Emed Invx & Mx Flashcards
(77 cards)
Tachydysrhythmia; unstable patient
- Monitor in high acuity area with continuous cardiac and vitals
monitoring. - Assess responsiveness and pulse. If pulseless, begin CPR.
- ABCs with IV access for drugs.
- Stable vs Unstable (signs of shock such as hypotension).
- Assess for clinical features of severe dysrhythmia. (Chest pain,
diaphoresis, dyspnoea, AMS, cold clammy skin). - 12-lead ECG for evaluation. (Wide vs Narrow complex tachycardia)
Unstable
1. consent sync cardioversion
2. sedation & analgesia
3. O2
4. 100J for Wide complex tachy; 50J for narrow complex tachy
5. reassess
Mx of Atrial flutter & A fib
Check reversible causes:
Infection, AMI, alcohol,
thyrotoxicosis, acute PE, myocarditis.
CHADVASCc score: >2 anticoagulation; HASBLED score risk of bleeding
Rate control:
assess presence of HF;
no HF:
CCBs:
avoid in hypotension or WPW + AF:
1. Dilt 0.25mg/kg IV over 2 min; 15min wait; repeat slow bolus 0.35mg/kg
2. Verapamil 5-10mg IV slow bolus, continuous infusion.
BB: use in thyrotoxicosis
1. Esmolol 500ug/kg IV over 1 minute, infusion 50-200ug/kg/min
2. Metoprolol 2.5-5mg IV slow bolus every 5 minutes up to 15mg
3. Propranolol 1mg IV over 1-minute repeat at 2–3-minute intervals up to 3 doses
AF with HF: Digoxin: 0.25-0.5mg IV;
avoid in WPW + AF
Use in AF + WPW
Procainamide 10-17mg/kg IV at a rate of 20-50mg/min loading dose. Stop if arrhythmia suppressed, hypotension, QRS >50% widened
HFpEF:
CCB or BB
HFrEF:
Amiodarone 150mg IV over 30 minutes then 1mg/min for 6 hours. Avoid in WPW with AF and
ABCD HF drugs.
SVT mx
- Vagal maneuvre:
Valsava; carotid sinus massage - pharm:
6,12,18mg IV adenosine rapid bolus 20ml saline flush; three-way plug ; lifting the IV arm 1-2 miutes in between.
inform impedening doom; transient asystole
Dilt: 0.25mg/kg IV 2min;
15 minutes, repeat slow bolus 0.35mg/kg.
Verapamil: 5-10mg IV slow bolus then continuous infusion
Monomorphic VT
Pulseless ACLS
stable:
1. IV amiodarone 150mg over 15 mins repeated once, 1mg/min infusion for 6 hours. Up to 2.2g
2. IV lid ocaine 1-1.5mg/kg IV infusion 10mg/min. Repeated once
at half the dose, if necessary, after 5 minutes. Up to 3mg/kg
If pharmacology fails, proceed to synchronized cardioversion
Monitor for VFib
TdP mx
- Correct electrolyte abnormalities causing prolonged QT especially
hypoMg and hypoK, hypoCa - IV MgSO4 1-2g over 60-90s then 1-2g/h infusion
Halt any drugs which may cause QT prolongation. (Eg. Procainamide, amiodarone, sotalol, TCAs, macrolides.)
HyperK Mx
ABCs; set 2 large bore IV cannulas.
a. Check potassium levels and ensure it is not pseudohyperkalemia.
- ECG assess
- Stabilize the cardiac membrane.
a. 10% 10ml Calcium gluconate over 10 minutes. - Shift potassium intracellularly.
a. IV Dextrose 50% 40ml over 10 minutes.
b. IV 10 units regular insulin. (Or 6 units in CKD)
c. Sodium bicarbonate if cardiac arrest or peri arrest.
d. Nebulised salbutamol 5mg in 3ml saline over 10 minutes. - Remove potassium from body.
a. PO Resonium A 15g 4-6 hourly
b. PO Zirconium cyclosilicate (Lokelma) 10g TDS up to 2
days, if available in the hospital.
c. Haemodialysis after renal medicine consultation - Prevent further increase in potassium.
a. Review all medications (Use of span K, ACE-Is, Betablockers) and diet (excessive banana consumption)
polymorphic VT
- Amiodarone for chemical cardioversion.
