Cardiology Flashcards
(40 cards)
1
Q
Management of acute pulmonary oedema/ congestion?
A
50mg IV furosemide
+ oxygen if hypoxia
+ IV opiate if severe distress
consider inotropic support if SBP <85 or shock
consider GTN infusion if SBP >110
2
Q
Atrial fibrillation initial Ix?
A
- 12-lead ECG: confirm AF and heart rate
- Bloods: FBC, U&Es, Mg2+, LFTs, TSH, Bone group
- Chest X-ray: assess pulmonary congestion/cardiothoracic ratio
- Echo: exclude valvular abnormalities; check LA size & LV function
3
Q
Management of AF
- adverse signs present (reduced LOC, SBP <90, chest pain, heart failure)
- reversible cause treated/ no reversible cause and <24h
- reversible cause treated/ no reversible cause and >24h
- reversible causes persist
A
- get senior help asap
- attempt rhythm control
- attempt rate control
- attempt rate control
4
Q
what does rhythm control in AF involve?
A
Chemical Cardioversion (Amiodarone or Flecainide)
OR
Early DC Cardioversion (Fasted, under sedation or general anaesthetic.) Also an option following unsucessful chemical cardioversion
If unsucessful, try rate control
5
Q
Rate control in AF
- Acute LV failure or marked hypotension present
- not present
A
- oral digoxin
- beta blocker OR CCB e.g. diltiazem. Digoxin 3rd line
6
Q
T/F: long-term thromboprophylaxis should be considered in all patients in atrial fibrillation
A
True - AF increases risk of stroke by up to 5x
7
Q
Need for long-term thromboprophylaxis in AF should be guided by what risk stratification scheme?
A
CHA2DS2-VASc stroke risk stratification scheme
8
Q
T/F: Paroxysmal AF carries a lower stroke risk than permanent or persistent atrial fibrillation
A
false - same risk
9
Q
first line rate control agent for atrial fibrillation? + route
A
beta blockers
- oral in stable patients (bisoprolol)
- IV in unstable patients (metoprolol)
10
Q
suspected ACS immediate management
A
- oxygen, aspirin 300mg
- check obs, secure IV access, obtain bloods
- urgent 12 lead ECG
11
Q
what changes on a 12 lead ECG would warrant referral to ST elevation pathway?
A
- >2mm in 2 chest leads
- >1mm in 2 limb leads
- New / Presumed new LBBB
- True Posterior Myocardial Infarction
12
Q
suspected ACS > no ST elevation on 12-lead ECG > next step?
A
- prescribe dalteparin (LMWH)
- clopidogrel 300mg if ECG changes consistent with ischaemia (ST segment depression/ T-wave inversion)
- HR>65 and SBP>105 add beta blocker
13
Q
secondary prevention following ACS?
A
- statins: all pts with angina/ MI
- ACE inhibitors: all pts with a troponin + event
- beta blockers: all pts with angina/ MI
- aspirin: all pts with IHD
- clopidogrel: in troponin + ACS without ST-elevation (at least 3 months)
14
Q
Ix for suspected ACS?
A
- Routine bloods: FBC, U&E, LFTs, TFTs, Bone group, Cardiac markers, Cholesterol, Lipid profile
- CXR: pulmonary oedema / CTR
- Echo: LV function / valves
- ETT: in Troponin negative patients. If negative at high workload makes angina unlikely
15
Q
Acute on chronic heart failure (existing pulmonary oedema in ACS)
- prescribe IV _____ 50-100mg
- prescribe _____ (in the absence of hypotension or aortic stenosis
- prescribe _____ if acutely SOB
- prescribe _____ s/c OD
- prescribe _____ (reduce dose in elderly)
- prescribe ______
- consider _____
A
- furosemide
- nitrate
- opiate
- LMWH
- ACEI
- spironolactone
- digoxin
NB: pts with severe resp failure, MI, hypotension, significant arrhythmia to be managed in CCU
16
Q
Ix for acute on chronic heart failure (existing pulmonary oedema in ACS) ?
A
- urgent 12-lead ECG
- routine bloods (FBC, U&E, LFTs, TFTs, Bone group, Cardiac markers, Cholesterol, Lipid profile)
- CXR (pulmonary oedema/ CTR)
- echo (LV function/ valvular abnormalities)
- daily weights
- urinary catheter (monitor urine output)
17
Q
what is shock?
