Cardiology handbook Flashcards
What is management of NSTEMI?
- Admit CCU for high risk cases*.
- Bed rest with continuous ECG monitoring
- ECG stat and repeat at least daily for 3 days (more frequently in severe cases to look for evolution to MI).
- Serial cardiac injury markers (CK-MB, troponin, myoglobin; depending on availability). Troponin stat (can repeat 3–12 hours later if 1st Troponin is normal)
- CXR, CBP, R/LFT, lipid profile (within 24 hours), aPTT, INR as baseline for heparin Rx.
- Allay anxiety - Explain nature of disease to patient.
- Morphine IV when symptoms are not immediately relieved by
nitrate e.g. Morphine 2–5 mg iv (monitor BP). - Correct any precipitating factors (anaemia, hypoxia,
tachyarrhythmia). - Stool softener & supplemental oxygen for respiratory distress.
- Consult cardiologist to consider GP IIb/IIIa antagonist, IABP, urgent coronary angiogram/revascularisation if refractory to medical therapy
What is specific drug treatment for NSTEMI/unstable angina?
Anti thrombotic therapy:
aspirin
clopidogrel 300-600mg stat, then 75mg faily or ticagrelor 180mg stat, then 90mg BD
LMWH e.g. enoxaparin 1mg/kg sc q12h
Antiischemic therapy
Nitrates: Nitrophol, isosorbide dinitrate, isosorbide dinitrate
B blockers: reduce HR and BP
Metoprolol (betaloc) 25-100mg bd
Atenolol 50-100mg daily
CCB (when B blocker is contraindicated in the absence of clinically significant LV dysfunction): diltiazem, verapamil
Other therapies
Statin: given regardless of baseline LDLc
ACEI: within first 24 hours in the absence of hypotension or contraindications. ARB if intolerant to ACEI
What are high risk features in NSTEMI/untable angina that may warrant early PCI?
Ongoing or recurrent rest pain
Hypotension & APO
Ventricular arrhythmia
ST segment changes 0.1 mV; new bundle branch block Elevated Troponin > 0.1 mg/mL
High Risk Score (TIMI, GRACE)
What are absolute contraindications and relative contraindications for fibrinolytic therapy?
Absolute:
* Previous haemorrhagic stroke at any time, other strokes or CVA within 3 months; except acute ischaemic stroke within 4.5 hours
* Known malignant intracranial neoplasm (primary or metastatic)
* Known structural cerebrovascular lesion (e.g. AV malformation)
* Active bleeding or bleeding diathesis (does not include menses)
* Suspected aortic dissection
* Significant closed head or facial trauma within 3 months Intracranial or intraspinal surgery within 2 months Severe uncontrolled hypertension (unresponsive to emergency therapy)
* For Streptokinase, prior treatment within previous 6 months
Relative:
* Severe uncontrolled hypertension on presentation (blood pressure > 180/110 mmHg) †
* History of chronic, severe, poorly controlled hypertension
* History of prior ischaemic stroke > 3 months or known intracerebral pathology not covered in absolute contraindications
* Traumatic or prolonged (>10min) CPR
* Oral anticoagulant therapy
* Major surgery < 3 weeks
* Noncompressible vascular punctures
* Recent (within 2–4 weeks) internal bleeding Pregnancy
* Active peptic ulcer
What is BLS (basic life support) for CPR?
Determine unresponsiveness
Call for help, defibrillator
Wear PPE
Check for breating and pulse (no more than 10 secs): no normal breathing, has pulse –> provide rescue breathing; 1 breath every 5-6 secs.
No breathing or gasping, no pulse –> start CPR
C: circulation with CPR. Chest compressions at a rate of 100/min to 120/min. At least 2 inches (5cm), avoid excessive depths. CPR 30 compression and 2 breaths
A: Airway: clear airway obstruction –> head tilt chin lift or jaw thrust, insert oropharyngeal airway
B: breathing: bag mask device ventilation with supplementary oxygen, tight seal between face and mask. Cycles of 30 compressions and 2 breaths before advanced airway
D: when defibrillator arrives: check rhythm. If shockable rhythm (VF/ pulseless VT) -> given 1 shock (biphasic 200J, or monophasic 360J), resume CPR immediately until nexdt rhythm check or patient moves
If non shockable rhythm –> continue CPR
What is the ACLS management?
