EKMedicine

Aspirin acid-base abnl

"adult: mixed metabolic acidosis-resp alkalosis w near normal pH

child: severe metabolic acidosis"

...

AV Block types and treatment

1st degree and 2nd degree Mobitz I / Wneckebach - no treatment; 2nd degree Mobitz II and 3rd degree: pacemaker

Plasma Osmolalility

2 x Na + BUN / 2.8 + Glucose / 18 + Ethanol / 4.6; normal osmol gap b/w calculated and measured osmol = 10 mOsm/kg; NORMAL OSMAL: 280 - 295

idioventricular tachycardia

AKA slow ventricular tachycardia; EKG: wide QRS without P waves, 60 < HR < 100

Chronic venous insufficiency

AKA: postphelbitis syndrome; PATHOPHYS: often 2/2 DVT b/c destruction of venous valves => abulatory venous HTN => edema => reduced blood flow/hypoxia; FEATURES: swelling, ulcers, skin changes; TREAT: leg elevation, elastic stocking

TIMI score: thrombolysis in MI

AMERICA: age >65, elevated cardiac enzymes, EKG change ST changes > 0.5 mm, 3+ RF for CAD, 2+ severe angina in past 24 hrs, CAD (>50% stenosis), ASA in past 7d

Aorta coarctation

ASSOC: bicuspid AV, Turner's syndrome; FEATURES: HA, cold extremities, claudication, leg fatigue; EXAM: systemic HTN, HTN in UE with hypo LE; mid-systolic murmur; reduce/delayed pulses in LE vs UE; ejection click (if bicuspid AV); rib notching; DIAGNOSE: EKG w LVH, CXR w notching & figure 3; TREAT: surgical decompression, balloon aortoplasty; COMPLICATIONS: severe HTN, rupture of cerebral aneurysms, IE, aortic dissection

PDA

ASSOC: congenital rubella, high altitude, premature births; FEATURES: often asx, loud P2 if pHTN/HF, LVH, RVH, LE clubbing; EXAM: continuous machinery murmur in 2nd LIC, widened pulse pressure and bounding peripheral pulses; DIAGNOSE: CXR w dilated PA, enlarged heart; Echo shows PDA; TREAT: surgical ligation if pulm dz absent otherwise contraindicated if severe pulm HTN; COMPLICATIONS: heart failure, IE

Metab compensation for resp acidosis

Acut resp acid (inc HCO3 by 1 for each 10 CO2 change); Chronic resp acid (inc HCO3 by 4 for each 10 CO2 change)

Metab compensation for resp alkalosis

Acut resp alk (dec HCO3 by 2 for each 10 CO2 change); Chronic resp alk (dec HCO3 by 5-6 for each 10 CO2 change)

CHADS2

Assess stroke risk: CHF, HTN, age > 75, DM, past stroke; if score >2 = anticoagulation

VT

CAUSE: CAD, ischemia, hypotension, cardiomyopathies, prolonged QT, drug; DEFINE: rapid, repetitiave firing of 3+ PVC; sustained if > 30s; nonsustained usually asx; FEATURES: cannon a waves; DIAGNOSE w EKG: wide, bizarre QRS; poly vs monomorphic; TREAT: nonsustained and asx - no treat; nonsustained & HD - EP study => ICD > amiodarone; sustained & stable (IV amiodarone, procainamide, sotalol); sustained & unstable (cardioversion then follow with amiodarone and ICD placement);

ischemic cardiomyopathy

CAUSE: CAD; ECHO: focal hypokinesis

Aflutter

CAUSE: COPD > heart disease, ASD; PATHOPHYS: reentrant circuit that rotates around tricuspid annulus; PRESENT: palpitations, CP, SOB, LH; EKG: saw-tooth pattern in II, III, aVF with narrow-QRS q 2/3 P wave; TREAT: rate control +/- anticoagulation as in Afib

AR

CAUSE: acute (IE, trauma, dissection); chronic (valvular - RF, bicuspid, marfans, ehlers danlos, AS, SLE; aortic root disease); PATHOPHYS: AR => LVH/dilation => LHF; FEATURES: DOE, PND, orthopnea, palpitations, angina, cyanosis/shock if acute; EXAM: widened pulse pressure, early blowing diastolic murmur loudest at left sternal border, Corrigan's pulse (sudden collapse in late systole), Austin-Flint murmur, displaced PMI, +S3, head/uvula bobbing, pistol-shot heard over femora arteries; DIAGNOSE: CXR, EKG, Echo - serial exams; cardiac cath fo severeity; PROG: dec w angina/HF development; TREAT: stable/asx - conservative (salt restriction, diuretics, vasodilators, digoxin, afterload reduction); AV replacement is definitive and considered in sx/significant LV dysfunction; if acute - emergent AV replacement; PROPHYLAXIS: IE before dental/GI/GU procedures

