EMED ACS AND PNEUMOTHORAX
Terms in this set (88)
Leading cause of death among adults in US
Represents a spectrum from chronic stable angina to acute MI.
Ischemic Heart Dx
Describes patients who present with acute chest pain and other symptoms of myocardial ischemia
Chest pain from decreased blood flow (O2 and nutrients) to cardiac tissue. Reversible
Chest pain from necrosis of cardiac tissue from complete blockage of blood flow. Nonreversible
"Which coronary artery? Supplies some anterior wall and a large portion of the lateral wall
"Which coronary artery supplies the anterior & septal regions
Left anterior descending branch
Which coronary arteries branch from LCA?
"Left Circumflex and Left anterior descending branch
"Which coronary artery supplies the right side of the heart. Supplies blood to the inferior aspect of the left ventricle through the posterior descending artery. AV conduction system.
Right Coronary Artery
MI is usually due to?
atherosclerotic disease and a reduction in myocardial blood flow
Coronary artery spasm, Disruption or erosion of atherosclerotic plaque, Platelet aggregation, Thrombus formation can all cause?
Ischemia occurs ONLY when activity induces oxygen demands beyond oxygen supply restrictions secondary to PARTIAL occlusion of a coronary vessel.
"Ischemia is relatively unpredictable (i.e. at rest) and changes occur rapidly. Reversible myocardial ischemia. Necrosis does NOT occur
Describe how the heart is sequentially effected by MI
"Dyssynchrony (dissociation of time course in adjacent tissues), Hypokinesis (reduction in shortening with contraction), Akinesis (cessation of shortening with systolic contraction), Dyskinesis (paradoxical expansion of infarcted tissue during systole)
lasts longer than 20 minutes and little to no response to rest or NTG. The pain is usually more severe and there are more associated symptoms
Who would you suspect to have atypical chest pain history?
DM, women, elderly
Chest pain and hx of angioplasty or stent what should you assume?
Assume they have had an abrupt vessel occlusion until proven otherwise
What are some high risk factors for younger patients with ACS
SLE, Prothombotics (Protien S/C, Leiden Factor V), Kawasaki's, Grossly ABNL ECG
What effect does lack of risk factors have on ACS workup?
Lack of RFs DOES NOT r/o disease*** In the ED, cardiac risk factors are poor predictors of risk for MI or other ACS\
Why are S1 and S2 diminished in ACS?
New systolic murmur-ominous sign in ACS why?
Signifies papillary muscle involvement, Mitral valve failure or VSD
Why is an anterior wall infarction presenting with bradycardic rhythm or heart block a poor prognostic sign
The AV Node has been affected which implies the RCA is involved.
HR may be bradycardic, tachycardic or irregular. Bradycardic rhythms are more common in inferior wall MIs.
RCA feeds the AV node as well as the inferior wall.
Single best test for AMI
5 ways to diagnose an AMI on ECG:
"1mm ST changes in 2 contiguous leads, Reciprocal depression, Q waves, Compare to Old ECGs, Serial ECGs Q5-10 min, or Pt changes, or NEW LBBB
ST segment depression means?
ST segment elevations means?
Q waves suggest?
myocardium has died (infarction)
All inferior wall acute MI require what?
Right sided lead V4R prior to using NTG
Name some atypical ACS symptoms (1/3 don't have chest pain)
Dyspnea, N/V, Weakness, Diaphoresis, Acute CNS changes
Septal ECG leads
Anterior ECG leads
Inferior ECG leads
II, III, AVF
Lateral ECG leads
I, aVL, V5, V6
ST-segment elevation in lead III greater than in lead II plus ST-segment depression of >1 mm in lead I, lead aVL, or both. Which coronary artery
ST-segment elevation in lead III greater than in lead II plus ST-segment depression of >1 mm in lead I, lead aVL, or both. ST-segment elevation on V1, V4R, or both. Which coronary artery
ST-segment elevation in leads I, aVL, V5, and V6 and ST-segment depression in leads V1, V2, and V3. Which coronary artery
ST-segment elevation in leads V1, V2, and V3. ST-segment elevation of >2.5 mm in lead V1, or right bundle-branch block with Q wave, or both. Which coronary artery?
ST-segment elevation in leads V1, V2, and V3, ST-segment depression of >1 mm in leads II, III, and aVF. Which coronary vessel?
ST-segment elevation in leads V1, V2, and V3. ST-segment depression of ≤1 mm, or ST-segment elevation in leads II, III, and aVF. Which vessel affected?
Anterioroseptal MI; which leads
Anterolatal MI which leads
Inferiorolateral MI which leads
II, III, AVF, V5-V6
RV MI which leads?
Goal of treat for ACS
achieve immediate reperfusion and limit infarct size
When do we give fibrinolytics with ACS
Within 30 minutes and only if PCI unavailable
Whats loading dose of ASA with MI? What can you give if allergic?
162-325 mg, Clopidogrel (Plavix)
When should you give BB with MI? What are some CI's?