- Look for evidence of ischemia.
- Look out for QTc>500ms or ‘R on T’ phenomenon suggesting
impending TdP development.
Bradyrhythms acute mx
- ABCs and establish IV access.
- Obtain FBC, RP, Cardiac enzymes.
- Attach continuous ECG monitoring and defibrillation pads.
- Assess vitals and take a history and physical exam.
a. Assess for serious signs and symptoms of bradycardia
(CHAPS)
i. Chest pain or breathlessness
ii. Hypotension
iii. AMS
iv. Pulmonary edema
v. Shock
b. IF present then proceed with intervention
c. IF no serious signs and symptoms then type II 2nd degree
HB and complete HB are the ones that need to be closely
monitored and prepared for pacing as they may
deteriorate.
mx of bradyrhythms
1st line:
IV Atropine 0.6mg every 3-5 minutes up to 2.4mg
a. Target is to resolve symptoms and 60-70 BPM.
CI post heart transplant - paradoxical bradycardia; consider theophylline or aminophylline
2nd line
1. IV Dopamine 5-20ug/kg/min infusion
2. IV adrenaline 2-10ug/min infusion
BB or CCB overdose:
IV glucagon + Ca gluconate OR HDIT
3rd line
Transcut pacing
sedation analgesia
60-70bpm
pacer ON ; electrical capture
STEMI equivalents + requiring PCI
Hyperacute T waves
Posterior MI
L MCA Occlusionn
De winter T waves
NSTEMI + VT/VF + cardiogenic shock
Persistent cardiac ischemia despite medical therapy
DW T waves & underlying cause
ST D; V1-6; J point up sloping
tall symmetrical T waves
no ST elevation
acute occlusion of Prox LAD
Left Main CA occlusion features
ST D; >1mm 6 leads; esp inferior leads
Max ST dep in I,II, v4-6
aVR STE reciprocal elevation – dx from prox LAD
PCI
Wellens syndrome
angina;
v2-v4 LAD T wave inversion
LAD critical stenosis
high risk of anterior AMI
Brugada; ECG findings; syndrome diagonosis
inherited dz
RBBB + ST elevations V1-3
ST segment - convex or coved
J pt elevation
no ST depression
prolonged PR interval
Syndrome
documented VT or VF
fmhx sudden cadiac death <45
no struc heart disease
syncope of unknown
treat implantable defib
ST depression ddx
Ischemia
posterior STEMI (inferoposterior or isolated posterior)
LMCA occlusion
DW T wave - LAD occlusion
Severe hypoK
ACS acute mx
- ABCs IV
FBC, RP, trops (UA or STEMINSTEMI) - hx
- ECG; hypocount, CXR
- DAPT: PO aspirin 300 + 180mgtica/600clopidogrel (low risk NSTEMI)
- SL GTN + nitroderm 5mg;
persistent pain IV GTN 5-10ug/min
CI: RV infarct (inferior STEMI),
severe AS, PDEs (erectile)
a. IV fentanyl pain relief
- Cath lab activation
Acute HF mx
ADHF; cardiogenic APO; cardiogenic shock; hypertensive AHF; high output HF; isolated RHF
ABC IV;
FBC,RP,T
ECG
Upright
NIV CPAP
CXR
POCUS - EF, B lines on US - interstitial edema
US Of IVC
Pharm:
lower preload & afterload
GTN
2nd line: ACEi (E, Cpril)
3rd line: Diuretics (f)
RV infarct mx
no GTN
IV fluid challenge 100-200ml;5-10min
inotropic support
avoid morphine - increased mortality
DAPT A300, T180mg
PCI
HTN emergency mx
confirm HTN
ABCs, IV, clsely monitor
ECG, Dipstick (proteinuria, hematuria), UPT
FBC, RP, Trops, LFT (PreE)
CXR (widened mediastinum), CT brain
