Cardiovascular emergencies Flashcards
Differentiate between the ultrasound features of PE vs MI
Suggestive of PE:
- Right ventricular dilation
- Right ventricular strain/dysfunction
- Elevated Pulmonary Arterial Systolic Pressure (PASP)
Only by a skilled operator
Suggestive of Mi:
Ventricular regional wall motion abnormalities e.g. hypokinesia/akinesia
Describe the ECG features of WPW?
- short PR interval <120ms
- Delta wave slurring slow rise of the initial portion of
the QRS - QRS prolongation > 110ms
- ST Segment and T wave discordant changes i.e. in the
opposite direction to the major component of the QRS
complex - Pseudo-infarction pattern can be seen in up to 70% of
patients due to negatively deflected delta waves in
the inferior/anterior leads (pseudo-Q waves), or as a
prominent R wave in V1-3 (mimicking posterior
infarction).
How do you differentiate between type A and type B WPW?
Type A :
has a positive delta wave in all precordial leads with R/S >1 in V1
(left sided accessory pathway).
Type B:
has a negative delta wave in leads V1 and V2 (right sided accessory pathway).
What are the causes of SVT?
Causes of SVT:
- congential heart disease
- rheumatic heart disease
- previous MI
- Previous cardiac surgery
- chronic lung disease
- alcohol dependency
- digoxin toxicity
A patient presenting with an SVT that has signs of adverse features ( Myocardial ischaemia, Shock, syncopy, heart failure ) - what is your next step in the management?
As per the ALS algorithym for tachyarrythmias- 6thEdition.
- synchronised DC shock ( up to 3 attempts )
- if no response to this, then 4 steps to carry out:
- seek expert help
- administer 300mg amiodarone IV
- repeat shock
- then give 900mg Amiodarone iv over 24hours
In right ventricular myocardial infarction,
1. What drugs are contra-indicated?
- What treatment would you give in the ED?
- B-blockers and nitrates are contra-indicated.
Because b-blockers are negatively ionotropic and increase the risk of bradycardia with inferior MI.
Nitrates reduce the preload to the right ventricle and lead to hypotension. - treatment in ED with IV fluid boluses of 250mL normal saline.
- List the specific indications for commencing Non-invasive ventilation in acute heart failure?
- List the specific indications for considering Invasive ventialtion ?
Resource:
CG 187 NICE guidelines for treating acute heart failure
- Indications for Non-Invasive Ventialtions in Acute heart failure due to cardiogenic pulmonary oedema:
a. severe dyspnoea
b. and acidaemia
- Indications for Invasive ventialtion:
* physical exhaustion & reduced conciousness
* ultimately leading to respiratory arrest
What is the formula for MAP?
(( 2x DBP) + SBP ) /3
double diastolic add single systolic and divide it all by 3
NSAIDS are used in the first line management of acute pericarditis.
- Name 1 drug that can be added to aid recovery and prevent recurrence?
- name 1 drug that can be added if there is no response to NSAIDS in 48 hours?
- if no response to NSAIDS in 48 hours - steroids
2. Aid recovery and prevent recurrence- colchicine
According to the REVERT trial -
what vagal maneuvre is recommended to terminate an SVT?
15 seconds of valsalva manoeuvre
followed by leg elevation to 45 degrees
for 15 seconds
In a patient with an acutely ischaemic lower limb - What 5 clinical features need to be assessed in order to appropriately risk stratify this patient to determine further management?
RCEM Learning SAQ
- Sensory function
- motor function
- arterial doppler
- venous doppler
- capillary return
in a patient with an acutely ischaemic lower limb:
List four key management steps which are appropriate in the emergency department.
- supplemental oxygen
- iv heparin 5000 units
- iv opiate analgesia
- urgent referal to vascular surgery
What you will do if a patient presented with a repetitive ICD shocks in the absence of tachyarrhythmias that is haemodynamically well tolerated by the patient?
Place a magnet over the device to inhibit further shock delivery.
