ACC Flashcards
anyones who’s critially ill
15L oxygen in non-rebreathe mask
what does the TIMI score do
Assesses the risk of mortality in patients with unstable angina or NSTEMI
management of all pt with chest pain suspected to be cardiac
Morphine - Oxygen – 15L non-re-breathable mask, aim for 94-98% (88-92% in COPD patients) Nitrates (GTN spray) Aspirin (300mg PO) Ticagrelor 180mg PO
for STEMI Mx
Ring PRIMARY PERCUTANEOUS INTERVENTION
If PCI is unsuccessful or cannot be performed (> 120 mins after STEMI); thrombolysis can be performed
Once a STEMI has been confirmed the first step is to immediately assess eligibility for coronary reperfusion therapy. There are two types of coronary reperfusion therapy: PCI or thrombolysis
Patients undergoing PCI should also receive
either an unfractioned heparin or LMWH (such as enoxaparin) as further anticoagulation.
If PCI cannot be performed, what can be administered with the thrombolytic drug.
LMWH, unfractioned heparin or fondaparinux
Non-stable angina/NSTEM Mx
Offer fondaparinux to patients who do not have a high bleeding risk, unless coronary angiography is planned within 24 hours of admission
Offer unfractionated heparin as an alternative to fondaparinux to patients who are likely to undergo coronary angiography within 24 hours of admission
2d prevention of STEMI / NSTEMI
B blocker ACE inhibitor Aspirin – 75mg PO daily Statin e.g. Atorvastatin Clopidogrel/ticagrelor
ACS SUMMARY:
ECG & CXR
If ACS confirmed: aspirin 300mg, ticagrelor 180mg and analgesia
If STEMI: PPCI + LMWH
If NSTEMI/unstable angina: calculate risk score (e.g. TIMI/HEART’GRACE)
If not for PCI in 24 hours, give fondaparinux
Secondary prevention: atorvastatin 80mg PO, aspirin 75mg PO, clopidogrel 75mg, ACEi, B blocker
stable angina Mx - short term
Sublingual glyceryl trinitrate (GTN spray) - works by vasodilation
call an emergency ambulance if the pain has not gone 5 minutes after taking a second dose
long term Mx stable angina
Consider aspirin 75 mg daily for people with stable angina
Consider angiotensin-converting enzyme (ACE) inhibitors for people with stable angina and diabetes
offer statin
PE acute Mx
A to E;
(Oxygen 15L, monitor RR and pulse oximetry
Obtain IV access, monitor BP, HR, take ABG and bloods
Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40 mm Hg, for 15 minutes
Give analgesia if necessary (e.g. morphine)
heparin or fondaparinux
long ter Mx following OE
avoid dehyndartion encourage mobilisation aspirin /antiplatelet therapy compression stockings warfarin / rivaroxaban continue LMWH is malignant or pregnent
massive PE Mx
Thrombolysis e.g. alteplase
Thrombolysis is only used for massive PE where there are signs/risk of cardiac arrest. Not used routinely for all PEs because 4% risk of intracranial haemorrhage.
MSK chest pain - rib fracture Mx
Check for features which are suggestive of pneumothorax - if there are any CXR
Warn patient that rib may remain painful for >3 weeks and to seek medical advice if additional symptoms develop
Prescribe oral analgesia e.g. co-codamol
MSK chest pain - costochondiasis Mx
Causes unknown, but are associated with URTI and excessive coughing
Assessment: ECG and CXR to exclude other diagnoses
Management: usually resolves within a few months, advise NSAIDs and paracetamol, consider physiotherapy
fibromyalgia Mx
CBT
physiotherapy
pain Mx
Aortic Dissection Mx
Initial assessment – high flow oxygen and IV access (2 large bore cannulas); fluid resuscitation should be done cautiously
Adequate analgesia – e.g. morphine
Refer to Cardiac-Thoracic surgeons and transfer to an intensive care unit or high dependency unit
Reduce stress on aorta by managing HTN aggressively – IV beta blockers e.g. labetalol - aim for systolic pressure of 100-120 mm Hg
pericarditis (with effusion, and with tamponade) initial management - treat underlying cause
e.g. bacterial infection: blood cultures, empirical antibiotics – IV flucloxacillin and gentamicin/cefotaxime
symptom relief for pericarditis
Corticosteroids and NSAIDs can be used as symptomatic relief, especially for rheumatic fever or idiopathic
Do not use NSAIDs in first few days after MI though – as they are associated with increased risk of myocardial rupture
Pericardiocentesis – consider for significant effusion or signs of cardiac tamponade
cardiac tamponade - pericardial sac fills pressure is put on the ventricles, which compromises their pumping function. Mx
