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Y4 PPT > B43 - cardio, anaphylaxis > Flashcards

B43 - cardio, anaphylaxis Flashcards

1
Q

Shockable rhythms (2)

A

VF, pulseless VT

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2
Q

Non-shockable rhythms

A

include pulseless electrical activity/asystole

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3
Q

Patient in VF, 3 shocks administered. What next? (3 steps)

A

Give 1mg adrenaline IV (every 3-5 mins) and amiodarone 300mg IV (after 3 shocks) whilst performing further CPR.
Give further adrenaline 1mg IV after alternate shocks.
Further amiodarone 150mg IV may be administered after a total of five defibrillation attempts.

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4
Q

How would drug choice change in CPR if rhythm was non-shockable (as opposed to adrenaline every 3-5 mins and amiodarone after 3 shocks in shockable)

A

Amiodarone would not be administered but adrenaline 1mg IV is given as soon as intravascular access is achieved and repeated every 3-5 minutes

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5
Q

What is adrenaline?

A

endogenous catecholamine hormone and neurotransmitter in the sympathetic nervous system.

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6
Q

Where and from what is adrenaline normally synthesised?

A

from noradrenaline in the adrenal medulla, specifically chromaffin cells.

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7
Q

Adrenaline MOA

A

α and β adrenoceptor agonist

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8
Q

Actions of adrenaline on α1 (4)

A

vasoconstriction
relaxation of smooth muscle in GI
saliva secretion
hepatic glycogenolysis

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9
Q

Actions of adrenaline on α2 (3)

A

vasoconstriction
inhibition of transmitter release
platelet aggregation

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10
Q

Actions of adrenaline on β2

A

position ionotropic and chonotropic effects

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11
Q

Actions of adrenaline on β2 (2)

A

broncodilation

vasodilation

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12
Q

Action of adrenaline on β3

A

lipolysis

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13
Q

Actions of adrenaline with regards to cardiac arrest scenario

A

increases coronary and cerebral perfusion pressure as a result of vasoconstriction

thought to increase the chance of restoring a heartbeat and of improving long-term neurological outcome.

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14
Q

Adrenaline cautions in non-emergency situations (11)

A 
ischaemic heart disease, 
cerebrovascular disease, 
diabetes, 
hypertension, 
hyperthyroidism 
Hypokalaemia
hypertension (risk of cerebral haemorrhage)
hypokalemia
palpitations - dysrhythmias
tissue necrosis (e.g. ring blocks)
metabolic acidosis
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15
Q

Adrenaline side effects (10)

A 
hypersalivation,
 headache,
 hyperhidrosis, 
angle closure glaucoma, 
reduced appetite, 
hyperglycaemia, 
hypertension, 
mydriasis, 
peripheral coldness, 
urinary disorders
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16
Q

Adrenaline interactions (3)

A 
Amitriptyline (increased effects of adrenaline)
Beta blockers (severe hypertension)
MAO inhibitors (hypertensive crisis - MAO is one of the routes of metabolising adrenaline, therefore inhibiting their action leads to an increase in adrenaline.)
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17
Q

Route and dose adrenaline administered in cardiac arrest

A

1mg by IV injection using 1 in 10,000 solution (100micrograms/mL) i.e. 10ml
Followed by 20ml flush of 0.9% sodium chloride

Flush is required to aid entry into central circulation.

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18
Q

Beta blockers can be used as antihypertensive drugs.Why is there a risk of severe hypertension when beta blockers and adrenaline interact?

A

In the absence of a beta-blocker, adrenaline does not have much effect on mean blood pressure because it has both alpha-adrenergic effects (producing vasoconstriction) and beta-adrenergic effects (producing vasodilation). If a patient on a nonselective beta-blocker receives adrenaline however, the beta-blocker prevents the beta-adrenergic vasodilation, leaving unopposed alpha vasoconstriction. Cardio-selective beta-blockers would not be expected to precipitate hypertensive reactions.

