09. AKT: ECG/CKD Flashcards
What is a precordial thump and when is it indicated?
- A precordial thump is a single, sharp blow delivered by the rescuer’s fist to the mid sternum of the victims chest
- It may be considered for patients with monitored, pulseless ventricular tachycardia if a defibrillator is not immediately available
What is preferred for defibrillation, monophasic or biphasic?
Biphasic
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
V1-V2
- Septal
- Proximal LAD
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
V3-V4
- Anterior
- LAD
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
V5-V6
- Apical
- Distal LAD, LCx or RCA
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
I, AVL
- Lateral
- LCx
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
II, III, aVF
- Inferior
- 90% RCA. 10% LCx
ECG Localisation - if these leads are affected, 1) what myocardial area is affected and 2) what coronary artery is affected?
V7, V8, V9 (reciprocal ST depressions are frequently evident in V1-V3)
- Posterolaeral (AKA inferobasal or posterior)
- RCA or LCx
What is benign early repolarisation?
- Benign early repolarization is a usually benign ECG pattern producing widespread ST segment elevation that is commonly seen in young, healthy patients less than 50 years old
- J point morphology/fish hook pattern with a high take off
- ST elevation is limited to the precordial leads
Differentials for chest pain?
Isolated musculoskeletal chest wall pain
* Costochondritis
* Low rib pain syndrome
* Sternalist syndrome
* Thoracic costovertebral joint dysfunction
Rhuematic causes
* Fibromyalgia
* Rheumatoid arthritis
* Axial spondyloarthropathy (including anklyosing spondylitis)
* Psoriatic arthritis
Non-rheumatic systemic Causes
* Osteoporotic fracture
* Neoplasm with pathological fracture or bone pain
Pharmacotherapy for haemodynamically stable patient with sustained ventricular tachycardia (lasting more than 30 seconds)?
Amiodarone300mg IV infusion over 30 minutes, followed by 900mg IV infusion over 24 hours if required
Management for haemodynamically stable patient with narrow complex tachycardia?
- Vagal manoeuvres
- Adenosine 6mg rapid IV bolus; if unsuccessful, give 12mg; if unsuccessful, give further 12mg
- Continuous ECG monitoring
What must you always consider with a ventricular rate of 150bpm (range 130-170) with narrow QRS complexes?
Atrial flutter with 2:1 block (might be hard to see the sawtooth pattern)
How can you differentiate between atrial flutter with 2:1 block and AVNRT/AVRT?
Give a test dose of adenosine
* Atrial flutter: slowing of the ventricular rate shows the sawtooth pattern
* AVNRT/AVRT: will often revert to sinus rhythm
What are delta waves and what are they associated with?
- Slurred upstroke of QRS
- Associated with pre-excitation syndromes
What are characteristics ECG findings for Wolff-Parkinson-White syndrome?
- Short PR interval (<120ms)
- Broad QRS complex (>100ms)
- Slurred upstroke of QRS (delta wave)
What are the ECG definitions for a ST elevation myocardial infarction?
- ST elevation (length varies depending on the patient demographic) in 2 or more contiguous leads
- Development of new onset left bundle-branch block (use Sgarbossa criteria)
Contraindications for the use of GTN in the acute management of suspected cardiac related chest pain?
- Suspected right ventricular myocardial infartion (pre-load sensitive)
- Recent phoshodiesterase type 5 inhibitor use -> severe hypotension
What medications should be given in out of hospital suspected cardiac chest pain?
- GTN if blood pressure is good (0.3-0.6mg tablet OR 0.4-0.8mg spray sublingually every 5 minutes for 3 doses)
- Aspirin 300mg PO STAT
- IV opioids if pain is not responsive to GTN (fentanyl preferred as morphine may reduce absorption of oral antiplatelets)
ECG characteristics for a posterior myocardial infarction?
- ST depression in V1-3 (usually horizontal)
- Tall, broad R waves (>30ms) in V1-3
- Dominant R wave (R/S ratio > 1) in V2
- Upright terminal portions of the T waves in V1-3
Note: in patients presenting with ischaemic symptoms, horizontal ST depression in the anteroseptal leads (V1-3) should raise the suspicion of posterior MI
What should you consider if a patient presents with cardiac ischaemic symptoms and has an ECG with horizontal ST depression in the anteroseptal leads (V1-3)?
