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Year 4 ACC > Acute Medicine Core Conditions > Flashcards

Acute Medicine Core Conditions Flashcards

1
Q

What is ACS?

A

Acute coronary syndrome

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2
Q

What does ACS refer to?

A

Symptoms resulting from acute myocardial ischaemia. It refers to an NSTEMI, STEMI and unstable angina

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3
Q

ACS is divided into two groups, what are they?

A
  1. STEMI

2. NSTEMI and unstable angina

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4
Q

What is the difference between an NSTEMI and unstable angina?

A

An NSTEMI will have biochemical changes, e.g. raised troponin, whereas unstable angina will not have a rise in enzymes

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5
Q

What is the initial management of ACS?

A
  • All patients with suspected ACS should be placed on ECG monitoring and be an environment with defibrillation capacity
  • Give 300mg aspirin and 300mg clopidogrel (though some evidence indicates 600mg loading dose of clopidogrel achieves quicker platelet inhibition)
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6
Q

Why should IM injections be avoided in someone with ACS?

A

As this would cause a rise in creatinine kinase and there is a risk of bleeding with thrombolysis/anticoagulation

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7
Q

What is the immediate assessment of someone with ACS? (9)

A
  1. Rapid examination (to exclude hypotension/identify and treat acute pulmonary oedema)
  2. Secure IV access
  3. 12-lead ECG
  4. High-flow O2 (if sats are low)
  5. Diamorphine 2.5-10mg IV PRN
  6. Anti-emetic (metoclopramide 10mg IV)
  7. GTN spray 2 puffs (unless hypotensive)
  8. Take bloods - FBC/U&Es, glucose, cardiac enzymes, lipid profile
  9. Portable CXR (assess cardiac size, pulmonary oedema)
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8
Q

What conditions may mimic the pain of ACS? (7)

A
  1. Pericarditis
  2. Dissecting aortic aneurysm
  3. Pulmonary embolism
  4. Oesophageal reflux
  5. Biliary tract disease
  6. Perforated peptic ulcer
  7. Pancreatitis
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9
Q

In addition to ST elevation on an ECG, what other ECG finding is treated exactly the same as a STEMI?

A

Left bundle branch block

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10
Q

What is the typical presentation of a STEMI? (5)

A
  1. Chest pain (similar to angina but greater severity)
  2. Nausea and vomiting
  3. Sweating
  4. Breathlessness
  5. Distress
    * the pains may be atypical - epigastric or radiate through to the back
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11
Q

When are people more likely to suffer silent (painless) MIs? (3)

A
  1. Diabetic patients
  2. Elderly patients
  3. Hypertensive patients
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12
Q

What are the presenting features of a silent STEMI? (5)

A
  1. Breathlessness (acute pulmonary oedema)
  2. Syncope (from arrhythmias)
  3. Acute confusional states (mania/psychosis)
  4. Diabetic hyperglycaemic crises
  5. Hypotension/cardiogenic shock
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13
Q

What treatment is more urgent in patients with STEMI compared to NSTEMI/UA?

A

Reperfusion (PCI) - all patients with STEMI should be admitted to CCU

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14
Q

What factors are associated with a poor prognosis in people experiencing a STEMI? (7)

A
  1. Age >70
  2. Previous MI
  3. Anterior MI or RV infarction
  4. Hypotension at presentation
  5. DM
  6. Mitral regurgitation
  7. Ventricular septal defect
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15
Q

How is a STEMI diagnosed?

A
  1. History
  2. ECG
  3. Biochemical markers
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16
Q

What height does the ST elevation need to be to fulfil criteria for thrombolysis?

A

> 2mm in chest leads or >1mm in limb leads

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17
Q

If there is ST elevation in leads V1-V4/5, where has the STEMI occurred?

A

Anteriorly

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18
Q

If there is ST elevation in leads II, III and aVF, where as the STEMI occurred?

A

Inferiorly

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19
Q

ST elevation in V5 - V6 and/or I aVL, where has it occurred?

A

Laterally

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20
Q

ST elevation in II, III aVF, V5-6, where has it occurred?

A

Inferolateral

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21
Q

Which cardiac troponins are highly sensitive and specific markers of cardiac injury? (2)

A

TnI and TnT

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22
Q

What are troponins a measure of?

A

Myocyte damage

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23
Q

What are the causes of raised troponins other than MI? (6)

A
  1. Sepsis
  2. Myocarditis/pericarditis
  3. PE
  4. Cardiac failure
  5. Renal failure
  6. Stroke
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24
Q

In addition to dual antiplatelets, morphine, nitrates and oxygen, what else is given to patients with a STEMI?

