Emergency Medicine EOR

What does the AP and lateral neck radiographs show in patients with croup?

"steeple" sign - child may also have a mild leukocytosis -- Remember, PE shows a bark-like cough

Restrictive cardiomyopathy: often caused by a ____process, or post-radiation or post open-heart surgery. What is the most common first symptom?

--infiltrative process - amyloidosis, sarcoidosis, and hemochromatosis -- changes in myocardium --most common first symptom is exertion intolerance and fluid retention, signs of right heart failure

What are the adjunctive tx for fibrinolysis or PCI?

1. antiplatelets (ASA, clopidogrel) 2. anticoagulants (UFH, LMWH, DTI, direct factor Xai)

Atrial flutter - sawtooth pattern in II, III, aVF - what three treatments are used?

1. cardioversion if no contraindications 2. acute rate control tx w BB, CCB - amiodarone, sotalol, quinidine, or procainamide 3. If site of reentrant is known, catheter ablation

Atrial fibrillation - regularly irregular - the most common sustained arrhythmia in adults - what three treatments are used?

1. rate control w BB, CCB, or digoxin 2. Anticoagulation w heparin & warfarin 3. rhythm control w amiodarone or cardioversion

For synchronized cardioversion, use ____Joules for paroxysmal supraventricular tachycardia and _____Joules for a fib and VT.

50J, 100J

Hypertension Drug of Choice for: angina diabetes hyperlipidemia CHF Previous MI Chronic Renal Failure Asthma, COPD

Angina - BB, CCB Diabetes - ACEi & CCB, avoid diuretics Hyperlipidemia - ACEi & CCB, avoid diuretics/BB CHF - diuretics & ACEi, avoid CCB/BB Previous MI - BB/ACEi Chronic renal failure - diuretics, CCB Asthma - diuretics & CCB, avoid BB

_____is a diastolic murmur heard along left sternal border. Austin-Flint murmur. What kind of pulse?

Aortic regurgitation; "water hammer" pulses

What two meds should be given to all ACS patients that do not have contraindications?

BB - unless brady or severe COPD - then do NDCCB (verapamil/diltiazem) ACEi - if cough, use ARB

_____is released from cardiac ventricles in response to increased wall tension.

BNP - B-type natriuretic peptide

_______is the abnormal dilation of large conducting airways - due to congenital abnormalities (cystic fibrosis) or an acquired process (alplha-1-antitrypsin deficiency).

Brochiectasis

_____presents with distended neck vein, indistinct heart sounds, narrow pulse pressure, and pulsus paradoxus. Tx: pericardiocentesis and treat underlying cause.

Cardiac tamponade

_____refers to the condition of excess mucus production and productive cough occurring for at least 3 months a year for 2 consecutive years. "blue bloater", course rhonchi

Chronic Bronchitis

Functional Classification of Heart Failure: ___-No cardiac symptoms with ordinary activity. ___-Cardiac symptoms w MARKED activity but asymptomatic at rest ___-Cardiac symptoms w MILD activity but asymptomatic at rest ___-Cardiac symptoms at rest.

Class I, Class II, Class III, Class IV

Cardiac Markers: _____appears 3-6 hours after MI and stays elevated for 2-4 days. Specific to heart muscle.

Creatine kinase Mb

_____is inflammation or infection of supraglottic structures ie. tongue, vallecula, arythenoid, and tonsils. What age is most commonly affected?

Epiglottitis; between 2 and 6 years old

If a patient with a DVT has active internal bleeding, uncontrolled HTN, CNS tumor, recent trauma or surgery, or recurrent DVT despite anticoagulation, what alternative treatment should be considered?

IVC filter

ST Elevations in II, III, aVF

Inferior MI; right coronary artery

Which bacteria in Pneumona is common in diabetes, alcoholism, and nosocomial infections?

Klebsiella

What are the pre hospital treatments for ACS?

MONA; morphine, oxygen, nitroglycerin (0.4mg SL x3 prn), aspirin (325mg)

____hypertension is potentially life threatening - HTN plus rentinopathy, cardiovascular/renal compromise, or encephalopathy.

Malignant

______presents with a mid-systolic click heard best at apex.

Mitral valve prolapse

Cardiac Markers: _____is detectable within 1-2 hours after acute MI. Duration <1 day. Low specificity.

Myoglobin

What meds should a patient go home with after ACS?

Nitroglycerin BB ACEi ASA/Clopidogrel anticoagulant (up to 8days for LMWH) aldosterone agonist statin LIFESTYLE CHANGES

What PE and EKG changes are seen with dilated cardiomyopathy?

PE: S3, JVD, crackles - possible mitral regurg EKG: nonspecific ST and T wave changes, LBBB

____is an early systolic opening ejection click followed by a systolic ejection murmur which radiates to the base.

Pulmonic Stenosis

What virus causes most cases of bronchiolitis? What are the hallmarks signs of this type of infection?

