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115 Cards in this Set
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- 3rd side (hint)
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what are the reversible causes of Cardiac arrest?
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4 H's and 4 T's
Hypoxaemia, hypovolaemia, hypo/hyperthermia, hypo/hyperkalaemia, Tamponade, trauma, tension pneumothorax, toxins, thrombosis. |
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what are the 'shockable' rhythms?
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Ventricular fibrilation
pulseless ventricular tachycardia |
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what are the non shockable rhythms?
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asystole
pulseless electrical activity (Rx = atropine, external pacing) |
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patient has cardiac arrest 24 hrs after episode of severe chest pain. what is the likely casue
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pulseless VT or VF caused by abnormal automaticity in infarcted myocardium
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what are the causes of arrythmia
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abnormal impulse formation
1. abnormal automaticity 2. afterdepolarisations Abnormal impulse conduction 1. re entry circuit 2. conduction block 3. bypass tracts |
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what factors make up the CHADS 2 score?
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Congestive heart failure
hypertension Age >75 Diabetes Stroke/TIA (previous) x 2 Score > 2 should be on warfarin unless CI |
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What are the general management principles of AF?
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'RACE'
Rate control Anti-coagulation Cardioversion - if <24-48hr cardiovert then anticoagulate) - if >24-48 hr anticoagulate for 3 weeks prior and 4 weeks after cardioversion. - if hemodynamically unstable, cardiovert regardless Etiology - Rx cause- HTN, CAD, COPD, thyrotoxicosis, drug OD. |
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Someone presenting with acute AF who is haemodynamically unstable should receive?
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DC cardioversion (synchronised with the R wave of ECG)
(200-400J) |
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When is it safe to cardiovert in AF
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<48hrs
TO US shows no thrombus in LA |
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If AF has lasted >48 hrs and a TOUS is not available or shows a thrombus what is the appropriate management
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anticoagulation for at least 4 weeks
LMWH for 5 days and INR >2 over 2 days Warfarin - 5mg for 2 days then adjust to INR 2-3 Then cardiovert generally continue warfarin for 12/12 |
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when can heparin be stopped in the changeover to warfarin>?
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should be given for at least 5 days and the INR should be above 2 on two consectutive days
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what drug therapy is available for cardioversion
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- flecainide
- amiodarone |
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in an asymptomatic patient with AF and heart failure what is the optimal treatment
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- Digoxin for rate control
+ warfarin in CHADS 2 score is > 2 (which it probably would be in this case) |
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what is the optimal treatment for people with long standing asymptomatic AF
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rate control (Digoxin in elderly or heart failure; beta blockers or verapamil if young/more active)
+ anticoagulation if CHADS 2 score >2 if symptomatic long term Rhythm control - flecainide, propafone, sotalol (amiodarone if heart failure) |
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what is the treatment of symptomatic sinus bradycardia?
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atropine 0.5-1.5mg IV (repeat after 15 minutes if necessary)
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what conditions make up 'sick sinus syndrome'
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chronic sinus bradycardia, sinoatrial block, atrioventricular block, sinoatrial block
- requires electrical pacing |
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what are the indications for electrical pacing?
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symptomatic/ heomodynamically unstable bradycardias = Sick sinus syndromes
- SA nodal dysfunction - AV block (mobitz II or complete 3* heart block. can be temporary or permanent. |
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patient presents with symptomatic tachycardia (190), is haemodynamically stable, an ECG shows a regular wide complex tachycardia.
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ventricualr tachycardia
Rx= amiodarone (300mg IV then 10-15mg over 24/24 OR Lignocaine - 75-150mg IV |
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patient collapses and CPR is commenced. defibrilator says there is a schockable rhyhthm (VT or VF) and a shock is given. CPR is recommenced, - this cycle is repeated 3 times with no response, what is the next step
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IV adrenaline 1mg repeat every 5 minutes - continue CPR and defib.
patient still doesn't respond - what should be considered |
reversible causes of cardiac arrest - 4 Hs 4Ts
give antiarrhythmic- amiodarone or lignocaine. continue cycles. |
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what factors make up the CHADS 2 score?
