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Cardiovascular Board Review II

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Title: Cardiovascular Board Review II


1
Cardiovascular Board Review II
  • Sohan Parekh, MD
  • Department of Emergency Medicine
  • Mount Sinai School of Medicine

2
Question 1
  • Regarding treatment of heart failure in patients
    with diastolic rather than systolic dysfunction
  • Aggressive therapy with diuretics is more
    effective
  • b-Blocking agents might improve cardiac output
  • Both are associated with impaired cardiac
    contractility
  • Most patients with CHF have diastolic dysfunction
  • Ventricular filling pressures are higher in
    systolic dysfunction than in diastolic dysfunction

PEER VII 268
3
Q1 Answer
  • Regarding treatment of heart failure in patients
    with diastolic rather than systolic dysfunction
  • Aggressive therapy with diuretics is more
    effective
  • b-Blocking agents might improve cardiac output
  • Both are associated with impaired cardiac
    contractility
  • Most patients with CHF have diastolic dysfunction
  • Ventricular filling pressures are higher in
    systolic dysfunction than in diastolic dysfunction

4
Heart Failure Syndromes
  • Systolic dysfunction
  • EF lt 40
  • Decreased contractility due to ischemic heart
    disease
  • Intolerant to high afterload
  • Diastolic dysfunction
  • Preserved contractility, EF normal or increased
  • Impaired relaxation and diastolic filling
  • Due to long-standing hypertension
  • Intolerant to tachycardia which reduces filling
    time

5
Heart Failure Syndromes
  • Left Heart Failure
  • DOE, orthopnea, PND
  • Cough with pink, frothy sputum
  • Rales on lung exam
  • CXR pulmonary edema, cephalization, Kerley B
    lines
  • Right Heart Failure
  • Less common than left heart failure
  • Cause include left heart failure, pHTN, PE
  • Anasarca, Hepatomegaly, Ascites

6
Question 2
  • A 30 yo M with a history of prior episode of
    tachycardia presents with palpitations. His
    pulse is 170, and blood pressure is 100/50. The
    EKG reveals the rhythm depicted in EKG below.

PEER VII 142
7
Q2 (continued)
8
Q2 (continued)
  • Which of the following treatments would
    terminate the tachycardia most rapidly?
  • A. Adenosine 6 mg IV rapid bolus
  • B. Amiodarone 150 mg IV over 10 minutes
  • C. Diltiazem 15 mg IV slow push
  • D. Lidocaine 75 mg IV slow push
  • E. Procainaminde 1000 mg over 20 minutes

9
Q2 Answer
  • Which of the following treatments would
    terminate the tachycardia most rapidly?
  • A. Adenosine 6 mg IV rapid bolus
  • B. Amiodarone 150 mg IV over 10 minutes
  • C. Diltiazem 15 mg IV slow push
  • D. Lidocaine 75 mg IV slow push
  • E. Procainaminde 1000 mg over 20 minutes

10
Post adenosine
11
Supraventricular Tachycardia
  • Regular rhythm
  • Originates above bifurcation of His bundle
  • Palpitations, chest pain, syncope, APE
  • Treatment approach based on hemodynamic stability
    QRS morphology
  • If wide-complex treat as VT
  • If unstable synchronized cardioversion

12
Supraventricular Tachycardia
  • Stable SVT
  • Vagal Manuevers carotid massage, diving reflex,
    Valsalva manuever
  • Adenosine 6 12 12 ( 18?)
  • Diltiazem, Esmolol, Digoxin
  • Amiodarone
  • If known SVT with normal lytes and return to
    baseline, can be discharged

13
Question 3
  • Which of the following statements comparing
    dilated cardiomyopathy and hypertrophic
    cardiomyopathy is correct?

PEER VII 335
14
Q3 (continued)
  1. Both are improved by digitalis and nitrate
    therapy
  2. Both involve four-chamber heart enlargement
  3. Dilated cardiomyopathy is a more common cause of
    sudden death in young patients
  4. Dilated cardiomyopathy is associated with
    diastolic dysfunction
  5. Most cases of hypertrophic cardiomyopathy are
    hereditary

15
Q3 Answer
  1. Both are improved by digitalis and nitrate
    therapy
  2. Both involve four-chamber heart enlargement
  3. Dilated cardiomyopathy is a more common cause of
    sudden death in young patients
  4. Dilated cardiomyopathy is associated with
    diastolic dysfunction
  5. Most cases of hypertrophic cardiomyopathy are
    hereditary

