1
Q
Dosing of Diltiazem
A
- 0.25 mg/kg over 2 min, may repeat at 0.35 mg/kg
- infusion at 5-15 mg/h (increase by 5 mg/h)
- 5 mg/h drip = 60 mg PO Q6h
- 10 mg/h drip = 90 mg PO Q6h
- 15 mg/h drip = 120 mg PO Q6h
- DC IV drip 2-3 h after oral dose given
2
Q
Verapamil Dosing
A
- 2.5-5 mg IV over 2 min
- if no response after 15 min give 5-10 mg
- max total dose 30 mg
3
Q
IV Digoxin Load (AF)
A
- 8 to 12 mcg/kg total loading dose, give 50% IV over 5 min, then 25% of dose x 2 at 4-8hr intervals
- i.e. 0.25 mg IV then 0.125 mg IV Q8h x 2 then check levels
4
Q
Dopamine
A
- a1, b1, b2
- increases SVR, HR, BP, CO
- more beta at lower doses (5-10 mcgs/kg/min)
- more alpha at higher doses (>15 mcgs/kg/min)
- 2-20 mcgs/kg/min
5
Q
Epineprhine (pressor)
A
- nonselective alpha + beta agonist
- 0.1 - 2 mcg/kg/min (7-140 mcg/min)
6
Q
Norepinephrine
A
- a1, b1 agonist
- 0.1-2 mcg/kg/min (7-140 mcg/min)
7
Q
Phenylephrine
A
- pure alpha-1 agonist
- may cause reflex bradycardia
- 100 mcg - 500 mcg bolus Q 10-15 min or
- infusion 50-200 mcg/min
8
Q
Dobutamine
A
- synthetic dopamine analog
- B1>B2>alpha
- increased HR + contractility, neutral on BP
- 2 mcg/kg/min-40 mcg/kg/min (max 20 mcg/kg/min in septic shock)
- avoid in AF, aortic stenosis
9
Q
Milrinone
A
- inotrope with vasodilator properties (inodilator)
- increased CO, decreased SVR
10
Q
Dose of Bicarb in Arrest
A
1-1.5 mEq/kg IV, repeat at 50% dose in 10-15 min PRN
11
Q
Pulsus Paradoxus
A
- exaggeration of normal physiology
- stroke volume decreases during inspiration because of RV filling and pushing on LV to make it smaller
- exaggerated when pericardium is constrained (e.g. pericarditis, tamponade, hyperinflation of asthma)
- > 10 mm Hg difference in SBP between inspiration and expiration is +ve
12
Q
Normal 2-point discrimination on fingerpads
A
< 6 mm
13
Q
DDx for short QTc
A
- hypercalcemia
- digoxin toxicity
- congenital short QT
14
Q
DDx for ST elevation
A
- AMI
- Vasospasm
- Early Repolarization
- Myo/pericarditis
- Ventricular aneurysm
- LVH/high voltage
- LBBB/Pacemaker
- PE
- HyperK
- Brugada
- Hypothermia
- Post-cardioversion
- Tako tsubo
- Intracranial abnormalities
- Spiked Helmet Sign
- Hypercalcemia
15
Q
Bacteria from dog bites responsible for life-threatening infections in immunocompromised patients.
A
- Capnocytophaga canimorsus
- slow-growing GNR
- dogs, cats
- responds to Augmentin
16
Q
Cat-scratch Disease
A
- bartonella henselae
- low-grade fever
- painful, fluctuant LAN
- sometimes multi-organ involvement
- usually resolved spontaneously 2-5 months
- Z-pack for painful LAN
- Cipro for immunocompromised
- may aspirate lymph nodes for relief but do not I&D (scarring, fistula formation)
17
Q
UHF Bolus + Infusion Dose
A
- 60 units/kg bolus (max 4, 000 units)
- infusion 12 units/kg/h (max 1, 000 units/h)
18
Q
Blood supply to cardiac conduction system
A
- LAD (septal perforating branch)
- RCA (AV branch)
19
Q
Dose of Plavix ACS
A
- NSTEMI/Fibrinolysis STEMI
- Age < 75: 300 mg then 75 mg daily
- Age >= 75: 75 mg daily
- STEMI for PCI
- 600 mg (all ages)
20
Q
When to give second antiplatelet agent in ACS
A
- 2/3 CCS criteria
- ST changes
- +ve biomarkers
- any of
- age >60
- DM
- hx CV disease
- 2 or 3 vessel CAD
- CrCl < 60
21
Q
Plavix vs. Ticagrelor in ACS
A
- OAC/NOAC, Afib, Hx ICH, 2nd/3rd deg AVB?
