Cardiology Flashcards
Pericardial Tamponade
EXAMINATION
- Muffled heart sounds
- Distended jugular veins
- Raised JVP
- Sinus tachycardia
- Hypotension
- Pulsus paradoxus
- Kussmaul’s sign – elevation of JVP on inspiration
ECG
- Low voltage QRS
- Electrical alternans of the QRS or P waves
- Widespread concave ST elevation
- Sinus tachycardia
- Features of pericarditis may be present
ECHO
- Black anechoic band >2cm thick around the heart (effusion)
- Right ventricle collapse during diastole
- Distended IVC that does not collapse during inspiration
PERICARDIOCENTESIS
- Position: patient sitting at 45 degree angle
- Perform under ultrasound guidance
- Equipment: 18G needle >5cm in length
- Insert needle under left xiphoid
- Advance toward left shoulder aspirating as you go
- Aspirate fluid until cardiac output restored
- Advance guidewire and dilator over wire
- Advance pigtail drain and remove guidewire
- Suture pigtail drain to hold in place
AORTIC DISSECTION
MANAGEMENT
“to prevent propagation of the dissection”
Aim for SBP 100-120, HR 60-80
1st line:
Beta blockers
- Esmolol loading with 500mcg/kg iv over 1min, followed by maintenance infusion 50-200mcg/kg/min
- Metoprolol 1mg iv every minute up to 5mg
- Labetalol 2-4mg/min iv infusion, followed by 5-20mg/hr
2nd line:
Vasodilators
- Sodium nitroprusside iv infusion. Start at 500mcg/kg/min, increase by 500mcg/kg/min every 5min up to 10mg/kg/min
Risk of cyanide toxicity if infusions continue >24hrs
GTN infusion. Start at 10mcg/min, increase by 5mcg/min every 20min, up to 100mcg/min
Hydralazine 1-5mg iv
Phentolamine 1-5mg iv bolus every 5min
HOCM
Hypertrophic obstructive cardiomyopathy
Presentation: Syncope during exercise
- Genetic, autosomal dominant inheritance
- Unexplained hypertrophy of ventricular septum, and LV,
- No LV dilatation
- Causes LV outflow obstruction – may only be apparent during exercise
a) HOCM exam findings:
- S3/S4
- Ventricular heave/apical heave
- Prominent a wave in JVP
- Ejection systolic murmur - increased by Valsalva, decreased by squatting
b) HOCM ECG:
- LVH - tall R waves in V4-V6
- Septal thickening - Deep, narrow ‘dagger like’ Q waves in inferolateral leads
- Arrythmias – AF, SVT
- Conduction defects
Complications:
- Congestive cardiac failure
- MI’s
- Infective endocarditis of mitral valve
- AF, SVT, VF
- Sudden death
d)
TTE - assess for septal and LV hypertrophy, LVOT obstruction, MR,
Holter monitoring - SVT, VF, AF
Cardiac MRI - confirm diagnosis
e) Management:
Screen first degree relative
Beta-blockers
Calcium channel blockers
Antibiotic prophylaxis for endocarditis
Automatic Implantable Cardiac Defibrillator (AICD)
Dual chamber pacemaker
Septal myectomy
f)
NOT to participate in active sports until cleared by cardiologist
Wolf Parkinson White Syndrome
ECG
- PR interval < 120ms
- Delta wave: slurring slow rise of initial portion of the QRS
- QRS prolongation > 110ms
- Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
- Pseudo-infarction pattern in up to 70% of patients — due to negatively deflected delta waves in inferior/anterior leads (“pseudo-Q waves”), or prominent R waves in V1-3 (mimicking posterior infarction)
AF
Management:
RHYTHM CONTROL:
onset <48hrs, anticoagulated >6wks
Flecainide 2mg/kg (up to 150mg) IV over 10min –
- Need structurally normal heart, no LV dysfunction, no intra-ventricular blocks (eg BBBs), no ischemic heart disease
Amiodarone (5mg/kg) 300 mg IV infusion over 1hr, followed by 900 mg by IV infusion over 24hrs
- preferred in patients with LV dysfunction and coronary artery disease
- not suitable in thyroid dysfunction and long QT
Sotalol 40 – 80mg
- not suitable in long QT, asthma, hypotension
digoxin 500mcg po/iv - rate control in CCF/LV dysfunction
RHYTHM CONTROL:
metoprolol 2.5mg aliquots, repeat in 10min (max 10mg) - symptomatic, no heart failure, no hypotension
verapamil 2.5mg aliquots, repeat in 10min (max 10mg)
- no heart failure, no hypotension
VT
PHARMACOLOGICAL MANAGEMENT:
Procainamide
- 100mg IV bolus, repeat (max dose 500mg)
- most effective agent but not readily available in Australia
- negative inotropy –> hypotension
- avoid in AMI and LV dysfunction
Amiodarone
- 300mg IV over 20min, followed by 900mg over 24hrs
- preferred in patients with AMI and LV dysfunction
- contraindicated in pregnancy
Sotolol 1.5mg/kg IV
- need to be haemodynamically stable with normal QTc
Lignocaine 1mg/kg IV (3rd line agent)
- more effective in ischemic VT
Amiodarone 5mg/kg
Lignocaine 1mg/kg
Transcutaneous Pacing
Explain procedure/Informed consent
Position electrodes
Pad placement in the anterior-posterior position
Sedation/analgesia
IV morphine and IV midazolam
Set rate to 80bpm
Set energy level - increase by 10mA until consistent electrical capture (average 50-80mA)
Confirm electrical capture on monitor
Confirm mechanical capture by presence of regular pulse and improved cardiac output
Post-procedural care
*initiate definitive care (e.g. permanent pacemaker insertion)
-isoprenaline infusion
-treat hyperkalaemia