PAC

CAUSE: adrenergic excess, drugs, alcohol, tobacco, electrolyte imbalance, ischemia, infection; TREAT: only if sx - BB

AS

CAUSE: calcification of normal trileaflet valve or bicuspid, conenital unileaflet valve, rheumatic fever; PATHOPHYS: AS => LVH => LV dysfunction => MR; EXAM: harsh Diamond shaped murmur; loudest at RUSB; radiation to carotid arteries; small and late carotid pulsations if severe; sustained apical PMI; percordial thrill; S4; ADVANCE DISEASE: long, late-peaking murmur, syncope, angina, dyspnea; FEATURES: angina => syncope => heart failure; DIAGNOSE: CXR, EKG w LAE/LVH, Echo is diagnostic, cardiac cath is definitive; TREAT: only surgical - AV replacement indicated in all symptomatic, severe AS undergoing CABG/vascular surgery, asx pt with severe AS or poor LV sys function, LVH > 15 mm, valve area <0.6 cm, abnl response to exercise

Hypophosphatemia: causes, presentation, treat

CAUSE: dec intestinal absorptoin (etoh, vit d deficiency, excessive antacids); inc renal excretion (excess pth, hyperglycemia/glycosuria, hypokalemia); hungery bones syndrome; dka; PRESENT: none if mild; otherwise - neruo, msk, heme, cardiac, rhabdomyolysis, anorexia; TREAT: mild (oral suplemention); severe or npo (parenteral supplementation)

Hyperphosphatemia

CAUSE: dec renal excretion (crf, bisphos, hypopth, vit d intox, tumor calcinosis); inc phos administration (repletion, enema); rhabdomyolysis, cell lysis, acidosis; PRESENT: metastatic / soft-tissue calcification (if ca x po4 > 70 likely to calcify); TREAT: phosphate-binding antacids; hemodialysis

DVT

CAUSE: endothelial injury + venous stasis + hypercoagulability; FEATURES: LE pain/swelling, Homan's sign, palpable cord, fever; DIAGNOSE: Doppler analysis and Duplex U/S initial, venography most accurate but invasive; LABS: increaesd D-dimer; TREAT: anticoagulation with heparin => warfarin; thrombolysis for massive PE/HD unstable/RHF; also IVC filter; PREVENT: SCD, LMWH; COMPLICATIONS: PE, postthrombotic syndrome/chronic venous insufficiency, phlegmasia cerulia dolens (severe edema compromises arterial supply)

Superficial thrombophelbitis

CAUSE: endothelial injury + venous stasis + hypercoagulability; RF: IV infusion in UE, varicose veins in LE; FEATURES: pain, induration, erythema along vein, possible tendor cord; TREAT: mild analgesic, if severe - elevation/hot compresses/elastic stockings w embulation; if septic, remove IV cannula; BE WARY: if migratory superficial thrombophlebitis = occult malignancy

PVC

CAUSE: hypoxia, electrolyte abnl, stimulants, caffeine, meds; RF: postMI; TREAT: if asx none, beta-blocker otherwise; antiarrythmics use post MI can increase death 2/2 asystole; PROG: if frequent, repetitive + structural heart disease => EP study

Printzmel's variant angina

CAUSE: idiopathic in young females; RF: smoking; LABS: rarely elevated cardiac markers; EKG: transient ST elevations; FEATURES: episodes of CP at night assoc w transient ST elevations, possibe arrythmias; DIAGNOSE: coronary angiography showing vasospams when given IV ergonovine; TX: avoid beta-block 2/2 unopposed alpha stimulation - labetolol okay; CCB, nitrates, avoid aspirin

restrictive cardiomyopathy

CAUSE: infiltration - amyloidosis, sarcoid, HH, scleroderma, carcinoid; ECHO: diastolic dysfunction, variable systolic dysfunction; often thickened ventricular walls w preserved dimensions; FEATURES: dyspnea, RHF signs; DIAGNOSE: low-voltage ECG, echo - thick myocardium & inc atrium size, endomyocardial bx; TREAT: underlying disorder (HH-phlebotomy/deferoxamine, sarcoid-steroids); digoxin if systolic dysfunction (except amyloid); use diuretics/vasodilators cautiously

VF

CAUSE: ischemic heart disease, antiarrythmic drugs that prolong QT, Afib w RVR; PATHOPHYS: reentrant ventricular arrythmia; RF: VT; PROGNOSIS: high recurrence if not postMI; postMI-good, no chronic tx required; FEATURES: unconcsious, no BP; DX w EKG: no waves at all, irregular; TREAT: defibrillate +/- CPR +/- intubation => epinephrine => IV amiodarone (>lidocaine, Mg) + shock => if successful: continue infusion of antiarrythmic; long-term: ICD

