Chest pain and Cardiology

Question 1

causes of long QT

Answer 1

antiarrhythmics: amiodarone, sotalol
TCA
antipsychotics
chloroquine
erythromycin
hypocalcaemia
hypokalaemia
hypomagnesaemia
myocarditis
hypothermia
subarachnoid haemorrhage

Question 2

acute management of torsades de pointes

Answer 2

IV magnesium sulphate
if VT occurs, defibrillation

Question 3

management of long QT syndrome

Answer 3

avoid drugs
avoid strenuous exercise
beta blockers
implantable cardioverter defibrillators

Question 4

definition of status epilepticus

Answer 4

a single seizure lasting >5 minutes, or
>= 2 seizures within a 5-minute period without the person returning to normal between them

Question 5

management of status epilepticus

Answer 5

Secure the airway
Give high-concentration oxygen
Assess cardiac and respiratory function
Check blood glucose levels
Gain intravenous access (insert a cannula)
IV lorazepam 4mg, repeated after 10 minutes if the seizure continues
If seizures persist: IV phenobarbital or phenytoin

Question 6

acute management of SVT

Answer 6

valsalva
carotid sinus massage
adenosine or verapamil
direct current cardioversion

Question 7

prevention of SVT episodes

Answer 7

beta blockers
radio-frequency ablation

Question 8

hypoglycaemia management

Answer 8

If the patient is alert, a quick-acting carbohydrate may be given (as above)
If the patient is unconscious or unable to swallow, subcutaneous or intramuscular injection glucagon may be given.
Alternatively, intravenous 20% glucose solution may be given through a large vein

Question 9

clinical features of HHS

Answer 9

General: fatigue, lethargy, nausea and vomiting

Neurological: altered level of consciousness, headaches, papilloedema, weakness

Haematological: hyperviscosity (may result in myocardial infarctions, stroke and peripheral arterial thrombosis)

Cardiovascular: dehydration, hypotension, tachycardia

Question 10

HHS diagnosis

Answer 10

severe hyperglycaemia (>=30mmol/L)

hypotension

hyperosmolality (usually >320 mosmol/kg).

Question 11

management of HHS

Answer 11

fluid resuscitation with saline and KCl
insulin at 0.05units/kg/hr if ketones>1 or glucose fails to fall
VTE prophylaxis

Question 12

presentation of CO monoxide poisoning

Answer 12

Confusion
Nausea and vomiting
Cherry red skin
Tachycardia
100% oxygen saturations on pulse oximetry

Question 13

CO poisoning investigation

Answer 13

VBG/ABG: A carboxyhaemoglobin concentration >20% is diagnostic
Chest x-ray - looking for evidence of Acute Respiratory Distress Syndrome
ECG - looking for ischaemic changes
Bloods including a Creatine Kinase (rhabdomyolysis)

Question 14

management of CO poisoning

Answer 14

100% oxygen via face mask - helps unbind CO from the haemoglobin molecule
Hyperbaric oxygen - controversial but widely considered gold standard

Question 15

causes of bradycardia

Answer 15

Can be normal in athletic individuals
Electrolyte disturbances
Hypothyrodism
Myocardial Infarction
Sepsis
Drugs e.g beta blockers
Increased intracranial pressure
Heart block

Question 16

management of bradycardia

Answer 16

IV atropine
epinephrine
dopamine
temporary pacing if no response to medical therapy

Question 17

causes of ventricular tachycardia

Answer 17

hypokalaemia
hypomagnesaemia
MI/HOCM
Brugada

Question 18

common causes of AF (mrs SMITH)

Answer 18

Sepsis
Mitral Valve Pathology (stenosis or regurgitation)
Ischemic Heart Disease
Thyrotoxicosis
Hypertension

Question 19

management of acute pulmonary oedema

Answer 19

Take an ABCDE approach
Sit the patient up
Administer oxygen
Ensure IV access
IV Furosemide
Consider non-invasive ventilation such as CPAP if failed medical therapy (usually in an intensive care setting)
Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails

Question 20

pulmonary oedema management with heart failure and renal impairment

Answer 20

Therefore, by off-loading fluid with diuresis, the stroke volume improves, there is greater output from the heart, and so perfusion to the kidneys improve. Overall, when there is elevated central venous pressure, the renal function may recover with the aid of diuresis.

