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Cardiology Flashcards

1
Q

Acute coronary syndrome (ACS)

A

Myocardial ischaemia commonly caused by plaque rupture and thrombosis, inc:
- STEMI
- NSTEMI
- Unstable angina

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2
Q

pathophysiology of ACS?

A
  • atherosclerotic plaque
  • gradual narrowing - less blood to myocardium - angina on exertion
  • sudden plaque rupture - sudden occlusion - MI

STEMI: infarction with ST elevation on ECG

NSTEMI: infarction without ST elevation on ECG

Unstable angina: ischaemia causing chest pain at rest or minimal exertion OR in a crescendo like fashion

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3
Q

types of MI?

A

Type 1 – spontaneous e.g. atherosclerotic plaque rupture
Type 2 – secondary to ischaemic imbalance eg coronary artery vasospasm, hypotension, severe anaemia
Type 3 – MI resulting in death without biomarkers
Type 4a – MI from PCI
Type 4b – MI from stent thrombosis
Type 5 – MI from CABG

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4
Q

ACS risk factors?

A

Unmodifiable
- Older age, male, FHx

Modifiable
- Smoking, DM, HTN, hypercholesterolaemia, obesity

ABCDEF
- Age, BP, cholesterol, diabetes, exercise, fags / fat / family

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5
Q

ACS Px?

A
  • > 20mins sx
  • chest pain - central/left side, may radiate to jaw/L arm, heavy, like dyspepsia
  • silent MI - diabetics/elderly
  • palpitations, SOB, sweaty, clammy, pale, faint
  • N+V
  • HF sx
  • tachycardia, hypotensive
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6
Q

ACS Ix?

A

Bloods
- FBC, U/E, LFTs, lipids, glucose
Serial troponins - I/T - take at px, 3hrs, 6hrs
12 lead ECG
Coronary angiography if high risk for CV event mortality

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7
Q

stemi ecg findings?

A
  • ST elevation, tall/hyperacute T waves, new LBBB
  • pathological Q waves after >6hrs
  • long term - ST normal/depressed, T wave inversion, Q waves persist
  • inf MI - PR prolongation (RCA -> AVN)
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8
Q

NSTEMI ECG findings?

A
  • ST depression, T wave flattening / inversion
  • normal ECG
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9
Q

unstable angina ECG findings?

A
  • normal
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10
Q

ECG coronary territories?

A

Anterior – V1-4 – LAD
Inferior – II, III, aVF – RCA (LCx in minority of pts)
Lateral – I, V5-6 – LCx
Posterior – horizontal ST depression in V1-3, STEMI V7-9 – RCA / LCx

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11
Q

ACS general Mx?

A
  • morphine
  • O2
  • nitrates - sublingual GTN
  • aspirin 300mg
  • insulin infusion to keep BM<11
  • cardiac rehab
  • stop smoking, drink less, healthy eating, regular exercise, lose weight
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12
Q

STEMI Mx?

A

ABCDE
Analgesia
Nitrates
Aspirin 300mg

Primary PCI - if <12hrs since sx onset and possible in <2 hours
- Prasugrel/Ticagrelor 180mg / Clopidogrel 300mg

Thrombolysis if available - alteplase / streptokinase / tenecteplase
- + give antithrombin - heparin/fondaparinux

CABG
- consider if multivessel coronary artery disease…

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13
Q

NSTEMI / unstable angina diagnostic criteria?

A

NSTEMI
- raised trop, may have normal ECG / ST depression / T wave inversion

Unstable angina
- sx of ACS, normal trop, normal ECG / ST depression / T wave inversion

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14
Q

NSTEM / unstable angina Mx?

A

B – Base the decision about angiography and PCI on the GRACE score
A – Aspirin 300mg stat dose
T – Ticagrelor 180mg stat dose (clopidogrel if high bleeding risk, or prasugrel if having angiography)
M – Morphine titrated to control pain
A – Antithrombin therapy with fondaparinux (unless high bleeding risk or immediate angiography)
N – Nitrate (GTN)

GRACE risk assessment
>3% (intermediate, high, highest) - is high risk

Coronary angiography +/- PCI - for the following:
- immediate - hypotensive
- <72hrs - GRACE >3%
- sx of ischaemia after admission

PCI - give:
- heparin
- DAPT

Conservative
- DAPT

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15
Q

ACS secondary prevention medication?

A
  • Aspirin 75mg once daily indefinitely
  • Another Antiplatelet (e.g., ticagrelor or clopidogrel) for 12 months
  • Atorvastatin 80mg once daily
  • ACE inhibitors (e.g. ramipril) titrated as high as tolerated
  • Atenolol (or another beta blocker – usually bisoprolol) titrated as high as tolerated

Aldosterone antagonist for those with clinical heart failure (i.e. eplerenone titrated to 50mg once daily)

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16
Q

ACS complications?

A

D: Death
A: Arrhythmia
R: Rupture of the heart septum or papillary muscles
T: Tamponade
H: Heart failure
V: Valve disease
E: Embolism
D: Dressler’s syndrome
A: Aneurysm
R: Recurrence or mitral regurgitation

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17
Q

what is Dressler’s syndrome?

A

2-6wks - autoimmune reaction - fever, pleuritic pain, pericardial effusion, raised ESR/CRP, tx with NSAIDs/steroids

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18
Q

stable angina?

A
  • chest pain caused by insufficient blood supply to myocardium
  • cause by atherosclerosis
  • demand for O2 greater than supply
  • stable - pain on exertion, relieved by rest/GTN
  • unstable - angina of increasing frequency/severity, present at rest
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19
Q

angina presentation?

A

All 3 core features – typical angina, 2 features – atypical, 0-1 – non-anginal chest pain

Core features
- constricting, heavy chest pain, radiation to jaw/neck/L arm
- Sx on exertion
- relieved by rest <5mins/GTN

  • sweaty, clammy, SOB, N+V, faint
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20
Q

angina investigations?

A
  • ECG
  • BP
  • Bloods - FBC, U/E, LFTs, lipids, TFTs, HbA1c, fasting glucose

[ cardiac stress testing
- CT coronary angiography
- invasive coronary angiography]

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21
Q

angina management?

