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1 CV, Vasc/Shock
Step Up to Medicine, Chap 1: Vascular diseases, Shock
| Question | Answer |
|---|---|
| Definition of hypertensive emergency? | systolic BP>220 or diastolic >120 in addition to end organ damage |
| Definition of hypertensive urgency? | systolic BP>220 or diastolic >120 without end organ damage |
| Which end organs can be damaged with HTN emergency? | Eyes (papilledema), CNS (AMS, ICH, enceph), kidneys (renal failure or hematuria), heart (MI, CHF, unstable angina, aortic dissection), and lungs (pulmonary edema) |
| Management for hypertensive urgency? | Lower BP in 24h using oral agents |
| Goal for hypertensive emergency? | Lower MAP by 25% in 1-2h. Reduce BP gradually. |
| Management for severe hypertensive emergency (diastolic >130, enceph)? | IV agents: nitroprusside, labetalol, or nitro |
| Management for less severe hypertensive emergency (diastolic <130, no enceph)? | Oral agents: captopril, clonidine, labetalol, and diazoxide |
| Management for pt presenting with severe HA and very high BP? | 1. Lower BP with antihypertensive 2. Order CT head to rule out ICH 3. If CT is neg, proceed to lumbar puncture |
| Which valvular abnormality puts pts at an increased risk for aortic dissection? | Bicuspid aortic valve |
| Anterior chest pain is MC with which type of aortic dissection? | Type A (proximal). Type B (distal) is more likely to have interscapular back pain. |
| Diagnostic tests of choice in aortic dissection? | TEE and CT. |
| What are the CXR findings in aortic dissection? | Widened mediastinum |
| Tx for aortic dissection? | IV beta blockers, IV nitroprusside. Medical vs surgical management depending on type of dissection. |
| Difference in management between type A and type B aortic dissection? | Type A (proximal): surgery Type B (distal): medical management |
| MC site for AAA? | Between renal aa and iliac bifurcation |
| Classic triad for AAA? Name 2 eponymous signs you might expect to see on physical exam. | Abdominal pain, hypotension, and a palpable pulsatile abdominal mass. Grey-Turner's sign (ecchymoses on back/flanks) and Cullen's sign (periumbilical ecchymoses) |
| Test of choice to dx AAA? | US=100% sens (CT is also 100%, but takes longer so should only be used in hemodynamically stable pts) |
| Tx for unruptured AAA (all ruptured-> surgery)? | Aneurysm >6cm or symptomatic, surgical resection with synthetic graft placement. <6cm, f/u with periodic imaging. |
| What is Leriche's syndrome? | bilateral claudication, impotence |
| MC site of occlusion in PVD? | Superficial femoral artery (in Hunter's canal) |
| Which labs and tests should be ordered when evaluating a pt with PVD? | EKG, CBC, renal f'n, coag profile |
| Aorticoiliac occlusive disease causes claudication in which areas? | Buttocks and hips in add'n to calves. |
| Which type of PVD pain is associated with nightime prominence? | Rest pain (continuous); more concerning for frank ischemia; pts report hanging foot over side of bed relieves pain |
| Define intermittent claudication. | Cramping leg pain that is reliably reproduced by the SAME walking distance. Pain is COMPLETELY relieved by rest. |
| Dx test for PVD? | Arteriography is gold std, but is only req'd if surgery (revasc) is being considered |
| Why might ABI not be the best test in diabetic pts for diagnosing PVD? | Pts with calcified aa, esp those with DM, have false ABI readings b/c vessels are not compressible |
| Which ABI numbers indicate intermittent claudication vs rest pain? | ABI <0.7= intermittent claudication. ABI <0.4. |
| How does Trental (pentoxifylline) help with PVD pain? | Makes blood less viscous which improves blood flow. More studies needed, though. |
| MC site for acute arterial occlusion? | Femoral a. |
| 6 Ps of acute arterial occlusion presentation? | Pain (acute onset, severe), Pallor, Polar (cold), Paralysis, Parasthesias, Pulselessness (use Doppler to assess pulses) |
| Tx for acute arterial occlusion? | Anticoagulate with IV heparin. Emergent surgical embolectomy via cutdown and Fogarty balloon. Bypass if above fails. |
| 3 MC sources of cholesterol emboli "showers?" | Abdominal aorta, iliacs, and femoral aa |
| What usually triggers cholesterol embolization syndrome? | Surgical or radiographic intervention (arteriogram) or thromboyltic therapy |
| Tx for cholesterol embolization syndrome? Which tx should NOT be given? | Supportive (control BP). Amputation or surgery only in extreme cases. Do NOT anticoagulate! |
| An aneurysm resulting from damage to aortic wall 2/2 infection. | Mycotic aneurysm; tx with IV abx and surgical excision |
| What is leutic heart? | Complication of syphilitc aortitis; aneurysmo f aortic arch with retrograde extension causing aortic regurg and stenosis (usually of coronary aa) |
| Tx for leutic heart? | IV penicillin and surgical repair |
| Dx study of choice for DVT? | Doppler analysis with Duplex US |
