?
What are the counter-regulatory responses to this activation
SOB Edema Fatigue
NorEpi Endothlin ADH TNF-a: activate RAAS/Symp-NS
Natriuretic peptide- inhibit RAS/sympathetic NS
A: atrial B: ventricle C: endothelium
EF normally is ?
? dysfunction is seen early on in ischemic induced HF cascade
What Sxs have the highest sens/spec for HF
60%; Systolic failure <50%
Diastolic dysfunction leading to CADz
Sensitivity: dyspnea w/ exertion
Specificity: PNDyspnea, Orthopnea, Edema
What PE finding has the highest positive likelihood for acute HF
What CXR findings are the most specific for Dx of Acut HF
? E-FAST finding suggests elevated central venous pressure
S3 sound
Pulm congestion, Megaly, Interstitial edema
IVC >2cm, Collapse <50%
Acute HF Pts need to keep O2 levels above ?
? intervention can help avoid intubation for these Pts
What is the next step for persistent HOTN after Nitro use
95%
Dec after load w/ vasodilators- Nitro then Nitroprusside
Dec volume or RV infarct- give NS bolus
? is the best predictor for recurrence of syncope
Prolonged QTc is defined as ?
Myocarditis can lead to ? and is definitively Dx by ?
Syncope w/in preceding year
> 470msec
Dilated myopathy, Biopsy
? is the MC Sx of Pericarditis
? is a distinguishing feature
? is the MC and most important PE finding
Chest pain worse w/ supine, relieved w/ sitting
Pain referred to L trap
Friction rub w/ diaphragm at LLSB
What rare CXR finding may aid w/ Dx pericarditis
? is the image modality of choice for detection and confirmation
How do Pts die from PE
Epicardial fat pad sign
Echo
PEA/Asystole or RV failure and circulatory shock
? joint are most and least likely to be the origin of PEs
? combo causes the greatest risk for VTEs
? surgical procedures have the highest rates of VTE formation
Least: Elbow Shoulder Ankle Knee Hip- most
Same sided hip-knee immobile w/ non-weight bearing
Abdominal to remove cancer
Joint replacement
Brain/spine w/ neuro deficits
When are cancer Pts at highest risk for developing VTEs
? are the two MC Sxs of PE
What are the two rare CXR findings of PE
During chemo Tx
Dyspnea, Chest pain
Westermark- lobar artery obstruction
Hampton- pulmonary infarction
Leg size difference of ? suggests PE
Where are these measurements taken
PE R/o Criteria
≥2cm
10cm below tibial tubercle
HAD CLOTS:
Hormones Age >50 +DVT/PE Hx
Coughing blood Leg swollen O2 <95 Tachy >100 Surgery/Trauma <4wks
Well’s Score for DVT
EAT CHIPS: Edema/Pain/DVT Sx- 3 Alternative Dx unlikely- 3 Tachy- 1.5 Ca- 1 Hemoptysis- 1 Immobile >3 days: 1.5 Previous DVT/PE: 1.5 Surgery <1mon: 1.5
MC imaging modality for PE
Criteria for Pre-E
What are the 4 etiologies of catecholamine induced HTN emergencies
CT angiography w/ contrast
≥140/≥90 after 20wks
Clonidine d/c or withdrawl
Autonomic dysfunction
Pheo
Sympathetic drug use- cocaine, meth, PCP
How quickly is BP lowered during HTN Emergency
What is the therapeutic goal for aortic dissections
? is the mainstay of Tx
Dec SBP x 25% in first hour
<160/100 over 2-6hrs
To normal <48hrs
SBP 100-20 w/ HR ≤60bpm w/in first hour
Nitrates
How are HTN Emergencies induced by cocaine/meth Tx
What is used if Pts don’t respond to this Tx
What is used as 3rd line agents
IV Benzos, avoid BBs (except labetalol- +A-blocker effect)
Nitro or Phentolamine
CCBs
First line Tx for Pheo induced HTN Emergency
? medication is used pre-op
Aortic dissections occur d/t damage to ?
Phentolamine
Phenoxybenzamine
Intima- blood enters between intima and adventitia
How are aortic dissections Dx
If properly trained, ? is equally sensitive and specific
Criteria for P-HTN
CT w/ and w/out contrast
TEE
Aterial pressure >25mm at rest, >30 w/ exertion
Definitive method to Dx P-HTN
Why does P-THN lead to RV failure
? is the MC EKG finding
R-sided catheter
RCA perfusion depends on diastolic, RA pressure during systole and diastole. Dz dec systolic perfusion, CO
RAD
? is the best initial test to assess P-HTN
What Tx step is avoided if possible in this population
Size criteria for AAA and repair is needed ?
