Term
|
Definition
|
|
Term
|
Definition
| O2 bound to hgb + dissolved O2 in plasma |
|
|
Term
| How does arterial oxygen affect cardiac output? |
|
Definition
speed ad shortening capacity of myocardium
contraction rate
ability to relax and fill chambers |
|
|
Term
| When heart attack or shock reduce the blood supply to a level that is not reasonable for carrying oxgen, what is produced? |
|
Definition
lactic acid
-if an excess accumulates, lactic acidosis a=occurs.
-normally excreted by the liver |
|
|
Term
| How much lactic acid is in the venous blood during shock? arterial? |
|
Definition
4.5-19.8 mg/dl
4.5-14.4 mg/dL |
|
|
Term
| What is stimulated during shock? |
|
Definition
stimulation of carotid baroceptors
Sympathetic nervous system:
-vasoconstriction
-increased HR and contractility
-constriction of venous capacitance vessels
-release epi, norepi, dopamine and cortisol
-release ADH/activates renin angiotensin system |
|
|
Term
| Can BP detect global tissue hypoperfusion? |
|
Definition
NO!
-shock may occur with normal BP
-Hypotension may occur without shock
- |
|
|
Term
| The shock index is HR/systolic BP, what is normal? |
|
Definition
|
|
Term
| Is there a single lab value that is sensitive or specific to shock? |
|
Definition
NO!
-can order the following to figure out the cause of shock: CBC/CH18/ CaMgPhos/PT/APTT/UA/CXR/ECG |
|
|
Term
| After you figure out the cause of shock, what other labs can be considered? |
|
Definition
Echo/Blood Cultures/LP/CT Chest-Abd or U/S
HCG |
|
|
Term
| What are the types of shock? |
|
Definition
hypovolemic
cardiogenic
obstructive
distributive (metabolic)
septic
respiratory |
|
|
Term
| Why should hypovolemia be corrected rapidly by airway/ventilation/O2? |
|
Definition
| May significantly diminish venous return and result in decreased CO |
|
|
Term
| What is the order in which shock should be treated? |
|
Definition
1. give 02
2. IV fluids (probably LR first in this case)
3. order tests
4. cath (how much fluid is going in and coming out?)
5. consider blood tranfusion
6. pressors (dopamine and debutamine)
-increase CO and decrease peripheral resistance |
|
|
Term
| The rate of fluid infused is dependent on catheter size... 18 g perfuses what? 16 g? |
|
Definition
due to gravity..
18 g: 50-60 ml/min
16 g: 90-125 ml/min |
|
|
Term
| What should continuous be running on a shock pt? |
|
Definition
continuous ECG, pulse Ox/ MS and peripheral perfusion
-Monitor I and Os |
|
|
Term
| What kind of IV fluid are preferred? |
|
Definition
isotonic crystalloid solutions NS or LR
-for every amt of blood lost, 3x that amt required to store intravascular volume bc about 30% of the increased fluid stays intravascular |
|
|
Term
| When is a blood transfusion considered? What should you consider for a massive transfusion? |
|
Definition
6 g/dL
massive blood transfusion > 10 units in 24 hrs
-consider 1:1:1 PRBC:FFP:Plt |
|
|
Term
| Pressors are administered only after what? |
|
Definition
| adequate fluid resuscitation |
|
|
Term
Dopamine hydrochloride has variable effects according to dosage.
What occurs at 2-3 ug/kg/min?
at higher doses<5 ug/kg/min? |
|
Definition
-stimulation of dopaminergic and beta-agonist receptors produces increased GFR, HR, and contractility
-a-adrenergic effects predominate, resulting in peripheral vasoconstriction |
|
|
Term
| What is the first line drug for cardiogenic shock? |
|
Definition
dobutamine.
