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Emergency Medicine Assistantship > Cardiac Emergencies > Flashcards

Cardiac Emergencies Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is an acute coronary syndrome?

A

A medical emergency referring to a range of acute myocardial ischaemic states.

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2
Q

Which conditions come under the category of acute coronary syndromes?

A

STEMI
NSTEMI
Unstable angina

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3
Q

Why are acute coronary syndromes so important?

A

Single biggest cause of death in the UK, especially important in premature mortality

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4
Q

Easy one - list as many risk factors for an acute coronary syndrome as you can.

A

Non-modifiable:

  • Increasing age
  • Male
  • FHx
  • Premature menopause
  • Structural coronary anomalies

Modifiable:

  • Smoking
  • DM
  • HTN
  • Dyslipidaemia
  • Obesity
  • Physical inactivity
  • Cociane use
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5
Q

How do acute coronary syndromes typically present?

A
  • Anginal pain at rest or activity - central, crushing, radiating to (left) shoulder/arm, jaw, or back
  • Nausea/vomiting
  • Fatigue
  • Sense of impending doom
  • SoB
  • Palpatations
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6
Q

What are some cardiac differentials for an acute coronary syndrome?

A
  • Acute pericarditis
  • Myocarditis
  • Aortic stenosis
  • Aortic dissection
  • PE
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7
Q

What are some respiratory differentials for an acute coronary syndrome?

A
  • Pneumothorax

- Pneumonia

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8
Q

Other than cardiac and respiratory, what are the other differentials for acute coronary syndrome?

A
  • Oesophageal spasm
  • GORD
  • Acuute gastritis
  • Cholecystitis
  • Acute pancreatitis
  • MSK chest pain
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9
Q

A patient presents with central crusing chest pain. What initial investiagtions are essential?

A
  • ECG (continuous monitoring)
  • Troponins (at 6 and 12 hours after)
  • Baseline bloods
  • Blood glucose
  • Coronary angiography
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10
Q

What initial therapy should be given for NSTEMI or unstable angina, providing there are no contraindications?

A

Aspirin and antithrombin therapy.

Aspirin - 300mg loading dose

Also oxygen as per requirements

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11
Q

What immediate pain relief can be given to those with suspected actue coronary syndrome?

A

GTN and/or IV opioid (with antiemetic)

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12
Q

What can be given to an ACS pt who has an aspirin sensitivity?

A

Clopidogrel

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13
Q

What is the difference between an NSTEMI and unstable angina in terms of investigations?

A

NSTEMI has elevated cardiac enzymes, unstable angina does not.

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14
Q

Which groups of patients may have atypical pain with an ACS?

A

Diabetics
The elderly
Hypertensives

May not feel the pain at all - silent MI.

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15
Q

Does a normal ECG exclude ischaemic origin for chest pain?

A

NO

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16
Q

How would an ECG of unstable angina differ to an ECG of a STEMI?

A

In unstable angina there may be T wave inversion or ST segment depression, or may show no chnages if done some time after episode of pain has finished.

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17
Q

When are tropoinins more sensitive than CK-MB?

A

In the first 3-6 hours following the event.

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18
Q

How long does troponin stay elevated?

A

Up to 14 days, peaking at 12-24 hours.

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19
Q

Is hyperglycaemia at presentation a good or poor prognostic factor for pateints who have had an ACS?

A

Poor

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20
Q

Which scoring system is used for post-ACS risk stratification?

A

GRACE score

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21
Q

Following initial management, what hsould be given to patients with ischaemic ECG changes or elevated troponin?

A

300mg aspirin if not already been loaded

180mg Ticagrelor loading dose

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22
Q

If a patients GRACE score shows medium to high risk, what should be offered following ACS?

A

Early in-hospital coronary angiography

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23
Q

What are the benefits of beta blockers for patients post ACS?

A

Improve outcomes long term and reduce severity and frequency of attacks

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24
Q

When are calcium channel blockers used for patients post-ICS?

A

If beta blockers are not tolerated

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25
Q

What ebenfit do ACE inhibitors have for patients post-ACS?

A

Reduce mortality

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26
Q

Inaddition to ACE-I, beta blockers, and calcium antagonists, what medications hsould be started post-ACS?

A

Statin

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27
Q

What complications can occur post ACS?

A 
Acute MI
Cardiogenic shock
Ischaemic mitral regurgitation
SVT
VT
AVN blockade
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28
Q

A patient presents with an irregularly irregular pulse. What is this most likely to be?

