Emergency cardiology Flashcards
What are the potential rhythms in a pulseless patient?
Shockable - VT or VF
Non shockable - PEA, asystole
Define narrow complex tachycardia
QRS < 0.12 seconds or 3 small squares
What are the differentials for narrow complex tachycardia?
- Sinus tachycardia
- SVT
- AF
- Atrial flutter
What are some causes of sinus tachycardia?
> 100 BPM
- Fever
- Normal response - pain, anxiety, exercise, dehydration
- Hyperthyroid
- Anaemia
- Shock - septic, hypovolaemia/hypotension
- PE
- Cocaine
Sinus tachy vs SVT
Presenting complaint for SVT = very sudden (paroxysmal), no reason
Sinus tachy normally has an explaination and gradually increases in speed
What is the management of SVT for HISS patients?
Pt w adverse features (HISS) need synchronised DC shock
HF
Ischaemia
Shock
Syncope
What is the management of stable SVT patients?
Regular = vagal manoeuvres eg. blowing into an empty plastic syringe (valsalva), carotid sinus massage
If this fails:
IV adenosine 6mg (can do 12mg and 18mg after as well)
What is important to remember when using adenosine?
- Have arrest trolley nearby
- Impending doom sensation
- CI in asthmatics -> use verapamil
- Give 20ml IV NaCl bolus after
What are some complications of SVT?
Syncope
DVT
PE
Cardiac tamponade
HF
MI
Death
How do you prevent SVT?
B blockers
What is the ECG appearance of AF?
Fast = >100bpm
Slow = <60bpm
Irregular
No P waves
What are some causes of AF?
IHD (most common)
HTN
Inflam of heart
Dehydration
Hyperthyroid
Sepsis
PE
What are the sx of narrow complex tachycardia?
- Palpitations
- Chest pain
- SOB
- Lightheadedness
- Syncope
AF vs A flutter
AF = fibrillatory waves on ECG
A flutter = sawtooth
What is the management of acute AF?
Adverse signs (HISS) = synchronised DC cardioversion +/- amiodarone
Stable:
<48 hours = rate or rhythm control
>48 hours = rate control only
Need to anticoagulate for 3 weeks before starting cardioversion due to risk of throwing off clot
What is used for rate control?
B blockers
CCB eg. diltiazem (CI in HF)
Digoxin
What is used for rhythm control?
B blockers
Dronedarone = 2nd line in pt following cardioversion
Amiodarone, especially if HF
Flecainide = younger pt w normal hearts
What is catheter ablation?
Remove electrical pathways causing AF, used in pt who don’t response to medication or want to avoid
Anticoag 4 weeks before and during procedure
Pt still require anticoagulation after procedure
What are the anticoag options in AF?
1st line = DOAC eg. apixaban
Warfarin w LMWH cover for 5 days
LMWH eg. enoxaparin
What are the CF of digoxin poisoning?
- Heart signs - palpitations, bradycardia
- Visual signs - haloes and yellow -> green
- Autonomic dysreg - dizzy, N+V, sweat and clammy
Hyperkalaemia
What are the Ix into digoxin poisoining?
Immediate digoxin level
U+Es - so can correct abnormalities
Cont cardiac monitoring - to resus or ITU
What is the management of digoxin poisoning?
IV fluids
Correct electrolyte abnorm
Cont cardiac monitoring
+/- Digibind
What is digibind and what are the indications for using it?
Digoxin specific ab = antidote - if level >15ng/ml >6 hours last dose or >10ng/ml <6 hours
What is cardiac tamponade?
Accumulation of fluid (normally blood) in the pericardial sac.
Fluid increases intrapericardial pressure = reduces cardiac filling during diastole = reduced cardiac output.
Causes of cardiac tamponade
Stab wounds!!!!
Other trauma eg. RTA
Pericarditis
Malignancies
SLE
Myocardial rupture following MI
What are the CF of cardiac tamponade?
