NBME Shelf Review (Part 9) – Cardiopulmonary

Pulmonary Embolism

* Three types of pulmonary embolism* “Massive”* Hypotension or severe bradycardia* Treat with tPA or thrombectomy* “Submassive”* Normotensive but with Right Heart Strain* S1Q3T3 on EKG* Elevated BNP* Elevated troponin* Dilation of RV on ultrasound* Treat with heparin/lovenox and admit* “Low Risk”* Treat with anticoagulation* Outpatient vs inpatient treatment* Testing* CTA of the Chest* If severe contrast allergy or other contraindication* Ventilation/Perfusion (V/Q) Scan

Inferior STEMI

* EKG shows ST elevation in 2, 3, aVF* Can involve AV node (bradycardia)* Avoid beta blockers* Treat with atropine* Can involve RV (preload dependent)* Avoid nitroglycerine* Treat with fluids

Common to Nitroglycerine

* Hypotension* Current sildenafil usage

Aortic Dissection

* Type A (ascending) Dissection* Surgical emergency* Type B (descending) Dissection* Medical management* Testing* CTA of the chest* Chest X-Ray SOMETIMES shows a widened mediastinum* Treatment* Esmolol (decrease heart rate)* Labetelol (decrease blood pressure)* PEARL: Aortic dissection can cause STEMI

Heart Failure

* Treatment* Diuresis* Nitroglycerin* BiPAP* If patient needs fluids* Decrease size of fluid bolus

COPD

* Treatments* Albuterol/Ipratropium* Antibiotics* Steroids* BiPAP

Pneumonia

* If alcoholic/homeless/dementia/parkinson’s* Treat for aspiration (anaerobes)* If recent hospitalization/ventilator* Treat for pseudomonas and MRSA* If pneumonia PLUS atypical symptoms* Treat for legionella* If recent influenza* Treat for MRSA

Additional Reading

* Pulmonary Embolism Basics (EM Clerkship)* Pulmonary Embolism Severity (PubMed)