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Houseman (break your leg) > Houseman handbook_Cardiology > Flashcards

Houseman handbook_Cardiology Flashcards

1
Q

ACS (unstable angina/ NSTEMI)

A
  • CCU if high risk
  • bed rest
  • O2 to keep SpO2 >94%
  • cardiac monitor
  • ECG stat + daily x3
  • Serial cardiac marker (CK, TnI)
  • CXR
  • Bld x CBP LRFT clotting lipid
  • +- Morphine 2-5mg IV
  • Correct anemia, hypoxia, tachyarrhythmia
  • Antithrombotic
    &raquo_space;» Aspirin 160mg stat, then 80-100mg daily
    &raquo_space;» Clopidogrel 300mg stat, then 75mg daily / Ticagrelor 180mg stat, then 90mg BD
    &raquo_space;» Enoxa/ Clexane 1mg/kg SC q12H OR Fraxiparine SC 0.4ml BD if <50kg BW, 0.5mL BD if 50-59kg BW, 0.6mL BD if >60kg BW
  • Antiischemic
    &raquo_space;» nitrate (contraindicated if sidenafil in 24H): SL TNG 1tab q5min for 3 doses; IV TNG (first 48H if persistent ischemia/ HF/ hypertension) Isoket 2-10mg/H IV (w/h if SBP<100) / Isordil 10-30mg TDS / Imdur 60-120mg daily
    &raquo_space;» BB (titrate to HR<70)
    &raquo_space;» CCB if BB c/i without clin sig LV dysfunction: herbesser 30-60mg TDS, verapamil 40-120mg TDS
  • Statin ALWAYS
  • ACEI (w/in 24H if LVEF <40%; if no hypotension)
  • Consult cardiac x urgent PIC/ revascularization/ IABP/ other mechanical circulatory support
    e.g. ongoing rest pain, APO, hypotension, ventricular arrhythmia, ST change >0.1mV / new BBB, elevated TnI, TIMI/ GRACE
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2
Q

ACS (STEMI): UNFINISHED

A

ECG stat + daily x 3

  • inf: II III aVF
  • alt: I aVL V6
  • anteroseptal: V1-3
  • anterolateral: V4-6
  • anterior: V1-6
  • Rt vent: V3R V4R

Cardiac marker
CXR
Bld x CBP LRFT clotting lipi

CCU bed
BP I/O q1H
Cardiac monitor
Complete bed rest
O2 to keep SaO2 >90%
Diazepam 2-5mg PO TDS for anxiety
Morphine 2-5mg IV

Aspirin 160mg stat, then 80mg daily
Metoprolol 25mg BD PO (if not decompensated HF state; bisoprolol if LVEF reduced)
P2Y12 inhibitor
&raquo_space;> Clopidogrel 600mg loading, 75mg daily (for PCI/ fibrinolytic; no loading if fibrinolytic in >75yo)
&raquo_space;> Prasugrel 60mg loading, 10mg daily (for PCI)
&raquo_space;> Ticagrelor 180mg loading, 90mg BD (for PCI)
1. Eligible for PCI> activate PCI protocol
2. Eligible for fibrinolytic
3. Not for reperfusion (too old, poor premorbid)

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3
Q

Arrhythmia

A

VF/ pulseless VT:
- defib 360J monophasic/ 200J biphasic
- CPR 2 min
- defib 360J monophasic/ 200J biphasic
- CPR 2 min
- Adrenaline 1mg (10mL 1: 10000 soln) q3-5min
- defib 360J monophasic/ 200J biphasic
- CPR 2 min
- Antiarrhythmics
&raquo_space; Amiodarone 300mg IV bolus, further 150mg IV bolus
&raquo_space; Lignocaine 1-1.5mg/kg IV push, then 0.5-0.75mg/kg q10min (max 3mg/kg)

========================
Asystole/ PEA
- CPR
- Adrenaline 1mg IV (10ml 1: 10000 soln) q3-5mins
- 5H and 5T
&raquo_space;» Hypovolemia, hypoxia, hypothermia, hyperK, H+
&raquo_space;» Tamponade, Tension, Thrombosis x2, Toxin