-doses up to 20 ug/kg/min increases cardiac output, decreases peripheral vascular resistance, decreases pulm. occlusive pressure |
|
|
Term
| What else might be a part of the tx regimine of cardiogenic shock in the face of an acute MI? |
|
Definition
diuretic
thrombolytics
morphine
nitroglycerin
antiarrhythmics
antiplatelet agents |
|
|
Term
| What might distributive shock require? |
|
Definition
| peripheral vasoconstrictors (epinepherine or norepinepherine) |
|
|
Term
| What is avoided in neurogenic shock because of potential for reflex bradycardia? |
|
Definition
|
|
Term
| What is used for the tx in distributive shock? How does it work? |
|
Definition
Vasopressin (ADH)
-peripheral vasoconstriction
-decreased heart rate
-hemostasis
-increased serum cholesterol |
|
|
Term
| What is the lethal triad of trauma in shock? |
|
Definition
acidois
hypothermia
coagulopathy |
|
|
Term
| What are your differentials for chest pain? |
|
Definition
cardiac- MI, angitis, pericarditis, aortic stenosis
pulm- pneumonia, pneumothorax, PE
GI- esophagitis, GERD, FB
Vascular- dissection, aneruysm
MSK: costochondritis, rib fx, contusion, strain |
|
|
Term
| What are the RFs for CAD? |
|
Definition
smoking
HTN
diabetes
obesity
family hx
hypercholesterolemia |
|
|
Term
| What is the heart rate for sinus tachycardia? What are posisble underlying causes? |
|
Definition
100-160
fever, hypoxia, anemia, hypovolemia, infection, medications, drugs, hyperthyroid etc |
|
|
Term
| What are the symptoms for A-fib? |
|
Definition
Palpitations
Decreased blood pressure
Weakness
Lightheadedness
Confusion
Shortness of breath
Chest pain |
|
|
Term
| What leads best allow seeing A-fib? |
|
Definition
|
|
Term
| what can sinus tachycardia lead to? |
|
Definition
| V-fib or tachycardia and then death |
|
|
Term
| A-fib gives the risk of what? |
|
Definition
|
|
Term
| At what joules should synchronized cardioversion of A-fib be administered? |
|
Definition
|
|
Term
| A-fib longer than __ hours needs to be heparinized 80 units/kg IV followed by infusion of 18 init/kg/hour before cardioversion |
|
Definition
|
|
Term
| What med is used for A-fib? |
|
Definition
*Diltiazim 20 mg IV over 2 minutes (0.25 mg/kg)
Verapamil IV
Metoprolol IV
Digoxin IV
Amiodarone IV |
|
|
Term
|
Definition
| is ionotropic and makes the heart pump harder |
|
|
Term
| How many BPM is atrial flutter? |
|
Definition
|
|
Term
| In what leads is atrial flutter best seen? |
|
Definition
|
|
Term
| What is the tx for an atrial flutter? |
|
Definition
carotid massage and valsalva
heparin 80 units/kg IV followed by infusion of 18 unit/kg/hour
Diltiazim 20 mg IV over 2 mins
-2nd does at 25 mg in 15 mins
-5-15 mg/hr
Verapamil, metoprolol, digoxin, amiodarone, ibutilide |
|
|
Term
| You DO NOT do a carotid massage on people with risk factors, why? |
|
Definition
|
|
Term
| What is the atrial rate during supraventricular tachycardia? |
|
Definition
100-250
-arises form ectopic pacemaker above bundle of his, impulse re-rentry |
|
|
Term
| How is supraventricular tachycardia managed? |
|
Definition
carotid massage, diving reflex (face in cold water), valsalva
adenosine 6 mg rapid iV, and taper up til works
diltiazim, esmolol, metoprolol, propanolol, digoxin |
|
|
Term
| What do most patients experience when given adenosine? |
|
Definition
| chest pain, flushing anxiety, transient a-fib, a-flutter |
|
|
Term
| With what drugs can toxicity occur when taken with digoxin? |
|
Definition
|
|
Term
| How many BPM is ventricular tachycardia? |
|
Definition
|
|
Term
| If a ventricular tachycardic pt is unstable what do you give them? stable? |
|
Definition
-200-260 joules of unsynchronized cardioversion
-150 mg amiodorone over 10 minutes, lidocaine over 60-90 secs. |
|
|
Term
|
Definition
Unsynchronized defibrillation at 200, again at 200 then 300 then 360 if unsuccessful do CPR, BVM with high flow oxygen, Intubate
epinepherine (1mg IV with 20 ml of salin)