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19
Q

Amiodarone drug class

A

Class III anti-arrhythmic

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20
Q

Amiodarone MOA (3)

A

Multiple anti-arrhythmic actions across all four groups
Prolongs cardiac action potential and delays refractory period
Inhibits K+ channels involved in repolarisation

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21
Q

Challenges of amiodarone (3)

A

Incomplete oral absorption
Large volume of distribution
Extremely long half-life

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22
Q

Amiodarone SE

A
  • GI disturbance (constipation, nausea, vomiting, taste disturbance)
  • Corneal microdeposits (reversible on withdrawal of treatment, associated with night glare, if
    vision impaired or optic neuritis/neuropathy develops amiodarone must be stopped to
    prevent blindness)
  • Hypo/Hyperthyroidism
  • Skin reactions – photosensitive skin rashes and blue-grey discolouration
  • Hepatotoxicity – severe LFT abnormalities or clinical signs of liver disease require
    discontinuation of treatment.
  • Progressive pneumonitis and lung fibrosis – should be suspected if new onset SOB or
    cough
  • Proarrhythmic effects
  • Peripheral neuropathy/myopathy – reversible with withdrawal of treatment
23
Q

Amiodarone eye SE

A

Corneal microdeposits – reversible on withdrawal of treatment, associated with night glare, if vision impaired or optic neuritis/neuropathy develops amiodarone must be stopped to prevent blindness

24
Q

Amiod

A
25
Q

How does amiodarone cause hypothyroidism

A

prevents conversion of T4 to T3 resulting in hypothyroidism requiring replacement with thyroxine

26
Q

How does amiodarone cause hyperthyroidism

A

high iodine content, can cause a destructive thyroiditis leading to release of preformed thyroid hormones and refractory thyrotoxicosis

27
Q

Amiodarone monitoring

A

TFT and LFT should be checked before treatment and every 6 months
Check potassium levels and chest x-ray before treatment

With IV use ECG monitoring must be available

28
Q

Amiodarone CI (5)

A 
Severe cardiac conduction disturbances (unless pacemaker fitted)
Thyroid dysfunction
Iodine sensitivity
Severe respiratory failure
Circulatory collapse
29
Q

What does amiodarone interact with to cause bradycardia (3)

A

Beta blockers
Calcium channel blockers
Digoxin

30
Q

What does amiodarone interact with to cause prolonged QT (2)

A

Lithium

Ondansetron

31
Q

What does amiodarone interact with to cause hypokalaemia (3)

A

Steroids
Thiazide diuretics
Loop diuretics

32
Q

What does amiodarone interact with to cause peripheral neuropathy (1)

A

Phenytoin

33
Q

What does amiodarone interact with to cause rhabdomyolysis (1)

A

Statins

34
Q

What is the effect of amiodarone interaction with warfarin?

A

increased anticoagulant effect

35
Q

Narrow complex tachycardia Mx

A

Monitor/record ECG continuously

1) Vagal maneouvres
2) adenosine 6mg IV bolus large cannula and large vein (antecubital fine) followed by NaCl flush
3) if no effect give adenosine 12mg IV
4) if no effect give further 12mg bolus

36
Q

What does failure to terminate a regular narrow-complex tachycardia with adenosine suggest?

A

atrial tachycardia such as atrial flutter (unless the adenosine has been injected too slowly or into a small peripheral vein).

37
Q

Narrow complex tachycardia Mx If adenosine is contra-indicated, or fails to terminate a regular narrow-complex tachycardia without demonstrating that it is atrial flutter:

A

consider giving verapamil 2.5–5 mg IV over 2 min.

