A+E Flashcards
what are the 3 types of Acute coronary syndrome (ACS)?
Unstable Angina
ST-Elevation Myocardial infarction (STEMI)
Non-ST-elevation MI (NSTEMI)
where do the coronary arteries branch from?
the root of the aorta
what areas of the heart does the right coronary artery supply?
R Atrium
R ventricle
Inferior aspect of L ventricle
Posterior Septal area
what 2 vessels does the Left coronary artery split into?
circumflex artery
Left anterior descending (LAD)
what areas of the heart does the circumflex artery supply?
L atrium
Posterior aspect of L ventricle
curves around top, left and back of heart
what areas of the heart does the LAD supply?
anterior aspect of left ventricle
Anterior aspect of septum
travels down middle of heart
what are 6 presentations of ACS?
Central crushing chest pain radiating to jaw or arm
Nausea and vom
Sweaty and clammy
SOB
Palpitations
feeling of impending doom
How long do symptoms of ACS have to occur to be considered ACS?
> 15 mins at rest
who is at risk of silent MIs?
people with diabetes
what are 2 ECG changes seen in STEMIs?
ST segment elevation
New Left bundle branch block
what are 2 ECG changes seen in NSTEMIs?
ST segment depression
T wave inversion
what are Q waves on ECG and when do they typically appear?
Indicate deep full thickness infarction of heart (transmural)
typically appear >6 hours post symptoms
An infarct in the LCA would cause disruption in which leads?
Anterior and Lateral region =>
I
aVL
V3-6
An infarct in the LAD would cause disruption in which leads?
Septal/Anterior region =>
Leads V1-4
An infarct in the circumflex artery would cause disruption in which leads?
Lateral region
I
aVL
V5-6
An infarct in the RCA would cause disruption in which leads?
Inferior region =>
II
III
aVF
what are 5 conditions other than MI that can cause raised troponin?
CKD
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism
what are 6 investigations for ACS?
ECG
Troponin
Bloods - FBC, U+E, LFT, Lipids, Glucose
CXR - for other cause of CP
Echo - to assess damage
coronary angiogram
what causes a diagnosis of unstable angina?
symptoms of ACS with normal troponin and either a normal ECG or ST depression and T-wave inversion
What is the initial management of ACS?
MONA
Morphine - IV
O2 if low sats
Nitrates - GTN
Aspirin - 300mg
Also perform ECG
what is the management of STEMI?
Percutaneous coronary intervention if available <2 hours since presentation
Thrombolysis - if PCI unavailable - with alteplase, streptokinase or tenecteplase
what is the medical management of NSTEMI?
BATMAN
Base decision for angiography/PCI on GRACE score
Aspirin 300mg stat
Ticagrelor - 180mg stat (clopi if bleed risk, prasugrel if angiography)
Morphine
Antithrombin therapy - fondaparinux
Nitrates - GTN
Oxygen if low sats
what scoring system can be used to asses risk of 6 month mortality in acs?
GRACE score
patients over what GRACE score are considered for angiography with PCI within 72 hours?
3% - medium to high risk
what is the secondary prevention for ACS?
6As
Aspirin 75mg daily for life
Another Anti-platelet - ticagrelor/clopi for 12 months
Atorvostatin 80mg OD
ACEi
Atenolol - or another beta blocker
Aldosterone - for those with clinical heart failure - eplerenone titrated to 50mg OD
what are 5 complications of MI?
DREAD
Death - most commonly due to cardiac arrest
Rupture of heart septum or papillary muscles
Oedema - heart failure
Arythmia and Aneurysm
Dressler’s syndrome and acute pericarditis
what is Dressler’s syndrome?
usually 2-3 weeks after MI
caused by localised immune response that results in inflammation of pericardium causing pericarditis symptoms
How is dresslers syndrome diagnosed?
ECG - ST elevation, T wave inversion
ECHO - pericardial effusion
raised inflammatory markers
what is the management of dresslers syndrome?
NSAIDs
Steroids - if severe
pericardiocentisis may be required with significant pericardia effusion
what are the different types of MI?
ACDC
Type 1: A- ACS type MI
Type 2: C - Cant cope MI - ischaemia secondary to to increased demand or reduced supply of O2
Type 3: D - Dead by MI
Type 4: Caused by us MI - iatrogenic
What is the 3vcriteria for AKI?
Rise in creatinine >25 micromol/L in 48 hours
Rise in creatinine >50% in 7 days
Urine output <0.5ml/Kg/hour in 6 hours
what are 9 risk factors for AKI?
Age >65 years
Sepsis
Chronic kidney disease
Diabetes
Heart failure
Liver disease
Cognitive impairment - reduced fluid intake
Medications - NSAIDs, Gentamicin, diuretics, ACEi
Radiology contrasts - iodine based
what are 3 pre-renal causes of AKI?
Dehydration
Shock
Heart failure
Due to insufficient blood supply - hypoperfusion
what are 5 renal causes of AKI?
Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis
Due to intrinsic disease of kidney
what are 5 post-renal causes of AKI?
Kidney stones
Tumours
strictures
BPH
neurogenic bladder
Due to obstructed outflow leading to back-flow
what is acute tubular necrosis?
damage and death of epithelial cells of the renal tubules due to ischaemia or nephrotoxins
renal epithelial cells can regenerate - recovery usually takes 1-3 weeks
what is the most common renal cause of AKI?
acute tubular necrosis
what is seen on urinalysis in acute tubular necrosis?
muddy brown casts
renal tubular epithelial cell may also be seen
what is the management of aki?
