ICCM - T4 and T5

what are the components to a preceptor presentation?

one-liner

past medical history

review of systems

physical exam

differential diagnosis

plan (meds, labs, imaging)

unstable angina diagnosis

history - pain at rest or a change in character of pain

additional - normal troponin, normal or minimal changes on EKG (potential ST depression or T wave inversion on EKG)

NSTEMI diangosis

positive troponin

additional - symptoms, no ST elevation on EKG, potential ST depression or T wave inversion on EKG

STEMI diangosis

ST elevation on EKG (2 continuous leads)

additional - positive troponin, symptoms, compensatory EKG changes

ACS medications

nitroglycerin

aspirin

heparin

ticagrelor - brand name is brilinta (alternative is clopidegrel)

ACS treatment

STEMI - cath lab within 90 min

unstable angina and NSTEMI - cath lab, but not immediately

nitroglycerin dosage for ACS

0.4 mg sublingual

repeat every 5 minutes for up to three doses

aspirin dosage for ACS

325 mg uncoated chewable

heparin IV bolus dosage for ACS

60 units/kg

max 4000 units

heparin IV drip dosage for ACS

12 units/kg

max 1000 units/hour

ticagrelor (brilinta) dosage for ACS

180 mg PO

clopidogrel dosage for ACS

300-600 mg loading dose

75mg PO QD after

what are the symptoms for atrial fibrillation?

palpitations, chest pain, dizziness, SOB

what are the two most common causes of atrial fibrillation?

CHF and sepsis

what are other causes of atrial fibrillation?

alcohol (holiday heart)

PE

pericarditis

myocarditis

valvular abnormalities

endocarditis

what trial supports that there is equal mortality to rhythm control vs rate control?

AFFIRM trial

what does the AFFIRM trial support?

equal mortality to rhythm control vs rate control in treatment for atrial fibrillation

the RACE II trial supports that when you rate control you should aim for a heart rate of what?

less than 110 bpm

what trial supports that you should aim for a heart rate of less than 110 bpm when rate controlling?

RACE II

what medications are used to rate control?

diltiazem or metoprolol

diltiazem dosage for rate control atrial fibrillation

bolus - 5, 10, 15, or 20 mg

drip - 5 mg/hour

what is happening during atrial fibrillation and what do you see on EKG?

multiple foci in the atria are firing, leading to the an irregularly irregular rhythm seen on EKG

what are you at risk for with atrial fibrillation?

stroke

what are the risk factors for atrial fibrillation?

hypertension

coronary artery disease

congestive heart failure

alcohol abuse

cocaine use

what arrhythmias are included in supra-ventricular tachycardia?

sinus tachycardia

atrial flutter

AVNRT - atrioventricular nodal reentrant tachycardia

AVRT - atrioventricular reentrant tachycardia (ex. WPW)

what does an EKG look like for supra-ventricular tachycardia?

regular narrow complex tachycardia

what is happening with the electrical conduction of the heart in sinus tachycardia?

follows normal pathway

heart rate >100 bpm

what is happening with the electrical conduction of the heart in atrial flutter?

dominant ectopic foci with an atrial rate of 250-350 bpm

what is happening with the electrical conduction of the heart in AVRT?

re-entry circuit through an accessory pathway (bundle of Kent)

what is happening with the electrical conduction of the heart in AVNRT?

re-entry circuit within or near the heart's AV node

what is the step-wise treatment for supra-ventricular tachycardia?

IV fluids

vagal maneuvers (valsalva, cough)

adenosine

which SVT would IV fluids treat?

sinus tachycardia

which SVT would vagal maneuvers treat and why?

AVRT or AVNRT

works by stimulating the vagus nerve -> blocking the AV node -> slowing down heart rate

which SVT would adenosine treat and why?

AVRT or AVNRT

works by producing a transient AV node block -> slowing down heart rate

which SVT would adenosine diagnose and why?

atrial flutter

works by slowing the conduction and can reveal the characteristic flutter waves on EKG, but won't break the rhythm/treat

why is adenosine considered diagnostic and therapeutic?

diagnostic - atrial flutter

therapeutic - AVRT and AVNRT

adenosine dosage for SVT

6, 12, 12 mg rapid IV push

what are the two types of ventricular tachycardia?

monomorphic

polymorphic

what does an EKG look like for ventricular tachycardia?

wide complex tachycardia

what are the treatment options for ventricular tachycardia for a patient with a pulse?

cardioversion

IV amiodarone

IV lidocaine

what is the treatment for ventricular tachycardia for a patient without a pulse?

defibrillation

what voltage is used to defibrillate a patient in ventricular tachycardia without a pulse?