PSVT

CAUSE: ischemic heart dz, digoxin toxicity, atrial flutter w RVR, excessive caffeine; TYPES: AV nodal vs AV re-entrant; TREATMENT: vagal manuevers; acute pharm tx - IV adenosine > verapamil, esmolol, digoxin; cardioversion if drugs fail; PREVENTION: digoxin > verapamil / BB; radiofrequency catheter ablation

constrictive pericarditis

CAUSE: likely prior pericarditis/radiation/idiopathic; TB in developing countries; PATHOPHYS: fibrous scarring of pericardium = impaired diastolic filling near end of diastole; FEATURES: patient ill, RHF sx => LHF sx; JVD, Kussmal sign (rise in JVP with inspiration), pericardial knock (early heart sound after S2); pulsus paradoxus (>10 drop SBP w inspiration); DIAGNOSIS: low-voltage EKG, T wave flattening, LA abnl, atrial fibrillation; ECHO - pericardial thickening, posterior motion of ventricular septum in early distole with inspiration; CT/MRI show pericardial thickening; CARDIAC CATH with elevated/equal diastolic pressures in all chambers, rapid y descent = square root sign; TREAT: surgical resection of pericardium

TR

CAUSES: 2/2 RV dilatation, tricuspid endocarditis, rheumatic heart disease (w MV/AV disease), Epstein's anomaly; FEATURES: RVF; EXAM: pulsatile liver, blowing holosystolic, loudest at lower left sternal border, louder w inspiration; DIAGNOSE: Echo, EKG; TREAT: treat LHF, ednocarditis, pulmonary HTN; severe regurge may be surgically corrected if pulmHTN not present (native valve repair, valvuloplasty, valve replacement)

Pulseless electrical activity

CAUSES: 6 H (hypovolemia, hypoxia, H ions/acidosis, hypothermia, hypoglycemia, hyper/hypoK); 6Ts (tamponade, tension pneumo, thrombosis/MI/PE, trauma, tablets, toxins); TREAT: CPR, airway establishment, ventilation with 100% O2 => epinephrine or vasopressin

MR

CAUSES: acute (endocarditis, papillary muscle ruptation), chronic (rheum fever, marfan's, cardiomyopathy); FEATURES: DOE, PND, orthopnea, palpitations, pulm edema; SIGNS: holosystolic murmur at apex, loudest at apex w radiation to axilla, prominent P2; DIAGNOSE: CXR, Echo; TREAT: medical (afterload reduction, salt restriction/diuretics, digoxin/antiarrythmics, anticoagulation for afib); IABP for acute; surgical (MV repair before LV function compromised); PROGNOSIS: acute = higher mortality, otherwise related to LV cavity dilatation

Pericarditis

CAUSES: idiopathic/postviral, infectious, acute MI, uremia, CVD, neoplasm, drug-induced, postMI, post surgery, amyloidosis, radiation; PROGNOSIS: most recover within 1-3 wk; FEATURES: severe/pleurtic/positional CP relieved by sitting forward, friction rub with 3 possible compnents heard best during expiration while patient sits up, viral prodrome DIAGNOSE: pan-ST elevation but ST depression in aVR, V1, PR depression in aVL, aVF, V5, V6; Echo to r/o effusion; TREAT: underlying cause, high-dose NSAID/aspirin with 5-7 d taper for pain; 2nd line -steroids / colchicine if pain unresponsive to NSAID; COMPLICATIONS: pericardial effusion, cardiac tamponade

MI complications

CHF; ARRYTHMIA (PVC, afib, VT, VF, accelerated idioventricular rhythm, PSVT, S tachy, S brady, asystole, AV block); RECURRENT INFARCT (check CK-MB, tx with repeat thrombolysis/cath); FREE WALL RUPTURE (esp in 1st 2 weeks => hemopericardium/cardiac tamponade; tx pericardiocentesis/surgical repair); SEPTAL RUPTURE (<10d post MI; tx surgery); PAPILLARY MUSCLE RUPTURE (MR; obtain Echo; emergent surgery needed + afterload reduction with nitroprusside gtt / intra-arotic balloon pump); VENTRICULAR PSEUDOANEURYSM (incomplete free wall rupture; acquire echo; surgical emergency); VENTRICULAR ANEURYSM (rarely rupture, inc VT risk, medical mgmt); ACUTE PERICARDITIS (ASA, no NSAID/steroids); DRESSLER'S SYNDROME (postMI-pericarditis, fever, leukocytosis, pleuritis, weeks to months post MI, tx with ASA)

HCOM vs MVP : manuevers and murmur volume

DECREASE: squatting; INCREASE: Valsave manuever, standing, straight leg rise by dec LV volume; SUSTAINED HAND GRIP = inc SVR = dec HCOM, but inc MVP