5 features of syncopy that suggest a high probability of arrythmia?
ALS 6th edition
- syncopy in a patient with a family history of SCD
- syncopy during exercise
- syncopy in supine position
- No prodromal symptoms
- recurrent and unexplained syncopy
Name any 4 common non-neurological causes of coma?
ALS 6th edition
- profound hypoxia
- hypercapnia
- cerebral hypoperfusion
- recent administration of sedatives or analgesic drugs
What are the clinical features and the ECG features of a Right ventricular MI ( complicating an inferior MI )
Clinical features of a Right Ventricular MI
- Hypotension
- raised JVP
- but no pulmonary oedema
ECG features of a right ventricular MI
- ST elevation in lead II, lead III and lead aVf
- st elevation is greater in lead II than in lead III
- st elevation also in lead V1 and lead V2
# Management of Rt ventricular MI: IV fluids avoid nitrates
- What are the ECG features of a posterior MI?
- Where would you place the modified ECG leads?
ALS 6th edition
- ECG of posterior MI:
* ST segment depression in V1, V2, V3
* Dominant R waves in V1-V3 - Modified ECG Leads:
V7 - posterior axillary line at the level of V6 horizontal line
V8 - halfway between V7 & V9
V9 - To the left of the
V10 to the right of the spine
What are the Non- ACS causes of raised troponin?
ALS 6th edition
Life threatening causes:
Pulmonary embolism
AOrtic dissection
Other cardiac casues: Rheumatic fever myocarditis pericarditis post- cardiac surgery pericardial effusion/tamponade arrythmias
Other non-cardiac causes:
uraemia
sepsis
renal failure
What are the 2 main therapies in STEMI in which coronary reperfusion may be achieved?
ALS 6th edition
- percutaneous coronary intervention ( PCI ) to re-open the occluded artery
- Fibrinolytic therapy - in an attempt to dissolve the occluding thrombus that precipitated the MI
What are the 3 indications for IMMEDIATE reperfusion therapy in Acute MI?
ALS 6th edition
Presentation within 12 hours onset of chest pain suggestive of AMI and :
- New onset LBBB
OR - ST segment elevation > 2mm in 2 adjacent chest leads or > 1mm in 2 or more adjacent limb leads
OR - ST depression in V1-V3 and Dominant R waves
What are the ABSOLUTE contra-indications to fibrinolytic therpay in a patient requiring treatment for Acute MI?
ALS 6th edition
7 ABSOLUTE contra-indications to fibrinolytic therapy:
- brain - any haemorragic CVA
- brain - recent ischaemic CVA in last 6 months
- brain - recent head injury within last 3 weeks
- brain - CNS neoplasm
- Blood -known bleeding disorder
- heart - known aortic dissection
- GIT - active GI bleed in last 1 month
In a patient with STEMI - What are the indications for rescue angioplasty?
ALS 6th edition
failed fibrinolytic management of STEMI evidenced by:
failure of ST segment elevation to resolve by > 50% from pre-treatment ECG on repeat ECG 60-90min post therapy
What are the complications of an acute MI?
ALS 6th edition
- arrythmias - vf/vt
- heart failure
- cardiogenic shock -
severe hypotension accompanied by poor peripheral perfusion and pulmonary oedema with mental confusion. Treatment with early revascularisation therapy ( PCI ) , ionotropic support or intra-aortic balloon pump. - cardiac tamponade
What are the components of the chain of survival in ALS?
ALS 6th Edition
ALS 6th edition
Early recognition
Early cpr
Early defibrillation
Post resuscitation care
you are called to assess A patient in the department that has agonal breathing. What are your immediate steps in the initial management?
ALS 6th edition
Agonal breathing is a sign of cardiac arrest.
immediately:
- shout for help
- turn patient onto his back
- open the airway with head tilt & chin lift
- keep airway open - and rapidly look, listen and feel
for 10 seconds - if no signs of life - start CPR 30:2
What is your immediate treatment In a patient that has a monitored and witnessed cardiac arrest in the cath lab OR early after cardiac surgery and the rythym is VF/VT ?
