Tassie Prep Flashcards
-What leads would you see elevation in with a inferior STEMI
- what artery is affected?
- How can you confirm RCA occlusion?
Leads II, III and AVF
The main artery affected would be the right coronary artery.
Less commonly the Left circumflex.
You can confirm RCA occlusion by moving V4 from L) side to right side (in same position) if there’s elevation this will confirm RCA occlusion.
Will All patients present with pain during a STEMI event?
Not all patients will present with pain during a STEMI event, some pt for example, Diabetic, Elderly and atypical presentations may not present with pain.
What is AT standard treatment for ACS
300mg Aspirin
400mcg of GTN at 5min intervals (if BP >100)
Pain relief
- Morphine 0.05mg/kg (max 5mg) per dose, total (max 20mg)
OR
Fentanyl 0.5mcg/kg (Max 50mcg) per dose. total (200mcg).
What are the criteria for SVT
Regular
Narrow QRS complex (<120ms)
Rate >100 (generally >140bpm)
Buried or Absent P waves
How does AT manage AVNRT and AVRT SVT?
Either Asymptomatic or symptomatic manage as per Abdominal modified Valsalva maneuver
ICP may give Adenosine, if ineffective and pt deteriorating then they may Sync Cardioversion.
What is the criteria for VT
Wide QRS > 120 ms (Generally >160ms)
Regular
> 100bpm
No P Waves
What are some unstable signs of VT
- Congestive cardiac failure
- BP <80
- GCS <13
Rapidly deteriorating
What are some signs of Severe Cardiogenic Pulmonary Oedema?
- Hypertension > 160 systolic
- Decreasing GCS
- Dyspnea
- Coarse Crackles on lungs
- Formulating
- Coughing
- Irritability
- Patient may also have pitting Oedema in legs (fluid overload), not all patients with this will be severe APO.
Why do patients respond to GTN with APO
GTN causes
- Venodilation which allows for venous pooling and reduces venous return (reduces preload)
- Ateriodilation reduces systemic vascular resistance and arterial pressure (reduces afterload).
These reduces the pressure in the heart, causing veneo and aterio- dilation, thus reducing hydrostatic pressure which allows for oncotic pressure to push fluid back out of interstitial spaces.
Why do patients with APO respond to CPAP?
CPAP works on both Cardiac and respiratory systems. CPAP increases intrathoracic pressure, which reduces preload by decreasing venous return.
CPAP lowers afterload by increasing the pressure gradient between the left ventricle and the extra-thoracic arteries.
Decrease the systemic venous return and the left ventricular (LV) afterload, thus reducing LV filling pressure and limiting pulmonary edema.
Essentially it causes cardiac vasodilatation, reducing pressure in the heart, this also causes a reduction in hydrostatic pressure (allowing for oncotic pressure to overcome and push fluid out of the interstitial spaces.
Due to CPAP increasing pressure in the lungs it also assists in pushing fluid back out of the alveoli.
What is Tassie Ambulance Management for APO (basal/ Midzone Crackles)
Firstline
- Posture: sit patient upright
- If BP >100 systolic: GTN 400mcg at 5/60 intervals (no max)
Note: if nil improvement treat as per Full field crackles.
What is Tassie Ambulance Management for APO (full field Crackles)
Manage same as Basal/ Midzone crackles
- Provide positioning
- GTN at 400mcg if BP >100 systolic
- Call for ICP backup
ICP
- CPAP
- Potential GTN Infusion.
- Potential administration of frusemide.
Pain Management.
What are the specific indication to give Fentanyl over Morphine.
- Contraindication to Morphine
- Short Duration desirable.
- Hypotension
- Nausea and/ or vomiting.
Notes
Fentanyl should be a drug of choice for trauma pt who have inadequate perfusion.
What is the dosage of Morphine and Fentanyl in the pain management guideline.
Morphine IM or Subcut
- Up to 0.1mg/kg (max single dose 10mg) repeated once after 20 minutes if required.
Morphine IV/IO
- Up to 0.05mg/kg (max 5mg) to a total of 20mg.
