GET AHEAD! MEDICINE SBAs PAPER 1 Flashcards
What are the guidelines for treating someone with ACS without ST elevation?
- Admit to CCU
- Low flow oxygen if O2 sats <40%
- Fondaparinux 2.5 mg OD SC / LMWH 1 mg/kg/12hrs
- If pain continues IV nitrates (50 mg/50 ml of 0.9% saline)
- High risk patients give GPIIb/IIIa antagonist and refer for angiography as in patient.
- Low risk patients discharge and treat medically. Consider stress test and echo.
Why might you not give someone with ACS without ST elevation a beta-blocker?
COPD Asthma LVF Bradycardia Coronary spasm
What would you give someone with ACS without ST elevation if a beta blocker was contraindicated but you needed to control their blood pressure?
Ca antagonist (rate limiting) Verapamil 80-100 mg every 8 hours
What is the mechanism of fondaparinux?
Factor Xa inhibitor
When deciding whether to refer a patient with ACS without ST elevation for angiography or discharge with medical treatment, what factors would constitute a high risk patient?
Rise in troponin Dynamic ST/T wave changes Diabetes Chronic kidney disease Ejection fraction <40% Early angina post MI Recent PCI Prior CABG Intermediate to high GRACE score
When deciding whether to refer a patient with ACS without ST elevation for angiography or discharge with medical treatment, what factors would constitute a low risk patient?
No new chest pain
No signs of heart failure
Normal ECG
-ve troponin 6-9 hours after symptom onset
What are the guidelines for treating someone with ACS with ST elevation?
- Gain IV access
- Take bloods (FBC, U+Es, lipids, glucose, cardiac enzymes)
- Brief assessment including history, examination and contraindications to PCI
- Aspirin 300 mg
- Morphine 5-10 mg (plus metoclopramide 10 mg IV)
- PCI if available within 120 mins of medical assessment / Fibrinolysis within 30 mins of admission
Why would you do U+Es in someone with ACS?
Check renal function for AKI and future drug treatment
What are some of the risk factors you would want to ask about when taking a history from someone with suspected ACS?
Hypertension Hyperlipidaemia Diabetes Previous angina Previous MI Previous stroke Family Hx Smoking Diet Exercise Occupation
What are the contraindications for fibrinolysis?
Known bleeding disorder GI bleed in the last month Previous intracerebral heamorrhage Ischeamic stroke within last 6 months Cerebral malignancy Major trauma or head injury in the last 3 weeks Aortic dissection Non-compressible puncture such as liver biopsy
What are the fibrinolytic agents used in fibrinolysis in someone with a STEMI?
Tissue plasminogen activators:
Alteplase
Retaplase
Tenecteplase
What changes might be seen on an ECG of someone having a posterior MI?
Reciprocal changes in the anterior leads (V1-V4):
ST depression
Tall R waves
Which of the following is not a potential cause of obstructive renal impairment? For each one say why it does or does not cause obstructive renal impairment.
Benign prostatic hypertrophy Recurrent kidney stones Retroperitoneal fibrosis Schistosomiasis Systemic sclerosis
Benign prostatic hypertrophy causes obstructive urinary retention which if left untreated will cause renal impairment.
Kidney stones for the same reason are an obstructive cause.
Retroperitoneal fibrosis is widespread fibrosis with the retroperitoneum. This includes the ureter, which as a result of fibrosis, cease to be able to peristalse and an obstruction is created.
Schistosomiasis is a disease caused by parasitic worms. S. haematobium produce eggs that can become lodged retrogradely in the ureter and initiate inflammatory response and granulomas can form. This leads to obstruction.
Systemic sclerosis can cause renal impairment however it is not obstructive. The disease causes fibrinoid thickening of the afferent arterioles which leads to reduced perfusion of the kidney and hence damage.
What is polycythemia rubra vera?
A myelo proliferative disorder where the bone marrow makes too many red blood cells, caused by mutation in single pluripotent stem cell.
What are some of the symptoms of polycythemia rubra vera?
Headache Visual disturbances Lethargy Pleuritis which is worse after bathing Increased risk of artero and veno thrombosis Increased risk of paradoxical bleeding