ALS 6th edition
Give 3 stacked /successive shocks and start Chest compressions immediately for 2 minutes.
These 3 stacked shocks are regarded as the 1st shock.
This is called the 3-shock strategy. can also be given to patients with witnessed VF/VT arrest if they are already connected to a manual defibrillator
A patient with an unstable arrythmia.
When selecting Defibrillator energy levels- what energy would you select in the following scenarios?
- concious patient with adverse features -
ECG shows atrial flutter or narrow QRS ( SVT ) - concious patient with adverse features -
ECG shows atrial fibrillation or broad complex QRS - cardiac arrest patient -
ECG shows VF/VT
ALS 6th edition - pg 45
- atrial flutter/SVT =
70-120J initially - Atrial fibrillation / Broad complex QRS=
120-150J - VF/VT cardiac arrest =
1st shock 150-200J
2nd shock 150-360J
What 3 interventions improve survival after cardiac arrest?
ALS 6th edition
ALS 6th edition
- Prompt effective bystander CPR
- High quality chest compressions
- Early defib in vf/vt arrest
What is the standard defibrillation pad positions to attach?
ALS 6th edition
right sternum , left apical
below the right clavicle and in the left axilla at V6 electrode position in the midaxillary line
In a patient with vf/vt after 3 shocks and rythym is still in VF. what alternate drug can be given if you have not already given amiodarone?
ALS 6th edition
Lidocaine 1mg/kg
During cardiac arrest you insert a supraglottic airway device. how will you ventilate this patient?
ALS 6th edition
uninterrupted chest compressions and ventilate 10 breaths/minute
What are the 3 indications of IV calcium chloride in cardiac arrest?
ALS 6th edition
- hyperkalaemia
- hypocalcaemia
- calcium channel blocker overdose
- beta-blocker overdose
How will you differentiate between partial and complete airway obstructions?
ALS 6th edition
Partial airway obstruction signs:
- inspiratory stridor
- expiratory wheeze
- Snoring
- gurgling
Complete airway obstruction:
- paradoxical chest and abdominal movement - see-saw breathing
- silent breathing on auscultation
How do you confirm correct placement of ETT other than clinical assessment?
ALS 6th edition
the persistence of exhaled CO2 after 6 ventilations indicates placement of the tracheal tube in the trachea
What are the 3 uses of waveform capnography in a patient in cardiac arrest?
ALS 6th edition
- confirm placement of ETT in trachea
- continuous monitoring of ETT position during CPR
- sensitive indicator of ROSC
What is the role of cricoid pressure in cardiac arrest?
ALS 6th edition - pg 66
the role has not been studied. do not use cricoid pressure routinely in cardiac arrest.
In a difficult intubation - what aids to intubation can you name?
ALS 6th edition - pg 67
- alternative laryngoscope blade -
Mcintosh blade
McCoy levering laryngoscope
Airtraq - introducers:
GEB
Memory aid: think blades and Boujie
You have intubated a patient during cardiac arrest - what ventilator settings will you apply to the auto- resuscitator?
ALS 6th edition
Tidal volume : 6-7ml/kg at 10 breaths /minute
If an ECG shows VF - but the patient has a pulse - what is your differential diagnosis?
ALS 6th edition
pre-excited AF ( occurs as a result of an accessory pathway -eg in WPW )
i.e vf with a pulse is pre-excited af ( AVRT due to wpw )
What is Mobitz type 1 AV block?
ALS 6th edition
it is the progressive prolongation of the PR interval after each P-wave untill a P-wave occurs without a following QRS
What factors affect defibrillation success?
ALS 6th edition
- transthoracic impedence
( shave the chest to reduce this ) - Electrode position -
- Defibrillation must be performed as soon as possible i.e. do not wait for rythym analysis
- shock sequence:
improved defibrillation success and increased survival to hospital discharge with single -shock defibrillation protocol conmpared to 3-stacked shock protocol for VF arrest - shock energy :
biphasic defirbillators supercede monophasic pulse of current - importance of early uninterrupted chest compressions
What are the positions of the defibrillation pads?
