STEMI management? when to give O2? when to give nitrates ?
all pts if not contraindication:
- IV Morphine 5-10mg
- O2 if sats <94%
- NItrates-SL/IV (given for pain +HTN, do not give if hypotensive)
- Aspirin 300mg
- Ticagrelor/ prasugrel (if PCI)
If PCI:
- Unfractionated heparin
- Glycoprotein IIb/IIIa inhibitor
Definitive
- PCI (if available in 120 mins + pt present within 12 hrs)
- if no PCI available- thrombolysis (tissue plasminogen activator (tPA))
NSTEMI/unstable angina management? when to give O2?
all pts if no contraindication:
- O2 if sats <94%
- IV Morphine 5-10mg
- Nitrates-SL/IV
- Aspirin 300mg
- Fondaparinux if no PCI planned
Pts who are unstable (immediate) or GRACE score >3% (within 72hrs)-> coronary angio ->PCI
- Ticagrelor/ prasugrel
- Unfractionated heparin
<=3% risk
- ticagrelor
what is the GRACE score used for
NSTEMMI/ unstable angina to workout 6 month mortality risk
>3% is high risk
MI secondary prevention
DABS:
dual antiplatelet therapy (aspirin lifelong + prasugrel/ticagrelor 12 months)
ACE inhibitor
beta-blocker
statin
lifestyle advice
which stemi pts are considered for PCI
. If patient presents within 12 hours of the symptomatic onset
. If PCI is available within 120 minutes, otherwise consider fibrinolysis
. Patients with ongoing ischaemia after 12 hours may be considered for PCI
Mx of AF
Presents in 48hrs from onset
- rate control or rhythm control (Cardioversion- pharmacological or electrical)
Presents >48 hrs - only rate control
rate control options in AF
- Beta blocker first-line (e.g., atenolol or bisoprolol)
- Calcium-channel blocker (e.g., diltiazem or verapamil) (not preferable in heart failure)
- Digoxin (only in sedentary people with persistent atrial fibrillation, requires monitoring and has a risk of toxicity)
pharmacological cardioversion, the options are:
Flecainide
Amiodarone (the drug of choice in patients with structural heart disease)
delayed cardioversion- how long need to be anticoag for?
3 weeks-
benefits of doacs over warfarin ?
No monitoring is required
No issues with time in therapeutic range (provided they have good adherence)
No major interaction problems
Equal or slightly better than warfarin at preventing strokes in atrial fibrillation
Equal or slightly lower risk of bleeding than warfarin
acute heart failure Mx
Sit pt upright
O2 if <94%
IV loop diuretics
IV GTN infusion
If resp failure: CPAP
Continue normal heart failure meds unless HR drops
Heart failure on CXR findings
Pulmonary oedema findings:
Alveolar shadowing ‘bat wing sign’
Kerley B lines
Cardiomegaly
Dilated upper lobe vessels
acute heart failure on examination
cyanosis
Tachypnoea
bibasal crackles/wheeze
Tachycardia
Raised JVP
displaced apex beat/ S3 heart sound
peripheral oedema
Pulmonary Embolism presentation
Tachycardia, hypoxia
ECG: sinus tachycardia ± S1Q3T3
Raised D-dimer
PE Mx:
Unstable pt: thrombolysis
Stable pt:
CTPA/ V/Q scan
DOAC- apixaban or rivaroxaban
or
If severe renal impairment <15/min= LMWH/unfractionated heparin
how long to carry on anticoagulation in PE?
provoked VTE- 3 months
Active cancer-3-6 months
unprovoked VTE=6 months
Pts with repeated PEs despite anticoag consider
IVC filters
Pneumothorax Mx:
Initial:
o2 if low
analgesia if in pain
Tension:
emergency needle decompression- 5th intercostal space mid axillary line
Asymptomatic- conservative Mx
Symptomatic- High risk features-> chest drain
Symptomatic- No high risk features -> conservative/ ambulatory device/ needle aspiration (if needle aspiration unsuccessful -> chest drain)
what makes it a tension pneumothorax
- trachea not central/deviated on CXR
- haemodynamically unstable - Low BP, high HR
- resp distress- high RR
High risk characteristics for pneumothorax
- > =50yo with smoking hx
-underlying lung condition- COPD, bronchiectasis - severe hypoxia
- bilateral pneumothoraxes
- haemothorax
Follow-up for pt with pneumothorax
- Conservative Mx-
Primary spon-review every 2-4 days as outpt until resolved
Secondary spon- inpatient until resolved
Stable asymptomatic- outpt FU in 2-4 w - Needle aspiration- outpt FU 2-4w
- Chest drain- inpatient with daily review - after resolved discharge and FU in 2-4w
Secondary prevention pneumothorax advice
Secondary prevention: smoking cessation!!
No flying until 2 weeks after successful drainage and no residual air on CXR
Permanently avoid diving
Acute ischaemic stroke Mx:
Important to handover when onset of sxs was
CT head- assess for haemorrhage
If ischaemic:
300mg aspirin PO/PR as soon as bleed ruled out
Thrombolysis (IV alteplase) within 4.5hrs of onset (BP should be lowered to <185/110 before )
Thrombectomy- within 6hs of onset
secondary prevention/long-term Mx of stroke:
- Clopidogrel lifelong only
- Atorvastatin if cholesterol high
- Improve control HTN and diabetes
- Carotid endarterectomy if ICA stenosis >50%
- Feeding assessment by SALT +mx
- Smoking cessation
- Reduce alcohol intake
- Increase exercise
- Healthy balanced diet
- Weight loss
