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Y4: Acute Care Guide > Cardiology > Flashcards

Cardiology Flashcards

1
Q

Management of acute pulmonary oedema/ congestion?

A

50mg IV furosemide

+ oxygen if hypoxia

+ IV opiate if severe distress

consider inotropic support if SBP <85 or shock

consider GTN infusion if SBP >110

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2
Q

Atrial fibrillation initial Ix?

A
  • 12-lead ECG: confirm AF and heart rate
  • Bloods: FBC, U&Es, Mg2+, LFTs, TSH, Bone group
  • Chest X-ray: assess pulmonary congestion/cardiothoracic ratio
  • Echo: exclude valvular abnormalities; check LA size & LV function
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3
Q

Management of AF

  1. adverse signs present (reduced LOC, SBP <90, chest pain, heart failure)
  2. reversible cause treated/ no reversible cause and <24h
  3. reversible cause treated/ no reversible cause and >24h
  4. reversible causes persist
A
  1. get senior help asap
  2. attempt rhythm control
  3. attempt rate control
  4. attempt rate control
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4
Q

what does rhythm control in AF involve?

A

Chemical Cardioversion (Amiodarone or Flecainide)

OR

Early DC Cardioversion (Fasted, under sedation or general anaesthetic.) Also an option following unsucessful chemical cardioversion

If unsucessful, try rate control

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5
Q

Rate control in AF

  1. Acute LV failure or marked hypotension present
  2. not present
A
  1. oral digoxin
  2. beta blocker OR CCB e.g. diltiazem. Digoxin 3rd line
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6
Q

T/F: long-term thromboprophylaxis should be considered in all patients in atrial fibrillation

A

True - AF increases risk of stroke by up to 5x

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7
Q

Need for long-term thromboprophylaxis in AF should be guided by what risk stratification scheme?

A

CHA2DS2-VASc stroke risk stratification scheme

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8
Q

T/F: Paroxysmal AF carries a lower stroke risk than permanent or persistent atrial fibrillation

A

false - same risk

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9
Q

first line rate control agent for atrial fibrillation? + route

A

beta blockers

  • oral in stable patients (bisoprolol)
  • IV in unstable patients (metoprolol)
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10
Q

suspected ACS immediate management

A
  • oxygen, aspirin 300mg
  • check obs, secure IV access, obtain bloods
  • urgent 12 lead ECG
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11
Q

what changes on a 12 lead ECG would warrant referral to ST elevation pathway?

A
  • >2mm in 2 chest leads
  • >1mm in 2 limb leads
  • New / Presumed new LBBB
  • True Posterior Myocardial Infarction
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12
Q

suspected ACS > no ST elevation on 12-lead ECG > next step?

A
  • prescribe dalteparin (LMWH)
    • clopidogrel 300mg if ECG changes consistent with ischaemia (ST segment depression/ T-wave inversion)
  • HR>65 and SBP>105 add beta blocker
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13
Q

secondary prevention following ACS?

A
  • statins: all pts with angina/ MI
  • ACE inhibitors: all pts with a troponin + event
  • beta blockers: all pts with angina/ MI
  • aspirin: all pts with IHD
  • clopidogrel: in troponin + ACS without ST-elevation (at least 3 months)
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14
Q

Ix for suspected ACS?

A
  • Routine bloods: FBC, U&E, LFTs, TFTs, Bone group, Cardiac markers, Cholesterol, Lipid profile
  • CXR: pulmonary oedema / CTR
  • Echo: LV function / valves
  • ETT: in Troponin negative patients. If negative at high workload makes angina unlikely
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15
Q

Acute on chronic heart failure (existing pulmonary oedema in ACS)

  1. ​prescribe IV _____ 50-100mg
  2. prescribe _____ (in the absence of hypotension or aortic stenosis
  3. prescribe _____ if acutely SOB
  4. prescribe _____ s/c OD
  5. prescribe _____ (reduce dose in elderly)
  6. prescribe ______
  7. consider _____
A
  1. furosemide
  2. nitrate
  3. opiate
  4. LMWH
  5. ACEI
  6. spironolactone
  7. digoxin

NB: pts with severe resp failure, MI, hypotension, significant arrhythmia to be managed in CCU

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16
Q

Ix for acute on chronic heart failure (existing pulmonary oedema in ACS) ?

A
  • urgent 12-lead ECG
  • routine bloods (FBC, U&E, LFTs, TFTs, Bone group, Cardiac markers, Cholesterol, Lipid profile)
  • CXR (pulmonary oedema/ CTR)
  • echo (LV function/ valvular abnormalities)
  • daily weights
  • urinary catheter (monitor urine output)
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17
Q

what is shock?

