Acute cardiac

Question 1

ACS initial management

Answer 1

Keep on cardiac monitor
Serial ECG and troponins
Monitor for chest pain
Bedside echo to look at LV function and evidence of complications e.g., VSD

o Aspirin (+ticagrelor 180) (300mg initially, then maintenance 75mg OD)
o Oxygen (if O2 sats <94%)
o If in pain, morphine 2-4mg IV every 5-15 minutes + Metclopr 10mg
 Unless Inferior MI (II/II/AvF ST elevation - may have RV involvement, preload dependent)
o GTN (0.3-1mg sublingually)
 Unless inferior MI, see above

Question 2

Haemodynamically unstable ACS management

Answer 2

Urgent focussed TTE to evaluate LV function
o PCI within 48h [NSTEMI] OR immediate [STEMI]
o Aim for Door2Cathlab time of 90 minutes, Door2Needle 90min
o Anticoagulation guidelines pre lab:
 Heparin + Abiciximab (gp2b3a-i) (HEAT-PPCI trial 2014)
 OR bivalirudin (ACUITY trial 2009)
o aspirin 300mg, Ticagrlor 180 (PLATO 2009), morph and oxygen A/A
o Ionotropic support if required (dobutamine, involve ITU) +/- mechanical circulatory support (VA-ECMO or Impella)

Question 3

Chest pain DDX

Answer 3

I would normally like to start by ruling out the more sinister differential diagnoses first, including: Pulomnary causes (3P), Cardiac causes (4A,P), gastro causes (P, PPU) gynae (Ectopic), and if no cause is identified among these I would think about alternative low-risk causes such as msk/panic
* Pulmonary : PTX, PE, pneumonia
* Cardiac: ACS, Ao Dissect, Aort Sten, sev Anaemia, Pericarditis
* Gastro causes: Pancreatitis, Perf peptic ulcer
* Gynae causes: ectopic pregnancy

Question 4

Key features in Aortic dissection

Answer 4

AD specific: tearing pain, very sudden. Radiates to back, may also extent to head, arms, neck, legs etc.

RF to look out for: Hx of CT disorder, Ao aneurysm, trauma, HTN, atherosclerosis, aortitis (Takayatsu, syphillis, AS). Iatrogenic recently (TAVI/PCI)

Question 5

Acute management of aortic dissection

Answer 5

• ABCDE, 10U X-Match, Bloods, Fluid resuscitate and send to CT for CT-Thorax concurrent to resuscitation.
• Monitor pulse and BP in both arms until Vascular surgery see, insert urinary catheter and call ITU to prepare for possible need for bed.

Type A
* Treated surgically, emergency surgery (high risk of tamponade) to replace the aortic arch with a tube graft.
* Aortic valve may be replaced if compromised.

Type B
* Lower risk of tamponade therefore may be managed medically or endovascularly.
* Medical = IV nitroprusside or IV labetalol (or CCB nifedipine if BB C/I).
* Surgical = in patients with uncontrollable HTN, expanding dissection, if symptomatic with chest pain which worsens or if there is compromise of a vessel (i.e. mesenteric ischaemia). Repair usually preformed endovascularly.

Question 6

Cmx of aortic dissection

Answer 6

Complications include aortic rupture, cardiac tamponade, coronary/brain/gut ischaemia, spinal ischaemia leading to paralysis

Question 7

Types of tachyarrhythmias

Answer 7

Narrow vs broad complex

Narrow complex - atrial, supraventricular or AV nodal (‘junctional’)

Broad complex - ventricular or supraventricular with bundle branch block

Question 8

ACLS management of tachyarrhythmias

Answer 8

ECG, BP and SpO2 monitoring

Establish whether adverse features present (HF, chest pain, low BP, hypoxia) - if YES, up to 3x synchronised DC shocks

If no adverse features, establish whether NARROW complex vs BROAD

If BROAD [likely VT, could be SVT with BBB] -> Amiodarone 300/1h then 900/24h & monitor for instability and shock requirement

If NARROW & REGULAR [likely SVT / EAT / MAT / Junctional] - try vagal manouvres, if no success adenosine 6/12/12

If NARROW & IRREGULAR - rate control with BB/ CCB/ digoxin/ amiodarone, CHADSVASC HASBLED, investigate for new AF/flutter, consider DCCV under TOE