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Emergency Medicine > Cardiology > Flashcards

Cardiology Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

What is Wellens’ syndrome?

A

Critical stenosis of the proximal LAD - imminent risk of acute AMI

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2
Q

What are the ECG findings in Wellens’ syndrome?

A

Biphasic T-wave inversion in leads V1-V4 that usually only appear on a pain-free ECG

Two variants - type A and type B (biphasic vs deeply inverted T wave changes) most obvious in leads V2 and V3

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3
Q

What should be done for a patient with suspected Wellens’ syndrome?

A

Must be admitted to a monitored bed under a cardiology team for an inpatient coronary angiogram

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4
Q

What ECG findings are diagnostic of Wolff-Parkinson-White syndrome? (2)

A 
Short PR interval
Delta wave (slurred upstroke of the QRS complex)
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5
Q

What is Wolff-Parkinson-White syndrome?

A

The presence of an accessory pathway (bundle of Kent) allows conduction from the atria to the ventricles, bypassing the AV node.

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6
Q

In WPW, what makes a QRS complex narrow vs broad?

A

Narrow - anterograde conduction in Bundle of His and return conduction through accessory pathway

Broad - anterograde conduction via accessory pathway, with retrograde conduction back up the normal AV nodal pathway (rhythm can be indistinguishable from VT)

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7
Q

What are the ECG criteria for thrombolysis? (3)

A

More than 2mm ST segment elevation in 2 contiguous chest leads
OR
More than 1mm ST segment elevation in at least 2 contiguous limb leads
OR
A new LBBB pattern

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8
Q

What are the absolute contraindications to thrombolysis? (7)

A

Risk of bleeding

  • active bleeding
  • significant closed head or facial trauma within 3 months
  • suspected aortic dissection

Risk of ICH

  • any prior ICH
  • ischaemic stroke within 3 months
  • known structural cerebral vascular lesion (e.g. AVM)
  • known malignant intracranial neoplasm
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9
Q

What are the relative contraindications to thrombolysis? (10)

A

Risk of bleeding

  • Current use of anticoagulants
  • non-compressible vascular punctures
  • recent major surgery (less than 3 weeks)
  • traumatic or prolonged (more than 10 minutes) CPR
  • recent (within 4 weeks) internal bleeding (e.g. GI or urinary tract haemorrhage)
  • active peptic ulcer

Risk of ICH

  • hx of chronic, severe, poorly controlled HTN
  • severe uncontrolled HTN on presentation
  • ischaemic stroke more than 3 months ago

Other
- pregnancy

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10
Q

What ECG findings are evident in WPW AF?

A

Irregular broad complexes of varying morphology

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11
Q

What are the treatment options for WPW AF? (3)

A

DC reversion, flecainide or procainamide

Admission to monitored bed

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12
Q

Which medications should be avoided in WPW AF and why?

A

“ABCD” rule

Adenosine
Beta-blockers
Calcium channel blockers
Digoxin

These all have degrees of AV nodal blocking activity. If AV node is blocked, preferential conduction can occur via the accessory pathway, resulting in a very rapid tachycardia, which can degenerate into VF

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13
Q

What is the valsalva maneouvre?

A

Increasing intrathoracic pressure by expiration against a closed glottis

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14
Q

Management of SVT (3)

A
  1. Valsalva maneouvre
  2. Adenosine (transiently inhibits AV conduction for about 30 seconds - unpleasant feeling of impending doom, anxiety and facial flushing) OR IV verapamil (contraindicated in young children and in patients with hypotension)
  3. if first episode, ECG and follow-up with local doctor. If recurrent, cardiologist referral for consideration of prophylaxis (verapamil, beta-blockers) or radio-frequency ablation
    3.
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15
Q

What CPAP settings can be used in patient with APO?

A

EPAP 8cm H20
IPAP 12cm H20
100% FiO2

EPAP can be increased gradually to 10-12 cm H20 as tolerated

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16
Q

What adjuvant treatment, apart from CPAP can be given in patients with APO? (4)

A
  1. If hypertensive, IV GTN to decrease pre-load (aim for MAP 90mmHg)
  2. Seek and treat possible precipitants e.g. myocardial ischaemia, volume overload, sepsis and anaemia
  3. Morphine to treat pain
  4. Frusemide ONLY if there is clinical evidence of volume overload
    - in APO there is not necessarily an ‘excess of fluid’ but rather, it is in the wrong compartment (intra-alveolar, rather than intravascular)
17
Q

What is the difference between CPAP and BIPAP?

