Cardiology Flashcards
4Hs and 4Ts causing cardiac arrest
Hypoxia
Hypothermia
Hypovolaemia
Hyper/hypokalaemia
Thrombosis
Toxins
Tamponade (cardiac)
Tension pneumothorax
Shockable rhythms + their treatment
Ventricular tachycardia + ventricular fibrillation
CPR (30:2)
Shock
Resume CPR for 2 mins then reassess
1mg IV adrenaline every 3-5 mins
300mg IV amiodarone after 3 shocks
150mg IV amiodarone after 5 shocks
Non-shockable rhythms + their treatment
Pulseless electrical activity + asystole
CPR (30:2)
1mg IV adrenaline ever 3-5 mins
What to do if circulation resumes during cardiac arrest
ECG Maintain O2 94-98% Aim for normal CO2 Treat cause Control temperature
Investigations needed in MI
ECG FBC Troponin CK Glucose LFTs + UEs Random blood glucose Lipids
CXR (HF signs)
Initial management of MI
AMON
Aspirin 300mg PO
Morphine 5-10mg PO (+anti-emetic)
Oxygen (if O2 <94%)
Nitrates (GTN, IV if fails)
When to do PCI for STEMI + other tx also needed
<12h since symptom onset
Within 120m of when fibrinolysis could have been given.
DAPT
- Aspirin 300mg loading dose –> 75mg OD
+ 60mg Prasugrel loading dose –> 5mg OD (low bleeding risk) OR
+ 300mg clopidogrel loading dose –> 75mg OD (high bleeding risk)
Anticoagulation (e.g. 2.5mg fondaparinux)
When to do fibrinolysis for STEMI + other tx also needed
<12h since symptom onset
PCI not available within 120m.
DAPT - Aspirin 300mg loading dose –> 75mg OD
+ 180mg ticagrelor loading dose –> 90mg OD (low bleeding risk) OR
+ 300mg clopidogrel loading dose –> 75mg OD (high bleeding risk)
Anticoagulation (e.g. 2.5mg fondaparinux)
Repeat ECG in 60-90 mins.
If STE not resolved –> urgent PCI
When is fibrinolysis contraindicated
Recent stroke (<3 months) Malignancy GI bleed Aortic dissection HTN (>200/120) Trauma (including recent CPR)
Treatment for stable NSTEMI
BATMAN
- bisoprolol (2.5mg OD)
- Aspirin (300mg loading –> 75mg OD)
- Ticagrelor (180mg loading –> 90mg OD)
- Morphine (+anti-emetic)
- Anticoagulant (2.5mg SC fondaparinux for 8 days)
- Nitrate (GTN)
When is an NSTEMI unstable + what is the tx
Haemodynamic instability Pain continuing despite tx Dynamic ECG changes LVF Life threatening arrythmias
refer for coronary angiography + revascularisation
then commence BATMAN
Ix if ? acute left ventricular failure
ECG - often ischaemic changes CXR - 80% have signs of HF Troponin - ?MI precipitating cause Baseline bloods ABG - T1 respiratory failure Echo
Initial Tx for acute left ventricular failure
SIT UP Stop IV fluids Oxygen if hypoxic 40mg IV furosemide 2.5-5mg IV diamorphine (can act as vasodilator) GTN (2 SL sprays - acts as vasodilator)
When is specialist input needed for acute left ventricular failure
Input from HF specialist within 24h.
If cardiogenic shock (SBP <100) = refer to ICU
- inotropes (dobutamine)
- vasopressers (adrenaline)
- to increase BP and maintain perfusion
Management of acute left ventricular failure once patient is stable
daily weights
switch to oral furosemide
ACEi if LVEF <40%
repeat CXR
When is referral for same day assessment needed in HTN?
If ? accelerated hypertension.
BP >180/110 AND
- signs of retinal haemorrhage/papilloedema
- signs of end organ damage (AKI, HF, chest pain, new confusion)
if ?phaeochromocytoma
Immediate treatment for accelerated hypertension
20mg IV labetalol every 10 mins according to response
Maximum dose = 300mg
Who gets ACEi 1st line for HTN (+ doses + monitoring)
T1DM + <55s
- 5-2.5mg PO ramipril OD.
