Emergency Medicine EOR Exam study questions and answers.

Dilated Cardiomyopathy: most common cause is ____. Others? alcohol; may also be idiopathic, myocarditis, or drugs (doxorubicin) -- 1 in 3 cases of heart failure are caused by dilated cardiomyopathy What PE and EKG changes are seen with dilated cardiomyopathy? PE: S3, JVD, crackles - possible mitral regurg EKG: nonspecific ST and T wave changes, LBBB 00:57 01:14 Hypertrophic cardiomyopathy: is due to hypertrophy of the _____. PE reveals mitral regurgitation, a ____heart sound, and prominent left ventricular impulse. EKG reveals LVH cardiac septum; S4 Restrictive cardiomyopathy: often caused by a ____process, or post-radiation or post open-heart surgery. What is the most common first symptom? --infiltrative process - amyloidosis, sarcoidosis, and hemochromatosis -- changes in myocardium --most common first symptom is exertion intolerance and fluid retention, signs of right heart failure Atrial fibrillation - regularly irregular - the most common sustained arrhythmia in adults - what three treatments are used? 1. rate control w BB, CCB, or digoxin 2. Anticoagulation w heparin & warfarin 3. rhythm control w amiodarone or cardioversion Atrial flutter - sawtooth pattern in II, III, aVF - what three treatments are used? 1. cardioversion if no contraindications 2. acute rate control tx w BB, CCB - amiodarone, sotalol, quinidine, or procainamide 3. If site of reentrant is known, catheter ablation Multifocal atrial tachycardia - noted in patients with COPD or severe systemic illness - EKG shows multiple shaped P waves and differing PR intervals. ____are agents of choice? CCB BLOCKS 1. ____=prolonged PR interval 2.____=progressive increase in PR until Pwave is blocked. 3._____=sudden block in P wave w no change in PR 4._____=atrial and ventricular rhythm are independent of each other. First degree; Wenckebach Mobitz type I; Mobitz type II, Third degree block A _____may develop after acute MI, PE, aortic stenosis and is due to a conduction delay in the right or left bundles. Bundle branch block Paroxysmal supraventricular tachycardia is a reentry tachycardia, commonly noted in elderly patients with underlying heart disease. What treatment may be helpful before using adenosine ie. the drug of choice? vagal maneuvers or antianxiety medication What are some drugs associated with Torsades de pointes? tricyclic antidepressants, erythromycin, ketoconazole, haloperidol, cisapride, disopyramide, pentamidine, sotalol, class I anti-arrhythmics CHF - Systolic dysfunction means a problem with the ____. What drug is contraindicated? pump; CCB! CHF - Diastolic dysfunction means a problem with the ____. compliance or relaxation of the heart during ventricular filling The ________principle means that as preload increases, the ventricle is stretched during diastole filling and the ejection fraction is increased. Frank-Starling principle _____is released from cardiac ventricles in response to increased wall tension. BNP - B-type natriuretic peptide What is the pharmacologic therapy for heart failure? 1. diuretics for fluid retention 2. ACEi 3. vasodilators (hydralazine & nitrates) 4. BB for LV dysfunction 5. digitalis to increase cardiac contractility Functional Classification of Heart Failure: ___-No cardiac symptoms with ordinary activity. ___-Cardiac symptoms w MARKED activity but asymptomatic at rest ___-Cardiac symptoms w MILD activity but asymptomatic at rest ___-Cardiac symptoms at rest. Class I, Class II, Class III, Class IV Stage 1 Hypertension is defined as greater than ____. Stage 2 Hypertension is defined as greater than ____. 140/90; 160/100 Hypertension Drug of Choice for: angina diabetes hyperlipidemia CHF Previous MI Chronic Renal Failure Asthma, COPD Angina - BB, CCB Diabetes - ACEi & CCB, avoid diuretics Hyperlipidemia - ACEi & CCB, avoid diuretics/BB CHF - diuretics & ACEi, avoid CCB/BB Previous MI - BB/ACEi Chronic renal failure - diuretics, CCB Asthma - diuretics & CCB, avoid BB Secondary hypertension is HTN due to an ______. identifiable cause ie. renovascular disease, coarctation of the aorta, primary aldosteronism, Cushing's, Pheochromocytoma, OSA, renal parenchymal hypertension ____hypertension is potentially life threatening - HTN plus rentinopathy, cardiovascular/renal compromise, or encephalopathy. Malignant Malignant hypertension bp? What is the rule of thumb for lowering? greater than 220/140; 10% in first hour and 15% for the next 3-12 hours, to normal over next 2 days What is the agent of choice for BP lowering for patients with hypertensive encephalopathy, intracranial bleeding, and heart failure? Use with what for dissecting aneurysm? nitroprusside; propranolol -- clonidine can also be used but sedation is common Hypotension is defined as a systolic blood pressure less than _____mm Hg or a decrease from baseline by more than 30mmHg. What are the 3 treatments for improving blood pressure? 