Week 3 Clinical Medicine: Shock, PAD, Pediatric Cardiology Flashcards

1
Q

What are the 3 determinants of Stroke Volume (SV)?

A

Preload, Myocardial Contractility, Afterload

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2
Q

What is Shock and what is it caused by?

A
  • inadequate tissue perfusion to meet metabolic demand and tissue oxygenation
    causes: inadequate supply or increased demand (or both!)
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3
Q

What is the difference between Compensated, Decompensated, and Irreversible Shock?

A

Comp: reflex compensatory mechanisms activated to maintain perfusion to vital organs

  • blood shunts CENTRAL; HR/contractility INC
  • Sympathetic tone, catecholamines, RAAS INC

Decomp: tissue hypoperfusion and circulatory/metabolic derangement
- hypotension and lactic acidosis

Irreversible: organ/tissue injury SEVERE, correction CANNOT fix (survival impossible)

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4
Q

What is the difference between:

Cardiogenic Shock
Hypovolemic Shock
Distributive Shock
Obstructive Shock

What are they caused by?

A

C: BAD PUMP
- cardiomyopathy, Arrhythmias, Mechanical (ex: valves)

H: dec. intravascular volume
- hemorrhage or dehydration (non-hemorrhagic)

D: dec. SVR
- drugs or sepsis

O: mechanical obstruction of circulatory system
- ex: tension pneumothorax, pulmonary embolism

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5
Q

What is Cardiogenic Shock and what are its 3 subtypes?

What physiological changes are associated with it? (CO/SVR/CVP)

A
  • “pump failure” = HEART is the PROBLEM
  • CO dec. and SVR/CVP inc.

Subtypes:

  • Cardiomyopathies (MC; ischemic, infect., drugs)
  • Rhythm Problems (bradycardia/tachycardia)
  • Valvular/Congenital (stenosis/VSD/etc)

Heart Muscle Problems (Cardiomyopathies) MOST COMMON CAUSE

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6
Q

What is Hypovolemic Shock and what are its 2 subtypes?

What physiological changes are associated with it? (CO/SVR/CVP)

A
  • loss or lack of INTRAVASCULAR VOLUME
  • CO/CVP dec. and SVP inc.

Subtypes:

  • Hemorrhagic (blood loss)
  • Non-hemorrhagic (fluid loss)
    • dehydration (vomit, diarrhea, dec. intake)
    • 3rd spacing (cirrhosis)
    • through the skin (BURNS)
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7
Q

What is Distributive Shock and what are its 2 subtypes?

What physiological changes are associated with it? (CO/SVR/CVP)

A
  • vasodilation of vascular beds causes dec. Systemic Vascular Resistance (SVR)
  • SVP/CVP dec. and CO inc. (Neuro? = ALL decreased)

Subtypes:

  • Septic (septic shock)
  • Non-septic (neuro, anaphylactic, toxin/meds)
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8
Q

What is Obstructive Shock?

What physiological changes are associated with it? (CO/SVR/CVP)

What are 3 examples of this type of shock?

A
  • mechanical obstruction within the cardiopulmonary system causing restriction of blood flowing into/out of heart
  • dec. CO, inc. SVR, variable CVP
    ex: tension pneumothroax, pericardial tamponade, pulmonary embolism
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9
Q

What is the goal of Shock treatment and what are 4 things that should be given to pts. suffering from shock? (F/V/US/A)

A

Goal: initial/rapid restoration of tissue hypo-perfusion and identifying the underlying cause

Tx: IV fluids, vasopressors, US evaluation (RUSH protocol to determine type), and broad spectrum antibiotics if infection thought to be cause (SEPSIS)

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10
Q

What are considerations when treating children and the elderly patients for possible shock?

A

Kids: hypotension not seen till too late

  • will present with tachycardia and NORMAL BP
  • work FAST to correct underlying tachycardia

Elderly: usually on cardiac medication

  • may not see tachycardia (masked by meds)
  • WORK UP
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11
Q

What are the screening guidelines for patients with Carotid Artery Stenosis?

A
  • asymptomatic pts. should NOT be screened
  • screening for pts with known atherosclerotic disease OR pts with carotid BRUITS using Carotid Duplex Ultrasound (tells us if stenosis is there, but not grade)
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12
Q

What are the screening procedures for patients suspected of Abdominal Aortic Aneurysm?

What pathology is seen on screening?

A
  • abdominal ultrasonography as initial screen
  • useful for 65-75 yo men (NOT women) who have a history of smoking
  • see curvilinear calcifications outlining portions of aneurysm wall in 75% of pts.
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13
Q

What are the two treatment options for pts. with Aortic Aneurysm?

A
  1. Emergency Repair: endovascular repair has some improvement over open surgery
    • bleeding hopefully confined to retroperitoneum
    • open surgery: graft above and below aneurysm
  2. Elective Repair: indicated for aneurysms > 5.5 cm or those with rapid expansion (> 0.5 cm in 6 months)
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14
Q

What imaging is used to visualize an Abdominal Aortic Aneurysm?

A

CT scans or CT scans /contrast (can see vasculature)

  • can also use US which is less risky (no contrast)
    • can estimate size and see presence of aneurysm
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15
Q

Lower Extremity Arterial Disease

What is the most commonly affected artery due to atherosclerosis?

What testing can be done on these patients?

A

MC: superficial femoral artery

  • common femoral and popliteal arteries also involved
  • result in short-distance claudication (CALF PAIN)

Testing: Ankle-Brachial Indices

  • no recommended for ASYMPTOMATIC pts.
  • has excellent accuracy compared to angiography
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16
Q

Lower Extremity Arterial Disease

What findings on ABI are diagnostic for PAD?