A

AF

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29
Q

What are the 2 main complications that occur due to AF?

A

Thrombus formaiton in atria -> stroke

Reduced CO -> HF

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30
Q

When is AF defined as acute?

A

Onste within last 48 hours.

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31
Q

When is AF defined as paroxysmal?

A

AF that stops within 7 days, usually before 48 hours.

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32
Q

When is recurrent AF termed persistent rather than paroxysmal?

A

If the arrythmia requires electrical or pharmacological cardioversion to terminate

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33
Q

What is permanent AF?

A

AF present for longer than a year and has not been successfully treated with cardioversion.

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34
Q

What are the common causes of AF?

A
  • Idiopathic
  • Coronary artery disease
  • HTN
  • Valvular heart disease
  • Hyperthyroidism
35
Q

How might a patient with new or undiagnosed AF present?

A
  • Breathless
  • Palpitations
  • Syncope/dizziness
  • Chets pain/discomfort
  • Stroke/TIA
36
Q

What is the gold standard of diagnosis of AF?

A

ECG except between attacks in paroxysmal AF.

37
Q

How can paroxysmal AF be diagnosed by ECG?

A

24 hour tape if episodes suspected to happen less than 24 hours apart.

38
Q

Which bloods should be done for a pt who is found to be in AF?

Why?

A

FBC - anaemia can cause HF
U&Es - abnormal K+
LFTs and Coag screen - pre-anticoag and other drug commencement
TFTs - hyperthyroid can cause AF

39
Q

What investiagtions can be done for a pt who is in new AF in whom structural heart dsease is the suspected culprit?

A

CXR

Echocardiogram

40
Q

How should AF be managed in broad terms?

A

Treat cause.
Treat complications.
Control the arrythmia.
Prevent thromboembolisms.

41
Q

How can AF arrhythmia be managed?

A

Either with rate or rhythm control.

42
Q

When is rhythm control used to treat AF?

A

Reversible cause of AF found
If the pt has HF secondary to AF
New onset AF

43
Q

How can rhythm control be achieved?

A

Cardioversion

44
Q

Why does a ruptured aortic aneurysm cause death so quickly?

A

It is a large blood vessel so blood loss is very rapid if it ruptures.

45
Q

What is the largest risk factor for a ruptured AA?

A

Presence of aneurysm

46
Q

What risk of rupture do aneurysms over 6cm have yearly?

A

25%

47
Q

A patient who is unconscious is brought in to A&E following acute abdominal pain and a collapse. What is the most serious pathology that needs to be ruled out?

A

Ruptured AAA

48
Q

A patient who is unconscious is brought in to A&E following acute chest pain and a collapse. What are the top 2 differentials we have to rule out?

A

Acute MI

Thoracic AA

49
Q

Why are thoracic aortic aneurysms often rapidly fatal?

A

If they bleed into the mediastinum, cardiac tamponade can occur.

50
Q

What is the classic triad of ruptured AAA?

A
  • Pain in flank or back
  • Hypotension
  • Pulsatile abdominal mass
51
Q

How will a patient with a ruptured AAA appear?

A

Weak, pale, and unwell, often sweating, and dizzy when they stand up.

52
Q

O/E of the abdomen of a patient with a ruptured AAA, what might you find?

A
  • Pulsatile mass in central abdomen
  • Tender to palpation
  • Bruit
53
Q

What lab studies should be done for a patient with ruptured AAA?

A
  • FBC
  • Crossmatch
  • Baseline biochemistry
54
Q

What imaging can confirm the presence of an AAA?

A

CT angiography

55
Q

How is a ruptured AAA managed?

A

Surgically secure aorta, graft placement if possible.

Emergency endovascular aneurysm repair.

56
Q

What is the prognosis for a ruptured AAA?

A

Very poor - less than 30% of patients reach hospital alove, and only 80% of those make it to theatre.

57
Q

What is a cardiac tamponade?

A

Extra-cardiac compression of heart causing reduced ventricular filling and haemodynamic compromise, due to accumulation of blood/fluid/pus/clots/gas in the pericardial space

58
Q

What are the most common causes of cardiac tamponade?

A

Trauma or HIV in young adults

Malignancy or CKD in elderly

59
Q

A young man who was in a car crash presents with shortness of breath, tachycardia, and cold clammy extremities. What signs on examination would suggest cardiac tmponade had occurred?