16
The Cardiomyopathies
  • Dilated cardiomyopathy
  • 80 idiopathic
  • Dilation and hypertrophy of myocardium resulting
    in decreased cardiac output
  • Pump failure results in CHF, syncope, DOE
  • Stagnant blood flow in LV can results in mural
    thrombi with resultant embolic complications
  • ECG shows LVH CXR shows cardiomegaly and CHF
  • Treatment with diuretics and nitrates acutely
  • Long term ACE-I and b-blockers decrease mortality

17
The Cardiomyopathies
  • Hypertropic (aka HCM, HOCM, IHSS)
  • 50 of cases are hereditary
  • Hypertrophy of the intraventricular septum
    without ventricular dilation
  • CO is normal, diastolic filling is impaired
  • Symptoms DOE, palpitations, chest pain
  • SEM which increases with Valsalva
  • ECG shows LVH only 30 CXR negative
  • Outflow obstruction worse with exertion,
    nitrates, dig

18
The Cardiomyopathies
  • Restrictive
  • Decreased diastolic volume of both ventricles
  • Uncommon, often idiopathic
  • Infiltrative disease
  • Symptoms CHF. Chest pain uncommon
  • CXR CHF without cardiomegaly
  • ED treatment is symptomatic for CHF and/or
    underlying disease

19
The Cardiomyopathies
Dilated Hypertrophic Restrictive
Cause 80 idiopathic 50 hereditary Idiopathic and infiltrative disease
Pathology 4-chamber dilation Septal hypertrophy Restricted myocyte compliance
Symptoms CHF, chest pain Syncope, palpitations, CHF CHF
Failure Systolic Diastolic and outflow obstruction Diasolic
Findings Cardiomegaly SEM Non-specific
ED Treatment Diuretics No Nitrates or Digoxin Diuretics
20
Question 4
  • A 51 yo M with a history of HTN and ERSD
    presents with chest heaviness and SOB. Vital
    signs are blood pressure 95/80, HR 135, RR 18,
    and temperature 36.7oC. Exam reveals JVD,
    bibasilar inspiratory crackles, distant heart
    sounds, and pitting peripheral edema. CXR
    demonstrates cardiomegaly with mild bilateral
    pulmonary vascular congestion. The rhythm strip
    is shown below.

PEER VII 38
21
Q4 (continued)
Which of the following is the most appropriate
therapy?
22
Q4 (continued)
  1. Blood cultures x 2, broad-spectrum antibiotics,
    and dopamine infusion at 10 units/kg/min
  2. Calcium gluconate IV, insulin 10 units IV,
    detrose 50 g IV, and arrange for emergent
    dialysis
  3. Diltiazem 20 mg IV bolus, followed by drip at 5
    mg/hr
  4. Heparin 5000 units IV bolus, followed by
    synchronous cardioversion at 75J
  5. Normal saline 500 mL IV bolus, and emergent
    pericardiocentesis

23
Q4 Answer
  1. Blood cultures x 2, broad-spectrum antibiotics,
    and dopamine infusion at 10 units/kg/min
  2. Calcium gluconate IV, insulin 10 units IV,
    detrose 50 g IV, and arrange for emergent
    dialysis
  3. Diltiazem 20 mg IV bolus, followed by drip at 5
    mg/hr
  4. Heparin 5000 units IV bolus, followed by
    synchronous cardioversion at 75J
  5. Normal saline 500 mL IV bolus, and emergent
    pericardiocentesis

24
Cardiac Tamponade
  • Pericardial effusion compressing RV causing
    impaired filling and decreased cardiac output
  • Effusion can be medical or traumatic
  • Medical usually chronic and large volume
  • Traumatic small volume (lt 100 cc)
  • Causes uremia, cancer, infectious, SLE

25
Cardiac Tamponade
  • Findings
  • Becks triad
  • Hypotension
  • Distended neck veins
  • Muffled heart tones
  • Narrow pulse pressure
  • Pulsus Parodoxus
  • EKG low voltage, electrical alternans (20 )

26
Cardiac Tamponade
  • CXR /- enlarged cardiac silhouette
    (water-bottle)
  • Treatment
  • IVF trial
  • Pericardiocentesis