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Congestive heart failure
hypertension Age >75 Diabetes Stroke/TIA (previous) x 2 Score > 2 should be on warfarin unless CI |
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What are the general management principles of AF?
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'RACE'
Rate control Anti-coagulation Cardioversion - if <24-48hr cardiovert then anticoagulate) - if >24-48 hr anticoagulate for 3 weeks prior and 4 weeks after cardioversion. - if hemodynamically unstable, cardiovert regardless Etiology - Rx cause- HTN, CAD, COPD, thyrotoxicosis, drug OD. |
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Someone presenting with acute AF who is haemodynamically unstable should receive?
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DC cardioversion (synchronised with the R wave of ECG)
(200-400J) |
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When is it safe to cardiovert in AF
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<48hrs
TO US shows no thrombus in LA |
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If AF has lasted >48 hrs and a TOUS is not available or shows a thrombus what is the appropriate management
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anticoagulation for at least 4 weeks
LMWH for 5 days and INR >2 over 2 days Warfarin - 5mg for 2 days then adjust to INR 2-3 Then cardiovert generally continue warfarin for 12/12 |
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when can heparin be stopped in the changeover to warfarin>?
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should be given for at least 5 days and the INR should be above 2 on two consectutive days
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what drug therapy is available for cardioversion
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- flecainide
- amiodarone |
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in an asymptomatic patient with AF and heart failure what is the optimal treatment
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- Digoxin for rate control
+ warfarin in CHADS 2 score is > 2 (which it probably would be in this case) |
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what is the optimal treatment for people with long standing asymptomatic AF
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rate control (Digoxin in elderly or heart failure; beta blockers or verapamil if young/more active)
+ anticoagulation if CHADS 2 score >2 if symptomatic long term Rhythm control - flecainide, propafone, sotalol (amiodarone if heart failure) |
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what should all patients with heart failure be on
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ACEi
Beta blocker (start low and go slow) Diuretic (loop diuretic) if not controlled on ACE and diuretic add spironolactone (careful in patients with renal impairment as can get hyperkalaemia) |
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What are the indications for digoxin in heart failure?
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patients with atrial fibrillation
patients with heart failure not adequetely controlled with ACEi, loop, Beta blocker |
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when should warfarin be used in heart failure
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AF; previous CTE; severe LV systolic dysfunction.
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patient presents 1 week after viral illness with sharp chest pain worse on inspiration, a friction rub on ausciltation, ECG changes = PR depression and concave ST elevation
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acute pericarditis
for pain use - aspirin (600mg) or NSAID. If suspected renal impairment use paracetamol |
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what are the options available for patients with recurrent ventricular arrhythmias in heart failure
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amiodarone
implanatble cardiac defib. |
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what can be used as an alternative to ACEi in someone with heart failure and acute renal failure
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hydralazine and nitrates
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what are the 5 most common causes of heart failure?
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1. IHD (60-70%)
2. HTN 3. Idiopathic (dilated cardiomyopathy 4. Valvular 5. ETOH (dilated cardiomyopathy |
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patient presents with chest pain which started 1 hr ago. ECG shows ST elevation. He is in Broken Hill and it will take 2 hours to fly him to adelaide
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Give aspirin and clopidogrel + GTN
then Thrombolise within 30 minutes alteplase, reteplase, sreptokinase |
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what should all patients be sent home with post STEMI
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- statin
- ACEi or ARB - Aspirin and clopidogrel for 1st month - Beta blocker (use CCB if angina and CI to BB) - spironolactone if HF long term anticoagulation if large MI |
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what is always given before coronary angiography
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Glycoprotein IIb/IIIa inhibito (tirofiban, abciximab
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what is the treatment of high risk NSTEMI
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'BEMOAN'
Beta blocker enoxaparin (LMWH) morphine Oxygen aspirin nitrates |
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what are the long term complications following STEMI
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'CRASH PAD"
cardiac rupture arrhythmia shoch HTN/ heart failure pericarditis/PE aneurysm DVT |
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what is the maintenance therapy for stable angina
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statin
antiplatelet - aspirin (75-300mg) ACEi Beta blocker - =/-amlodipine/nifedipine nitrates |
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what are the indications for PCI (baloon angioplasty and stent)
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angina refractory to medication
NSTEMI/UA with high risk w/in 90 min of presentation STEMI - w/in 90 minutes of presentation |
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what are the indications for CABG
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triple vessel or left main artery disease
Diabetes 2 vessel disease with sig proximal LAD disease |
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what is the artery of choice for CABG conduit
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left internal thoracic artery
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what operations are particularly high risk for DVT
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THA - 51%
TKA-47% multiple trauma - 50% General surgery = 25% |
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who should be given anti coagulation prophylaxis in hospital?