- Plavix
- None of above?
- Ticagrelor 180 mg then 90 mg BID
22
Q
Doses of Fonda, Enox for ACS
A
- Fondaparinux - 2.5 mg subcut
- Enoxaparin - 1 mg/kg subcut
- use UFH if eGFR < 30
23
Q
Pulmonary Hypertension (Read Through)
A
- Definition: mean pulmonary arterial pressure >25 mm Hg at rest or >30 mm Hg on exertion
- Not from left heart failure: PCWP < 15 mm Hg
- From left heart failure: PCWP > 15 mm Hg
- Categories
- Group 1: Pulmonary Arterial
- idiopathic, generic, drug/toxin, HIV, liver disease
- Group 2: Pulmonary Venous (Left Heart Disease)
- most common
- systolic or diastolic dysfunction
- mitral or aortic valve disease
- Group 3: Chronic Hypoxemic Lung Disease
- COPD, ILD (IPF), OSA, chronic high altitude
- Group 4: Embolic Disease
- Group 5: Misc
- lymphatic obstruction, myeloproliferative, sarcoidosis, metabolic disorders
- Group 1: Pulmonary Arterial
- Normal Pulmonary Arterial Pressures
- Systolic Pressure: 15-30 mm Hg
- Diastolic Pressure: 4-12 mm Hg
- Signs/Symptoms
- early: dyspnea, syncope, anorexia
- late: R side heart failure
- RCA ischemia (RCA perfusion depends on Aorto-pulmonary artery gradient)
- RAD, RVH, RBBB
- Treatment
- careful with PPV/intubation and fluids
- Dobutamine 2-10 mcgs/kg/min (higher may cause low BP)
- Milrinone 0.375-0.75 mcgs/kg/min (higher may cause low BP)
- Norepi 0.05 mcgs/kg/min for RCA perfusion
24
Q
Grading of Heart Murmurs
A
- 1 - Faint, may not be heard in all positions
- 2 - Quiet, but heard immediately with stethoscope placed on chest wall
- 3 - moderately loud
- 4 - loud
- 5 - Heard with stethoscope partially off chest wall
- 6 - Heard with stethoscope completely off chest wall
25
Mitral Stenosis
* RHD most common cause
* nonrheumatic mitral annular calcification, slow progression, common in elderly
* SOBOE, LAE, orthopnea, PAC's, Afib, pulmonary HTN, hemoptysis
* mid-diastolic rumble at apex
26
Mitral Regurg
* acute: dyspnea, flash CHF, harsh apical systolic murmur loudest in early/mid systole
* nitro (improves forward flow), BiPap, sx
* chronic: MVP or old age, high-pitched holosystolic murmur radiating to axilla, S3, Afib, LAE, LVH
* MVP: mid-systolic click, can occur with or without regurg, refer for echo/cards
27
Aortic Stenosis
* dyspnea + CP + syncope
* usually from HTN, calcification, smoking, bicuspid aortic valve
* late peaking systolic murmur RSB 2nd ICS rad to carotids, carotid pulsus parvus et tardus, narrowed pulse pressure, brachioradial delay, LVH
* caution with nitro, BB, may need to cardiovert afib as ++ preload dependent
* if symptomatic, admit (40-50% mortality within 1 year)
28
Aortic Regurg
* chronic: (with ao stenosis, RHD, IE, bicuspid Ao valve)
* SOBOE, ischemic CP
* acute: AAD, aortitis
* high-pitched, blowing diastolic murmur LSB 2nd ICS, waterhammer pulse
* de Musset sign: pulsatile head bobbing
* LVH
* avoid BB (need tachycardia to compensate)
29
Tricuspid Valve Disease
* common in normal people
* severe, acute in IE
* regurg: soft, blowing, holosystolic @ LLSB, increases with inspiration
* stenosis: crescendo-decrescendo diastolic rumble @ LLSB, increases with inspiration
30
Pulmonic Valve Disease
* mostly congenital