-repeat every 3-5 mins
can use vasopressin once
shock at 360 BPM
Amiodorone every 5 mins
Mg sulfate 2g IV |
|
|
Term
|
Definition
Unsynchronized defibrillation at 200, again at 200 then 300 then 360 if unsuccessful do CPR, BVM with high flow oxygen, Intubate
epinepherine (1mg IV with 20 ml of salin)
-repeat every 3-5 mins
can use vasopressin once
shock at 360 BPM
Amiodorone every 5 mins
Mg sulfate 2g IV |
|
|
Term
| what is meant by synchronized? |
|
Definition
| a-fib, meaning the ventricles are working right, so DONT shock these people |
|
|
Term
| what is meant by unsynchronized? |
|
Definition
| can do any kind of shocking bc want to stop the system and start the rhythm all over again. |
|
|
Term
| What is a general definition of an unstable cardiac pt? |
|
Definition
Cool- bc trying to pump everything back to the core, not the legs and feet
Tachycardic then bradycardic then nocardic
Dizziness- not getting enough blood flow to the brain
Chest pain- usually due to some sort of ischemic effect
Pale
Diaphoretic
tachypnic |
|
|
Term
| Any condition brought on by sudden reduced flow to the heart is called what? |
|
Definition
acute coronary syndrome
-can be chest pain felt during a heart attack to chest pain felt while doing physical activity |
|
|
Term
|
Definition
| when it doesn't stop when you stop (running, walking lalala) |
|
|
Term
| What are the symptoms of acute coronary syndrome? |
|
Definition
Chest pain that feels like burning, pressure or tightness and lasts
several minutes or longer
Pain radiating to the left upper arm or jaw (referred pain)
Nausea/Vomiting
Shortness of breath (dyspnea)
Sudden, heavy sweating (diaphoresis) |
|
|
Term
| What are the atypical symptoms of acute coronary syndrome? |
|
Definition
Abdominal pain/heartburn
Clammy skin
Lightheadedness, dizziness or fainting
Unusual or unexplained fatigue
Feeling restless or apprehensive |
|
|
Term
| Nothing is normal for what kind of pt bc they dont feel pain in normal places that other people would feel pain? |
|
Definition
|
|
Term
| What are some causes of acute coronary syndrome? |
|
Definition
coronary artery dz: develops slowly over time by building up of plaques in heart arteries
atherosclerosis |
|
|
Term
| What are some RFs of acute coronary syndrome? |
|
Definition
Obesity
Older age (older than 45 for men and older than 55 for women)
High blood pressure
High blood cholesterol
Cigarette smoking
Lack of physical activity
Type 2 diabetes
Family history of chest pain, heart disease or stroke
Substance abuse, especially cocaine which is myotoxic, accelerates
atherosclerosis and coronary artery disease. |
|
|
Term
| What are some important tests for acute coronary syndrome? |
|
Definition
CBC (anemia, H&H and pltlt fxn)
CMP (diabetes, renal fxn, electrolytes)
cardiac markers: myoglobin, CK-MB, troponin
-dont send them home unti have 3 serial cardiac marker tests
D-dimer
Pulse oximetry
ABGs
ECG
CXR/CT: pneumonia, pneumothorax, aneurysm |
|
|
Term
| Myoglobin has a rise at ___ and a peak at ____. |
|
Definition
|
|
Term
| CK-MB has a rise at ___ and a peak at ____. |
|
Definition
|
|
Term
| Troponin has a rise at ___ and a peak at ____. |
|
Definition
|
|
Term
| Use a D-dimer to rule out what? |
|
Definition
PE
-it measures degradation products of circulating cross-linked fibrin
-measures if you're clotting or have a clot thats forming in the body |
|
|
Term
|
Definition
Non-ST segment elevation myocardial infarction
ST segment elevated myocardial infarction |
|
|
Term
| What is the tx of ACS or MI? |
|
Definition
M.O.N.A.
Morphine sulfate: 2-10 mg IV given in 2-4 mg increments
Oxygen 10-15 liters
Nitroglycerin 0.4 mg tab sublingual repeated up to 3 times every 3-5
minutes to BP reduction/pain resolution
Aspirin 160-325 mg by mouth (chewed)
AND
Beta Blockers: metoprolol
Heparin
Fibrinolytics: TPA
Glycoprotein IIB/IIIA inhibitors block platelet aggregation.
