Cardio: Exam 4 Vignette Questions (mostly Tx)

Pt presents to ER with a wound to their thorax from a gunshot, what is the tx for most cases?

left thoracotomy

(penetrating trauma)

Pt presents to the ER with a knife wound in their abdomen, what is needed to dx this condition?

subxiphoid window

(penetrating trauma)

What is the goal of treating penetrating trauma?

relieve tamponade, stop life-threatening hemorrhage

Tx penetrating trauma depends on _______

stability of pt

Pt presents to the ER after withstanding a MVA, they do not have any symptoms, how would you manage this pt?

observe, SC

(blunt trauma)

Pt presents to the ER after withstanding a fall down the stairs, EKG is showing arrhythmias and the pt is unstable, tx?

rate control

(blunt trauma)

Pt presents to ER after getting hit in the chest during a football game, you get imaging which reveals severe ventricular dysfunction and a low CO, how would you tx this pt?

inotropic support

(blunt trauma)

What tx can be considered for a pt with blunt cardiac trauma if all other tx options fails?

intra-aortic balloon counterpulsion

What tx is almost always needed in great vessel injuries?

surgery

Pt presents to the office with substernal CP that is improving with sitting upright. You take a listen to their heart and hear a friction rub. You send cultures which return positive for S. aureus, what tx should you proceed with?

emergency surgical drainage, IV abx

(pericarditis d/t bacteria)

When would you not use NSAIDs to tx pericarditis?

if myocarditis is present

Pt presents with pericarditis caused by coxsackie virus, how would you tx this pt?

self limiting

NSAIDs/Aspirin AND colchicine

(pericarditis d/t viral infx)

How would you tx pericarditis caused by TB in calcific form?

pericardiectomy

Pt presents to office after traveling to India for volunteer work. They are experiencing sharp substernal pain that is radiating to their neck. You get an EKG that shows PR-segment depression, and widespread ST elevation. How would you tx this pt?

RIPE and prednisone

(pericarditis d/t TB)

Pt presenting with new onset of dyspnea and pleuritic chest pain, you get a CXR that shows a "watter bottle heart", how would you manage the pain that this pt is experiencing?

NSAIDs and colchicine

(pericardial effusion/cardiac tamponade)

If you have a high suspicion of bacterial/fungal/protozoan cause of pericardial effusion/tamponade or a high suspicion of cancer, how should you tx?

pericardiocentesis

Pt vital signs show hypotension, PE shows distended neck veins, and muffled heart sounds. What is tx based off of for this pt?

underlying etiology

(Becks triad, pericardial effusion/cardiac tamponade)

A pericardiocentensis is necessary in cardiac __________ and _______ pericardial effusions.

tamponade, large

Pt presents to ER with progressive dyspnea, and weakness. Pt is homeless and typically stays in shelters at night. On PE you note and elevated JVP and Kussmaul sign. How would you tx inflammation in this patient?

anti-inflammatory medications

(constrictive pericarditis)

ECHO comes back for your pt and shows a "septal bounce". You also heard a pericardial knock on PE. How do you tx venous congestion and edema in this pt?

diuretics, loop/thiazides/aldosterone antagonists

(constrictive pericarditis)

After dx constrictive pericarditis with a cardiac catheterization, you try tx your pt with diuretics however they are not improving, what now?

surgical pericardiectomy

14 yo pt present with signs of GAS infection, how should we tx? How can we prevent the progression to rheumatic fever?

abx, treat the sx of arthritis and fever

tx within 8 days of onset

What can be prescribed to prevent reinfection of rheumatic fever?

long-term prophylaxis

What needs to be done before any tx of IE?

blood cx

How long do you tx IE for?

generally 4-6 weeks

What do we use to tx IE?

penicillin or micin based abx

(spoke to Raines she said just to know this)

Pt had IE and had to get a nonporcine prosthetic valve placed, what do we need to prescribe this pt?

anticoags

When should medication be used to prophylactically prevent IE?

- dental procedures (manipulation)

- respiratory tract procedures

- infected skin or MSK tissue procedures

Pt presents with a fever and fatigue. On PE you notice macules on their hands that they state are not painful. You send cultures that come back + for S. Aureus, which type of endocarditis is more common with this presentation?

acute endocarditis

Pt presents with fever and chills. You note painful raised lesions on their digits, and splinter hemorrhages under their nails. You also know signs of drug use on their arms. You get an TTE ECHO that shows vegetations on a valve, what valve is more likely affected with this presentation?

