4th Year Extras Flashcards by Eilidh Selfridge

What investigations should you perform on someone presenting with chest pain

Bloods - troponin, U&E, FBC
ECG
CXR - look for heart size, signs of heart failure
ABG if hypoxic
Might do amylase, d-dimer, echo, CT chest

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What are the main 3 differentials for acute chest pain

Acute Coronary Syndrome -STEMI, NSTEMI etc

Acute Aortic Syndrome - rupture, dissection, penetrating ulcer

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List the immediate treatment for an acute coronary syndrome

MONA + T/C

Morphine + anti-emetic
Oxygen 
Nitrates 
Aspirin 
\+ Ticegralor or Clopidogrel

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How is chronic stable angina managed

With medication - aspirin, statins, b-blocker, GTN

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Reciprocal ST depression on an ECG is suggestive of what

That the STEMI is real

e.g. if ST elevation is present it will often have depression in the opposite leads

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How can BNP be used to diagnose heart failure

If BNP is low it excludes heart failure

If it comes back high the patient should get an echo to confirm

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Which investigations would you do for suspected heart failure

Cardio examination
Basic bloods to check baseline
CXR (not great for diagnosing heart failure itself but can show fluid balance)
ECG
BNP
Can also do MRI and angiogram to determine cause
Cardiopulmonary exercise test - helps assess severity and part of workup for transplant

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List some lifestyle changes that can help in the treatment of heart failure

Weight management
Smoking cessation
Diet - salt and fluid restriction
Exercise - cardiac rehabilitation

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List some of the medical options for heart failure treatment

Conventional medical therapy - loop diuretics (helps with oedema), B-blocker (reduce mortality), ACEi or ARB

Advanced medical therapy - spironolactone, IV iron (makes them feel better), may also add thiazides, digoxin

New therapy - entresto (combination of ARB and another), SGLT2 (diabetes drug)

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List some of the surgical options for heart failure treatment

Pacemakers or implantable defibs

In very advanced cases - intra-aortic balloon pump, LVAD and ECMO (only done pre-transplant in the UK)

Transplants (rare but successful)

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What can cause heart failure

LV systolic dysfunction - most common
Valve disease
Arrhythmia
Ventricular dysfunction

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The generic term heart failure typically refers to what underlying cause

LV systolic dysfunction

This is the most common and where all the research lies

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How does left heart failure present

SOB, PND, orthopnoea, pulmonary oedema (affects the lungs)

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How does right heart failure present

SOB (due to pulmonary hypertension not oedema)
Raised JVP
Peripheral oedema
Palpable liver edge (affects venous system

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How does acute heart failure present

Basically very acute Breathlessness (severe and acute)
Raised JVP
Pink frothy sputum
Extreme sweating
Distress

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What can cause acute heart failure

Post MI
Arrhythmia
Blocked artery
Valvular disease (AS, MR etc.)

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How do you treat acute heart failure

Sit them up
Oxygen,
Diuretics
Morphine for distress
If BP is good give them nitrates and put on CPAP
If BP is not good then they get inotropes and CPAP

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What causes chronic heart failure

Caused by LVSD
This is turn can be caused by hypertension, CAD or IHD and also arrhythmia, myopathy, toxins (alcohol, drugs, radiation, cytotoxic drugs), myocarditis, rheumatic heart disease, sarcoid, malignancy, genetic disorders (DCM)

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What are the main purposes of IV fluids (5 R’s)

Resuscitation 
Replacement 
Routine Maintenance 
Redistribution 
Reassessment

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What is the main difference between a crystalloid and colloid fluid

A colloid is much larger molecules so stays intravascular - increases volume and BP

Crystalloid gets into the cell so helps replenish all compartments

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Which type of fluid is best for resuscitation

Best approached with a crystalloid rather than colloid

Balanced one like Hartmann’s solution or normal crystalloid like 0.9% saline

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What is the issue with giving too much sodium chloride as fluid

Can result in hyperchloremic metabolic acidosis if excessive amounts given
Increased the serum chloride causes a decreases in bicarbonate (both negative charge) in order to maintain electrical balance which in turn causes an acidosis

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What is the one situation in which you would use NaCl for large fluid bolus

Rhabdomyolysis (and AKI/CKD) as there is a risk of hyperkalaemia
Normal saline would be preferred as you don’t want to add more K+

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Where is most of the fluid distributed to when given IV