What imaging can be done on pts. with PAD?

A

Diagnostic: ABI < 0.9

  • < 0.4 = chronic limb-threatening ischemia
  • toe-brachial index < 0.7 diag. (DM/CKD pts)
  • vessels above are calcified; ABI can be misleading

Imaging: duplex US, CT angiography, MR angiography

  • show anatomic location of lesions
  • done ONLY if revascularization is planned
17
Q

Lower Extremity Arterial Disease

What are the two treatment options available to pts. with PAD?

A
  1. Medical/Exercise Therapy
    • dec. risk factors, high-dose statin, exercise
  2. Surgical intervention - claudication incapacitating
    • bypass/endovascular surgery
    • thromboendarterectomy
18
Q

Lower Extremity Arterial Disease

What are the 4 drugs used to medical treat this disease?

A

Antiplatelet drugs: aspirin/clopidogrel
- prevent clotting in region of the plaques

PDE3 inhibitor: Cilostazol (selective antiplatelet/vasodil.)
- shows inc. exercise tolerance in severe claudication

Pentoxifylline: NOT RECOMMENDED

19
Q

What are major risk factors of PAD, especially below and above age 50?

A

age < 50 w/Diabetes and an additional risk factor
- smoking, hypertension, homocysteinemia, lipidemia

age 50-69 yrs with smoking AND diabetes

  • abnormal LE pulses, leg symptoms w/exertion or rest, known atherosclerotic disease
20
Q

What is the screening process for pts. with suspected PAD?

A
  • if patient has risk factors for PAD or symptoms of claudication, screen with ABI
  • if ABI is negative but are still suspicious of PAD, perform an Exercise Stress Test and then recheck ABI
21
Q

What does the leg of a patient with Chronic Venous Insufficiency (CVI) look like?

A
  • discolored skin from stasis dermatitis; yellow color from lipodermosclerosis
  • large ulcerations seen at or above medial ankle (venous ulcers)
  • darker brown areas from hemosiderin deposition as fluid leaks into tissue (heme pigment)

NOT CELLULITIS

22
Q

What are the clinical findings of patients with Chronic Venous Insufficiency?

A
  • progressive pitting edema is presenting symptom
  • usually itching, dull discomfort with standing, pain if ulcer present (above ankle)
  • varicosities may be present
23
Q

What imaging is done on a patient with Chronic Venous Insufficiency and what is the classical scenario of presentation?

A

Image: duplex US to determine superficial reflux and degree of deep reflux/obstruction

CS: elderly female with CVI, given compression stockings and rest w/leg elevation = no help
- now do duplex US to look for venous reflux

24
Q

What are the two treatment options available to a patient suffering from Chronic Venous Insufficiency?

A
  1. fitted, graduated compression stockings from foot to just below knee during day/evening
    • avoid long times of sitting/standing, elevate leg
  2. Vein Treatment
    • superficial vein reflux (varicose) surgery can dec. venous ulcer rate
    • do NOT remove varicose if femoral/popliteal vein obstruction
25
Q

What congenital heart defects are associated with Trisomy 21?

What sounds does an Atrial Septal Defect make?

A

Midline Septal Defects (ASD and VSD/AVSD/PDA)

  • ASD causes as FIXED SPLIT S2 on auscultation
26
Q

What congenital heart defect is associated with a Holosystolic murmur?

Are diastolic murmurs ever normal?

A

VSD

  • obscures normal S1 and S2 sounds
  • diastolic murmurs are NEVER NORMAL (usually low pitched with a “rumbling” characteristic)
27
Q

What is the only Diastolic Murmur that does NOT warrant referral to cardiology?

A

Venous Hum

  • caused by flow of venous blood from the head and neck into the thorax (can be heard continuously while child is sitting)
28
Q

What pathologic murmur increases in intensity as the pt stands or during Valsalva maneuver?

What does it sound like and where?

A

HYPERTROPHIC CARDIOMYOPATHY (idiopathic hypertropic subaortic stenosis)

  • harsh crescendo-decrescendo systolic murmur best heard at apex and LSB
  • causes a left ventricular outflow tract obstruction
29
Q

What is a Still’s Murmur?

A
  • innocent murmur heard best at the apex and LLSB using the BELL of the stethoscope
  • dec. intensity with inspiration, sitting up, standing
30
Q

What are the 5 cyanotic lesions of the heart?

How are ductal dependent lesions screened for in children?

A

Truncus Arteriosus (1 big trunk)
Transposition of Great Vessels (2 interchanged vessels)
Tricuspid Atresia (3)
Tetralogy of Fallot (4)
Total Anomalous Pulmonary Venous Return (5)

  • do O2 saturation checks both pre-ductally and post-ductally
31
Q

What is the screening procedure for checking of CHD in children?

A
  1. check children > 24 hrs old or shortly before discharge if < 24 hrs old
  2. if < 90% O2 in right hand/foot = failed screen
  3. if 90-95% in right hand/foot OR > 3% difference between –> screen in 1 hr, then screen 1 more hour if needed
    • if failed 3 screenings = failed screen
  4. if > 95% in right hand/foot AND < 3% difference between right hand/foot = PASSED SCREEN
32
Q

Pediatric Hypertension

Which children should be checked and how does using too small/too large of cuff change the readings?

A
  • check pediatric BP in all children > 3 yrs old

Cuff too small = artificial ELEVATED BP
Cuff too large = artificial LOWERED BP