A
  • Neck veins distended
  • Hypotension
  • Muffled heart sounds
  • Pericardial friction rub
  • Pulsus paradoxus
60
Q

What is pulsus paradoxus, and what does it signify?

A

Exaggeration of normal decrease in systemic BP during inspiration. >10mmHg

On ECG, pulse wave amplitude lower on a regular cycle.

61
Q

What is the investigation of choice for diagnosing cardiac tamponade?

A

Echocardiogram

62
Q

How should cardiac tamponade be managed?

A

Depends if it causes cardiac arrest or not. If yes, ALS.

If no, ITU monitoring, pericardiocentesis, supportive care.
Positive inotropic drugs.
Treat underlying cause.

63
Q

What is the prognosis associated with cardiac tamponade?

A

Depends on how quickly it is diagnosed and treated. Good if speedily treated and underlying cause removed.

64
Q

What are the 2 main types of hypertensive emergency?

A
  • Accelerated hypertension

- Malignant hypertension

65
Q

What pressure is considered a hypertensive emergency?

A

Recent increase of BP to 180 systolic or 110 diastolic.

66
Q

Which organs are damaged in hypertensive emergencies?

A

Neurological (encephalopathy)
Cardiovascular
Renal

67
Q

How can we distinguish between accelerated and malignant hypertension?

A

Presence of papilloedema +/or retinal haemorrhages indicate malignant hypertension over accelerated hypertension.

68
Q

What pathologies can cause secondary malignant hypertension?

A
  • Renovascular hypertension
  • Renal artery stenosis
  • Renin-secreting tumours
  • Kidney trauma
  • Phaeochromocytoma
  • Cocaine
  • Pre-eclampsia/eclampsia
  • Thyroid disease
69
Q

How may a person with malignant hypertension present?

A

May be asymptomatic, but:

  • Headaches
  • Fits
  • N&V
  • Chest pain
  • Neurological symptoms
  • Bleeding
70
Q

How should malignant hypertension be managed?

A
  • Reduced BP over 24-48 hours
  • Arterial line can be used for continuous BP monitoring
  • IV nitroprusside/labetolol/nicardipine
  • Treat underlying cause
71
Q

If it is suspected that a phaeochromocytoma is the cause of malignant hypertension, what can be given to manage the BP?

A

Phentolamine

72
Q

What is Torsades de pointes?

A

A distinctive polymorphic ventricular tachycardia

73
Q

How does Torsades de pointes present on an ECG?

A

QRS amplitude varies, and complexes appear to twist around the baseline.

74
Q

Is Torsades de pointes life-threatening?

A

Yes

75
Q

If Torsades de pointes occurs in a young patient, what is most likely to be the cause?

A

Congenital long QT syndrome due to CHD

76
Q

If Torsades de pointes occurs in an older patient, what is most likely to be the cause?

A

Aquired Long QT syndromes

77
Q

What are the risk factors a patient can have for acquired long QT syndrome which can lead to Torsades de pointes?

A
  • Acute MI
  • Drugs
  • Electrolyte disturbance
  • AKI
  • Liver failure
  • Metabolic disturbance
  • Bradycardia
  • Toxins
78
Q

A patient presents with episodes of palpitations, dizziness, and syncope. What would the most worrying thing be to see on their ECG?

A

Torsades de pointes

79
Q

A young woman who has a FHx of congenital deafness dies suddenly. What cardiac arrythmia might this reflect?

A

Long QT syndrome -> Torsades de pointes

Jervell and Lange Nielson syndrome

80
Q

A young woman with palpitations, dizziness, and syncope has an ECG done which shows torsades de pointes. What further investigations should be done?

A
  • Bloods - look for electrolyte disturbance.
  • Cardiac enzymes - assess for MI
  • CXR and echo - structural heart disease
81
Q

How should torsades de pointes be managed immediately?

A
  • Resus and defibrillation

- IV Magnesium

82
Q

How should torsades de pointes be managed once the immediate threat is managed?

A
  • Medication review
  • Correct underlying cause
  • Temporary transvenous pacing if IV magnesium doesn’t work
  • Propranolo long term
  • Permenant pacing long term/ICD
83
Q

What are the consequences of torsades de pointes?

A

VT
VF
Sudden cardiac death

It’s real bad.

84
Q

What is the prognosis like for torsades de pointes?

A

Patients may revert spontaneously or cpnvert to VT/VF. Can cause sudden death, but prognosis is excellent once any precipitating cause is dealt with.

Emergency Medicine Assistantship (12 decks)

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