RSV - respiratory syncytial virus; tachypnea, tachycardia, fever, hypoxia

What is the EKG changes in a PE?

S1Q3T3 - with or without a RBBB

_____angina is brought on by activity/exercise. ____angina may show transient ST changes and inverted T waves. ____is pain mainly occurring at rest due to vasospasm of coronary arteries.

Stable, unstable, prinzmetal/variant (responds well to CCB or nitrates, BB may exacerbate vasospasm)

Endocarditis (or infection of the endothelial surface of the heart) is most commonly caused by what bacteria?

Strep viridans, Staph aureus, and Enterococcus

Aortic dissections - Stanford type A vs. Stanford type B. What's the difference and which is treated surgically?

Type A - involves ascending aorta - surgical tx!!! Type B - involves descending aorta - BP control

What are the two signs of PE on CXR?

Westermark's sign - area of decreased pulmonary vascularity with a cutoff sign Hampton's hump - shadow or density in contact with one or more pleural space corresponding to lung segment involved

Hypotension, tracheal deviation, and elevated jugular venous pressure indicates that a simple pneumothorax has progressed to what? What does CXR show for this?

a tension pneumothorax; lack of lung vascular markings at periphery

What are the criteria for diagnosing ARDS - acute respiratory distress syndrome? Mortality 40-60%

a. ratio of PaO2/FiO2 < or = 200 b. detection of bilateral pulmonary infiltrates on CXR c. pulmonary wedge pressure < or = 18mmHg or no clinical sign of elevated left atrial pressure

Epiglottitis MC b/w ages 2 and 6. What is the treatment of epiglottitis?

airway management w intubation or tracheostomy; oxygen; hydration; antibiotics (Ceftriaxone or Cefotaxime) ; steroids

Traumatic rupture of thoracic aorta: If high clinical probability of aortic injury, ____should be done. Unstable patients with suspected aortic rupture should have a bedside ___. All other stable patients may undergo ____of the chest for evaluation of aortic rupture.

aortography; TEE (transesophageal echocardiogram); CT angiogram

How long should Plavix/Clopidogrel be used for bare metal or drug eluting stents?

bare metal - 30d-12m drug eluting - >/=12mon

What does CXR show with pleural effusion? What is the tx?

blunting of costophrenic angle - free pleural fluid on lateral decubitis film; thoracentesis

In pericardial tamponade, the ECG may show ____as the heart swings within the accumulated pericardial fluid. What diagnostic tool helps identify pericardial tamponade?

electrical alternans; FAST exam

Malignant hypertension bp? What is the rule of thumb for lowering?

greater than 220/140; 10% in first hour and 15% for the next 3-12 hours, to normal over next 2 days

What is the emergent treatment for arterial embolism/thrombosis (pain, pallor, pulselessness, paresthesias, paralysis)?

heparin, emergency embolectomy-thrombectomy to restore blood flow

Pulmonary ____occurs when resistance to flow across the pulmonary vasculature increases. - may see prominent upper lobe pulmonary veins, increased density in the central lung fields, and Kerley B lines.

hypertension

No nitroglycerin in which kind of MI?

inferior

Cardiology

is fun!

ST Elevations in I, aVL, V4, V5, V6

lateral wall MI, left circumflex artery

What is the most common cause of pleural effusions?

left sided heart failure (increased hydrostatic pressure in microcirculation) ALSO - 1. decreased oncotic pressure - hypoalbuminemia 2. decreased pressure in pleural space - collapsed lung 3. increased permeability - in pneumonia 4. impaired lymphatic drainage - in malignancy 5. movement of fluid from peritoneal space - in ascites

Pneumonia CXR findings and associated bacteria: 1. Strep Pneumo, H Flu, and Klebsiella have ____consolidations. 2. Staph Aureus, Legionella, and Mycoplasma appear ___. 3. Pneumocystitis jiroveci is common in AIDS patients and appears _____.

lobar; patchy; diffuse interstitial and alveolar infiltrates

What is the treatment for mild and more severe bronchiolitis/RSV?

mild - albuterol, racemic epinephrine more severe - add IV hydration, ribavirin, RSV-IG prophylaxis Steroids not beneficial

Patients with pericardial tamponade present with Beck's triad. What is that?

muffled heart sounds distended neck veins hypotension

What is the classic arrhythmia associated with COPD?

multifocal atrial tachycardia

With croup, protect airway first! What does less severe treatment of croup involve?

nebulized saline, racemic epinephrine, and steroids if patient has stridor at rest.

