A 55-year-old man presents to the emergency department after suffering from a severe motor vehicle accident involving serious chest wounds. The paramedics had difficulty obtaining IV access. On arrival, he is found to be GCS 3 with an ECG that shows ventricular fibrillation. Advanced life support (ALS) is started. Several attempts at cannulation are unsuccessful. However, he is successfully intubated.
Given this information, what is the most appropriate step to take to deliver medications for ALS?
Administer intramuscularly
Administer rectally
Administer via endotracheal tube
Central line insertion
Intraosseous line insertion
Intraosseous line insertion
A 62-year-old female is reviewed in the heart failure clinic. Despite current treatment with furosemide, bisoprolol, enalapril and spironolactone she remains breathless on minimal exertion. On examination the chest is clear to auscultation and there is minimal ankle oedema
Recent results are as follows:
ECG Sinus rhythm, rate 84 bpm
Chest x-ray Cardiomegaly, clear lung fields
Echo Ejection fraction 35%
A combination of isosorbide dinitrate with hydralazine has been tried recently but had to be stopped due to side-effects.
What additional medication would best help her symptoms?
Bosentan
Isosorbide mononitrate
Diltiazem
Losartan
Digoxin
Digoxin
Digoxin may be useful in this situation whether the patient is in atrial fibrillation or not. Whilst it has not been shown to be of prognostic benefit it may help reduce symptoms. In the United States a large proportion of patients with heart failure take digoxin for this reason. Another option to consider in such a patient would be a biventricular pacemaker (cardiac resynchronization therapy).
CHF management drugs guideline
Criteria for starting ivabradine in HF
sinus rhythm > 75/min and a left ventricular fraction < 35%
Criteria for starting sacubitril-valsartan
- left ventricular fraction < 35%
- is considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
- should be initiated following ACEi or ARB wash-out period
Indication for cardiac resynchronisation therapy in HF
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
May be beneficial for patients with heart failure and ventricular dyssynchrony to improve heart function and symptoms.
A 75-year-old man in the cardiology ward complains of muscle cramps, palpitations and constipation. Blood test are taken and the following results are found:
Sodium 140mmol/L
Potassium 3.1mmol/L
Calcium 2.2mmol/L
Phosphate 1.1mmol/L
Magnesium 0.7mmol/L
What drug is most likely to have caused this derangement?
Bumetanide
Digoxin
Enalapril
Propranolol
Spironolactone
Bumetanide
A 74-year-old woman is brought to the acute admissions unit after collapsing at home. She has a history of hypertension and heart failure with preserved ejection fraction. On arrival, she is alert but confused, with cool peripheries. Her pulse is 154 bpm and regular. Blood pressure is 86/54 mmHg. ECG confirms a broad-complex tachycardia. Oxygen saturations are 98% on room air.
What is the most appropriate immediate management step?
Immediate synchronised DC cardioversion
IV amiodarone infusion
IV adenosine bolus
Urgent expert electrophysiology review
IV magnesium sulphate administration
Immediate synchronised DC
A 65-year-old male on the high dependency unit has just undergone a complex hip arthroplasty 12 hours ago. They are now complaining of feeling their heart pounding out of their chest and has become short of breath 30 minutes ago. An electrocardiogram (ECG) showed supraventricular tachycardia (SVT). The patient attempted blowing into a syringe with the guidance of a doctor and this terminated the SVT.
A short while later, the patient has another episode of palpitations and breathlessness and again has visible SVT on an ECG. His temperature is noted to be 37.2 ºC, with oxygen saturations of 98% on air, a heart rate of 180 beats per minute, a respiratory rate of 24 breaths per minute, and a blood pressure of 85/65 mmHg.
What is the appropriate immediate management of this patient?
Adenosine
Amiodarone
DC cardioversion
Repeat vagal manoeuvre
Unsynchronised cardioversion
DC cardioversion
A 55-year-old man comes to see you following a myocardial infarction 4 weeks ago. He has been started on ramipril, bisoprolol, aspirin and clopidogrel following the event. He was also offered a statin but felt that he was being asked to start too many medications at the same time so he declined the statin at that time.