TTE
RV failure exacerbated w/ intubation (pos-press ventilation)
≥3cm w/ repair indicated at ≥5cm
? part of the GI tract is involved in aortoenteric fistula development
? images are used to Dx AAA
Define Trepopnea
Duodenum
Unstable: bedside US
Stable: CT w/ contrast
Dyspnea when laying on side w/ more diseased lung
What does negative inspiratory force assess
What is this used to Dx
Define Hypoxia and Hypoxemia
Diaphragm/Inspiration muscle strength
Neuromuscular dz
Insufficient O2 content/delivery to tissues
Low arterial oxygen tension
Only medication FDA approved to Tx hiccups
Define Pneumonia
Organisms can distribute through the lungs by spreading through the pores called ?
Chlorpromazine
Infection of alveolar portion of lungs
Pores of Kohn
MC microbe identified in CAP
What are the two MCC of infections of nursing homes
How is Aspiration pneumonia Tx
How is CAP Tx
Pseudomonas
UTIs > Aspiration pneumonia
Clinda, Amp-Sulbactam, Moxifloxacin
Clinda, Azith, Doxy
MC PE finding during pneumothorax
? is the initial image ordered
What are two normal findings on US
Tachypnea
Standing PA CXR
Comet tail, Sliding sign
When can pneumothorax be observed for Tx
These Pts are observed for a minimum of ? long
When are f/u exams needed after d/c
First time and stable w/ <20% of lung volume affected
4hrs
1-2wks
Needle decompressing pneumothorax need ? size
What are the two locations decompression is performed
What size chest tube are used
14g, 2”/5cm long
2nd ICS above rib at mid-clavicular line
4th ICS above rib at anterior axillary line
Non-traumatic: 10-14F
14-22F: larger w/ need for mechanical vent
? is the MC chronic dz of childhood w/ ? MC acute stimulus of attacks
What are three PE findings suggesting a severe case is present
Asthma; Viral respiratory infections
Accessory muscle use
Inability to speak in full sentence
Pulsus paraduoxus
? is the preferred initial therapy for asthma bronchospasms
? maintenance therapy meds are used
What is given to Pts upon d/c after attack/exacerbation
Albuterol (B2-agonist): promote broncho/vaso-dilation
LABAs: Salmeterol, Formoterol
5-10 day non-tapered course of Pred or,
2 day course of Dexamethasone or,
Non-compliant Pt: Methylprednisolone x 1 dose
? medication can be added to Albuterol in the ED during asthma exacerbations to reduce severity and admission
Pts are safe to d/c home w/ ? FEVR measurement
Criteria for COPD O2 therapy
Ipratropium bromide
FEVR >70%
PaO2 ≥55, SaO2 ≤88%
Define Visceral pain
Define Parietal pain
Define Referred pain
Crampy/dull pain d/t unmyelinated fiber stretching/inflammation
Irritated mylinated fibers covering anterior peritoneum causing tender/guard/rebound= immobile Pt
Ipsilateral pain d/t embryological development
Why does appendicitis pain begin in umbilical region
How much blood loss is needed for systolic changes
to be seen
PE sine a quon for peritonitis
Bilateral, T-10 innervation causing sensation at midline
30-40%
Rebound tenderness
? type of image to Dx appendicitis, kidney/ureter stones
? type of image to Dx aortic aneurysms and mesenteric ischemia
? is the MCC of N/V in USA
Non-contrast CT
IV contrast CT
VGE
Where is the vomit center in the brain
? type of image used for suspected intestinal obstruction
? medication can help w/ frequency of BMs in adults w/ chronic constipation
4th ventricle- chemo receptors outside of BBB
CT w/ IV/PO contrast
Psyllium (bulking agent)
Define Ogilvie Syndrome
What causes this syndrome to develop
MCC of upper GI bleeds
Colonic pseudo-obstruction w/ S/Sxs and image findings of large bowel obstruction but no evidence of distal obstruction
Dysregulated autonomic control of colonic motor activity
PUDz
BUN elevation above ? suggests bleeding source from upper GI
? study is c/i in these Pts
? is the most reliable method to Dx this issue in ED
≥30
Barium contrast studies
Visual inspection of aspirate for blood/maroon/coffee ground appearance (endoscopy- study of choice)
