Y3 - Cardio & ALS Flashcards by Sophia Chan

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)

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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

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what are the 4 Hs and 4 Ts that could cause reversible cardiac arrest?

Hypoxia

Hypovolaemia

Hypothermia

Hypo/Hyperkalaemia

Tension Pheumo

Toxins

Tamponade

Thrombosis

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What is a bradycardia and what is a tachycardia?

bradycardia <60

Tachycardia >100

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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

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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

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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

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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

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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

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
Long term anticoagulation with DOAC if cha2ds2vasc is 2 or above, or in men with 1 or above

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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

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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

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what are some causes of a prolonged QT?

inherited long qt syndrome
antipsychotics
citalopram
amiodarone
macrolides
sotalol
flecainide
hypoK, hypoCa, hypoMg

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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

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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

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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

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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