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Previous stroke, active cancer, > 60, previous VTE
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who should be given an inferior vena cava filter?
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-proven proximal DVT + anticoagulation CI
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what is the wells criteria for DVT
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active Ca
calf swelling >3cm collateral superficial veins pitting oedema pain on palpation swelling of whole leg recent immobilisation recent rurgery/ hospitalisation previous VTE alternative more likely = -2 if >2 40% chance of DVT |
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what is the treatment of proven DVT
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LMWH
+ Graduated compression stockings + mobilisation |
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patient develops DVT after small operation, how long should they be anticoagulated for?
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3 months (1st episode with transient risk factor)
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patient develops DVT, it is the 2nd time they have had one. How long should they be anticoagulated
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indefinately
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'patient with no identifiable cause develops DVT how long should they be anticoagulated
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6-12 months
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what is the wells criteria for PE
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clinical signs of DVT = 3
no alternative =3 immobilisation/surg in past 4/52 = 1.5 previous DVT/PE = 1.5 heart rate >100 = 1.5 haemoptysis = 1 malignancy = 1 >4 PE likely, <4 unlikely |
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what is the most specific test for PE
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CTPA
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what is the standard treatment for PE
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oxygen and analgesia
+ LMWH and Warfarin |
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what is the treatment of PE with haemodynamic compromise
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Oxygen + analgesia
+ IV unfractionated heparin infusion +/- fibrinolysis alteplase or streptokinase |
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patient presents with sudden onset dyspnoea, cough, pleuritic pain and tachypnoea
what is your initial treatment |
suspect PE but need to be wary of MI
- oxygen, aspirin, ECG, CXR - examine calves for DVT, wells score CTPA commence LMWH |
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patient presents with acute left calf pain, sensory and motor loss.
examination shows atrophic changes over both lower legs.absent pulse in left and weak pulse in right leg |
Dx = thrombus (acute on chronic)
Rx = unfractionated heparin + thrombectomy +/-stent or bypass. |
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what investigations are available for peripheral arterial disease
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Ankle brachial index (<.9 abnormal; <.3 = pain at rest - critical ischaemia)
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what is the most common cause of pericarditis
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coxsachie virus
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what valve is most frequently involved in infective endocarditis?
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Mitral valve (regurg)what is
MV>>AV>TV>PV |
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what organism is most commonly involved in native valve Infective endocarditis?
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Strep Viridans
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what is the treatment of Q fever endocarditis
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Doxycyclin, rifampicin
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30 year old IVDU presents with fever, dyspnoea, chest pain.
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Infective endocarditis
most likely S.Aureus |
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what are the major organisms causing prosthetic valve endocarditis?
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Staph. epidermis if early
staph aureus if late |
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which organisms have highest mortality in infective endocarditis?
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fungi
(lowest = S. viridans) |
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patients with staph aureus Infective endocarditis (IVDU)
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more likely to die
have an embolit event have a CNS event |
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what is the empirical treatment for Infective endocarditis?
