• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/131

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

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
Stable angina - Tx
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
Unstable angina - Tx
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
Variant (Prinzmetal's) angina - Dx and Tx
Dx ECG (hallmark) - transient ST elevation (transmural ischemia) Coronary angiogram (definitive) - coronary vasospasm when given IV ergonovine Tx - vasodilators (CCB, nitrates)
MI - Tx
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)
Ventricular tachycardia (sustained, >30 sec) - Tx
Hemodynamically unstable - electrical cardioversion Hemodynamically stable - IV amiodarone
Ventricular fibrillation - Tx
Immediate unsynchronized defibrillation and CPR
Sinus tachycardia - Tx
Tx underlying cause - pain, anxiety, fever, pericarditis, medications, etc
Asystole - Tx
VERY high mortality Begin with electrical defibrillation for Vfib (hard to distinguish from asystole) If asystole, trancutaneous pacing
AV block - Tx
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
Post-MI free wall rupture - Tx
Most common days 1-4, 90% first two weeks 90% mortality rate Tx - hemodynamic stabilization, immediate pericardiocentesis, surgical repair
Post-MI rupture of interventriclar septum - Tx
Within 10 days Tx - emergent surgery
Post-MI acute pericarditis - Tx
Dressler's syndrome - pericarditis, dever, malaise, leukocytosis, pleuritis - weeks to months after MI Tx - ASA **NSAIDs/CS contraindicated (may hinder myocardial scar formation)
Mild CHF (NYHA class I/II) - Tx
Mild sodium restriction (<4g/d) + activity
Loop diuretic if volume overload/pulm congestion ACEI
Mild to Moderate CHF (NYHA class II/III) - Tx
Loop diuretic + ACEI
Add BB if moderate disease + suboptimal response
Moderate to Severe CHF (NYHA class III/IV) - Tx
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)
Digoxin toxicity
GI: N/V, anorexia Cardiac: ectopic (ventricular) beats, AV block, AFib CNS: visual disturbances, disorientation
Cardioversion
Definition - delivery of shock in synchrony wih QRS to terminate dysrhythmia Indications - AFib, atrial flutter, VT w/pulse, SVT
Defibrillation
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
Acute atrial fibrillation - Tx
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.
Chronic atrial fibrillation - Tx
Rate - BB or CCB Anticoagulation - < 60 w/o HD - ASA, all others - warfarin
Atrial flutter - Causes
COPD - most common association HD - rheumatic HD, CAD, CHF ASD
Atrial flutter - Tx
**Similar to atrial fibrillation Rate - BB or CCB Anticoagulation - < 60 w/o HD - ASA, all others - warfarin
Multifocal atrial tachycardia
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
Paraoxysmal SVT - Pathophysiology
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
PSVT - Tx
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
Adenosine - SE
HA Flushing SOB Chest pressure Nausea
Wolff-Parkinson-White Syndrome - Pathophysiology
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
WPW - ECG findings
Narrow comlex, short PR, delta wave (upward deflection QRS)
WPW - Tx
Radioablation of accessory pathway Avoid drugs active on AV node (digoxin) - may accelerate conduction through accessory pathway **Use Type IA or IC antiarrhythmics
Wide, bizarre QRS complexes
Ventricular tachycardia
Sustained VT (>30 sec w/sx) - Tx
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
Nonsustained VT - Tx
Asx w/o HD - no tx HD, recent MI, LV dysfxn, or sx - order EP study to assess for ICD placement (alt - amiodarone tx)
No atrial P waves, no QRS complex, very irregular rhythm
Ventricular fibrillation
VFib - Tx
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
Refractory VFib - Tx
IV amiodarone followed by shock Alterative antiarrythmics (many)
Dilated CM - Tx
Similar to CHF - digoxin, diuretics, vasodilators, cardiac transplantation **Anticoagulation should be considered
HCM - Tx
All patients - avoid strenuous exercise Asx - NONE (controversial) Sx - BB (alt - CCB), diuretics if fluid, myomectomy or MV replacement (↓sx in severe dz)
Restricted CM - Causes
Amyloidosis Sarcoidosis Hemochromatosis Scleroderma Carcinoid syndrome Idiopathic
Dyspnea and exercise intolerance with increased LA and RA on echocardiogram
Restricted cardiomyopathy Tx (depends on cause) Amyloidosis - none, NO digoxin (↑risk of toxicity) Sarcoidosis - glucocorticoids Hemochromatosis - phlebotomy or deferoxamine
