Medicine: AcuteMed Flashcards
Three components of assessing ACS
Hx
ECG
Troponin
Classic cardiac chest pain hx
Retrosternal heaviness, radiates to jaw +/- arm, exertion exacerbates sx, GTN may help, a/w autonomic features
ACS RFs
HTN, hyperlipidaemia, diabetes, FHx, smoking
Unstable Angina (inc both at rest + crescendo angina)
Hx is vital, no acute ECG findings, normal troponin -> admit for ACS tx + cardio review
What is crescendo angina?
Chest pain comes on after shorter and shorter distances of exertion
NSTEMI vs STEMI
NSTEMI - mismatch of O2 demand/consumption w some myocardial damage
STEMI - complete blockage of blood flow and transmural damage
There’s an elevated troponin in both
NSTEMI
ECG: normal, subtle ST abnormalities, ST depression, inverted T waves
Mx: A-E, cardiac monitor, serial ECGs, admit for ACS tx +/- angiography
What is the ACS tx?
- Load w Dual AntiPl (300mg Aspirin + 300mg Clopidogrel / 180mg Ticagrelol)
- 2-8d AntiCoag (2.5mg Fundaparinox OD)
- 1y Dual AntiPl (75mg Aspirin OD + 75mg Clopidogrel OD / 90mg Ticagrelol BD)
- If they had PCI then after 1y stop the clopidogrel/ticagrelol and persist w lifelong aspirin
When should angiography be performed?
Fit individuals within 72hrs
STEMI
ECG: ST elevation of 2mm in chest leads/1mm in two consecutive inferior leads, new LBBB, hyperacute T waves
Mx: A-E, PCI <90mins if in capable hospital, PCI <120mins if requires transfer, thrombolysis <30mins if PCI unavailable, plus MONA w/o high flow O2 due to free radicals unless sats are low
Which antiemetic doesn’t cause tachycardia?
Metoclopramide
The classification of stroke
Ischaemic - lacunar, atherosclerotic, cardiogenic emboli, cryptogenic
Haemorrhagic - SAH + intracerebral
The different types of a lacunar stroke
Pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, clumsy hand, silent
The vasc territories of the brain
Ant Circulation - ACA, MCA, internal carotid
Post Circulation - PCA, basilar, vertebral
Cerebellum - SCA, AICA, PICA
ACA Stroke Syndrome
Contralateral leg > arm paresis or bilateral if both ACAs involved + mild sensory defect, disinhibition, executive dysfunction
MCA Stroke Syndromes
Face -> Arm -> Leg Weakness
Left Hemisphere ie dominant - right hemiparesis, sensory loss, homonymous hemianopia + dysarthria, aphasia, apraxia
Right Hemisphere ie non-dominant - left hemiparesis, sensory loss, homonymous hemianopia + dysarthria, neglect of left side, flat affect
PCA Stroke Syndromes
Occipital Lobe - contralateral homonymous hemianopia or quadrantanopia + cortical blindness if bilateral lesions
Medial Temp Lobe - deficits in long and short term memory + behaviour alteration
Thalamic - contralateral sensory loss, executive dysfunction, aphasia, memory impairment, dec level of consciousness
Where must the infarct be if the patient has a quadrantanopia?
The occipital lobe
Which strokes can cause a dec level of consciousness?
Large MCA, thalamic, brainstem
Cerebellar Stroke
Dysdiadochokinesis Ataxia Nystagmus Intention Tremor Scanning Dysarthria Hypotonia
+/- nausea, vomiting, headache
What else can AICA ischaemia present with?
Deafness
What are you worried about if a pt following a cerebellar stroke becomes drowsy?
Hydrocephalus, repeat CT head, may require surgery
What simple test should you always do for a pt w collapse and neurology?
Glucose
Tx of ischaemic stroke following CT head
IV alteplase within 4.5hrs unless absolute CI of intracerebral or active bleeding
If you miss the timeframe or there’s a CI then IV thrombectomy within 6-24hrs
Plus two wks 200mg aspirin then switch to long term 75mg clopidogrel, statin, lifestyle advice