Y3 - Cardio & ALS Flashcards
How would you manage shockable rhythms?
- first confirm cardiac arrest (10 seconds with cheek over their mouth, watching their chest, feeling their carotid)
- shout for help, call 2222 resuscitation team and defibrillator to …(ward, site)…
- Start CPR = 30:2
- compressions at 5-6cm with hand at middle of lower half of sternum
Defib is here!
- place pads, continue CPR, and then stop for analysis
- Shockable!!! = VT/VF
- Charge to 150J , continue CPR, stand clear, shock
- continue CPR again for 2 mins, analyse
- if still VF/VT then shock again at 240J
- repeat CPR for 2 mins then analyse again
- if still VF/VT, shock for a 3rd time at 360J
- also give adrenaline 1:10000 1mg IV and amidoarone 300mg IV
- Continue compressions for 2 mins then analyse
- Give adrenaline every other cycle now
(not sure about shocks but just range between 120-360 and increase each time)
How would you manage non shockable rhythms?
- same as shockable…confirm cardiac arrest etc
Defib is here
- start cpr 30:2
- give adrenaline 1mg IV/IO asap
- continue cpr 30:2
- check rhythm at 2 mins
- Non shockable!!! pulseless Electrical Activity or Asystole
- Continue cpr 30:2
- recheck rhythm at 2 mins
- give adrenaline 1mg every other cycle
what are the 4 Hs and 4 Ts that could cause reversible cardiac arrest?
Hypoxia
Hypovolaemia
Hypothermia
Hypo/Hyperkalaemia
Tension Pheumo
Toxins
Tamponade
Thrombosis
What is a bradycardia and what is a tachycardia?
bradycardia <60
Tachycardia >100
How would you treat tachycardia in a cardiac arrest?
- Identify any life threatening features (shock, syncope, MI, Severe HF)
- If yes then synchronised DC shock x3
- give 300mg Amiodarone IV if unsuccessful
- then repeat synchronised DC shock
- If no, look at the QRS (broad >0.12s or narrow <0.12s)
Irregular Broad QRS Tachy
- AF with bundle branch block
- BB, anticoagulate
- Polymorphic VT like torsades
- give magnesium infusion
Regular Broad QRS Tachy
- VT = amidoarone 300mg IV
Irregular Narrow QRS Tachy
- AF = BB, anticoagulate
Regular Narrow QRS Tachy
- Vagal manouvres like valsalva or carotid sinus massage
- then adenosine 6mg, then 12mg, then 18mg
- Monitor ECG!!
- Then try Verapamil or BB
Last resort for regular broad/narrow QRS Tachys = synchronised DC shock 3 attempts
How would you manage bradycardia as a peri-arrest rhythm?
- identify life threatening signs (syncope, shock, MI, HF)
- If Yes
- atropine 500mcg IV (can repeat up to 3mg)
- Then isoprenaline or adrenaline IV
- Or Transcutaneous pacing
- ask for expert help
- If No, assess for risk of asystole (recent asystole, mobitz2, complete heart block, ventricular pause >3s)
- If there is risk, start giving atropine/isoprenaline/pacing etc pathway
- If No risk, observe
How would you otherwise treat bradycardia?
Bradycardia is either…
Sinus Node Dysfunction
- sick sinus syndrome, sinus brady in athletes, hypothyroid, BBs, etc
- Manage with dual chamber Pacemaker if symptomatic
or AV Node Dysfunction
- 1st degree heart block (prolonged Pr>0.2s)
- p is normaly 0.12-0.2s
- check their meds are they on digoxin?
- Manage with Pacemaker
- 2nd degree Mobitz 1 (Wenckebach) = elongating pr then drop qrs
- Manage with pacemaker
- 2nd degree mobitz 2 = Prolonged PR then drop qrs
- typically 3:1 or 4:1 ratio
- Manage with isoprenaline or pacemaker
- 3rd degree = no relationship between PR/QRS
- Manage with trascutaneous pacing, isoprenaline infusion/atropine, permanent pacemaker
What are the different kinds of tachycardias? What would you be thinking on an ECG?
Most common tachycardia is AF
Narrow complex Tachycardias QRS<0.12s are Supraventricular
- atrioventricular nodal re-entrant tachy (AVNRT) where re-entry point into atria is AV node
- atrioventricular re-entrant tachy (AVRT) like WPW where re-entry point into atria is an accessory pathway
- atrial tachy where ectopics are generated in atria (not from SA ndoe)
Broad compelx tachycardias QRS>0.12s are Ventricular
How would you manage AF? all the kinds
Paroxysmal AF
- 1st line = bisoprolol pill in pocket approach
- 2nd line = flecanide
- Anticoagulation using CHA2Ds2Vasc and hasbled
- Heparin at initial presentation if no CI
AF
- 24 hour cardiac monitor, prolonged holter monitior, implantable loop recorder
- Cha2ds2vasc and Hasbled
- Unstable = electrical cardioversion + DOAC (rivaroxaban)
- Otherwise just Rate control and Rhythm control
- Rate:
- BB or CCB (diltiazem)
- combine both if not enough
- Rhythm:
- Amidoarone or fleccainide (if structurally normal heart and no IHD)
- or electrical cardioversion
- Rate:
- Long term anticoagulation with DOAC if cha2ds2vasc is 2 or above, or in men with 1 or above
How would you manage supraventricular tachycardia?
