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131 Cards in this Set
- Front
- Back
Angina - Dx (stable or unstable) |
Resting ECG - usually normal Exercise stress ECG or Echo (preferred) OR pharmacologic stress test (IV adenosine, dypyramidole or dobutamine) - ST seg depression, CP, hypotension or significant arrhythmias If + stress test, cardiac cath w/ coronary angiogram
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Stable angina - Tx
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All patients RF modification - smoking cessation ↓CHD risk by 50% within 1 year, BP, lipid and DM control, wt loss/exercise/diet - and ASA Mild (normal EF, mild angina, single-vessel) - nitrates, BB +/- CCB Mod (normal EF, mod angina, two-vessel) - above, consider coronary angiogram for revasc assessment (PTCA or CABG) Severe (decreased EF, severe angina, three-vessel, LMA or LAD) - coronary angiogram for CABG
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Unstable angina - Tx
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Admission (IV, O2, pain control - nitrates, morphine)
Medication - ASA, BB, LMWH (enoxaparin) > UFH, nitrates, glycoprotein IIb/IIIa inhibitors if PTCA or stents Conservative vs. aggressive mgmt - stress ECG plus cath/revasc w/in 48 hours OR only after 48 hr failure of med mgmt (no study shows difference) Post-acute mgmt - ASA, BB, nitrates, statin, RF mod, consider folic acid |
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Variant (Prinzmetal's) angina - Dx and Tx
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Dx ECG (hallmark) - transient ST elevation (transmural ischemia) Coronary angiogram (definitive) - coronary vasospasm when given IV ergonovine Tx - vasodilators (CCB, nitrates)
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MI - Tx
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Morphine Oxygen Nitrates ASA -mortality benefit Statins Beta blocker (carvedilol) - mortality benefit ACEI (ramipril) - mortality benefit Thrombolytics < PTCA (revascularization) - possible mortality benefit for PTCA Heparin (enoxaparin)
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Ventricular tachycardia (sustained, >30 sec) - Tx
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Hemodynamically unstable - electrical cardioversion Hemodynamically stable - IV amiodarone
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Ventricular fibrillation - Tx
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Immediate unsynchronized defibrillation and CPR
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Sinus tachycardia - Tx
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Tx underlying cause - pain, anxiety, fever, pericarditis, medications, etc
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Asystole - Tx
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VERY high mortality Begin with electrical defibrillation for Vfib (hard to distinguish from asystole) If asystole, trancutaneous pacing |
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AV block - Tx
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1st degree, 2nd degree (type 1) - no treatment 2nd degree (type 2), 3rd degree Anterior MI - emergent temporary pacemaker (then permanent) Inferior MI (better prognosis) - IV atropine
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Post-MI free wall rupture - Tx
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Most common days 1-4, 90% first two weeks 90% mortality rate Tx - hemodynamic stabilization, immediate pericardiocentesis, surgical repair
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Post-MI rupture of interventriclar septum - Tx
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Within 10 days Tx - emergent surgery
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Post-MI acute pericarditis - Tx
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Dressler's syndrome - pericarditis, dever, malaise, leukocytosis, pleuritis - weeks to months after MI Tx - ASA **NSAIDs/CS contraindicated (may hinder myocardial scar formation)
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Mild CHF (NYHA class I/II) - Tx
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Mild sodium restriction (<4g/d) + activity
Loop diuretic if volume overload/pulm congestion ACEI |
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Mild to Moderate CHF (NYHA class II/III) - Tx
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Loop diuretic + ACEI
Add BB if moderate disease + suboptimal response |
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Moderate to Severe CHF (NYHA class III/IV) - Tx
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Loop (or thiazide) diuretic + ACEI (↓mortality)
Digoxin (can add any pt w/systolic dysfxn to ↓sx) Class IV still sx - adding spironolactone may ↓sx and improve morbidity and mortality - RALES study) Post-MI - BB (↓mortality) - carvedilol>metoprolol (COMET study) Digitalis - short-term relief w/ EF <30%, severe CHF, severe Afib If cannot tolerate ACEI, ARB or hydralazine/isosorbide dinitrates (↓mortality) |