27
Question 5
  • Which of the following statements regarding
    cocaine-associated chest pain is correct?
  • Cardiac markers are often unreliable in patient
    with cocaine-associated MI
  • Aspirin and b-blockers are indicated
  • A minority of patients with cocaine-associated MI
    have evidence of underlying coronary artery
    disease
  • Palpitations and tachycardia are the most
    commonly associated symptoms
  • The average time from cocaine use to the
    presentation of the patient in the ED is 2 hours

PEER VII 381
28
Q5 Answer
  • Which of the following statements regarding
    cocaine-associated chest pain is correct?
  • Cardiac markers are often unreliable in patient
    with cocaine-associated MI
  • Aspirin and b-blockers are indicated
  • A minority of patients with cocaine-associated MI
    have evidence of underlying coronary artery
    disease
  • Palpitations and tachycardia are the most
    commonly associated symptoms
  • The average time from cocaine use to the
    presentation of the patient in the ED is 2 hours

29
Cocaine Chest Pain
  • Causes arterial vasoconstriction, sympathetic
    surge, and increased platelet aggregation
  • Greatest risk from cocaine use is in the first
    hour
  • Patients present with chest pain, tachycardia,
    HTN
  • Workup EKG, serial cardiac enzymes

30
Cocaine Chest Pain
  • Treatment
  • Benzodiazepines are the mainstay of treatment
  • ASA can be given
  • Chest pain should be controlled with NTG
  • Blood pressure control can be achieved with
    direct a-blockade or Ca-channel blocker
  • b-blockers absolutely contraindicated

31
Cocaine Chest Pain
  • Dispo
  • If they make enzymes, admit
  • If older with other risk factors, consider stress
  • If young, discharge with Rx for cocaine and
    metoprolol

32
Question 6
  • In the treatment of hyperkalemia-induced cardiac
    arrest, which of the following treatment
    modalitites provides the most rapid reduction in
    serum potassium levels?
  • Calcium gluconate
  • Insulin
  • Magnesium sulfate
  • Sodium bicarbonate
  • Sodium polystyrene sulfonate

PEER VII 143
33
Q6 Answer
  • In the treatment of hyperkalemia-induced cardiac
    arrest, which of the following treatment
    modalitites provides the most rapid reduction in
    serum potassium levels?
  • Calcium gluconate
  • Insulin
  • Magnesium sulfate
  • Sodium bicarbonate
  • Sodium polystyrene sulfonate

34
Hyperkalemia
  • EKG changes
  • Peaked T waves
  • PR prolongation
  • QRS prolongation, P wave flattening
  • Loss of P wave, QRS prolongation to sine wave

Webster, et al. Recognising signs of danger.
Emerg. Med. J., Jan 2002 19 74 77.
35
Hyperkalemia
http//sprojects.mmi.mcgill.ca/heart/ecgk1.html ht
tp//urbanhealth.udmercy.edu/ekg/pdf/hyperkalemia.
pdf
36
Hyperkalemia
  • Treatment
  • Calcium chloride or gluconate
  • Dextrose Insulin (onset 20 min, duration 1
    hr)
  • Bicarbonate (onset 10 min, duration 2 hr)
  • Lasix
  • Albuterol
  • Kayexalate (onset 2 hr)

37
Question 7
  • Which of the following is true concerning the
    rhythm in the EKG below?

PEER V
38
Q7 (continued)
  1. Is a benign rhythm with low mortality
  2. Overdrive pacing is an effective treatment
  3. Occurs in patients with shortened QT interval
  4. Responds to IV calcium
  5. Procainamide is first-line therapy

39
Q7 Answer
  1. Is a benign rhythm with low mortality
  2. Overdrive pacing is an effective treatment
  3. Occurs in patients with shortened QT interval
  4. Responds to IV calcium
  5. Procainamide is first-line therapy

40
Torsades de Pointes
  • Polymorphic V-tach
  • Can degenerate into Vfib
  • Underlying long-QT (QTc gt 460 ms)
  • Drug-induced (Haldol, TCAs, procainamide)
  • Congenital prolonged QT syndrome
  • Treatment
  • Magnesium IV
  • Overdrive pacing
  • Cardioversion if unstable

41
Question 8
  • Which of the following statements regarding
    posterior wall infarction is correct?
  • Associated with ST-segment depression in V1
  • ECG shows an inverted T wave in V1
  • ECG shows large S waves in V1
  • Occurs in 5 of all acute MIs
  • Results from occlusion of the LAD

