Cardio Vascular Emergencies

Question 1

D/D of Chest pain?

Answer 1

Musculoskeletal pain, Acute coronary syndrome, PUD, Pancreatitis, pulmonary embolism, pneumothorax, aortic dissection, cholecystitis, esophageal rupture etc.

Question 2

ECG character of angina?

Answer 2

ST depression or inversion

Question 3

Names of Acute coronary syndromes

Answer 3

Unstable angina, STEMI, NSTEMI

Question 4

Mx of Unstable Angina?

Answer 4

1. O2
2. Opoid analgesic w or w/o anti emetics
3. Tab. Aspirin & clopidogrel (300mg) PO
4. LMW Heparin (enoxaparin) 1mg/kg SC every 12h
5. GTN if SBP >90. (0.6mg/hr & inc as necessary)
6. Beta blocker (Atenolol) if there’s risk of NSTEMI, pt is hemodynamically stable, has no C/I
   Inj. Atenolol (5mg) IV slowly over 5 mins (u can repeat 1x after 15 mins)
   [ C/I of B-blocker :
   Low BP, low HR, Acute HF, 2 or 3 degree heart block ]
7. Inv : ECG, Troponin I

Question 5

C/I of B-blocker

Answer 5

Low BP, low HR, Acute HF, 2 or 3 degree heart block, COPD

Question 6

MI Mx?

Answer 6

• Oxygen
• Opoid analgesics
• Tab. Aspirin & Clopid (300mg) PO
• PCI (<12h)

💠If PCI N/A:

• Thrombolysis (>12h)
  Ateplase (1st choice)
  Streptokinase (2nd choice)
• enoxaparin SC ( 1mg/kg) every 12h
• if pain persists, start IVI GTN (0.6mg/hr) If SBP >90
• Inj. Atenolol (5mg IV slowly over 5 mins.) repeat 1x after 15mins. Unless Contraindication (+)

Question 7

MI ma Thrombolysis ko protocol (dose etc.) for:
- Ateplase
- Streptokinase

Answer 7

Ateplase:
- 15 mg IV Inj bolus. Then,
- IVI of 0.75 mg/kg over 30 mins (max 50mg) then,
- IVI 0.5 mg/kg over 60 mins (max 35mg) then,
- Enoxaparin 1mg/kg stat (simultaneously, in separate IV line)

Streptokinase:
- 1.5 mega units (1.5 million units) IVI over 1 hr
- may require : slow IV Chlorphenamine 10mg & IV hydrocortisone 100mg (bc of strep allergy)

Question 8

Mx of Brady arrhythmia?

Answer 8

• O2
• 1st line of Tx: Atropine
  Inj Atropine (500 mcg) IV
  Maybe repeated to total dose of 3mg
• Adrenaline (epinephrine) prior to transvenous pacing if no external pacemaker.
  IVI Adrenaline (2-10 mcg) ; titrate
  6mg Adrenaline mixed in 500 ml NS @ 10-50 ml/hr

Definitive Tx: Trans-venous cardiac pacing

Question 9

Tachy arrhythmia:
If ( shock, syncope, HF, M. ischemia) present, Mx?

Answer 9

• secure ABC
• O2
• 3 Attempts of DC Shock then,
• Amiodarone (300mg) over 10-20 mins
• repeat DC Shock
• Amiodarone (900mg) over 24 hrs

Question 10

Tachy arrhythmia:
- If no shock, syncope, HF, M. ischemia &
- QRS Broad & :
Irregular

Answer 10

**Dangerous, call for senior **
Then:
If it is:
1. AF ě BBB:
Tx: B-blocker OR Diltiazem

2. Torsades de pointes:
   Tx: Magnesium (2g) over 10 mins.

Question 11

Tachy arrhythmia:
- If no shock, syncope, HF, M. ischemia &
- QRS Broad & :
Regular

Answer 11

If its Ventricular Tachycardia :
Tx: Amiodarone (300mg) IV over 20-60 mins
Then, 900mg over 24h

If SVT ě BBB:
Adenosine

Question 12

Tachy arrhythmia:
- If no shock, syncope, HF, M. ischemia &
- QRS Narrow & :
Regular
Tx?

Answer 12

• Vagal maneuver
• Adenosine (6mg) rapid IV bolus
  If (x) : give 12mg | again if (x) : give 12 mg more
  If unsuccessful :
  Maybe Atrial flutter. Give: B-Blocker

Question 13

Tachy arrhythmia:
- If no shock, syncope, HF, M. ischemia &
- QRS Narrow & :
Irregular
Tx?

Answer 13

If AF:
- B-blocker OR Diltiazem

If HF:
Digoxin OR Amiodarone

Question 14

Atrial Fibrillation Mx?

Answer 14

• cardioversion:
  Electrical (if present : shock, m. ischemia, acute HF, syncole)
  & chemical
  Chemical :
• Amiodarone (300mg) IV (safer ě heart dz pt)
• CI in heart dz pt: Flecainide (50-150mg) IV

If symptoms r for >48h, there’s risk of pulmonary embolism so:
Pt’s given rate control drugs:
- B-blocker & CCB : metoprolol (5mg) IV & Diltiazem
- also, LMWH
If pt has CCF:
- Digoxin (500mcg) IV