Transcript ITE Review Must Know Cardio

ITE Review
Must Know Cardio
Angela Pugliese MD
Department of Emergency Medicine
Henry Ford Hospital
Outline
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Dysrhythmias
ACS
CHF/Cardiogenic Pulmonary Edema
Cardiomyopathies
DVT
PE
Pericardial Disorders
Myocarditis/Pericarditis
Aortic Dissection/AAA
HTN Emergency/Urgency
Valvular Heart Disease
EKG Trivia
First and Foremost
• KNOW ACLS
• Meds that can be given through the ET tube - LEAN
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L - lidocaine
E - epinephrine
A – atropine
N – nalaxone
• Give 2 times normal dose diluted in normal saline
Dysrhythmias
• Always assess hemodynamics…….
• SHOCK THE UNSTABLE PATIENT
Dysrhythmias
• SVT
• Regular
• Vagal maneuvers and adenosine
• Afib
• Irregularly irregular
• Normal EF – CA/Beta blockers, Low EF – dig/amiodarone
• Think anticoagulation
• WPW
• Short PR, delta wave
• Narrow tx like SVT
• Wide procainamide vs amiodarone
• A-flutter
• Rate control
• MAT
• Irregularly irregular, p-wave variation 3 types
• Treat underlying cause ie COPD/CHF
• Avoid beta blockers, think CA block or mag
Dysrhythmias
• Sick Sinus Syndrome
• Combination brady-tachy arrhythmia
• Refer to cardiology for pacer
• Vtach
• 3 + PVCs with rate >120
• Amiodarone, lidocaine, procainamide
• Torsades
• Axis swinging from + to – in single lead
• Mag and overdrive pacing
• Vfib
• ACLS
Dysrhythmias
• AV Blocks
• 1st – prolonged PR, no treatment if no symptoms
• 3rd – AV dissociation, requires pacing
• 2nd
• Mobitz 1 (Wenckebach)
• Mobitz 2 – avoid atropine, needs pacing
ACS
• Continuum
• Angina – Unstable Angina – NSTEMI - STEMI
• AMI – STEMI or CP with elevated markers
• Treatment –
• ASA, plavix, heparin, nitro
• Thrombolytics – TPA
• Give within 30 minutes if PCA > 60 min away
• Complications
• Vfib highest in first hour
• LV failure
• >20 % loss = pulm edema
• > 40% loss = shock
CHF/Cardiogenic Pulm Edema
• Left sided
• Ischemic heart disease, HTN
• Aortic/mitral valvular disease
• Right sided
• Left sided failure, pulm HTN, tricuspid/pulmonic disease
• Signs and symptoms
• SOB, ‘cardiac asthma’
• Pleural effusions
• S3, JVD, dependent edema
CHF/Cardiogenic Pulm Edema
• CXR/Symptom progression
• Stage 1 – cephalization, dyspnea
• Stage 2 – interstitial edema (kerley B lines), dry cough
• Stage 3 – alveolar edema (butterfly pattern), wet cough
pink frothy sputum
• Lab – BNP <100 excludes
• Treatment
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OXYGEN
BIPAP
Afterload reduction, diuresis
Think pressors for shock (dopamine, dobutamine)
Cardiomyopathies
• Idiopathic Dilated – most common
• Restrictive
• Hypertrophic
Dilated Cardiomyopathies
• All four chambers, systolic pump failure
• Have signs of left and right failure
• Afib most common dysrhythmia
• Tx – vasodilators, diuretics
Restrictive Cardiomyopathies
• Diastolic restrictive of ventricular filling
• Mimics constrictive pericarditis
• Right sided symptoms predominate
• Exercise intolerance
• Tx – diuretics, AVOID vasodilators
Hypertrophic Cardiomyopathy
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LVH without dilation (septum greater)
50% inherited
DOE, syncope or pre-syncope with exertion
Sudden death with exercise induced dysrhythmias
• Tx
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Propanolol
Avoid increasing myocardial contractility
Septal myomectomy for severe cases
Abx prophylaxis for dental procedures
DVT
• Virchow’s Triad
• Venostasis, hypercoagulability, vessel wall injury
• Presentation
• Unilateral pain, swelling and edema (>3cm difference)
• Diagnosis
• Duplex US (repeat testing in 7 days)
• Tx
• Aimed at preventing PE
• Anti-coagulation
• Thrombolytics (vascular surgery consult
Cerulea Dolens
Alba Dolens
Pulmonary Embolism
• Presentation
• Dyspnea
• Classic triad – dyspnea, pleuritic CP or tachypnea
• CXR
• Dyspnea, hypoxia and normal are very suggestive
• Diagnostics
• EKG, d-dimer, V/Q, CT, Angiography
• Tx –
• Anticoagulation
• Thrombolytics
• Hemodynamic instability
• TPA, 100 mg over 2 hours
PE – CXR Findings
PE - Diagnostics
• EKG – sinus tach most common
• S1, Q3, T3
• D-dimer – know Well’s, low risk pt only
• V/Q
• Limited in lung disease
• Needs clinical context
• Low-mod pretest prob with normal study 98% exculsion
• CTA
• 95% sensitive for segmental or large PE, 75% for subsegmental
• Angiography
• Gold standard
Pericardial Disorders
• Pericarditis
• Idiopathic and viral most common causes
• Diagnosis
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Hx – sharp precordial pain relieved by sitting up and leaning forward
PE – friction rub
EKG – diffuse concave ST elevation, PR depression
Echo – to look for effusion
BUN/Crt – look for uremia
• Treatment
• Outpatient NSAID for idiopathic/viral and reliable pts
Pericardial Disorders
• Pericardial Tamponade
