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1 CV, Vasc/Shock

Step Up to Medicine, Chap 1: Vascular diseases, Shock

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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