A
  • refer to cardio - rapid access chest pain clinic
  • stop smoking, eat healthily, exercise, healthy weight, limit alcohol

Short-term
- sublingual GTN - 1 to 2 puffs and repeat after 5 mins

Long-term
- BB - bisoprolol
- CCB - diltiazem / verapamil (amlodipine if adding to BB)

Secondary prevention
- aspirin 75mg OD
- atorvastatin 80mg OD
- ACEi
- BB

Secondary care
- isosorbide mononitrate
- ivabradine (HCN channel blocker, slows HR)
- nicorandil
- ranolazine

persistant Sx? Surgical
- PCI - angioplasty + stent
- CABG
admit if - pain at rest / minimal exertion

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22
Q

acute pericarditis?

A
  • inflammation of pericardial sac <4-6wks
  • may lead to effusion/tamponade
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23
Q

acute pericarditis risk factors?

A
  • Idiopathic (no underlying cause)
  • Infection (e.g., TB, HIV, coxsackievirus, EBV)
  • Autoimmune and inflammatory conditions (e.g., SLE & RA)
  • Injury to the pericardium (e.g., after myocardial infarction, open heart surgery or trauma)
  • Uraemia (raised urea) secondary to renal impairment
  • Cancer
  • Medications (e.g., methotrexate)
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24
Q

acute pericarditis presentation?

A

KEY Sx = chest pain + low grade fever

Chest pain is:
* Sharp
* Central/anterior
* Worse with inspiration (pleuritic)
* Worse on lying down
* Better on sitting forward

  • pericardial rub on ausc
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25
Q

acute pericarditis investigations?

A
  • ECG - diffuse saddle-shaped ST elevation, PR depression
  • ECHO - effusion
  • Bloods - FBC, raised CRP/ESR, trops
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26
Q

acute pericarditis management?

A
  • can tx as OP
    1. tx cause - no strenuous activity until resolution
    2. NSAIDS or aspirin + gastroprotection
    3. Colchicine
  • may need prednisolone
  • pericardiocentesis if indicated
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27
Q

constrictive pericarditis?

A
  • pericardium becomes rigid
  • fibrosis, calcified, impairs diastolic filling of heart
  • eg post-pericarditis, viral, TB, idiopathic
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28
Q

constrictive pericarditis presentation?

A
  • SOB
  • RHF - elevated JVP, ascites, oedema, hepatomegaly
  • pericardial knock - loud S3
  • Kussmaul’s sign - rise in JVP on insp
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29
Q

constrictive pericarditis Ix?

A
  • CXR - pericardial calcification
  • ECG - low voltage QRS
  • ECHO - thickened pericardium, small ventricles
  • CT / MRI
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30
Q

constrictive pericarditis Mx?

A

pericardiectomy

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31
Q

pericardial effusion?

A
  • fluid in pericardial sac
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32
Q

cardiac tamponade?

A
  • life threatening pericardial effusion that constricts heart, drops CO
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33
Q

causes of pericardial effusion?

A
  • any cause of pericarditis
  • myocardial rupture, aortic dissection, trauma, TB, malignancy
  • post-cardiac surgery, central line insertion
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34
Q

pericardial effusion Px?

A
  • muffled heart sounds
  • apex beat obscured
  • JVP raised
  • Ewart’s sign - bronchial breathing at left base (compressed LL lobe)
  • SOB, chest pain, nausea, tachycardia
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35
Q

cardiac tamponade Px?

A

Beck’s
- low BP
- muffled HSs
- raised JVP

  • Kussmaul’s sign - rise in JVP with inspiration
  • Pulsus paradoxus - >10mmHG reduction in BP with inspiratio
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36
Q

pericardial effusion Ix?

A
  • CXR - large globular heart
  • ECG - low voltage QRS, sinus tachy, electrical alternans
  • ECHO
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37
Q

Mx of pericardial effusion?

A

Effusion
- spontaneously resolve
- pericardial fenestration
- pericardiocentesis - can be diagnostic or therapeutic

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38
Q

Mx of tamponade?

A

ABCDE
- pericardiocentesis
- cardiac surgery - midline sternotomy / thoracotomy

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39
Q

myocarditis definition and causes?

A
  • inflammation of myocardium
    Causes
  • Viral – coxsackie B, HIV
  • Bacteria – diphtheria, clostridia
  • Lyme disease, Chagas, toxoplasmosis
  • Autoimmune
  • Drugs – doxorubicin
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40
Q

myocarditis Px?

A
  • acute onset
  • chest pain
  • SOB
  • arrhythmias, palpitations
  • faint, dizzy
  • recent flu-like sx
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41
Q

myocarditis Ix?

A
  • bloods - raised CRP/ESR / trops / BNP
  • ECG - non specific abnormalities: tachycardia, arrhythmias, ST elevation, T wave inversion, other S/T changes
  • CXR
  • ECHO - to rule out valve dysfunction and dilated cardiomyopathies
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42
Q

myocarditis Mx?

A
  • tx cause, eg abx
  • supportive tx - of HF / arrhythmias
  • avoid exercise until recovered
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43
Q

infective endocarditis?

A
  • infection of endocardium, most commonly heart valves
  • mitral mostly, tricuspid in IVDU
  • valves have no direct blood supply
  • septic emboli / immune complexes thrown off
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44
Q

IE causes?

A
  • S aureus - most common
  • Strep - viridans - mouth/dental
  • Staph epidermidis - indwelling lines
  • Strep bovis - colorectal cancer
  • enterococcus
  • pseudomonas, HACEK, fungi
  • SLE, malignancy, CKD, malnutrition
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45
Q

IE risk factors?

A

Normal valves:
- IVDU
- skin breeches e.g. recent piercing
- immunosuppression
- DM
- CKD

Abnormal valves:
- Rheumatic fever
- structural heart pathology - eg valvular disease, HOCM
- prosthetic heart valves
- PDA

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46
Q

IE Px?

A
  • fever, fatigue, night sweats, myalgia, anorexia
  • new/changing murmur
  • aortic root abscess -> long PR / AV block
  • splinter haemorrhages
  • petechiae
  • Osler’s nodes
  • Roth spots
  • AKI / glomerulonephritis
  • Janeway lesions
  • Organ abscesses
  • splenomegaly / finger clubbing
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47
Q

IE Ix?

A
  • Bloods - FBC, U/E, CRP, cultures (3 sets from 3 sites at 3 different times >6hrs)
  • urinalysis - haematuria
  • ECHO - TOE more accurate
  • ECG - ?HB
  • CXR
  • CT - for emboli
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48
Q

IE modified Duke’s criteria - to Dx?