Becks triad:
1. Raised JVP
2. Hypotension
3. Muffled HS
Kussmaul’s sign = paradoxical rise in JVP during inspiration
Dyspnea and fatigue
What are the ix into cardiac tamponade?
Echo
ECG - tall QRS, alt QRS amplitude
What is the management of cardiac tamponade?
Pericardiocentesis - fluid removed to relieve pressure
What is the MOA of amiodarone?
Blocks K+ so reduces heart speed
What is the MOA of adenosine?
Transient AVN block
What is broad complex tachycardia?
QRS >0.12 secs or 3 small squares
What are some examples of broad complex tachycardia?
VT
PVT eg. torsades de pointes
AF w BBB
SVT w BBB
What does VT look like on ECG?
Regular broad QRS complex, no other waves
Causes of VT
Hypokalaemia or hypomg
MI
Brugada syndrome
What is the management of VT?
Adverse features HISS = synchronised DC shock
Stable pt = IV amiodarone
What is polymorphic VT?
VT twists, like up and down, like sound waves
Torsades de pointes is a type - life threatening and can cause sudden cardiac death
What is the acute management of TdP?
HISS = DC cardioversion
Stable = 2mg IV Mg sulphate
Address triggers
What are the ECG features of BBB?
Right = little bunny ear, big bunny ear
Left = tooth/M ????
What are the ECG features of axis deviation?
Right - reaching to each other
Left - away from each other
Normal - both up
Causes of LBBB
MI !!!!!
Define prolonged QT
> 440 ms
What are some causes of prolonged QT?
- Long QT syndrome, inherited
- Meds eg. clarithromycin, erythromycin, antipsychotics, citalopram
- Electrolyte imbalances (hypo)
What is the management of prolonged QT interval?
Stop offending meds
Correct electrolytes
B blockers but not sotalol
Pacemakers or ICD
What does a ventricular ectopic look like on ECG?
Isolated, random, broad QRS complex on otherwise normal ECG
What is bigeminy?
every other beat is a ventricular ectopic - this is abnormal, needs specialist advice
What are the different types of heart block?
1st degree - PR interval >0.2 seconds/ >5small squares but QRS always follows
2nd degree - type 1 = progressively longer PR then QRS fails or type 2 = fixed prolonged PR and sudden drop QRS
3rd degree - no relationship between P waves or QRS complexes
2:1 block - 2 p waves for every QRS
Which heart blocks are most dangerous?
2nd degree Mobitz type 2 - risk of asystole
3rd degree - significant risk of asystole
When is bradycardia a medical emergency?
<60 bpm and haemodynamic compromise - hypotension, cerebral hypoperfusion, HF or angina
Causes of bradycardia
Electrolyte disturb
Hypothyroid
MI
Sepsis
B blockers
Increased ICP
Heart block
What is the management of bradycardia w adverse features?
IV atropine - inhibits parasympathetics
Adrenaline
Dopamine
If don’t respond to meds = temporary pacing - transcutaneous or transvenous
What is sick sinus syndrome?
Clinical manifestations of sinus node dysfunc, may need a pacemaker if v symptomatic
What are the CF of pericarditis?
- Sharp pleuritic chest pain relieved by leaning forward
- Flu like prodrome
- Pericardial rub (like walking in snow)
- ECG = saddled shaped ST elevation
- Troponin +/- elevated
What is the management of pericarditis?
NSAIDs
Bed rest
+/- colchicine and steroids
Treat underlying cause eg. MI, trauma, malignancy, SLE, drug
What are the CVS causes of raised troponin?
MI (cardiac ischaemia)
Arrhythmia
Coronary artery spasms
Aortic dissection
HTN
What are the non CVS causes of raised troponin?
CKD
PE
Sepsis
What is dissection?
Tear in the tunica intima of the aorta = blood flows between the inner and outer layers of the walls of the aorta
What are the RF of aortic dissection?
HTN
Connective tissue disease eg. Marfan’s
Valvular HD
Cocaine
What is the classification of aortic dissection?
Stanford Type A - ascending aorta and arch, more common
Standford Type B - descending aorta
What are the CF of aortic dissection?