* stenosis: harsh systolic murmur LUSB
* regurg: high-pitched blowing diastolic murmur LUSB
31
Murmur of HOCM
* LLSB or apical systolic murmur
* louder with decreased LV filling or stronger LV contractions
* straining on Valsalva, standing
* quieter with increased LV filling
* squatting, passive leg raise, hand grip
32
Paradoxical Embolism Syndrome
* 20% patients have PFO
* PE embolizes through PFO causing TIA/myelopathies/shower emboli type symptoms
33
Enoxaparin Dose VTE Tx
* 1 mg/kg SC Q12h
* or
* 1.5 mg/kg SC daily
* Actual body weight, eGFR \>30
34
Rivaroxaban (Xarelto) VTE Tx Dose
* 15 mg BID for 21 days then 20 mg daily with food
35
Superficial vs. Deep Veins (Upper + Lower Extremity)
* **superficial veins**
* greater + short saphenous veins, perforating veins; cephalic, basilic
* **deep veins**
* calf (distal DVT): anterior tibial, posterior tibial, peroneal veins
* popliteal vein --\>femoral (superficial femoral) vein --\> joins with deep femoral to make common femoral --\> iliac vein
* axillary vein
36
Superficial Venous Thrombophlebitis Treatment
* NSAIDS, heat, 30-40 mm Hg compression stockings
* repeat US in 2-5 d
* if progressing, anticoagulate x 10 d and repeat US
* If risk factors or \> 7 cm, upper half of thigh, may anticoagulate right away.
37
Calf DVT Treatment
* ECASA 325 mg daily ---\> repeat US in 2-5 days
* **anticoagulate if:**
* all 3 deep veins involved
* clot close to popliteal vein
* severe symptoms
* clot \> 5 cm
previous VTE
* +ve Ddimer
* progression of clot on repeat imaging
38
Massive PE
(definition, indications for thrombolysis, contraindications, dosing)
* SBP \< 90 mm Hg x 15 min, SBP \< 100 mm Hg with Hx HTN, or 40% reduction in baseline BP
* **best evidence for fibrinolysis is for PE +**
* cardiac arrest
* hypotension
* hypoxemia \<90% on max O2 + increased WOB
* evidence of R heart strain on echo, elevated Trop, or both
* **major contraindications to thrombolysis**
* intracranial disease
* uncontrolled HTN at presentation
* recent major surgery/trauma (3 weeks)
* if trauma from syncope from PE, CT Head to r/o bleed before thrombolysis
* metastatic cancer
**Alteplase:** 15 mg IV bolus, then 85 mg over 2h, after complete start UFH 80 u/kg bolus + 18 u/kg/h, goal apTT\<120s
39
Submassive PE
Definition
* PE with evidence of R heart strain, elevated Trop or BNP
* consider thrombolysis if young, consult with cards first
40
DVT Dx Algorithm
See Evernote DVT/PE
41
BP Targets for Hypertensive Emergencies
* **AAD:** SBP 100-120, HR \<60
* **APE:** 20% reduction
* **AMI:** 20% reduction
* **AKI:** 20% reduction
* **Hypertensive encephalopathy:** 20% reduction
* **SAH/ICH:** SBP 120-160
* **Ischemic CVA, tPA candidate:** tx if BP \>180/110 on 3 separate readings target SBP 140-150
* **Ischemic CVA, non-tPA candidate:** tx if BP \>220/120 on 3rd of 3 measurements, 15 min apart, tx to 10-15% reduction in first 24h
42
Stanford and DeBakey Classifications of AAD
**Stanford**
* Type A — Involves ascending aorta. Can extend distally ad infinitum. Surgery usually indicated.
* Type B — Involves aorta beyond left subclavian artery only. Often managed medically with BP control.