PCI: Alternative to thrombolytic if performed in less than 90 minutes
ACE inhibitors: All patients with AMI especially with CHF and Systolic BP >100 within 24 hrs.
Clopidogrel: indicated for ASA allergy. Dose: Initial 300 mg p.o. then 75 mg /day |
|
|
Term
| what acute coronary syndrome pts are admitted? |
|
Definition
Any pt with chest pain with abn finding (vital signs, ECG, elevated cardiac enzymes)
Heart/Stroke Center
Serial ECG and Cardiac Enzymes
consider CT chest prior to D/C |
|
|
Term
|
Definition
|
|
Term
| One year mortality after dx ranges bw __-__% (ICES Atlas) |
|
Definition
|
|
Term
| Heart fsilure is the ____ ______ diagnosis that brings a pt to hospital for admission. |
|
Definition
|
|
Term
| Heart failure is the quintessesntial disorder of cardiovascular aging due to age related changes in cardiovascular structure and fxn and the rising prevalence of what 3 things? |
|
Definition
hyprtension
coronary artery dz
valvular heart dz |
|
|
Term
| In an acute infarction, the infarction expands and then what? |
|
Definition
| global remodeling of the heart |
|
|
Term
| In diastolic and systolic heart failures, the normal heart hypertrophies in ________ _____ _______ and then dilates in ________ _____ _______. |
|
Definition
diastolic heart failure
systolic heart failure. |
|
|
Term
| What are the FACES symptoms of heart failure? |
|
Definition
Fatigue
Activity decrease
Cough (especially supine)
Edema
Shortness of breath |
|
|
Term
| What is the DIET approach to the patient with heart failure? |
|
Definition
Diagnose (etiology and severity of LV dysfxn)
Initiate (diuretics/ACE inhibitors, beta blockers, spirolactone, digoxin)
Educate (diet, exercise, lifestyle, CV risk)
Titrate (optimize ACE inhibitor or beta blocker) |
|
|
Term
| What are the S/S of heart failure? |
|
Definition
fatigue (low cardiac output)
SOB
^JVP
Rales
S3
Edema
Radiologic congestion
Cardiomegaly |
|
|
Term
| Why should a CXR be obtained when diagnosing heart failure? |
|
Definition
| to r/o interstitial lund dz and PPH |
|
|
Term
| There are 3 natriuretic peptides to be assessed in the dx of HF, what is the role of ANP? |
|
Definition
| produced in the atria in response to wall stress |
|
|
Term
| ***There are 3 natriuretic peptides to be assessed in the dx of HF, what is the role of BNP? |
|
Definition
| produced in the ventricles in response to volume and pressure overload |
|
|
Term
| There are 3 natriuretic peptides to be assessed in the dx of HF, what is the role of CNP? |
|
Definition
| produced in response to endothelial stress |
|
|
Term
| Natriuretic peptides are produced as prohormones and cleaved to active molecules (____,___) and inactive NT forms. |
|
Definition
|
|
Term
| When are ANP/*BNP elevated? |
|
Definition
heart failure
systemic pulmonary HTN
Hypertrophic and restrictive cardiomyopathy
pulmonary embolism
COPD
cor pulmonale
AMI Cirrhosis
renal failure |
|
|
Term
| What do higher levels of BNP coordinate with? |
|
Definition
higher PCW pressures (in compensated and decompensated pts)
larger LV volumes
lower ejection fractions (in symptomatic HF pts) |
|
|
Term
| With ejection fractions (how much is actually squirting out of the left ventricle when it contracts), what is normal? symptomatic? |
|
Definition
|
|
Term
| BNP has a sensitivity of ___ and a specificity of ___ |
|
Definition
|
|
Term
| BNP > 400 pg/L is indicative of what? |
|
Definition
|
|
Term
| BNP 100-400 pg/L is diagnostic of what? what should be ruled out/ |
|
Definition
CHF likely
r/o pulmonary embolism ,LV dysfxn without acute CHF or cor pulmonale |
|
|
Term
| BNP <100 pg/L means what? |
|
Definition
| 98% NEGATIVE predictive accuracy |
|
|
Term
| When heart failure is acute what are some identifying triggers? |
|
Definition
ischemia
arrhythmia
infection
pulmonary embolism
acute valvular pathology |
|
|
Term
| What are some identifying triggers of chronic CHF? |
|
Definition
anemia
thyrotoxicosis
non-compliance
diet
NSAIDs |
|
|
Term
| In what 3 ways can you evaluate LV fxn? |
|
Definition
clinically
echocardiogram
gated study |
|
|
Term
LV ejection fraction (LVEF) obtained via echo or LV gated study:
-LVEF< 40% is indicative of what?