Airway management 15 L oxygen, pulse oximetry, ABG BP, fluids IV, pulse and HR Consider inotropes (i.e. adrenaline) Pericardiocentesis (If it keeps coming back after being drained, then it is most likely the result of malignancy - can create a window through which the fluid can drain)
acute AF Mx - in acute setting what do you need to Be thinking about TART)
In acute setting, you need to be thinking about:
Treating any precipitating factors that may have triggered AF e.g. infection/sepsis, PE, thyroid disease, ischaemia/MI
Assessing the patient’s stroke risk and need for anticoagulation
Controlling the rapid heart rate
Controlling the symptoms of an irregular rhythm
Mnemonic for this: Trigger Anticoagulation Tachycardia Rhythm
Rhythm control in haemodynamic instability AF
either electrical cardioversion – or pharmacological – flecainide or amiodarone
rate control in AF
B blockers and diltiazem/verapamil
anti-coagulation in AF
LMWH
SVT Mx - A to E Mx;
Oxygen 15L
IV access and take bloods
BP and O2 monitoring
12 lead ECG
For SVT need to identify adverse features including; Shock (systolic BP < 90mmHg) Syncope Myocardial ischaemia Heart failure if pt has adverse features what is Mx?
Synchronised DC shock (cardioversion)
For SVT need to identify adverse features including; Shock (systolic BP < 90mmHg)
Syncope
Myocardial ischaemia
Heart failure
If patient doesn’t have adverse features:
Vagal manoeuvres – e.g. lie flat and head down, carotid sinus massage (ensure no bruits first)
Most cases are treated with ADENOSINE –
If this does not revert the SVT – call for expert help
If pulseless VT – cardiac arrest – ALS protocol!
Also need to idetify adverse features including;
Identify adverse features (will inform management):
Shock – Assess BP
Syncope
Myocardial ischaemia – Assess with ECG
Heart failure – Assess with listening to chest or echocardiography
if adverse features present for VT what is Mx
Synchronised DC shock (cardioversion)
If no adverse features for SVT what is Mx
Still a medical emergency as can degenerate into unstable VT and VF
Treat with Amiodarone infusion
Cardioversion if medical therapy fails (will need sedation for this)
complete heart block Mx - chronic Mx
Pacemaker implantation
complete heart block acute Mx
Check blood pressure
Atropine IV
Isoprenaline (2nd line)
cardiac arrest Mx
Approach patient, checking for safety. Call for help (crash trolley – 2222).
Open airway with head tilt/chin life manoeuvre, palpate the carotid pulse and look, listen and feel for breathing for 10 seconds
If there is a risk of a cervical spine injury, open the airway using a jaw thrust
If no pulse, or signs of life – commence cardiopulmonary resuscitation (CPR) in ratio of 30 compressions to 2 ventilations, depth of 5-6cm at rate 100bpm
dose of adrenaline for cardiac arrest
1mg 1:10,000 IV
A to E Mx ALS - A
Check airways for mechanical obstruction! Make sure ventilation is up and running with LMA or intubation.
A to E Mx ALS - B
Make sure chest is expanding with the ventilation and thus patient is getting oxygen.
A to E - ALS protocol C
IV access! 2 large bore cannulas. BP assessed; fluid bolus given if required. If IV access cannot be obtained within two minutes, use intraosseous (IO) access.
try to identify the reversibel causes cardiac arrest
Hypoxia – oxygen delivered via LMA and bag-valve-mask
Hypovolaemia – IV access – check BP, and then give IV 500 ml fluid bolus over 15 minutes
Hypothermia – assess temperature and if low, re-warm
Hypokalaemia – VBG and correct balance
Hyperkalaemia – VBG – correct balance with hyperkalaemia management: calcium gluconate, insulin (with dextrose) and salbutamol
Thrombosis – assess by hx of risk factors and P/C, and bedside USS (or echocardiography), treat with LMWH or thrombolysis (e.g. fibrinolytics – Alteplase)
Tension pneumothorax - auscultate the patient’s lung fields during ventilations and perform needle decompression if indicated
Toxins – look at drug chart and collateral hx
Tamponade - obtain a beside echocardiogram (echo) and perform pericardiocentesis as indicated
Mx hypothermia
Removing the patient from the cold environment and removing any wet/cold clothing,
Warming the body with blankets
Securing the airway and monitoring breathing,
If the patient is not responding well to passive warming, you may consider maintaining circulation using warm IV fluids or applying forced warm air directly to the patient’s body
pneumonia Mx
Consider Pain relief: paracetamol or NSAIDs.
