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