-LVEF 40-55% is indicative of what?
-LVEF >55% is indicative of what? |
|
Definition
systolic dysfxn
mixed systolic and diastolic dysfxn
diastolic dysfxn |
|
|
Term
| When diastolic dysfxn is identified, what should be done? |
|
Definition
identify triggers
treat underlying disorder (HPT, ischemia, pericardial constriction, restrictive CM, infiltrative disorders) |
|
|
Term
An echocardiogram checks ________.
An EKG checks ________.
A PCI checks __________. |
|
Definition
valvular fxn
electrical impulses
little camera in the arteries, looking at the heart from the outside. |
|
|
Term
| Diastolic dysfxn gives right sided heart failure and causes what symptom? What does systolic dysfxn cause? |
|
Definition
SOB or dyspnea on exertion
fatigue |
|
|
Term
| What is the LVEF (left ventricular ejection fraction) with LV dysfxn at Grades 1-4? |
|
Definition
1: >50%
2: 35-49%
3: 20-34%
4: <20% |
|
|
Term
| What are some possible etiologies of LVHF? |
|
Definition
Ischemic (Cardiomyopathy, CM)
HPT-CM
Valvular HD-CM (AS/AR/MR)
Metabolic (thyroid, hemochromatosis, pheophromocytoma)
Toxins
Idiopathic dilated CM |
|
|
Term
| what kind of toxins can cause LVHF? |
|
Definition
| anthracyclines, Etoh, cocaine, amphetamines |
|
|
Term
| What are some general measures to consider taking when treating heart failure? |
|
Definition
consider triggers and precipitants of acute and chronic HF
low sodium diet
fluid restriction
regular exercise
activity
HR Rx
treat ischemia
control HTN
d/c smoking
treat lipid abns
treat and control diabetes
identify and Rx depression |
|
|
Term
| What is the therapeutic goal of mild/moderate heart failure? |
|
Definition
reduce mortality
-beta blockers + ACE inhibitors
-prevent progression to symptoms
-prevent progressive LV symptoms |
|
|
Term
| What is the therapeutic goal of moderate-severe heart failure? |
|
Definition
Reduce symptoms:
-improve quality of life (QOL)
-reduce hospitalizations
-prevent sudden death |
|
|
Term
| For symptomatic therapy what two modes of medication are used? |
|
Definition
|
|
Term
| with diuretics an ideal body weight needs to be maintained, how do you calculate this body weight? |
|
Definition
| dry weight = JVP normal/trace pedal edema |
|
|
Term
| A diuretic that is used is furosemide, what is the dosage and what can be used if there is refractory congestion? |
|
Definition
20-80 mg OD-BID
HCT/Zaroxolyn can be used for refractory congestion |
|
|
Term
|
Definition
for persisting symptoms in dydtolic dysfxn
or for symptoms and rate control in Afib |
|
|
Term
| What is the dose on digoxin? |
|
Definition
0.125 mg-0.25 mg
lower dose in elderly: 0.0635 mg |
|
|
Term
| Digoxin proved to not have an effect on overalll CHF survival, but what did it have an effect on? |
|
Definition
reduced worsening heart failure deaths
reduced worsening heart failure hospitalizations |
|
|
Term
| What are the cornerstone of Rx in CHF? |
|
Definition
|
|
Term
| Basically, with an EF below __%, pt is on ACE inhibitors. |
|
Definition
|
|
Term
| kidney dysfxn + cardiac dysfxn = _____. |
|
Definition
|
|
Term
| What is the optimal dosing of ACE inhibitors (in general) ? |
|
Definition
| start low and titrate to the target does used in the clinical trials aka the maximum tolerated dose |
|
|
Term
| What is the dosage for catopril? |
|
Definition
| 6.25-12.5mg -->50 mg BID-TID |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What is the most important progress in heart failure Rx in the last 5 years? |
|
Definition
|
|
Term
With beta blockers, you titrate to the target dose:
What is the target dose for bisoprolol?