A
a state of tissue hypoperfusion relative to the tissues’ metabolic requirements.
18
Q
Shock has classically been divided into which subgroups based on the underlying pathology? (5)
A
- Cardiogenic
- Septic (NHS Tayside Sepsis 6 Bundle)
- Hypovolaemic (Massive Transfusion Policy)
- Anaphylactic
- Neurogenic
Practically, there is either a problem with one or more of the following:
- the pump (cardiogenic) blood volume (e.g. hypovolaemia / haemorrhage),
- blood vessels are too dilated eg sepsis, anaphylaxis, neurogenic).
19
Q
T/F: regardless of the type of shock mortality is high and should be regarded as a medical emergency
A
True - you need to summon senior help immediately, including the possibility of putting out a cardiac arrest call on 2222.
20
Q
clinical presentation in shock?
A
- Tachypnoea
- Tachycardia
- Hypotension (late sign in hypovolaemia)
- Cool peripherally (early anaphylactic, septic and neurogenic shock pts may have warm peripheries due to vasodilatation).
- Oliguria
- Altered conscious level (may only be irritable/ non-compliant due to cerebral hypoperfusion).
21
Q
The mainstay of treatment of any type of shock is maximising what?
A
oxygen delivery to the tissues
22
Q
ABCDE approach in shock
A
- A: check patency (airway maneuvres + 2222 if not)
- B: RR, sats, examine chest. 15L oxygen via non re-breathe mask. ABG if possible.
- C: HR, BP, cap refill. Peripherally cool/warm? IV access (large bore if poss) and bloods: FBC, U&Es, LFTs, lactate, coag screen, G&S (cross match if blood loss suspected cause), blood culture (if sepsis suspected). Fluid resuscitation (except in cardiogenic shock): start with colloid/ crystalloid 250 or 500mls stat. If hypovolaemia secondary to haemorrhage suspected, consider O neg blood whilst waiting for cross matched.
- D: AVPU, BG, pupils
- E: temperature, expose (blood, rash/ wheals, inspect wounds/ drains, urine output (consider catheter)
23
Q
what is cardiogenic shock
A
Hypotension caused by primary pump failure eg post MI, arrhythmia..
24
Q
Cardiogenic shock management
- ABCDE assessment
- Call for senior help
- Urgent Ix: ???
- Pulmonary oedema present: ???
- Pulmonary oedema absent: ???
- Patient will likely require transfer to HDU/CCU/ICU for further management including ??? support
A
- ECG/CXR/ABG/FBC/U&Es/Echo
- IV 50mg furosemide, GTN infusion, CPAP
- Fluid challenge e.g. 250ml stat of colloid
- inotropic
25
Components of sepsis 6?
* Give 3: high flow oxygen, IV antibiotics, IV fluid resuscitation
* Take 3: blood cultures, lactate and FBC, montor accurate hourly urine output
should be delivered within 1 hour
26
what is hypovolaemia shock?
Hypotension secondary to fluid loss, eg. bleeding, severe dehydration.
the hypotension is a late sign, indicating the compensatory tachycardia and peripheral vasoconstriction have ceased to be effective
27
**Hypovolaemic shock management**
* ABCDE
* Ensure high flow oxygen and IV access & ___ \_\_\_ in situ (plus bloods sent)
* Summon appropriate help urgently (e.g. relevant surgeon/medic/gynaecologist +/- anaesthetist)
* If blood loss likely, ensure G&S converted to ___ \_\_\_
* Replace intravascular volume with what?
* Definitive management if bleeding is the cause is likely to be what?
* urinary catheter
* cross match
* fluid – crystalloid, colloid or blood (O negative in emergency).
* theatre or endoscopy
28
what is 'massive transfusion'
replacement of the patient’s total blood volume in less than 24 hours or the acute administration of more than half the patient’s blood volume in less than 3 hours
29
commonest reason to access a shock pack?
ruptured AAA
NB: shock pack = 4units type specific RBCs, 4units FFP and 1 unit platelets
30
**Massive transufion protocol (Major trauma/ vessel rupture/ GI/ other source bleed)**
* Manage ABC, call for help (**who**?)