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Digoxin toxicity
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GI: N/V, anorexia Cardiac: ectopic (ventricular) beats, AV block, AFib CNS: visual disturbances, disorientation
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Cardioversion
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Definition - delivery of shock in synchrony wih QRS to terminate dysrhythmia Indications - AFib, atrial flutter, VT w/pulse, SVT
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Defibrillation
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Definition - delivery of shock NOT in synchrony with QRS to convert dysrrhythmia to normal sinus rhythm Indications - VFib, VT w/o pulse Automatic Implantable Defibrillator - surgically inplanted device to detect and disrupt lethal arrhythmias Indications - VFib, VT not controlled by medication
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Acute atrial fibrillation - Tx
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Hemodynamically unstable - immediate converversion Hemodynamically stable Rate control (target 60-100 bpm) - CCB, BB (alt), if LV systolic dysfxn, consider digoxin or amiodarone Rhythm - cardioversion to sinus, if electrical fails, use pharmacologic (ibutilide, procainamide, flecainide, sotalol, amiodarone) Anticoagulation (INR target 2-3) 3 wks before cardioversion OR TEE w/o thrombus, IV heparin, cardioversion w/in 24 hrs. Continue 4 wks after cardioversion.
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Chronic atrial fibrillation - Tx
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Rate - BB or CCB Anticoagulation - < 60 w/o HD - ASA, all others - warfarin
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Atrial flutter - Causes
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COPD - most common association HD - rheumatic HD, CAD, CHF ASD
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Atrial flutter - Tx
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**Similar to atrial fibrillation Rate - BB or CCB Anticoagulation - < 60 w/o HD - ASA, all others - warfarin
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Multifocal atrial tachycardia
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Think COPD ECG - variable P waves (at least 3), atrial rate > 100, irregular ventricular rhythm Tx Improved oxygenation and ventilation If LV fxn preserved - CCB, BB, digoxin, amiodarone, IV flecainide, IV propafenone If no/little LV fxn - digoxin, diltiazen, amiodarone
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Paraoxysmal SVT - Pathophysiology
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AV nodal reentry - two pathways (fast/slow) within AV node - most common cause of SVT, initiated/terminated by PACs ECG - narrow QRS w/o notable P waves (buried in QRS) Orthodromic AV reentry - accessory pathways btw atria and ventricles conducts retrogradely, initiated/terminated by PACs or PVCs ECG - narrow QRS w/ or w/o notable P waves
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PSVT - Tx
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Manuevers - Valsalva, carotid sinus massage, breath holding, head immersion in cold water/ice bag Acute - IV adenosine (alt if LV fxn - IV verapamil, esmolol, digoxin) --> cardioversion if unstable Prevention - digoxin, (alt - verapamil, BB) --> radiofrequency ablation of AV node or accessory tract if recurrent/sx
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Adenosine - SE
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HA Flushing SOB Chest pressure Nausea
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Wolff-Parkinson-White Syndrome - Pathophysiology
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Accessory pathway (bundle of Kent) causes premature ventricular excitation by 1. reentry loop to atria (no delta wave) or 2. bypassing AV nodal control of SVT impulses to ventricles
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WPW - ECG findings
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Narrow comlex, short PR, delta wave (upward deflection QRS)
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WPW - Tx
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Radioablation of accessory pathway Avoid drugs active on AV node (digoxin) - may accelerate conduction through accessory pathway **Use Type IA or IC antiarrhythmics
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Wide, bizarre QRS complexes
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Ventricular tachycardia
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Sustained VT (>30 sec w/sx) - Tx
