Emergency Medicine Exam 1: Cardiovascular Emergencies Part 2 Study Guide

the clinical features of tachydysrhythmias depend on the ________________ consequences of abnormal rhythm

hemodynamic

what are the clinical features of stable tachydysrhythmias?

- palpitations

- fatigue/weakness

- mild dizziness/lightheadedness

- mild dyspnea

what are the clinical features of unstable tachydysrhythmias?

- ischemic chest pain

- hypotension

- dyspnea to pulm edema

- AMS

- syncope

which tachydysrhythmias have a narrow complex and regular rhythm?

- sinus tachy

- PSVT

- AFlutter

which tachydysrhythmias have a narrow complex and irregular rhythm?

- MAT

- AFib

- Aflutter w/ variable AV conduction

which tachydysrhythmias have a wide complex and regular rhythm?

- monomorphic VT

- PSVT or Aflutter w/ aberrancy or BBB

which tachydysrhythmias have a wide complex and irregular rhythm?

- polymorphic VT (TdP)

- Afib or Aflutter w/ aberrancy or BBB

what is the management of a patient presenting w/ an unstable tachydysrhythmia?

if presenting w/ a stable tachydysrhythmia?

IV meds and/or electrical cardioversion

med tx

what are some causes of sinus tachy?

what is the tx?

pain, exertion, caffeine, fever, anemia, PE, hypovolemia

tx underlying condition

what is the cause of PSVT?

what is the tx if unstable?

what is the tx if stable?

impulse reentry or ectopic pacemaker

sedation and synch cardioversion starting at 50J

vagal maneuvers, adenosine 6mg IV push followed by flush (second dose at 12mg), CCBs or BBs

what are some causes of aflutter?

what is the tx if unstable?

what is the tx if stable?

atrial dilation from CHF/valvular disease/PE/pulm HTN

sedation and synch cardioversion starting at 50J

anticoags, rate control w/ CCBs or BBs

T/F: aflutter may degenerate to atrial fibrillation

true

1 multiple choice option

what are the causes of multifocal atrial tachycardia?

what is the tx for MAT?

pulm disease in 60% of cases (COPD), coronary disease, valvular heart disease

tx directed at underlying disorder

what are the causes of afib?

what are the tx considerations?

what is the disposition?

ischemia, valvular heart disease, HTN, EtOH

consider ventricular response rate, hemodynamic stability, duration, and underlying heart disease; in otherwise healthy pts w/ acute onset, 70% spontaneously convert 48-72 hrs

admission if hemodynamically unstable, require tx for associated dx, HF, ischemia

in all patients w/ afib, what scoring system is used to determine the risk and need for anticoags?

CHA2DS2-VASc score

what is the tx for unstable afib?

tx for stable afib persisting longer than 48 hrs or for an unknown duration of time?

tx for stable afib persisting less than 48 hrs?

synch cardioversion (150-200J) w/ conscious sedation

rate control = primary goal; diltiazem, verapamil, metoprolol, procainamide; anticoags for 3 wks prior to cardioversion

consider for pharm or electrical cardioversion; rate control and admission if high risk; rate control and cards consult (to determine disposition on PO rate control med) if low risk

always assume that any wide complex tachycardia is _______________ _________________ and treat accordingly

ventricular tachycardia

what are the causes of VT?

what is the tx of pulseless VT?

what is the tx if unstable w/ pulse?

what is the tx if stable?

ischemic heart disease, acute MI

defib unsynchronized 200J

synch cardioversion at 100J w/ sedation

procainamide, amiodarone, or sotalol

what is the cause of Torsades?

what is the tx if unstable/pulseless?

what is the tx if hemodynamically stable?

drug-induced or congenital prolonged QT syndrome, electrolyte derangements

defib at 200J

IV mag sulfate

what is the tx for vfib?

- immediate defib at 200J and chest compressions

- repeat 2 cycles if unsuccessful

- epi 1mg IV or IO q3-5min

- amiodarone 300mg IV or IO

what are the initial actions and primary survey if a patient presents/there is concern for a conduction abnormality?

- ABCs

- place pt on cardiac monitor

- place defib pads on pt

- obtain EKG

- check labs (BMP, Mg level, phosphorus level, cardiac markers)

what is the tx for a 1st degree AV block?

most pts are asyx so no tx needed

what is the tx for an asyx pt w/ a 2nd degree Mobitz type 1 heart block?

if unstable or symptomatic?

no tx

cards consult, atropine, transcutaneous pacing (if no response to atropine)

what are the typical symptoms and PE findings of a patient w/ a 2nd degree Mobitz type 2 heart block?

what is the tx?

sx = DOE, fatigue, dizziness, syncope

PE = bradycardia, irregular pulse, hypotension

tx = atropine, transcutaneous pacing (if no response to atropine); cards consult and admission

what is the tx for 3rd degree (complete) heart block?

transcutaneous cardiac pacing, followed by permanent pacemaker; cards consult and admission

what are the two ways to pace pts in the ED? describe each.