Hypotonic hyponatremia

DEFINE: true hyponetremia w sOsm <280; HYPOVOLEMIC - low urine sodium (<10 mEq) suggest extra renal loss; high urine sodium (>20 mEq) suggest renal loss; EUVOLEMIC - no evidence of ecf expansion or contraction (siadh, psychogenic polydipsia, postop hyponatremia, hypothyroidism, too much free water, drugs); HYPERVOLEMIC - due to water retaining states (chf, nephrotic syndrome/renal failiure, liver dz)

Endocarditis: diagnosis, treatment

DIAGNOSE (DUKE: 2 major, 1 major + 3 minor, 5 minor); MAJOR (sustained bacteremia by endocarditis organism, endocardial involvement via TEE or new vlave regurge); MINOR (predisposing condition, fever >38, vascular phenomena - emboli/mycotic aneurysm/ICH/Janeway lesions; immune pheonomena - GN, painful Osler's nodes, Roth's spots, RF; + blood cultures; + echo); TREAT: IV abx for 4-6 wk; if negative but high suspicion treat with PCN/vanc + AG

Rheumatic heart disease

DIAGNOSE rheumatic fever: 2 major, 1 major + 2 minor; MAJOR (JONES); MINOR (fever, inc ESR, polyarthrlagias, prior h/o rhum fever, prolonged PR, preceding strep infection); TREAT: PCN/erythromycin for strep pharyngitis, NSAID for ARF, Abx ppx with erythromycin/amoxicillin; PPX: PCN until 18 yo if get rheumatic fever

Hypernatremia: diagnosis & treatment

DIAGNOSE: urine volme low; urine osmol should be > 800mOsm; use desmopressin to ddx central di from nephrogenic di; TREAT: hypovolemic hypernatremia (give isotonic nacl to restore hemodynamics; then restore free water deficit); isovolemic hypernatremia (vasopressin or oral fluids); hypervolemic hypernatremia (diuretics and d5w to remove excess sodium)

MI: diagnosis

DIAGNOSIS: CARDIAC ENZYME (CK-MB inc 4-8 hr, peak 24, normal 48-72; Trop inc 3-5 hr, peak 24-48 hr, normal 5-14d); trend q 8hrs; EKG (criteria for MI with LBBB); CP, new LBBB = STEMI

NSTEMI

EKG: ST depression and/or T wave inversions without Q waves (vs ST elevation in STEMI, variant angina, acute pericarditis)

HCOM

EPI: AD trait; FEATURES: DOE, CP, syncope, palpitations, arrythmia, cardiac failure, sudden death; PE: variable, dynamic systolic murmur best heard in LLSB increased by Valsava manuever and standing; dec by hand gribbing, leg elevation, squatting; two brisk carotid upstrokes; loud S4; ECHO: assymetric hypertrophy of LV, small LV cavity; TREAT: avoid exercise, BB > CCB in sx patients, diruetic for symptomatic, myomectomy if eligible, afib treatment if present

MVP

EPI: in genetic CTD - Marfan, osteogenesis imperfecta, Ehlers-Danlos; PATHOPHYS: excessive, redundant mitral leaflet tissue 2/2 myxomatous degeneration; FEATURES: asx, palpitation/CP, rarely TIA; EXAM: midsystolic/late systolic click, mid-to-late systolic murmur that increased with standing/Valsava/sustained handgrip, but dec w squatting; DIAGNOSE: echo; TREAT: asx (reassurance); with murmur (abx ppx); CP (beta-block)

dilated cardiomyopathy

EPI: m/c cardiomyopathy; CAUSE: CAD m/c, toxic (alcohol, doxorubicin/adriamycin), metabolic (B1 deficiency, uremia), infectious (viral, Chagas, Lyme, Cornyebacterium), thyroid disease, PPM, CVD (SLE, scleroderma), pheo/cocaine, idiopathic; ECHO: both ventricles dilated + globally hypokinetic; TREAT: like CHF (digoxin, diuretics, vasodilators, cardiac transplantation, anticoagulation)

VSD

EPI: m/c congenital cardiac malformation; FEATURES: CHF, growth failure, recurrent lower resp infections => Eisenmenger's; EXAM: harsh, blowing holosystolic murmur with thrill at 4th LIC that dec with Valsava & handgrip; louder with smaller defect; P2 increases w PVR increase; DIAGNOSE: EKG shows BVH; CXR shows enlarged PA/heart; ECHO shows septal defect; TREAT: endocarditis ppx, surgical repair if flow > 1.5/1, nothing if asx; COMPLICATIONS: endocarditis, progressive AR, heart failure, pulmonary HTN & shunt reversal

AV nodal re-entrant

EPI: mcc SVT; PATHOPHYS: 2-pathways within AV node: atri and ventricles simultaneously activated; EKG: narrow QRS that buries P wave, regular rhythm, smooth baseline

