ShockDefinition Severe cardiovascular failure caused by poor blood flow or inadequate distribution of flow | 1) Hypovolemic Shock Hemorrhage, fluid loss, loss of plasma or electrolytes. All result in decreased intravascular volume. Caused by obvious loss or subtle third-space sequestration. | 2) Cardiogenic Shock MI, dysrhythmias, heart failure, valve/septal failure, HTN, myocarditis, cardiac contusion, septum rupture, myocardiopathies | 3) Obstructive Shock Tension PTX, pericardial tamponade, obstructive valvular disorder, pulmonary embolism | 4) Distributive Shock (poorly regulated distribution of blood volume) Septic shock, SIRS (signs of systemic inflammation w/out end-organ damage), anaphylaxis, neurogenic shock | Clinical features Hypotension + Tachycardia (also AMS, orthostatic changes, metabolic acidosis, insulin resistance, oliguria/anuria, peripheral hypoperfusion) | Sign of end-organ hypoperfusion Cool or mottle extremities, and weak ("thready") or absent peripheral pulses | Treatment 1) ABCs. 2) Treat the underlying cause. 3) T-Burg maximizes brain perfusion 4) O2 + IV fluids 5) Urine output at least 0.5 mL/kg/hr 6) Cardiac monitoring and central venous pressure 7) Pressors (Dopamine, etc.) will increase GFR, contractility, HR |
ACS (Acute Coronary Syndromes)Definition Spectrum of problems ranging from unstable angina to MI | Classified into 2 types ST-elevated and Non-ST-elevated events | Most common etiology of MI Preexisting atherosclerotic plaque-->thrombus formation-->prolonged myocardial ischemia-->MI | What is a common cause of death in MI patients before they can get to hospital? V-fib | Clinical features **Chest pain (most common), sweating, anxiety, weakness, dyspnea, light-headedness, syncope, N/V, fever | EKG changes Acute MI: progression from peaked T-waves-->ST-degment elevation/depression-->Q-wave-->T-wave inversions (hours-days) | **One of the most sensitive tests to quantify extent of infarction MRI w/ gadolinium | Treatment--all patients IV fluids + O2 + NO + pain management +/- benzo + anti platelet/anticoagulation + B-blockers +/- CCBs | Treatment--ACS + STEMI Reperfusion interention: aspirin + clopidogrel, coronary angiography w/in 90 min, thrombolytic therapy, statin therapy |
| | Orthostasis/Postural HypotensionDefinition >20mmHg drop in systolic pressure between supine and sitting &/or standing measurements | Etiology May be related to reduced cardiac output, paroxysmal cardiac dysrhythmias, low blood volume, medications, and various metabolic and endocrine disorders | A reversible cause of syncope and major cause of falls in this population Elderly | If the cause is depleted blood volume then there will also be a rise in pulse of more than 15 bpm when testing orthostatics | If there is no change in pulse accompanying the change in BP then consider CNS disease or peripheral neuropathies | Labs and Treatment Directed at the specific cause |
Ischemic Heart DiseaseDefinition Characterized by insufficient oxygen supply to cardiac muscle | Etiology 1) **Atherosclerotic narrowing (most common). 2) Constriction of coronary arteries. 3) (Rare) congenital, emboli, arteritis, dissection | Risk Factors Metabolic syndrome, male, older age, smoking, FmHx, HTN, DM, low-estrogen state, abdominal obesity, inactivity, dyslipidemia, EtOH, low fruits/veggies (cocaine-->MI) | Metabolic Syndrome is 3 or more of: abdominal obesity, Tri>150, HDL<40men<50women, fasting sugar>110, HTN | Clinical Features Angina pectoris (chest squeezing/pressure, can radiate, <3min.), three types: | 1) Stable Angina Exacerbated by physical activity, relieved by rest | 2) Prinzmetal's (Variant) Angina Caused by vasospasm at rest, exercise capacity preserved | 3) Unstable Angina Increasing pattern of pain in previously stable patients. Occurs at rest or with exertion. | Levine's Sign Clenched fist over sternums and clenched teeth | How to relieve angina Sublingual nitroglycerin | EKG Findings Horizontal or downsloping ST-segment depression | Treatment Lifestyle changes, NO, nitrates, B-blockers, CCB, Ranolazine, ASA/Clopidigrel, revascularization |
| | CHFDefinition Clinical syndrome: dyspnea + water/sodium retention | Results from changes in 1+ of the following Contractile ability of heart muscle, preload and after load of the ventricle, and heart rate | Etiologies of these changes MI, pericardial disorders, valvular disorders, congenital abnormalities, and non cardiac causes (high-output heart failure from thyrotoxicosis or severe anemia) | CHF adversely affects Left atrial pressure + cardiac output | Clinical features of LEFT-sided failure Exertional dyspnea, non-productive cough, fatigue, orthopnea, PND, basilar rales, gallops, exercise intolerance | Clinical features of RIGHT-sided failure Distended neck veins, hepatic congestion, nausea, dependent pitting edema, *edema + hepatomegaly, (R-sided failure often caused by L-sided failure) | Other symptoms of CHF Nocturia, cold/clammy skin, hypotension, narrow pulse pressure, S3 gallop | CXR signs Kerley B lines (aka interstitial edema) | Treatment 1) Thiazide or Loop diuretic + ACEi. 2) CCB (amlodipine). 3) Anticoagulants or antiarrhythmics 4) Pacers/difibrillators 5) Coronary revascularization/transplant |
EKG LocationsInferior | II, III, aVF | Posterior | V1, V2 | Anteroseptal | V1, V2 | Anterior | V1, V2, V3 | Anterolateral | V4, V5, V6 |
HypertensionPrimary HTN Causes 95% of cases of HTN; multifactorial pathogenesis (genetics, salt, obesity, RAAS, NSAIDs, smoking, lack of exercise, metabolic syndrome) | Secondary HTN coarc. of aorta, RAS, chronic steroids, Cushings syndrome, pregnancy, thyroid and parathyroid disease, primary hyperaldosteronism, parenchymal renal dz) | Essential HTN is exacerbated in this population Males, blacks, sedentary people, smokers | Hypertensive urgency def. Must bring down BP within hours | Hypertensive emergency def. Must bring down BP within 1 hour to prevent end-organ damage/death | Malignant hypertension def. Elevated BP + papilledema + encephalopathy/nephropathy. In untreated-->progressive renal failure. | Complications of untreated HTN Cardiovascular dz, cerebrovascular dz, dementia, renal dz, aortic dissection, and atherosclerotic complications | Diagnostic criteria--essential HTN Systolic >140 OR Diastolic >90 on 3 diff. occasions | Diagnostic criteria--hypertensive urgency Systolic >220 OR Diastolic >125 | Diagnostic criteria--hypertensive emergency Diastolic >130 + papilledema | Complications of hypertensive emergency Hypertensive encephalopathy, nephropathy, intracranial bleeding, aortic dissection, preeclampsia/eclampsia, pulmonary edema, unstable angina, MI | Treatment--HTN 1) DASH diet/lifestyles changes/smoking cessation. 2) Diuretics (*HCTZ). 3) Beta blockers 4) ACEi 5) ARB 6) CCB | Treatment--HTN urgency/emergency Parenteral agents, but don't lower BP too fast. Use NO, B-blockers, hydrazine, loops, clonidine, nifedipine |
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