| Use of D-dimer testing in DVT? | Very high sens (95%) but low spec (50%). Can be used to r/o DVT when combined with doppler and clinical suspicion |
| Management for intermed-high pretest probability of DVT? | + doppler: begin anticoag. - doppler: repeat US q2-3d x 2 weeks. |
| Management for low to intermediate pretest prob of DVT? | + doppler: observation; no anticoag needed. Repeat US in 2 days. |
| DVT is a major risk factor for developing which venous disease? | Chronic venous insufficiency (CVI)/Post-phlebitic syndrome |
| Tx for chronic venous insufficiency ulcers that don't heal with Unna boot? | Apply split-thickness skin grafts w/ or w/out ligation of adjacent perforator vv. |
| Superficial thrombophlebitis that occurs in different sites over a short period of time? | Migratory superficial thrombophlebitis (2/2 occult malignancy, usually of pancreas) |
| Where does superficial thrombophlebitis of the upper extremities usually occur? | At site of an IV infusion |
| What is lower extremity superficial thrombophlebitis usually associated with? | Varicose vv (in the greater saphenous system) |
| Tx of uncomplicated supf thrombophlebitis? | Mild analgesic (aspirin) with normal activity. If severe pain and cellulitis, bed rest, elevation, and hot compresses. |
| Tx for septic phlebitis? | Usually due to infection of an IV cannula. Remove cannula and start systemic abx. |
| Hypotension, oliguria, tachycardia, and AMS. | s/s of shock (common to all types) |
| Shock profile (effects on CO, SVR, PCWP): cardiogenic | CO dec, SVR inc, PCWP inc |
| Shock profile (effects on CO, SVR, PCWP): hypovolemic | CO dec, SVR inc, PCWP dec |
| Shock profile (effects on CO, SVR, PCWP): neurogenic | CO dec, SVR dec, PCWP dec |
| Shock profile (effects on CO, SVR, PCWP): septic | CO INC, SVR dec, PCWP dec |
| Which type of shock is suggested?: fever and site of infection | Septic |
| Which type of shock is suggested?: trauma, GI bleed, vomiting, diarrhea | Hypovolemic |
| Which type of shock is suggested?: h/o MI, angina, or heart disease. Or JVD present | Cardiogenic |
| Which lines to put in pt in shock? | 2 large bore venous catheters, central line, and an arterial line |
| Labs and tests for pt in shock? | CBC, electroyltes, renal f'n, PT/PTT, EKG, CXR |
| How to stabilize BP in pt in shock? | Give fluid bolus (500-1000ml of NS or lactated Ringer's sol'n). If remain hypotensive, give vasporessors (dopamine or norepi) |
| General tx for ALL shock pts? | Manage the ABCs: airway, breathing, and circulation |
| Jugular venous pulse/PCWP is only elevated in which type of shock? | Cardiogenic shock |
| Definition of cardiogenic shock? | Systolic BP <90 with urine output <20ml/hr and adequate LV filling pressure |
| Vasopressor of choice in cardiogenic shock? | Dopamine |
| Why are nitroprusside and nitroglycerin generally not used to treat cardiogenic shock? | May worsen hypotension |
| IV fluids are likely to be harmful in which situation in cardiogenic shock? | If LV pressures are elevated |
| Use of which device in cardiogenic shock has been shown to decrease afterload, increase CO, and decrease myocardial oxygen demand? | Intra-aortic balloon pump (IABP). Works opposite of heart to pump during diastole and relax during systole. |
| Most useful indicator of effectiveness of treatment in hypovolemic shock? | Urine output |
| Difference in skin presentation in septic vs hypovolemic shock? | Septic: flushing, warm skin (severe peripheral vasodilation; just think of fever) Hypovolemic: cool skin (periperhal vasoconstriction) |
| Hypothermia is more likely to be seen in septic shock in which pt populations? | Very young, elderly, debilitated, or immunocompromised |
| MCC death in ICU? | Septic shock |
| Vasopressor of choice in septic shock? | Dopamine |
| Define SIRS. | 1. Fever (>38) or hypothermia (<36) 2. Hyperventilation (RR>20) or PaCO2 <32 3. Tachycardia (>90bpm) 4. Increased WBC ct (>12,000 or >10% bands) |
| What causes neurogenic shock? | Sympathetic denervation (failure of sympathetic nervous system to maintain adequate vascular tone) |
| Mainstay of tx in neurogenic shock? | Judicious use of fluids. Vasoconstrictors may be used with caution. |
| Which is MC: primary tumors in or mets to heart? | Mets |
| Name 6 sites of primary tumors that met to the heart. | Lung, breast, skin, kidney, lymphomas, and Kaposi's in MSM w/AIDS. |
| Benign gelatinous growth that is usually pendunculated and arises from interatrial septum of heart in the fossa ovalis. | Atrial myxoma |
| MC primary tumor of heart. | Atrial myxoma |
| Pt presenting with fever, fatigue, syncope, palpitations, malaise, and a low-pitched diastolic murmur that changes character with changing body positions ("diastolic plop"). Dx? | Atrial myxoma |
| Tx for atrial myxoma? | Surgical excision |
Created by:
sarah3148
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