transcutaneous - pacing pads applied to pt's torso, applies small periodice electrical shocks to pace myocardium

transvenous - involves floating a pacemaker through internal jugular/subclavian vein and into RV

what is the tx for unstable pts w/ WPW syndrome?

what is the tx if pt is stable?

synch cardioversion 150-200J

vagal maneuvers, adenosine, procainamide

what meds should not be given to pts w/ WPW?

nodal-blocking meds (BBs and CCBs)

this is a genetic disorder that can result in sudden death from polymorphic VT or vfib; EKG findings include:

- R-bundle branch morphology

- coved ST-elevation >2mm in V1-V3

- T-wave inversion in V1-V3

Brugada syndrome

what is the difference btw Brugada pattern and Brugada syndrome

pattern = EKG pattern but asyx

syndrome = sustained VT or SCD (EKG pattern and pt showing sxs)

what is the tx for Brugada syndrome?

implantable cardiac defibrillator (ICD)

what is the tx for PEA?

- initiate CPR

- epi 1mg IV or IO q3-5min

- if detected rhythm is bradycardia = atropine 1mg IV

- tx potential underlying causes (6H, 6T)

what are the 6 H's of PEA?

- hyperkalemia

- hypoxia

- hypothermia

- hydrogen ion access (acidosis)

- hypovolemia

- hypoglycemia

what are the 6 T's of PEA?

- tamponade (cardiac)

- tension pneumo

- thrombosis (PE)

- thrombosis (MI)

- toxins

- trauma

what is the tx for asystole?

- CPR

- epi 1mg IV or IO q3-5min

- terminate resuscitation if no response

what are the clinical features of hypertensive urgency?

- asyx or possible mild HA

- SBP 180+ and/or DBP 120+

- no s/sx of acute end-organ damage

what diagnostic workup should be done for pts presenting w/ HTN urgency?

- labs to r/o end organ damage (CBC, BMP, UA)

- EKG

- CXR

- imaging guided by clinical presentation

what is the tx for HTN urgency?

- no rapid BP lowering (lower over hours-days)

- start PO hypertensives (short acting clonidine or captopril; long acting amlodipine or chlorthalidone)

- f/u w/ PCP in 1-2 days

why is nifedipine contraindicated in HTN urgency/emergency?

unpredictable and uncontrolled results

what are the clinical features of HTN emergency?

- acute, marked elevation of BP w/ signs of target organ dysfunction

- diastolic pressure typically 120+ (no specific threshold)

- w/w/o known preexisting HTN

identify target organ findings for each body system

- neuro

- CV

- renal

- eye

- neuro = HA, visual changes, seizures, AMS, focal deficits

- CV = CP, palpitations, dyspnea, rales, syncope, murmurs, pulsatile abd mass

- renal = anuria or dec. urine output, peripheral edema, hematuria

- eye = papilledema, flame hemorrhages

what is the dx workup for HTN emergency?

- UA

- BMP

- troponins

- EKG

- CXR

- BNP

- chest CT w/ contrast

- brain CT

what is the tx for most HTN emergencies?

- reduce BP gradually by 10-20% in first hr (target <180/120)

- reduce a further 5-15% over next 23 hrs (target <160/110)

what are the major exceptions to gradually lowering BP over the first day in pts presenting w/ HTN emergency?

- acute phase of ischemic stroke NOT lowered unless...

- 185/110+ in pts who are candidates for reperfusion therapy

- 220/120+ in pts who are not candidates for reperfusion therapy

- acute aortic dissection = rapidly lowered to a target of 100-120 (w/in 20 min) to reduce aortic shearing forces

- intracerebral hemorrhage = antiHTN therapy goals in these pts are variable

what is the tx for HTN emergency?

if d/t aortic dissection?

if acute HTN pulm edema?

if d/t ACS?

ABCs, supplemental O2, IV, cardiac monitor; safely reduce BP w/ IV meds while avoiding hypotension

rapidly lower SBP to target 100-120; BBs followed by vasodilator

vasodilator (NTG or nitroprusside)

BBs (esmolol), NTG

what is the tx for HTN emergency if acute renal failure is present?

if HTN encephalopathy or subarachnoid hemorrhage is present?

if sympathetic crisis (cocaine, amphetamines) is present?

antiHTN therapy often leads to worsening kidney function; use fenoldopam (rapid-acting vasodilator) to reduce BP <20%

nicardipine or labetalol

lorazepam or NTG (do NOT use BBs)

what are the two "categories" of HF?

- new onset HF

- acute exacerbation of chronic HF

what are the most common precipitants of HF? (4)

- afib

- acute MI or ischemia

- d/c of meds (esp diuretics)

- increased sodium load

what are the three classifications of acute HF?

- systolic vs diastolic dysfunction

- high vs low output

- right vs left failure

which type of HF?

dilated LV, heart can't contract (MI, HTN, valve disease)

systolic dysfunction

which type of HF?

normal size LV, heart can't relax or fill (LVH, HoCM)

diastolic dysfunction

which type of HF?