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Hemodynamically unstable or severe sx - immediate cardioversion followed by IV amiodarone to maintain rhythm Hemodynamically stable w/ mild sx - IV amiodarone, IV procainamide or IV sotalol All patients - EF normal - amiodarone, EF ↓- ICD placement
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Nonsustained VT - Tx
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Asx w/o HD - no tx HD, recent MI, LV dysfxn, or sx - order EP study to assess for ICD placement (alt - amiodarone tx)
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No atrial P waves, no QRS complex, very irregular rhythm
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Ventricular fibrillation
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VFib - Tx
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MEDICAL EMERGENCY Defibrillation (unsynchronized cardioversion) - up to 3 shocks, assess rhythm btw shocks CPR if equipment not available/ready or VFib persists Intubation may be indicated Epinephrine (1mg bolus, then q 3-5 min) - ↑ cerebral and myocardial bld flow + lower defib threshold Attempt defibrillation again 30-60 sec after epi
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Refractory VFib - Tx
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IV amiodarone followed by shock Alterative antiarrythmics (many)
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Dilated CM - Tx
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Similar to CHF - digoxin, diuretics, vasodilators, cardiac transplantation **Anticoagulation should be considered
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HCM - Tx
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All patients - avoid strenuous exercise Asx - NONE (controversial) Sx - BB (alt - CCB), diuretics if fluid, myomectomy or MV replacement (↓sx in severe dz)
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Restricted CM - Causes
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Amyloidosis Sarcoidosis Hemochromatosis Scleroderma Carcinoid syndrome Idiopathic
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Dyspnea and exercise intolerance with increased LA and RA on echocardiogram
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Restricted cardiomyopathy Tx (depends on cause) Amyloidosis - none, NO digoxin (↑risk of toxicity) Sarcoidosis - glucocorticoids Hemochromatosis - phlebotomy or deferoxamine
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Elevation in cardiac enzymes and ESR
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Myocarditis Causes - virus (coxsackie), bacteria (GAS, Lyme, mycoplasma), SLE, med (sulfonamides), idiopathic Tx - supportive (underlying cause and complications)
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Pleuritic, positional chest pain Pericardial friction rub (best - exp) Diffuse ST elevation and PR depression (Sp) Pericardial effusion
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Acute pericarditis
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Acute pericarditis - Tx
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Self-limiting (most) - resolve 2-6 wks Treat underlying cause if known NSAIDs, ASA - mainstay* Glucocorticoids can be tried if no response to NSAIDs, but should be avoided * Exception: post-MI - avoid NSAIDs
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Kussmaul sign - JVD (venous pressure) fails to decrease during inspiration Pericardial calcifications on CXR Thickened pericardium on echocardiogram, CT/MRI Elevated + equal DP in all chambers
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Constrictive cardiomyopathy Distinguish from restrictive CM and cardiac tamponade Dx confirmed with negative endomyocardial bx Tx: surgical resection of pericardium (sig MR)
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Muffled heart sounds Soft PMI Dullness on left lung base +/- Pericardial friction rub
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Pericardial effusion Causes any cause of acute pericarditis, CHF, cirrhosis, nephrotic syndrome
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Pericardial effusion - Dx
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Echo (test of choice) most Sn CXR cardiac silhouette enlargement w/o pulm vascular congestion; "water bottle" appearance *Pericardial fluid analysis - clarify underlying cause
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Pericardial effusion - Tx
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Depends on hemodynamic stability Pericardiocentesis OR repeat echocardiogram in 1-2 wks
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Hypotension Muffled heart sounds JVD
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Beck's triad - cardiac tamponade Other clinical features - pulsus paradoxus (>10mm Hg decrease in arterial pressure during inspiration) Dx echocardiogram (most Sn), ECG (electrical alternans)
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Mitral stenosis - think...