A

Dx requires either
- 1 major + 3 minor
- 5 minor

Major criteria
- Positive blood cultures on 2+ samples
- Specific imaging findings – eg vegetation on ECHO

Minor criteria
- Predisposition – eg IVDU, valve pathology
- Fever >38
- Vascular phenomena – splenic infarct, intracranial haemorrhage, Janeway lesions, petechiae, splinter haemorrhages
- Immunological phenomena – Ostler’s nodes, Roth spots, glomerulonephritis
- Microbiological phenomena – eg positive cultures 1x

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49
Q

IE Mx?

A

IV abx for 4-6 weeks:
native valve: amoxicillin + gentamicin
NB if pen allergic give vancomycin

prosthetic valve: vancomycin + rifampicin + gentamicin

Surgery to repair valve if:
- severe valvular incompetence, resistant to tx, abscesses

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50
Q

chronic heart failure definition and pathophysiology?

A
  • heart unable to pump enough blood to meet metabolic demands of the body
  • cor pulmonale - right heart enlargement - from disease of lungs/pulmonary vessels
  • also RAAS activation and salt/fluid retentio
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51
Q

key causes of HF?

A

IHD, valvular heart disease (AS), HTN, arrhythmias, cardiomyopathy

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52
Q

classification of HF?

A

left ventricular failure: caused by IHD, MI

right ventricular failure: chronic lung disease, pulmonary stenosis, LVF

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53
Q

HF Px?

A

Breathlessness - worsened by exertion
Cough - produce frothy white/pink sputum
Orthopnoea - breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use)
Paroxysmal nocturnal dyspnoea
Peripheral oedema
Fatigue

LVF: dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea, low exercise tolerance

RVF: peripheral oedema

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54
Q

HF patho in terms of ejection fraction and cardiac output ?

A

HF-rEF - inability of ventricle to contract normally - reduced CO, EF<40% - systolic dysfunction
- IHD, MI, dilated cardiomyopathy, arrhythmias, myocarditis, AS

HF-pEF - inability of ventricle to relax + fill normally, SV decreased, EF>50% - diastolic dysfunction
- HOCM, restrictive cardiomyopathy, tamponade, constrictive pericarditis

High-output HF - increased metabolic demands of body
- anaemia, AV malformation, Paget’s disease of bone, pregnancy, thyrotoxicosis

Low-output HF - CO reduced, fails to increase normally with exertion

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55
Q

HF signs on examination?

A

Tachycardia
Tachypnoea
Hypertension
Murmurs - valvular heart disease
3rd heart sound
Bilateral basal crackles (sounding “wet”) - indicating pulmonary oedema
Raised jugular venous pressure (JVP), caused by a backlog on the right side of the heart, leading to an engorged internal jugular vein in the neck
Peripheral oedema of the ankles, legs and sacrum

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56
Q

HF Ix?

A
  • CXR
  • ECG
  • ECHO
  • Bloods: BNP, U&Es, LFTs, fbCC, TFTs

BNP 400-2000 = echo in 6 weeks
BNP >2000 = echo in 2 weeks

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57
Q

HF CXR findings?

A

Alveolar oedema – ‘bat’s wing shadowing’
Kerley B lines – interstitial oedema
Cardiomegaly – cardiothoracic ratio >50%
Dilated prominent upper lobe veins (upper lobe diversion)
Pleural Effusions

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58
Q

New York Heart Association (NYHA) HF classification?

A

Class I – no symptoms on ordinary physical activity
Class II – mild sx, slight limitation of physical activity
Class III – moderate sx, comfortable at rest but less than ordinary activity leads to sx
Class IV – severe sx, inability to carry out any activity without s

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59
Q

HF Mx - all patients?

A

R – Refer to cardiology
A – Advise them about the condition
M – Medical treatment
P – Procedural or surgical interventions
S – Specialist heart failure MDT input e.g. heart failure specialist nurses, for advice and support

Medical 1st line:
A – ACE inhibitor (e.g., ramipril) titrated as high as tolerated
B – Beta blocker (e.g., bisoprolol) titrated as high as tolerated
L – Loop diuretics (e.g., furosemide or bumetanide)

Medical 2nd line:
A – Aldosterone antagonist when symptoms are not controlled with A and B (e.g., spironolactone or eplerenone)

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60
Q

HF-pEF Mx

A
  • manage comorbidities
  • tx cause
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61
Q

HF-rEF Mx

A

1st line
- ACEi (ramipril) + BB (bisoprolol)
- ARB (candesartan) if not tolerating ACEi
- hydralazine + nitrate if intolerant of ACEi/ARB
- add MRA (spironolactone/eplerenone) if sx continue
- check U/E (before/after each drug + dose change)

Specialist mx if sx continue
- replace ACEi/ARB with sacubitril valsartan if EF<35%
- add ivabradine if sinus rhythm >75, EF<35%
- add hydralazine + nitrate, esp if Afro-Caribbean
- digoxin
- SGLT2 inhibitor - dapagliflozin
- amiodarone

Specialist procedures
- cardiac resynchronisation therapy (CRT) - triple chamber pacemaker
- implantable cardioverter defibrillator (ICD)
- heart transplant

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62
Q

HF complications?

A
  • arrhythmias, depression, cachexia, CKD, sexual dysfunction, sudden cardiac death, VTE, hepatic dysfunction
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63
Q

acute HF / acute pulmonary oedema pathology?

A
  • acute deterioration in cardiac function
  • LVF -> CO reduced, backlog of blood, excess fluid leaks -> pulm oedema - lung/alveoli filled with interstitial fluid - impaired gas exchange

De-novo AHF - AHF w/o hx of HF - eg ischaemia, viral, toxins, valvular

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64
Q

causes of AHF / pulmonary oedema?

A

Cardiac
- acute LVF, ACS, arrhythmias, valvular heart disease, HTN, cardiomyopathy, tamponade

Non-cardiac
- fluid overload, high-output HF, ARDS, RAS

Triggers
- preload increase - eg IV fluids, retention
- contractility decrease - ischaemia, infarction, arrhythmias, valvular, cardiomyopathy
- afterload increase - HTN
- direct lung damage

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65
Q

AHF Px?

A
  • acutely SOB
  • cough - frothy white / pink sputum
  • hypoxia, cyanosis, increased RR/HR
  • bibasal creps on ausc
  • peripheral oedema
  • fatigue, raised JVP
  • 3rd HS
  • chest pain, fever, palpitations (depends on cause)
  • BP normal / increased
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66
Q

AHF Ix?

A
  • A-E
  • ECG
  • Bloods - FBC, U/E, BNP, ?trop, ABG, Mg, Ca, TFTs
  • CXR
  • ECHO
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67
Q

AHF Mx?