Fentanyl IM or Subcut
- Up to 1mcg/kg (max single dose 100mcg) Repeated once after 20 minutes if required
Fentanyl IV/IO
- Up to 0.5 mcg (max of 50mcg/kg), repeat at 5/60 to a total of (200mcg) if required.
Consider reducing narcotic doses for what patient who
- > 65 years old
- Shocked patients
- Frail patients
- Cardiovascular compromised patients
- Underlying lung disease
- Metabolism disorders e.g (kidney or liver)
- Clinical decision making from paramedics.
How do Ambulance Tasmania clinically define Asthma
A combination of variable respiratory symptoms including
1. Wheezing
2 Shortness of breathe
3. Coughing
4. Chest tightness
Asthma is acute and reversible.
How does Ambulance Tasmania treat Mild to Moderate Asthma
Salbutamol pMDI with spacer
- Deliver 12 puffs at 20/60 intervals until resolution.
Or
Nebulize
Salbutamol 5mg in 2.5ml, repeat at 5/60 intervals if required.
How does Ambulance Tasmania treat Severe Asthma
Salbutamol pMDI with spacer
- Deliver 12 puffs at 5-10/60 intervals until resolution.
Ipratromium bromide pMDI with Spacer
- Deliver 8 doses at 20/60 (max 3 repeats)
If pMDI Spacer Unavailable
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat salbutamol
- 5mg in 2.5ml at 5/60 as required
Repeat Atrovent at
- 500mcg at 20/60 intervals (max 3 doses)
Dexamethasone
8mg in 2ml IV, IM or oral.
How does Ambulance Tasmania treat life threatening Asthma
Adrenaline IM
- 500mcg IM at 5/60 as required.
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat salbutamol
- 5mg in 2.5ml at 5/60 as required
Repeat Atrovent at
- 500mcg at 20/60 intervals (max 3 doses)
Dexamethasone
- 8mg in 2ml IV, IM or oral.
Normal Saline
- 20mls/kg
What is Ambulance Tasmania treatment for COPD
Salbutamol pMDI with spacer
- Deliver 8 puffs with 4 breaths repeat 10/60 as required
Ipratropium bromide pMDI with Spacer
- Deliver 4 doses and 4 breathes per dose at 10/60 as required
Or
Nebulize
Salbutamol 5mg in 2.5ml, repeat at 5/60 intervals if required.
If pMDI spacer unavaible or unable to tolerate
Salbutamol Nebulized
- 10mg in 5ml
with
Atrovent
- 500mcg in 1ml
Repeat at 10 minute intervals as required
Dexamethasone
- 8mg in 2ml IV, IM or oral.
Oxygen therapy (nasal prongs)
- titrate to 88-92
If pt deteriorates
- Ventilate at 5-8 ventilations per minute at 7ml/kg.
-Allow for prolonged expiratory phase.
-Gentle lateral chest pressure if required.
Why do we give bronchodilators to patients in Resp distress
Bronchodilators primarily function by relaxing the smooth muscle surrounding the airways, which allows the airways to dilate (widen) and reduce resistance to airflow.
Beta-2 Adrenergic Agonists: Salbutamol
Mechanism: They activate beta-2 adrenergic receptors (beta-2 receptors) located on the smooth muscle cells of the bronchi.
When these receptors are activated by the drug, they stimulate adenylyl cyclase, an enzyme that increases the production of cyclic AMP (cAMP) within the smooth muscle cells.
The increased levels of cAMP activate protein kinase A which then lead to the relaxation of bronchial smooth muscle. This process ultimately dilates the airways and reduces airway resistance.
Atrovent
Mechanism: block the action of acetylcholine (ACh), a neurotransmitter released from parasympathetic nerve endings that typically stimulates muscarinic receptors (M1, M2, M3) on bronchial smooth muscle cells.
When acetylcholine binds to these receptors, it causes the smooth muscle to contract (bronchoconstriction).
By blocking muscarinic receptors, anticholinergics inhibit this bronchoconstrictor effect and promote bronchodilation.
