Emergency Treatment Flashcards
ECG changes for STEMI?
ST elevation
New LBBB
Tall T waves
normalisation on ST segments
T wave inversion
STEMI acute treatment?
- ECG
- Aspirin 300mg
- Morphine (w/ metoclopramide), oxygen, GTN spray
- Angiography with PCI (ST elevation >2mm din 2 chefs leads or >1mm in limb leads) - if presenting within 12 hrs of symptoms and PCI can be delivered in 120 mins, offer prasurgrel with aspirin if not already on oral anticoagulant
- Fibrinolysis with alteplase/streptokinase - if presenting pithing 12 hours of symptoms and PCI not possible in 120 mins
STEMI secondary prevention?
Dual anti platelet - lifelong aspirin, ticagrelor (at least 12 months)
ACEi - indefinitely, titrated as high as possible eg. ramipril
BB - indefinitely, titrated a high as possible eg. atenolol or bisoprolol
Statin - atorvastatin 80mg OD
Lifestyle - stop smoking, cardiac rehab, no driving for 4 weeks, reduce alcohol, diet
ECG changes for NSTEMI?
No ECG changes
ST depression, T wave inversion
NSTEMI acute treatment?
BATMAN:
Beta blocker
Aspirin 300mg stat
Ticagrelor 180mg stat dose OR Prasugrel (clopidogrel 300mg if high bleeding risk)
Morphine
Anticoagulant - Fondaparinux
Nitrates - GTN
What is the GRACE score?
Assess for PCI in NSTEMIs - 6 month risk of death or repeat MI
<3% low risk
>3% intermediate/high risk - angiography with PCI within 72 hours (if indicated)
What is the definition of shock?
Acute circulatory failure with inadequate or inappropriately distributed tissue perfusion, resulting in generalised hypoxia and/or an inability of the cells to utilise oxygen
What are the different types of shock?
Hypovolaemic
Cardiogenic
Anaemic
Cytotoxic
What are the subgroups of hypovolaemic shock?
Haemorrhagic
Septic
Anaphylactic
Neurogenic
Clinical presentation: hypovolaemic shock
Skin - cold, clammy, pale
Drowsiness/confusion
Increased sympathetic tone
Tachycardia
Sweating
What are the 4 classes of hypovolaemic shock?
Blood loss:
I - 0-15%
II - 15-30%
III - 30-40%
IV - > 40%
Clinical presentation: cardiogenic shock
Signs of myocardial failure
Raised JVP
Gallop rhythm
Basal crackles and pulmonary oedema
Clinical presentation: septic shock
Pyrexia and rigors
Nausea and vomiting
Vasodilation and warm peripheries
Bounding pulse
What are the sepsis 6?
High flow oxygen, maintain sats >94%
Blood cultures
Measure serial lactate levels
IV antibiotics
IV fluids
Monitor urine output
Clinical presentation: anaphylactic shock
Profound vasoldilation
Warm peripheries
Low BP
Tachycardia
Bronchospasm
Pulmonary oedema
Treatment: neurogenic shock
Vasopressin and atropine
When is rhythm control 1st line treatment for AF?
Reversible cause
New onset < 48 hours
AF causing HF
Symptomatic despite rate control
What is usually 1st line treatment for AF?
Rate control
BB or rate limiting CCB (diltiazem or verapamil) monotherapy
Digoxin if non paroxysmal AF (if does no or little exercise or other rate drugs ruled out)
What is paroxysmal AF?
Intermittent episodes of AF that terminate within 7 days either spontaneously or with treatment
What type of drug is digoxin?
Cardiac glycoside
When is cardioversion used for rhythm control in AF?
Immediate - if < 48 hours or haemodynamically unstable
Delayed - if > 48 hours and stable
What medication needs to be given for delayed cardioversion?
Antiocoagulate for min 3 weeks prior
Consider amiodarone 4 weeks prior and 12 weeks after
What treatment is used for AF if monotherapy fails?
Combination therapy: any 2 of:
- BB
- diltiazem
- digoxin
What antiarrhythmic drug is contraindicated in patients with known IHD or structural HD?
Class 1c
eg. flecainide and propafenone
Long-term rhythm control:
- BB
- Dronedarone - 2nd line for rhythm control after successful cardioversion
- Amiodarone - LV impairment or HF
When is ‘pill-in-pocket used? and which drug?
Paroxysmal AF
Flecainide - take when episode starts
When is left atrial ablation considered in AF?
Drug treatment not tolerated/not suitable/unsuccessful in symptomatic paroxysmal or persistent AF
3 months of antiarrhythmic drugs after
What is CHA2DS2VASc?
Calculates stroke risk in patients with AF
Chadvasc score of 2 or more - action?
Anticoagulate with DOAC - apixaban, dabigatran, edoxaban, rivaroxaban
Men can have if score of 1 or more
Warfarin if DOAC contraindicated
What is the ORBIT score?
Predicts risk of major bleeding in patients on anticoagulation for AF
ORBIT score criteria:
- Haemoglobin - 2 points
- Male - Hb < 13 or haematocrit < 40%
- Female - Hb < 12 or haematocrit < 36% - Age > 74 - 1 point
- Bleeding history - 2 points
- GI, intracranial, haemorrhagic stroke - - GFR < 60ml/min - 1 point
- Antiplatelet treatment - 1 point
ORBIT score outcomes:
Low risk - 0-2
Intermediate risk - 3
High risk - 4 or more
Acute management of stable SVT?
Valsalva manoeuvre
Carotid sinus massage
Adenosine 6mg IV bolus -> 12mg -> 12mg (verapamil as alternative)
Acute management of unstable or unsuccessful management SVT?
Direct current cardio version with amiodarone 100J -> 200J -> 300J
Amiodarone loading dose of 300mg over 20 mins -> 900mg over next 23 hours