90mmHg; 1. IV Fluids 2. Vasopressors - dopasmine, dobutamine (risk is aggravation of arrhythmias and increase myocardial oxygen demand) 3. intra-aortic balloon pump ST Elevations in II, III, aVF Inferior MI; right coronary artery ST Elevations in I, aVL, V4, V5, V6 lateral wall MI, left circumflex artery ST Elevations in V1, V2, V3, V4, V5 Anterioseptal MI, left anterior descending artery ST Elevations in V1, V2 posterior wall MI, posterior descending artery No nitroglycerin in which kind of MI? inferior What are the pre hospital treatments for ACS? MONA; morphine, oxygen, nitroglycerin (0.4mg SL x3 prn), aspirin (325mg) What two meds should be given to all ACS patients that do not have contraindications? BB - unless brady or severe COPD - then do NDCCB (verapamil/diltiazem) ACEi - if cough, use ARB What are the adjunctive tx for fibrinolysis or PCI? 1. antiplatelets (ASA, clopidogrel) 2. anticoagulants (UFH, LMWH, DTI, direct factor Xai) How long should Plavix/Clopidogrel be used for bare metal or drug eluting stents? bare metal - 30d-12m drug eluting - /=12mon What meds should a patient go home with after ACS? Nitroglycerin BB ACEi ASA/Clopidogrel anticoagulant (up to 8days for LMWH) aldosterone agonist statin LIFESTYLE CHANGES Cardiac Markers: _____is detectable within 1-2 hours after acute MI. Duration 1 day. Low specificity. Myoglobin Cardiac Markers: _____is the test of choice and appears 2-6 hours after MI and stays elevated for 5-10 days. Troponin Cardiac Markers: _____appears 3-6 hours after MI and stays elevated for 2-4 days. Specific to heart muscle. Creatine kinase Mb Timeline: Reperfusion should take place before ___hours of symptom onset. Door to needle time for fibrinolysis is ____min. Door to balloon time for PCI is ___min. 12; 30min; 90min Cardiology is fun! What are the treatments for bradyarrhythmias? atropine, pacing, or epinephrine/dopamine For synchronized cardioversion, use ____Joules for paroxysmal supraventricular tachycardia and _____Joules for a fib and VT. 50J, 100J _____angina is brought on by activity/exercise. ____angina may show transient ST changes and inverted T waves. ____is pain mainly occurring at rest due to vasospasm of coronary arteries. Stable, unstable, prinzmetal/variant (responds well to CCB or nitrates, BB may exacerbate vasospasm) _________is considered the gold standad test for aortic dissection but is also the most invasive of all the radiographic studies. What is more normally done in the ED? Aortography; CT with contrast Aortic dissections - Stanford type A vs. Stanford type B. What's the difference and which is treated surgically? Type A - involves ascending aorta - surgical tx!!! Type B - involves descending aorta - BP control What is the emergent treatment for arterial embolism/thrombosis (pain, pallor, pulselessness, paresthesias, paralysis)? heparin, emergency embolectomy-thrombectomy to restore blood flow Virchow's Triad for DVT? venous stasis, endothelial injury, hypercoagulable state _______sign is pain with dorsiflexion of the foot. May be positive with DVT. Homan's ____is a decrescendo-crescendo rough, systolic murmur. Heard best at base of heart and radiates to neck. What drug is contraindicated? Aortic stenosis; ACEi _____is a diastolic murmur heard along left sternal border. Austin-Flint murmur. What kind of pulse? Aortic regurgitation; "water hammer" pulses ______presents with an opening snap in early diastole. Soft, low-pitched, diastolic rumble heard best at the apex in the left decubitus position, palpable right ventricular heave. Mitral stenosis ______is a pansystolic, blowing in nature, high pitch, musical sound. Radiates to left axilla. Mitral regurgitation ______presents with a mid-systolic click heard best at apex. Mitral valve prolapse _____is blowing and musical best heard along left sternal border. Tricuspid regurgitation ____is an early systolic opening ejection click followed by a systolic ejection murmur which radiates to the base. Pulmonic Stenosis Endocarditis (or infection of the endothelial surface of the heart) is most commonly caused by what bacteria? Strep viridans, Staph aureus, and Enterococcus What are some of the PE findings for infective endocarditis? Roth spots - small white spots on retina surrounded by hemorrhage Osler nodes - small tender lesions on fat pads of fingers and toes Janeway lesions - painless, reddish, macular lesions on hands or feet Duke Criteria for dx of infective endocarditis Dx with 2 major or 1 major and 3 minor Major a. positive blood cultures b. endocardial involvelment on echo Minor a. predisposing condition: cardiac or IV drug use b. fever c. vascular phenomenon d. immunologic phenomenon Pericarditis is inflammation of the pericardium. How is pain improved? What is the PE finding? sitting and leaning forward; ST elevation in all precordial leads, normal cardiac enzymes What is the treatment for constrictive pericarditis? pericardiectomy --- otherwise NSAIDs and Steroids _____presents with distended neck vein, indistinct heart sounds, narrow pulse pressure, and pulsus paradoxus. Tx: pericardiocentesis and treat underlying cause. Cardiac tamponade ________can lead to cardiac tamponade if it is large. Friction rub noted if secondary to pericarditis. Pleural effusion. Hypotension, tracheal deviation, and elevated jugular venous pressure indicates that a simple pneumothorax has progressed to what? What does CXR show for this? a tension pneumothorax; lack of lung vascular markings at periphery Where is the needle decompression performed for a tension pneumothorax? second intercostal space, mid-clavicular line What is the most common cause of pleural effusions? left sided heart failure (increased hydrostatic pressure in microcirculation) ALSO - 1. decreased oncotic pressure - hypoalbuminemia 2. decreased pressure in pleural space - collapsed lung 3. increased permeability - in pneumonia 4. impaired lymphatic drainage - in malignancy 5. movement of fluid from peritoneal space - in ascites Transudates vs. Exudates: ______occur when systemic factors that control formation and absorption of pleural fluid are altered. Left sided heart failure/cirrhosis. ______occur when local factors that control formation and absorption of pleural fluid are altered - pneumonia, malignancy, viral infex, PE Transudates; Exudates