**DeBakey**
* 1 – entire aorta affected
* 2 – confined to the ascending aorta
* 3 – descending aorta affected distal to subclavian artery
43
ABI
* \<0.9 is abnormal
* \<0.5 critical limb ischemia likely
* \>1.3 calcified vessel, unreliable
44
AAA size
* Dx: AA \>= 3 cm
* Sx: \>= 5 cm
45
Signs of agranulocytosis on tapazole
Fever, sore throat
46
Light's Criteria
* does not apply to patients with CHF treated with diuretics
* effusion is exudative if one of the following present:
* pleural/serum fluid protein ratio \>0.5
* pleural/serum fluid LDH ratio \>0.6
* pleural fluid LDH level \>2/3 upper limit of normal for serum LDH
47
CAP vs. HAP vs. HCAP vs. VAP
* CAP: \> 2 wks since hospitalization
* HAP: \>48h since admission
* VAP: \>48h since intubation
* HCAP:
* hospitalized 2 or more days within past 90 days
* LTC
* Home IV Abx
* Chronic Wound Care
* Dialysis, chemo, immunocompromise
48
Pertussis
* bordetella pertussis
* treat with z-pack
* only really effective in 1st week
49
Atypical Pneumonia
* h. influenzae
* moraxella catarrhalis
* legionella
* lack a cell wall, respond to quinolones and macrolides
50
Bells Palsy Treatment
* prednisone 60-80 mg PO daily x 7 d
* valtrex 1 g TID x 7 d
51
Causes of Mono Syndrome
* HHV 4 (EBV)
* CMV
* HHV 6
* Toxoplasma
52
Infectious Mononucleosis Clinical Signs
Infectivity
* Fever
* Exudative pharyngotonsillitis
* Lymphadenopathy (usually posterior chain)
* Fatigue
* Older = more symptomatic
* Infects B Cells. Mostly college-high school kids through kissing. Incubation can be as long as 4-6 weeks. Pharyngeal excretion can persist for \>1yr.
* 95% young adults have abnormal LFTs, 4% have jaundice. Hepatosplenomegaly common (50%).
* Resolves 1-3 weeks. Malaise and fatigue rarely for months. Splenic rupture rare (~1/1000) but consider if LUQ + decreasing Hct
Often morbilliform rash if treated with Pen/Amoxil
53
Mono BW
* Lymphocytosis (\>50% total WBC)
* Monospot test (elevation in heterophil antibodies), +ve in 90% (25% false neg in 1st week, 5% week 2, 5% week 3) Very specific, but can persist at low levels for up to 1 year.
* Abnormal lymphocytes on peripheral smear
* if mono picture but -ve monospot & preg
* draw CMV titres and contact obs/gyn
54
PEF in Asthma
* 1h post treatment
* \> 70% mild
* 40-69% moderate, decide clinically
* \< 40% admit
* \<25% intubate, ICU
55
COPD Spirometry Definition and staging
* FEV1/FVC \<0.7
* FEV1 \< 0.8
* mild: FEV1 \> 80%
* moderate: FEV1 50-80%
* severe: FEV1 30-50%
* very severe: FEV1 \< 30%
56
COPD Criteria for Home O2
* PaO2 \<= 55
* or \<=59 with pul HTN, cor pulmonale, or polycythemia
* SaO2 \<= 88%
* goal is PaO2 \>= 60 mm Hg or SpO2 \>=90% at rest
* long-term O2 therapy reduces mortality
57
COPD Rate of Progression (FEV1 loss)
* ~40-60 cc/year in smokers, ~20-30 in those who quit
58
When to get ABG in COPD for Home O2 consideration
* FEV1 \< 40%
59
Low vs. high risk AECOPD and abx choice
* low risk: FEV1 \> 50% and no co-morbidities
* z-pack, septra, amoxil, doxy, biaxin
* high risk: FEV1 \< 50% or co-morbidities, age \>65, \> 3 exacerbations/year, abx within past 3 months
* clavulin, levaquin, moxi
60
Dieulafoi Lesion
* Gastric artery protruding into stomach
* Sometimes multiple negative endoscopies
61
Dose of octreotide for cirrhotic UGI
* 50 mcg bolus + 50 mcgs/h
* 50% dose for elderly
62
Meckel's Diverticulum
* embrionic vestige in terminal ileum
* contains gastric mucosa cells and causes erosions and GI bleeds in young patients
EM
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