300 joules (max)

amiodarone dosage for ventricular tachycardia

bolus - 150 mg IV over 10 minutes

drip - 1 mg/min for 6 hours

lidocaine dosage for ventricular tachycardia

bolus - 1 mg/kg IV

drip - 1-1.5 mg/kg at rate of 1-3 mg/min

T/F - amiodarone and IV lidocaine are equal mortality for treatment of ventricular tachycardia

true

what are the inferior EKG leads and artery associated?

II, III, aVF

RCA

what are the anterior EKG leads and artery associated?

V1-V4

LAD

what are the lateral EKG leads and artery associated?

I, aVL, V5, V6

LCfx

after an anterior STEMI what rhythm will a patient go into?

ventricular fibrillation

pulseless ventricular tachycardia

after an inferior STEMI what rhythm will a patient go into?

3rd degree heart block

normal PR interval for EKG

120s - 200 ms

normal QRS interval for EKG

< 120 ms

normal male QTc interval for EKG

< 440 ms

normal female QTc interval for EKG

< 460 ms

what does a prolonged QTc put a patient at risk for?

torsades de pointes

what labs and imaging should be obtained for all chest pain patients?

labs - CBC, CMP, magnesium, and troponin

imaging - EKG and chest x-ray

what is the dose for morphine and ondansetron (zofran) in the ED?

4 mg

gram positive bacteria list

staphylococcus

streptococcus

enterococcus

clostridium

listeria

bacillus

corynebacterium

gram negative bacteria list

escherichia

vibrio

salmonella

haemophilus

moraxella

pseudomonas

bartonella

pasturella

proteus

neisseria

klebsiella

enterobacter

helicobacter

yersinia

campylobacter

shigella

brucella

francisella

treponema

anaerobe bacteria list

bacteroides

eikenella

fusobacterium

eubacterium

atypical bacteria list

chlamydia

legionella

mycoplasma

what is unique about legionella

confirmatory diagnostic test - urine antigens

hyponatremia and elevated LFTs

what is the #1 cause of UTIs?

E. coli

what is the #2 cause of UTIs?

staphylococcus saprophyticus

what are 95% of blood culture contaminants?

staph epidermidis

staph hominis

staph haemolyticus

what are the different types of staphylococcus?

staph aureus

staph saprophyticus

staph epidermidis

staph hominis

staph hemolyticus

what are the different types of streptococcus?

alpha hemolytic - strep pneumoiae, strep viridans

beta hemolytic - group A (strep pyogenes), group B (strep agalactiae)

what are the different types of clostridium?

clostridium difficile

clostridium botulinum

clostridium perfringens

what are the different types of bacillus?

bacillus anthraces

bacillus cereus (reheated rice)

what are the non-STI chlamydias?

chlamydia pneumoniae

chlamydia psittaci

what is the history of penicillins?

discovered in 1928 by Dr. Fleming

a mold, Penicillium notatum, inhibited the growth of bacteria

what is the mechanism of action of penicillins?

inhibit bacterial cell wall synthesis

penicillin G (IM)

covers gram pos, gram neg, anaerobes

100% covers syphilis (treponema pallidum) and strep pyogenes

amoxicillin and ampicillin

covers gram pos, gram neg, anaerobes

100% covers strep pyogenes (not 100% for syphilis)

nafcillin, oxacillin, methacillin

covers gram pos ONLY

made to cover staph - good for MSSA

beta-lactamase inhibitors

covers gram pos, gram neg, anaerobes

amoxicillin/clavulanic acid (augmentin)

ampicillin/sulbactam (unasyn)

piperacillin/tazobactam (zosyn)

what is the MRSA and pseudomonas coverage for beta-lactamase inhibitors?

MRSA - no coverage from augmentin, unasyn, or zosyn

pseudomonas - no coverage from augmentin or unasyn; 95% coverage from zosyn