A

S – Sit up
O – Oxygen (15L)
D – Diuretics (IV furosemide 40mg)
I – Intravenous fluids should be stopped
U – Underlying causes need to be identified and treated (e.g., myocardial infarction)
M – Monitor fluid balance

  • IV morphine 2.5-10mg
  • IV GTN 1mg/ml at 2ml/hr - if BP not low
  • cardiogenic shock - dobutamine (inotrope) / noradrenaline (vasopressor)
  • CPAP
  • intubate
  • continue regular HF meds
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68
Q

HTN?

A
  • high BP
  • clinic reading >140/90, 24hr BP avg >135/85
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69
Q

HTN causes?

A

Primary / essential HTN
- 90%, no cause

Secondary
- Renal - glomerulonephritis, chronic pyelo, PKD, RAS
- Endocrine - hyperaldosteronism, phaeo, Cushing’s, Liddle’s, CAH, acromegaly
- other - glucocorticoids, NSAIDs, pregnancy, coarctation of aorta, cOCP

[ROPED]

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70
Q

HTN RFx?

A
  • older, ethnicity, FHx, overweight, sedentary, smoking, alcohol, diabetes, stress
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71
Q

HTN Px?

A
  • asym
  • headaches
  • visual disturbance
  • seizures
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72
Q

HTN Ix?

A
  • BP monitoring - clinic / 24hr ABPM / home BP monitoring
  • Stage 1 - >140/90 / >135/85 at home
  • Stage 2 - >160/100 / >150/95 at home
  • Stage 3 - >180/120
  • BP both arms
  • urine albumin:creatinine ratio
  • urine dipstick
  • Bloods - HbA1c, U/E, lipids
  • fundoscopy
  • ECG
  • QRISK
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73
Q

HTN general Mx?

A
  • healthy diet, stop smoking, reduce alcohol, lower caffeine/salt, exercise
  • <40yo, ?refer to r/o secondary causes

BP targets
<80yo - <140/90 in clinic, <135/85 at home
>80yo - <150/90 in clinic, <145/85 at home

  • if stage 1 - tx if <80yo AND organ damage / CV disease / renal disease / DM / QRISK>10%
  • stage 2 - drug tx regardless of age
  • stage 3 - same day assessment for retinal haemorrhage / papilloedema / phaeo / life-threatening sx
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74
Q

HTN Mx algorithm?

A

Step 1
<55yo / T2DM
- ACEi (ramipril)
- if T2DM Afro-Caribbean - ARB (candesartan)
- change to ARB if ACEi not tolerated

> 55yo / Afro-Caribbean
- CCB (amlodipine)

Step 2
- if on ACEi/ARB - add CCB / thiazide-like (indapamide)
- if on CCB - add ACEi/ARB / thiazide-like (ARB in Afro-Caribbean)

Step 3
- add the 3rd drug left

Step 4
- K<4.5 - low dose spironolactone
- K>4.5 - add alpha/beta blocker
- specialist review if still not controlled

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75
Q

HTN complications?

A
  • IHD, CVA, PAD, aortic dissection, AAA, atherosclerosis
  • hypertensive retinopathy
  • hypertensive nephropathy
  • LVH
  • HF
  • malignant HTN / hypertensive emergency
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76
Q

hypertensive emergency?

A

Hypertensive urgency – severe hypertension with no evidence of acute end organ damage

Hypertensive emergency – severe hypertension with evidence of acute end organ damage

Malignant/accelerated hypertension – a hypertensive emergency involving retinal vascular damage

77
Q

hypertensive emergency Px?

A
  • headache, visual disturbance, N+V, confusion, seizures, coma, drowsy
  • ischaemic chest pain, SOB, bibasal creps, raised JVP
  • focal neurology
  • tearing chest pain…
78
Q

hypertensive emergency Ix?

A
  • CT head
  • fundoscopy
  • ECG, urinalysis, U/E, CXR
  • Ix for secondary causes
79
Q

hypertensive emergency Mx?

A
  • A-E
  • IV Sodium nitroprusside
  • IV labetalol
  • IV GTN, nicardipine
  • If asymptomatic - start chronic HTN mx
80
Q

discuss broad complex tachycardia

A
  • QRS >120ms / 3 small squares

VT
- broad complex tachycardia originating from ventricles
- monomorphic / polymorphic / Torsades de pointes (…long QT)
- ALS guidelines to mx - synchronised DC cardioversion / IV amiodarone
- Mg for Torsades de pointes

AF with BBB
- tx as AF

SVT with BBB
- tx as SVT

VF
- cardiac arrest rhythm

81
Q

discuss narrow complex tachycardia?

A
  • high HR with QRS <120ms

Sinus tachycardia
- normal PQRST pattern
- tx cause

AF
- technically an SVT

AFl
- technically an SVT

SVT
- tachycardia that originates from above the ventricles

82
Q

SVT

A
  • tachycardia that originates from above the ventricles
  • signal re-enters atria from ventricles, then goes through AVN to ventricles - loop

Paroxysmal SVT: SVT reoccurs / remits
AVNRT: re-entry point through AVN
AVRT: re-entry point is accessory pathway - eg WPW
Atrial tachycardia: signal from atria somewhere other than SAN
Junctional tachycardia: impulse from AVN/junction - ECG narrow QRS, absent/inverted P waves

83
Q

WPW syndrome ?

A
  • congenital accessory pathway (bundles of Kent) between atria / ventricles - AVRT
  • L/R sided
  • pathway causes abnormal early depolarisation
  • if SAN delivers premature beat, signal travels down septum then back up accessory pathway - re-entry circuit - tachyarrhythmia

Associations
- HOCM, mitral valve prolapse, Ebstein’s, thyrotoxicosis, secundum ASD

ECG
- Short PR
- Wide QRS, slurred upstroke - delta wave
- LAD if R sided pathway
- RAD if L sided pathway

84
Q

SVT Px?

A
  • chest pain, palpitations, sweaty/clammy, faint, dizzy, HF
85
Q

SVT Mx?

A
  • ALS guidelines
  • synchronised DC cardioversion if unstable
  • modified valsalva
  • IV adenosine
  • BBs / verapamil
  • long-term - BB / CCB / amiodarone
  • radiofrequency ablation
  • WPW + AF/AFl - use procainamide / electrical cardioversion
86
Q

AF

A
  • Disorganised electrical activity of atria leading to fibrillation and irregularly irregular ventricular contraction
  • type of SVT
  • blood can stagnate in atrial appendage - stroke risk
  • HF from impaired diastolic filling of ventricles
  • may go into AF wRVR - tachycardic ventricular rate
87
Q

AF causes?