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benzyl penicillin + flucloxacillin + gentamycin
whilst 3 cultures from 3 occasions are being tested for sensitivity if suspect MRSA- vancomycin +gentamycin continue for 4/52 min |
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patient presents with central abdo pain, hypotension and pulsatile abdominal mass
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ruptured AAA
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when is surgery indicated for AAA
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if asymptomatic
- males >5.5cm - females >5 cm if symptomatic, rapidly growing (>4mm/year) or comorbidities/RF (HTN, COPD, smoking. |
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a 3.1cm AAA is found incidentally on US, how would you manage this patient
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- CVD risk reduction - smoking, HTN, DM, lipids control
diet and exercise U/S every 2-3 years until it is 4cm then every 6-12 months until it is 5.5 cm then endoluminal graft repair |
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patient has painful (worse at night and with elevation), punched out ulcers on metatarsal head, lateral malleolus and heel, they don't bleed and the surrounding skin is white and shiny
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arterial ulcers
Rx = debridement and revascularisation |
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patient has painless ulcer on medial aspect of lower leg that occasionally bleeds. it is relieved by elevation.
What investigation would aid in Dx |
Duplex U/S
(venbous ulcer caused by chronic venous insufficiency) how would you manage this? |
compression stockings, ambulation, treat infections, debride tissue, - surgery - high ligation and stripping of great saphenous vein.
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patient has deep painless ulcer on sole of foot and under big toe. Examination reveals a warm pulsatile foot.
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Neuropathic ulcer
Rx = Xray for osteomyelitis, callus debridement, Abx for infection, pads/custom shoes |
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what are the non surgical treatment options for varicose veins
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regular walking (MV pump)
weight loss. compression stockings Sclerotherapy (injection of hypertonic saline) |
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what are the 3 treatment aims in AF
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- control rate (beta blocker or non- dihydropine (diltiazem, verapamil); digoxin if LV failure
- restore sinus rhythm - DC cardioversion or flecainide/amiodarone. - anticoagulation |
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loud snap following S2 followed by diastolic murmur
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mitral stenosis (RhHD or IE)
- snap is tensing of chordae tendinae as they open. Rx n= percutaneous baloon valvuloplasty if severe |
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mild systolic click followed by late systolic murmur best heard at the apex
Or holosystolic murmur radiating to apex |
mitral regurgitation
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click followed by cresendo decresendo systolic ejection murmur which radiates to R clavicle and carotid
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aortic stenosis
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patient presents with daytime somnolence, leg swelling .
Examination reveals a splitting of the left heart sound. wife complains of snoring. |
pulmonary hypertension caused by OSA
- Rx - control of OSA, weight loss etc. CPAP. |
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what three components make up atherosclerotic plaques
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1. cells - VSMCs; macrophages, other leukocytes
2. extracellular matrix - collagen, elastic, proteoglycans 3. intracellular and extracellular lipid |
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what 2 changes in arteries can be seen with long standing HTN
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hyaline arteriosclerosis
hyperplastic arteriosclerosis |
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what treatment should be given to someone with
total Cholesterol 6 LDL-C - 3 HDL - C 1 fasting TG - 1.5 after 6 weeks of diet and exercise has not worked |
statin
Statin is drug of choiuce for lowering LDL-C if doesn't work - add ezetimibe then bile acid binding resins then fibrate then nicotinic acid |
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Patient has TC = 5
LDL-C = 2.2 HDL-C =.7 fasting TG = 4 |
treat with fibrates and fish oil
fibrates and fish oil are more effective at lowering TGs than statins. If raised LDL-C as well would start on statins. |
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what is the clinical definition of dyslipidemia
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HDL-C <1
TGs >1.7 |
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what are the target values for lipid levels
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LDL-C <2.5
TC <4 HDL-C> 1 fasting TGs <1.5 NB. lowering LDL-C has greatest benefit |
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what are the ECG findings in Hypokalaemia?
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- U waves
- small or absent T waves (occasionally inversion) - prolong PR interval - ST depression - long QT |
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ENG features of hypokalaemia
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In Hypokalaemia, U have no Pot and no T, but a long PR and a long QT
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1st line treatment for HTN in >55
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calcium channel blocker
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1st line Rx for HTN in <55
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ACEi
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what is the acute management of SVT
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vagal manoeuvres: e.g. Valsalva manoeuvre
intravenous adenosine: contraindicated in asthmatics - verapamil is a preferable option electrical cardioversion |
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What are the contraindications for commencing ACEi for BP management
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pregnancy
angioneurotic oedema hyperkalaemia bilateral renal artery stenosis |
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an elderly man presents with Urinary incontinence + gait abnormality + dementia.