carvedilol?
metoprolol? |
|
Definition
1.25-10 mg OD
3.125 -25 mg BID
12.5-50 to 75 mg BID |
|
|
Term
| What should the pt do if they cannot maintain the high dose beta blocker? |
|
Definition
maintain highest tolerated dose
continue indefinitely |
|
|
Term
| What requirements must a pt meet before starting beta-blockers? |
|
Definition
stable background on heart failure meds
no recent CV hospitalization
Stable CV status (no hypotension or bradycardia)
euvolemic status
start low and titrate slowly |
|
|
Term
| What are the contraindications to starting a HF pt on beta blockers? |
|
Definition
bronchospastic pulmonary dz
severe bradycardia, high degree AV block, sick sinus syndrome
asthmatics can only be on cardioselective beta blockers |
|
|
Term
| What considerations for a HF pt must be made pertaining to HF before starting them on beta blockers? |
|
Definition
congestive symptoms at rest
pts requiring IV therapy for HF
unstable symptoms
recent change sin background meds
hospitalized pts (esp if HF is wosening) |
|
|
Term
| What is cardiac resynchronization therapy? |
|
Definition
atrial-biventricular stimulatin
electrical synchronization--> narrower QRS
Mechanical synchronization--> reverse remodeling |
|
|
Term
| What does RAFT stand for? |
|
Definition
| Resynchronization/defibrillation for Advanced heart Failure Trial |
|
|
Term
| What are some heart failure management issues? |
|
Definition
high mortality
high re-admisison rates
poor understanding of dz
poor rx adherence
on-giong symptoms
reduced quality of life
dose adjustments in the elderly |
|
|
Term
| Why don't some pts adhere to their HF therapy? |
|
Definition
cost of meds
complacency (pt and physician)
side effects
lack of understanding
infrequent monitoring intervals
lack of reinforcement
lack of feedback |
|
|
Term
|
Definition
|
|
Term
| What is the pathogenesis of an aortic dissection? |
|
Definition
1.Intramural hemorrhage due to rupture of vasa vasorum in a defective media
2. intimal tear as primary event
-dissecting hematoma within media |
|
|
Term
| What are the RFs of an aortic dissection? |
|
Definition
Cystic medial necrosis
-not always present
-also present tin pts without dissection
Aortic dissection associated with CT diseases
-Marfans, Ehlers-Danlos
-aortic dilation (thoracic or abdominal)
Aortic dissection associated with bicuspid aortic valve, aortic coarctation, turner syndrome.