What is the agent of choice for BP lowering for patients with hypertensive encephalopathy, intracranial bleeding, and heart failure? Use with what for dissecting aneurysm?

nitroprusside; propranolol -- clonidine can also be used but sedation is common

What is the treatment for constrictive pericarditis?

pericardiectomy --- otherwise NSAIDs and Steroids

ST Elevations in V1, V2

posterior wall MI, posterior descending artery

CHF - Systolic dysfunction means a problem with the ____. What drug is contraindicated?

pump; CCB!

What is the progression of CO2 in an asthmatic or COPD patient?

respiratory alkalosis (loss of CO2) and hypoxia THEN respiratory acidosis which indicates impending respiratory failure

Foreign body aspiration: 1. MC location of obstruction? 2. TX: ____for <1 year old; ____for >1 year old. 3. MC causes of obstruction?

right main stem bronchus; back blows for <1 year; Heimlich for >1 year; nuts, peanuts, hot dogs

Where is the needle decompression performed for a tension pneumothorax?

second intercostal space, mid-clavicular line

Pericarditis is inflammation of the pericardium. How is pain improved? What is the PE finding?

sitting and leaning forward; ST elevation in all precordial leads, normal cardiac enzymes

What are some drugs associated with Torsades de pointes?

tricyclic antidepressants, erythromycin, ketoconazole, haloperidol, cisapride, disopyramide, pentamidine, sotalol, class I anti-arrhythmics

Virchow's Triad for DVT?

venous stasis, endothelial injury, hypercoagulable state

Dilated Cardiomyopathy: most common cause is ____. Others?

alcohol; may also be idiopathic, myocarditis, or drugs (doxorubicin) -- 1 in 3 cases of heart failure are caused by dilated cardiomyopathy

What are the treatments for bradyarrhythmias?

atropine, pacing, or epinephrine/dopamine

In ____, auscultation of the chest reveals fine rales or audible wheezing and a prolonged expiratory phase secondary to air trapping. CXR: hyperinflation, air trapping, peribronchial cuffing/thickening.

bronchiolitis

Hypertrophic cardiomyopathy: is due to hypertrophy of the _____. PE reveals mitral regurgitation, a ____heart sound, and prominent left ventricular impulse. EKG reveals LVH

cardiac septum; S4

ST Elevations in V1, V2, V3, V4, V5

Anterioseptal MI, left anterior descending artery

Pertussis: Catarrhal stage - 1-2 weeks - resembles a ____ Paroxysmal stage - 2-4 weeks - _____ Convalescent stage - 1-2 weeks - ______. Nasal swab culture for Bordetella pertussis is diagnostic.

upper respiratory infection; whooping cough; cough disappears

Paroxysmal supraventricular tachycardia is a reentry tachycardia, commonly noted in elderly patients with underlying heart disease. What treatment may be helpful before using adenosine ie. the drug of choice?

vagal maneuvers or antianxiety medication

_____is blowing and musical best heard along left sternal border.

Tricuspid regurgitation

Cardiac Markers: _____is the test of choice and appears 2-6 hours after MI and stays elevated for 5-10 days.

Troponin

Transudates vs. Exudates: ______occur when systemic factors that control formation and absorption of pleural fluid are altered. Left sided heart failure/cirrhosis. ______occur when local factors that control formation and absorption of pleural fluid are altered - pneumonia, malignancy, viral infex, PE

Transudates; Exudates

________can lead to cardiac tamponade if it is large. Friction rub noted if secondary to pericarditis.

Pleural effusion.

Timeline: Reperfusion should take place before ___hours of symptom onset. Door to needle time for fibrinolysis is ____min. Door to balloon time for PCI is ___min.

12; 30min; 90min

Stage 1 Hypertension is defined as greater than ____. Stage 2 Hypertension is defined as greater than ____.

140/90; 160/100

What are some of the PE findings for infective endocarditis?

Roth spots - small white spots on retina surrounded by hemorrhage Osler nodes - small tender lesions on fat pads of fingers and toes Janeway lesions - painless, reddish, macular lesions on hands or feet

How do patients with tension pneumothorax present?

hypotension, distended neck veins, absent breath sounds over affected hemithorax, tracheal deviation

____is a decrescendo-crescendo rough, systolic murmur. Heard best at base of heart and radiates to neck. What drug is contraindicated?

Aortic stenosis; ACEi

Foreign body aspiration: S/S ____aspiration presents with cough, decreased air entry, dyspnea, and wheezing ____aspiration presents with cough, cyanosis, dyspnea, and stridor

Bronchial; Laryngotracheal

CHF - Diastolic dysfunction means a problem with the ____.

compliance or relaxation of the heart during ventricular filling

_________is considered the gold standad test for aortic dissection but is also the most invasive of all the radiographic studies. What is more normally done in the ED?