Afib

ETIOLOGY: heart disease, pericarditis, pulmonary dz, hyper/hypothyroidism, systemic illness, stress, excessive alcohol intake, sick sinus syndrome, pheo; PATHOPHYS: source in PV; FEATURES: fatigue, exertional dyspnea, palpitaitons, dizziness, blood stasis; EXAM: irregularly irregular; EKG: no discernible P waves, rough, irregular baseline; WORK-UP: TTE r/o occult valve / structural heart disease; TFT; TREAT: ACUTE [unstable patient (cardioversion); stable (rate control with CCB/beta-block; cardioversion electrical > pharm; antiplatelet vs anticoagulation - CHADS2)] CHRONIC (rate control-BB/CCB, anticoagulation if>60/RF); CARDIOVERSION CONCERNS: cardioversion if afib present > 48hr/unknown = anticoagulate for 3 wk before cardioversion or TEE; need 4 wk anticoagulation post cardioversion

HTN Emergency (malignant hypertension if have papilledema)

ETIOLOGY: nonadherence, Cushing, cocaine/LSD/methampehtamine, hyperaldost, eclampsia, phe, alcohol withdrawal; DEFINE: SBP/DBP > 180/120 + end-organ damage (malignant - retinal hemorrhage, papilledema, exudate); (AMS/ICH/encephalopathy, AKI/hematuria, UA/MI/CHF/dissection, pulm edema); FEATURES: HA, vision change, AMS; PATHO: fibrinoid necrosis of small arterioles; TREAT: dec MAP by 25% in 1-2 hr (IV nitroprusside, labetaolol, nitroglycerin => PO if less severe)

Winter formula

Expected pCO2 = 1.5 [HCO3] + 8 +/- 2

Cocaine induced vasospams

FEATURES: CP, STEMI, NSTEMI; TX: like regular MI, but avoid beta-block; also benzo, ASA, nitro

Heart Failure: features, dx, mgmt

FEATURES: displaced PMI, pathologic S3 (can be normal in children), S4, lung crackles/rales, pleural effusion, inc pulmonic component of S2 2/2 pulm HTN, and right-sided heart failure; DIAGNOSIS: Echo is test of choice to determine systolic dysfunction (EF <45%); CXR, EKG, radionuclide ventriculography with Tch-99, cardiac cath, stress testing; LABS: BNP > 100 if decompensated MANAGEMENT: NYHA class II-III (beta-block, ACE-i, loop diuretic/salt restriction < 4g, PA restriction); class III-IV (beta-block, loop diuretic, ACE, spirinolactone, digoxin helps with systolic dysfunction); SURVIVAL IMPACT: ACE-i, beta-block, spirinolactone; NOTE: hydralazine+nitrate replace ACE-i if ACE not tolerated

RV Failure: features, TX

FEATURES: inferior EKG changes, hypotnesion, JVD, hepatomegaly, clear lungs; TREAT: Preload dependent; IVF; avoid nitrates/diuretics

pericardial effusion

FEATURES: muffled heart sound, soft PMI, dullness at left lung base, +/- friction rub; DIAGNOSE: echo is image of choice showing >20 mL fluid, CXR, EKG with low voltages/T wave flattening/electrical alternans, CT/MRI, pericardial fluid analysis to determine cause; TREAT: pericardiocentesis if unstable/dx cause, repeat echo in 1-2 wk if asx

Resp compensation

For metab acidosis (dec pCO2 by 1.25 x HCO3 change); For metab alkalosis (inc pCO2 by 0.75 x HCO3 change)

Hyponatremia: treatment

ISOTONIC AND HYPERTONIC HYPONATREMIA: treat underlying disorder; HYPOTONIC HYPONATREMIA: mild (120-130): withold water; moderate (110-120): loop diuretics + ns; severe or symptomatic (<110): hypertonic saline to inc na by 1 to 2 meq/L to prevent central pontine demyelinations

Glucose impact on sodium

In hyperglycemia: correct Na by 1.6-2.4 mEq/L for each 100 mg/dL increase in plasma glucose > 100 mg/dL

Ethylene glycol poisoning

Inc osmolar gap (unlike EtOH/DKA and lactic acidosis), AG metabolic acidosis, renal failure, calcium oxalate crystals in urine

PVD

LOCATIONS: superficial femoral, popliteal, oartoiliac; FEATURES: intermittent claudication, rest pain; DIAGNOSE: ABI > 1 normal, <0.7 claudication, <0.4 rest; TREAT: conservative for intermittent claudication w RF reduction/aspirin/ptentoxifylline; srugery if rest pain/ischemic ulcerations/severe sx - surgical bypass grafting or angioplasty

Unstable Angina/NSTEMI mgmt

MEDICAL MGMT: ASA, BB, nitrates, LMWH for at least 2 days (enoxaparin drug of choice: ESSENCE), GpIIb/IIIa ihibitors (abciximab/tirofiban) are adjunct; No benefit of CCB/thrombolytics; REVASCUL: attempted if medical mgmt fail after 48 hr; LT MGMT: ASA, beta-block, nitrate, RF modifications - statin (CARE), folate if hyperhomocystinemia