ALS 6th edition
- standard position:
right sternum- left apical ( at level of V6 electrode in mid axillary line ) - other alternate positions include:
* anterior-posterior - over left precordium and inferior to
left scapula
- Bi-axillary
- Posterior-lateral
In a cardiac arrest , you prepare to defibrillate a patient.
What measures will you take before shocking the patient to ensure team safety?
ALS 6th edition
- using self-adhesive pad electrodes ( eliminates the possibility of anyone touching any part of the electrode )
- remove wet clothes and dry the skin
- do not hold IV infusion equipment or the patients trolley during shock
- Take off the oxygen and hold at least 1 metre away from the chest
- operator must ensure everyone is clear before delivery of shock
- gloves may provide limited protection from the electric current, therefore it is strongly recommended that all the team members wear gloves
What specific interventions can an ALS provider implement compared to a BLS provider?
ALS 6th edition
A - advanced airway
B - ventilation
C - IV access and drugs
Name 2 advantages of a manual defibrillator over an AED?
ALS 6th edition
- enables the operator to diagnose the rythym and dleover a shock rapidly ( without waiting for rythym analysis ) thereby minimizing CPR interuption
- additional functions i.e.
* delivery of synchronized shock
* pacing
In which circumstances can you deliver an unsynchronised shock?
ALS 6th edition - pg 97
- VF
- Pulseless VT
- unstable patient with VT - in this instance you can deliver unsynchronised shock to avoid prolonged delay in restoring sinus rythym
What energy selection you you set for internal defibrillation?
ALS 6th edition
Use internal paddles applied across the ventricles
Biphasic shock - 10-20 joules
monophasic shock - 50 joules
When deliver a shock to a patient in cardiac arrest or unstable arrythmia , if they have a Permanent pacemaker or ICD - what are the risks?
ALS 6th edition
- risks to patient - theoretical risk to myocardium due to excess current flow
- risk to operator - small risk to rescuer during CPR when ICD’s fire mild shocks
- risk to device - small risk of damage to device if defib pad placed directly on it
What adaptations would you apply in during ALS for a patient with PPM or ICD?
ALS 6th edition - pg 98-104
- avoid standard defib pad positions ( AP, Post-lat or bi-
axillary ) - place defib pad at least 10-15cm between edge of the
ICD/PPM and edge of the defib electrode - deactivation of pacemakers is NOT required. this is
innapropriate and application of magnets over
pacemakers during CPR should be avoided.(page 98 )however - patients with ICD, carrier a small risk to the
rescuer to deliver a shock, in this case you
can deactivate the ICD with a magnet ( pg 104 )
name 2 methods of pacing in a patient with complete heart block?
- Non-invasive i.e.
* percutaneous and
* transcutaneous - Invasive i.e.
* temporary transvenous pacing
* permanent pacing with IPM
Briefly describe the steps to perform transcutaneous pacing?
- ensure skin is dry and remove excess hair
- attach ECG monitoring
- position electrodes in right pectoral - apical position
- Select pacing rate ( 60-90bpm )
- select the energy/current at its lowest value and turn on the pacemaker. graduallyincrease the output while observing the ECG & patient.
- Increase the current ( usually between 50-100mA) untill each pacing spike is followed by a QRS complex, and check that the QRS complex is followed by a T-wave
- If the highest current is reached and electrical capture has not occured:
* 1st try changing the elctrode positions
if this doesnt work, look for 2 other reasons of this
You are trying to perform transcutaneous pacing on a patient with complete heart block but you are unable to achieve electrical capture at the highest current even after changing the electrode positions.
What may this indicate?