PEER VII 249
42
Q8 Answer
  • Which of the following statements regarding
    posterior wall infarction is correct?
  • Associated with ST-segment depression in V1
  • ECG shows an inverted T wave in V1
  • ECG shows large S waves in V1
  • Occurs in 5 of all acute MIs
  • Results from occlusion of the LAD

43
STEMI
  • Complete occlusion of coronary artery
  • ECG with characteristic ST elevations
  • ASA /- b-blocker
  • PCI vs Thrombolytics

44
STEMI
  • Posterior Wall MI
  • ST depression, RS ratio gt 1 in V1 to V2

http//emj.bmj.com/cgi/content/abstract/19/2/129?c
knck
45
STEMI
  • Anterior Wall MI
  • ST elevations in V2-V4
  • Reciprocal ST depressions in II, III, aVF

http//urbanhealth.udmercy.edu/ekg/pdf/acuteAnterW
allMI.pdf
46
STEMI
  • Inferior Wall MI
  • ST elevations in II, III, aVF
  • Must obtain Right-sided EKG

http//www.lf2.cuni.cz/Projekty/interna/heart_soun
ds/ekg4/ekg12.jpg
47
STEMI
  • Lateral Wall MI
  • ST elevations in I, aVL, V5, V6

http//sprojects.mmi.mcgill.ca/heart/ecg9805316.ht
ml
48
Question 9
  • Which of the following is most commonly seen in
    infants with congestive heart failure?
  • Bilateral pedal edema
  • Bounding femoral pulses
  • Excessive weight gain
  • Jugular venous distention
  • Sweating with eating

PEER VII 376
49
Q9 Answer
  • Which of the following is most commonly seen in
    infants with congestive heart failure?
  • Bilateral pedal edema
  • Bounding femoral pulses
  • Excessive weight gain
  • Jugular venous distention
  • Sweating with eating

50
Infant CHF
  • CHF results from left-to-right shunting
  • VSD
  • PDA
  • Coarctation of the Aorta
  • Symptoms
  • Poor feeding with sweating during feeds
  • Poor growth and weight gain
  • Weak cry Coughing and wheezing

51
Infant CHF
  • Findings
  • Weak peripheral pulses
  • Rales
  • EKG possible SVT, otherwise non-specific
  • CXR
  • Cloudy lung files
  • Cardiomegaly

52
Question 10
  • A 45 yo F s/p heart transplant five years ago,
    presents to the ED with a 2d of SOB, and
    non-productive cough. She is on immunosuppressant
    therapy. VS include BP 98/60, HR 130, RR 22, T
    37.9 0C, and SaO2 95. The physical exam is
    unremarkable except for scattered basilar rales.
    CXR shows cephalization, interstitial
    infiltrates, a slightly enlarged heart, and no
    effusions. EKG shows sinus tachycardia.

53
Q10 (continued)
  • Which study is indicated next, as part of an
    appropriate ED evaluation of this patient?
  • Blood cultures, then start empiric antibiotics
  • V/Q Scan
  • Serum cardiac markers
  • Cardiac MRI
  • TEE

54
Q10 Answer
  • Which study is indicated next, as part of an
    appropriate ED evaluation of this patient?
  • Blood cultures, then start empiric antibiotics
  • V/Q Scan
  • Serum cardiac markers
  • Cardiac MRI
  • TEE

55
Heart Transplant
  • Post-transplant physiology
  • Heart is denervated
  • Both recipient and donor sinus nodes are
    functional thus 2 sets of P waves

Circulation. 2007 Jan 23115(3)e41-2
56
Heart Transplant
  • Ischemia of graft difficult to detect
  • Patients with CHF, SOB must have serial CE
  • Rejection
  • Mostly asymptomatic but can have dysrhythmia
  • Dose with steroids
  • Dysrhythmias
  • Bradycardia isoproterenol (atropine doesnt
    work)
  • Trachycardia Standard resuscitation measures

57
Question 11
  • What is the most effective medication to lower
    blood pressure in a patient with an acute aortic
    dissection?
  • Fentanyl
  • Labetalol
  • Metoprolol
  • Nitroglycerin
  • Sodium Nitroprusside

PEER VII Q331
58
Q11 Answer
  • What is the most effective medication to lower
    blood pressure in a patient with an acute aortic
    dissection?
  • Fentanyl
  • Labetalol
  • Metoprolol
  • Nitroglycerin
  • Sodium Nitroprusside