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Rheumatic heart disease *Usually asx until diameter reduced from 4-5 to 1.5 cm^2
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Low-pitched diastolic rumble Heard best with bell in left lateral decubitus Opening snap
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Mitral stenosis
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Three classic symptoms of aortic stenosis
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Angina (35%) - avg survival 3 yrs Syncope - usually exertional (15%) - avg survival 2 yrs HF - DOE, orthopnea, PND (50%) - avg survival 1.5 yrs
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Harsh, crescendo-decrescendo systolic murmur Heard best at right intercostal space Radiates to carotids
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Aortic stenosis Other signs - S4, parvus tardus (diminished/delayed carotid upstrokes), sustained PMI, precordial thrill Definitive dx test - cardiac cath (valve gradient and area) Dx test - echocardiogram
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Valvuloplasty
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Excellent results - mitral stenosis Poor results - aortic stenosis (valve replacement)
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Aortic regurgitation - Px
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Chronic AR - survival 75% in 5 yrs Angina - death within 4 yrs HF - death within 2 yrs Acute AR - mortality HIGH w/o surgery
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Acute aortic regurgitation - Causes
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IE Trauma Aortic dissection
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Chronic aortic regurgitation - Causes
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Primary valvular - rheumatic fever (MS, AR), bicuspid AV, Marfan's, Ehlers-Danlos, ankylosing spondylitis, SLE Aortic root dz - syphilitic aortitis, osteogenesis imperfecta, aortic dissection, Behcet's syndrome, Reiter's syndrome, sx HTN
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Widened pulse pressure (↑SBP ↓DBP) Diastolic decrescendo murmur (heard best at LSB) Corrigan's pulse (water-hammer) - rapid ↑,sudden collapse Austin-Flint murmur - low-pitched diastolic rumble Displaced PMI (down + left) S3
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Aortic regurgitation Other signs - De Musset's (head bobbing), Muller's (uvula bob), Duroziez's (pistol-shot femoral arteries) *Austin-Flint dt stream of bld hitting ant leaflet of MV causing relative MS
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Aortic regurgitation - Tx
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Conservative (stable, asx) salt restriction, diuretics, vasodilators, digoxin, afterload reduction (ACEI), restrict strenuous activity Definitive tx - AV replacement ACUTE - emergent AV replacement
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Dilated CM - Causes
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Most common - CAD with prior MI Toxic: EtOH, doxorubicin, adriamyin Met: thiamine or selenium def, hypophos, uremia Infectious: viral, Chaga's (T.cruzi), Lyme, HIV Thyroid: hyper or hypo Peripartum CM Collagen vascular dz: SLE, scleroderma Prolonged uncontroled tachycardia Catecholamine-induced: pheochromocytoma, cocaine Familial/genetic Idiopathic
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Myocarditis - Causes
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Virus: coxsackie B Bacteria: GAS - rheumatic fever, Lyme, mycoplasma SLE Medications: sulfonamides Idiopathic Dx: elevations in cardiac enzymes and ESR Tx: supportive, underlying cause
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Acute pericarditis - Causes
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Idiopathic: most likely postviral (URI or GI sx) Infectious: viral (echo, cox, HIV, HBV/HAV), bact (TB), fungal, toxo Acute MI (first 24 hours) Post MI (wks-mos) - Dressler's syndrome Uremia Collagen vascular dz (SLE, scleroderma, RA, sarcoidosis) Neoplasm Drug-induced lupus: procainamide, hydralazine After surgery - postpericardiotomy syndrome Amyloidosis Radiation
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Constrictive Pericarditis - Causes
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Most - idiopathic (probably previous pericarditis) Uremia XRT TB Chronic pericardial effusion Tumor invasion Connective tissue d/o Prior surgery involving pericardium
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Aortic stenosis - Causes
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Calcification of bicuspid aortic valve Senile calcifications in elderly Congenital unileaflet valve Rheumatic fever
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Acute mitral regurgitation - Causes
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Infective endocarditis (most - Staph aureus) Papillary muscle rupture (infarction) or dysfxn (ischemia) Result: abrupt elevation in LA pressure causing backflow and pulmonary edema and possible hypotension and shock
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Chronic mitral regurgitation - Causes
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Rheumatic fever Marfan's syndrome Cardiomyopathy Result: gradual elevation of LA pressure with dilated LA and LV causing LV dysfxn (dt dilatation) and subsequent pulmonary HTN
