12. Emergency management of ACS,pulmonary oedema, cardiogenuc shock

Question 1

What initial steps should be taken in all patients with suspected ACS?

Answer 1

Brief history and assess for contraindication for PCI, fibrinolysis
ECG
Examination (JVP, pulses, murmurs, HF)
IV access

Question 2

What investigations are done in all patients with ACS?

Answer 2

U&E’s, Troponin, Glucose, Cholesterol, FBC,

CXR

Question 3

What drugs are given for suspected STEMI

Answer 3

Aspirin (300mg)
Tricagrelor (180mg)
Morphine (5-10mg IV)
Oxygen if sats below 95%/breathless/LVF

B-blockers- if stared early then added benefit

Question 4

What drugs are given for suspected NSTEMI

Answer 4

Morphine 5-10mg+ metacloporomide (anti-emetic)
sats<90% low flow oxygen
Nitrates (GTN p/a)
Aspirin 300mg

Question 5

What decides further management for STEMI patients?

Answer 5

PCI available after 120 mins of first medical response?

YES- PCI
NO- Thrombolysis (achieved with tissue plasminogen activators)

Question 6

What decides further management for NSTEMI patients?

Answer 6

Raised troponin, dynamic ST or T wave changes, secondary criteria- invasive pathway

Normal ECG, no more chest pain, no HF- Conservative

Question 7

How do you treat STEMI patients presenting after 12 hours?

Answer 7

Fondaparinaux (anticoagulant)
or enoxaparin (anticoagulant)

Question 8

What is further management in the high risk pathway of NSTEMI’s

Answer 8

Fondaparinaux
Second antiplatelet (tricagrelor or clopidogrel)
IV nitrate if pain continues
Oral B-blockers
Cardiologist review for angiography

Question 9

What further criteria decides which patients are high risk and should receive inpatient coronary angiography

Answer 9

History of unstable angina
ST dperession or widespread T wave inversion
Raised troponin
Age>70 years
General comorbidity, previous MI, poor LV function or DM

Question 10

What further measures should be taken in NSTEMI patients between baseline and discharge?

Answer 10

Wean off GTN
Continue fondaparinux until discharge 
Check serial ECGS's and troponin levels
Address modifiable risk factors
Gentle mobilisation
Ensure patient on dual anti platelet therapy

Question 11

What are the causes of pulmonary oedema?

Answer 11

left sided heart failure
ARDS
Fluid overload
Nuerogenic shock

Question 12

Why is pulmonary oedema tricky to diagnose?

Answer 12

Not much different from Asthma/COPD, pneumonia

If unsure consider treating both with furesomide, salbutamol, diamorphine and amoxicillin

Question 13

If pulmonary oedema is suspected what investigations should be carried out?

Answer 13

ECG
CXR
U&E's, troponin, ABG
Consider ECHO
BNP

Question 14

What emergency treatment should be conducted (before investigations)

Answer 14

Sit patient up
High flow oxygen
IV access
Treat arrhythmia’s

Question 15

What drugs are given in the emergency situaiton?

Answer 15

Diamorphine IV (slowly)
Furosemide 40-80mg (slowly)
GTN (dont give if systolic <90mmHg)

Question 16

What should be done if the patient is worsening?

Answer 16

Further doses of furesomide
Consider CPAP
Increase nitrate infusion without dropping sytolic <100mmHg
Consider alternative diagnosis

Question 17

When is it classes as cardiogenic shock?

Answer 17

when systolic is <100mmHg

Question 18

What management should be undertaken once patients are stable and improving?

Answer 18

Daily weights, aim reduction of 0.5kg/day
Repeat CXR
Change to oral furosemide
If on large doses of loop diuretic consider thiazide diuretic
Is patient suitable for biventricular pacing or cardiac transplantation

Question 19

What is cardiogenic shock and what causes it?

Answer 19

Inadequate perfusion of tissues due to cardiac dysfunction.

MI, arrythmias, PE, Valve destruction

Question 20

What investigations are done for cadiogenic shock?

Answer 20

ECG, 
U&E's, 
troponin, 
ABG
ECHO
CXR
CT thorax

Question 21

What do you monitor in cardiogenic shock?

Answer 21

CVP
BP
ABG
ECG
urine output
12 lead ECG

Question 22

What is meant by cardiac tamponade?

Answer 22

Pericardial fluid collects–> intrapericardial pressure increases–> heart cannot fill–> pumping stops

Question 23

How do you treat cardiac tamponade?

Answer 23

Give O2, monitor ECG adn set up IVI

Take blood for group and save

Question 24

How do you treat cardiogenic shock?

Answer 24

Oxygen (maintain sats)
Diamorphine
Correct arhythmias/abnormalities
Optimise filling pressure

Question 25

What are the two options for optimising filling pressure?

Answer 25

Underfilled-

Give a plasma expander
100ml every 15 mins IV
Aim MAP 70mmHg

Overfilled

Inotropic support
2.5-10mcg/kg/min
Aim MAP 70mmHg

Question 26

What is the final aspect of treating cardiogenic shock?

Answer 26

Look for and treat any reversible cause (MI/PE)

Surgery for acute VSD, mitral or aortic incompetence