59
Aortic Dissection
  • Violation of intima of aorta resulting in false
    lumen
  • Bimodal distribution
  • Young patients with connective tissue disease
  • Older patients with hypertension
  • Clinical presentation
  • Abrupt onset of tearing chest pain or back pain
  • Neurologic symptoms are common

60
Aortic Dissection
  • Diagnosis
  • CXR Abnomal in 90 of cases
  • Wide mediastinum
  • Abnormal aortic contour
  • Pleural effusion
  • CT-A with IV contrast or aortogram if stable for
    transport
  • Bedside TEE

61
Aortic Dissection
  • Disposition depends on type
  • Type A (ascending) surgery
  • Type B (descending) medical mangement
  • Treatment
  • Must control the shear force on the intimal flap
  • b-blocker to decrease pulse
  • Anti-hypertensive to decrease BP
  • Sodium nitroprusside, fenoldopam, nicardipine

62
Question 12
  • A 74 yo F presents by ambulance after she passed
    our at church. She is awake and alert but says
    she feels dizzy. VS include BP 80/50, HR 41, and
    temperature 36.8oC, O2 sat 99 on 3L. Cardiac
    monitoring reveals the rhythm depicted below.

PEER VII Q331
63
Q12 (continued)
  • Administration of atropine 1 mg IV has no effect
    on her blood pressure or heart rate. The next
    step should be
  • Dopamine infusion at 20 mcg/kg/min
  • Epinephrine 1 mg IV slow push
  • Stat cardiology consultation
  • Transcutaneous cardiac pacing
  • Transvenous cardiac pacing

64
Q12 Answer
  • Administration of atropine 1 mg IV has no effect
    on her blood pressure or heart rate. The next
    step should be
  • Dopamine infusion at 20 mcg/kg/min
  • Epinephrine 1 mg IV slow push
  • Stat cardiology consultation
  • Transcutaneous cardiac pacing
  • Transvenous cardiac pacing

65
AV Nodal Blocks
  • Caused by conduction delay in AV node
  • First-Degree
  • PR interval gt 0.2s (200ms)
  • All P waves followed by QRS
  • No intervention required

http//urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pd
f
66
AV Nodal Blocks
  • Second-Degree Mobitz I (Wenckebach)
  • Progressive lengthening of PR interval followed
    by dropped beat
  • Seen in MI, digoxin toxicity, myocarditis, CAD
  • Stable rhythm

http//urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pd
f
67
AV Nodal Blocks
  • Second-Degree Mobitz Type II
  • Fixed-length PR interval with one or more
    non-conducted beats
  • Signifies major damage to conduction system
  • Unstable Requires permanent pacemaker

68
AV Nodal Blocks
  • Third-Degree (Complete) Heart Block
  • No P waves are conducted through AV node
  • Junctional or Ventricular escape paces the heart
  • Unstable Requires permanent pacemaker

http//urbanhealth.udmercy.edu/ekg/pdf/AVBlocks.pd
f
69
Question 13
  • A 28 yo M presents with a laceration to the left
    forearm. The patient is in good health and has no
    other complaints. At triage the patient's blood
    pressure was noted to be 155/94 mmHg the
    remainder of his vital signs are normal.
    Following repair of the laceration, the patient's
    blood pressure is rechecked and is unchanged.

70
Q13 (continued)
  • What is the best approach to this patient's
    elevated blood pressure?
  • Administer labetalol or nifedipine with
    observation until SBP is lt 140
  • Evaluate for end-organ damage with CXR, ECG,
    electrolytes, BUN/Cr and UA
  • Instruct the patient to follow-up with his
    private physician within two months for recheck
  • No further management required
  • Admit for blood pressure control and workup

71
Q13 Answer
  • What is the best approach to this patient's
    elevated blood pressure?
  • Administer labetalol or nifedipine with
    observation until SBP is lt 140
  • Evaluate for end-organ damage with CXR, ECG,
    electrolytes, BUN/Cr and UA
  • Instruct the patient to follow-up with his
    private physician within two months for recheck
  • No further management required
  • Admit for blood pressure control and workup

72
Hypertension
  • Classifications
  • Emergency Elevated blood pressure with
    associated end-organ dysfunction
  • Urgency Elevated blood pressure with risk of
    imminent target organ dysfunction
  • Essential hypertension SPB gt 140 or DBP gt90