38
Q

Adenosine MOA

A

Adenosine A1 receptor agonist

Inhibits adenylyl cyclase enzymes resulting in reduced production of cyclic AMP (cAMP). This promotes opening of adenosine-sensitive potassium channels and increased K+ efflux out of myocardial cells – as a result cells become hyperpolarised. This slows the rate of rise of the pacemaker potential. This is transient, with the effects of a bolus dose of adenosine lasting only 20-30 seconds

39
Q

Why is adenosine useful in SV tachycardia

A

it has potent effects on the SA node inducing sinus bradycardia and slows impulse conduction through the AV node, with no effect on conduction in the ventricles. Therefore, it is useful in the emergency management of supraventricular tachycardia (SVT) for rapid conversion back to sinus rhythm

40
Q

Adenosine CI (5)

A

Asthma/COPD
Decompensated heart failure
Long QT syndrome/AV block/sick sinus syndrome
Severe hypotension
Many cautions associated with cardiac disease

41
Q

Adenosine interactions (3)

A

Dipyridamole (increased adenosine exposure)
Aminophylline/Theophylline (decreased adenosine efficacy)
Some local anaesthetic agents (risk of cardiodepression)

42
Q

Adenosine SE (15)

A

Side effects common but last <1 min

Arrhythmias
chest discomfort/pain
dizziness
dyspnoea (bronchospasm, resp failue)
flushing
headache
hypotension
apprehension
sweating
metallic taste
blurred vision
nausea/vomiting
cardiac arrest
apnoea
loss of consciousness
43
Q

Most important step after administering adenosine

A

12 lead ECG - see if returned to sinus rhythm

44
Q

What does a fluid challenge usually consist of?

A

500ml of a sodium containing crystalloid (0.9% Sodium Chloride or Hartmann’s solution) given over 15 minutes.

45
Q

Sinus bradycardia Mx

A

ABCDE

adverse features -> atropine 500mcg IV

46
Q

Atropine Class and MOA

A

Class:
Muscarinic antagonist

Mechanism of action:
Increases firing of the SA node by blocking actions of the vagus nerve on the heart. Achieved by inhibiting potassium channels and preventing hyperpolarisation of the cell membrane (opposite effect of adenosine).

47
Q

Atropine SE (lots)

A

Able to predict effects by considering the function of the parasympathetic nervous system

Eyes (pupillary dilatation): blurred vision, mydriasis, angle closure glaucoma
GI tract (decreased motility/secretions/tone): constipation, abdominal distension, nausea, vomiting, dysphagia
CVS (increased HR, contractility, BP): tachycardia, palpitations, angina, hypertension, arrhythmias
Secretions (decreased sweat/salivary gland secretion): dry mouth, anhidrosis, thirst, increased body temperature
Urinary tract (decreased detrusor function and increased sphincter tone): urinary retention,
CNS: confusion, hallucination

48
Q

Atropine CI (3ish)

A

GI: obstruction, paralytic ileus, pyloric stenosis, severe ulcerative colitis, toxic megacolon
Urinary tract: bladder outflow obstruction, prostatic enlargement, retention
Myasthenia gravis

49
Q

Atropine interactions (6)

A 
Tricyclic anti-depressants
Muscarinic antagonists 
Antihistamines 
Antipsychotics
Phenylephrine (severe hypertension)
Levodopa (decreased absorption levodopa)
50
Q

Immediate Mx suspected anaphylaxis

A

Adrenaline.

Additional measures include call for help, lie patient flat, raise patients legs and remove trigger if known/possible.

51
Q

Anaphylaxis steps after adrenaline when skills and equipment available (6)

A 
establish airway
high flow O2
IV fluid challenge
chlorphenamine
hydrocortisone
Monitor: pulse oximetry, BP, ECG
52
Q

Adrenaline doses for anaphylaxis by age

A

Adult/child >12y - 500mcg IM
Child 6-12y - 300mcg IM
Child <6y - 150mcg IM

53
Q

Adrenaline MOA anaphylaxis

A

As an alpha-receptor agonist, it reverses peripheral vasodilation and reduces oedema. Its beta-receptor activity dilates bronchial airways, increases force of myocardial contraction and suppresses histamine release.

54
Q

Adrenaline administration route/timing

A

Further doses at 5 minute intervals if no improvement

Anterolateral aspect of the middle third of the thigh

Y4 PPT (10 decks)

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