STEMI Tx

MEDICAL MGMT: beta blocker, aspirin, ACEi <= all reduce mortality; oxygen, nitrates, morphine sulfate, enoxaparin; statin as maintenance; REVASCULARIZATION: <12 hr after sx start: fibrinolytic/tPA (<30 min from ED admission) or PCI (<90 min) with goal to reperfuse in <90 min from presentation; if present > 12 hr not candidate for reperfusion tx; CONTRAINDICATIONS TO THROMBOLYSIS: uncontrolled HTN, trauama, active PUD, previous stroke, recent invasive procedure, aortic dissection; PTCA INDICATIONS: STEMI >12 hr after sx but still residual ST-elevation, in past CABG patients, cardiogenic shock; LONG-TERM: cardiac rehab of exercise/RF reduction

Succinylcholine

MOA: depolarizing neuromuscular blocker that causes significant K release; CONTRAINDIC: hyperkalemic conditions (crush/burn injuries > 8hrs old, demyelinating syndromes eg GBS, tumor lysis syndrome)

Drugs: impact on preload, afterload

NITRATE: dec cardiac work + inc oxygen delivery = venodilatation = dec preload + modest dec afterload; sfx - HA, orthostasis, tolerance, syncope; CA-CHANNEL-BLOCK: afterload reduction; MORPHINE: venodilation = dec preload

Hypertonic hyponatremia

PATHOGEN: osmotic substances that cause osmotic shift of water out of cells; CAUSE: hyperglycemia, mannitol, sorbitol, glycerol, maltose

MS

PATHOPHYS: F => MS => LAP => pulm congestion/HTN => Afib; RF: rheumatic fever; EXAM: loud S1, opening snap post S2, SEVERITY indicated by less time b/w S2 and opening snap low-ptiched diastolic rumble; FEATURES: LAE = elevation of left main stem bronchus = hemoptysis = Afib; DOE, orthopnea, PND, palpitations, CP; DIAGNOSE: LAE on CXR, Echo confirms: LAE, thick MV; TREAT: medical (diuretics, IE ppx, Afib treatment); surgical (percutaneous balloon valvulopasty if severe); asx - no tx

AV re-entrant

PATHOPHYS: accessory pathway b/w atria and ventricles; anterograde through AV node, retrograde through bypass (e.g., WPW); EKG: short RP b/c atrial activation rapid after QRS

Mycotic aneurysm

PATHOPHYS: aneurysm 2/2 damage to wall 2/2 infection; BCX positive; TREAT IV abx + surgical excision

Wolff-Parkinson-White

PATHOPHYS: anterograde conduction in accessory pathway; EKG: short PR interval and delta wave initiating R wave deflection; regular rhythm; smooth baseline; TX: radiofrequency catheter ablation; avoid drugs active on AV node; okay IA, IC antiarrythmics

Hypervolemic hypernatremia

PATHOPHYS: high total body sodium; high total body water; CAUSE: iatrogenic m/c; exogenous steroids; cushing's; saltwater drowning; 1' hyperaldosteronism

ASD

PATHOPHYS: inc RH work; PROG: usually asx until middle age; FEATURES: mild SEM at pulmonar area 2/2 inc pulmonary blood flow, wide/fixed split S2, diastolic flow rumble; DIAGNOSE: TEE, CXR, EKG w RBBB/RAD/atrial abnl; TREAT: surgical repare when pulm-to-systemic blood flow > 1.5/1; COMPLICATIONS: pHTN, Eisenmenger's disease rarely, RHF, atrial arrythmia/fibrillation, stroke

Pseudohyponatremia / Isotonic hyponatremia

PATHOPHYS: marked elevation of plasma lipids, proteins; SX: low calculated sOsm but normal measured sOsm

Myocarditis

PATHOPHYS: myocardium inflammation; ETIOLOGY: viruses (Coxsackie B), bacteria (GAS, Lyme), SLE, medications; FEATURES: large range - asx to pericarditis/CHF/death; LABS: inc cardia markers/ESR; TREAT: supportive, underlying cause

High-output-HF

PATHOPHYS: need more CO for peripheral tissure requirement; ETIOLOGY: chronic anemia, pregnancy, hyperthyroidism, AV fistulas, wet beriberi, Paget's disease of bone, MR, aortic insufficiency

Isovolemic hypernatremia

PATHOPHYS: normal total body sodium; low total body water; CAUSE: diabetes insipidus

