Three presentations of unstable angina
1) angina on exertion w/ increasing frequency over a few days, provoked by less exertion (crescendo)
2) angina recurring unpredictably and not specific to exercise
3) unprovoked/prolonged episodes of chest pain
Features to diagnose NSTEMI
1) Symptoms suggestive of MI
2) Troponin release
3) Non-specific ECG abnormalities
Immediate treatment for all acute coronary syndromes
1) Aspirin 300mg
2) Nitrate (GTN or tablet)
3) Morphine
4) O2 if hypoxic
Unstable angina and NSTEMI treatment
Aspirin 300mg
Fonda 2.5mg SC (don’t give if on warfarin DOAC)
GTN
Clopi 300mg
Aspirin 75mg OD
Absolute contraindications to fibrinolysis
Previous haemorrhagic stroke
Stroke or CVA within six months
CNS damage/neoplasm
Active internal bleeding
Aortic dissection
Recent major surgery/trauma
Known bleeding disorder
STEMI downstream treatment
Anti-thrombotic therapy
Beta blocker
ACEi
SGLT-2
Coronary angiography and reprfusion strategies
Non-ACS cardiac causes of arrrest
Structural
Electrical
Life-threatening features of tachycardia
1) Shock
2) Syncope
3) Myocardial ischaemia
4) Severe HF
Tachycardia with life threatening features management
Synchronised DC shock
with appropriate sedation
If unsuccessful amiodarone 300mg IV over 10-200 minutes then repeat shock
Irregular broad QRS causes and treatment
AF w/ BBB - treat as irregular narrow complex
Polymorphic VT -> 2g magnesium over 10 minutes
Regular broad QRS complex causes and management
VT - amiodarone 300mg IV over 10-60 minutes
Very rarely SVT with bundle branch
Regular narrow QRS tachy management
Vagal manoeuvres
Adenosine 6mg rapid to 12 to 18mg with ECG monitoring
If ineffective consider verapamil or BB
Narrow irregular QRS
BB, digoxin if HF, anti-coagulate if over 48hr
Should defib deliver synchronised or unsynchronised shock in an unstable tachyarrythmia?
Synchronised - to avoid shock coinciding with t wave which could lead to VF
Next steps if cardioversion fails after 3 rounds
300mg amiodarone IV over 10-20 minutes then attempt further cardioversion
Treatment for stable patient with broad-complex tachy
Amiodarone 300mg IV over 20-60 minutes
Bradycardia with life threatening signs treatment
Atropine 500mcg IV (up to max 3mg)
Rhythms with increased risk of asystole
Recent asystole
Mobitz II
Complete HB w/ broad QRS
Ventricular pause >3 seconds
Measures further to atropine
Isoprenaline 5mcg min
Adrenaline 2-10mcgs min IV
Transcutaneous pacing - if available do first)
(then transvenous pacing)
Describe what percussion pacing is and when you would use it
Praecordial thump lateral to lower left sternal edge, try harder until find a place that produces repeated ventricular stimulation
Used in bradycardic arrests (only try for a few seconds)
Management of anaphylaxis
0.5mg IM adrenaline
Oxygen
Fluids
If more than two doses refractory - needs ICU
Signs of near fatal asthma
Raised pCO2
Mechanical ventilation with raised inflation pressures
Signs of life-threatening asthma
Altered conscious
Exhaustion
Arrhythmia
Hypotension
Cyanosis
Silent chest
Poor expiratory effort
pEF <33%
Sats <92%
PO2 <8
Normal pCO2
Hyperkalaemia cardiac arrest management
10ml 10% calcium IV
Insulin dex
Give 1 in 10000 adrenaline IV
Soda bic 50mmol
Consider dialysis