Posterior myocardial infarction
ECG changes in pericarditis?
- Widespread concave ST elevation and PR depression throughout most of the limb leads and precordial leads
- Reciprocal ST depression and PR elevation in lead aVR (+/- V1)
- Sinus tachycardia is also common in acute pericarditis due to pain and/or pericardial effusion
What is Beck’s triad?
- Hypotension
- Elevated JVP
- Muffled heart sounds
NB: indicates cardiac tamponade
Clinical features of cardiac tamponade?
Beck’s triad:
* Hypotension
* Elevated JVP
* Muffled heart sounds
- Tachypnoea
- Tachycardia
- Atrial arrhythmias - e.g. atrial fibrillation
- Kussmaul sign (paradoxical rise in JVP on inspiration)
- Positive hepatojugular reflux
- Weakened peripheral pulses
- Peripheral oedema
- Cyanosis
- Pulsus paradoxus
- ECG: electrical alternans (alteration in the amplitude of QRS complexes thought to be due to the swinging movement of the heart within the pericardial cavity)
What is normal QT interval?
Men: >440ms
Women: >460ms
Causes of left ventricular hypertrophy?
- Hypertension
- Aortic stenosis
- Aortic regurgitation
- Mitral regurgitation
- Hypertrophic cardiomyopathy
- Coarctation of the aorta
Clinical features of aortic stenosis?
- Usually asymptomatic
- Decreased exercise tolerance
- Shortness of breath on exertion
- Dizziness
- Heart failure
- Angina
- Syncope
- Low volume and slow rising carotid pulse
- Mid to late peaking systolic murmur in the right intercostal space
How do you differentiate between the murmurs of aortic stenosis and hypertrophic cardiomyopathy?
HCM:
* An increase in intensity, due to enhancement of obstruction, is seen with the assumption of an upright posture from squatting, sitting, or supine position
* Increase in intensity during Valsalva manoeuvre
* Decrease in intensity, due to attenuation of obstruction, is heard after going from a standing to a sitting or squatting position
Aortic stenosis: does not change substantially with the above
What is the management of acute symptomatic bradycardia?
Atropine 500microg IV, repeat after three to five minutes if necessary, up to a maximum of 3 mg
Note: if atropine isn’t effective, consider transcutaneous or temporary transvenous pacing
Causes of frequent or symptomatic premature ventricular complexes?
- Anxiety
- Sympathomimetic’s
- Beta agonists
- Excess caffeine
- Hypokalemia
- Hypomagnesemia
- Digoxin toxicity
- Myocardial ischaemia
What is the optimal long-term ventricular rate for patients in AF?
85 BPM
List indications for dose reduced apixaban
- Age 80 or older
- Weight 60 kg or less
- Serum creatinine 133 or more
What complication are you concerned about after an inferior myocardial infarction?
Third degree atrio-ventricular block
* 20% of patients will develop a 2nd degree or 3rd degree AV block
* Bradyarrhythmias and AV block in the context of inferior STEMI are usually transient (lasting hours to days), respond well to atropine and do not require permanent pacing
List some commonly prescribed drugs that may need to be reduced in dose or ceased in chronic kidney disease
- Allopurinol
- Apixaban
- Benzodiazepine’s
- Colchicine
- Fenofibrate
- Gabapentin
- Gliclazide
- Metformin
- NSAIDs
- Opioids
- Pregabalin
- Rivaroxaban
- Sitagliptin
- Sotalol
- Spironolactone
At what renal function is metformin contraindicated?
eGFR < 30
What change in eGFR and serum potassium is acceptable when starting an ACEi or ARB?
- Reduction in eGFR less than 25% within 2 months of starting therapy
- 0.5mmol/L rise in serum potassium is expected
- ACEi and ARBs can be safely prescribed at all stages of CKD and should not be deliberately avoided just because eGFR is reduced
Causes of nephrotic syndrome in children?
- Idiopathic - 90%
- Systemic lupus erythematosus
- Henoch Schonlein Purpura
Classic triad of nephrotic syndrome?
- Oedema - can be non-dependent locations e.g. periorbital
- Proteinuria
- Hypoalbuminuria
Diagnostic criteria for nephrotic syndrome on investigations?
- Heavy proteinuria (dipstick 3-4+ or urine protein/creatinine ratio >0.2g/mmol = >200mg/mmol)
- Hypoalbuminaemia (<25g/L)