Elevation in cardiac enzymes and ESR
Myocarditis Causes - virus (coxsackie), bacteria (GAS, Lyme, mycoplasma), SLE, med (sulfonamides), idiopathic Tx - supportive (underlying cause and complications)
Pleuritic, positional chest pain Pericardial friction rub (best - exp) Diffuse ST elevation and PR depression (Sp) Pericardial effusion
Acute pericarditis
Acute pericarditis - Tx
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
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
Constrictive cardiomyopathy Distinguish from restrictive CM and cardiac tamponade Dx confirmed with negative endomyocardial bx Tx: surgical resection of pericardium (sig MR)
Muffled heart sounds Soft PMI Dullness on left lung base +/- Pericardial friction rub
Pericardial effusion Causes any cause of acute pericarditis, CHF, cirrhosis, nephrotic syndrome
Pericardial effusion - Dx
Echo (test of choice) most Sn CXR cardiac silhouette enlargement w/o pulm vascular congestion; "water bottle" appearance *Pericardial fluid analysis - clarify underlying cause
Pericardial effusion - Tx
Depends on hemodynamic stability Pericardiocentesis OR repeat echocardiogram in 1-2 wks
Hypotension Muffled heart sounds JVD
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)
Mitral stenosis - think...
Rheumatic heart disease *Usually asx until diameter reduced from 4-5 to 1.5 cm^2
Low-pitched diastolic rumble Heard best with bell in left lateral decubitus Opening snap
Mitral stenosis
Three classic symptoms of aortic stenosis
Angina (35%) - avg survival 3 yrs Syncope - usually exertional (15%) - avg survival 2 yrs HF - DOE, orthopnea, PND (50%) - avg survival 1.5 yrs
Harsh, crescendo-decrescendo systolic murmur Heard best at right intercostal space Radiates to carotids
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
Valvuloplasty
Excellent results - mitral stenosis Poor results - aortic stenosis (valve replacement)
Aortic regurgitation - Px
Chronic AR - survival 75% in 5 yrs Angina - death within 4 yrs HF - death within 2 yrs Acute AR - mortality HIGH w/o surgery
Acute aortic regurgitation - Causes
IE Trauma Aortic dissection
Chronic aortic regurgitation - Causes
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
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
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
Aortic regurgitation - Tx
Conservative (stable, asx) salt restriction, diuretics, vasodilators, digoxin, afterload reduction (ACEI), restrict strenuous activity Definitive tx - AV replacement ACUTE - emergent AV replacement
Dilated CM - Causes
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
Myocarditis - Causes
Virus: coxsackie B Bacteria: GAS - rheumatic fever, Lyme, mycoplasma SLE Medications: sulfonamides Idiopathic Dx: elevations in cardiac enzymes and ESR Tx: supportive, underlying cause
Acute pericarditis - Causes
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
Constrictive Pericarditis - Causes
Most - idiopathic (probably previous pericarditis) Uremia XRT TB Chronic pericardial effusion Tumor invasion Connective tissue d/o Prior surgery involving pericardium
Aortic stenosis - Causes
Calcification of bicuspid aortic valve Senile calcifications in elderly Congenital unileaflet valve Rheumatic fever
Acute mitral regurgitation - Causes
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
Chronic mitral regurgitation - Causes
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
Holosystolic murmur at apex - radiates to back or clavicular area Atrial fibrillation (common) S3 gallop Laterally displaced PMI Loud, palpable P2
Mitral regurgitation
Mitral regurgitation - Tx
Medical (↓afterload) Vasodilators, salt reduction, diuretics, digoxin, antiarrythmias Chronic anticoagulation (afib) IABP as bridge to surgery (acute MR) Surgical MV repair or replacement
Tricuspid regurgitation - Causes
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
Blowing holosystolic murmur at LLSB, ↑ w/inspiration Signs of RVF (ascites, hepatomegaly, edema, JVD) Pulsatile liver Afib
Tricuspid regurgitation
Tricuspid regurgitation - Tx
Tx LHF, endocarditis, pulmonary HTN Severe - surgical repair or replacement (rare) if pulmonary HTN no present
Mid-to-late systolic murmur Midsystolic or late systolic click
Mitral valve prolapse (MVP) Like HCM, MVP ↑ w/ standing + Valsalva (↓LV vol) and ↓w/ squatting (↑ LV vol). Unlike HCM, MVP ↑ w/sustained handgrip (↑SVR)