A
  1. Beta-blockers - can limit infarct size and reduce mortality
  2. ACE inhibitors (within first 24 hours of presentation)
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25
Q

What are the contraindications for giving beta-blockers post-STEMI? (4)

A
  1. HR <60 or SBP <100mmHg
  2. Heart failure
  3. Airway disease
  4. Large inferior MI involving right ventricle
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26
Q

What is the time window in which PCI can be performed on someone with an MI?

A

12 hours from onset

27
Q

What is the difference in terms of time between a STEMI and NSTEMI/UA?

A

A STEMI will be diagnosed rapidly whereas NSTEMI/UA may not be definitive until progression over hours to days

28
Q

What is the initial management of someone with an NSTEMI/UA? (6)

A
  1. Strict bed rest
  2. ECG monitoring
  3. O2, aspirin 300mg PO, SL nitrate
  4. Morphine IV PRN and metoclopramide 10mg IV
  5. FBC, cardiac enzymes, lipid profile, CRP, TFT
  6. Portable CXR
29
Q

What is the management/treatment for NSTEMI/UA? (5)

A
  1. Continuous ECG monitoring
  2. O2
  3. Analgesia: diamorphine (+metoclop), GTN
  4. Aspirin, clopidogrel, LMWH
  5. Beta-blockers (metoprolol)
  6. High-dose statins
30
Q

What may be seen on an ECG for NSTEMI? (3)

A
  1. ST-segment depression of >0.05mV = myocardial ischaemia
  2. T-wave inversion is sensitive but not specific
  3. Very rarely Q waves evolve
31
Q

What questions/focussed history would be asked in a patient presenting with tachyarrhythmias >120? (7)

A

Associated symptoms/cardiac history/conditions associated with arrhythmias

  1. Previous cardiac disease
  2. Palpitations/dizziness
  3. Chest pain
  4. AF?
  5. Alcohol?
  6. Thyrotoxicosis?
  7. Valve disease?
32
Q

What investigations should be done in someone with tachyarrhythmias >120?

A
  1. ECG
  2. Blood tests: FBC, U&Es, cardiac enzymes, blood cultures, CRP, TFTs, ABG
  3. CXR
33
Q

What is the typical presentation of PE? (5)

A
  1. Sudden onset
  2. Pleuritic chest pain
  3. Breathlessness
  4. Haemoptysis
  5. Postural dizziness/syncope
    (massive PE may present as cardiac arrest)
34
Q

What are the typical signs on examination for PE? (5)

A
  1. Tachycardia
  2. Tachypnoea
  3. Cyanosis (large PE)
  4. Examine lower limbs
  5. Mild fever
35
Q

What are the causes of PE? (8)

A
  1. Most frequently secondary to DVT
  2. Septic emboli (e.g. tricuspid endocarditis)
  3. Fat embolism (post-fracture)
  4. Air embolism (venous lines, diving)
  5. Amniotic fluid
  6. Parasites
  7. Neoplastic cells
  8. Foreign bodies
36
Q

What is the problem with the D-dimer test? (in terms of sensitivity and specificity)

A

It is very sensitive but not specific - the D-dimer will exclude PE with 95% accuracy, but a positive D-dimer does not necessarily indicate it is a PE

37
Q

Which investigation is the gold standard for PE?

A

Pulmonary angiography

38
Q

What is the management for someone with a PE? (7-ish)

A
  1. Obtain venous access and start IV fluids (crystalloid or colloid)
  2. Give maximal inspired O2
  3. Give LMWH
  4. IV fluids if hypotensive
  5. Analgesia - oral NSAIDs
  6. Warfarin (continue with LMWH too until INR is confirmed 2-3)
  7. If haemodynamically unstable consider thrombolysis - streptokinase
39
Q

How does pulmonary oedema typically present? (6)

A
  1. Acute breathlessness
  2. Cough
  3. Frothy pink sputum (blood-stained)
  4. Collapse
  5. Cardiac arrest
  6. Shock
  7. Other associated features may reflect underlying cause..e.g. chest pain, palpitations, haematuria etc.
40
Q

How are the underlying causes of pulmonary oedema categorised?

A
  1. Increased pulmonary capillary pressure
  2. Increased pulmonary capillary permeability
  3. Decreased intravascular oncotic pressure
41
Q

What is the main differential diagnosis for pulmonary oedema?

A

An acute (infective) exacerbation of COPD

42
Q

What urgent investigations need to be carried out for all patients with suspected pulmonary oedema?

