Heart Failure
The definition of heart failure with reduced ejection fraction
What is LVEF </= 40%?
*HFmrEF: LVEF 41- 49%
The 3 cardinal symptoms of a COPD exacerbation.
What are: 1. Increase in cough frequency and severity, 2. Increase in sputum volume and/or changes character, 3 Increased dyspnea
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) defines as COPD exacerbation as "an event characterized by dyspnea and/or cough and sputum that worsens over ≤14 days, which may be accompanied by tachypnea and/or tachycardia, and is often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insult to the airways"
The three categories of AKI and one example of each.
What are prerenal, intrarenal and postrenal?
Prerenal: dehydration, hemorrhage, sepsis, heart failure, cirrhosis
Intrarenal: ATN (ischemic vs nephrotoxic), glomerulonephritis (autoimmune, infectious) acute interstitial nephritis, renal vasculature emboli/thrombi
Postrenal: BPH, kidney stones, tumors, infection
Primary tool used to determine pre-test probability of a PE
What is a Well's score?
https://www.mdcalc.com/calc/115/wells-criteria-pulmonary-embolism
Bonus question 1: Screening tool that can rule out PE if all the criteria are negative and pre-test probability </=15%
Bonus question 2: What is the utility of a D-dimer
Definition of sepsis
What is life-threatening organ dysfunction* caused by a dysregulated host response to infection?
(2016 SCCM/ESICM task force definition)
*Organ dysfunction is defined by the 2016 SCCM/ESICM task force as a SOFA score of ≥2 or a SOFA score increase of ≥2 from a chronic baseline
https://www.mdcalc.com/calc/691/sequential-organ-failure-assessment-sofa-score
The equivalent to 40 mg PO lasix in IV form.
What is 20 mg IV lasix?
(40 mg furosemide = 20 mg torsemide = 1 mg bumetanide)
The O2 saturation goal for someone with COPD
What is 88-92%?
The definition of an AKI
What is:
-Increase in serum creatinine by ≥0.3 mg/dL (≥26.5 micromol/L) within 48 hours, OR
-Increase in serum creatinine to ≥1.5 times baseline, which is known or presumed to have occurred within the prior seven days, OR
-Urine volume <0.5 mL/kg/hour for six hours
(2012 KDIGO guidelines)
Contraindications to getting a CTA to diagnose a PE.
What are pregnancy and severe contrast allergy?
Other relative contraindications include renal impairment, poorly controlled pulmonary or cardiac disease that would make it hard to hold breath or interfere with the necessary heart rate control required for the exam.
Bonus question: What is an alternative scan you can get instead of a CTA?
First choice vasopressor for someone with septic shock
What is norepinephrine?
Bonus question: what is the definition of septic shock?
The 4 classes of medicines that make of guideline directed medical therapy for HFrEF
What are: 1. ACEi/ARB/ARNI, 2. Beta Blocker, 3. Mineralocorticoid Receptor Antagonists (MRAs), 4. SGLT-2 inhibitors ?
Bonus: Which has a Class I recommendation for treatment of HFpEF?
The inhaled medications typically used to treat a COPD exacerbation.
What are ipratropium bromide and albuterol sulfate (aka DuoNeb)?
What is FENa?
A value less than 1 percent indicates a prerenal cause of acute kidney injury, whereas a value greater than 2 percent indicates an intrinsic renal cause.
Score used to determine need for VTE prophylaxis in hospitalized patient.
What is Padua Prediction Score.
https://www.mdcalc.com/calc/2023/padua-prediction-score-risk-vte
Other validated tools: Caprini score (surgical), IMPROVE model
The volume of fluid that should be given to someone suspected of having sepsis within the first 3 hours of presentation.
What is 30mL/kg of a crystalloid fluid?
Bonus question: In which patients might you be more cautious with fluids?
At least 3 tests you might order for a patient who you suspect is presenting with a heart failure exacerbation.
What are: EKG, CXR (or lung ultrasound), BNP/proBNP, BMP+mag, troponin, lactate, echo ?
A typical steroid course for a COPD exacerbation in a non critically ill patient.
What is 40 mg prednisone PO X 5 days?
At least three common medications you would want to stop/hold in the setting of an AKI.
What are NSAIDs, ACEi/ARBs, thiazides, loop diuretics, metformin, SGLT-2 inhibitors?
The definition of a low risk PE and recommended treatment.
What is PE not associated with RV dysfunction* or hemodynamic instability AND what is anticoagulation therapy with DOAC (rivaroxaban or apixaban--others require pre-treatment w/ heparin) for minimum of 3 months
* Evidence of RV dysfunction includes biochemical markers, such as BNP/proBNP and troponin levels, as well as echo or CT evidence of RV enlargement or reduced function.
Bonus question: Alternative to anticoagulation in patient with high bleeding risk.
Common empiric broad spectrum antibiotic regimen and time frame in which it should be administered for someone with suspected sepsis of unknown source.
What is vancomycin and cefepime given within an hour of presentation (but after blood cultures are collected)?
Other options: piperacillin-tazobactam (especially if concerned about intrabdominal source), a carbapenem
-If low concern for pseudomonas, 3rd gen cephalosporin can be considered
-If severe beta-lactam allergy: aztreonam
A clinical tool that estimates probability of underlying heart failure in patients with preserved ejection fraction on echo.
What is the The H2FPEF score?
https://www.mdcalc.com/calc/10105/h2fpef-score-for-heart-failure-with-preserved-ejection-fraction
Two examples of appropriate empiric antibiotic therapy for COPD exacerbation in a hospitalized patient.
What are: respiratory fluroquinolones (i.e. levofloxacin, moxifloxacin), third generation cephalosporins (i.e ceftriaxone)
IF pseudomonal coverage indicated: cefepime, ceftazidime, piperacillin-tazobactam (Zosyn)
Bonus question: Name 2 risk factors for pseudomonal infection
Urgent indications for dialysis
What is AEIOU
A: Acidosis (metabolic, typically pH<7.1 not responsive to medical therapy)
E. Electrolyte Imbalances (severe hyperkalemia - K>6.5, hyerK w/ EKG changes or muscle weakness, >5.5 + ongoing potassium source- i.e. Rhabdomyolisis, GI bleed)
I: Ingestion/toxins (dialyzable substances such as lithium, alcohols, salicylates, ethylene glycol)
O: Overload (refractory to loop diuretics)
U: Uremia (symptomatic, ex pericarditis, encephalopathy, platelet dysfunction, intractable N/V)
Echo findings concerning for right heart strain.
What are increased R ventricle to L ventricle size ratio, "D sign" (flattened intraventricular septum or even bowing into L ventricle), dilated pulmonary artery, McConnell’s (right ventricular free wall akinesis with sparing of the apex)
At least 5 test you would order as part of your initial work-up for someone with concern for sepsis?
CBC, CMP, coags, lactate, blood gas, blood culture, site specific testing guided by hx/exam (urinalysis/urine culture, RPP, CXR, sputum culture, GIPP, etc.)