* Patent airway, high flow oxygen/ 100% FiO2, adequate ventilation
* Large bore IV cannula (x2), **what bloods?**
* IV fluids as indicated, control haemorrhage
* Early surgical intervention as required
* Contact BTS - give clear details of case and degree of urgency
* O neg blood should only be used if cannot wait for type specific
* Activate Massive Transfusion Protocol Request ‘**what** pack’
* senior surgeon & anaesthetist
* Xmatch, FBC, coag screen and fibrinogen, U&E, Ca2+
* shock
31
what is anaphylactic shock?
cardiovascular collapse with shortness of breath, wheeze, urticaria, mucosal angioedema
32
Management of anaphylactic Shock
* ABCDE assessment
* Put out call on \_\_\_\_\_
* Remove \_\_\_\_\_
* 15L oxygen via non re-breathe mask
* Lie patient flat, raise legs
* IV access
* Administer \_\_\_\_\_\_
* Give 5mg nebulised \_\_\_\_\_
* Give 1L 0.9% ____ stat
* Give 20mg _____ slow IV
* Give 300mg _____ IV
* When help has arrived and patient been stabilised consider serum _____ and follow up.
* 2222 (arrest call)
* precipitant eg. infusion of antibiotic
* 500mcg IM adrenaline ASAP (1:1000) to mid-anterolateral thigh (can ask a nurse to do this whilst you get IV access), repeat every 10 minutes if necessary
* salbutamol
* saline
* chlorphenamine
* hydrocortisone
* tryptase
33
**Massive haemorrhage policy**
* call 2222 state 'massive haemorrhage ward X'
* call blood bank state 'massive haemorrhage, pts name and CHI, location and your details'
* urgent samples: **(1)**
* blood bank will issue: **(2)**
* Resuscitate Patient (ABCDE approach). Use emergency blood if required immediately - **what type is this(3)**
* Trauma \< 3 hours - Consider **(4)** 1g
* Aim to control haemorrhage
* Transfuse red cells/ FFP/ platelets
* Use blood warmer
* Consider cell salvage where available
* If bleeding ongoing after initial transfusion Repeat blood samples, Transfuse further **(5)** and **(5)** at a ratio of 2:1 (1:1 in trauma). **(6)** if fibrinogen \<1g/L. Consider further platelets
* When bleeding controlled, notify blood bank to ‘stand down’
1. FBC, coag screen, Fibrinogen, Crossmatch, U&E, Calcium
2. 4 units Red Cells, 4 units FFP, 1 unit platelets
3. O RhD negative
4. Tranexamic acid
5. FBC and FFP
6. Cryoprecipitate
34
what to do if massive haemorrhage patient is on oral anticoagulants
* Stop the drug
* Document timing of last dose of drug
* Assess half life of drug
* administer antidoate if available
* Contact haematologist on call for advice if required
35
**Warfarin**
1. mechanism of action?
2. Monitor how?
3. Reverse how?
1. vitamin K antagonist
2. with INR
3. IV vitamin K 10mg or IV Beriplex
36
**Dabigatran**
1. mechanism of action?
2. Half life 13hrs (80% ___ excretion)
3. Monitor how
4. Contact haematologist on call for advice Reverse with IV \_\_\_\_\_
1. Direct thrombin inhibitor
2. renal
3. thrombin time v sensitive - if normal this indicates that there is a very low level of the drug in the system
4. Idarucizumab
37
**Edoxaban/ Rivaroxaban/ Apixaban**
1. mechanism of action?
2. 65-75% ____ excretion
3. Monitor how
4. antidote?
1. Direct factor Xa inhibitors
2. Hepatic
3. Monitor- send coagulation screen and contact haematologist on call for advice interpreting results
4. No specific antidote available - contact haematologist on call for advice
38
T/F: FFP and cryoprecipitate should not ordinarily be transfused to correct blood coagulation abnormalities in the absence of bleeding, or to reverse effect of warfarin
true
39
**FFP**
1. A source of what?
2. Clinical indications?
1. coagulation factors
2. Massive haemorrhage (RBC: FFP 2:1 or 1:1 in trauma). PT ratio\>1.5 plus clinically significant bleeding PT ratio\>1.5 and pre-procedure
40
**Cryoprecipitate**
1. A source of what?
2. Clinical Indications?
1. fibrinogen
2. Fibrinogen\<1g/L and pre-procedure Fibrinogen\<1g/L and bleeding (\<2g/L in obstetric bleeding
