Chest pain & Breathlessness Flashcards
Management of ACS?
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
What are the causes of raised troponin T & I?
MI, sepsis, PE, pneumonia, renal F, HF, SAH, seizure, myocardial damage
What are the ECG features of STEMI?
ST elevation ≥2mm. Pathological Q wave, T wave inversion.
Poss - LBBB
Patient’s ECG shows ST elevation in leads I, V5, V6 and AvL. Where is the infarct and what is the vessel involved?
Lateral STEMI. Usually blockage of branches of L circumflex + LAD.
How do you differentiate between NSTEMI & unstable angina?
NSTEMI = raised Troponin T ≥ 0.1, troponin I ≥1
what are the 3 distinctive clinical features of NSTEMI?
Resting angina, new-onset severe angina, increasing angina (freq, duration, lower threshold etc)
How is unstable angina defined clinically?
Angina at rest or increasing severity or duration >20 mins
How is the management of NSTEMI or unstable angina determined?
Risk stratification using TIMI or GRACE scales.
High risk –> MONAC + PCI within 96h.
Low risk –> MONAC + stress test
What might you find when assessing the pulse and BP in aortic dissection?
increased HR, unequal radial pulses. BP difference of ≥15mmHg between the two brachial pressures
What features might be present on CXR of aortic dissection?
Widened mediastinum >8cm
Double knuckle aorta
L pleural effusion
Tracheal deviation to RHS, calcium sign
What blood test is important to get in suspected aortic dissection?
Cross match - 6 units
What feature may distinguish MSK chest pain from cardiac or respiratory?
Worse on movement
What simple movement can you do in a breathless patient to hopefully maximise their comfort?
Sit them up
Patient presents with stridor. What do you need to do immediately?
Call the anaesthetist
What are the CURB parameters?
Confusion Urea >7 RR ≥30 BP - systolic <90 or diastolic <60 Age ≥65y
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?
Curb score is 1 (for DBP). Appropriate plan = home Abx, e.g. amoxicillin 500mg TDS (but follow local guidelines)
Mx of patient with CURB score of 3?
Hospital admission –> IV Abx e.g. co-amoxiclav + clarithromycin.
Take: blood cultures, pleural fluid, urine sample (pneumococcal + legionella).
If worsens –> consider ICU
What progression might you see on ABG of an acute asthma attack?
Initial ABG –> low CO2, low O2 (hyperventilating)
Later ABG –> normalising or high CO2 (patient tiring)
Features of life-threatening asthma attack?
33, 92, CHEST: PEFR <33% Sats <92% Cyanosis Hypotension Exhaustion Silent chest Tachycardic
Mx of asthma attack?
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
What is the investigation process for possible PE?
Wells score:
<4 –> D-dimer –> if -ve send home, if +ve do CTPA
>4 –> CTPA
How can you avoid doing any investigations in patient with possible PE?
Do PERC rule out criteria. If none of criteria are met –> can send home without tests.
Mx of PE?
ABCDE
Give O2, NSAIDs (avoid opiates)
LMWH (tinzaparin) –> start NOAC or warfarin. Continue for at least 3m
Mx for massive PE?
Thrombolyse with alteplase or streptokinase.