A

CPAP = continuous positive airway pressure = just EPAP

BiPAP = bi-level positive airway pressure = EPAP + IPAP

(EPAP is set below level of IPAP)

18
Q

How does EPAP help in patients who require it? (3)

A
  1. Presents collapse of alveoli, extending time available for gas exchange, increasing oxygenation and carbon dioxide elimination
  2. decreases work of breathing as there is no req’ment to re-open collapsed alveoli
  3. re-distributes lung water from alveoli into interstitial space
19
Q

How does IPAP work? (2)

A
  1. Assists and enhances inspiration

2. Reduces work of breathing and may be useful in patients with respiratory muscle fatigue

20
Q

What triad of ECG findings are found in a massive pericardial effusion?

A
  1. Low voltages
  2. Tachycardia
  3. Electrical alternans
21
Q

What is electrical alternans and what is it caused by?

A

When there is alternating amplitude of normally-conducted QRS complexes. Produced by the heart swinging backwards and forwards within a large fluid-filled pericardium (alternating position of heart relative to recording electrodes)

22
Q

What ECG findings are evident in a complete heart block?

A

AV dissociation - no relationship between the p waves and QRS complexes

23
Q

Define a wide complex tachycardia. (2)

A
  1. QRS complex more than 120ms (more than 3 small squares)

2. HR more than 100/min

24
Q

List 3 differential diagnoses of a wide complex tachy.

A
  1. VT
  2. SVT with aberrancy
  3. Pacemaker rhythms
25
Q

What history features would help differentiate between SVT and VT?(2 vs 3)

A

VT more likely if: no prior hx of tachy, age more than 35, history of structural cardiac disease known pacemaker or ICD
SVT more likely if: hx of AVNRT or other previous SVT

26
Q

What examination features would make VT more likely in a patient with wide complex tachycardia on ECG? (4)

A
  1. Unstable
  2. has cardiac failure
  3. midline sternotomy scar
  4. has pacemaker ICD
27
Q

List two ECG algorithms that help distinguish between SVT and VT. What is the consensus with the use of these sorts of criteria?

A

Brugada
Vereckei

Distinction between SVT and VT using these criteria is purely academic, with 10% chance of getting it wrong. Because VT is a medical emergency, it is important that in any patient who is haemodynamically compromised and displays wide complex tachycardia on ECG, that it be treated as a VT

28
Q

How is haemodynamically unstable VT treated? (8)

A
  1. O2
  2. IV access
  3. Rapid exclusion of reversible factors (wire, PA catheter in RV, hypokalaemia or magnesaemia)
  4. Amiodarone 5 mg/kg infusion
  5. Synchronised DC shock
  6. Consider other anti-arrhythmic agents: procainamide, lignocaine, sotalol
  7. Repeat DC shock
  8. Overdrive pacing
29
Q

How is clinically stable VT treated? (5)

A

Controversial! Debate between cardioversion and pharmacological rx BUT still a medical emergency because can degenerate into unstable VT and VF

  1. O2
  2. Amiodarone or sotalol
  3. Cardioversion if medical rx fails (quickly) - will need sedation
  4. Consider pacing if cardioversion not effective
  5. if assoc. w/ long QT - consider Mg2+
30
Q

What is overdrive pacing?

A

Pacing the heart at a higher rate than native rate HR. VT or VF can occur so always have DC cardioversion available

31
Q

What is Brugada syndrome?

A

ECG abnormality (STE +/- RBBB in V1-V3) with a high incidence of sudden death in patients with structurally normal hearts, caused by mutation in sodium channel

32
Q

What is the definition of sustained vs non-sustained VT?

A

Sustained = Duration > 30 seconds or requiring intervention due to hemodynamic compromise.

Non-sustained = Three or more consecutive ventricular complexes terminating spontaneously in

Emergency Medicine (6 decks)

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