Oral Boards:
Have a system/flow/approach, use the grid layout if that helps
Remember to go through AMPLEFRIENDS
Make sure to let the patient know what you’re doing/why.

Cardiac Tamponade:
200-400cc of fluid usually necessary to cause tamponade, faster accumulation more likely to cause tamponade.
Cardiac path (CA, trauma, etc) -> pericardiac filling -> cycle of heart failure to pump against building pressure
Signs: SOA, CP, fatigue, dizziness, elevated JVD, hypotension, narrow pulse pressure, possible cardiomegaly
-Beck’s triad only 10% of the time
EKG: sinus tach or alternans
Dx: clinically, can use US +/- CXR, EKG
Tx: 1L IVF, pericardiocentesis, window

AAA:
50% increase in normal diameter (normal ~3cm)
Infrarenal is most common location (classified by where it starts/location of most superior aspect)
Smoking and Age are biggest RFs, also fluorquinolones (don’t use em)
Asymptomatic Signs: pulsatile abdominal mass
Symptomatic non-rupture: abd pain, back pain, flank pain, limb ischemia
Symptomatic ruptured: pain, hypotension, pulsatile mass. Pain radiating to back.
Dx: Stable gets CTA (non-con CT for those who can’t do contrast). Unstable gets OR (CT surg or vascular) if known AAA, if unknown then US.
Tx: crossmatch 6U, pain control, esmalol/labetalol/nitroprusside (permissive hypotension 80-100 SBP if conscious), get them to OR
Complications: aortoenteric fistula, aortocaval fistula, limb ischemia, graft infection, inflammatory AAA, endoleak
Beware of thrombolytics since it can break up mural thrombus and send emboli

Aortic Dissection:
Tear in aortic intima. Type A involves ascending aorta, Type B doesn’t
Hypertension is #1 RF, also some sort of prior cardiac path, connective tissue disorders, inflammatory vasculitities
Hx: sudden onset chest pain most common, look for pulse deficit
Paraplegia if it involves the vertebral arteries
Mitral valve complications if involvement of aortic root
Horner’s syndrome if dissection compresses superior cervical ganglion
Dx: BP in both arms, CTA chest
Tx: control HR and BP, as well as pain
-Esmolol (quick on/quick off, good for HR control, titrate to HR 60-70), add cardene if BP still too high once HR controlled (SBP goal 100-110)
-Fentanyl for pain
Surgery for Type A, Type B can be medically managed
Complications: MI, Tamponade, rupture

Air embolism:
Iatrogenic is common, occurs due to pressure gradient (low pressure in venous system allows air from central line to easily enter system)
Central line air embolism 1 in 772
RFs: patient sitting upright, hypovolemic, negative intrathoracic pressure
Lethal dose thought to be 200-300cc of air (3ml/kg)
Signs and symptoms: sudden CNS/Resp/cardiac symptoms with central line placement
-looks like PE with CP, SOB, cough, tachy, syncope, anxiety, possible cardiac arrest, mental status change
Tx: prevent further air, reduce air volume, 100%FiO2, fluids, ionotropic support, hyperbaric oxygen (less so with CVC related), ECMO, L lateral decub positioning (takes embolus out of RV outflow track), and trandelenburg (unless arterial then avoid for cerebral complications)
Prevention: flush lumens and cap hubs prior to placement, adequately hydrate patient, keep insertion site below the heart

SHOCK:
Hypotension doesn’t mean hypoperfusion
Stressor->body compensates->decompensates->end-organ dysfunction->Death
-goal is to treat the stressor
diastolic is good indicator for PVR, systolic is good indicator for the strength of the heart
Shock index: HR/SBP, normal is 0.5-0.7 (HR goes up before BP)
Lactate up in times of lack of blood flow/oxygenation, but also depends on sympathetic nervous system and B-blockade can lead to lower lactate despite how sick patient is
Shock types: Obstructive, cardiogenic, hypovolemic, distributive
Obstructive: decreased CO, increased CVP, increased SVP (trying to shunt blood to heart), cool extremities (from shunting)
-PE, tension pneumo, tamponade, restrictive pericarditis, abdominal compartment syndrome, dissection
Cardiogenic: decreased CO, increased CVP, increased SVR, cool extremities
-MI, arrhythmia, cardiomyopathy, valve disease
-Ionotropes: dobutamine, milrinone, dopamine, epi (below 5-10mcg/kg/min)
-Milrinone solely renal clearance and better in chronic B-blockade, dobutamine is fast on/fast off. Make sure properly fluid resuscitated prior to starting these meds
Hypovolemic: CO normal or decreased, decreased CVP, increased SVR (trying to get blood back to heart), cool extremities (elderly might be a little warm due to slowed response)
-Fluid loss (GI/kidney/skin/DKA/3^rd space) or hemorrhage
-Permissive hypotension (MAP 65-70) has mortality benefit in trauma
-Balanced resuscitation (whole blood, keeping prbcs:ffp:plts 1:1:1)
-Calcium will be low because all the product are in citrate which will bind Ca so make sure to replete
Distributive: Septic, anaphylactic, neurogenic
Anaphylactic: consider delayed sequence intubation, need IM epinephrine (slowly diffuses over hours), consider glucagon if chronically B-Blockade
Neurogenic: Dx of exclusion, MAP>85