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Holosystolic murmur at apex - radiates to back or clavicular area Atrial fibrillation (common) S3 gallop Laterally displaced PMI Loud, palpable P2
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Mitral regurgitation
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Mitral regurgitation - Tx
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Medical (↓afterload) Vasodilators, salt reduction, diuretics, digoxin, antiarrythmias Chronic anticoagulation (afib) IABP as bridge to surgery (acute MR) Surgical MV repair or replacement
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Tricuspid regurgitation - Causes
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Most - secondary to RV dilatation (most - LV failure, RV infarction, inferior wall MI, cor pulmonale) Endocarditis - IV drug users Rheumatic heart dz (with mitral and aortic valve dz) Epstein's anomaly - downward displaced leaflet Carcinoid syndrome, SLE, myxomatoous valve degen
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Blowing holosystolic murmur at LLSB, ↑ w/inspiration Signs of RVF (ascites, hepatomegaly, edema, JVD) Pulsatile liver Afib
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Tricuspid regurgitation
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Tricuspid regurgitation - Tx
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Tx LHF, endocarditis, pulmonary HTN Severe - surgical repair or replacement (rare) if pulmonary HTN no present
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Mid-to-late systolic murmur Midsystolic or late systolic click
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Mitral valve prolapse (MVP) Like HCM, MVP ↑ w/ standing + Valsalva (↓LV vol) and ↓w/ squatting (↑ LV vol). Unlike HCM, MVP ↑ w/sustained handgrip (↑SVR)
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MVP - Tx
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Asx: reassurance Systolic murmur or thickened valves: Ab prophylaxis Chest pain: BB (not required)
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Most common valvular abnormality in rheumatic heart dz
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Mitral stenosis May also have aortic and tricuspid involvment
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Rheumatic heart dz - Dx criteria
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2 major OR 1 major + 2 minor Major (5) - cardiac (pericarditis, CHF, valve dz), erythema marginatum, subcutaneous nodules, migratory arthritis, chorea Minor (6)- prior h/o RF, ↑ASO, fever, ↑ESR, polyarthralgias, prolonged PR interval
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Rheumatic heart dz - Tx
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Prevention: tx strep pharyngitis with PCN or erythromycin Acute RF: NSAIDS (CRP to monitor) Prophylaxis: erythromycin or amox before dental/GI/GU procedures
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Infective endocarditis - Causes
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Acute - native valve, Staph aureus (virulent), fatal < 6wks if untreated Subacute - damaged valves, Strep viridans (less virulent) and enterococcus, >>6wks to cause death
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Infective endocarditis - Native valve organisms
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Native valve MOST - Strep viridans Staph aureus > staph epidermidis and enterococci HACEK - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
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Infective endocarditis - Prosthetic valve organisms
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Prosthetic valve Early onset (<60d of surgery) - Staph epidermis > staph aureus Late onset (>60d of surgery) - Streptococci
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Infective endocarditis - IV drug users (organisms)
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IV drug user Most common - Staph aureus Other - Enterococci, streptococci Less common - fungi (candida), gram-neg rods (Pseudomonas) **Right-sided endocarditis (tricuspid valve)
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Infective endocarditis - Complications
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Cardiac failure Myocardial abscess Various solid organ damage from showered emboli Glomerulonephritis
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Infective endocarditis - Dx testing
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TEE better than TTE
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Infective endocarditis - Duke Dx criteria
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2 major OR 1 major + 3 minor OR 5 minor Major 1) positive bld cx (IE-assoc org) 2) endocardial involv (pos echo, new valvular regurg) Minor 1) Predisposing cardiac condition or IV drug use 2) Fever (>38C = 100.4F) 3) Vascular phen (emboli, aneursm, ICH, conj hemorrhage, Janeway lesions) 4) Immune phen (GN, Osler's nodes, Roth spots, RF) 5) Pos bld cx not meeting major criteria
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Infective endocarditis - Tx