Cardiac tamponade

PATHOPHYS: rate of fluid accumulation improtant, effusion that impairs diastolic filling of heart; RF: pericarditis; CAUSES: penetrating trauma to thorax, iatrogenic, pericarditis, postMI c/b free wall rupture; FEATURES: JVD with prominent x descent & absent y descent, narrowed pulse pressure SBP-DBP, pulsus paradoxus, distant/muffled heart sounds, tachypnea/tachy/hypotension w cardiogenic shock; DIAGNOSE: ECHO: diagnostic; CXR; EKG: electrical alternans (amplitude of QRS alternates as heart moves in fluid-filled sac); CARDIAC CATH: shows equal pressures in all chambers during diastole, elevated RAP loss of y descent; TREAT: NONHEMORRHAGIC (stable - monitor; unstable - pericardiocentesis); HEMORRHAGIC (emergent surgery)

Hypovolemic hypernatremia

PATHOPHYS: sodium and water loss but more water loss than sodium loss; CAUSE: renal loss (diuretics, osmotoc diuresis/glycosuria, renal failure)

Hypermagnesia: presentation, treat

PRESENT: n/v, facial paresthesia, loss of dtr, ekg changes resemble hyperkalemia, somnolence, muscular paralysis causing death; TREAT: withold exogenously administered mg, prescribe iv calcium gluconate for cardioprotection, administer saline and furosemide, dialysis

Hypomagnesium: presentation; treat

PRESENT: neuromuscular / cns hyperirritability (muscle twitching, weakness, tremor, hyperreflexia, seizure, mental status change); coexisting hypoca (dec pth release / resistance to pth when low mg); coexisting hypoca; ekg changes (prolonged qt, t wave flattening, ultimately torsades); TREAT: if mild (mg oxide); if severe (mgso4)

Valve disorders: prophylaxis indication

PROCEDURES: dental, GI, or GU; NOT cardiac cath; DISORDERS: ABX: amoxicilin

Hyperkalemia: treatment

REMOVAL: diuretics, cation-exchange resin - kayexlate / sodium polystyrene sulfonate, dialysis; MOVE INTRACELLULAR: insulin + dextrose, sodium bicarbonate, beta agonist; PREVENT COMPLICATIONS: calcium gluconate; EMERGENCY: calcium most quick response => insulin + glucose takes 30 min + nahco3 => dialysis / kayexylate takes 1-2 hours + diuretic

Stable Angina: treatment

RF modification; DRUGS: ASA, beta-blocker, nitrates for symptomatic mgmt, CCB if beta-blockrs/nitrates not effective; REVASCULARIZATION: PTCA/CABG preferred if stenosis >70%, with CABG for 3+ vessel/left main/2 vessel w proximal LAD

Acute arterial occlusion

RF: afib; PATHOPHYS: emobil from heart most of time, also aneurysm, atheromatous plaque; OCCURS in ARTERIAL CIRCULATION; FEATURES: 6 p's - pallor, pulseless, pain, polar, parasthesia, paralysis; DIAGNOSE: arteriogram, EKG/Ech to find etiology; TREAT: resetablish perfusion < 6hr via embolectomy or intra-arterial fibrinolysis/mechanical embolectomy via VIR; anticoagulation with IV heparin; COMPLICATIONS: compartment syndrome

aortic dissection

RF: pregnancy, bicuspid AV, aorta coarctation, Marfan's/Ehlers-Danlos, HTN; FEATURES: disparate BP b/w arms, diastolic murmur of AR involving RCA / inferior STEMI, diaphoresis, AR, neurological manifestations 2/2 ischemia spinal cord arteries, pleural effusion, widened mediastinum; TYPES: A (proximal), B (descending only); DIAGNOSE: CXR, TEE, chest CT, arotic angiography; TREAT: antiHTN w IV nitro, IV beta blockers +/- surgery (if involves ascending aorta/type A)

Bradyarrythmia

RF: prolonged QRS interval

Torsades de pointes

RF: prolonged QT interval, TCA, class III anti-arrhythmics/amiodarone/sotalol, anti-infective agents (moxi, fluconaozle), familial long QT ; CAUSE: hypomagnesemia; TREAT: IV magnesium sulfate, d/c QT prolonging agent

multifocal atrial tachycardia

RF: severe pulmonary disease; DX with EKG: 3 or more P wave morphologic patterns and variable PR/RR intervals; TREAT: underlying dz process; preserved LVEF = CCB, beta-block; non-preserved LVEF = digoxin, dilt, amiodarone

Cholesterol embolziation syndrome

RF: surgical/radiographic intervention or thrombolytic therapy; TREAT: supportive

Sinus brady vs sick sinus

S BRADY (tx with atropine; cardiac pacemaker if bradycardia persists); SICK SINUS (persistent spontaneous s brady causing dizziness/confusion/syncope/fatigue/CHF, tx with pacemaker)