Sudden onset tearing chest pain or interscapular pain radiating to the back
+/- bowel/limb ischaemia, renal failure, syncope
O/E - radio radial delay, radio femoral delay, BP different between arms
What are the ix into aortic dissection?
CT angiogram = gold standard
- ECG = ischaemia?
- Echo
- CXR = widened mediastinum
- Raised troponin and +ve Ddimer
What is the management of aortic dissection?
Need to prevent rupture = 80% mortality
Initial - resus, cardiac monitoring, BP control eg. IV metoprolol infusion
Type A - surgical management
Type B - bed rest, blood pressure control eg. IV labetalol
What are the complications of aortic dissection?
Rupture and death
End organ damage
Cardiac tamponade
Stroke
Limb and mesenteric ischaemia
What are the signs of AAA?
Pulsatile abdo mass
Sudden severe abdo or back pain - pain = late sign, indicates impending rupture
Rupture = sudden severe pain, signs of shock
What is the management of AAA?
Open repair and endovascular aneurysm repair are the two options.
Indications = >5.5cm or rapid expansion
What are the 3 ACS?
- Unstable angina - partial occlusion, troponin -ve, ECG -ve, chest pain +ve
- NSTEMI - severe occlusion, troponin +ve, chest pain +ve, ST depression or T wave inversion
- STEMI - complete occlusion, troponin +ve, chest pain +ve, ECG ST elevation
What is a type 2 myocardial infarction?
MI due to cardiac hypoperfusion eg. sepsis, hypotension, hypovolaemia or coronary artery spasm
CF of MI
Chest pain - central, sudden, crushing, radiating to L arm and jaw, N+V, clammy, sweaty, SOB, constant, better w GTN worse w exercise
Atypical - epigastric pain or no pain - syncope SOB or palpitations
What are the Ix into MI?
ECG - LBBB, ST elevation or other ST abnorm
Bloods - troponin, U+E, HbA1c, lipids, FBC and CRP, D dimer
CXR
ECG and MI - what vessel affected?
II III and aVF - inferior = right coronary artery
V1 and V2 - septal = proximal LAD
V3 and V4 - ant = LAD
V5 and V6 - apex = distal LAD
I and aVL - lat = left circumflex
V7-V9 - post lat = right coronary or L circumflex
What is the management of a STEMI?
- O2
- Loading dose aspirin 300mg
- GTN
- IV morphine
- PCI <12 hours of pain and <2 hours in hospital - need clopidogrel 300mg
Management of NSTEMI and unstable angina
- O2
- 300mg aspirin, calc 6month mortality = if med/high = prasugrel
- GTN
- IV morphine
- LMWH or fondaparinux
- Angiogram
What is the post MI management?
- Aspirin 75mg
- Clopidogrel 75mg
- B blocker
- ACEi
- Atorvastatin 80mg
Have an echo and cardiac rehab.
What is Dressler’s syndrome?
Persistent fever and pleuritic chest pain 2-3 weeks post MI
Sx resolve in few days
Manage w high dose aspirin
What are some distinguishing features of the different causes of collapse?
Cardiac syncope - before = lightheaded, chest pain, SOB, palpitations, rapid recovery after
Vasovagal - clear trigger, narrowing of vision, sweating and nausea, can sometimes lower self to floor
Seizure - tongue biting, incontinence, post ictal, neuro deficit, seizure movements
What are the ix into collapse?
ECG
Bloods - U+E, FBC, BM
Echo - look for structural cause of cardiac syncope
What are the regulations of unexplained syncope?
6 months off driving and have to inform DVLA
NO baths, don’t lock doors
What are the different types of shock?
Hypovolaemic
Septic
Anaphylactic
Cardiogenic - reduced cardiac output
Neurogenic
Obstructive
What is trifasicular blcok?
Incomplete - RBBB, L axis deviation and 1st degree heart block
Complete - RBBB, L axis deviation and 3rd degree heart block
What is bifasicular block?
RBBB and axis deviation (L or R)