========================
Tachy with pulse
 - Underlying cause
 - O2
 - Cardiac monitor
 - BP/P q1H x3, q4H if stable
 - ECG
  1. UNSTABLE (hypotension, mental status, shock, chest discomfort, acute HF)
    - SYNCHRONIZED cardioversion:
    Narrow regular: 50-100J
    Narrow irregular 120-200J
    Wide regular: 100J
    Wide irregular: defib
  2. STABLE
    AF/ Aflut:
    - correct cause (hypoxia, E-, sepsis, thyroid)
    - control rate:
    &raquo_space;> diltiazem 0.25mg/kg IV bolus over 2min, then 5-15mg/H, oral maintenance 120-360mg/D
    &raquo_space;> metoprolol 2-5mg IV over 2mins (max 3 dose), oral maintenance 25-100mg BD
    &raquo_space;> amiodarone 300mg IV over 1H, then 10-50mg/H over 24H, oral maintenance 100-200mg/D
    &raquo_space;> digoxin 0.25mg IV with repeat to max 1.5mg over 24H, oral maintenance 0.125-0.25mg/D
    *If thyrotoxicosis, BB and verapamil more effective
    *If impaired cardiac function EF<40/ CHF: use digoxin/ amiodarone
    - anticoagulation: UFH with maintenance APTT 1.5-2x control; then LT warfarin with PT 2-3x control
    CHA2DS2-VASc score
    - if persistent:
    &raquo_space;» amiodarone 150mg over 10 mins, then 1mg/min for 6H then 0.5mg/min for 18H then PO 600-800 daily (<10mg per dose) then 200mg daily as maintenance
    &raquo_space;» Synchronized DC: AF 120-200J, AFlut 50-100J

Regular narrow complex

  • Vagal maneouver (carotid sinus pressure, ice water immersion)
  • ATP 10mg rapid IV push; further 20mg IV push after 1-2mins, can repeat once 20mg IV push (NOT for asthma + warn patient chest discomfort)
    1. BP low: synchronized DC: start with 50J, increase by 50-100J
    2. BP normal: verapamil 2.5-5mg IV; further 5-10mg after 15-30mins
  • Consider digoxin, BB, diltiazem, amiodarone

Regular wide complex
Unknown type
- ATP 10mg IV push; further 20mg IV push after 1-2mins
- if cardiac function preserved: amiodarone 150mg IV over 10mins, repeat 150mg IV over 10mins, then infuse 600-1200mg/D (max 2.2g in 1D)/ procainamide infusion 20-30mg/ min till max, total 17mg/kg
- if EF<40% or acute HF: amiodarone 150mg IV over 10mins, repeat 150mg IV over 10mins, then infuse 600-1200mg/D (max 2.2g in 1D); then cardioversion

Brady with a pulse

  • cause
  • O2
  • Cardiac monitor
  • BP/P q1H x3, if stable q4H
  • ECG
    1. UNSTABLE (hypotension, mental status, shock, chest discomfort, acute HF)
  • atropine 0.5mg IV bolus, then q3-5min (max 3mg); NOT effective if T2 2nd/ 3rd degre HB
  • transcutaneous pacing/ dopamine infusion 2-20mcg/kg/min / adrenaline infusion 2-10mcg/mi
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4
Q

APO

A

Mx

  • complete bed rest
  • prop up
  • 0-4L O2 to keep SpO2 >=94%
  • low salt diet + FR <1-1.2L/D
  • identify precipitating cause: arrhythmia, IHD, uncontrolled HT, chest infection
  • BP/P I/O SaO2 Q1H x3, Q4H if stable

STABLE BP:

  • IV lasix 40-120mg IV
  • IV nitrate e.g. GTN 1ug/kg/min
  • IV morphine 2-5mg slow infusion

UNSTABLE BP:

  • Dopamine 2.5-10ug/kg/min OR dobutamine 2.5-15ug/kg/min
  • Refractory: IABP/ PCI for ischemia/ intervention for valvular

UNSTABLE PATIENT (desat, shock, exhaustion)

  • intubation, mech ventilation
  • NIV: BIPAP/ CPAP
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5
Q

AD

A

Clinical feat: chest pain, back pain, abd pain, unequal pulse, acute AR

Dx: CXR, ECG, cardiac enzyme, transthoracic+- transesophageal ECHO, U CT aortogram/ MRA

Mx:

  • NPO, complete bed rest
  • O2 0-4L to keep SpO2 >=94%
  • Analgesics e.g. IV morphine 2-5mg
  • CCU x monitoring bp
  • BP/P SpO2 Q1H, Chart I/O
  • ECG
  • Look for Cx: severe HT, cardiac tamponade, massive h’age, AR, MI, stroke, renal ischemia
  • Aim stabalize dissection, prevent rupture, clot emboli
  • Target BP 100-120mmHg (60-75mmHg mean pressure); HR 60-70
  • Choice:
    &raquo_space; IV labetalol 10mg over 2 mins, 20-80mg q10-15mins (MAX 300mg); maintenance infusion 2mg/min, up to 5-20mg/min
    &raquo_space; IV Na nitroprusside 0.25mcg/kg/min, increase 10ug/min Q2min (MAX 8mcg/kg/min; if eGFR <30 then MAX <3mcg/kg/min); AVOID in uncontrolled HR (reflex tachy)
    &raquo_space; Diltiazem/ verapamil if BB c/i
  • PO anti-HT unless surgery
  • CTS x Type A / complicated Type B (shock, renal artery inv, limb/ visceral ischemia, periaortic / mediastinal hematoma, hemoperitoneum, persistent pain, progression of dissection)

Acute aortic syndrome (IM hematoma, penetrating aortic ulcer) = AD

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6
Q

Cardiac tamponade

A

pericardial effusion compression on chamber leading to HD instability
acute: pericardium fail to distend, pressure rise, tamponade if 200mL acute effusion

Causes: neoplastic, pericarditis, pericarditis treated with anticoag, uremia, iatrogenic, trauma, idiopathic

Dx: clinical (effusion + HD instable)

Signs: tachypnea, tachycardia, small pulse vol, pulsus paradoxus; JVP prominent x descent, kussmaul; abx spex, faint heart sound, hypotension, clear chest

Ix

  • ECG: low voltage, tachycardia, electrical alternans
  • CXR: enlarged heart silhouette (if >250mL), clear lung field
  • ECHO: RA, RV, LA collapse, distended IVC, exaggerated tricuspid flow increase + mitral flow decrease during inspiration

Mx

  • IV volume expansion D5/ NS/ plasma, FR if shock
  • AVOID mechanical ventilation (thoracic pressure impair cardiac filling)
  • AVOID ACEI/ vasodilator/ diuretics
  • Pericardiocentesis with ECHO - apical/ subcostal
  • Open drainage under LA/ GA
  • Permit pericardial bx
  • Recurrent tamponade due to catheter blockage / reaccumulation
  • c/o medical oncology x malignant pericardial effusion to see if benefit from pericardiectomy (pericardial window) + plan onco intervention
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7
Q

CPR

A
  1. unresponsive?
  2. call for help + defib
  3. PPE
  4. breathing and pulse in 10sec
    - no breathing: rescue breath q5-6s
    - no pulse: CPR
  5. CPR
    - 100/min, 5cm - 6cm depth, 30:2
  6. Airway
    - clear secretion
    - head tilt chin lift jaw thrust
    - oropharyngeal airway
  7. Breathing
    - bagmask + O2 10-12L
  8. Defib
    - shockable (VF/ pulseless VT): biphasic 200J/ monophasic 150J + CPR
    - non-shockable: CPR

========================
ACLS
6. Airway (intubation if skilled)
- confirm airway: 5 pointauscultation, waveform capnogrpahy, 1 breath every 6 sec
7. Drugs
- Adrenaline: 1mg (10 mL of 1: 10000) q3-5min IV
- Lignocaine: 1mg/kg IV bolus, then 1-4mg infusion
- Amiodarone: pulseless VT/ VF, 300mg IV bolus, further 150mg bolus
- MgSO4: torsades, 1-2g in 10mL D5 IV bolus

Tracheal if IV NA: 
Ligno, Epinephrine, Atropine, Narcan
 - double dosage in 10mL NS/ WFI, quick insufflation + w//h CPR during so
========================
ROSC
1. 100% O2 to maintain SpO2 >94%
2. Advance airway + waveform capno
3. IVF/ vasopressor to maintain BP
4. Treatable cause 5H 5T
Hypovolemia, Hypoxia, hyperK, H+, hypothermia
Tamponade, Tension, Thrombosis x2, Toxin
5. Targeted temperature management
6. Anticonvulsant
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8
Q

Hypertensive emergency

A

Definition
- BP >180/120 + organ damage
&raquo_space; hypertensive encephalopathy, AMI, APO, Dissecting aneurysm, renal failure, eclampsia, ICH/ stroke

BP target

  • AD/ eclampsia/ pheochromoytoma: SBP <140 first H, <120 in AD
  • otherwise: SBP reduce <25% first H, 160/100 in 2-6H, normal in 24-48H