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Parenteral Ab x 4-6 weeks If cx negative but high suspicion - tx empirically with PCN (or vancomycin) plus aminoglycoside (gentamicin) until organism isolated **Prophylactic amox before dental/GI/GU procedures for known valvular dz or prosthetic valve
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Metastatic cancer Sterile deposits of fibrin and platelets on closure line Can embolize to brain or periphery
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Nonbacterial thrombotic endocarditis (NBTE)
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Small warty vegetations on both sides of valve Usually involves aortic valve Source of systemic embolization
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Nonbacterial verrucous endocarditis (Lipman-Sacks) Tx: underlying SLE (corticosteroids) and anticoagulate
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Mild systolic ejection murmur at pulmonary area Wide, fixed splitting S2 Diastolic rumble across tricuspid valve area Atrial fibrillation
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ASD (asx until middle age) Wide, fixed split S2: 1) ↑pulm vol 2) RBBB Murmurs: ↑ blood flow through PV and TV Dx: TEE, EKG shows RBBB + right axis deviation
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ASD - Tx
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Surgical repair when pulmonary-to-systemic BF ratio is >1.5: 1 or 2:1 OR if patient sx
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Harsh, blowing holosystolic murmur w/thrill at 4th left ICS Sternal lift
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VSD **Smaller defect = louder holosystolic murmur Dx: EKG: biventricular hypertrophy when PVR high, Echo
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VSD - Complications + Tx
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Complications - endocarditis, progressive AR, HF, pulmonary HTN, Eisenmenger's Tx: endocarditis prophylaxis, surgical repair if pulm:sx BF is > 1.5:1 or 2:1
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Turner's syndrome Notching of ribs HA, cold extremities, claudication w/exercise, leg fatigue
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Coarctation of aorta Complications: severe HTN, rupture of cerebral aneurysms, IE, aortic dissection Tx: surgical decompression, percutaneous balloon aortoplasty (select cases)
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Congenital rubella syndrome High altitude Premature births
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PDA - persistent communication btw aorta + PA
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Loud P2 Bilateral ventricular hypertrophy Continuous murmur Wide pulse pressure w/ bounding pulses Lower extremity clubbing
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PDA Tx: surgical ligation if pulmonary vascular dz (pulmonary HTN or Eisenmenger's) absent **Leading causes of death in adults with PDA - HF and IE
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Hypertensive crisis - Causes Emergency = SBP>220 and/or DBP>120 + end-org Urgency = elevated BP w/o end-organ damage
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Non-adherence with BP medications Cushing's syndrome Drugs - cocaine, LSD, methamphetamines Hyperaldosteronism Eclampsia Vasculitis EtOH withdrawal Pheochromocytoma Non-adherence with kidney dialysis
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Hypertensive crisis - Tx
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Emergency - reduce MAP by 25% in 1-2 hours (out of danger --> then gradual reduction) - DBP>130 or encephalopathy - IV nitroprusside, labetalol or nitroglycerin - Less immediate danger - labetalol, captopril, clonidine, diazoxide Urgency - lower BP w/in 24 hrs using oral agents
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Long-standing HTN Severe, tearing anterior chest or intrascapular pain Diaphoresis BP asymmetry btw limbs
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Aortic dissection Type A - proximal, ascending, anterior CP Type B - distal, descending, intrascapular BP
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Aortic dissection - Dx
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TEE - high Sn + Sp, good for unstable pt (bedside) CT scan - fast, highly accurate, good for less acute setting **Aortic angiography - invasive but best test to determine extent of dissection for surgery
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Aortic dissection - Tx
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Immediate IV BB - ↓HR, force of LV ejection IV nitroprusside - ↓SBP <120 (afterload) Type A - surgical mgmt Type B - medical mgmt
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Sense of fullness" Sudden onset severe pain in back or lower abdomen radiating to groin
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buttocks or legs Echymosis on back or flanks (Grey Turner's sign) Echymosis around umbilicus (Cullen's sign)"
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Abdominal pain HYPOtension Palpable pulsatile abdominal mass
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Rupture AAA Next step: emergent laparotomy Other signs/symptoms - CV collapse, syncope/near-syncope, nausea, vomiting