Tricuspid (IV drug user)

When should medication NOT be used to prophylactically prevent IE?

- dental procedures (XRAY)

- GI tract procedure

- GU tract procedure

Pt presents to your office for a sports physical. You perform an EKG and see upright P waves preceding every QRS and a rate of 146 bpm. What is the recommended tx?

address underlying cause

(sinus tachy)

Pt presents to your office for a routine physical. They are currently on a beta-blocker and take vitamin D daily. You obtain an EKG that reveals upright P waves preceding every QRS and a rate of 40 bpm. What should be the first step in management (non-pharm) of this pt?

discontinue AV nodal slowing agents

r/o underlying disease

(sinus brady)

Pt presents to ER with a HR of 42 bpm. EKG is obtained and shows upright P waves preceding every QRS. What is a pharm tx option for this pt?

atropine

(sinus brady)

What are some pacing options for sinus brady?

external pacing (60-80), permanent pacemaker

TCP is CI in pt that are ...... (2)

hypothermic, asystole

18yo pt presents to office for sports evaluation. They mention that they have felt some differences in their heart rate when they are out on the field breathing heavily. EKG shows alterations when she is breathing. What tx is recommended for this condition?

no tx, just monitor

(Sinus arrhythmia)

70yo male present to ER after having a syncopal episode, you get an EP study that shows decreased activity of the SA node. What tx option should you offer to this pt?

permanent pacemaker, usually dual chamber

(SSS)

Pt comes into your office for a routnine visits, she does not have any complaints and answers no to all of your ROS questions. You get a screening EKG which reveals some PACs, how should you manage this pt?

no tx

(asymptomatic)

Pt comes into your office after having intermittent palpitations, you get an EKG that shows PACs, how should you manage this pt?

treat underlying cause and in some cases a BB

(symptomatic PAC)

68yo pt presenting to office for a checkup. Pt has COPD and HTN. You get an EKG that reveals many different P waves and a rate of 130 bpm. How do you manage this patient?

tx underlying condition

(MAT)

Pt comes to ER with SOB, palpitations and chest pain. You complete an EKG that shows no P waves and a rate of 150bpm. What are the pharm options for rate control in this pt?

BB, CCB, digoxin

(Afib - rate control)

What are the pharm options for rhythm control in Afib?

amiodarone, ibutilide, flecainide

What are the pharm options for anticoagulation in Afib?

dabigatram, rivaroxaban, apixaban, warfarin, heparin

70yo male presents without any sx however due to underlying HTN, CAD and COPD you decide to order an ECHO. ECHO reveals left atrial enlargement. You calculate his CHA2DS2-VASc score and it is 2. Should this pt be treated with anticoags?

yes!

males: >/= 2

females: >/= 3

(Afib)

Who would benefit from rate control of Afib? (3)

- elderly

- asx

- preserved EF

Who would benefit from rhythm control of Afib? (3)

- young

- sx

- EF < 45%

Pt presents with palpitations after a fainting episode at work. EKG shows a rate of 130bpm and no P waves. What electrolytes need to be replaced in this patient?

K, Mg

(Afib -electrolytes)

Pt presents with Afib, they are hemodynamically unstable, tx?

immediate cardioversion

Pt presents with Afib that has been present for < 48 hours, tx?

immediate cardioversion

Pt presents with Afib that does not require immediate cardioverion, what needs to be done?

TEE, to r/o blood clot in LA before cardioversion

EKG shows a sawtooth pattern and a rate of 150bpm. How should you manage this pt?

electrical cardioversion or Ibutilide

(Aflutter)

Aflutter may require a _____ _____ for tx.

catheter ablation

Pt presents to ER with SOB, diaphoresis and palpitation. HR is 180 bpm. What is a non-pharm tx that you can try first to manage this patient?

vagal maneuvers

(SVT)

Pt presents with SVT in the ER, what are some pharmocological options to manage this pt?

IV adenosine

IV CCB

IV BB

(pharm tx of SVT in acute setting)

Tx if pt has SVT and is unstable

cardioversion, start at 100J

How is IV adenosine administered for a pt with SVT?

