Cardiac Emergencies

Question 1

Fibrinolysis if the patient is aged less than 75 years

Answer 1

Administer tenecteplase IV as per the dosing table below.
Administer 5000 units of heparin IV.
Administer enoxaparin SC as per the dosing table below.
Administer 300 mg of clopidogrel PO.

Question 2

Fibrinolysis if the patient is aged greater than or equal to 75 years

Answer 2

Administer tenecteplase IV as per the dosing table below.
Do not administer heparin IV.
Administer enoxaparin SC as per the dosing table below.
Administer 75 mg of clopidogrel PO.

Question 3

What time to PCI should you thrombolyse?

Answer 3

Within 90 minutes of STEMI diagnosis

Question 4

Controlling hypertension
If the systolic BP is greater than 180 mmHg or the diastolic BP is greater than 110 mmHg, commence the following treatment:

Answer 4

Administer 0.4 mg of GTN SL every five minutes. Move to the next step if hypertension is not controlled within approximately ten minutes of commencing GTN.
Administer 10-20 mg of labetalol IV every five minutes. Move to the next step if hypertension is not controlled within approximately 20 minutes of commencing labetalol.
Commence an IV infusion of GTN using an infusion device. Start the infusion at 2 mg/hr. Adjust the rate as required by 0.5 mg/hr every 5-10 minutes, titrating to effect.

Question 5

If ROSC occurs following cardiac arrest

Answer 5

Administer fibrinolysis (if not already administered), unless the patient has had greater than ten minutes of CPR, in which case clinical advice should be sought.
Transport the patient to a hospital with facilities for immediate PCI, provided it is feasible and safe to do so. Seek clinical advice if transport will be prolonged.
Update the receiving clinician when the patient’s clinical course is clear and it is feasible to do so.

Question 6

(STEMI) where transport to a hospital with facilities for immediate PCI can clearly occur within 90 minutes of STEMI diagnosis.

Answer 6

Same as UK treatment plus:

Administer 180 mg of ticagrelor PO if asked to do so by the receiving clinician.

If arrests: Administer tenecteplase IV (from the tables in the ‘fibrinolysis’ guideline) if ROSC does not occur within five minutes of commencing resuscitation.

Question 7

Cardiogenic Pulmonary Oedema

Answer 7

cquire a 12 lead ECG.
Administer 0.8 mg of GTN SL.
Continue to administer 0.8 mg GTN SL every five minutes as above if the patient is not improving. Increase the dosing interval to ten minutes if caution is required.
Apply CPAP if the patient has moderate to severe respiratory distress that is not rapidly improving (see the ‘CPAP’ guideline). If backup for CPAP is unavailable or delayed, apply PEEP.
Commence a GTN infusion IV if the patient is not rapidly improving.
Fentanyl in 10-20 mcg doses IV or morphine in 1-2 mg doses IV may be administered every five minutes as required for severe anxiety.