Management Flashcards
How would you treat aortic dissection?
Type A - cardiothoracic surgical emergency
Type B - vascular surgical emergency
Similar to ACS so if unsure do a CT scan - thrombolysing aortic dissection is fatal.
How would you treat an NSTEMI?
- GRACE score calculated to decide upon management
- > 3% for coronary angiography within 72 hours of admission
- High risk or clinically unstable - coronary angiography
- Morphine 5mg IV
- GTN 800 micrograms sublingually
- Aspirin 300mg orally once only
- Ticegrelor 180mg orally once only or clopidogrel 300mg (antiplatelet)
- Fondaparinux 2.5mg SC daily (anticoagulation)
What is the management for ACS?
MONA
- Morphine
- Oxygen - only if O2 <94%
- Nitrates
- Aspirin
What is the treatment for a STEMI?
- PCI/angiography with stenting or balloon angioplasty within 12 hours of onset and 2 hours of presentation to ED
- Oxygen 15L NRB
- Aspirin 300mg
- Ticagrelor 180mg or clopidogrel 600mg
- Diamorphine 2.5-5mg IV
- GTN
- Consider thrombolysis if PCI cannot occur within 2hrs of presentation
What is the management for SVT?
- Vagal manoeuvres e.g. carotid sinus massage, blowing into empty syringe
- IV Adenosine (6, 12, then 18mg) - avoid in asthmatics due to bronchospasm (verapamil preferable)
- Electrical cardioversion
What is the treatment of VF?
- Single shock followed by 2 minutes of CPR.
- If cardiac arrest is witnessed then up to 3 successive (stacked) shocks
How should medication be administered in a cardiac emergency?
- IV access is first line
- Second line is intraosseous (IO)
When should adrenaline be administered in a cardiac arrest?
- 1mg (1ml 1:1000) ASAP for non-shockable rhythms
- During a VF/VT cardiac arrest, adrenaline 1mg is given once chest compressions have restarted after the third shock
- Repeat adrenaline 1mg every 3-5 minutes whilst ALS continues
When should amiodarone be administered?
- Amiodarone 300mg for VF/pulseless VT after 3 shocks have been administered
- Further dose of amiodarone 150mg should be given to VF/pulseless VT after 5 shocks have been administered
- Lidocaine can be used as an alternative
What are reversible causes of cardiac arrest?
4 Hs and 4 Ts
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins
What is the rate control treatment of AF?
- Beta-blocker or rate-limiting calcium channel blocker e.g., diltiazem
- If 1 drug does not control it then combination therapy with any 2 of: a beta blocker, diltiazem and digoxin
What is the rhythm control treatment of AF?
- When considering cardioversion it is important to remember that when the rhythm switches from AF to sinus there is a high risk of embolism leading to stroke.
- For a patient to be eligible they need to have had a short duration of symptoms (<48 hours) or be anticoagulated for a period of time prior.
What are the ECG findings of AF?
- Absent p waves
- Narrow QRS complexes
- Irregularly irregular ventricular rhythm
What are the ECG findings of supraventricular tachycardia?
- P waves can be buried in the t waves
- Regular rhythm
- Can appear at rest with no apparent cause
What is the management of SVT?
Patients without life threatening features:
1. Vagal manoeuvres
2. Adenosine
3. Verapamil or beta blocker
4. Synchronised DC cardio version
With life threatening features (LOC, chest pain, shock, severe heat failure): synchronised DC cardioversion under sedation or GA, IV amiodarone if unsuccessful.
What is the management of heart failure?
- ACEi and beta blocker - one drug started at a time, neither have effect on mortality in HF with preserved ejection fraction
- Beta blockers: bisoprolol, carvedilol and nebivolol - Aldosterone antagonist: spironolactone and eplerenone
- These and ACEi cause hyperkalaemia - monitor K
- Can also used SGLT-2 inhibitors for HF with reduced EF - Started by specialist: ivabradine, digoxin, hydralazine in combo with nitrate, cardiac resynchronisation therapy
What other management is offered for heart failure patients?
- Annual influenza vaccine
- Offer one-off pneumococcal vaccine
What is the management of new onset AF?
Electrical cardioversion considered if patient presents within 48 hours of presentation
What is the treatment for angina?
- Aspirin and statin
- Sublingual GTN to abort angina attacks
- 1st line: beta blocker or calcium channel blocker
- If calcium channel blocker used in monotherapy then add rate-limiting such as verapamil or diltiazem
- If used in combination with beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine) - beta-blockers should not be prescribed concurrently with verapamil (risk of complete heart block)
- If still symptomatic after monotherapy with beta-blocker add calcium channel blocker and vice versa
- If asthmatic, then add a long-acting nitrate, ivabradine, nicorandil or ranolazine
