Week 4: Cardiology (1) (ABCDE, cardiac pain, symptom based approach)

Question 1

chest pain can be

Answer 1

cardiac or non cardiac

Question 2

cardiac pain

Answer 2

• Diffuse
• Crushing
• Radiates to neck and arm
• Associated with feeling unwell
• Worse on activity

Question 3

non-cardiac pain

Answer 3

• Focal
• Sharp
• Precipitated with breathing
• Improves on rest

Question 4

example of cardiac pain

Answer 4

 Angina
 Unstable angina
 MI
 Aortic dissection
 Pericarditis

Question 5

example of non cardiac pain

Answer 5

• MSK
• PE
• Pneumonia
• GORD
• Gall stones

Question 6

presentation of gall stones

Answer 6

• 40 year old female
• Dull right lower chest pain radiating to shoulder tip
• Started 3 days ago
• Approx. 2 hours after meal
• Nausea, vomiting and fever
• Eats fatty food, excess etoh, obese

Question 7

aortic dissection presentation

Answer 7

• Sudden onset (always thing AD)
• 10/10 tearing chest pain radiating to back
• Syncope, pallor, clammy
• Previous HTN, smoker, connective tissue disorder

Question 8

angina presentation

Answer 8

• Gradual onset central dull chest pain induced by exercise and relived by rest
• Past history HTN, smoker, DM, hyperchol, obese

Question 9

pulmonary embolism presentation

Answer 9

• Sudden onset sharp localised chest pain and SOB
• Worse on inspiration and coughing
• Haemoptysis
• Past history recent surgery, smoker, take OCP

Question 10

MSK presentation

Answer 10

• Localised sharp chest pain worse on movement and breathing
• Better with NSAIDS
• Manual job difficult to do

Question 11

MI presentation

Answer 11

• Gradual onset severe crushing central chest pain started 45 minutes ago
• Radiating to left arm
• Sweaty and nauseous
• Known hypertension and diabetes
• Smoker

Question 12

pericarditis presentation

Answer 12

• Retrosternal sharp stabbing chest pain radiating to shoulder and neck
• Fever
• Worse on inspiration and coughing
• Relieved by sitting forward
• SOB

Question 13

GORD presentation

Answer 13

• Retrosternal chest pain radiating to the neck
• Worse after food and lying down after meal
• Takes NSAIDs for arthritis
• Better with antacids
• Smoker, excess etoh, pregnant

Question 14

important to remember about ABCDE

Answer 14

tackle problems as you find them before moving onto the next category

• systematic method
  *

Question 15

airway

Answer 15

• Is the airway patent>
  
  • Yes
    
    • ‘Hi Mr X- I’ve been told you have come in with chest pain- are you okay?’
    • If they are speaking airway patent
    • Check inside mouth
    • Move onto breathing
  • No
    
    • Look for signs of airway compromise: cyanosis, use of accessory muscles, diminished breath sounds and added sounds
    • Open mouth and inspect e.g. secretions or foreign objects
      
      • Foreign bodies
      • Blood in airway
      • Vomit/secretions in airway
      • Soft tissue swelling e.g. angioedema
      • Laryngospasms
      • Depressed levels of consciousness
• Interventions
  
  • Seek immediate support from anaesthetist and crash team
  • Head tilt chin-lift
  • Jaw thrust
  • Airway
    
    • Oropharyngeal airway (guedel)
    • Nasopharyngeal airway
  • CPR
  • If anaphylaxis give adrenaline stat
  • Reassess patient

Question 16

breathing

Answer 16

• What does the patients breathing look like e.g. breathing fast or quite heavily (12-20bpm)
  
  • Bradpnoea
    
    • Sedation
    • Opioid toicity
    • Raised ICP
    • Exhaustion in airway obstructions
  • Tachypnoea
    
    • Airway obstruction
    • Asthma
    • Pneumonia
    • PE
    • Pneumothroax
    • Heart failure
    • anxiety
• Sats
  
  • On oxygen?
  • Normal Sp 94-98% (88-92% in COPD patients- risk of CO2 retention
  • Hypoxaemia causes
    
    • PE
    • Aspiration
    • COPD
    • Asthma
    • Pulmonary oedema)
• General inspection
  
  • Cyanosis
    
    • Bluish discoloration of the skin
    • Report sats
  • SoB
    
    • Nasal flaring
    • Pursed lips
    • Accessory muscles
    • Inability to speak in full sentences
  • Cough
    
    • Productive?
      
      • Pneumonia
      • Bronchiectasis
      • COPD
      • CF
    • Dry?
      
