12. Emergency management of ACS,pulmonary oedema, cardiogenuc shock Flashcards
What initial steps should be taken in all patients with suspected ACS?
Brief history and assess for contraindication for PCI, fibrinolysis
ECG
Examination (JVP, pulses, murmurs, HF)
IV access
What investigations are done in all patients with ACS?
U&E’s, Troponin, Glucose, Cholesterol, FBC,
CXR
What drugs are given for suspected STEMI
Aspirin (300mg)
Tricagrelor (180mg)
Morphine (5-10mg IV)
Oxygen if sats below 95%/breathless/LVF
B-blockers- if stared early then added benefit
What drugs are given for suspected NSTEMI
Morphine 5-10mg+ metacloporomide (anti-emetic)
sats<90% low flow oxygen
Nitrates (GTN p/a)
Aspirin 300mg
What decides further management for STEMI patients?
PCI available after 120 mins of first medical response?
YES- PCI
NO- Thrombolysis (achieved with tissue plasminogen activators)
What decides further management for NSTEMI patients?
Raised troponin, dynamic ST or T wave changes, secondary criteria- invasive pathway
Normal ECG, no more chest pain, no HF- Conservative
How do you treat STEMI patients presenting after 12 hours?
Fondaparinaux (anticoagulant) or enoxaparin (anticoagulant)
What is further management in the high risk pathway of NSTEMI’s
Fondaparinaux Second antiplatelet (tricagrelor or clopidogrel) IV nitrate if pain continues Oral B-blockers Cardiologist review for angiography
What further criteria decides which patients are high risk and should receive inpatient coronary angiography
History of unstable angina
ST dperession or widespread T wave inversion
Raised troponin
Age>70 years
General comorbidity, previous MI, poor LV function or DM
What further measures should be taken in NSTEMI patients between baseline and discharge?
Wean off GTN Continue fondaparinux until discharge Check serial ECGS's and troponin levels Address modifiable risk factors Gentle mobilisation Ensure patient on dual anti platelet therapy
What are the causes of pulmonary oedema?
left sided heart failure
ARDS
Fluid overload
Nuerogenic shock
Why is pulmonary oedema tricky to diagnose?
Not much different from Asthma/COPD, pneumonia
If unsure consider treating both with furesomide, salbutamol, diamorphine and amoxicillin
If pulmonary oedema is suspected what investigations should be carried out?
ECG CXR U&E's, troponin, ABG Consider ECHO BNP
What emergency treatment should be conducted (before investigations)
Sit patient up
High flow oxygen
IV access
Treat arrhythmia’s
What drugs are given in the emergency situaiton?
Diamorphine IV (slowly) Furosemide 40-80mg (slowly) GTN (dont give if systolic <90mmHg)
What should be done if the patient is worsening?
Further doses of furesomide
Consider CPAP
Increase nitrate infusion without dropping sytolic <100mmHg
Consider alternative diagnosis
When is it classes as cardiogenic shock?
when systolic is <100mmHg
What management should be undertaken once patients are stable and improving?
Daily weights, aim reduction of 0.5kg/day
Repeat CXR
Change to oral furosemide
If on large doses of loop diuretic consider thiazide diuretic
Is patient suitable for biventricular pacing or cardiac transplantation
What is cardiogenic shock and what causes it?
Inadequate perfusion of tissues due to cardiac dysfunction.
MI, arrythmias, PE, Valve destruction
What investigations are done for cadiogenic shock?
ECG, U&E's, troponin, ABG ECHO CXR CT thorax
What do you monitor in cardiogenic shock?
CVP BP ABG ECG urine output 12 lead ECG
What is meant by cardiac tamponade?
Pericardial fluid collects–> intrapericardial pressure increases–> heart cannot fill–> pumping stops
How do you treat cardiac tamponade?
Give O2, monitor ECG adn set up IVI
Take blood for group and save
How do you treat cardiogenic shock?
Oxygen (maintain sats)
Diamorphine
Correct arhythmias/abnormalities
Optimise filling pressure
