Donald – Cardiac US
4 main views – parasternal long, parasternal short, subcostal, apical
Parasternal long – probe 4th-5th mid nipple line, then start sliding down the chest wall until you see the heart. Older individuals move out and away from the sternum a few centimeters. COPD – move the probe down. Probe is angled toward the right shoulder. Older heart – probe angled more transferse. Fan toward the left shoulder.
Parasternal long – heart beating yes or now, pericardial effusion yes or no, does the mitral valve touch the septum, relative size of the RV compared to the aortic outflow tract and the LA (they should all be the same size). If not, thinking RV overload, PE, etc. Aortic diameter in an adult should be less than 4 cm
Parasternal short – rotate the probe 90 degrees to the left shoulder, want to see mitral valve and the papillary muscles, fanning through apex of the heart….. is the septum round or flat? – look at all of the walls and see if all of the walls contract toward the center of the chamber
Apical view – probe at apex, typically 3 o clock position on the chest, below and lateral to the nipple. Looking for LV squeeze, MAPSE, look at how the ventricles are contracting with respect to each other. Mcconnels sign?
Subcostal view – least useful view – probe marker subcostal space pointing toward the head. Imaging through the liver… Is there a pericardial effusion? is there RV free wall collapse in diastole?
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Rachel – management of HTN
HTN is a common complaint in the ED – estimated 25% of visits.
What is HTN? – JNC8 recommendations
- >60 yrs old – target <150/<90
- < 60 yrs old – target <140/<90
Make sure you have a proper fitting blood pressure cuff for the patient! – can affect the blood pressure
Severe HTN – >180/>110 –
Hypertensive emergency – consider rate of rise in BP, end organ dysfunction examination, determine primary vs secondary causes of HTN emergencies.
Most common symptoms with elevated BP: CP, SOB, headache, altered mentation, focal neuro deficits – can manifest as pulmonary edema, ischemic stroke, ACS, hemorrhagic strokes, acute aortic dissection, hypertensive encephalopathy
Evaluation of these patients: consider medication changes, PMHx such as diabetes and renal disease, cocaine use; can check EKG, troponin, renal function.
If you are going to treat the BP, don’t lower it too quickly – except in the case of dissection and intracranial hemorrhage.
Hemorrhagic stroke – SBP acute lowering to SBP 140, Maintain BP 130-150
HTN encephalopathy – lower the BP slowly
Ischemic stroke – TPA <185/110, no TPA if >220/120
Acute heart failure – can use high dose nitro, loop diuretics 1-2x maintenance dose.
ACS – goal to reduce myocardial O2 demand but be cautious with lowering BP
Aortic dissection – take care of HR first – 1st line is esmolol, cardene, labetalol, nitroprusside. Cardene has caution of reflex tachycardia. Goal SBP 100-120, HR around 60
Asymptomatic HTN – elevated blood pressure without end organ dysfunction
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Salen —
How much fluid resides in pericardial sac- 10-15 ml of fluid.
Common etiologies of pericarditis – viral, autoimmune, uremia, radiation, neoplastic disease
Triad of low grade fever, chest pain, and pericardial friction rub in post- MI patient -Dresslers syndrome – common in post bypass patients. Bad complications of Dresslers syndrome – tamponade, large pleural effusions part of mediastinal inflammation
Pericardia friction rub – best heard over the lower left sternal border with patient leaning forward, use diaphragm of stethoscope
Reiters syndrome – reactive arthritis – uveitis, urethritis, arthritis (cant see cant pee cant climb a tree) – reactive arthritis also has cardiac manifestations – pericarditis and myocarditis aortic regurgitation.
4 things on EKG about pericarditis:
PR depression, diffuse ST elevation, in AVR and V1 (R sided leads) see ST depressions.
Pericarditis ST segment – concave ST segments (looks like a smiley face!), convex would be STEMI
Benign early repol shoud have ST elevations in V2-V5,V6, not really diffuse like pericarditis
Useful labs for pericarditis and myopericarditis – Troponin, ESR, CRP, CBC for thrombocytopenia and leukocytosis, autoimmune markers (ANA), rapid HIV – but normal labs don’t rule it out. ECHO should be done in every suspect case to r/o pericardial effusion.
Beck’s triad – hypotension, muffled heart sounds, JVD
Post MI pericarditis or post bypass Dresslers syndrome – put them on ASA, NSAIDs. Recurrent pericarditis – Colchicine
Heart block with Lyme disease- treat with IV Ceftriaxone.
What kind of patients get endocarditis – IVDA, valve replacements, congenital heart disease, chronic indwelling catheters
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Cocaine use – Cheatle
Dilated cardiomyopathy associated with cocaine use – symptoms of heart failure
Arrhythmias can happen – most commonly ST, Paroxysmal atrial tachycardia, AF. Most of these arrhythmias go away on their own after drug is metabolized
Risk of ischemic stroke increases with cocaine use
LV hypertrophy is common, infectious endocarditis among IV users, mesenteric ischemia, accelerated atherosclerosis.
What to do? – EKG, CXR vs CTA if suspecting dissection, Serum cardiac markers
Treatment? – treat like any other chest pain – they can have no other risk factors and still have an MI so be careful!
Can give ASA. – helps with not forming clots
Nitro and calcium channel blockers
Benzos for sedation and blood pressure control
****Beta blockers traditionally taught to avoid! – Can cause unrestricted alpha vasoconstriction and systemic hypertension.
In patients with STEMI and recent cocaine use, cath and primary PCI is preferred over fibrinolysis (increased rate of intracranial hemorrhage after fibrinolytics after cocaine use)
Cocaine use can produce Wide QRS arrhythmias –
SR with TCA like QRS changes – use bicarb
VT/VF – Amiodarine if safe and effective, shock if refractory or unstable