A&E Flashcards
Criteria for PCI in ACS
<12 hrs of pain (symptoms) and one of: - (within 120 mins of medical contact can get PCI)
2+ consectutive >1mm STE in limb leads
2+ >2mm STE in chest leads
LBBB
Depolarisation right to left
Prolonged QRS
Negative S wave in aVR
Tall R wave in lateral leads
Notched S/R wave (W/M) due to sequential ventricle contraction rather than simultaneous.
Posterior infarct
ST dep and tall r wave
RBBB ECG
Broad QRS > 120 ms
RSR’ pattern in V1-3 (‘M-shaped’ QRS complex)
Wide, slurred S wave in the lateral leads (I, aVL, V5-6)
Associated Features
ST depression and T wave inversion in the right precordial leads (V1-3)
LBBB ECG
QRS duration of > 120 ms
Dominant S wave in V1
Broad monophasic R wave in lateral leads (I, aVL, V5-V6)
Absence of Q waves in lateral leads (I, V5-V6; small Q waves are still allowed in aVL)
Prolonged R wave peak time > 60ms in left precordial leads (V5-6)
Associated Features
Appropriate discordance: the ST segments and T waves always go in the opposite direction to the main vector of the QRS complex
Poor R wave progression in the chest leads
Left axis deviation
Thrombolysis for NSTEMI?
Never
Pathway NSTEMI
MONA Fondaparinux/ Heparin BB ACEi Prasugrel (IV nitrate possible) Cardiologist review - ongoing angina and evolving ST changes, cardiogenic shock or life threatening arryhtmias (120mins - <24 hrs if high risk (GREACE) - Within 72 if lower risk
HIgh risk NSTEMIS
History of unstable angina Age >70 High rise in Trop ST dep or widespread T wave inversion Comorbidities, previous MI
How to treat HF acutely
Management Patient sat upright Controlled O2 IV access and ECG Diamorphine Furosemide 40-80mg IV slowly GTN spray IF BP >100 isosorbide dinitrate infusion to keep systolic >90 Consider More furesemide CPAP Increase nitrates If BP <100 Fluids if underfulled Inotrophic support e.g. dobutamine if well filled - aiming MAP of 70
Broad complex tachy treatment
If stable:
Correct K/Mg
Amiodarone 300mg 20-60 mins via central line
Failure or long QT then DC cardiovert
After
Find cause - think PCI?
If after MI give IVC amioderone for 12-24hr and start oral sotalol (good LV function) or amiodarone (poor LV function)
High risk may need implanable deful
Adenosine MoA and effects/ side effect
• Endogenous but can also be given
• Acts on A1 of AV node inhibitin adenylyl cyclase?
• Enhances K+ conductance (decrease efflux) – hyperpolarises cells of conducting tissue
• Decrease cAMP
• Anti-arrhythmic – given via IV, very short acting.
• Causes vasodilatation
Slows ventricles showing underlying rhythm. 6mg then 12 after 2 min then another 12mg
Reg narrow complex tachy
Adenosine
Verapamil 2.5-5mg IV over 2 min. repeat
OR atenolol 2.5mg IV
OR amioderone
Failure = DC cardiovert
Bradycardia treatment
12 lead
Check electrolytes
Treat cause (e.g. glucagon if a BB)
Risk of asystole give atropine500 ug
If not then seek help e.g. transcutanous pacing
While waiting give Isoprenaline (beta agonist), adrenaline or repeat atropine
Clinical state more important than HR
Asthma classification
Mild: • No features of severe asthma • PEFR >75% Moderate: • No features of severe asthma • PEFR 50-75% Severe (if any one of the following): • PEFR 33 – 50% of best or predicted • Cannot complete sentences in 1 breath • Respiratory Rate > 25/min • Heart Rate >110/min Life threatening (if any one of the following): • PEFR < 33% of best or predicted • Sats <92% or ABG pO2 < 8kPa • Cyanosis, poor respiratory effort, near or fully silent chest • Exhaustion, confusion, hypotension or arrhythmias • Normal pCO2 Near Fatal: • Raised pCO2
Acute asthma management
Acute Asthma Management:
• ABCDE
• Aim for SpO2 94-98% with oxygen as needed, ABG if
sats <92%
• 5mg nebulised Salbutamol (can repeat after 15 mins)
• 40mg oral Prednisolone STAT (IV Hydrocortisone if
PO not possible)
If severe:
• Nebulised Ipratropium Bromide 500 micrograms
• Consider back to back Salbutamol
If life threatening or near fatal:
• Urgent ITU or anaesthetist assessment
• Urgent portable CXR
• IV Aminophylline
• Consider IV Salbutamol if nebulised route ineffective
COPD acute management
Infective
o Change in sputum volume / colour
o Fever
o Raised WCC +/- CRP
• Non-infective
ABCDE approach
Oxygen:
- via a fixed performance face mask due to risk of
CO2 retention
- aim for SaO2 88-92% being guided by ABGs
• NEBs – Salbutamol and Ipratropium
• Steroids – Prednisolone 30mg STAT and OD for 7
days
• Antibiotics if raised CRP / WCC or purulent sputum
• CXR
• Consider IV aminophylline
• Consider NIV if Type 2 respiratory failure and pH
7.25-7.35
• If pH <7.25 consider ITU referral
Can give doxapram (resp stim) if no response
Physio to aid mucus clearence?
Penumothorax
tension
14-16g then chest drain
Primary pneumothorax
SOB/ 2cm air - apirate and discharge unless failure then chest drain
Secondary
SOB or 2cm - chest drain If not (1-2cm) then aspriate. If failure chest drain. if success admit for 24hrs