A
  • idiopathic
  • atrial damage - fibrosis
  • HTN
  • HF
  • coronary artery disease, IHD
  • valvular heart disease - eg mitral stenosis
  • cardiomyopathy
  • rheumatic heart disease
  • alcohol, caffeine
  • thyrotoxicosis
  • infection
  • anaemia
88
Q

types of AF?

A
  • first detected episode
  • recurrent - 2+ episodes
  • paroxysmal AF - terminates spontaneously, <7d, typically <24hrs
  • persistent AF - not self-terminating - >7d
  • permanent AF - continuous AF - rate control/anticoagulation goals
89
Q

AF Px?

A
  • Palpitations
  • SOB
  • Chest pain
  • Syncope, dizziness
  • Sx of associated condition, eg infection, stroke
  • Irregularly irregular pulse
90
Q

AF Ix?

A
  • Bloods - FBC, U/E, TFTs, LFTs, coag, Mg, Ca
  • ECG - absent P waves, irregularly irregular QRS, absence of isoelectric baseline, may be tachycardic
  • CXR
  • ECHO
  • 24hr ambulatory ECG (Holter) / cardiac event recorder - for paroxysmal AF
  • CHA2DSVASc / ORBIT
91
Q

overview of AF Mx?

A

Unstable
- synchronised DC cardioversion

<48hrs of sx onset
- rate / rhythm control

> 48hrs of sx onset / uncertain of onset
- rate control
- if ?long-term rhythm control - delay cardioversion until >3wks anticoagulation

Catheter ablation
- if no response to antiarrhythmics

LAA occlusion
- anticoagulate first
- may insert catheter, place plug into LAA

92
Q

AF rate control use and options?

A

Offer as first line apart from:
- AF has reversible cause
- HF primarily caused by AF
- new onset <48hrs
- AFl suitable for ablation
- clinical judgement that rhythm control better

  • BB - bisoprolol / metoprolol
  • CCB - diltiazem (not in HF)
  • digoxin - eg if pt does no exercise
93
Q

AF rhythm control options?

A

Offer to pts:
- reversible cause for AF
- new onset AF <48hrs
- HF caused by AF
- sx despite rate control

<48hrs onset AF - immediate cardioversion
- heparin
- electrical - synchronised DC shock
- pharm - flecainide / amiodarone

> 48hrs onset AF - delayed cardioversion
- >3wks anticoagulation
- TOE to exclude LA appendage thrombus
- electrical cardioversion
- 4wks amiodarone / sotalol before
- anticoagulate >4wks after

Long term rhythm control
- BBs
- dronedarone
- amiodarone - esp if co-existing HF

94
Q

paroxysmal AF?

A
  • may use pill-in-the-pocket approach
  • flecainide / BB when sx of AF develop
95
Q

reducing stroke risk in AF?

A

CHA2DS2-VASc
- risk of stroke with AF

ORBIT
- risk of bleeding

Mx
- DOAC
- warfarin 2nd line

96
Q

when would you refer AF to cardiology?

A
  • If rhythm control is appropriate
  • Rate control fails to control sx - <4wk referral
  • Valvular disease, LVF on ECHO
  • WPW or prolonged QT
97
Q

atrial flutter? causes?

A
  • organised abnormal atrial rhythm, atrial rate 300
  • re-entry circuit in RA
  • thrombus risk
  • pulse tends to be 150, 100, 75
  • typical - rhythm origin in RA at level of tricuspid valve
  • atypical - origin from elsewhere

Causes
- idiopathic, coronary artery disease, HTN, HF, COPD, pericarditis, alcoholism, surgery

98
Q

atrial flutter Px?

A
  • palpitations, SOB, chest pain, dizzy, syncope, fatigue, HF
99
Q

atrial flutter Ix?

A
  • ECG - sawtooth baseline, narrow complex tachy, regular QRSs
  • Bloods - FBC, U/E, CRP, LFTs, TFTs, Mg, Ca
  • CXR
  • ECHO
100
Q

atrial flutter Mx?

A
  • rate / rhythm control
  • lower energy levels for cardioversion
  • radiofrequency ablation of tricuspid valve isthmus
101
Q

causes of bradycardia?

A
  • HB
  • Meds - BBs
  • sick sinus syndrome - conditions which cause dysfunction in SAN -> sinus brady, sinus arrhythmias, prolonged pauses
102
Q

1st degree HB?

A
  • PR >0.2s (5 small squares)
  • delayed conduction at AVN, P wave precedes every QRS

Causes
- low K, myocarditis, inferior MI, IHD, BBs, CCBs, digoxin, rheumatic fever, IE, lyme disease, sarcoidosis

Mx
- normally no tx
- tx cause if needed

103
Q

2nd degree HB - mobitz type 1

A

Mobitz T1 (Wenkebach)
- progressive PR prolongation, then P wave with no QRS, cycle restarts
- regularly irregular pulse

Causes - AVN blocking drugs, inferior MI, IHD

Px - light-headed, dizzy, syncope

Mx - maybe pacing / tx cause

104
Q

2nd degree HB - Mobitz type 2

A

Mobitz T2
- PR interval constant, absence of QRS at regular intervals
- regularly irregular pulse

Causes - anterior MI, mitral valve surgery, SLE, lyme disease, IHD….

Px - SOB, CP, light-headed etc

Mx - pacemaker, tx cause

105
Q

3rd degree HB

A
  • complete dissociation between P waves + QRS complexes

Causes
- structural heart disease, IHD, HTN, endocarditis….

Px
- syncope, HF, regular bradycardia, wide pulse pressure, variable S1

Mx
- atropine
- transcutaneous pacing / PPM

106
Q

BBB

A

block in lower conduction system

107
Q

RBBB?

A
  • lack of depolarisation down R branch - signal spreads from LV across septum, RV contraction delayed

Causes
- normal, RVH, cor pulmonale, PE, MI, ASD, IHD…

  • splitting of S2 on ausc

ECG
- Broad QRS >120ms
- MARROW

108
Q

LBBB?