Question 21

management of heart failure with hypotension

Answer 21

vasopressors
These measures are only temporary and aim to maintain perfusion to the end-organs until the acute trigger for the deterioration has been reversed, or a definitive therapy (e.g. coronary revascularisation, mechanical circulatory support, or heart transplantation) has been employed.

Question 22

well’s PE

Answer 22

3 points:
Clinical signs and symptoms of a deep vein thrombosis (DVT)
If no alternative diagnosis is more likely than a PE

1.5 points:
Tachycardia (heart rate >100 beats/minute)
If the patient has been immobile for more than 3 days or has had major surgery within the last month
If the patient has had a previous PE or DVT

1 point:
If the patient presents with haemoptysis
If there is an active malignancy

Question 23

acute management of PE

Answer 23

Airway: likely to be patent.

Breathing: the patient may be tachypnoeic and hypoxic. Oxygen should be administered.

Circulation: the patient may be tachycardic. Signs of right heart strain are suggestive of a sub-massive PE. Hypotension is suggestive of a massive PE. Consider intravenous fluids if the systolic blood pressure is <90 mmHg.

Disability: likely to be unremarkable.
Exposure: the patient may have a low grade pyrexia. It is important to check for signs of a deep vein thrombosis (DVT). Consider analgesia at this stage if required.

Question 24

medical management of PE

Answer 24

dabigatran, edoxaban, warfarin
LMWH for 5 days and until 48 hours of therapeutic INR >2 has been achieved if using warfarin
if using dabigatran or edoxaban them LMWH should be used for d days prior

Question 25

DKA diagnosis

Answer 25

Ketonaemia: 3mmol/L and over
Blood glucose over 11mmol/L
Bicarbonate below 15mmol/L or venous pH less than 7.3

Question 26

DKA resolution

Answer 26

pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L

Question 27

complications of DKA

Answer 27

gastric stasis
thromboembolism
arrhythmias secondary to hyperkalaemia/iatrogenic hypokalaemia
iatrogenic due to incorrect fluid therapy: cerebral oedema*, hypokalaemia, hypoglycaemia
acute respiratory distress syndrome
acute kidney injury

Question 28

management of addisonian crisis

Answer 28

Fluid resuscitation is hypotensive.

IV hydrocortisone 100mg (Stat and then continue regularly)

IV glucose if hypoglycaemic

Swap back to their oral steroids after 3 days

Consider fludrocortisone if there is adrenal disease

Question 29

complications of addisonian crisis

Answer 29

Low blood pressure
Vomiting and diarrhoea
Dehydration
Shock
Coma
Death

Question 30

clinical features of SCC

Answer 30

acute UMN and sensory disturbance below level of lesion

deep and localised back pain

bladder and bowel involvement

Question 31

causes of SCC

Answer 31

Trauma

Neoplasia (seen in 5-10% of cancer patients, presenting complaint in 20% of these)

Infection (especially TB in at-risk patients)

Disc prolapse

Epidural haematoma

Question 32

management of SCC

Answer 32

whole spine MRI
surgically decompress within 48 hours
dexamethasone 16mg daily in divided doses

Question 33

GI causes of chest pain

Answer 33

oesophagitis and oesophageal spasm
reflux/ gastritis
biliary colic
pancreatitis
oesophageal rupture
peptic ulcer disease, GORD, oesophageal spasm, oesophagitis
acute cholecystitis

Question 34

MSK causes of chest pain

Answer 34

chest wall pain
MSK injury or inflammation
referred cervical root pain
shingles
bornholm diseases
precordial catch (texidor twinge)

Question 35

respiratory causes of chest pain

Answer 35

pulmonary embolus
pneumothorax
pneumonia
pulmonary infarct
asthma
lung/ lobar collapse
lung cancer
pleural effusion