Study These Flashcards

Majority is intracellular - this is the body’s biggest compartment

What is the purpose of fluid resuscitation

To re-establish haemodynamic stability by restoring intravascular volume

What is the purpose of fluid replacement

Provides daily maintenance requirements and replacement of any ongoing abnormal losses

What types of fluid are best for fluid replacement

Balanced crystalloid like Hartmann's | Normal crystalloid like 0.9% saline

Which fluids are best for routine maintenance

Sodium chloride + dextrose

Describe the typical presentation of cardiac chest pain

Tight and crushing pain | May be caused by MI, angina

Describe the typical presentation of chest pain caused by lung pathology

Sharp pain worse on a deep breath | May be caused by pneumonia, pleurisy, PE

Describe the typical presentation of chest pain caused by GI pathology

Burning pain relieved by food May be caused by reflux oesophagitis or peptic ulcers

Describe the typical presentation of chest pain caused by MSK pathology

Lateral localised chest pain worse on pressing ribs May be caused by strains, fractured ribs or trauma

What is the most common cause of death in the UK

How do you diagnose oesophageal pain

By the characteristic history and confirmed by endoscopy, manometry, PH monitoring or contrast radiology

How do you treat MSK chest pain

NSAIDs | CXR to check for bony pathology

What can cause palpitations

Cardiac arrhythmia Benign rhythm disturbance - ectopic beat Anxiety

What are palpitations

An unpleasant awareness of the heart beat

Bradycardia rarely causes palpitations - true or false

True

How do arrhythmias cause symptoms

Cause palpitations due to irregular beats | May cause symptoms due to limitations of cardiac output, eg breathlessness, tiredness, dizziness and syncope.

A palpitation described as Isolated thumps in the chest suggests what

Ectopic beats

Fast irregular palpitations are suggestive of what

Atrial fibrillation Multiple ectopic beats and atrial flutter are other possibilities.

A fast, regular palpitation of sudden onset suggests what

Supraventricular tachycardia if the patient is young and apparently healthy If the patient has severe coronary disease it is more likely ventricular tachycardia

What factors can trigger arrhythmias or palpitations

Anxiety and stress Exercise - particularly in patients with coronary disease and cardiomyopathies Caffeine, tobacco and alcohol may trigger arrhythmias in susceptible individuals

Anaemia can cause which arrhythmia

Sinus tachycardia | Particularly on slight exertion

Hyperthyroidism can cause which arrhythmia

Tachycardia and supraventricular arrhythmias, | particularly atrial fibrillation

Those with wolf-parkinson white syndrome are pre-disposed to which arrhythmia

Supraventricular | tachycardia

Fever can cause tachycardia - true or false

True | Will subside as temp does

How can you treat palpitations

If sinus tachy or ectopic then reassure If a trigger is identified avoid it If exercise triggers an arrhythmia, consider beta blockade. If a cause is detectable, treat it, eg anaemia, hyperthyroidism If a significance arrhythmias is present, consider prescribing specific antiarrhythmic treatment, eg, DC cardioversion or Digoxin for atrial fibrillation or physical manoeuvres

How can you cardiovert those in AF

DC shock | Intravenous anti-arrhythmic drugs, eg Amiodarone.

Why should those with AF be put on warfarin

To reduce their risk of systemic embolism

The risk of embolism in atrial flutter is less than that of atrial fibrillation - true or false

True

How do you treat supra-ventricular tachycardia

Instruct patient in Valsalva manoeuvre to terminate attacks. If not contra-indicated, give IV Adenosine to terminate attacks. Consider Verapamil or Sotalol for long-term use, but not if Wolff-ParkinsonWhite Syndrome is present. If drug therapy is ineffective, refer ablation of the abnormal electrical circuit via cardiac catheter - curative

What is essential hypertension

High blood pressure for which a cause cannot be found

Renal ultrasounds should be done in which patients with hypertension

Young patients with raised blood pressure and evidence of renal impairment

List cardiovascular causes of collapse

``` Vasovagal episode Stokes Adams attack Postural hypotension, Myocardial infarction Pulmonary embolus ```

List infective causes of collapse

Severe sepsis

List neurological causes of collapse

Epilepsy Cerebrovascular disease Middle ear disease Motor neurone disease

List metabolic causes of collapse

Hypoglycaemia

List haematological causes of collapse

Anaemia

4th Year Extras Flashcards

(59 cards)