Generally…
- valsalva manouvre or carotid sinus massage
-
6mg IV adenosine with NaCl Flush
- then 12mg
- avoid adenosine in asthma, COPD, HF
- 2nd line verapamil
- serious BB interaction!!!
- Cardioversion
WPW = avrt via bundle of kent, D waves on ECG
- Radiofrequency ablation to destroy the pathway
Atrial Flutter = signals rapidly re-enter atria, only some sent to ventricles due to AV node being in refractory period.
- therefore 150bpm ventricular contraction. Sawtooth ECG
- manage with electrical cardioversion
- prevent with amiodarone and radiofrequency ablation
How would you manage ventricular tachycardias?
These are broad based tachycardias
Stable
- amiodarone or sotalol (BB)
- Cardioversion if med doesnt work
Torasdes de Pointes
- polymorphic ventricular tachycardia that happens when QT is prolonged (longer repolarisation of muscle cells after contraction)
- this allows more time for random spontaneous depolarisations to happen prior to repolarisation that spread through the ventricle and cause contractions
- Short term Management =
- Magnesium infusion
- correct causes
- Long term management =
- avoid meds that cause long qt
- Beta blockers (not sotalol)
- Pacemaker or implantable defib
what are some causes of a prolonged QT?
- inherited long qt syndrome
- antipsychotics
- citalopram
- amiodarone
- macrolides
- sotalol
- flecainide
- hypoK, hypoCa, hypoMg
What would you see in a mitral stenosis/mitral regurg patient?
Physical presentation, exam findings, medical hx
Mitral Stenosis
- mitral facies, malar flush, AF, pulmonary HTN, exertional dyspnoea
- causes = RHEUMATIC FEVER
-
Mid Diastolic Murmur heard loudest with bell at apex
- radiates to the axilla
- Snap post S2
- pt lying on L side breath held in exp
Mitral Regurg
- fatigue, rapid HF, pulmonary oedema
- causes = post CAD or MI where papillary muscle ruptures, IE, RHD (uncommon), Marfans/ED
-
Pansystolic Murmur at apex
- radiates to axilla
- quiet S1, S3 heard
How would Aortic stenosis and regurg present?
Aortic stenosis
- Syncope, Angina, Dyspnoea (SAD)
- slow rising pulse
- acquired VWD from shearing RBC
- Causes = degenerative calcification, bicuspid aortic valve (younger)
- Cresc-Decresc Ejection Systolic Murmur
- at Erbs point (parasternal 2nd R ICS)
- radiates to carotids
- absent or soft s2
Aortic Regurg
- Corrigans Sign, Quinkes Sign, Demussets sign, collapsing pulse, wide pulse pressure
- valve disease Causes = rheumatic fever, IE, bicuspid aortic valve
- aortic root damage causes = aortic dissection, HTN, Marfans/ ED
-
Decresc Early Diastolic Murmur right after S2
- lower left sternal edge
How would you manage MS, MR, AS, AR?
MS = percutaneous mitral comissurotomy. Treat AF and anticoagulate
MR =
- acute = nitrates, diuretics, inotropes, intra-aortic balloon pump
- HF = bb, aceI, spironolactone
- valve repair or replacement
AS =
- valvotomy or valve replacement (mechanical = lifelong anticoag)
- do coronary angiogram for atherosclerotic disease if calcification so you can do a CABG too
AR = aortic valve replacement or repair
How would you investigate murmurs?
- transthoracic echocardiogram
- ecg
- cxr eg. LA enlargement in MR
- Bloods for risk factors eg. AS for cholesterol
What are the 3 stages of hypertension?
stage 1 = 140/90
2 = 160/100
severe = 180/100
How would you manage hypertension?
Lifestyle = low salt, stop smoking, lose weight, exercise, low caffeine, fruit and veg
<55
- ACEI or ARB
- A+C/D
- A + C + D
- Resistant htn =
- if K+<4.5 = ACD + Spironolactone
- if K+>4.5 = ACD + alpha/beta blocker
>55 or african
- CCB
- C+A/D
- C+A+D
- Resistant is the same
If diabetic, use ACEI first regardless of age!
How would you manage emergency and urgent htn?
Emergency = lower dbp to 110 within 12 hours
- IV sodium nitroprusside
- iv labetalol
- gtn
- esmolol
Urgent = lower dbp over 72 hours
- amlodipine or diltiazem or lisnopril
- add ACEI/ CCB (nifedipine + amlodipine)
How would you manage pericarditis? How would it present?