A
  • lack of depolarisation down L branch - impulse spread from RV across septum to LV

Causes
- new LBBB always pathological
- MI - Sgarbossa criteria
- HTN, AS, cardiomyopathy, high K…

  • reverse splitting of S2

ECG
- broad QRS >120ms
- WILLIAM
- associated with - LAD, poor R wave progression

109
Q

Left anterior fascicular block (LAFB)

A
  • Anterior fascicle inserts into upper lateral wall of LV
  • Left axis deviation
  • qR complexes in I, aVL - positive
  • rS complexes in II, III, aVF - negative
  • prolonged R wave peak time in aVL >45ms
110
Q

Left posterior fascicular block (LPFB)

A
  • Posterior fascicle inserts into inferoseptal wall of LV
  • Right axis deviation
  • rS complexes I, aVL - negative
  • qR complexes II, III, aVF - positive
  • Prolonged R wave peak time aVF
111
Q

Bifascicular block

A

2/3 fascicles are blocked, so conduction is via single remaining fascicle, one of two patterns:
- RBBB + LAFB, manifested as left axis deviation
- RBBB + LPFB, manifested as right axis deviation

112
Q

Trifascicular block

A

Conduction delay in all 3 fascicles below AVN (RBBB, LAFB, LPFB)

Manifests as bifascicular block + 3rd degree AV block, one of two patterns:
- 3rd degree AV block + RBBB + LAFB
- 3rd degree AV block + RBBB + LPFB

113
Q

prolonge QT

A
  • QT interval - from start of QRS to end of T wave
  • use QTc - >440ms (men), >460ms (women) is prolonged
  • prolonged repolarisation of myocytes - can lead to spontaneous depolarisation of myocytes -> Torsades de pointes, VT, arrest
  • Long QT syndrome - inherited condition causing prolonged QT - most commonly defects in K channels
114
Q

causes of prolonged QT?

A

ASTHMATIC
- amiodarone
- sotalol, SSRIs
- terfenadine
- haloperidol
- methadone, macrolides
- antiarrhythmics class Ia
- TCAs
- chloroquine

  • congenital
  • low Ca, low K, low Mg
  • acute MI, myocarditis, hypothermia, SAH
115
Q

Prolonged QT Px

A
  • syncope, palpitations…
  • exertional syncope
  • sudden cardiac death
116
Q

Prolonged QT Ix

A
  • ECG - prolonged QTc
  • bloods
117
Q

Prolonged QT Mx

A
  • stop meds causing it
  • correct electrolytes
  • IV Mg
  • BBs
  • pacemaker / ICD
118
Q

ventricular ectopics?

A
  • premature ventricular complexes (PVCs)
  • beats originate from ventricular myocardium - wide QRS
  • common, healthy
  • more common if IHD, HF, HTN, MI etc
  • bigeminy / trigeminy / quadrigeminy - every 2nd/3rd/4th beat is PVC

Px
- asym
- cardiac sx
- pulse irregular

Ix
- ECG
- maybe ECHO

Mx
- reassure if healthy, infrequent
- refer if concerning sx
- BBs for sx

119
Q

Junctional / ventricular escape rhythms

A
  • abnormal heart rhythm with impulses originating from AVN / bundles of His at AV junction

Types
- Junctional bradycardia – <40BPM
- Junctional escape rhythm – 40-60BPM
- Accelerated junctional rhythm – 60-100BPM
- Junctional tachycardia – >100BPM
- ventricular escape rhythm - from ventricles

Causes
- anything that impairs SAN
- sinus brady, sinus arrest, 3rd HB, high K, BBs, CCB, digoxin

Px
- asym / SOB, CP etc

Ix
ECG
- P waves - absent / inverted before/after QRS
- junctional escape - narrow QRS
- ventricular escape - broad QRS

120
Q

murmur memory aid: murmur, character and systolic or diastolic?

A

P/ARD - decrescendo
P/ASS - crescendo decrescendo
T/MSD - decrescendo crescendo
T/MRS - pansystolic

121
Q

what is S2?

A
  • Closing of pulmonary / aortic valves at end of ventricular systole
  • Soft (?) in aortic stenosis
  • Splitting during inspiration is normal
122
Q

what is S1?

A
  • Closing of tricuspid / mitral valves at start of ventricular systole
  • Loud in mitral stenosis
123
Q

what is S4? what causes it?

A
  • Just before S1, atria contract and force blood against stiff / hypertrophic ventricle – sound is blood hitting ventricle wall
  • Always pathological
  • Heard in aortic stenosis, HOCM, HTN
124
Q

what is S3?

A
  • After S2, tensioning of chordae tendineae with rapid ventricular filling at start of diastole - ‘guitar twang’
  • Can be normal in young people
  • Can indicate HF – ventricles / chordae are stiff / weak
  • Heard in LVF, mitral regurg
125
Q

aortic stenosis: cardiac cycle, character, breathing, location, radiation?

A
  • systolic
  • ejection systolic
  • expiration
  • 2nd intercostal space, right sternal edge
  • radiate to carotid
126
Q

pulmonary stenosis: cardiac cycle, character, breathing, location, radiation?

A
  • systolic
  • ejection systolic
  • inspiration
  • 2nd intercostal space, left sternal edge
  • left shoulder / infraclavicular
127
Q

mitral regurgitation: cardiac cycle, character, breathing, location, radiation?

A
  • systolic
  • pan systolic
  • expiration
  • apex
  • axilla
128
Q

tricuspid regurgitation: cardiac cycle, character, breathing, location?

A
  • systolic
  • pansystolic
  • inspiration
  • left sternal edge
129
Q

aortic regurgitation: cardiac cycle, character, breathing, location?

A
  • early diastolic
  • decrescendo
  • expiration
  • left sternal edge or 2nd intercostal space right sternal edge)
130
Q

pulmonary regurgitation: cardiac cycle, character, breathing, location?

A
  • early diastolic
  • decrescendo
  • inspiration
  • 2nd intercostal space left sternal edge
131
Q

mitral stenosis?

A
  • Mid/late diastolic
  • Expiration
  • apex
132
Q

aortic stenosis?

A
  • narrowing of aortic valve
  • calcification / congenital bicuspid valve
  • reduced valve SA, increased afterload, LVH, LVF
133
Q

which murmur radiates to carotid?

A

aortic stenosis

134
Q

which murmur radiates to axilla?

A

mitral regurgitation

135
Q

aortic stenosis px?

A
  • angina
  • syncope
  • HF
  • SOB
  • dizziness
  • sx worse on exertion
  • ejection systolic crescendo-decrescendo murmur - radiates to carotids
  • slow rising pulse, decreased pulse amplitude, narrow pulse pressure
  • thrill
136
Q

aortic stenosis Ix? (same for all other valve diseases too)

A
  • ECHO
  • ECG
  • CXR
137
Q

aortic stenosis Mx?