73
Hypertension
  • Only HTN emergencies require immediate treatment
  • Labetalol
  • Nitroprusside
  • Fenoldopam
  • Nicardipine
  • For HTN urgencies, goal is reduction of blood
    pressure in the next 24-48 hours
  • For non-urgent blood pressure elevation, refer
    for timely follow up

74
Question 14
  • A 7 wk old full-term M is brought in 45 minutes
    after having a 60-second episode of
    unresponsiveness and cyanosis. He remained pale
    and limp for 20 minutes and refused to feed.
    Cardiac exam reveals a pulse of 160, a harsh
    pansystolic ejection murmur and the LSB, and a
    single second heart sound. O2 sat is 84.

PEER VI
75
Q14 (continued)
  • What is the most likely diagnosis?
  • Coarctation of the Aorta
  • Hypoplastic left heart syndrome
  • Patent ductus arteriosus
  • Tetrology of Fallot
  • Transposition of the great vessels

76
Q14 (continued)
  • What is the most likely diagnosis?
  • Coarctation of the Aorta
  • Hypoplastic left heart syndrome
  • Patent ductus arteriosus
  • Tetrology of Fallot
  • Transposition of the great vessels

77
Cyanotic Congenital Disease
  • Due to anatomic shunt with mixing of oxygenated
    and deoxygenated blood
  • The 5 Ts
  • Tetrology of Fallot
  • Truncus Ateriosus
  • Transposition of the Great Arerties
  • Tricuspid Atresia
  • Total Anomalous Venous Return

78
Cyanotic Congenital Disease
  • Tetrology of Fallot
  • VSD, overriding aorta, RV obstruction, RVH
  • Tet spells episodic SOB triggered by crying,
    eating, or playing
  • Tachypnea cyanosis seizures shock
  • O2, Position in knee-chest position
  • For severe shock within the first 2 weeks of
    life, possible closure of PDA
  • Prostaglandin E1

79
Question 15
  • Concerning the treatment of acute decompensated
    heart failure with nesiritide, which of the new
    following statements is most accurate?

PEER VII Q379
80
Q15 (continued)
  1. In controlled trials, nesiritide administration
    resulted in better hemodynamic improvements than
    placebo
  2. Nesiritide does not affect renal function in
    patients with acutely decompensated heart failure
  3. Nesiritide has demonstrated clear superiority to
    conventional vasodilator and diuretic based
    therapy
  4. The hemodynamic effects of nesiritide include
    vasoconstriction of the veins and arteries,
    including the coronary arteries
  5. The use of nesiritide is clearly associated with
    an increased death rate at 30 days

81
Q15 (continued)
  1. In controlled trials, nesiritide administration
    resulted in better hemodynamic improvements than
    placebo
  2. Nesiritide does not affect renal function in
    patients with acutely decompensated heart failure
  3. Nesiritide has demonstrated clear superiority to
    conventional vasodilator and diuretic based
    therapy
  4. The hemodynamic effects of nesiritide include
    vasoconstriction of the veins and arteries,
    including the coronary arteries
  5. The use of nesiritide is clearly associated with
    an increased death rate at 30 days

82
CHF and Cardiogenic Shock
  • Acute pulmonary edema
  • Oxygen
  • Nitro (SL and IV)
  • Non-invasive ventilation
  • CHF
  • Diuretics
  • Afterload reduction (blood pressure control)

83
CHF and Cardiogenic Shock
  • Nesiritide
  • Endogenous BNP counteracting renin system
  • Dilation of arterial and venous systems with
    increase in SV and CO versus placebo
  • Increased mortality and worsening renal failure
  • Dont use this in the ED

84
CHF and Cardiogenic Shock
  • Cardiogenic shock
  • Pump failure resulting in inadequate tissue
    perfusion
  • Most often secondary of massive acute MI
  • Also consider acute valvular disease or severe
    decompensated heart failure
  • Evidence of volume overload with poor perfusion
    (hypotension, cool, mottled skin)
  • Treatment focused on correcting poor perfusion

85
CHF and Cardiogenic Shock
  • Cardiogenic shock treatment
  • Fluid challenge if no pulmonary edema
  • Vasopressors Dopamine or norepinephrine
  • Inotropy Dobutamine
  • Phosphdiesterase inhibitors Milrinone
  • Find / steal / create a CCU bed immediately
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