Mx:
- IV labetalol 20mg over 2 mins, repeat 40mg bolus in 15mins, then 0.5-2mg/min in D5 (Max 300mg/D); maintenance 100-400mg PO BD
- IV Na nitroprusside 0.25-10mcg/kg/min (e.g. 50mg in 100mL D5 in 50kg person, start 10mL/H titrate acc BP); GOOD for LV fail
&raquo_space; BP Q2min, then Q30min if stable
- IV hydralazine 5-10mg over 20mins, repeat Q30min / Infusion 200-300mcg/min and titrate; then PO 10-100mg four times per day
- IV phentolamine 5-10g, repeat 10-20mins prn; GOOD for catecholamine crisis

APO: Nitroprusside/ TNG + loop diuretic; AVOID diazoxide/ hydralazine/ labetalol
AMI: TNG, nitroprusside, labetalol, CCB; AVOID hydralazine/ diazoxide
Sympathetic (clonidine w/drawal, pheo, GBS/ post spinal cord inj, drugs e.g. cocaine/ amphetamine/ MAOI): phetolamine, labetalol, nitroprusside
AD: (AIM SBP 100-120) nitroprusside + labetalol/ propanolol
Pregnant: hydralazine, nicardipine/ labetalol; AVOID nitroprusside, ACEI

HT urgency

  • BP elevation with no target organ damage
  • Mx: intensify anti-HT
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9
Q

IE (abx prophylaxis)

A
  1. DENTAL PROCEDURES (manipulation of gingival/ periapical region of teeth/ perforation of oral mucosa); 30-60mins before
  2. HIGH RISK FEATURES
    - prosthetic valve/ material x repair
    - prev IE
    - congenital heart (cyanotic, repaired with prosthetic material, residual shunt/ regurgitation)
  3. CHOICE OF ABX: cover staph
    - Amox/ ampicillin 2g PO/ IV
    - Clindamycin 600mg PO/IV (if pencillin/ampicillin allergy)

NOT for Resp/GI/Urogenital/skin procedures unless infection involved
(GI: cover enterococci, skin/MSK: cover staph + B-hemolytic strep)

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10
Q

Pulmonary embolism

A 
Ix
Bld x PT/INR/APTT, CK TnI LDH, ABG, DD
CXR (pleural effusion, focal oligemia, peripheral wedge)
ECG (ST, S1Q3T3, RBBB, RAD, P pulmonale)
TTE +- TEE, LL doppler (50%-ve in PE)
CTPA (Sensitivity 91%)
VQ scan (Sensitivity 41%)

Mx
O2
Analgesics (morphine 2-5mg iv)
HD stable
> ST anticoag (till D7-10)
- UFH 5000U IV bolus, then 500-1500U/H to keep APTT 1.5-2.5x control (if severe renal failure, high likelihood reversal required e.g. bleed risk) or
- Enoxaparin 1mg/kg q24H
> LT anticoag (start D2-3)
- Warfarin on D2-3: 5mg daily for 2/7, then 2mg x 1/7, adj to keep INR 2-3
- NOAC as alternative:
dabigatran other IV noac first, then PO 150mg BD
rivaroxaban 20mg BD x 21/7 then 20mg QD
apixaban: 10mg BD x7/7, then 5mg BD

HD unstable (no C/I to thrombolytics)

  • ICU/CCU
  • r-tPA 100mg iv over 2H, followed by heparin infusion 500-1500U/H to keep APTT 1.5-2.5 x control
  • surgical embolectomy/ percutaneous catheter-directed Tx if condition deteriorate/ CI to thrombolytic
  • IVC fiter if recur PE on anticoag/ CI to anticoag
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11
Q

Perioperative cardiovascular evaluation (INCOMPLETE)

A

Basic evaluation

  • Hx: functional capacity (4 METS as cutoff)
  • PE
  • ECG

CV risk: MI/CHF/Death

Delay/ cancel OT IF

  • unstable coronary syndrome (recent <30D or AMI with ischemic risk , Canadian III/IV angina
  • decompensated CHF
  • sig arrhythmia (high grade AV block, symptomatic ventricular arrhythmia with underlying heard ds, supraventricular arrhythmia with uncontrolled VR)
  • severe valvular ds (severe AS, symptomatic MS)

Enhanced risk, require careful assessment
- Hx of IHD, CHF, DM, renal impairment

Not proven to independently increase risk

  • advanced age
  • abn ECG (LVH, LBBB, ST/T abn)
  • Low functional capacity
  • Hx of stroke, uncontrolled systemic HT

MACE score (Major adverse cardiac event): surgicalriskcalculator.com

  • low risk <1%
  • elevated risk >=1%
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Houseman (break your leg) (23 decks)

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