He reports that since then he has been reading up about the beneficial effects of being on a statin and would like to start statin therapy.
Which one of the following should this patient be started on?
Rosuvastatin 20mg
Simvastatin 40mg
Atorvastatin 20mg
Atorvastatin 40mg
Atorvastatin 80mg
Atorvastatin 80mg
Statin in CV disease
atorvastatin 20mg for primary prevention, 80mg for secondary prevention
A 45-year-old woman who has Down’s syndrome comes to see you as she has recently been diagnosed with essential hypertension. She attends with her mother and asks you if you could please prescribe her some medication that does not involve regular blood tests as she is terrified of needles.
Which one of the following medication, would be suitable?
Ramipril
Candesartan
Bendroflumethiazide
Indapamide
Amlodipine
Amlodipine
Ramipril is an ACE inhibitor and candesartan is angiotensin 2 receptor blocker both of which require regular monitoring of renal function and electrolytes.
Amlodipine is a calcium channel blocker and does not require any blood test monitoring.
Indapamide and bendroflumethiazide are diuretics which require regular monitoring of renal function and electrolytes.
What can short acting dihydropyridines cause to vasculature?
Shorter acting dihydropyridines (e.g. nifedipine) cause peripheral vasodilation which may result in reflex tachycardia
A 55-year-old man is admitted following a road traffic accident to the emergency department. He is complaining of dyspnoea and some chest discomfort. On examination his pulse is 120/min and blood pressure is 106/70 mmHg. An ECG is taken:
© Image used on license from Dr Smith, University of Minnesota
What is the most likely cause of his symptoms?
Pulmonary embolism
Ventricular tachycardia
Cardiac tamponade
Myocardial infarction
Pacemaker lead disruption
Electrical alternans is suggestive of cardiac tamponade
Management of cardiac tamponade
urgent pericardiocentesis
A 24-year-old woman is admitted with unilateral calf pain and swelling. She is found to have an unprovoked DVT on Doppler ultrasound scan. She reports that she and her husband are very keen to start a family and plan to conceive within the following year. Which of the following medications is most suitable?
Unfractionated heparin
Low molecular weight heparin
Warfarin
Aspirin
Below-knee graduated compression stockings
Low molecular weight heparin
Warfarin is teratogenic
Indication for warfarin
- mechanical heart valves:
- second-line after DOACs
Mechanism of action of warfarin
inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form
this in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C
Monitoring of warfarin
patients are monitored using the INR (international normalised ratio), the ratio of the prothrombin time for the patient over the normal prothrombin time.
- warfarin has a long half-life and achieving a stable INR may take several days
Loading regimens for warfarin
- there are a variety of loading regimes and computer software is now often used to alter the dose
Factors that may potentiate warfarin
- liver disease
- P450 enzyme inhibitors
- cranberry and grapefruit juice
- drugs which displace warfarin from plasma albumin, e.g. NSAIDs
- Alcohol
- inhibit platelet function: NSAIDs and aspirin
CYP450 Inhibitors
- Macrolides (e.g. erythromycin, clarithromycin, azithromycin
- Protease inhibitors (indinavir, ritonavir, saquinavir)
- Grapefruit juice
- Ciprofloxacin
Sodium valporate - Some antidepressants
Mnemonics: GPACMAN (Grapefruit, proteise inhibitors, antifungals, cyclosporine/cimetidine, macrolides, amiodarone, non DHP CCBs diltiazem and verapamil)
CYP450 Inducers
COPS
Carbamazepine
Oxcarbazepine
Phenytoin/phenobarbital
Smoking/St.John’s Wort
Rifampin
Chronic alcholol
Side effects of warfarin
- haemorrhage
- teratogenic, although can be used in breastfeeding mothers
- skin necrosis
- when warfarin is first started biosynthesis of protein C is reduced this results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration
*thrombosis may occur in venules leading to skin necrosis - purple toes