Aortography; CT with contrast

Multifocal atrial tachycardia - noted in patients with COPD or severe systemic illness - EKG shows multiple shaped P waves and differing PR intervals. ____are agents of choice?

CCB

____is enlargement or dysfunction of the right ventricle due to pulmonary hypertension.

Cor pulmonale - may see prominent P waves in leads II, III, and aVF (anterior leads)

Pneumonia empiric treatment: 1. Augmentin, Macrolide (azithromycin, clarithromycin, erythromycin), doxycycline, second-generation cephalosporins ("a furry fox..") 2. Fluoroquinolone, ceftriaxone, cefotaxime. 3. Clindamycin, Pen G 4. Fluoroquinolone + Metronidazole, Ceftriaxone + metronidazole, Ticarcillan-Clav, Piperacillin-Tazo

1. CAP, inpatient 2. CAP, outpatient 3. Aspiration, community 4. Aspiration, hospital

What is the pharmacologic therapy for heart failure?

1. diuretics for fluid retention 2. ACEi 3. vasodilators (hydralazine & nitrates) 4. BB for LV dysfunction 5. digitalis to increase cardiac contractility

Hypotension is defined as a systolic blood pressure less than _____mm Hg or a decrease from baseline by more than 30mmHg. What are the 3 treatments for improving blood pressure?

90mmHg; 1. IV Fluids 2. Vasopressors - dopasmine, dobutamine (risk is aggravation of arrhythmias and increase myocardial oxygen demand) 3. intra-aortic balloon pump

BLOCKS 1. ____=prolonged PR interval 2.____=progressive increase in PR until Pwave is blocked. 3._____=sudden block in P wave w no change in PR 4._____=atrial and ventricular rhythm are independent of each other.

First degree; Wenckebach Mobitz type I; Mobitz type II, Third degree block

______presents with an opening snap in early diastole. Soft, low-pitched, diastolic rumble heard best at the apex in the left decubitus position, palpable right ventricular heave.

Mitral stenosis

Acute bronchitis is usually caused due to ____ie. Adenovirus, Influ A or B, Coronavirus, Rhinovirus, RSV. ______causes include H flu, Mycoplasma pneumonia, M cat, Chlamydia pneumo, or Strep pneumo.

Viruses; Bacterial

What does the lab testing show in an asthmatic patient?

high WBC with eosinophilia Sputum shows --- Curschmann's spirals (mucous casts of small airways) Charcot-Leyden crystals

Secondary hypertension is HTN due to an ______.

identifiable cause ie. renovascular disease, coarctation of the aorta, primary aldosteronism, Cushing's, Pheochromocytoma, OSA, renal parenchymal hypertension

CDC guidelines for PPD result interpretation: 1. __mm or greater positive when a. HIV positive or who have HIV risk factors; b. recent close contact w TB; c. CXR w evidence of healed TB infex 2. __mm or greater positive when a. born in high prevalence area b. IV drug user C. low income population d. nursing home resident e. <age4 f. DM, malignancy, corticosteroid use, immunosuppression, renal failure. 3. __mm or greater is positive in all other cases.

5mm; 10mm; 15mm

A _____may develop after acute MI, PE, aortic stenosis and is due to a conduction delay in the right or left bundles.

Bundle branch block

_____is a condition defined pathologically as dilation of the air space distal to the terminal brochiole with destruction of the interalveolar septa. "pink puffer" CXR - hyperinflated with flat diaphragms

Emphysema

The ________principle means that as preload increases, the ventricle is stretched during diastole filling and the ejection fraction is increased.

Frank-Starling principle

What is the criteria for the PERC SCORE????? HADCLOTS This is used to rule out the need for further imaging.

H - hormone/estrogen use A - age>50 D - dvt/pe history C - coughing up blood L - leg swelling disparity O - O2 sat<95 T - tachy>100 S - surgery/recent trauma

The most common pathogens of epiglottitis are Strep pyrogenes, Strep pneumo, and Staph aureus. Which vaccine has dropped the incidence of epiglottitis? Class lateral neck radiograph finding?

HIB; "thumb print" sign

_______sign is pain with dorsiflexion of the foot. May be positive with DVT.

Homan's

Influenza - caused by influenza A or B. Antivirals can shorten the course. Rimantadine and Amantadine can be used to shorten course of ______. Zanamivir and Oseltamivir can shorten the course of _____.

Influenza A; Influenza A or B.

Duke Criteria for dx of infective endocarditis Dx with 2 major or 1 major and 3 minor

Major a. positive blood cultures b. endocardial involvelment on echo Minor a. predisposing condition: cardiac or IV drug use b. fever c. vascular phenomenon d. immunologic phenomenon

______is a pansystolic, blowing in nature, high pitch, musical sound. Radiates to left axilla.

Mitral regurgitation