Metabolic alkalosis

SALINE RESPONSIVE (urine chloride < 20 mEq: result from GI proton loss, volume depletion, diuretic abuse): ecf contraction, also has hypokalemia; SALINE-RESISTANT (urine Cl > 20 mEq) ecf expansion and htn - often due to hyperaldosteronism, cushings, severe k deficiency, bartter, diuretic abuse; TREAT: isotonic saline if volume contracted; treat underlying cause or use spironolactone if volume expanded

Calcium: serum measurement, hormonal control

SERUM MEASURE: albumin; pH (alkalosis = higher binding to albumin); PTH (inc ca, dec po4: inc bone resorption from bone; kidney - inc ca, dec po4; gi - activates vitd); CALCITONIN (dec ca, dec po4: bone - dec resorption; kidney - dec ca, inc po4 resorption; gi - dec postprandial ca absorption); VITAMIN D (inc ca, inc po4: inc bone resorption; kidney - inc ca resorption, dec po4 resorption; gut - inc ca, inc po4 resorption)

ST elevation leads and location of MI

ST elevation: II, III, aVF (inferior = RCA); V1-V3 (anteroseptal = LAD); I, aVL, V4-V6 (lateral and apical = LCX); ST depression in V1-V2 (posterior), often found w inferior wall

Stress testing: stressors, imaging modalities, specific indications, interpretation, medication held

STRESSORS: exercise, iv dobutamine, iv adenosine/dipyramidole; IMAGING: ekg, echocardigram, nuclear perfusion imaging to determine reversible ischemia with ptca/cabg; INDICATIONS: rbbb can do EXERCISE; wpw, baseline >1mm st-depression, previous ptca/cabg, digoxin, lvh: use NPI/ECHO; ppm, lbbb, use ECHO; ABNORMAL IF (st depression, cp, hypotension/hf, signifcant arrythmia) => cardiac catheterization; MEDICATIONS: anti-ischemic meds, digoxin, meds that slow heart

Endocarditis: pathogens, complications

SUBACUTE (Strep viridans (esp S mutans), enterococcus); ACUTE: S Aureus m/c; IVDU (S aureus > strep, GNR, enterococcus, yeast); NATIVE VALVE (S viridans, S aureus > S epidermidis, enterococci, HACEK - Haemophilus, actinobacillus, cardiobacterium, eikenella, kingella); PROSTHETIC (Staph epi > S aureus if <60 d; >60d - streptococci); COMPLICATIONS: cardiac failure, abscess, solid organ damage, GN

aortic aneurysm

THORACIC: mc ascending 2/2 cystic medial necrosis; if descending 2/2 atherosclerosis; ABDOMINAL: etiology - atherosclerosis, features - fullness, pulsatile mass, ecchymosis on back/flanks/umbilicus indicate impending rupture; WORK-UP: U/S for AAA; chest/abdominal CT; abdominal radiograph not very helpful; TREAT: UNRUPTURED: if >5cm / symptomatic / rapid growth: surgery + graft placement recommended; RUPTURED AAA - abdominal pain, hypotension, palpable pulsatile abdominal mass required emergent laparotomy

Nonbacterial endocarditis

THROMBOTIC/MARANTIC: assoc w debilitating illness, sterile deposits of fibrin/platelets, vegetations can embolize; VERRUCOUS/LIBMAN-SACKS: usually AV in SLE, small warty vegetations on BOTH sides of valvue leaflets, need to tx SLE

Hypokalemia: treatment

TREAT: d/c aggravating meds; oral potassium chloride; iv k-cl if severe; NOTE: will predispose pt to digoxin toxicity

Cardiac catheterization: indications, coronary angiography

after positive stress test; with angina when noninvasive tests nondx/persist despite medical tx/soon after MI/diagnostic difficulty; severe sx with urgent dx/mgmt needed; evaluation of valvular disease to determine surgical intervention need; CORONARY ANGIOGRAPHY: performed concurrently, if >70% stenosis can produce angina, is definitive test for CAD

Shock types: CO, SVR, PCWP

cardiogenic (low CO, hi SVR, hi PCWP); hypovolemic (low CO, hi SVR, low PCWP); septic shock (hi CO, low SVR, low PCWP); neurogenic (low CO/SVR/PCWP)

Leutic heart

complication of syphilitic aortitits; aneurysm of aortic argh with extensionb ack to cause AR, stenosis of aortic branch including coronary arteries; TREAT: IV PCN, surgical repair

Metabolic acidosis

determine anion gap => then determine gap-gap => determine if respiratory is properly compensating; TREAT: na-bicarb may be needed; consider mechanical ventilation if fatigued from hyperventilation

STEMI EKG progression

hyperacute / tall, peaked T waves => ST elevation => Q wave => loss of R => further R reduction + Q wave deepening + inverted T waves; ALSO - T wave inversion sensitive, ST-segment depression subendocardial injury

Unstable Angina vs NSTEMI

often treated together; NSTEMI = elevation for cardiac enzymes