ALS 6th edition : pg 102
- a non-viable myocardium
- other conditions i.e. hyperkalaemia , may prevent
successful pacing
You perform transcutaneous pacing on a patient. you have good electrical capture but absent mechanical capture.
what does this indicate?
this indicates PEA
most likely due to myocardial failure
but also other causes of PEA
What 3 immediate management steps will you take to treat torsades de pointe in a patient that is alert and concious?
ALS 6th edition
- stop immediately all drugs known to prolong the QT
interval - correct electrolyte abnormalities ( especially hypokalaemia )
- give Mgso4 2g IV over 10 minutes
what is the commonest SVT to occur in patients?
and what specific type of SVT occurs in patients with WPW?
ALS 6th edition
commonest SVT is :
AV NODAL re-entry tachycardia
SVT that occurs in WPW is:
AV re-entrant tachycardia
i.e. ( electrical signals down the bundle of kent cause a premature contraction )
You treat a patient with a narrow complex tachycardia at a rate of 200bpm. you cannot exclude atrial flutter.
vagal maneuvres have failed, and adenosine ( 6mg + 12mg + 12mg ) has failed to slow the rate.
what does failure to terminate a regular narrow complex tachycardia with adenosine suggest and what is your next drug of choice?
ALS 6th Edition - pg 109
failure to terminate an SVT with vagal maneuvres and adenosine suggest atrial flutter. ( or that adenosine was injected too slowly or in a small vein )
If adenosine is contra-indicated , or fails to terminate a regular narrow complex tachy without demonstrating that it is atrial flutter -
consider giving a calcium-channel blocker i.e. verapimil 2.5mg - 5mg IV over 2 minutes
A patient is in atrial fibrillation for > 48 hours with no adverse features - which conditions need to be met before patient can be cardioverted ( chemically or electrically )?
ALS 6th edition
- must be fully anti-coagulated for 3 weeks
OR
- unless TOE has detected no evidence of atrial thrombus
A patient that has been in AF for more than 48 hours, for different reason you cant chemically or electrically cardiovert, so you choose to rate control them. if a beta blocker is contra-indicated- what is your next drug of choice?
ALS 6th edition
diltiazem or digoxin ( if in heart failure )
If duration of AF is < 48 hours and rythym control is appropriate. what is your drug of choice?
ALS 6th edition
flecanide.
but avoid in:
- heart failure
- known LV impairment
- IHD
- prolonged QT
alternate is amiodarone 300mg iv over 20 minutes followed by 900mg infusion over 24 hours
What are the non-cardiac causes of bradycardia?
ALS 6th edition
- Drugs: BADD
* B - beta blockers
* A - amiodarone
* D - Diltiazem
* D- Digoxin - Other:
* physiological
* vasovagal
* hyperkalaemia
* hypothermia
* hypothyroidism
Memory aid: BADD drugs in the Cold winter with underactive thyroid
A patient with bradycardia has adverse fetaures.
what is your 1st step in the treatment?
ALS 6th edition
Atropine 500mcg
a patient with bradycardia and adverse features has not responded to the 1st dose of atropine.
what is your next step in the management?
ALS 6th edition
if no response to atropine then cardiac pacing should be considered i.e. transvenous pacing.
while this is being arranged - you can try 1 of the 5 interim measures. and if this fails or is not possible then you can try 1 of the 4 alternatives
What are the 5 interim measures in treating bradycardia that has not responded to atropine while awaiting tranvenous pacing?
ALS 6th edition
Interim measures in management of bradycardia with adverse features:
- atropine 500mcg repeat to maximum of 3 mg
- isoprenaline 5mcg min IV
- adrenaline 2-10mcg min IV
- alternative drugs ( aminophyline, dopamine, glucagon, glycopyrrolate )
OR
- transcutaneous pacing
In a patient with bradycardia - what are the 4 high risk features of asystole?
ALS 6th edition
- recent asystole
- Mobitz II AV block
- Complete heart block with BROAD QRS
- ventricular pause > 3s
What are the features of hyperkalaemia on ECG?