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Bilateral claudication Impotence Absent/diminished femoral pulses
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Leriche's syndrome Atheromatous occlusions of distal aorta just above bifurcation
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Peripheral vascular dz - Site of occlusion/stenosis
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MOST - superficial femoral artery (Hunter's canal) Politeal artery Aortoiliac occlusive dz Femoral or poplieal - calf claudication Aortoiliac - buttock, hip, and calf claudication
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Peripheral vascular dz - Dx
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Arteriography - gold standard but only needed if surgery being considered Ankle-to-brachial index (ABI) - ratio of SBP Normal >1, claudication <0.7, resting pain <0.4
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Peripheral vascular dz - Tx
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Intermittent claudication - conservative mgmt Rest pain, ischemic ulcerations, severe sx - surgical bypass grafting (MOST), angioplasty (balloon dil)
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Pain - acute onset, LE Pallor Polar (cold) Paralysis Paresthesias Pulselessness (Doppler)
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Acute arterial occlusion MOST common site of occlusion - femoral artery MOST common source of emboli - heart (80%) dt afib
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Acute arterial occlusion - Tx
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Immediate IV heparin Emergent surg embolectomy - cutdown or Fogarty balloon Bypass - reserved for embolectomy failure < 6hrs ischemia - muscle can tolerate, reest perfusion Paralysis or paresthesias - amputation probably necessary
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Blue/black toes Renal insufficiency Abdominal pain or bleeding
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Cholesterol embolization syndrome Showers" of cholesterol crystals from proximal source MOST common - abd aorta
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Cholesterol embolization syndrome - Tx
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Do NOT anticoagulate!! Supportive tx - control BP Amputation or surgical resection - only in extreme cases
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Men - 4th or 5th decade Aneurysm in aortic arch AR and AS
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Luetic heart Complication of syphilitic aortitis Tx: IV PCN and surgical repair
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LE pain +swelling - worse w/walking, better w/rest+elev Calf pain on ankle dorsiflexion (Homan's sign) Palpable cord Fever
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Classic findings of DVT (50% of patients) Wells criteria for DVT Active Cancer (on treatment/within 6 months/palliative): 1 Paralysis, paresis, or recent plaster immob of LE: 1 Recently bedridden >3 days or major surgery within 4 weeks: 1 Localized tenderness along distribution of deep venous sx: 1 Entire leg swelling: 1 Calf swelling > 3 cm compared to asx leg (10 cm below tibial tuberosity): 1 Pitting edema (greater in the sx leg): 1 Collateral superficial veins (nonvaricose): 1 Alt dxas more likely than that of deep vein thrombosis: -2
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DVT - Dx
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Doppler - high Sn + Sp for proximal (pop + fem) NOT calf Venography - invasive, but most accurate for calf veins D-dimer - high Sn (95%) but low Sp (50%)
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DVT - Tx
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Intermediate/high pretest prob - Doppler pos - anticoagulation - Doppler neg - repeat U/S q 2-3d for up to 2 wks Low/intermediate pretest prob - Doppler neg - observation, repeat U/S in 2 d Anticoagulation - Heparin bolus + infusion - PTT 1.5 to 2 times aPTT - Warfarin once aPTT therapeutic - 3-6 months, INR 2-3 - Cont heparin until INR therapeutic for 48 hrs Thrombolytics - massive PE+hemodynamically unstable
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Phlegmasia cerulea dolens
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Severe leg edema compromising arterial supply to limb resulting in imparied sensory and motor fxn in extreme cases of DVT Tx: venous thrombectomy
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Pain, tenderness, induration + erythema along course of vein
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Superficial thrombophlebitis Cause - UE - usually at site of IV infusion - LE - usually assoc with varicose veins Tx - Analgesia - ASA - Severe cases (pain, cellulits) - bed rest, elev, hot compresses --> amb w/elastic stockings - Abx NOT needed unless suppurative
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Aching LE - worse at end of day Relieved by elev Worsened by recumbency (sitting/standing) Edema Pigmentation on shins Ulcers
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Chronic venous insufficiency Venous valve incompetency - offten assoc with h/o DVT Tx - leg elev, avoid prolonged standing, elastic stockings *Ulcers - Unna boots (comp stockings q 3-10d), wet-to-dry dressings TID