A
  • aortic valve replacement - surgical / TAVI
  • balloon valvuloplasty
138
Q

mitral regurgitation - definition and causes?

A
  • blood leaks back through incompetent mitral valve during systole
  • EF / SV reduced, LA enlargement, LVH, progressive heart failure

Causes
- mitral valve prolapse
- coronary artery disease / post MI
- IE
- rheumatic fever
- congenital
- EDS / Marfan’s

139
Q

mitral regurgitation Px?

A
  • SOBOE, fatigue
  • palpitations
  • signs of HF / pulm oedema
  • pansystolic murmur - radiates to axilla
  • thrill
140
Q

mitral regurgitation Mx?

A
  • drugs to increase CO in acute cases - nitrates, diuretics, inotropes, aortic balloon pump
  • HF - ACEi, BBs, spironolactone
  • surgery - repair/replacement - when sx / EF<60%
141
Q

aortic regurgitation - definition and causes?

A
  • incompetent aortic valve - blood leaks back into ventricle from aorta during diastole
  • increased preload, LV dilatation / hypertrophy -> LVF

Causes
- rheumatic fever, calcification, RA/SLE, bicuspid aortic valve, IE
- ankylosing spondylitis, HTN, syphilis, Marfans, EDS, dissection

142
Q

aortic regurgitation Px?

A
  • HF / pulm oedema sx
  • collapsing pulse
  • wide pulse pressure
  • early diastolic murmur
  • Quincke’s sign - nailbed pulsation
  • De Musset’s sign - head bobbing
143
Q

aortic regurgitation Mx?

A
  • medical mx of HF
  • aortic valve replacement - if sx / LV systolic dysfunction
144
Q

mitral stenosis?

A
  • narrow mitral valve, restricting blood flow from LA -> LV
  • increased pressure in LA, pulmonary vessels, R heart
  • rheumatic fever, IE
145
Q

mitral stenosis Px?

A
  • SOBOE, oedema, angina etc
  • haemoptysis
  • mid-diastolic murmur, loud S1, opening snap after S2
  • malar flush
146
Q

mitral stenosis Mx?

A
  • balloon valvuloplasty
  • mitral valve replacement
147
Q

discuss prosthetic heart valves?

A

Biological
- cow/pig
- deteriorate over time - replace in 10yrs
- warfarin for first 3mo then aspirin

Mechanical
- last longer
- life-long warfarin
- metallic click on ausc

Cx
- thrombus, IE, haemolytic anaemia

148
Q

types of cardiomyopathy?

A
  • disorders of the heart muscle

Primary - predominantly involving heart
Genetic:
- HOCM
- ARVD/C
Mixed:
- dilated cardiomyopathy
- restrictive
Acquired:
- peripartum
- Takotsubo

Secondary - pathological myocardial involvement due to systemic disorder
- eg coxsackie B, amyloidosis, HHC, alcohol, sarcoidosis, DM, thyrotoxicosis, acromegaly, DMD, thiamine, SLE

149
Q

Hypertrophic obstructive cardiomyopathy (HOCM)

A
  • autosomal dominant thickening/hypertrophy of LV
  • LV outflow blocked, thick wall poorly compliant, poor diastolic filling, reduced CO
  • increased arrhythmia/HF/MI risk
150
Q

HOCM Px

A
  • asym
  • SOBOE
  • angina, syncope, dizziness, palpitations
  • HF sx
  • sudden death
  • jerky carotid puls
151
Q

HOCM Ix

A
  • ECG - LVH
  • ECHO
  • CXR
  • cardiac MRI
  • genetic testing
152
Q

HOCM Mx

A
  • BBs / verapamil
  • amiodarone
  • ICD
  • surgical myomectomy
  • alcohol septal ablation
  • heart transplant
  • avoid intense exercise, heavy lifting, dehydration
  • avoid - ACEi, nitrates, inotropes
153
Q

Arrhythmogenic right ventricular dysplasia / cardiomyopathy (ARVD/C)

A
  • autosomal dominant - progressive fatty/fibrous replacement of ventricular myocardium
  • arrhythmia risk
154
Q

ARVD Px

A
  • palpitations
  • syncope
  • sudden death
155
Q

ARVD Ix

A
  • ECG
  • ECHO
  • MRI
  • genetic testing
156
Q

ARVD Mx

A
  • BB, amiodarone
  • catheter ablation
  • ICD
  • heart transplant
157
Q

Dilated cardiomyopathy - definitions and causes?

A
  • thinning / dilatation of heart muscle
  • genetic / secondary
  • poorly contracts - systolic dysfunction

Causes
- idiopathic, myocarditis, IHD, peripartum, HTN, drugs, DMD, HHC, sarcoidosis….

158
Q

Dilated cardiomyopathy Px

A
  • HF sx
  • systolic murmur
  • S3
159
Q

Dilated cardiomyopathy Ix

A
  • CXR - balloon appearance of heart
  • ECHO
  • ECG
160
Q

Dilated cardiomyopathy Mx

A
  • medical mx of HF
161
Q

Restrictive cardiomyopathy

A
  • heart becomes rigid / stiff -> impaired ventricular filling during diastole
  • genetic / secondary causes
  • amyloidosis, sarcoidosis, post-radiotherapy…
162
Q

Restrictive cardiomyopathy Px

A
  • raised JVP, hepatomegaly, oedema, SOB, fatigue
163
Q

Restrictive cardiomyopathy Ix

A
  • CXR, ECHO, ECG
  • cardiac catheterisation / MRI / heart imaging etc
164
Q

Restrictive cardiomyopathy Mx

A
  • poor prognosis
  • heart transplant
  • HF mx
165
Q

Peripartum cardiomyopathy

A
  • weakness of heart muscle that develops between last month pregnancy + 5mo post-partum
  • more common older, higher G/P
  • causes HF
166
Q

Alcohol-induced cardiomyopathy

A
  • type of dilated cardiomyopathy caused by long-term alcohol use
167
Q

Takotsubo cardiomyopathy

A
  • Stress-induced cardiomyopathy - rapid onset of LV dysfunction / weakness
  • Broken heart syndrome
  • Chest pain, HF sx
  • Transient apical ballooning of myocardium
  • Supportive tx, sx resolve with time
168
Q

discuss pacemakers - very long care!