A
  1. ECG (sinus tachycardia is most common)
  2. CXR (look for interstitial shadowing, enlarged hila, prominent upper lobe vessels, pleural effusion, and Kerley B lines)
  3. ABG (typically reduced pO2. pCO2 levels may be up or down. Pulse oximetry may be inaccurate due to peripheral shutdown)
  4. U&Es (pre-existing renal impairment?)
  5. FBC (anaemia or leukocytosis?)
  6. Echo (to assess LV function, valve abnormalities, VSD, etc.)
43
Q

What are the causes of an increased pulmonary capillary pressure (hydrostatic)? (4)

A
  1. Increased left atrial pressure (mitral valve disease, arrhythmia (AF))
  2. Increased left ventricular end diastolic pressure (ischaemia, cardiomyopathy, hypertension, fluid overload
  3. Increased pulmonary venous pressure (Lā€“>R shunt)
  4. Neurogenic (intracranial haemorrhage, cerebral oedema)
44
Q

What are the causes of an increased pulmonary capillary permeability? (3)

A
  1. Acute lung injury
  2. ARDS
  3. Decreased intravascular oncotic pressure
45
Q

What is the cause of decreased intravascular oncotic pressure? (1)

A

Hypoalbuminaemia (increased losses of albumin due to nephrotic syndrome, liver failure, decreased production for example in sepsis, and dilution due to crystalloid infusion)

46
Q

How is pulmonary oedema managed? (7)

A
  1. Sit the patient upright in bed
  2. Give 60-100% oxygen
  3. Patient may require CPAP or anaesthetic input
  4. Give diamorphine IV, metoclopramide IV, furosemide IV slow injection
  5. Sublingual GTN if SBP >90
  6. Insert urinary catheter to monitor output
  7. Repeat ABG
47
Q

What are the doses of morphine, furosemide and metoclopramide for someone with pulmonary oedema? (3)

A
  1. Diamorphine 2.5-5mg
  2. Metoclopramide 10mg
  3. Furosemide 40-120mg
48
Q

What are the causes of community acquired pneumonia? (5)

A
  1. Step. pneumoniae
  2. H. influenzae
  3. S. aureus
  4. Gram -ve anaerobes
  5. Viruses
49
Q

What are the atypical causes of CAP? (3)

A
  1. Mycoplasma
  2. Legionella pneumophilia
  3. Chlamydia pneumoniae
50
Q

How is the severity of CAP assessed?

A 
CURB65
confusion - AMTS <8
urea >7
resp rate >30
SBP <90 or DBP <60
51
Q

What is the immediate management for someone with moderate-severe CAP? (6)

A
  1. Check ABC
  2. Secure venous access; IV fluids if dehydrated
  3. Send for FBC, U&Es, LFTs, CRP, blood cultures and sputum
  4. ABG; correct hypoxia and if this failures to correct, or hypercapnia occurs, likely ventilation is required
  5. CXR urgently
  6. Pain relief: paracetamol/NSAID
52
Q

What score can be used to judge how many/which ABX to use in acute pneumonia?

A

CURB65 score, indicate what combination of ABX to use dependent on trust guidelines.

53
Q

If patients have COPD or asthma in addition to the acute pneumonia, what other therapy may need to be started alongside ABXs?

A

Salbutamol

54
Q

Although it may depend on trust guidelines, which ABX are usually prescribed for mild-moderate CAP?

A

Amoxicillin + clarithromycin or doxycycline

55
Q

If the pneumonia is severe, which ABX are usually prescribed (dependent upon trust guidelines)?

A

Co-amoxiclav + clarithromycin
OR
cefuroxime + clarithromycin

56
Q

What is the treatment of HAP?

A

Cefotaxime + metronidazole

57
Q

Which abx is often used to treat acute pneumonia MRSA?

A

Teicoplanin (or vancomycin)

58
Q

What is the classic triad for presentation of acute asthma?

A
  1. Breathlessness
  2. Wheeze
  3. Cough
59
Q

What factors increase the risk of severe life-threatening asthma? (5)

A
  1. Previous ventilation
  2. Hospital admission for asthma in past year
  3. Heavy rescue medication use
  4. > 3 classes of asthma medication
  5. Repeated A&E attendance for asthma
60
Q

What can precipitate an acute asthma attack? (5)

A
  1. Chest infection
  2. URTI
  3. Neglect/poor compliance with inhaled/oral steroids
  4. Emotional stress
  5. Cold air/exercise induced
61
Q

What constitutes a near-fatal asthma?

A

A raised pCO2

62
Q

What is the third commonest cause if sepsis in the UK?

A

Intra-abdominal sepsis

63
Q

What are the common causes of intra-abdominal sepsis?

A
  1. Cholangitis
  2. Cholecystitis
  3. Perforated bowel
64
Q

How many sepsis present if it is an intra-abdominal source? (7)

A
  1. Fever
  2. Altered mental state
  3. Abdominal pain
  4. Anorexia
  5. Nausea/vomiting
  6. Constipation/diarrhoea
  7. Rigid acute abdomen

Year 4 ACC (11 decks)

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