VASCULAR MANAGEMENT LESS GOOOO Flashcards
Stroke (Ischaemic)
ACUTE:
1. Airway support
2. BP and glucose monitoring
3. EXCLUDE HAEMORRHAGE with a CT head.
4. If presenting less than 4.5hrs since onset –> thombolyse with IV Alteplase.
If presenting later than 4.5hrs since onset, OR if thrombolysis is contraindicated by HAEMORRHAGE, pul hyptertension, trauma, then skip to 5.
5. Anticoagulate with 300mg of Aspirin. Also give heparin for VTE prophylaxis.
Also swallow asses and GCS assess
6. Rehab.
PREVENTION:
1. RFs
2. 75mg of Aspirin for 14 days, then clopidogrel for life
If they have AF, start on warfarin
3. if needed, carotid endectomy, is the carotid is >70% stenosed
Stoke (haemorrhagic)
BP control, and iV mannitol
TIA
ATHEROSCLEROTIC: 75mg of Aspirin, (or clopidogrel) Also, statins (endectomy) EMOBOLI: Warfarin and/or aspirin (or clopidogrel) Assess TIA risk with ABCD^2
Stable angina
PRIMARY:
Conservative so
1. Lose weight
2. stop smoking
SECONDARY:
DRUUUUGS
GTN –> BB –> CCB is BB is contraindicated –> Long acting nitrate if both of those are contraindicated
But bascially follow MONABASH
ACS
STEMI:
<12 hrs: PCI if it can be done within 2 hrs that a fibrinolysis could have
>12 hrs: Angiography, then PCI if still indicated
Then, see next for more…
NSTEMI/UNSTABLE ANGINA:
Acutely :
- MONA (300 of aspirin and 300 of clopidogrel)
- GRACE:
- High risk = NSTEMI = LMWH + GlpIIb/IIIb (e.g triofiban) –> angiography (within 72 hrs) If they are not planned to have the PCI within 24hrs tho, swap the LMWH for fondaparinux
- Low risk= USA = conservative management and discharge if their 12 hr troponin is negative
ONGOING TX: BASH 1. Beta blockers 2. ACEi 3. Statin 4. NSTEMI: Clopidogrel for 1 year, aspirin for life
Heart Failure
ACUTE:
- Sit up
- Oxygen (target 94-98%)
- IV access and ECG
- Diuretic (Furosemide IV)
- GTN (vasodilator, if angina)
- Analgesia (Morphine 2.5mg but not routine)
CHRONIC:
1. RFs: Weight loss, stop smoking, exercise, reduce salt
2. ACEi (elanapril, rampiril)/ARB
3. BBS (bisoprolol)
4. Diuretics (Aldo ag –> spirinolactone; loop –> furosemide; thiazide–> hydrochlorthiazide)
Other:
5. Hydralazine + nitrates (black people)
6. Digoxin (ionotrope, does not improve survival)
7. Cardiac resync therapy
8. Aspirin
AF
RHYTHM CONTROL:
1. Haemodynamically unstable = DC cardiovert (electrical or chemically w/ fleccanide or amiodarone)
2. Stable = <48 hrs = DC cardiovert
>48 hrs = anticoagulate w/ heparin and warfarin for 3-4 weeks, then cardiovert
RATE:
- BBs
- Digoxin
- CCB: Verapamil
RISK:
- CHADsVASC high = warfarin
- Low = Aspirin or non
Hypertension (essential)
STEP 1: <55/white = ACEi (e.g. rampiril) OR ARB (E.g. losartan)
>55/black = CCB (e.g. amlodipine) OR Thiazide diuretic (e.g. hydrochlorthiazide)
STEP 2: ACEi/ARB + CCB
STEP 3: ACEi + CCB + TZD
STEP 4: Another BB, or alpha blocker, or further diuretic
Hypertension (malignant)
- Labetalol
- Sodium nitroprusside (nicarpadine if raised ICP/renal failure)
- Fenoldepam
Pulmonary Embolism
- Oxygen, analgesia, fluids
- LMWH
- Well’s Score. >4 = CTPA (UNLESS CONTRAINDICATED BY PREGNANCY, THEN DO A V/Q SCAN). Positive? PE.
<=4 D-Dimer. Positive? Do a CTPA. Negative? Not a PE - HAEMODYNAMICALLY UNSTABLE: Thrombolyse with Alteplase, then LMWH and warfarin
HAEMODYNAMICALLY STABLE: LMWH (for 5 days until INR >2) and warfarin
Deep vein thrombosis
- Wells <2 –> D-dimer. Positive? Do USS. Negative? Not DVT. n.b. pregancies have high false positive D dimer rates
>=2 –> USS. Positive? DVT, and repeat in 6-8 days. Negative? Do D-dimer. - LMWH for 5 days
- Warfarin, started within 24hrs, taken for 3 months at least.
Also… - IVC filters (temporarily)
- Thrombolytic therapy (but bleed risk. Only if symptoms for less than 2 weeks, well, and good life expectancy and low bleed risk)
- Thrombectomy
PREVENTION:
- Stop OCP 4 weeks before surgery
- Compression stockings
- LMWH for high risk pts.
Venous Ulcers
Anticogulate basically:
Warfarin + LMWH/heparin/fondaparinux
SVT
STEP 1:
Haemodynamically stable?
- YES: Vasovagal manoeuvres (Carotid body message, blowing against a syringe). Step 2 if it doesn’t work.
- NO: DC Cardioversion
STEP 2: IV Adenosine 6mg –> Iv adenosine 12mg –> IV adenosine 12mg
(n.b 1. Wait 2 mins between adenosines to see if SVT terminates.
n.b. 2. if adenosine contraindicated by asthma, use verapamil 2.5 - 5mg instead. BUT verapamil is contraindicated if the pt is on BBs)
STEP 4:
- IV BB (metoprolol) OR
- IV amiodarone OR
- IV Digoxin OR
- Sync DC cardioversion
Pulseless VT/VF
- CPR (2 mins/5 cycles)
- Defib
- Repeat this once more
- Adrenaline 1mg (every 3-5 mins)
- Defib & CPR & Amiodarone (300mg IV)
If they were stable, just amiodarone
PEA/Asystole
NOT SHOCKABLE SO….
- CPR (2 mins/5 cycles)
- Adrenaline
- Atropine if PEA/Asystole still and <60bpm.
