Chest pain & Breathlessness

Question 1

Management of ACS?

Answer 1

Morphine - up to 10mg IV (+ metoclopramide)
Oxygen - if sats <94%
Nitrates - GTN 2 sprays
Aspirin 300mg STAT - then 75mg OD
Clopidogrel/Ticagrelor STAT then OD

Question 2

What are the causes of raised troponin T & I?

Answer 2

MI, sepsis, PE, pneumonia, renal F, HF, SAH, seizure, myocardial damage

Question 3

What are the ECG features of STEMI?

Answer 3

ST elevation ≥2mm. Pathological Q wave, T wave inversion.

Poss - LBBB

Question 4

Patient’s ECG shows ST elevation in leads I, V5, V6 and AvL. Where is the infarct and what is the vessel involved?

Answer 4

Lateral STEMI. Usually blockage of branches of L circumflex + LAD.

Question 5

How do you differentiate between NSTEMI & unstable angina?

Answer 5

NSTEMI = raised Troponin T ≥ 0.1, troponin I ≥1

Question 6

what are the 3 distinctive clinical features of NSTEMI?

Answer 6

Resting angina, new-onset severe angina, increasing angina (freq, duration, lower threshold etc)

Question 7

How is unstable angina defined clinically?

Answer 7

Angina at rest or increasing severity or duration >20 mins

Question 8

How is the management of NSTEMI or unstable angina determined?

Answer 8

Risk stratification using TIMI or GRACE scales.
High risk –> MONAC + PCI within 96h.
Low risk –> MONAC + stress test

Question 9

What might you find when assessing the pulse and BP in aortic dissection?

Answer 9

increased HR, unequal radial pulses. BP difference of ≥15mmHg between the two brachial pressures

Question 10

What features might be present on CXR of aortic dissection?

Answer 10

Widened mediastinum >8cm
Double knuckle aorta
L pleural effusion
Tracheal deviation to RHS, calcium sign

Question 11

What blood test is important to get in suspected aortic dissection?

Answer 11

Cross match - 6 units

Question 12

What feature may distinguish MSK chest pain from cardiac or respiratory?

Answer 12

Worse on movement

Question 13

What simple movement can you do in a breathless patient to hopefully maximise their comfort?

Answer 13

Sit them up

Question 14

Patient presents with stridor. What do you need to do immediately?

Answer 14

Call the anaesthetist

Question 15

What are the CURB parameters?

Answer 15

Confusion
Urea >7
RR ≥30
BP - systolic <90 or diastolic <60
Age ≥65y

Question 16

60 y/o female presents with 4/7 Hx SOB and productive cough (green). She has since started to develop feverish Sx.
O/E: HR 88, BP 100/55, urea 6.4, RR 25.
What is her CURB score and what is the appropriate Mx plan?

Answer 16

Curb score is 1 (for DBP). Appropriate plan = home Abx, e.g. amoxicillin 500mg TDS (but follow local guidelines)

Question 17

Mx of patient with CURB score of 3?

Answer 17

Hospital admission –> IV Abx e.g. co-amoxiclav + clarithromycin.
Take: blood cultures, pleural fluid, urine sample (pneumococcal + legionella).
If worsens –> consider ICU

Question 18

What progression might you see on ABG of an acute asthma attack?

Answer 18

Initial ABG –> low CO2, low O2 (hyperventilating)

Later ABG –> normalising or high CO2 (patient tiring)

Question 19

Features of life-threatening asthma attack?

Answer 19

33, 92, CHEST:
PEFR <33%
Sats <92%
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardic

Question 20

Mx of asthma attack?

Answer 20

Oxygen - 15L/min
Salbutamol 5mg nebs driven by O2 - back to back if needed.
Hydrocortisone 100mg IV or pred 40mg PO
Ipratropium 500mcg nebs

Call critical care if need more Tx!…
Theophylline - aminoph infusion 1g in 1L saline 0.5ml/kg/h
Mg sulphate - 2g IV over 20 mins
Escalate care

Question 21

What is the investigation process for possible PE?

Answer 21

Wells score:
<4 –> D-dimer –> if -ve send home, if +ve do CTPA
>4 –> CTPA

Question 22

How can you avoid doing any investigations in patient with possible PE?

Answer 22

Do PERC rule out criteria. If none of criteria are met –> can send home without tests.

Question 23

Mx of PE?

Answer 23

ABCDE
Give O2, NSAIDs (avoid opiates)
LMWH (tinzaparin) –> start NOAC or warfarin. Continue for at least 3m

Question 24

Mx for massive PE?

Answer 24

Thrombolyse with alteplase or streptokinase.

Question 25

What might fine-end resp crackles be a sign of?

Answer 25

Pulmonary oedema, pul fibrosis, CF

Question 26

What blood tests might you like to do on a patient experiencing trouble breathing when lying flat, SOB, and mild ankle oedema?

Answer 26

FBC - check for anaemia, infection or MI
BNP - check for HF
Troponin - for MI

Question 27

What are the Sx of pul oedema?

Answer 27

SOB, orthopnoea, PND, frothy sputum, swollen legs

Question 28

What are the CXR features of LVF?

Answer 28

A - alveolar oedema
B - Kerley B lines
C - cardiomegaly
D - dilated prominent upper lobe vessels
E - pleural effusion

Question 29

What must you remember when you prescribe morphine/diamorphine?

Answer 29

PRESCRIBE AN ANTIEMETIC as well!! e.g. metoclopramide

Question 30

Mx of pul oedema?

Answer 30

Furosemide slow IV injection +/- diamorphine and metoclopramide

Question 31

Mx of 1˚ pneumothorax?

Answer 31

If SOB or >2cm –> aspirate –> if unsuccessful –> drain.

If no Sx or <2cm –> discharge.

Question 32

Mx of 2˚ pneumothorax?

Answer 32

If SOB, >2cm or >50y –> chest drain

If not SOB, <2cm and <50y –> aspirate

Question 33

What is the difference between 1˚ and 2˚ pneumothorax?

Answer 33

1˚ has no obvious cause, 2˚ is in the presence of underlying lung disease or result of trauma.

Question 34

What are the different types of narrow and broad complex tachycardias?

Answer 34

Narrow - SVT, AF, atrial flutter

Broad - VT, VF, Torsades de pointes

Question 35

What do you need to ask about in a suspected AF history?

Answer 35

OPERATES etc

Any recent illnesses, surgery, time in hospitals (MI, PE), BP, thyroid problems, alcohol, stress,

Question 36

When is cardioversion perhaps offered for AF?

Answer 36

In younger patients + new presentations of AF.

Question 37

How is AF chemically cardioverted?

Answer 37

Either flecainide (PO/iV) or amiodarone via central line.

If known IHD –> amiodarone

Question 38

What are the possible Sx of heart block?

Answer 38

Asymptomatic, dizzy, palpitations, SOB, chest pain