A

a state of tissue hypoperfusion relative to the tissues’ metabolic requirements.

18
Q

Shock has classically been divided into which subgroups based on the underlying pathology? (5)

A
  • Cardiogenic
  • Septic (NHS Tayside Sepsis 6 Bundle)
  • Hypovolaemic (Massive Transfusion Policy)
  • Anaphylactic
  • Neurogenic

Practically, there is either a problem with one or more of the following:

  • the pump (cardiogenic) blood volume (e.g. hypovolaemia / haemorrhage),
  • blood vessels are too dilated eg sepsis, anaphylaxis, neurogenic).
19
Q

T/F: regardless of the type of shock mortality is high and should be regarded as a medical emergency

A

True - you need to summon senior help immediately, including the possibility of putting out a cardiac arrest call on 2222.

20
Q

clinical presentation in shock?

A
  • Tachypnoea
  • Tachycardia
  • Hypotension (late sign in hypovolaemia)
  • Cool peripherally (early anaphylactic, septic and neurogenic shock pts may have warm peripheries due to vasodilatation).
  • Oliguria
  • Altered conscious level (may only be irritable/ non-compliant due to cerebral hypoperfusion).
21
Q

The mainstay of treatment of any type of shock is maximising what?

A

oxygen delivery to the tissues

22
Q

ABCDE approach in shock

A
  • A: check patency (airway maneuvres + 2222 if not)
  • B: RR, sats, examine chest. 15L oxygen via non re-breathe mask. ABG if possible.
  • C: HR, BP, cap refill. Peripherally cool/warm? IV access (large bore if poss) and bloods: FBC, U&Es, LFTs, lactate, coag screen, G&S (cross match if blood loss suspected cause), blood culture (if sepsis suspected). Fluid resuscitation (except in cardiogenic shock): start with colloid/ crystalloid 250 or 500mls stat. If hypovolaemia secondary to haemorrhage suspected, consider O neg blood whilst waiting for cross matched.
  • D: AVPU, BG, pupils
  • E: temperature, expose (blood, rash/ wheals, inspect wounds/ drains, urine output (consider catheter)
23
Q

what is cardiogenic shock

A

Hypotension caused by primary pump failure eg post MI, arrhythmia..

24
Q

Cardiogenic shock management

  • ABCDE assessment
  • Call for senior help
  • Urgent Ix: ???
  • Pulmonary oedema present: ???
  • Pulmonary oedema absent: ???
  • Patient will likely require transfer to HDU/CCU/ICU for further management including ??? support
A
  • ECG/CXR/ABG/FBC/U&Es/Echo
  • IV 50mg furosemide, GTN infusion, CPAP
  • Fluid challenge e.g. 250ml stat of colloid
  • inotropic
25
Q

Components of sepsis 6?

A
  • Give 3: high flow oxygen, IV antibiotics, IV fluid resuscitation
  • Take 3: blood cultures, lactate and FBC, montor accurate hourly urine output

should be delivered within 1 hour

26
Q

what is hypovolaemia shock?

A

Hypotension secondary to fluid loss, eg. bleeding, severe dehydration.

the hypotension is a late sign, indicating the compensatory tachycardia and peripheral vasoconstriction have ceased to be effective

27
Q

Hypovolaemic shock management

  • ABCDE
  • Ensure high flow oxygen and IV access & ___ ___ in situ (plus bloods sent)
  • Summon appropriate help urgently (e.g. relevant surgeon/medic/gynaecologist +/- anaesthetist)
  • If blood loss likely, ensure G&S converted to ___ ___
  • Replace intravascular volume with what?
  • Definitive management if bleeding is the cause is likely to be what?
A
  • urinary catheter
  • cross match
  • fluid – crystalloid, colloid or blood (O negative in emergency).
  • theatre or endoscopy
28
Q

what is ‘massive transfusion’

A

replacement of the patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s blood volume in less than 3 hours

29
Q

commonest reason to access a shock pack?