HTN (present in 70-90% of dissections) |
|
|
Term
| The dx of aortic dissection requires a clinical evaluation, including what? |
|
Definition
msk and skin examination
detailed medical and family hx
EKG and echocardiogram, looking for cardiovascular involvement
Eye examination to assess for lens dislocation |
|
|
Term
| In marfann syndrome, the CT is weak and cannot withstand normal tension on the aorta, so how should these pt be managed? |
|
Definition
avoid strenuous exercise that increases BP
Meds to lower BP: beta blockers, verapamil, other calcium blockers or ACE inhibitors that lower BP
Replace aortic root/valve when aortic diameter >6.0 without AR, or >5.0 with 3+AR |
|
|
Term
| What is the etiologic mechanism of an aortic dissection in marfans? |
|
Definition
intimal tear with secondary extension into media
hemorrhage into media precipitating secondary intimal tear
intramural hematoma
penetrating atherosclerotic ulcer |
|
|
Term
| What is the Debakey classification of aortic dissections? |
|
Definition
1- ascending aorta exteding beyond arch
2- ascending aorta only
3- descending aorta
3b- descending aorta extending below diaphragm |
|
|
Term
| What is the Stanford classification of aortic dissections? |
|
Definition
|
|
Term
| 85-75% of dissections are ascending, with entry wear? |
|
Definition
within a few cms of the aortic valve
-50% extend to iliac bifurcation |
|
|
Term
| 25-35% of dissections occur descending, the false channel begins where? |
|
Definition
distal to L subclavian
-variable extension |
|
|
Term
| What are some complications of an aortic dissection? |
|
Definition
1. rupture through outer wall of false channel
-typically directly across the entry tear
-pericardial tamponad
-mediastinal or pleural rupture
-exsanguination
2. acute aortic regurgitation
-50% of ascending dissections
-medial split undermine support of aortic valve
-may lead to severe CHF
3. Branch Vessel Compromise
-compresion of orifice by intimal flap
-stroke
-paraplegia
-HTN-renal failure
-visceral ischemia
-MI
4. Aneurysmal Dilation and subsequent rupture |
|
|
Term
| What are some complications of an aortic dissection? |
|
Definition
1. rupture through outer wall of false channel
-typically directly across the entry tear
-pericardial tamponad
-mediastinal or pleural rupture
-exsanguination
2. acute aortic regurgitation
-50% of ascending dissections
-medial split undermine support of aortic valve
-may lead to severe CHF
3. Branch Vessel Compromise
-compresion of orifice by intimal flap
-stroke
-paraplegia
-HTN-renal failure
-visceral ischemia
-MI
4. Aneurysmal Dilation and subsequent rupture |
|
|
Term
| Are aortic dissections more frequent in males or females? |
|
Definition
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|
Term
| Ascending dissections usually happen in what age group, unless pt is what? |
|
Definition
50-55
marfan, pregnant, AV dz (if they're under 40 and have one, better start thinking about another funky dz) |
|
|
Term
| Descending dissections usually happen in what age group? |
|
Definition
|
|
Term
| What are the clinical features of an aortic dissection? |
|
Definition
1. sudden onset severe pain
-never experienced before, restless, sense of doom
-ripping, tearing, migratpry
2. look for underlying CT disorder
3. HTN or known aortic aneurysm
4. syncope
5. stroke, carotid artery
6. paraparesis, paraplegia, spinal artery
7. Horner Syndrome. |
|
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Term
| Physical examination will reveal what? |
|
Definition
HTN (catecholamines, renal ischemia)
hypotension (acute complication)
aortic insuffiiency
pulse deficits (acute leg ischemia, negative embolectomy)
sternoclavicular joint pulsation
high JVP
bruits
abdominal mass |
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|
Term
| The pain from an aortic dissection is usually severe, and is most severe at onset, what does anterior pain mean? posterior pain? |
|
Definition
proximal dissection
distal dissection |
|
|
Term
| If you cannot find a cause for pain (MI, pneumonia, pleurisy, pulmonary embolism, pneumothorax, ulcer, cholecystitis, pancreatitis) then you have to consider what? |
|
Definition
|
|
Term
| How long is an acute aortic dissection? chronic? |
|
Definition
|
|
Term
| What imaging can be used to dz an aortic dissection? |
|
Definition
CXR
transthoracic echocardiogram
transesophageal echocardiogram
computed tomography
MRI
aortography |
|
|
Term
| In a CXR, the signs or a dissection are _______. describe what is seen |
|
Definition
INDIRECT: abn aortic knob, widened mediastinum, pleural effusion
-aorta looks like a shoe
-look at changes with old films
-displaced intimal calcification >5 mm