How does Adrenaline Assist with life threatening airway presentations e.g Asthma
Beta-2 Adrenergic Receptor Stimulation:
Adrenaline primarily acts on beta-2 adrenergic receptors located on the smooth muscle cells of the bronchi and bronchioles.
When adrenaline binds to these receptors, it activates a cascade of events that leads to the relaxation of bronchial smooth muscle, causing bronchodilation (widening of the airways).
Vasoconstriction (Alpha-1 Receptor Activation):
-Adrenaline also stimulates alpha-1 adrenergic receptors, which are located on smooth muscle cells in blood vessels.
When these receptors are activated, it causes vasoconstriction, or the narrowing of blood vessels.
This effect is particularly helpful in reducing airway edema (swelling) that can occur during an asthma attack, as vasoconstriction decreases the permeability of blood vessels and limits the leakage of fluid into the tissues, which can worsen inflammation.
Inhibition of Inflammatory Mediators:
-Adrenaline has an indirect effect on inflammatory cells (such as mast cells, eosinophils, and neutrophils) in the airways. It can decrease the release of histamine and other pro-inflammatory mediators that contribute to airway inflammation and bronchoconstriction.
By reducing the release of these inflammatory substances, adrenaline helps to diminish the inflammatory response in the lungs.
Improvement of Mucociliary Clearance:
-Adrenaline can also enhance the function of the mucociliary escalator, the system that clears mucus from the airways. This helps remove excess mucus and reduces obstruction.
Whats the difference between coarse and fine crackles when listening to patients chests.
Fine Crackles:
Typically occur in rapid bursts or intermittent popping sounds during inspiration.
Timing:
Fine crackles are heard late in inspiration (end of the inspiratory phase).
Underlying Causes:
Fine crackles are usually a sign of fluid or inflammation in the alveoli and small airways.
They are often associated with conditions that involve interstitial lung disease, pulmonary fibrosis, or congestive heart failure (especially when there is fluid in the alveoli).
Other conditions include pneumonia, acute respiratory distress syndrome (ARDS), and atelectasis.
Clinical Significance:
- Coarse Crackles:
They have a bubbling, gurgling, or rattling quality.
Coarse crackles can be heard in both inspiration and expiration.
Timing:
Coarse crackles are typically heard early in inspiration but may also be audible during expiration, especially in more severe cases.
Underlying Causes:
Coarse crackles are commonly associated with the larger airways or bronchi and suggest more significant secretions in the airways or larger bronchi.
Common causes include bronchitis, pneumonia, chronic obstructive pulmonary disease (COPD), emphysema, and bronchiectasis.
They can also occur with severe pulmonary edema, where larger airways become filled with fluid.
Why is Glucagon used in Anaphylaxis for patient unresponsive to Adrenaline.
Glucagon can be used in the treatment of anaphylaxis when there is a severe or refractory case of hypotension (low blood pressure) that does not respond to adrenaline. Glucagon may be necessary in certain situations due to some patients taking beta-blockers
- Epinephrine Resistance in Beta-Blocked Patients
Beta-blockers (such as atenolol, metoprolol, or propranolol) are medications that block beta-1 and beta-2 adrenergic receptors, preventing the action of epinephrine and other catecholamines on the heart and smooth muscle. This can blunt the effectiveness of Adrenaline during anaphylaxis, especially in terms of its cardiovascular effects (e.g., increasing heart rate and blood pressure).
In such cases, glucagon becomes useful because it increases heart rate and cardiac output through beta-receptor-independent mechanisms. Specifically, glucagon activates the glucagon receptor, leading to an increase in cyclic AMP (cAMP) inside the cells, which stimulates the heart (positive inotropic and chronotropic effects) and improves vasoconstriction and blood pressure.
Glucagon’s Mechanism of Action in Anaphylaxis
-Glucagon acts on the glucagon receptor, which is distinct from the beta-adrenergic receptors that are typically targeted by adrenaline. This means that glucagon can work even in the presence of beta-blockers or when epinephrine’s effects are diminished or resistant.