Cardiac

Question 1

Within what timeframe should a patient with acute chest pain / suspected ACS receive a 12 lead ECG?

How often should ECGs be repeated?

Answer 1

Within 10min of first clinical contact

Serial 12lead ECGs should be obtained every 10-15min until the patient is pain free

Question 2

In which ACS conditions should GTN be used with caution?

Answer 2

GTN and other vasodilators must be used with caution or avoided in settings in which hypotension is likely or could result in serious haemodynamic decompensation, such as right ventricular infarction or severe aortic stenosis

Question 3

In which ACS patients are opioids indicated?

Answer 3

Patients with an unacceptable level of pain that is unresolved with aspirin and GTN (single dose)

Question 4

How does ECG acquisition change in patients with inferior STEMI?

Answer 4

Lead V4R should be obtained to investigate concomitant RV STEMI

Question 5

Fill in the blank:

If symptoms persist after _____ doses of SL GTN, assessment for the need for alternative therapy should be made

Answer 5

3 doses of GTN

Question 6

What treatment do patients with cardiogenic shock require?

Answer 6

Patients with cardiogenic shock will require clinical support for potential treatments which may include inotropes; and should be transported to a facility capable of providing emergency PCI without delay

Question 7

What are the contraindications for GTN (3x)?

Answer 7

GTN contraindicated:
* if recent use of PDE-5 inhibitor drug (commonly for erectile dysfunction or pulmonary arterial hypertension): 24 hrs: sildenafil, vardenafil or avanafil; or 48 hrs: tadalafil
* in hypovolaemic states that cannot be corrected
* if SBP < 100 mmHg

Question 8

What are the side effects of GTN (6x)?

Answer 8

Notable adverse effects include:
* severe headache
* flushing
* palpitations
* orthostatic hypotension (falls risks)
* fainting
* peripheral oedema

Question 9

What is the onset time for GTN?
What is the duration of action?

Answer 9

Onset: almost immediate
Duration: 10-15min

Question 10

What are the contraindications for aspirin (3x)?

Answer 10

• Anaphylaxis/severe allergy to aspirin and NSAIDs
• Severe active bleeding
• Pediatrics (associated with Reyes Syndrome)

Question 11

What is the onset of action time for aspirin?
What are the adverse effects?

Answer 11

Onset: approx 10min
Adverse effects - GI irritation and increased bleeding time

Question 12

What dose of aspirin should be given if patient has already taken aspirin today?

Answer 12

Normal dose: safe if patient has already taken aspirin, another antiplatelet and/or an anticoagulant earlier that day

Question 13

When is fentanyl indicated in ACS?

Answer 13

Indicated when patient has
* severe unresolved pain despite treatment with aspirin and GTN
* GCS 15 or normal GCS
* SBP>= 100mm Hg

Question 14

What are the indications for morphine in ACS (4x)?

Answer 14

Indicated when patient has all of
* severe unresolved pain despite treatment with aspirin and GTN
* GCS 15 or normal GCS
* SBP>= 100mmHG
* fentanyl unavailable or unsuitable

Question 15

What dose of fentanyl may be given in ACS?
Repeat dose/interval?
Max dose

Answer 15

25-50mcg IV (slow push over 1min)
Repeat prn every 5min
Max dose 300mcg

Question 16

What dose of morphine may be given in ACS?
Repeat dose/interval?
Max dose

Answer 16

2.5-5mg IV
Repeat prn every 5min
Max dose 30mg

Question 17

How should ACS treatment be changed if opiates are given?

Answer 17

EtCO2 should be monitored if opiates administered

Question 18

What are the indicators/criteria for cardiogenic shock (3x)?

Answer 18

Patient has:
* presumed cardiac chest pain and
* ischaemic ECG changes and
* SBP < 90 mmHg

Question 19

What treatments should be performed if cardiogenic shock suspected (4x)?

Answer 19

• Request urgent clinical support
• IV access
• Consider posture & prepare for patient deterioration (i.e. pads)
• Rapid transport with notification

Question 20

Which hospital should patients in cardiogenic shock be transported to?

Answer 20

Rapid transport with notification to:

Closest appropriate hospital if:
* without clinical support or
* in regional setting where PCI facility not available or
* patient unstable

PCI capable facility if:
* clinical support present and
* < 60 mins travel time
* Code STEMI notification if applicable

Question 21

What ECG changes indicate a high-risk ACS patient?

Answer 21

ECG features in 2 or more contiguous leads
* ST depression > 0.5 mm or
* transient ST elevation > 0.5 mm

Question 22

What risk factors for ischemic heart disease (i.e. previous medical conditions) indicate a high-risk ACS patient?

Answer 22

Risk factors for ischemic heart disease including
* Diabetes mellitus
* Chronic renal failure
* Previous PCI, AMI, coronary Stent or CABG

Question 23

Where should high-risk/ACS patients be transported?

Answer 23

Transport ‘high-risk chest pain / ACS’ to:

PCI capable facility if < 60 mins travel time

Closest appropriate hospital if:
in regional setting where PCI facility not available or
patient unstable

Question 24

In which patients should the STEMI tool be used?

Answer 24

Patients with all of
* Unresolved chest pain / ACS
* Onset < 12hrs
* Nil trauma

Question 25

What ECG criteria denotes STEMI according to the STEMI tool?

Answer 25

Persistent ST elevation in >=2 contiguous leads in serial ECGs

Question 26

According to the STEMI tool, what constitutes ST elevation?

Answer 26

For normal QRS duration (0.12s) or RBBB
* >=1mm in all leads other than V2-V3

In V2-V3
* >=2mm for men > 40yrs
* >=2.5mm for men < 40yrs
* >1.5mm for all women

Question 27

How is Code STEMI activated?
What if the phone is unanswered?

Answer 27

Phone SA Code Notification line
Select “Code STEMI” and “destination”
State “Code STEMI”, provide ISBAR notification and ETA

If phone unanswered, request notification of PCI team via GRN to ED

Question 28

What are the initial steps in treating acute cardiogenic pulmonary oedema?

Answer 28

Universal care with focus on
* Posture
* Oxygenation
* 12 lead ECG

Question 29

Should clinical support be called for ACPO? What treatments can they provide?

Answer 29

Yes, can perform CPAP and IV GTN