- commonly coxsackievirus B
- pleuritic chest pain relieved on leaning forwards
- pericardial rub, tachypnoea, tacycardia
- can have flu like symptoms
Investigations
- saddle st elevation on ecg, pr depression
- normal echo
- CXR = pericardial effusion
- bloods
Management
- ibuprofen or aspirin (+PPI)
- colchicine as adjunct
- restrict physical activity
Complications = tamponade!!! pericardial pericentesis
what are the most common organisms in IE?
- staph aureus is now most common (partcularly in IVDU)
- streptococcus viridans used to be most common (particularly post dental procedure)
-
staphylococcus epidermidis (particularly on indwelling lines and post prosthetic valve surgery)
- then post 2 months of prosthetic valve surgery staph aureus is most common
How would you investigate and manage infective endocarditis?
- Modified Duke Criteria
- positive echocardiogram or new valve regurg
- 3 blood cultures
- Abdominal US for splenic abscess
- ECG
- Urine dip
- Bloods
Management
- Empirical
- Native = amoxicillin +/- gentamicin
- Prosthetic = vancomycin + rifampicin + gentamicin
- Then go by cultures
- potentially surgery to reconstruct or remove infected valve
- prophylaxis amoxicillin for dental (not indicated anymore)
How would you manage pulmonary oedema?
- sit upright and give high flow o2
- diamorphine
- furosemide
- GTN
- CPAP
How would you manage heart failure?
-
furosemide (can add thiazide)
- bumetanide preferred for huuuge oedema
- add ACEI or spironolactone for hypoK
- 1st line = Beta Blockers and ACEI
- 2nd line = spironolactone aldosterone antagonist
- 3rd line = ivabradine, hydralazine in afro, etc
- Annual influenza and one off pneumococcal vaccine
- if IHD/AF/DVT then also aspirin and clopidogrel
- Devices = cardiac resynchronisation pacemaker or implantable cardiac defib
- Statin
What would you see on a CXR with heart failure?
What other key investigations would you do?
- BNP
- echocardiogram
- ecg
CXR
- alveolar oedema
- Kerley B lines
- Cardiomegaly
- Dilated upper lobe vessels
- Pleural effusions
How would you differentiate between the different stages of ACS?
- High sensitivity Troponin (Hs-TnI) on admission then in an hour
- ECG
STEMI
- ST elevation or LBBB
- Troponin >100
NSTEMI
- ST depression, T inversion/flat/normal
- elevated Troponin
Unstable Angina
- ST depression, T inversion/flat/normal
Posterior MI
- ST depression in V1-3
- Dominant R wave
- ST elevation in V5-6
- Troponin elevated
How would you tell the difference between different areas of MIs?
Anterior = left Anterior Descending
Inferior = Right Coronary artery
Lateral = Circumflex artery
How would you manage Stable Angina?
- Sublingual GTN to stop the angina
- Aspirin
- Statin
- BB or CCB (diltiazem)
- increase monotherapy to max dose
- then make dual therapy BB+CCB
- For Dual therapy, use Nifedipine CCB
You can get nitrate tolerance so make sure you take asymmetrical dosing interval to maintain daily nitrate free time fo 10-14 hours
Initial ACS management?
Nstemi, Unstable angina, Stemi
- Aspirin 300mg
- Oxygen if sats <94%
- Morphine only if Severe pain
- +metoclopramide
- Nitrates (sublingual or iv)
*
How would you manage an STEMI?
- dual antiplatelet therapy prior to PCI = aspirin + prasugrel/clopidogrel
-
Percutaneous coronary intervention or fibrinolysis!!!
- fibrinolysis within 12 hours of onset of symptoms if primary PCI cannot be delivered within 120 mins
- do an ECG 60mins after to see if they need further PCI after
- Give an antithrombin drug
- During PCI = unfractionated heparin
How would you manage an NSTEMI/Unstable Angina?
- Fondaparinux antithrombin therapy
- Risk assess with GRACE criteria
- Low risk = aspirin
- Med risk = dual antiplatelets
- High risk = coronary angiography + potentially a PCI
- PCI = unfractionated heparin and dual antiplatelets (aspirin + prasugrel/clopidogrel)
- If they are only having dual antiplatelets and no PCI = ticagrelor for low bleeding risk, clopdiogrel for high bleeding risk
How would you manage ACS long term?
(NICE secondary prevention and rehab)
- regular exercise 20-30 mins a day
- reduce alcohol
- better diet
- lose weight
- stop smoking
Pt who has just had an MI
- ACE Inhibitor
- Aldosterone antagonist like spironolactone for signs of HF or reduced LV ej fraction
- Aspirin (+dual antiplatelets for up to 12 months)
-
Beta Blockers
- if contraindicated, give diltiazem or verapamil
- Statins if evidence of cardiovascular disease
