Management

Question 1

Pneumonia

Answer 1

1. Assess CURB 65 for admission:
   * C - Confusion
   * U - Urea > 7 mmol/L
   * R - RR >30
   * B - sBp <=90 OR dBp <=60
   * 65 - Age >65

0-1: low risk

2: Probably admission
3: Admission (Mortality 30-d 22%)

2. Antibiotic: Ceftriaxone

Question 2

Shortness of breath (Cardiac-HF)

Answer 2

1. Non-pharmacotherapy:
   - Daily weight in hospital
   - Sleep in upright position
   - Sodium restriction (2-3 grams per day)
   - Fluid restriction: 1.5-2 L/day
   - Exercise program (e.g, supervised cardiac rehab or aerobic/resistance training)
   - Annual flu shot and pneumococcal vaccine
   - Smoking cessation, restricting alcohol
2. Pharmaco (HFrEF)
   • L -> Furosemide (Lasix)= loop diuretic
   • M -> Morphine
   • N -> Nitrates for dyspnea/angina PRN (contraindic if MI inferior wall)
   • O -> Oxygen
   • P -> Position + Positive airway pressure (CPAP/BiPAP)

• ACE inhibitors*- monitor as above
• Beta-blockers
• Spironolactone= aldosterone antagonist (NYHA class 2-4)
-Monitor serum potassium and renal function
• Digoxin if in sinus rhythm + moderate symptoms despite optimization
-Check digoxin level periodically
• The combination of sacubitril/valsartan (Entresto) is called an angiotensin receptor/neprilysin inhibitor (ARNI)
• New guidelines recommend ARNI for patients with HFrEF who have symptoms that meet NYHA class II or III heart failure

Meds with positive impact on mortality in CHF:

• Spironolactone
• ACE inhibitors
• Beta-blockers
• Systolic dysfunction/Dilated:
  - Diuretics
  - ACE/ARBs
  - BB
  - Spironolactone
  - Digoxin
• Diastolic dysfunction
  - BB
  - Diuretics

Question 3

ACS: STEMI, NSTEMI, Angina

Answer 3

• ABC: 
       -Airway 
       -B: Oxygen and sat
       -C: ASA 160 mg stat, vitals, ECG, 2 IV lines
• IV access, Cardiac monitoring

IF positive for MI:
• M orphine 2-4 mg IV prn
• O 2: 4 L/Min (Only if patient is hypoxic. No benefit if the patient is not hypoxic)
• N itroglycerin: spray SL or TAB SL Given up to 3 times, 5 min interval if there are no contraindications (Cialis or Viagra within the last 24 h, hypotensive, inferior wall infarct)
• ASA 160- 325 mg orally; Ask for any allergy - if ASA is contraindicated give Clopidogrel (Plavix) 75 mg alternatively.
• 2nd Antiplatelet: Clopidogrel, Ticagrelor, Prasugrel (Give to all; STEMI, and Unstable angina which may become NSTEMI)

Adjunctive: BB (if contraind, CCB) and Heparin

Note: For any MI or Angio-> give two different types of Antiplatelet (in which Prasugrel is one of them)

• STEMI: ask about nearest Cath-lab (if > 90 min, thrombolysis)
  - Thrombolysis: within 30 min (in LBBB, ST elev, <12 h chest pain)
  - Contraindications: 2 in hear, 2 recent, 2 in heart
  - Do NOT use: Angina, NSTEMI, ST depression

*NSTEMI: LMW Heparin and Glycoprotein IIb/IIIa inhibitors (Eptifibatide, Abciximab)

LASTLY: ADMIT to ICU or CCU!!! and cardiology consult.