Intro Wk: Acute

Question 1

Three components of assessing ACS

Answer 1

Hx

ECG

Troponin

Question 2

Classic cardiac chest pain hx

Answer 2

Retrosternal heaviness, radiates to jaw +/- arm, exertion exacerbates sx, GTN may help, a/w autonomic features

Question 3

ACS RFs

Answer 3

HTN, hyperlipidaemia, diabetes, FHx, smoking

Question 4

Unstable Angina (inc both at rest + crescendo angina)

Answer 4

Hx is vital, no acute ECG findings, normal troponin -> admit for ACS tx + cardio review

Question 5

What is crescendo angina?

Answer 5

Chest pain comes on after shorter and shorter distances of exertion

Question 6

NSTEMI vs STEMI

Answer 6

NSTEMI - mismatch of O2 demand/consumption w some myocardial damage

STEMI - complete blockage of blood flow and transmural damage

There’s an elevated troponin in both

Question 7

NSTEMI

Answer 7

ECG: normal, subtle ST abnormalities, ST depression, inverted T waves

Mx: A-E, cardiac monitor, serial ECGs, admit for ACS tx +/- angiography

Question 8

What is the ACS tx?

Answer 8

1. Load w Dual AntiPl (300mg Aspirin + 300mg Clopidogrel / 180mg Ticagrelol)
2. 2-8d AntiCoag (2.5mg Fundaparinox OD)
3. 1y Dual AntiPl (75mg Aspirin OD + 75mg Clopidogrel OD / 90mg Ticagrelol BD)
4. If they had PCI then after 1y stop the clopidogrel/ticagrelol and persist w lifelong aspirin

Question 9

When should angiography be performed?

Answer 9

Fit individuals within 72hrs

Question 10

STEMI

Answer 10

ECG: ST elevation of 2mm in chest leads/1mm in two consecutive inferior leads, new LBBB, hyperacute T waves

Mx: A-E, PCI <90mins if in capable hospital, PCI <120mins if requires transfer, thrombolysis <30mins if PCI unavailable, plus MONA w/o high flow O2 due to free radicals unless sats are low

Question 11

Which antiemetic doesn’t cause tachycardia?

Answer 11

Metoclopramide

Question 12

The classification of stroke

Answer 12

Ischaemic - lacunar, atherosclerotic, cardiogenic emboli, cryptogenic

Haemorrhagic - SAH + intracerebral

Question 13

The different types of a lacunar stroke

Answer 13

Pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, clumsy hand, silent

Question 14

The vasc territories of the brain

Answer 14

Ant Circulation - ACA, MCA, internal carotid

Post Circulation - PCA, basilar, vertebral

Cerebellum - SCA, AICA, PICA

Question 15

ACA Stroke Syndrome

Answer 15

Contralateral leg > arm paresis or bilateral if both ACAs involved + mild sensory defect, disinhibition, executive dysfunction

Question 16

MCA Stroke Syndromes

Answer 16

Face -> Arm -> Leg Weakness

Left Hemisphere ie dominant - right hemiparesis, sensory loss, homonymous hemianopia + dysarthria, aphasia, apraxia

Right Hemisphere ie non-dominant - left hemiparesis, sensory loss, homonymous hemianopia + dysarthria, neglect of left side, flat affect

Question 17

PCA Stroke Syndromes

Answer 17

Occipital Lobe - contralateral homonymous hemianopia or quadrantanopia + cortical blindness if bilateral lesions

Medial Temp Lobe - deficits in long and short term memory + behaviour alteration

Thalamic - contralateral sensory loss, executive dysfunction, aphasia, memory impairment, dec level of consciousness

Question 18

Where must the infarct be if the patient has a quadrantanopia?

Answer 18

The occipital lobe

Question 19

Which strokes can cause a dec level of consciousness?

Answer 19

Large MCA, thalamic, brainstem

Question 20

Cerebellar Stroke

Answer 20

Dysdiadochokinesis
Ataxia
Nystagmus
Intention Tremor
Scanning Dysarthria
Hypotonia

+/- nausea, vomiting, headache

Question 21

What else can AICA ischaemia present with?

Answer 21

Deafness

Question 22

What are you worried about if a pt following a cerebellar stroke becomes drowsy?

Answer 22

Hydrocephalus, repeat CT head, may require surgery

Question 23

What simple test should you always do for a pt w collapse and neurology?

Answer 23

Glucose

Question 24

Tx of ischaemic stroke following CT head

Answer 24

IV alteplase within 4.5hrs unless absolute CI of intracerebral or active bleeding

If you miss the timeframe or there’s a CI then IV thrombectomy within 6-24hrs

Plus two wks 200mg aspirin then switch to long term 75mg clopidogrel, statin, lifestyle advice

Question 25

What further ix do you do for a pt <65yrs following a stroke?

Answer 25

Prolonged heart recorder looking for AF, bubble echo looking for patent foramen ovale, homocysteine, thrombophilia screen, vasculitic screen, LP, HIV, FHx

Question 26

How do you dx TIA?

Answer 26

They’re having a stroke until all sx/signs revolve within 24hrs w/o tx

Question 27

How long should a pt be assessed by a specialist following a TIA?

Answer 27

Give 300mg aspirin STAT until reviewed within 24hrs

Question 28

What are the red flags for admission following a TIA?

Answer 28

AF, more than one event within last wk, on anticoags

Question 29

What should you do if TIA + AF?

Answer 29

Start anticoag w NOAC on the day

Question 30

What is SIRS?

Answer 30

Systemic inflam response syndrome w >=2: temp >38 or <36, HR >90bpm, RR >20bpm or pCO2 <4.3kPa, WCC >12 or <4 x10^9/L or >10% immature forms

Question 31

Def of sepsis

Answer 31

Life threatening organ dysfunction caused by a dysregulated host response to infection

Question 32

Outline how sepsis is operationalised

Answer 32

Quick sequential organ failure assessment (qSOFA) where 2/3 predicts poor outcome: RR >=22bpm, GCS <15, SBP <=100mmHg Plus just look at the pt: position, exhausted, temp, sweaty, confused, speaking

Question 33

Def of septic shock

Answer 33

Underlying circulatory, cellular +/or metabolic abnormalities are profound enough to substantially inc mortality

Question 34

Outline how shock is operationalised

Answer 34

Persisting hypotenion requiring vasopressors to maintain MAP >=65mmHg Plus lactate >2mmol/L despite adequate fluid resus

Question 35

Each section of the GCS

Answer 35

E4V5M6 Best eye response: spontaneous, to sound, to pressure, none Best verbal response: oriented, confused, words, sounds, none Best motor response: obey commands, localising, withdraws, decorticate, decerebrate, none

Question 36

What’s a quicker way of recording the level of consciousness? And it’s correlation to GCS?

Answer 36

The AVPU Scale Alert - 15, Verbal - 12, Pain - 8, Unresponsive - 3

Question 37

What would be the most likely source of sepsis?

Answer 37

Pneumonia 50% Urinary Tract 20% Abdomen 15% Skin + MSK 10% Endocarditis 1% Device Related 1% Meningitis 1%

Question 38

Sx that might indicate sepsis

Answer 38

Slurred speech or confusion Extreme shivering, muscle pain, fever Passing no urine all day Severe breathlessness It feels like they’re going to die Skin mottled or discoloured

Question 39

Sev Sepsis vs Septic Shock

Answer 39

Sev: evidence of end organ damage and hypotension responds to fluids Shock: evidence of end organ damage w an inc lactate and hypotension refractory to fluids and inotropes requiring ITU management