ALS 6th edition
Rate - bradycardia P-waves- flattened PR interval- prolonged > 0.2 sec QRS -widened > 0.12sec ST segment - depression T waves- peaked T waves ( T wave larger than R wave in > 1 lead )
How do you manage severe hyperkalaemia
( > 6.5 mmol/l ) ?
ALS 6th edition
It depends on wether there is ECG changes.
- If No ECG changes:
* 10 units actrapid with 25g glucose ( 50ML of 50% dextrose )
* salbutamol 5mg neb - up to 20 mg
*if severe acidosis consider - 50mmol IV of 8.4%
sodium bicarbonate
* if oliguria or refractory hyperkalaemia - consider
RRT ( renal replacement therapy )/ haemodialysis - If Toxic ECG changes:
* all the above AND10mL of 10% calcium chloride
What is the most effective method of removing potassium from the body?
what are the indications?
ALS 6th edition
- haemodialysis
indications for heamodialysis in hyperkalaemia:
- with established renal failure
- oliguric acute kidney injury < 400ml/day output)
- marked tissue breakdown
- hyperkalaemia resistent to medical therapy
List Scarbossa criteria used to diagnosed STEMI in presence of LBBB?
> 1mm concordant - st elevation in lead with +ve QRS ( 5pts )
1mm concordant - ST depression in lead V1-V3 (3 pts )
5mm Discordant ST elevation in lead with -ve QRS ( 2 pts )
scores > 3 have 90% specificity for MI
Memory aid: think of 3 factors
- concordance
- st wave
- QRS or V1-V3
Which patterns of bifascicular block can exist?
RBBB and left anterior fascicular block
RBBB and left posterior fascicular block
What is the diagnostic criteria for LBBB?
Broad QRS > 120ms
Dominant S wave in V1
Broad monophasic R wave in V5, V6
What are the characteristic ECG findings of pericarditits?
- galloping horse ( sinus tachycardia )
- Widespread saddle ST elevation
- widespread PR depression
- recipricol st depression and PR elevation in aVR
What is the difference between bifascicular heart lboack and trifascicular heart block?
BI-fascicular heart block -
- RBBB + left anterior OR left posterior fascicluar block
- risk of progression to complete heart block is low
- if asymptomatic - no treatment, if syncopy - PIP
Tri-fascicular heart block -
- prolongation of PR interval+ RBBB+ LAFB/LPFB
- conduction abnormality affecting all 3 fascicles
- can progress to CHB, although risk is low
- Pacemaker recommended for those with syncope
What is the immediate management of acute cardiogenic pulmonary oedema?
- sit the patient upright
- High flow oxygen via reservoir mask
- IV nitrates ( gtn infusion 2-20mg/hour )
- IV loop diuretics ( furosemide 20-80mg )
How do you make the diagnosis of Brugada syndrome?
Brugada syndrome is an autosomal dominant inherited disorder. death is due to VF ( due to sodium ion channel defects). ( whereas death in WPW is due to AVRT or pre-excited AF )
Diagnosis of Brugada requires:
ECG changes showing
* downsloaping coved ST segment elevation > 2mm in > 1 of leads V1-V3
* widespread upsloaping ST depression in all other leads
* RBBB
AND at least 1 of the following: 1. FH of SCD in age < 45 2. FH of ECG changes above 3. Syncopal episodes 4, Nocturnal agonal respiration 5. Documented VF
A patient with a STEMI si being taken to the cath lab for PCI. what medical treatment will you prescribe immediately?
he has already received aspirin, gtn spray and morphine pre-hospital.
Resource:
NICE CG 167
NICE CG 95
- clopidogrel 300mg
- UNfractionated heparin ( or bivalirudin )
if UNdergoing anaesthesia for PCI in the next 24 hours
if not undergoing anaesthesia in next 24 hours - give fondaparinux
What are the triad of clinical features of endocarditis that is often qouted?
- persitent fever ( FEVER )
- embolic phenomena ( FINGER TIPS )
- new murmur ( FUNNY MURMUR )
Blind therapy with FLUcloxacillin & Gentamycin
