Cardiogenic Emergencies
Acute ST Elevation MI
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ECG monitor
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High flow oxygen by face mask (caution if COPD)
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IV access. Bloods: FBC, U+E (is troponin not being excreted, and hence
is it falsely high?), glucose, lipids, cardiac enzymes
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Brief assessment:hx of CV disease, RFs,
Contraindications to thrombolysis
Ex: pulse, BP, JVP, murmurs, heart failure, peripheral pulses, cardiac scars
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Morphine (5-10mg IV + metoclopramide 10mg IV), Oxygen, Nitrates (2 puffs
of GTN s/l), Aspirin (300mg)
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Atenolol, ACE inhibitor, Atorvastatin, anti-ADP receptor (clopidogrel)
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CXR
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Thrombolysis or cardiac catheterisation if indicated
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Consider gluscose+insulin infusion for DM
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Consider DVT propylaxis
Indications for thrombolysis
Presentation within
3h
of pain with:
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ST elevation >2 mm in 2 or more chest leads or
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ST elevation >1 mm in 2 or more limb leads or
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Posterior infarction (dominant R waves and ST depression in V1-V3)
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New onset LBBB
Contraindications to thromboloysis
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Internal bleeding, vaginal bleeding
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Prolonged or traumatic CPR
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Acute pancreatitis
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Recent trauma or surgery < 2w
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Cerebral neoplasm
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Severe hypotension
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Suspected aortic dissection
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Previous allergic
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Pregnancy or <19w postpartum
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Severe liver disease
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Oesophageal varices
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Recent head trauma
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Recent haemorrhagic stroke
Indications for angiography
After 3h, or continuing pain, or contraindication
Acute coronary syndrome without ST elevation
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Same as above
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Brief assessment: previous angina, relief with
rest/nitrates, CVS hx, RFs
Ex: Pulse, BP...
Ix: ECG (ST depression, flat or inverted T waves, can be normal.)
Bloods (FBC, U+E, glucose, lipids, cardiac enzymes, CXR)
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Except
heparin
instead of
thrombolysis
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Tirofiban
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Optimise drugs: beta-blocker, calcium channel antagonist, ACEI,
nitrates, intensive statins
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Angioplasty
Pulmonary Oedema
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Sit the patient upright
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100% oxygen
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IV access and monitor ECG. Treat any arrhythmias.
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Start Ix whilst continuing treatment (ie don't
wait for results): CXR (cardiomegaly, oedema, effusions, fluid in
lung fissures, kerley B lines)
ECG (signs of MI)
Bloods: U+E (renal cause?), cardiac enzymes, ABG
Consider echo
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Diamorphine 2.5-5mg IV slowly (caution in liver failure and COPD)
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Furosemide 40-80mg IV slowly
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GTN spray 2 puffs SL
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If systolic BP>100mmHg start a nitrate infusion
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If the patient is worsening give a further dose of furosemide
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Consider ventilation/CPAP
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Once Improving
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Daily weighing, BP and pulse, repeat CXR
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Change to oral furosemide, or bumetanide
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Consider an additional thiazide if ↑doses of furosemide
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ACEI if LVF. Consider beta-blocker, spironolactone
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Consider digoxin, warfarin, especially if AF
Differential Diagnosis
Asthma/COPD, pneumonia and oedema often co-exist, so can treat for all
3 (eg salbutamol nebs, furosemide IV, diamorphine, amoxicillin)
Symptoms
Dyspnoea, orthopnoea, pink frothy sputum
Signs
Distressed, pale, sweaty, tachycardia tachypnoea, pulsus alternans,
raised JVP, fine lung crackles, triple/gallop rhythm, wheeze (“cardiac
asthma”)