IV fluids
withhold medications that may worsen aki
withhold/adjust medications that are renally excreted
relieve the obstruction
Dialysis
what are 3 ways to avoid aki?
avoid nephrotoxic medications
ensure adequate fluid intake
additional fluids before and after radiocontrast
what are 4 complications of AKI?
Fluid overload, heart failure, pulmonary oedema
hyperkalaemia
metabolic acidosis
uraemia - can lead to encephalopathy an pericarditis
when should people with AKI be referred to urology? (4)
pyonephrosis
obstructed solitary kidney
bilateral upper urinary tract obstruction
complications of AKI caused by urological obstruction
When should people with AKI be referred for dialysis?
Any not responding to medical management:
Hyperkalaemia
metabolic acidosis
symptoms or complications of uraemia
fluid overload pulmonary oedema
what classification system is used in AKI?
KDIGO
What is stage one aki?
creatinine rise >26 micromol in 48 hours
creatinine rise 50-99% from baseline within 7 days
urine output
<0.5ml/Kg/hour over 6 hours
what is stage 2 AKI?
100-199% creatinine rise from baseline within 7 days
Urine output
<0.5ml/kg/hour over 12 hours
what is stage 3 AKI?
> 200% or more creatinine rise in 7 days
creatinine rise to 354 micromol/L or more with acute rise of 26 micromol/L or more within 48 hours or 50% or more rise within 7 days
Urine output <0.3 ml/Kg/hour for 24 hours or anuria for <12 hours
what are 3 unmodifiable risk factors for ACS?
Increasing age - peak incidence 60-70
Male
Fhx
What are 5 modifiable risk factors for acs?
smoking
diabeted mellitus
hypertension
hypercholesterolaemia
obesity
What is the criteria for STEMI?
symptoms >20 mins
>2.5 small squares ST elevation in V2-3 if <40 years or >2 if >40 years MALE
>1.5 small squares in V2-3 in WOMEN
1 small square elevation in any other leads
new LBBB
What is the criteria for PCI in STEMI?
presentation <12 hours since onset of symptoms and PCI available within 120 mins
what is the criteria for thrombolysis in STEMI?
within 12 hours of symptom onset if PCI cannot be given within 120 mins of presentation
what antiplatelets are used prior to PCI?
ASPIRIN +
Parasugrel if patient not on anticoagulant
Clopidogrel if patient is on anticoagulant
what are 5 investigations that can be done for AKI?
Dipstick
Urine MSC
Protein:creatinine if glomerulonephritis suspected
Bloods - U+Es, FBC, CRP, Bone profile, creatinine kinase
USS
Strange bloods - ANA, ANCA, anti-GBM, complement levels, immunoglobulin levels, antistreptolysin O titre, HIV
what 5 medications should be stopped in AKI due to worsening renal function?
NSAIDs
Aminoglycosides
ACEi
ARBs
Diuretics
what 3 medications may need to be stopped in AKI due to increased risk of toxicity?
Metformin
Lithium
Digoxin
what are the 2 shockable rhythms in cardiac arrest?
ventricular tachycardia
Ventricular fibrillation
what are the 2 non-shockable rhythms in cardiac arrest
pulseless electrical activity
Asystole
what is a narrow QRS complex?
<0.12s (or 0.10) - 3 little squares
what are 4 causes of narrow complex tachycardias?
sinus tachycardia
supra ventricular tachycardia
atrial fibrillation
atrial flutter
what are 4 differentials for broad complex tachycardias?
ventricular tachycardia
polymorphic ventricular tachycardia - torsades de pointes
atrial fibrillation with bundle branch block
supra ventricular tachycardia with bundle branch block
what is a broad QRS complex?
> 0.12s - 3 small squares
what classes as sustained VT?
> 30 seconds or requiring intervention due to haemodynamic compromise
what are 3 causes of VT?
Re-entry - due to two conduction pathways usually due to myocardia scaring after MI
Triggered activities - early or late after-depolarisations - torsades de pointes or digoxin toxicity
Abnormal automaticity
what is brugada’s sign?
In ventricular tachycardia
distance from onset QRS to nadir (base) of S-wave >0.1s
What is usually seen in ventricular tachycardia (VT) on ECG? (6)
Broad QRS complexes - >0.12 (usually >0.2s)
Usually uniform (monomorphic)
Brugada’s sign - distance from onset QRS to nadir of S-wave >0.1s
Josephson’s sign - notching near nadir of S wave
RSR’ Complexes - complexes with taller LEFT rabbit ears
Extreme axis deviation - northwest axis
capture or fusion beats
what is josephson’s sign?
In ventricular tachycardia
notching near nadir of S wave
what is the management of ventricular tachycardia?
Unstable - DC cardioversion, then IV amiodarone hydrochloride
Stable - 1 - amiodarone hydrochloride 200mg TDS BO, 5mg/kg over 20-120 mins with ECG monitoring. Max 1.2g/day
flecainide acetate, propafenone hydrochloride. Catheter ablation can be used if indicated and non-urgent
what is torsade de pointes?
ventricular tachycardia with QRS complexes which vary in amplitude axis and duration along with long QT
what should the QT interval be?
Men - QTc should be <440ms
Women - QTc should be <460ms
QTc should not be <350ms
QTc over what increases risk of torsades de pointes?
> 500ms
what is the management of torsades de pointes and polymorphic VT?
IV magnesium sulfate
2g over 10-15 mins
correct underlying cause
defibrillation if VT occurs