      • Asthma
      • ILD
  • Stridors
    
    • High pitched
    • Turbulent airflow through narrowed upper airway
  • Cheyne-strokes respiration
  • Kussmauls respiration
  • Pull down garment and percuss the chest x6 down chest and at the axilla
• Tracheal position
  
  • Deviates away: T. pneumo and pleural effusion
  • Deviates towards: lopar collapse
• Chest expansion
  
  • Symmetrical: PF
  • Asymmetrical
    
    • Pneumothorax
    • Pneumonia
    • Pleural effusion
    • • Percussion
  • Dullness- increased tissue density (consolidation, tumour, lobar collapse
  • Stony dullness- pleural effusion
  • Hyper-resonance- pneumothorax
• Auscultate
  
  • Bronchial breathing- consolidation
  • Reduced breath sounds reduced air entry e.g. pleural effusion and pneumothorax
  • Wheeze- continuous, coardse, whistling sound produced in the resp airway (asthma, COPD, bronchiectasis)
  • Stridor
  • Coarse crackles- discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and pulmonary oedema.
  • Fine end-inspiraotry crackles- Velcro – PF
• Interventions
  
  • Oxygen
  • CPR
  • Acute severe asthma
    
    • Oxygen
    • Salbutamol
    • ICS
    • Ipratropium bromide
    • Aminophylline (magnesium sulphate)
  • Acute exacerbation of COPD
    
    • Oxygen
    • Nebuliser
    • Steroids
    • Antibiotics
  • Pneumonia
    
    • Oxygen
    • Antibiotics
  • Pneumothorax
    
    • If haemodynamically unstable decompress

Question 17

circulation

Answer 17

• Patients hand temp
  
  • Cool hands= poor peripheral perfsuon
  • Cool and sweaty- ACs
• Capillary refill (should be less than <2s)
• Radial pulse
  
  • Rate (60-99)
    
    • Tachy
      
      • Hypovolaemia
      • Arrhythmia
      • Infection
      • Hypoglycaemia
      • Thyrotoxicosis
      • Anxiety
      • Pain
      • Drugs e.g. SABA
    • Brady
      
      • ACS
      • IHD
      • Electrolyte abnormality
      • drugs
  • Character e.g. bounding
    
    • An irregular pulse is associated with arrhythmias such as atrial fibrillation.
    • A slow-rising pulse is associated with aortic stenosis.
    • A pounding pulse is associated with aortic regurgitation as well as CO₂ retention.
    • A thready pulse is associated with intravascular hypovolaemia (e.g. sepsis).
• Brachial pulse
• Blood pressure
  
  • Hypertension
    
    • Hypervolaemia
    • Stroke
    • Conns syndrome
    • Cushins
    • Pre-eclampia
    • Sever hypertension: confusion, drowsiness, breathlessness, chest pain, visual distrubances
  • Hypotension
    
    • Hypovolameia
    • Sepsis
    • Adrenal crisis
    • Opioids
    • Antihypertensives
    • Diuretics
  • General inspection
    
    • Pallor
    • Oedema (pedal or ascitic)
• JVP raised?
  
  • Right sided heart failure (pulmonary hypertension)
  • Tricuspid regurc
  • Constrictive pericarditis
• Listen to the heart
  
  • Where
    
    • Aortic (right 2^nd intercostal space)
    • Physicians (left 2^nd intercostal space)
    • Tricuspid (left 4^th intercostal sternal border)
    • Mitral (left 5^th intercostal, midclavicular line
  • Character
• An ejection systolic murmur is associated with aortic stenosis.
• An early diastolic murmur is associated with aortic regurgitation.
• A mid-diastolic murmur is associated with mitral stenosis.
• A pan-systolic murmur is associated with mitral regurgitation.
• A murmur of recent onset may suggest recent myocardial infarction (e.g. papillary muscle rupture) or endocarditis.
• A pericardial rub or muffled heart sounds may indicate underlying pericarditis.
• A third heart sound is typically associated with congestive heart failure.
• Look ankles and sacrum oedema- HF
• Investigations
  
  • Intravenous cannulation
    
    • Sepsis: CRP, lactate and blood cultures
    • Haemorrhage: coagulation
    • ACS: troponin
    • Arrhythmia: calcium, magnesium, phosphate, TFTs, coagulation
    • PE: D-dimer (using Wells score)
    • Overdose: toxicology screen
    • Anaphylaxis: serial mast cell tryptase levels
  • 12-lead ECG and review
  • Fluid output/catherization
    
    • Strict fluid balance
• Interventions
  
  • Hypovolaemia: fluid rescuss
    
    • 500ml bolus HArtmanns or 0.9% sodium cholodire) over 15 mins
    • 250 boluses in patients at increased risk of fluid overload (HF)
    • Repeat admin of boluses up to four times (2000ml or 1000ml in pts at increased risk of fluid overload)
  • CPR
  • ACS
    
    • Morphine
    • Oxygen
    • Nitrates
    • Aspirin, clopidogrel
  • Sepsis
    
    • Oxygen
    • Blood cultures
    • IV antibiotics
    • IV fluid
    • Serial lactates
    • Ongoing monitoring urine output
  • Haemorrhage
    
    • Fluid recuss
  • Fluid overload
    
    • Diuretics- furosemide
  • AF
    
    • Cardioversion (in people with life-threatening haemodynamic instability cauded by new-onset atrial fibrillation)
      