monitor, ECG SpO2, vitals q5-10
Ischemic stroke
HTN Enceph, APO, AMI, AKI, AD, PreE
IV labetolol, prop, esm, GTN, Nitroprusside, hydralazine, enealpril
Admit ICU Gen Med
A dissection mx;
common features
P1, vitals, ECG, SpO2
ABCs, IV
ECG (AMI), 2DE (widened AR>3cm)
FBC,RP, PT/PTT, GXM 4-6u, T
CXR, CT aortogram
infuse NS slowly
Observe chart: circulation, neruo
Aim: lower rate of B rise, mean BP, HR
SBP 100-120, UO>30ml/hr
IV labetalol 2-8mg/min rep 10min max 300mg 0.5-2mg/min, IV esm, IV prop
+ IV GTN 5-200ug/min, nicardipine, nitroprusside
IV morphine
Admit CT ICU
surgical repair be
Stanford A, B w complicatins, uncontrollable HTN, dissection
features:
Neuro (TIA, stroke, paraplegia)
BP diffeence >20mmHg between arms; LL BP<UL BP
Pain + AR murmur
ILEAD Pain
Inf MI
Ischemia - renal, spinal cord, mesenteric
GU cx - renal colic
AAA mx
ABCs, IV, BP 90-100
US >3cm AA diamter; FAST scan rupture
FBC, RP, PT/PTT, ABG, GXM 6u
CT aortogram CXR
p1; continuous monitoring ECG, SpO2, vitals
Surgery;
ruptured emergency repair
sx non ruptured – urgent
<5.5 asx - conservative
TEVAR stenting or open aneurysm
Pulm Embolism
signs; pleuritic CP, SOB, bloody sputum; syncope;
assesment
a. Sinus tachycardia.
b. Right heart strain pattern (T wave inversion V1-4,
R AxisD, S wave in I and aVL, P pulmonale,
c. RBBB
d. S1Q3T3
POCUS - D septum, RV enlargement; fixed dilated IVC
XR - normal; hamptons hump, fleischner sign, westermark
Ven compression US DVT
CTPA
PERC/Well’s – D dimer vs CTPA
Trop PBNP
Massive - arrest; pulseness; SBP<90
a. thrombolysis rTPA; thrombectomy embolectomy; IV heparin anticoag
Submassive - stable; RV injury Trops, PBNP>600, RV/LV>0.9
a. IV hep / SC LMWH
Low risk
DOACs
Asthma mx
Severity
Mild PEF>50, activity limitation, >90%, <120, phrases sentences
Moderate <50, rest, words, accessory muscle, <90& Sp,
Severe <25, unable to talk, mental status, cyanoiss, absent breath sound, bradycardia
RSI: drowsiness, confusion, silent chest, imminent respi collapse
Mild/moderate
a. 1ml (5mg) Salbutamol: 2ml Ipratropium bromide: 2ml normal saline nebulization
b. PO Prednisolone 0.5-1mg/kg up to 50mg or IV 100mg hydrocortisone.
c. O2 - SpO2 @ 93-95%
Unresponse:
i. MgSO4 1-2g/30 min
ii. rep neb
iii. admit EDTU
Severe
a. Salb 1:2:2, PO Pred, IV hydrocort
b. High flow O2
c. serial ABG
still in RD
ICU, CXR(PTX, infection, CCF)
Life threatening asthma
High flow O2;
Monitor ECG, SpO2, vitals every q5 minutes.
Serial ABGs
RSI
Well response
Discharge; TCU 48h
med compliance
ICS + 5-7 days oral corticosteroids
COPD
respiratory distress, hypercarbia, or imminent respiratory failure
a. continuous monitoring of vitals, SpO2, ECG.
CXR - pneumonia PTX
ABGs after 2 nebs
FBC, RP
Airway:
a. Supplemental low-flow oxygen @SpO2 at 88-92%.
b. Non-invasive ventilation (BiPAP)
c. judicious fluids
Bronchodilation
Sal, Ip, Pred, Hydrocort
No MgSO4
Abx - anthonisen criterai >2 (SOB, Sput vol, Purulent) ; signs of pneumonia or CXR consol
Aug, A Cythromycin, Cefuroxime, Levoflx
Disposition
