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In-Training Exam High Yield Cardiovascular

In-Training Exam High Yield Cardiovascular. Emergency Medicine Foundations Curriculum. In-training Exam (ITE) Content:. Written to level of EM3 Predicts performance on EM Boards 225 MC questions Given 4.5 hrs to take +/- 25 are visual stimuli – pictures/ ekg/xrays

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In-Training Exam High Yield Cardiovascular

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  1. In-Training ExamHigh Yield Cardiovascular Emergency Medicine Foundations Curriculum

  2. In-training Exam (ITE) Content: • Written to level of EM3 • Predicts performance on EM Boards • 225 MC questions • Given 4.5 hrs to take • +/- 25 are visual stimuli – pictures/ekg/xrays • Highest yield topics • Cardiovascular ~ 10% • Trauma ~ 10% • Abd/GI ~ 8% • Thoracic/Respiratory ~ 8% • Procedures/Skills ~8% • Note that Geriatrics makes up at least 6% of these and • Pediatrics at least 8%

  3. Foundations Challenge Overview • Rapid Review of High-Yield Test Topics • Visual Diagnosis • Clinical Concepts • Rapid Fire • Work in 2-4 different teams • Answer challenge questions for points • Point value per challenge varies by difficulty • Win test prep and pride

  4. Foundations Challenge Rules • Create a Team Name • Best Team Name starts the Challenge (as arbitrarily determined by your Instructor) • Your team must answer the entire question correctly to win points • If you team answers incorrectly, the Challenge Question points can be stolen by the next team • If they answer correctly, they get your points AND a chance to answer the next question • If they answer incorrectly, the turn passes again to the next team in line

  5. Cardiovascular

  6. 40 yo M with chest pain. 1pt Foundations Challenge Visual Diagnosis Dx and Tx?

  7. 1pt Foundations Challenge Visual Diagnosis Pericarditis, NSAIDs PR depression, global concave STE, no reciprocal STD

  8. 30 yo M with syncope. 2pts Foundations Challenge Visual Diagnosis Dx and Tx?

  9. 2pts Foundations Challenge Visual Diagnosis Brugada Syndrome, AICD

  10. Brugada Syndrome Foundations Challenge Visual Diagnosis • Type I (most common): Wide QRS and TWI, RBBB pattern with down-sloping STE in V1-3 • Defect in Na channels • Classically youngAsian males • Risk of VfibRequires AICD

  11. 45 yo F with syncope. 2pts Foundations Challenge Visual Diagnosis Dx and Tx?

  12. 2pts Foundations Challenge Visual Diagnosis WPW, AICD

  13. Wolff-Parkinson-White Foundations Challenge Knowledge Bomb • Short PR, Wide QRS, Delta Wave • Aberrant conduction pathway, can conduct very fast atrial arrhythmias (such as A Fib) • Treatment • Unstable: Synchronized cardioversion • Narrow Complex (orthodromic): treat like SVT • Wide Complex (antidromic): IV procainamide, AVOID AVN BLOCKERS

  14. 50 yo M with palpitations. 2pts Foundations Challenge Visual Diagnosis Predisposes to what arrhythmia? Requires what treatment?

  15. 2pts Foundations Challenge Visual Diagnosis Torsades, Magnesium

  16. Prolonged QT Foundations Challenge Knowledge Bomb • Abnormal repolarization • Causes: Inherited, Low K/Mg/Ca, Drugs • QT interval (to end of T wave) > 1/2 R-R interval • Predisposes to ventricular arrhythmia (classically torsades de pointes) • Test Treatment • Unstable: Shock • Stable: IV Magnesium

  17. 60 yo M with SOB and edema. 2pts Foundations Challenge Visual Diagnosis Dx and Tx?

  18. 2pts Foundations Challenge Visual Diagnosis Hyperkalemia, Calcium

  19. Hyperkalemia Foundations Challenge Knowledge Bomb • Hyperacute T waves  Wide QRS, Long PR  No P waves, Sine Wave • Cardioprotection (if Wide QRS) • Calcium Gluconate or Chloride • Potassium Shifters • Insulin/glucose, Bicarb if acidotic, Albuterol • Potassium Excretion • Lasix, Kayexylate, HD

  20. Name the EKG abnormality. 2pts Foundations Challenge Visual Diagnosis What do you want to rule out?

  21. Electrical Alternans 2pts Foundations Challenge Visual Diagnosis Pericardial Tamponade

  22. Pericardial Tamponade Foundations Challenge Knowledge Bomb • Beck’s Triad • Hypotension, JVD, muffled heart sounds • EKG • Low voltage • Electrical alternans • POCUS • RV scalloping/collapse during diastole • Requires immediate pericardiocentesis

  23. 65 yo F with CHF. 1pt Foundations Challenge Visual Diagnosis What medication does she take?

  24. 1pt Foundations Challenge Visual Diagnosis Digoxin Digitalis Effect Sagging ST segments (“Salvador Dali mustache”), short QT intervals and flat/inverted T waves

  25. 65 yo F with h/o CHF. 2pts Foundations Challenge Visual Diagnosis Name the Rhythm. Name the Cause.