IV 6mg followed by 12 mg

What can you offer to pts with SVT for prevention?

radiofrequency catheter ablation

Pt is asx however EKG shows a fixed prolonged PR interval >.20 sec, how should this pt be managed?

tx not usually needed

(Tx of first degree AV block)

EKG shows progressive PR interval prolongation until a QRS wave not conducte and a rate of 70bpm. You have ruled out all reversible causes, what are the next pharm options?

atropine, dopamine/epi

(Pharm tx of second degree AV block type 1 once bradycardia and reversible causes have been excluded)

You treated your Wenckebach pt with atropine, dopamine/epi, they did not respond, now what?

temporary pacemaker

What is a long term tx option for Wenckebach?

permanent pacemaker insertion

EKG shows extra P waves with a dropped QRS wave. The PR interval is fixed. What are the tx options?

- Address transient reversible causes

- Atropine and dopamine/epinephrine/temporary pacemaker if no response

- Permanent pacemaker (long-term)

(2nd degree AVB)

EKG shows mismatched P and QRS waves. HR is 30bpm. How do you manage this patient?

- address reversible causes

- temp pacemaker

- permanent pacemaker

(3rd degree AV block)

Criteria for permanent pacemaker (6)

1. pauses > 3 seconds

2. sinus brady < 35bpm

3. sinus brady 36-40bpm with sx

4. chronotropic incompetence

5. 2nd degree AVB type II

6. 3rd degree AVB

24yo female comes in for a visit after experiencing an increase in palpitations and SOB. She admits that she drinks a Celsius daily, sometimes twice a day. You get an EKG that shows wide complexes after the QRS wave. How do you manage this pt?

BB, CCB

(PVC - symptomatic)

Tx of Vtach depends on ....

hemodynamic status of the pt, if the pt has underlying cardiac disease

EKG shows a wide QRS complex with 4 consecutive PVCs. Rate is 120bpm but pt does not have a pulse, how do you manage this pt?

CPR/ACLS, electrical cardioversion

Pt presents in Vtach, they have a pulse but are suspicious for underlying heart disease, immediate tx?

immediate synchronized cardioverions

Pt presents in Vtach, they have a pulse but are suspicious for underlying heart disease, tx if recurrent Vtach?

amiodarone

Pt presents in Vtach, they have a pulse and are stable, tx options?

- IV amiodarone

- IV lidocaine

- +/- short acting BB, CCB

What is a longterm option for tx of Vtach?

radio frequency ablation

Pt is presenting with Vtach, you have found no reversible causes but they are expected to live for greater than a year, what do you recommend?

ICD

Pt presents with chest discomfort, LOC and SOB. EKG shows a "twisted party ribbon", how do you manage this pt?

- CPR/ACLS

- IV magnesium

- defibrillate

(Torsades)

Pt presents in vfib, tx?

- ACLS (defibrillate, epiphinephrine, antiarrhytmics)

Pt presents in vfib, what can be done to preserve neurologic function?

cooling

EKG is showing electrical activity but when you check your pt pulse they are pulseless, tx?

- CPR/ACLS

determine cause

(PEA)

EKG shows an absence of detectable electrical and mechanical cardiac activity in two leads, tx?

high quality CPR, epinephrine

(asystole)

EKG is showing normal QT interval but concave ST elevations and T wave inversions in leads V1-V3, tx?

ICD

(Brugadas)

80yo female presents after feeling dizzy, lightheaded and pain in her neck/suboccipital region when she gets out of bed in the morning. What are the nonpharm options to offer this pt?

- Stage moves

- Isometric counterpressure maneuvers

- Increase fluids

- Compression stockings

(orthostatic hypertension)

Pt has tried all of the nonpharm options for orthostatic hypotension syncope, what can you try next?

- Fludrocortisone

- midodrine

82yo male presenting to ER after fainting while he was shaving. What is the tx option if he was severely bradycardic?

- permanent pacemaker in cardiac-inhibitory forms of CSH

(severe brady carotid sinus syncope)

26yo pt is in your office for blood work. Your MA states that the pt became pale and sweaty when she was drawing their blood. What kind of syncope do you suspect in this patient? How do you treat?

vasovagal

If you know no underlying cause → reassurance, education, avoidance of stimuli

Pt presents after experiencing a short episode of blurry vision, nausea and dizziness. EKG shows a long QT interval, what syncope are you concerned about? How do we treat/manage?

cardiogenic syncope

- Aim at underlying issue

- Anti-arrhythmics

- Ablation

- Pacing for sinus node dz and AV blocks

- ICD for ventricular tachyarrhythmias