Cardio emergencies

Question 1

What is ACS?

Answer 1

collection of
syndromes resulting from acute myocardial ischaemia.
o STEMI
o NSTEMI
o Unstable Angina (UA)
􀀹 Similar presentation but no biochemical evidence of
injury (normal Troponin I)

Question 2

MI acute management

Answer 2

Airway, Breathing, Circulation
• IV access
• 12-lead ECG
• Give:
• Oxygen
• Nitrates (GTN spray 2 puffs sublingually)
• Aspirin (300mg)
• Diamorphine (2.5-10mg IV, plus antiemetic)
STEMI Further Management
• Thrombolysis or
• PCI (Percutaneous Coronary Intervention)

Question 3

Thrombolysis indications

Answer 3

Thrombolysis Indications
o < 12 hours onset pain
\+ any 1 of the following:
o ST elevation >1mm in 2+ consecutive limb
leads
o ST elevation >2mm in 2+ consecutive chest
leads
o Posterior infarct
o New onset LBBB

Question 4

Thrombolysis absolute contraindications

Answer 4

Haemorrhagic stroke or Ischaemic stroke < 6 months
CNS neoplasia
Recent trauma or surgery
GI bleed < 1 month
Bleeding disorder
Aortic Dissection

Question 5

Thrombolysis relative contraindications

Answer 5

Warfarin
Pregnancy
Advanced Liver Disease
Infective Endocarditis

Question 6

Thrombolysis complications

Answer 6

Bleeding
• Hypotension
• Intracranial haemorrhage
• Reperfusion arrhythmias
• Systemic embolisation of thrombus
• Allergic reaction (especially if Streptokinase)

Question 7

STEMI complications

Answer 7

S - Sudden death
P - Pump failure / Pericarditis
R - Rupture papillary muscles or septum
E - Embolism
A - Aneurysm / Arrhythmias
D - Dressler’s syndrome

Question 8

MI discharge

Answer 8

• Aspirin
• Clopidogrel
• ACE inhibitor
• β-blocker
• Statin
• Address modifiable risk factors
• 1 month off work
• Need to inform DVLA – no driving for 4 weeks.

Question 9

NSTEMI/UA management

Answer 9

1. Analgesia
o Morphine
2. Anti-ischaemic
o Nitrates (GTN infusion)
o ACE inhibitors
o β-blockers
o Calcium channel antagonists
o Statins
3. Antiplatelet
o Aspirin
o Clopidogrel
4. Antithrombotic
o LMWH

Question 10

Management of acute left ventricular failure

Answer 10

• Airway, Breathing, Circulation
• Sit upright
• 100 % O2 via non-rebreather mask
• IV access and monitor ECG
• Morphine 2.5-5mg IV (with antiemetic)
Other:
• If SBP >100mmHg – Nitrate (GTN) IV infusion
• Furosemide 40-80mg IV
• CPAP

Question 11

Regular SVT managment

Answer 11

• ABC + O2 + IV access
• Vagal Manoeuvres
• Adenosine
• SEEK HELP
• Antiarrhythmic
• DC cardioversion if haemodynamically unstable

Question 12

BCT managment

Answer 12

• ABC (if pulseless = arrest protocol)
• No adverse signs
o Amiodarone / Lidocaine
o K+/Mg2+ if needed
o Sedation and DC cardioversion
• Adverse signs
o Sedation
o DC cardioversion
o Amiodarone / Lidocaine

Question 13

Endocarditis management

Answer 13

• Airway, Breathing, Circulation – Stabilise the patient
• Always involve a microbiologist and a cardiologist
• Depends on organism
• Empirical treatment is:
o BENZYLPENECILLIN & GENTAMICIN
• Treatment can often be at least 4 weeks IV antibiotics

Question 14

AF management

Answer 14

rate control - Beta blocker/digoxin
if onset <48 hrs, consider cardiversion - amiodarone 300mg over 20-60 min then 900mg over 24 hr or DC shock.
anticoagulate

Question 15

Pericarditis management

Answer 15

• If a cause is found, this should be treated!
• Bed rest and oral NSAIDs
o High-dose aspirin, indometacin or ibuprofen.
o But NOT post-MI: NSAID associated with
myocardial rupture.
o Corticosteroids have been used when the
disease does not subside rapidly.
• Further Treatment:
o Pericardial window
o Pericardiectomy

Question 16

Tamponade management

Answer 16

Get senior help
• Pericardiocentesis
o Needle inserted at level of Xiphisternum, aim
for tip of left scapula, aspirating continuously.
o Blind – complication risk 5-50%, only if
emergency.
o USS guided – relatively safe.
o Send the pericardial fluid for microbiology and
cytology.
• A drain may be left in temporarily to allow sufficient
release of fluid