      • Flecaiaide, amiodarone
      • Or electrical
    • Rate control: beta blockers and diltiazem/ verapamil (CCB)
    • Anticoagulation (CHA2DS2-VASc and HAS BLED
      
      • DOAC
      • warfarin

Question 18

Disability

Answer 18

• Consciousness (hypovolaemia, hypoxia, hypercapnia, hypoglycaemia, seizure, rICP, drugs, iatrogenic causes, DKA )
  
  • Alert: fully alert
  • Verbal: patient responds when you talk (words, grunt)
  • Pain: patient responds to painful stimulus (supraorbital pressure)
  • Unresponsive: no evidence of any eye, voice or motor responses
• Check BM and ketones
• Pupil dilation
  
  • Size and symmetry
    
    • Pinpoint- opioid (naloxone)
    • Asymmetrical- stroke, SOL, rICP
  • Assess direct and consensual pupillary responses
• Imaging e.g. for head ijury
• Interventions
  
  • Opioid toxicity- naloxone
  • Hypoglycaemia- glucose
  • DKA
    
    • fixed rate insulin infusion
    • glucose infusion (after initial insulin therapy)
    • potassium infusion to prevent hypokalaemia)

Question 19

Exposure

Answer 19

• Inspection
  
  • Rashes
  • Bruising
  • Infection
  • Assess patients calves for erythema, swelling and tenderness (DVT)
  • Catheter output
• Bleeding
• Temperature (36-37.9)
  
  • >38 = infection
  • <36 – sepsis or cold exposure
• Investigations
  
  • Cultures and swabs
• Intervention
  
  • Haemorrhage- consider blood products (large bore intravenous access)
  • Infection- sepsis 6
  • DVT- Wells score and commence anticoagulation (heparinsation
  • CPR

Question 20

NEXT STEP after abcde

Answer 20

• History

Question 21

what to remember with ABCDE

Answer 21

Remember

• Critically ill patients should have continuous monitoring equipment attached for accurate obs
• Call for help early using appropriate SBAR handover
• Review results
• Use local guidelines and algorithms
• Any medication or fluids will need to be prescribed at the time

Question 22

SBAR

Answer 22

situation

background

assessment

recommendations

Question 23

differentials for acute cardiac presentation

Answer 23

1. severe pulmonary oedema
2. MI
3. arrhythmia
4. pericardial disease with effusion

Question 24

differentials for chronic cardiac presentation

Answer 24

• LV dysfunction
• Valvular heart disease
• Arrhythmia
• Pericardial disease
• CAD

Question 25

great way to come up with diagnosis

Answer 25

Question 26

autonimic synptoms related to inschaemia

Answer 26

sweating, N and V

Question 27

define syncope

Answer 27

• Spontaneous and transient loss of consciousness and postural tone caused by insufficient blood supply to the brain
• Reflex syncope- vasovagal/situational
• Cardiac syncope- arrhythmias, structural heart disease
• CSH: syncope associated with head turning, shaving, tight collars and neck extension

Question 28

syncope history taking

Answer 28

• Use open questions
  Actively listen to what patient is saying and repeat back to him/her avoid abbreviations and jargon
• Give patient time to recall events and what they were doing before note down all dates and times.
• Trauma especially facial injuries suggest syncope as patient failed to use arm to protect themselves
• WITNESS ACCOUNTS
• Demonstrate empathy

Question 29

3 Ps of syncope

Answer 29

posture (standing for long periods before LOC)

provoking factors (pain, needles, medical procedure, hot day, no food)

prodromals (feeling hot/flushed or sweating)

Question 30

Cardiac red flags for syncope

Answer 30

• Normal 12 lead ECG
• HF
• New or unexplained SOB
• A heart murmur
• >65 yrs old with TLOC without prodrome
• Structural heart disease
• FHx SCD, 40 years
• TLOC (transient loss of consciousness) during exercise

Question 31

palpitations hisotry

Answer 31

• Gradual or sudden onset/offset
• Duration
• Timing : exercise/rest
• Associated symptoms
  
  • Syncope
  • Chest pain
  • SOB
  • polyuria

Question 32

SOB

Answer 32

• A subjective experience of breathing discomfort
• that is comprised of qualitatively distinct sensations*
• that vary in intensity*
• The experience derives from interactions among multiple Physiological, psychological, social and environmental factors

Question 33

history taking SOB

Answer 33

• DURATION
• Speed of Onset acute vs chronic
• Precipitating events
  
  • Palpitations
  • Chest pain
  • Exercise
• Quantify
• Associated symptoms
  
  • Cough
  • Palpitations
  • PND
  • Orthopnoea
  • Chest pain
  • SOA
  • Tiredness and fatigability
• Other Hx
  
  • Smoking Hx
  • occupational HX
  • previous cardiac hx and risk fa tors
  • E.g. MI, CAD, DM, HT, Chol
  • FHx
  • Rheumatic fever