Within 24 hours in the absence of cardiogenic shock or comobdities: 2nd/ 3rd degree heart block, active asthma, RAD. (Metoprolol or Atenolol). Caution in pulse < 60, or SBP < 100
What are some general CI's to fibrinolytic therapy for Acute MI?
Hemorrhages, Severe uncontrolled B/P, pregnancy, PUD, major surgery or prolong CPR
What fibrinolytic is cheapest, and can have Antibodies may develop, retreatment is generally avoided
"What fibrinolytic has prolonged half life, is easiest to use; SINGLE bolus administration weight based
"Failed thrombolytic therapy and one of the following: Less than 75 years old in Cardiogenic shock, Severe CHF or pulmonary edema, Ventricular arrhythmias causing HD compromise, Failed thrombolytic therapy, Moderate to large area of myocardium at risk. Whats the next step?
What is only med proven to reduce mortality/morbdity of MI?
What type of drug is indicated in conjunction with patients undergoing PCI?
"Glycoprotein IIb/IIIa Inhibitors- Abciximab-binds irreversibly, Eptifibatide, Tirofiban
Pending CABG what antithrombin should patient get; Unfractionated Heparin or Low Molecular Weight Heparin
Unfractionated Heparin (also indicated for AMI)
When is Low Molecular Weight Heparin preferable to Unfractionaed Heparin?
UA/NSTEMI, STEMI and Lytics (NOT STEMI AND PCI),
What type of MI is CI for NTG?
"What drug class do we give to STEMI patient to reduce L ventricular dysfunction & dilatation, and slow development of CHF during AMI
What are some CI to ACE-I?
HOTN, renal artery stenosis, renal failure, Hx of cough or angioedema
"What drug do we give to suppress automaticity, protects myocytes from Ca++ influx during reperfusion. Given only if documented Torsade V-tach with prolonged QT interval.
Magnesium (can also give if documented hypomagnesia)
When do we use CCB in AMI?
Generally we don't
Whats starting dose of Morphine? What SBP level would cause you to hold off giving morphine?
Start at 2-5mg and titrate. SBP < 100
Post MI what type of dysrhytmias do not increase mortality and can be protective?
PSVT/A-Fib/Flutter leads to increased mortality after MI. A-fib common in first 24 hrs and transient due to increased catecholamines, hypoK+/Mag+, hypoxia, chronic lung disease, and sinus node or L Cirx ischemia. How should you tx?
cardioversion, amiodarone, B blockade
Complete heart block what type of MI do you suspect?
Sinus tach is more common with what type of MI?
Papillary muscle rupture is more common in what type of MI?
Inferior wall MI (new holosystolic murmur MR)
Complication of MI- New onset CP, dyspnea, "sudden" NEW holosystolic murmur (LLSB), palpable thrill
Interventricular septal rupture
Dressler syndrome post MI describe sxs and time frame to present, and tx.
"Chest Pain, Fever, Pleuropericarditis- 2-10 weeks after MI. Tx with ASA not Motrin
What is tx for preload dependent RV infarction (usually in presence of Inferior MI)
Fluids 1-2 L then dobutamine if no improvement in HOTN
Cocaine induced ACS what are mainstays of tx and what drug is CI?
ASA, Nitrates, Benzos are mainstays, Beta Blockers are CI
What should you assume with post procedural chest pain
asssume abrupt vessel closure
GI bleed, stroke, or Severe Infection (sepsis):pneumonia all get what tx during AMI?
IN ALL CASES: PCI Is recommended over thrombolysis
Where do NSTEMI and Angina typically get referred to?
Internal Med- STEMI goes to cardiology
Where does air initially present in pneumothorax?
Between visceral (covers lung) and parietal pleura (lines thoracic wall)
MC risk factor of pneumothorax?
What presents more dramaticly secondary or primary pnuemothorax?
"dyspnea, tachycardia, hypotension, hypoxia, acute pleuritic chest pain on one side
What are 3 clinical hallmarks of tension pnuemothorax
tracheal deviation, hyper-resonance on affected side, HOTN
What patients need confirmatory study (CXR or CT) to confirm diagnosis of tension pneumothorax
COPD to differentiate from severe bullous COPD
"Hallmark finding: visualization of the pleural line with an overlying radiolucent area without lung or vascular markings. What condition
Do we use safety net in pneumothorax?
Yup IV, O2, Monitor, pulse ox, EKG, CXR, labs
If you suspect tension PTX what must you do immediately?
Needle decompression and then chest tube later on as definitive tx
What defines stable PTX patient?
RR < 24, Pulse 60-120, Nml B/P, O2 >90%, absence of hemothorax
When would you use minicatheter "pig tail" chest tube vs std chest tube.
Small, pneumo, stable patient
A plastic chamber with a one-way flutter valve, with one end inserted into the chest tube or catheter and the other end to the drainage bag. Fluid and air will not reflux back into the pleural cavity
What occurs more often iagtrogenic or spontaneous pneumothorax
Name 2 procedures which cause 50% of iatrogenic PTX
transthoracic needle biopsy and thoracentesis
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