MVP - Tx
Asx: reassurance Systolic murmur or thickened valves: Ab prophylaxis Chest pain: BB (not required)
Most common valvular abnormality in rheumatic heart dz
Mitral stenosis May also have aortic and tricuspid involvment
Rheumatic heart dz - Dx criteria
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
Rheumatic heart dz - Tx
Prevention: tx strep pharyngitis with PCN or erythromycin Acute RF: NSAIDS (CRP to monitor) Prophylaxis: erythromycin or amox before dental/GI/GU procedures
Infective endocarditis - Causes
Acute - native valve, Staph aureus (virulent), fatal < 6wks if untreated Subacute - damaged valves, Strep viridans (less virulent) and enterococcus, >>6wks to cause death
Infective endocarditis - Native valve organisms
Native valve MOST - Strep viridans Staph aureus > staph epidermidis and enterococci HACEK - haemophilus, actinobacillus, cardiobacterium, eikenella, kingella
Infective endocarditis - Prosthetic valve organisms
Prosthetic valve Early onset (<60d of surgery) - Staph epidermis > staph aureus Late onset (>60d of surgery) - Streptococci
Infective endocarditis - IV drug users (organisms)
IV drug user Most common - Staph aureus Other - Enterococci, streptococci Less common - fungi (candida), gram-neg rods (Pseudomonas) **Right-sided endocarditis (tricuspid valve)
Infective endocarditis - Complications
Cardiac failure Myocardial abscess Various solid organ damage from showered emboli Glomerulonephritis
Infective endocarditis - Dx testing
TEE better than TTE
Infective endocarditis - Duke Dx criteria
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
Infective endocarditis - Tx
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
Metastatic cancer Sterile deposits of fibrin and platelets on closure line Can embolize to brain or periphery
Nonbacterial thrombotic endocarditis (NBTE)
Small warty vegetations on both sides of valve Usually involves aortic valve Source of systemic embolization
Nonbacterial verrucous endocarditis (Lipman-Sacks) Tx: underlying SLE (corticosteroids) and anticoagulate
Mild systolic ejection murmur at pulmonary area Wide, fixed splitting S2 Diastolic rumble across tricuspid valve area Atrial fibrillation
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
ASD - Tx
Surgical repair when pulmonary-to-systemic BF ratio is >1.5: 1 or 2:1 OR if patient sx
Harsh, blowing holosystolic murmur w/thrill at 4th left ICS Sternal lift
VSD **Smaller defect = louder holosystolic murmur Dx: EKG: biventricular hypertrophy when PVR high, Echo
VSD - Complications + Tx
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
Turner's syndrome Notching of ribs HA, cold extremities, claudication w/exercise, leg fatigue
Coarctation of aorta Complications: severe HTN, rupture of cerebral aneurysms, IE, aortic dissection Tx: surgical decompression, percutaneous balloon aortoplasty (select cases)
Congenital rubella syndrome High altitude Premature births
PDA - persistent communication btw aorta + PA
Loud P2 Bilateral ventricular hypertrophy Continuous murmur Wide pulse pressure w/ bounding pulses Lower extremity clubbing
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
Hypertensive crisis - Causes Emergency = SBP>220 and/or DBP>120 + end-org Urgency = elevated BP w/o end-organ damage
Non-adherence with BP medications Cushing's syndrome Drugs - cocaine, LSD, methamphetamines Hyperaldosteronism Eclampsia Vasculitis EtOH withdrawal Pheochromocytoma Non-adherence with kidney dialysis
Hypertensive crisis - Tx
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
Long-standing HTN Severe, tearing anterior chest or intrascapular pain Diaphoresis BP asymmetry btw limbs
Aortic dissection Type A - proximal, ascending, anterior CP Type B - distal, descending, intrascapular BP
Aortic dissection - Dx
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
Aortic dissection - Tx
Immediate IV BB - ↓HR, force of LV ejection IV nitroprusside - ↓SBP <120 (afterload) Type A - surgical mgmt Type B - medical mgmt
Sense of fullness" Sudden onset severe pain in back or lower abdomen radiating to groin
buttocks or legs Echymosis on back or flanks (Grey Turner's sign) Echymosis around umbilicus (Cullen's sign)"
Abdominal pain HYPOtension Palpable pulsatile abdominal mass
Rupture AAA Next step: emergent laparotomy Other signs/symptoms - CV collapse, syncope/near-syncope, nausea, vomiting