CO is high or normal, but insufficient to supply oxygen demands (hyperthyroidism, anemia)

high output

which type of HF?

CO is low or decreased d/t myocardial damage (ischemia, dilated CMP, valvular disease, or chronic HTN)

low output

which type of HF?

fluid builds up in RV, leads to hepatic enlargement, increased JVD, dependent edema of extremities

right HF

which type of HF?

fluid builds up in LV, leads to pulm congestion

left HF

what are the symptoms of HF?

- dyspnea (DOE, orthopnea, PND, SOB at rest)

- leg swelling

- epigastric pain or abd fullness

what are the physical exam findings of HF?

- resp distress

- tachycardia, HTN, hypoxia

- rales, wheezing

- S3 heart sounds, JVD

- hepatomegaly

- edema, ascites

what may be seen on the CXR of a pt in HF?

- cardiomegaly

- cephalization

- interstitial edema (pulm edema, Kerley B lines)

- pleural effusions

a BNP less than what indicates that CHF is unlikely?

a BNP between what indicates the a pt may have CHF, but it could be something else (PE, pulm HTN, ESRD)?

a BNP greater than what indicates that CHF is highly likely?

< 100

100-500

> 500

a pt w/ severe CHF may have an EF less than what percentage on ECHO?

< 20%

what is the tx for HF?

- supplemental O2, IV access, monitor, frequent vitals

- diuretics IV to alleviate volume overload (mainstay of therapy)

- afterload reduction w/ vasodilators if BP >150/100

under what conditions would it be appropriate to discharge a patient or keep them in the ED observation unit for HF?

- good response to therapy

- no high-risk features

- good social support

which HF patients need ICU admission?

- ongoing cardiorespiratory compromise

- acute ischemia

what is syncope? what causes it?

transient loss of consciousness accompanied by loss of postural tone d/t inadequate cerebral blood flow and oxygenation

what is near syncope?

premonition of fainting w/o LOC but w/ same pathophysiologic process and same risks as syncope

what is the MCC of syncope?

what is the most concerning cause?

vasovagal (reflex-mediated)

cardiac

what prodromal sxs are assoc/w vasovagal syncope?

what are some causes of vasovagal syncope?

lightheaded, nausea, diaphoresis, blurred vision, weakness

unpleasant sight/sound/smell, fear, severe pain, emotional distress; prolonged standing in warm environment

what are some situational causes of syncope?

cough, micturition, defecation

what are the causes of carotid sinus syndrome?

- if hypersensitive = bradycardia, hypotension

- inadvertent pressure on carotid sinus, leading to syncope

what are the causes of orthostatic syncope?

- autonomic failure (postural hypotension)

- volume depletion

- POTS

- meds (diuretics, vasodilators, antidepressants)

what are the causes of cardiac-related syncope?

- structural disease (limits heart's ability to increase CO to meet demand) (i.e. AMI, AS, HCM, PE, MI)

- dysrhythmias (brady/tachydysrhythmias, severe AS, PE)

dysrhythmia-related syncope is dependent on the compensatory ability of what? (3)

- ANS

- heart

- CV system

what conditions can mimic syncope? (5)

- seizures

- metabolic disorders

- stroke/TIA

- psychogenic pseudosyncope

- cataplexy

what is the most helpful in determining the cause of syncope

history

what important aspects of pt history need to be explored to determine the cause of syncope?

- frequency and duration

- triggers and circumstances

- patient position

- onset/prodrome

- witnessed signs

- clinical features after event

what are the red flags assoc/w syncope? (7)

- absence of prodrome

- exertional (cardiac outflow obstruction)

- supine or seated position

- CP, palpitations or heart irregularities

- abd or back pain

- fam hx of sudden death

- older age

list the potential causes of the syncope "plus"...

HA

chest pain

SOB

palpitations

vomiting

abd or back pain

vaginal bleeding

SAH, elevated ICP

MI, PE, aortic dissection, aortic stenosis, tamponade

PE, dysrhythmia, MI, hypoxia, aortic stenosis, tamponade

dysrhythmia

MI, GI bleed

AAA, dissection, GI bleed, ectopic pregnancy

ectopic pregnancy

what are the two risk scores to eval for unexplained syncope?

San Francisco syncope rule

Canadian syncope risk score

what are the components of the San Francisco syncope rule?

- CHF hx

- Hct <30%

- EKG/cardiac monitoring abnormal

- SOB hx

- SBP <90 at triage

using the San Francisco rule, patients with how many of the "CHESS" predictors are considered high risk for serious outcomes at 7 or 30 days

any (only needs 1 of 5)

using the Canadian syncope risk score, what score(s) indicate the patient should undergo further investigation for cardiac and non-cardiac causes of syncope?

any score greater than 1 (max score 11)

what is the tx for syncope in low-risk pts?

- clear reflex-mediated syncope w/o hx of heart disease, currently asyx, normal PE and EKG

- may be discharged w/ non-urgent PCP f/u

what is the tx for syncope in high-risk pts?

recommend admission