  26. 2pts Foundations Challenge Visual Diagnosis Atrial Tachycardia with Blockcaused by Digoxin Toxicity

  27. Digoxin Toxicity Foundations Challenge Knowledge Bomb • Blocks Na-K-ATPase • Yellow halos, nausea/vomiting; hyperkalemia indicates severe toxicity • EKG–can be almost anything • Paroxysmal atrial tachycardia with block is pathognomonic • Bidirectional VTachis highly suggestive (but rare) • DigiBind Criteria: give for severe poisoning • K+ >5.5 • Life-threatening arrhythmias (Conduction blocks,Vtach/fib, symptomatic bradycardia) • Dig level >10 • Cardiovascular arrest • Avoid giving calcium for HyperK (theoretical stone heart)

  28. Name the leads associated with the following types of MI. 2pts Foundations Challenge Clinical Concepts Inferior Lateral Septal Anterior

  29. Name the leads associated with the following types of MI. 2pts Foundations Challenge Clinical Concepts Inferior Lateral Septal Anterior II, III, aVF I, aVL, V5-6 V1-2 V1-4

  30. Foundations Challenge Knowledge Bomb EKG Territories

  31. When should tPA be given instead of PCI for AMI? 4pts Foundations Challenge Clinical Concepts In a patient with STE in lead III > lead II, what drug is likely to be contraindicated? ??? PCI site? Non-PCI site?

  32. When should tPA be given instead of PCI for AMI? 4pts Foundations Challenge Clinical Concepts In a patient with STE in lead III > lead II, what drug is likely to be contraindicated? Nitroglycerin If PCI not available within 90m (PCI site) or 120m (transfer to PCI site)

  33. Foundations Challenge Knowledge Bomb ED Management of MI

  34. What is the treatment for the following patients with tachycardia? 3pts Foundations Challenge Clinical Concepts + Hypotension + Asymptomatic + Asymptomatic

  35. What is the treatment for the following patients with tachycardia? 3pts Foundations Challenge Clinical Concepts + Unstable SHOCK + Stable ADENOSINE + Stable PROCAINAMIDE

  36. Tachyarrhythmia Simplified Foundations Challenge Knowledge Bomb

  37. Which of the following require pacemaker placement? Foundations Challenge Clinical Concepts 2pts 1 2 3 4

  38. Which of the following require pacemaker placement? Foundations Challenge CLINICAL CONCEPTS 2pts 1- 2nd Degree Mobitz Type II 2- 1st Degree AV Block 4- 2nd Degree Mobitz Type I 3- Complete Heart Block

  39. Foundations Challenge Knowledge Bomb Heart Block

  40. Foundations Challenge Knowledge Bomb Unstable Bradycardia • Atropine (if narrow, 0.5 mg IV, up to 3mg total) • Dopamine (2-20 mcg/kg/min gtt) • Epinephrine (2-10 mcg/min gtt)

  41. Once correctly placed, electrode attached to catheter tip will create what EKG morphology? 2pts Foundations Challenge Clinical Concepts What is the best location fora transvenouspacing catheter? ??? ???

  42. Once correctly placed, electrode attached to catheter tip will create what EKG morphology? 2pts Foundations Challenge Clinical Concepts What is the best location for a transvenouspacing catheter? Right IJ LBBB

  43. What is the most common cause of pacemaker failure? Foundations Challenge Clinical Concepts 4pts Battery Depletion Oversensing Wire Fracture Undersensing What is the effect of a magnet placed over a Pacemaker??? AICD???

  44. 4pts Foundations Challenge Clinical Concepts What is the most common cause of pacemaker failure? Battery Depletion Oversensing Wire Fracture Undersensing What is the effect of a magnet placed over a Pacemaker-> Fixed Rate AICD-> Turns Off

  45. Name the H’s (6) and T’s (6). Foundations Challenge Clinical Concepts 2pts

  46. Name the H’s (6) and T’s (6). Foundations Challenge Clinical Concepts 2pts H’s T’s Tension PTX Tamponade Thrombosis (coronary) Thrombosis (PE) Trauma Toxins/Tablets (OD) • Hypoxia • Hypovolemia • H+ (acidosis) • Hypo/Hyperkalemia • Hypothermia • Hypoglycemia

  47. What are the most common causes (organisms) of Endocarditis? 2pts Foundations Challenge Clinical Concepts Right-sided??? Left-sided???

  48. What are the most common causes (organisms) of Endocarditis? 2pts Foundations Challenge Clinical Concepts Right-sided: Staph aureus Left-sided: Strep Viridans

  49. Endocarditis Foundations Challenge Knowledge Bomb • Risk Factors • Diseased or artificial valves • IVDA (right-sided) • Dental Extractions • Most Common Cause • Left sided: Strep Viridans, followed by Staph aureus, Enterococcus • Right Sided: Staph aureus, followed by Strep pneumo • Complications • Left sided: septic emboli in systemic circulation • Right sided: septic emboli to pulmonary circulation (PE) • Diagnosis/Treatment • Blood cultures x3 • Echo (transesophageal is best) • Broad-spectrum IV antibiotics(cover Staph/Strep/Gram neg)

  50. Foundations Challenge Knowledge Bomb Endocarditis IVDA Dental Extractions Artificial Valves Roth Spots Osler Nodes Janeway Lesions Splinter Hemorrhages

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