A

ruptured AAA

NB: shock pack = 4units type specific RBCs, 4units FFP and 1 unit platelets

30
Q

Massive transufion protocol (Major trauma/ vessel rupture/ GI/ other source bleed)

  • Manage ABC, call for help (who?)
  • Patent airway, high flow oxygen/ 100% FiO2, adequate ventilation
  • Large bore IV cannula (x2), what bloods?
  • IV fluids as indicated, control haemorrhage
  • Early surgical intervention as required
  • Contact BTS - give clear details of case and degree of urgency
  • O neg blood should only be used if cannot wait for type specific
  • Activate Massive Transfusion Protocol Request ‘what pack’
A
  • senior surgeon & anaesthetist
  • Xmatch, FBC, coag screen and fibrinogen, U&E, Ca2+
  • shock
31
Q

what is anaphylactic shock?

A

cardiovascular collapse with shortness of breath, wheeze, urticaria, mucosal angioedema

32
Q

Management of anaphylactic Shock

  • ABCDE assessment
  • Put out call on _____
  • Remove _____
  • 15L oxygen via non re-breathe mask
  • Lie patient flat, raise legs
  • IV access
  • Administer ______
  • Give 5mg nebulised _____
  • Give 1L 0.9% ____ stat
  • Give 20mg _____ slow IV
  • Give 300mg _____ IV
  • When help has arrived and patient been stabilised consider serum _____ and follow up.
A
  • 2222 (arrest call)
  • precipitant eg. infusion of antibiotic
  • 500mcg IM adrenaline ASAP (1:1000) to mid-anterolateral thigh (can ask a nurse to do this whilst you get IV access), repeat every 10 minutes if necessary
  • salbutamol
  • saline
  • chlorphenamine
  • hydrocortisone
  • tryptase
33
Q

Massive haemorrhage policy

  • call 2222 state ‘massive haemorrhage ward X’
  • call blood bank state ‘massive haemorrhage, pts name and CHI, location and your details’
  • urgent samples: (1)
  • blood bank will issue: (2)
  • Resuscitate Patient (ABCDE approach). Use emergency blood if required immediately - what type is this(3)
  • Trauma < 3 hours - Consider (4) 1g
  • Aim to control haemorrhage
  • Transfuse red cells/ FFP/ platelets
  • Use blood warmer
  • Consider cell salvage where available
  • If bleeding ongoing after initial transfusion Repeat blood samples, Transfuse further (5) and (5) at a ratio of 2:1 (1:1 in trauma). (6) if fibrinogen <1g/L. Consider further platelets
  • When bleeding controlled, notify blood bank to ‘stand down’
A
  1. FBC, coag screen, Fibrinogen, Crossmatch, U&E, Calcium
  2. 4 units Red Cells, 4 units FFP, 1 unit platelets
  3. O RhD negative
  4. Tranexamic acid
  5. FBC and FFP
  6. Cryoprecipitate
34
Q

what to do if massive haemorrhage patient is on oral anticoagulants

A
  • Stop the drug
  • Document timing of last dose of drug
  • Assess half life of drug
  • administer antidoate if available
  • Contact haematologist on call for advice if required
35
Q

Warfarin

  1. mechanism of action?
  2. Monitor how?
  3. Reverse how?
A
  1. vitamin K antagonist
  2. with INR
  3. IV vitamin K 10mg or IV Beriplex
36
Q

Dabigatran

  1. mechanism of action?
  2. Half life 13hrs (80% ___ excretion)
  3. Monitor how
  4. Contact haematologist on call for advice Reverse with IV _____
A
  1. Direct thrombin inhibitor
  2. renal
  3. thrombin time v sensitive - if normal this indicates that there is a very low level of the drug in the system
  4. Idarucizumab
37
Q

Edoxaban/ Rivaroxaban/ Apixaban

  1. mechanism of action?
  2. 65-75% ____ excretion
  3. Monitor how
  4. antidote?
A
  1. Direct factor Xa inhibitors
  2. Hepatic
  3. Monitor- send coagulation screen and contact haematologist on call for advice interpreting results
  4. No specific antidote available - contact haematologist on call for advice
38
Q

T/F: FFP and cryoprecipitate should not ordinarily be transfused to correct blood coagulation abnormalities in the absence of bleeding, or to reverse effect of warfarin

A

true

39
Q

FFP

  1. A source of what?
  2. Clinical indications?
A
  1. coagulation factors
  2. Massive haemorrhage (RBC: FFP 2:1 or 1:1 in trauma). PT ratio>1.5 plus clinically significant bleeding PT ratio>1.5 and pre-procedure
40
Q

Cryoprecipitate

  1. A source of what?
  2. Clinical Indications?
A
  1. fibrinogen
  2. Fibrinogen<1g/L and pre-procedure Fibrinogen<1g/L and bleeding (<2g/L in obstetric bleeding

Y4: Acute Care Guide (8 decks)

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