A
  • Pulse generator + pacing leads – carry electrical impulses to heart to improve function

Indications
- Bradycardia with sx
- Mobitz T2
- 3rd degree block
- AVN ablation for AF
- Severe HF – biventricular pacemakers

Single chamber
- RA/RV

Dual chamber
- both RA/RV

Biventricular (triple chamber) pacemaker
- RA,RV,LV
- CRT

ICDs
- shock if VF/VT

ECG changes
- sharp vertical line

Indications for temporary pacemaker
- sx/unstable bradycardia, unresponsive to atropine
- post-anterior MI
- trifascicular block prior to surgery

169
Q

atrial myxoma

A
  • most common primary cardiac tumour
  • 75% in LA, attached to fossa ovalis
    Px
  • SOB, fatigue, wt loss, fever, clubbing
  • emboli
  • AF
  • mid-diastolic murmur
    Ix
  • ECHO - pedunculated heterogenous mass
    Mx
  • surgical removal by median sternotomy
170
Q

Brugada syndrome

A
  • autosomal dominant condition causing arrhythmia - can cause tachycardia
    Px
  • dizzy, syncope, SOB, palpitations
    Ix
    ECG
  • Downward sloping ST segment, inverted T wave, incomplete RBBB – in V1-3
  • Changes more apparent after flecainide
    Mx
  • ICD
171
Q

shock definition

A

Circulatory failure leading to inadequate organ perfusion and tissue hypoxia

172
Q

causes of shock?

A

Hypovolaemic
Cardiogenic
Obstructive
Distributive - reduced SVR
- Septic shock
- Anaphylactic shock
- Neurogenic shoc

173
Q

hypovolaemic shock?

A
  • shock due to low BV
  • haemorrhage, D+V, burns, diuresis
174
Q

hypovolaemic shock Px?

A
  • Reduced GCS, agitation, confusion
  • Skin pale, cold, sweaty, vasoconstricted
  • Cool peripheries
  • Tachycardia
  • Tachypnoea
  • Oliguria - reduced urine output
  • Increased cap refill time (CRT)
  • Weak, rapid pulse
  • Reduced pulse pressure
175
Q

hypovolaemic shock Ix?

A
  • A-E
  • bloods
  • Ix for cause - CXR, ECG, ECHO, CT, FAST
176
Q

hypovolaemic shock Mx?

A
  • IV fluids
  • blood - MHP etc
  • tx cause
177
Q

cardiogenic shock ? causes, Px, Ix and Mx

A
  • shock due to cardiac dysfunction / failure of the pump action of heart

Causes
- MI, myocardial contusion, myocarditis, cardiac arrhythmias, BBs, CCBs
Px
- signs of heart disease
- signs of shock
Ix
- for cause
- ECG / ECHO
Mx
- tx caus

178
Q

neurogenic shock?

A
  • spinal cord injury above T6 - loss of sympathetic outflow, decreased SVR, decreased preload/CO

Px
- Instant hypotension
- Warm, flushed peripheries
- Priapism
- Bradycardia
- Flaccid paralysis, loss of reflexes
- Loss of bladder / bowel control
Mx
- IV fluids
- adrenaline infusion

179
Q

obstructive shock?

A
  • shock due to obstruction of cardiac output
  • tension PTX, massive PE, cardiac tamponade

Mx
- tx cause

180
Q

sepsis?

A
  • body launches large immune response to infection, causing systemic inflammation + organ dysfunction
  • cytokine/interleukin/TNF release -> systemic inflammation, release of vasodilators
  • SOFA score to assess severity of organ dysfunction
181
Q

sepsis RFx?

A
  • <1yo / >75yo
  • Chronic conditions
  • Chemo, immunosuppressants, steroids
  • Surgery, recent trauma, burns
  • Pregnancy, childbirth
  • Indwelling devices - catheters, central lines
182
Q

sepsis Px?

A
  • sx of infection source - cough, SOB, dysuria, N+V, abdo pain, cellulitis….
  • reduced UO
  • mottled skin, cyanosis
  • warm peripheries, clammy skin
  • bounding pulse
  • confusion, drowsy, off legs
  • high HR/RR/temp, low BP,
183
Q

sepsis Ix?

A
  • A-E, obs
  • Bloods - FBC, U/E, LFTs, CRP, BMs, coag, cultures, VBG
  • urine dip + culture
  • CXR
  • ECG
  • CT / LP
184
Q

sepsis Mx?

A
  • O2
  • Broad spec abx - eg tazocin / meropenem
  • IV fluids
  • Catheter + UO
  • Blood cultures
  • Serum lactate
185
Q

anaphylaxis?

A
  • severe life-threatening T1 hypersensitivity reaction
  • allergen reacts with IgE ABs on mast cells/basophils - rapid histamine release - capillary leakage, mucosal oedema, shock, airway compromise
  • anaphylaxis - ABC compromise
186
Q

anaphylaxis Px?

A

Hx of exposure to allergen, rapid onset sx

A – swelling of tongue/throat (angioedema) -> hoarse voice + stridor
B – wheeze, SOB, fatigue, cyanosis, low sats
C – hypotension, tachycardia, shock, confusion, reduced consciousness
D – confusion…
E – urticarial rash, pruritis

187
Q

anaphylaxis Mx?

A
  • IM adrenaline - 500mcg (>12yo), 300mcg (6-12yo), 150mcg (6mo-6yrs), 100-150mcg (<6mo)
  • IV fluids

Refractory anaphylaxis
- IV adrenaline infusion
- IV fluids
- consider salbutamol nebs + ipratropium

188
Q

anaphylaxis Mx post stabilisation?

A
  • Non-sedating oral antihistamine (chlorphenamine is sedating)
  • Serum mast cell tryptase - measure <6hrs of event - confirm dx
  • Refer to specialist allergy clinic
  • Prescribe 2 adrenaline auto-injectors
  • Beware biphasic reactions (20%)
189
Q

anaphylaxis approach to discharge

A

Fast-track discharge (>2hrs of sx resolution)
- Good response to single dose adrenaline
- Complete resolution of sx
- Has epipen, trained on how to use
- Adequate supervision following discharge

> 6hrs sx resolution
- 2 doses IM adrenaline needed
- Or previous biphasic reaction

> 12hrs after sx resolution
- Severe reaction requiring 2 doses IM adrenaline
- Severe asthma
- Possibility of ongoing reaction (eg slow release medication)
- Pt presents late at night
- Patient in area where access to emergency care difficult

finals (21 decks)

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