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Hypotension Oliguria Tachycardia Altered mental status
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Shock (all forms) Cardiogenic Hypovolemic Neurogenic Septic
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Hypotension, oliguria, tachycardia, altered sensorium Engorged neck veins (elevated venous pressure) Pulmonary congestion
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Cardiogenic shock ↓CO*, ↑SVR, ↑PCWP *only form of shock with ↓CO
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Cardiogenic shock - Causes
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Most common - after acute MI Cardiac tamponade Tension pneumothorax Arrhythmias Massive PE leading to RVF Myocardial disease (CM, myocarditis)
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Cardiogenic shock - Tx
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NO FLUIDS - likely harmful if LV pressures elevated ABCs Tx underlying cause - Acute MI: ASA, heparin +/- PTCA or CABG - Cardiac tamponade - pericardiocentesis/surgery - Valvular abnl - surgery - Tx arrhythmias Vasopressors - Dobamine --> + NE or phenylephrine, if severe or resistant IABP - increased survival - ↓afterload + myocardial O2 demand - ↑ CO + coronary perfusion
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Hypovolemic shock - Causes
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Hemorrhagic Trauma, GI bleed, retroperitoneal Non-hemorrhagic Severe V or D, severe dehydration, burns, third-space losses in bowel obstruction ↓CO, ↑SVR*, ↓PCWP/CVP *Distinguish from neurogenic shock
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Hypovolemic shock - Classes
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Class I (10-15% loss) Class II (20-30% loss) - mild sx Class III (30-40% loss) - ↓SBP Class IV (>40% loss) - absent cap refill, anuria
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At what level of blood volume loss do compensatory mechanisms begin to fail?
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20-25% of blood volume
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Hypovolemic shock - Tx
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Hemorrhagic - Stop bleeding (cauterize, direct pressure) - Blood volume replacement Non-hemorrhagic IV hydration - 500-1000 mL bolus of NS or LR followed by continuous infusion (classes II, III, IV)
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Symptoms of shock Severe peripheral vasodilation (↓↓SVR) - warm skin ↑ or normal CO (maintained SV and ↑HR)
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Septic shock Sepsis-induced hypotension that persists despite adequate fluid resuscitation ↑CO*, ↓↓SVR, ↓PCWP *Only form of shock with ↑CO
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Hypovolemic shock - Common causes
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Pneumonia Pyleonephritis Meningitis Abscess formation Cholangitis Cellulitis Peritonitis
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SIRS definition criteria
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Characterized by two of the following - Fever (>38C) or hypothermia (<36C) Hyperventilation (>20bpm) or PaCO2 <32 mmHg Tachycardia (>90bpm) ↑WBC (>12K cell/hpf, <4K cell/hpf or >10% bands)
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Sepsis
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SIRS plus infection (+ blood cx)* Two sets from two sites - should be positive but often not and must make clinical diagnosis and treat empirically
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Septic shock
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Sepsis (SIRS + infection) plus hypotension despite adequate fluid resuscitation **If not treated, followed by MODS - altered organ fxn in acutely ill patient likely leading to DEATH
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Septic shock - Tx
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1. IV antibiotics (broad) at max dosages - Source unclear - carbapenem (dori, erta, imi-cilastatin, mero) PLUS vancomycin 2. Surgical drainage if necessary 3. Fluids - ↑MAP 4. Vasopressors if hypotension despite aggressive fluids - Dopamine --> + NE if severe or refractory
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Warm, well-perfused skin Oliguria Bradycardia + hypotensive ↓ to normal CO, ↓ SVR, ↓ to normal PCWP
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Neurogenic shock *Warm skin and ↓SVR distinguish from hypovolemic shock (cool skin, ↑ SVR) * ↓CO distinguish from septic shock which also has warm skin with ↑ SVR
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Neurogenic shock - Tx
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Judicious use of IV fluids - mainstay Cautious use of vasoconstrictors to restore venous tone Supine or Trendelenberg position Maintain body temperature
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Fatigue, fever, syncope, palpitations, malaise Low-pitched diastolic murmur that changes with body positions (diastolic plop)
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Atrial myxoma Benign gelatinous, pedunculated growth usually from interatrial septum *Most common primary cardiac neoplasm Tx: surgical excision
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