• Becks Triad – hypotension, JVD, muffled heart tones
• Tachycardia is earliest finding
• Diagnosis
• EKG – electrical alternans, low voltage
• Echo – gold standard, large effusion, diastolic RV collapse
• Treatment
• Monitor, IV, O2
• Aggressive volume resuscitation and pressors if needed
• Cardio/CT surgery consult and pericardiocentesis (under US)
Myocarditis
• Presentation
• Range from non specific fatigue to florid CHF
• Watch for tachycardia out of proportion to fever
• Diagnosis
• Echo – dilated chambers with diffuse or focal hypokinesis
• Labs – elevated ESR, trop rise and fall slowly
• Biopsy for definitive
• Etiology
• Viral most common cause
• Treatment
• Supportive, treat like CHF
• Avoid immunosuppressives and NSAIDs
• IVIG for Kawasaki
Endocarditis
• Localized infection of endocardium with hallmark vegetation
• Causative Organisms
• Native valve – non-viridan strep
• Prosthetic valve – coag-neg strep (<60 day post op)
• IVDA – staph aureus (found on right, ie pulmonic)
• Presentation
• Fever most common finding
• Signs of metastatic infection
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Roth spots
Splinter hemorrhages
Osler nodes – TENDER nodules on volar fingers
Janeway lesions – non tender macules on fingers, palms, soles
Endocarditis
• Diagnosis
• Positive blood cultures
• Duke criteria
• Treatment
• Native valve – ampicillin + gent or vanc + gent
• Prosthetic – vanc + gent + rifampin
Duke Criteria
• Major
• Positive blood culture
• Evidence of endocardial involvement (TEE)
• Minor
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Predisposition
Fever
Vascular and/or immunologic phenomenon
Microbiology evidence
Echo evidence
• Need 2 major or 1 major with 3 minor or 5 minor
Endocarditis Prophylaxis
• Needed for procedures with significant manipulation of
infected tissue
• Not needed for foley, intubation, routine dental cleaning
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Prosthetic valve
Hx of endocarditis
Cyanotic congenital heart lesions
Acquired valvular disease (ie rheumatic fever)
Hypertrophic cardiomyopathy
Aortic Dissection
• Males age 50-70
• HTN most common risk factor
• Presentation
• pain
• Classification – type A vs B
• Definitive Testing –
• TEE – unstable patients
• CTA – may miss rapid moving flap
• Treatment –
• 10-15 units of blood on standby with surgical consultation
• Control HR and BP, esmolol first then nipride
• Treat pain with IV narcotics
Aortic Dissection
• EKG –
• Usually abnormal
• STEMI most common misdiagnosis (inferior)
• CXR findings
• Widened mediastinum
• Right side
• Tracheal deviation
• Left side
• Apical cap
• Effusion
• Depressed mainstem bronchus
Expanding/Ruptured AAA
• > 95 % infrarenal
• Males > 60
• Presentation
• Thing middle age male with syncope or near syncope and lower
abdominal or back pain
• PE classic pulsatile abdominal mass
• Diagnosis and Management
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Bedside echo
IV, O2, monitor
10 units of blood on standby
Surgical consultation
HTN Emergency/Urgency
• End Organ Damage
• DBP > 115
• Arrest and lower BP
rapidly, 30% in first
hour
• Asymptomatic pt
discharge to follow
up with PCP
• Oral agents to lower
BP over 24-48 hours
Valvular Disorders
Mitral Valve Prolapse
• Click murmur syndrome
• High pitched late systolic murmur with mid-systolic click
• Most common – 5-10% of population
• Presentation
• Young women – palpitations
• Elderly – syncope
• Treatment
• Only symptomatic pts
• Beta blockers for CP or dysrhythmias
• ASA or anticoagulation with hx TIA/stroke
Mitral Regurgitation
• Acute
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Rupture chordae tendineae or papillary muscle after…
Presents with fulminant CHF
Apical systolic murmur
Tx- hemodynamic support and CT surgery consult
• Chronic
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Evolves slowly and usually coexists with mitral stenosis
High pitched holosystolic murmur
Afib in 75% of patients
Abx prophylaxis
Aortic Stenosis
• Etiology
• <65 bicuspid valve
• >65 calcification
• Symptoms
• Exertional dyspnea or syncope
• Harsh crescendo-decrescendo murmur radiating to carotids
• Treatment
• Mild – d/c home avoid strenuous activity
• CHF – admit, reduce preload/afterload
• Refer all symptomatic patients for surgical therapy
EKG Trivia
EKG & Electrolytes, etc.
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Hypothermia =
‘J wave’ or osborn wave
Sinus brady an afib w/out RVR
Hypokalemia =
Prolonged QT
Also seen in hypomag
Hyperkalemia =
Peaked T’s (5.5-6.5)
Prolonged PR, flattened p’s, wide QRS (6.5-8)
Sine wave, vfib, asystole (>8)
Hypocalcemia =
Prolonged QT
EKG & Electrolytes, etc
• Hypercalcemia =
• shortened ST and QT intervals
• Narrow QRS
• Digitalis =
• Sagging ST, concave up
• Treatment – multiple dose charcoal and FAB
The END