In patients with COPD or asthma, consider treatment with salbutamol.
Antibiotics:
Start on empirical antibiotics as soon as blood cultures have been sent.
ABx Tx used in CAP pneumonia
Example of antibiotics used for CAP pneumonia:
Mild/moderate: Amoxicillin plus clarithromycin or doxycycline
Severe: Co-amoxiclav plus clarithromycin
3 aims of the Mx of COPD
Correct hypoxaemia
Correct acidosis: by reducing hypercapnia (or preventing further hypercapnia)
Remove cause of exacerbation e.g. infection
Too much oxygen in someone with chronic hypoxaemia can lead to dangerous CO2 levels. In someone who retains CO2, the amount of oxygen that is given needs to be carefully balanced to optimise their pO2 whilst not increasing their pCO2. This is guided by what two things?
oxygen saturations and repeat ABGs.
what mask do you use in COPD
Venturi masks are designed to deliver a specific percentage concentration of oxygen
medical Mx COPD
Nebulised bronchodilator driven through oxygen e.g. salbutamol, ipratropium
Steroids
Antibiotics if evidence of infection e.g. amoxicillin
Infective exacerbation of COPD: first-line antibiotics are what?
amoxicillin or clarithromycin or doxycycline
Options in severe infective exacerbation of COPD cases not responding to first line treatment
IV aminophylline
Non-invasive ventilation (NIV)
Intubation and ventilation with admission to intensive care
acute exacerbation of asthma - acute but clinically stable PEF >75%
Give Salbutamol 5mg nebuliser driven through oxygen
Consider nasal cannula if hypoxic (because nebuliser max flow rate only = 6L)
Consider ipratropium 0.5mg through nebuliser if severe/life-threatening asthma
Give Prednisolone 40-50mg orally,
if clinically unstable asthma PEF <75%
Repeat salbutamol (+ ipratropium) nebs after 15 minutes
Consider continuous salbutamol nebuliser 5-10mg/hr
Consider IV magnesium sulphate 1.2-2mg over 20 minutes
Correct fluid/electrolytes, especially K+ disturbances
after acute exaberabtion asthma Mx
observation after nebulisers
PEFR must be >75% expected prior to discharge
Check inhaler technique
Organise FU in GP
All patients should be given prednisolone orally (PO) daily, which should be continued for at least five days
pneumothorax Mx - standard pneumothorax do CXR before attempting to treat
If the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
Otherwise, aspiration should be attempted
If this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
secondary pneumothroax Mx (all pt should be admitted for 24hrs at least)
If the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted
Otherwise aspiration should be attempted if the rim of air is between 1-2cm
tension pneumothorax Tx
Aspiration – 2nd intercostal space, midclavicular line
And the chest drain - to continue decompression
pulmonary oedema Mx
Breathing:
Sit the patient up in bed
15L O2 is critically unwell, venturi mask if COPD
If dyspnoea cannot be significantly improved, CPAP or intubation may be necessary
Fluid Management:
Diuretic e.g. furosemide
treat underlying cause
DVT Mx - Low risk well’s score (<2) and low D-dimer
no further investigation is required, can discharge
DVT Mx - High risk well’s score (≥2) OR low risk and high D-dimer
lower leg USS
Prescribe Rivaroxaban
following the diagnosis of a DVT what is the Tx
Apixaban or rivaroxaban (both DOACs) should be offered first-line
Instead of using low-molecular weight heparin (LMWH) until the diagnosis is confirmed, NICE now advocate using a DOAC once a diagnosis is suspected, with this continued if the diagnosis is confirmed
Length of anticoagulation following a VTE
provoked - 3 months
unprovoked - 6 months
cellultitis Mx - analgesia, follow up, admission if systemically unwell - what ABx
flucloxacillin
If this is unsuitable, or the person has a penicillin allergy, prescribe either:
Clarithromycin or Doxycycline
complicated cases of cellulitis
IV flucloxacillin
or IV clindamycin or vancomycin if CI
acutely iscahemic leg Mx - Resuscitation: 15L oxygen IV access – heparin infusion Analgesia e.g. opioids and what else?
surgical Mx - Re-vascularization is required within 6hr to avoid permanent muscle necrosis