A: place arway devices; intubation if skilled (if not conitneu with bag mask ventilation)
B: confirm and secure airway: maintain ventilation. Confirm corect placement of endotracheal tube by PE (5 point auscultation) and confirmation device
Continous waveform capnography is recommended in addition to physical examination
Once advanced airway in place, give 1 breath every 6 secs with continous chetd compression
C: intravenous access; use monitor to identify rhythm
D: differential dx
Drugs used in resuscitation
Adrenaline 1mg (10ml of 1:10000 solution) q3-5min iv
Lignocaine 1mg/kg iv bolus, then 1-4mg/min infuison
Amiodarone In cardiac arrest due to pulseless VT or VF, 300mg iv bolus, further doses of 150mg iv bolus if required
MgSO4: 1-2g in 10ml D5 iv bolus in torsade de pointes
IV or intraosseous route of drug admin preferrred over endotracheal tube
Tracheal admin of resuscitation medications:
Lignocaine, epinephrine (adrenaline), atropine, narcan (LEAN)
Double dosage
Dilute in 10ml NS or water
Put catheter beyond tip of ET tube
Inject drug solution quickly down ET tube, followed by several quick insufflations
What is the post resuscitation care with return of spontaneous circulation (ROSC)?
- Correct hypoxia with 100% oxygen to maintain oxygen saturation >94%
- Consider advanced airway and waveform capnography
- Do not hyperventilate
- Treat hypotension with volume expander or vasopressor
- Consider treatable causes
- Initiate targeted temperature management in comatose patients
- Treat seizure with anticonvulsants (diazepam or phenytoin)
What is the management of VFib or pulseless ventricular tachycardia?
What is the management of asystole/pulseless electrical activity (PEA)?
Causes (5Hs and 5Ts)
What is the general management of tachycardia with a pulse?
Identify and treat underlying cause
Maintain patent airway; assist breathing
Oxygen (if hypoxemic)
Cardiac monitor to identify rhythm, monitor BP and oximetry
IV access
12 lead ECG
What is the initial management for AFib/A flutter (irregular pulse)?
In WPW syndrpome, AF comp[licating acute illness, impaired cardiac function (EF <40%, CHF)?
- Correct underlying cause: hypoxia, electrolyte disorders, sepsis
- Control of ventricular rate
Diltiazem 0.25mg/kg iv bolus over 2min, then 5-15mg/hr oral maintenance 120-360mg daily (ER)
Verapamil 0.075-0.15mg/kg iv bolus over 2 min, may give additional 10mg after 30 min if no response, than 0.005mg/kg/min infusion. Risk of hypotension, check BP before 2nd dose
Metoprolol: 2-5mg iv bolus over 2 min; up to 3 doses; oral maintenance 25-100mg BD
Amiodarone: 300mg iv over 1 hour, then 10-50mg/hr over 24 hr; oral maintenance 100-200mg daily
Digoxin: 0.25 mg iv with repeat dosing to a maximum of 1.5mg over 24hr; oral maintenance 0.125-0.25mg daily
WPW syndrome with preexcited AF, consider IV procainamide (all AVN blocking agents should be avoided)
AF complicating acute illness e.g. thyrotoxicosis, B blockers and verapamil may be more effective than digoxin
Impaired cardiac function (EF <40%, CHF), use digoxin or amiodarone
What is the anticougulant, termination of arrhythmia, prevention of recurrence for AFib/A flutter (irregular pulse)?
Anticoagulation: unfractionated heparin with maintenance of aPTT 1.5-2 time control or low molecular weight heparin. Long term anticoagulation can be achieved with warfarin with maintenance of PT 2-3 times control (depends on CHA2DS2VASc score general condition.
Termination of arrhythmia: persistent AF, anticoagulate for 3 weeks before conversion and continue for 4 weeks after (delayed cardioversion approach)
Pharmacological conversion
Amiodarone 150mg over 10min then 1mg/min for 6hr than 0.5mg/min for 18 hours or orally 600-800mg daily in divided doses up to 10g, then 200mg daily as maintenance dose
Flecainide 200-300mg orally, preferably given BB or non DHP CCB >30 mins beforehand
Propafenone 450-600mg orally, preferable give BB or or DHP >30 mins beforehand
Procainamide: 15mg/kg iv loading at 20mg/min (max 1g), then 2-6mg/min iv maintenance
Synchronized DC cardioversion
Afib 120-200J and up
Aflutter 50-100J and up
Prevention of recurrence: class 1a, 1c, sotalol, amiodarone or dronedarone
What is management of stable regular narrow complex tachycardia?
What is the management of stable wide complex tachycarida (confirmed SVT, unknown type, confirmed VT)?
What is the management of bradycardia with a pulse?