- Increase up to 10mg if necessary at 2-4w intervals
- U&Es 2 weeks after initiation
Alternative to ACEi (+ dose)
ARBs
50mg PO Losartan OD
- increase up to 100mg if necessary
- start with 25mg if >76
Who gets CCB 1st line for HTN (+ doses + monitoring)
Black people + >55s
5mg PO amlodipine OD
- Increase to 10mg if necessary
Dose of thiazide diuretic used in HTN
- 5mg PO indapamide OD
- take in morning
- U&Es before and 2-4w after
How to confirm diagnosis of HTN
Suspect if clinic BP >140/90
- measure in both arms
- repeat
Ambulatory BP monitoring to confirm - >135/85 or Home BP monitoring if not tolerated - 2 consecutive measures, 1 min apart - morning + eve for 7 days
When to refer HF patients to a specialist
- BNP values + others
2 weeks if BNP >2000
6 weeks if BNP >400
HF not responding to tx HF resulting from valvular heart disease LVEF <35% Severe HF (NYHA IV) ? if co-morbidities (e.g. CKD)
Treatment of reduced ejection fraction HF
Loop diuretic - Furosemide
- 20-40mg PO OD (increase to 120mg if needed)
- Check U&Es/BP before and 1-2 weeks after
ACEi - Ramipril
- 2.5mg PO OD (increase to 10mg if needed)
- Check U&Es/BP before and 1-2 weeks after
- 1st line if DM/signs of fluid overload
Beta blocker - bisoprolol
- 1.25mg PO OD (increase to 10mg if needed)
- 1st line if angina symptoms
EVENTUALLY COMBINE ACEi + BB
Spironalactone
- 25mg PO OD (can increase)
- improves mortality
Treatment of preserved ejection fraction HF
Loop diuretic
- up to 80mg furosemide
Ix and action if ? DVT
Wells score + Ix within 4 hours <2 = DVT unlikely - D-dimer then USS if +ve >2 = DVT likely - Proximal leg USS
Baseline bloods if starting anticoagulants
- do not delay tx for results, but review in 24 hours
1st line tx for DVT (2 )
Anticoagulation
- 10mg Apixiban PO BD for 7 days –> 5mg BD maintenance
- 15mg Rivaroxiban PO BD for 21 days –> 20mg OD maintenance
2nd line tx for DVT
SC LMWH for 5-10 days
- e.g. 1.5mg/kg fondaparinux
THEN
- dabigatran
- edoxoban
If pregnant = LMWH
How long to anti-coagulate for in DVT
Provoked = 3m then review
Unprovoked = at least 6 months
When to refer pt with DVT
- Pregnant/given birth within past 6 months
- If Ix needed for ?cancer
- If Ix needed for ?thrombophilia
Ix if ? acutely ischaemic limb
ABPI (PAD if <0.9)
Duplex ultrasound = assess degree of stenosis
ECG (underlying cardiac probs causing embolism)
Bloods
- FBC, ESR
- thrombophilia screen
- lipids
Management of acutely ischaemic limb
Urgent vascular referral!!
- endovascular thrombolysis/thrombectomy
- surgical thrombolysis/thromectomy/angioplasty
- amputation if non-viable limb
Meanwhile
- anti-platelet (75mg aspirin/clopidogrel)
- anti-coagulant
- analgesia
When should patient with superficial thrombophlebitis be referred to a specialist
- underlying cause thought to be due to cancer
- signs of infection
Signs that superficial thrombophlebitis might progress to DVT and how to manage this?
- Superficial thrombus >5cm
- Superficial thrombus at junction joining superficial and deep veins (e.g. sapheno-femoral)
- Superficial thrombus not associated with varicose vein
- Patient immobile
- Patient has cancer
Anticoagulate (e.g. 10mg apixiban BD –> 5mg BD)
Management of simple thrombophelbitis
- Analgesia (paracetamol, NSAID, topical NSAID)
- keep leg elevated
- stay mobile
- warm towel to relieve discomfort
- treat underlying varicose veins
- Compression stockings (rule out PAD 1st)
Initial management of complete heart block
500 micrograms IV atropine
can repeat dose up to 3mg
Management if complete heart block refractory to initial tx or risk of asystole
SEEK HELP
Repeat IV atropine up to 3mg
? transcutaneous pacing
5 micrograms IV isoprenaline
2-10 micrograms IV adrenaline
What increases risk of asystole in complete heart block
- recent asystole
- broad QRS
- ventricular pause >3 seconds
Medications to treat postural hypotension
1st line
- 0.1-0.2mg fludrocortisone + 1mg of NaCl with meals
- SE: hypertension, AKI, cardiac fibrosis
2nd line = sympathomimetics
- 2.5mg midodrine TDS