NORMAL in 18% and should not deter further evaluation |
|
|
Term
| If readily available, what is the first procedure of choice when suspecting a dissection? |
|
Definition
transesophageal echo
highly sensitive and specific
also tells you about aortic regurgitation, pericardial effusion, ostia of coronary arteries, LV fxn |
|
|
Term
| A CT requires what? How accurate is it? |
|
Definition
rapid IV bolus (contrast) and sequential imaging
88-100% accurate |
|
|
Term
| What are the limitations of a CT? |
|
Definition
no evaluation of aortic regurgitation
Limited information on branch vessels
“streak artefacts” may cause false (+)
(Bone-air interface may simulate flap)
False (-) from poor bolus of contrast
*USEFUL FOR FOLLOW UP OF DISSECTIONS |
|
|
Term
| If readily available, an MRI is a good alternative to a TEE or CT. What are the limitations? |
|
Definition
requires pt to be in claustrophobic apparatus without standard ECG monitoring
useful for follow up |
|
|
Term
| What can an aortography identify? |
|
Definition
intimal flap, true and false lumen
thickened wall (thrombosed false lumen
aortic insufficiency, branch vessel involvement |
|
|
Term
| Is less accurate than an TEE, CT or MRI bc why? |
|
Definition
5-10% false negative rate
-misses intramural hematomas
Also there is a time delay
Not necessary in acute ascending dissections |
|
|
Term
| How is a dissection treated? |
|
Definition
ICU admission
immediate cardiothoracic surgical consultation
close observation of BP, urine output, neurologic status
prompt BP control is critical
-decrease BP and LV contractility with sodium nitroprusside and a beta blocker |
|
|
Term
| What are some indications that a dissection pt needs surgery? |
|
Definition
all pts really
hypotension or ascending dissection: emergency surgery
descending dissections if acute and have no other comorbidities |
|
|
Term
| What are some indications that a dissection pt needs surgery? |
|
Definition
all pts really
hypotension or ascending dissection: emergency surgery
descending dissections if acute and have no other comorbidities |
|
|
Term
| What are the goals of surgery? (aortic dissectin) |
|
Definition
excise the intimal tear
obliterate entry into false lumen proximally and distally
reconstitute the aorta (Dacron graft) |
|
|
Term
| What are some indications of surgical therapy after 'resolution' of aortic dissection |
|
Definition
hemorrhage or rupture
end-organ ischemia
continued pain
rapid extension of diameter (>5mm in 6 mos)
uncontrolled HTN |
|
|
Term
| What are the leading causes of death in an aortic dissection? |
|
Definition
| aneurysmal dilation and rupture |
|
|
Term
| What is the purpose of an ABG? |
|
Definition
assess degree to which the lungs are able to provide adequate oxygen and remove CO2
and degree to which the kidneys are able to reabsorb or excrete HCO3 |
|
|
Term
What is a normal pH?
paCO2?
paO2?
HCO3? |
|
Definition
7.35-7.45
35-45 mmHg
80-100 mmHg
22-26 mEq/l |
|
|
Term
| paCO2 is the _______ component, and an abnormality here will represent a subsequent problem here. |
|
Definition
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|
Term
A high paCO2 indicates ________.
A low paCO2 indicates _______. |
|
Definition
|
|
Term
| Lungs will decrease or increase ventilation to remove the appropriate amt of CO2, how quickly does this occur? |
|
Definition
| lung compensation begins quickly |
|
|
Term
| An abnormality in the HCO3 indicates what? |
|
Definition
|
|
Term
A low HCO3 indicates _______.
A high HCO3 indicates _________. |
|
Definition
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|
Term
| The kidneys excrete ________ and retain _________ to help maintain pH. How quickly does this occur? |
|
Definition
hydrogen (acid)
bicarbonate (base)
renal compensation is slow |
|
|
Term
| When does acidosis occur? |
|
Definition
excess accumulation of acid
decreased amt of alkali |
|
|
Term
| When does meatbolic acidosis occur? |
|
Definition
too much acid in body or loss of bicarb
-diarrhea
-diabetic ketoacidosis
-renal failure |
|
|
Term
| Why does a respiratory acidosis occur? |
|
Definition
acid build up due to lungs not elminating CO2
-anything that decreases respiration
-chronic respiratory dz
-CNS depression |
|
|
Term
| When does alkalosis occur? |
|
Definition
excess accumulation of bicarbonate
loss of acid |
|
|
Term
| Why does metabolic alkalosis occur? |
|
Definition
loss of acid or increase in HCO3
-vomiting or NG drainage (loss of hydrogen)
-excessive use of antacids |
|
|
Term
| Why does respiratory alkalosis occur? |
|
Definition
too much CO2 being excreted in the lungs
-hyperventilation |
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