Regarding management of cardiogenic shock, which ONE of the following is TRUE?
Answer: B: The medical treatment of acute mitral regurgitation aims to increase forward flow. This can be achieved by using an inotrope to improve cardiac contractility and a vasodilator to decrease afterload. IV fluids are a first-line treatment for cardiogenic shock caused by RV failure. In this situation, an increase in preload will improve RV output.
Endotracheal intubation will nearly always exacerbate hypotension in cardiogenic shock by decreasing preload. Cardiac arrest is common post intubation in these patients.
Intra-aortic balloon pump counter pulsation will increase cardiac output by timed inflation during diastole and deflation during systole. Therefore, diastolic BP is increased (and coronary artery flow improved) and afterload reduced when the balloon deflates in systole.
Reference:
Regarding hypertensive crises, which ONE of the following is TRUE?
Answer: C: Hypertensive encephalopathy is characterised by neurological dysfunction resulting from severe hypertension. Common symptoms are decreased level of consciousness, headache, vomiting, seizures and visual disturbances. The symptoms are acute in onset and reversible. Treatment should aim to reduce the mean arterial pressure (MAP) by about 25% over 1–2 hours. Malignant hypertension is not characterised by a BP reading alone but requires end-organ dysfunction for diagnosis. There is no evidence for reduction of blood pressure in ischaemic stroke. Indeed, hypertension is often required for adequate cerebral perfusion of neighbouring viable brain tissue.
References:
In the pharmacological treatment of hypertensive crises in the ED, which ONE of the following is TRUE?
Answer: B: Hydralazine is a direct arteriolar vasodilating agent. It is usually given in 5 mg boluses. Reflex tachycardia is common.
The treatment of aortic dissection requires reduction of shearing forces on the torn intima of the aorta. Initial treatment with vasodilators will actually increase shearing forces by predominantly reducing diastolic pressure (thereby increasing pulse pressure and hence flow). Reflex tachycardia resulting from vasodilation also increases the shear forces per unit of time. Hence, initial treatment of aortic dissection should be with rate control and systolic BP reduction. Beta-blockers are ideal.
Sodium nitroprusside has a rapid onset and short duration of onset, and therefore is given via infusion.
GTN predominantly reduces preload by reducing venous tone.
Regarding ECG changes in pericarditis, which ONE of the following statements is TRUE?
Answer: B: It is often difficult to differentiate pericarditis from AMI and benign early repolarization (BER) on the ECG. Consequently, the diagnosis is primarily clinical. ECG changes associated with pericarditis include ST segment elevation and PR depression (stage 1) which are present in 60% of initial ECGs, followed by normalization, followed by T wave inversion and then normalization. The ST segment elevation is concave and is not associated with reciprocal changes. Changes occur over more than one anatomical area compared with BER, which typically occurs in the precordial leads only. Tall-tented T waves are characteristic of hyperkalaemia, or hyperacute infarction.
With respect to pericarditis, which ONE of the following is TRUE regarding ECG findings?
Answer: D: PR segment depression is suggestive of pericarditis, and is not present in AMI.
ECG may be useful in the diagnosis of cardiac tamponade. Electrical alternans, where the QRS axis alternates between beats, and low voltage complexes may suggest the diagnosis of tamponade.
ECG findings may be present for several months following acute pericarditis. Generally the ECG will follow four stages:
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