Bilateral claudication Impotence Absent/diminished femoral pulses
Leriche's syndrome Atheromatous occlusions of distal aorta just above bifurcation
Peripheral vascular dz - Site of occlusion/stenosis
MOST - superficial femoral artery (Hunter's canal) Politeal artery Aortoiliac occlusive dz Femoral or poplieal - calf claudication Aortoiliac - buttock, hip, and calf claudication
Peripheral vascular dz - Dx
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
Peripheral vascular dz - Tx
Intermittent claudication - conservative mgmt Rest pain, ischemic ulcerations, severe sx - surgical bypass grafting (MOST), angioplasty (balloon dil)
Pain - acute onset, LE Pallor Polar (cold) Paralysis Paresthesias Pulselessness (Doppler)
Acute arterial occlusion MOST common site of occlusion - femoral artery MOST common source of emboli - heart (80%) dt afib
Acute arterial occlusion - Tx
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
Blue/black toes Renal insufficiency Abdominal pain or bleeding
Cholesterol embolization syndrome Showers" of cholesterol crystals from proximal source MOST common - abd aorta
Cholesterol embolization syndrome - Tx
Do NOT anticoagulate!! Supportive tx - control BP Amputation or surgical resection - only in extreme cases
Men - 4th or 5th decade Aneurysm in aortic arch AR and AS
Luetic heart Complication of syphilitic aortitis Tx: IV PCN and surgical repair
LE pain +swelling - worse w/walking, better w/rest+elev Calf pain on ankle dorsiflexion (Homan's sign) Palpable cord Fever
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
DVT - Dx
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%)
DVT - Tx
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
Phlegmasia cerulea dolens
Severe leg edema compromising arterial supply to limb resulting in imparied sensory and motor fxn in extreme cases of DVT Tx: venous thrombectomy
Pain, tenderness, induration + erythema along course of vein
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
Aching LE - worse at end of day Relieved by elev Worsened by recumbency (sitting/standing) Edema Pigmentation on shins Ulcers
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
Hypotension Oliguria Tachycardia Altered mental status
Shock (all forms) Cardiogenic Hypovolemic Neurogenic Septic
Hypotension, oliguria, tachycardia, altered sensorium Engorged neck veins (elevated venous pressure) Pulmonary congestion
Cardiogenic shock ↓CO*, ↑SVR, ↑PCWP *only form of shock with ↓CO
Cardiogenic shock - Causes
Most common - after acute MI Cardiac tamponade Tension pneumothorax Arrhythmias Massive PE leading to RVF Myocardial disease (CM, myocarditis)
Cardiogenic shock - Tx
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
Hypovolemic shock - Causes
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
Hypovolemic shock - Classes
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
At what level of blood volume loss do compensatory mechanisms begin to fail?
20-25% of blood volume
Hypovolemic shock - Tx
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)
Symptoms of shock Severe peripheral vasodilation (↓↓SVR) - warm skin ↑ or normal CO (maintained SV and ↑HR)
Septic shock Sepsis-induced hypotension that persists despite adequate fluid resuscitation ↑CO*, ↓↓SVR, ↓PCWP *Only form of shock with ↑CO
Hypovolemic shock - Common causes
Pneumonia Pyleonephritis Meningitis Abscess formation Cholangitis Cellulitis Peritonitis
SIRS definition criteria
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)
Sepsis
SIRS plus infection (+ blood cx)* Two sets from two sites - should be positive but often not and must make clinical diagnosis and treat empirically
Septic shock
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
Septic shock - Tx
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
Warm, well-perfused skin Oliguria Bradycardia + hypotensive ↓ to normal CO, ↓ SVR, ↓ to normal PCWP
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
Neurogenic shock - Tx
Judicious use of IV fluids - mainstay Cautious use of vasoconstrictors to restore venous tone Supine or Trendelenberg position Maintain body temperature
Fatigue, fever, syncope, palpitations, malaise Low-pitched diastolic murmur that changes with body positions (diastolic plop)
Atrial myxoma Benign gelatinous, pedunculated growth usually from interatrial septum *Most common primary cardiac neoplasm Tx: surgical excision