CT scan shows an enlarged 4th ventricle |
normal pressure hydrocephalus
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A patient is referred due to the development of a third nerve palsy associated with a headache. On examination meningism is present
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Posterior communicating artery aneurysm
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what is allodynia
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a painful response to normally nonpainful stimuli (eg to brushing or cold stimuli)
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what is hyperalgesia
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an increased responsiveness to normally painful stimuli
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what is the first line treatment for neuropathic pain
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amytriptiline
gabapentin pregabalin |
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what are the causes of chorea?
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Huntington's disease, Wilson's disease, ataxic telangiectasia
SLE, anti-phospholipid syndrome rheumatic fever: Sydenham's chorea drugs: oral contraceptive pill, L-dopa, antipsychotics neuroacanthocytosis chorea gravidarum thyrotoxicosis polycythaemia rubra vera carbon monoxide poisoning cerebrovascular disease |
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how does a stroke involving ACA present
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• contralateral hemiparesis and sensory loss, lower extremity > upper
• disconnection syndrome |
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how does a stroke involving MCA present
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• contralateral hemiparesis and sensory loss, upper extremity > lower
• contralateral hemianopia • aphasia (Wernicke's) • gaze abnormalities |
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how does a stroke involving PCA present
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• contralateral hemianopia with macular sparing
• disconnection syndrome |
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what is the Rx of Bell's palsy
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Prednisolone within 72 hours for 10 days
eye protection - patch, drops |
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what are the causes of bilateral facial nerve palsy
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sarcoidosis
Guillain-Barre syndrome polio, Lyme disease |
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what is first and second line Rx of generalised seizures?
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1. Na valproate
2. lamotrigine, carbamazepine |
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what is first and second line Rx for partial seizures
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1. carbemazapine
2. lamotrigine, Na valproate |
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What is the most common clinical pattern seen in motor neuron disease?
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Amyotrophic lateral sclerosis (50% of patients)
typically LMN signs in arms and UMN signs in legs in familial cases the gene responsible lies on chromosome 21 and codes for superoxide dismutase |
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What drugs have been shown to have survival benefit in CCF
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ACEi; Beta Blockers; ARBs, Aldosterone antagonists.
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following Rh fever what heart valve abnormality is most common
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mitral stenosis
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what are the components of the wells score?
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Active cancer (treatment within last 6 months or palliative): +1 point
Clinical signs of DVT + 3 points(Calf swelling ≥ 3 cm compared to asymptomatic calf (measured 10 cm below tibial tuberosity): +1 point Swollen unilateral superficial veins (non-varicose, in symptomatic leg): +1 point Unilateral pitting edema (in symptomatic leg): +1 point) Previous documented DVT: +1 point Swelling of entire leg: +1 point Localized tenderness along the deep venous system: +1 point Paralysis, paresis, or recent cast immobilization of lower extremities: +1 point Recently bedridden ≥ 3 days, or major surgery requiring regional or general anesthetic in the past 12 weeks: +1 point Alternative diagnosis at least as likely: −2 points |
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what is first line for management of primary pulmonary arterial hypertension
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amlodipine
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what is Beck's triad of cardiac tamponade?
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Hypotension
Muffled heart sounds Distended Neck veins |
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what is the treatment of primary pulmonary HTN
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vasodilation - dihydropine Ca c blockers - nicardidipine, amlodipine (not verapamil - -ve ionotropic) ; Endothelian receptor antagonists - bosentan
Anticoagulation - warfarin |
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what is first line management of torsaddes de pointes?
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MgSO4
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what is the most common cause of SVC syndrome? (SVC obstruction - sweling of face in morning)
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Interthoracic malignancy
(bronchogenic Ca most common) |
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what thyroid malignancy is associated with MEN syndrome
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Medullary (MEN 2)
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