scenario 1scenario 1 58 year old man 30 minute history of severe chest pain, 10/10, radiating to...
TRANSCRIPT
Acute coronary syndrome (ACS)
Dr Darren Reed FY1
Scenario 1
58 year old man
30 minute history of severe chest pain, 10/10, radiating to jaw, not relieved by anything, associated with sweating and nausea. Known angina.
What investigations would you like?
What do you expect to find?
What would you do next?
Atherosclerosis
ACS – umbrella term
Stable Angina Unstable Angina NSTEMI STEMI
ACS
ACS is a spectrum, especially between UA and NSTEMI, where the severity affects degree of cardiac insult.
Terminology
Differentiating ACS
ECG
No ST-elevationST-elevation
Troponin T
Raised Not raised
STEMI
NSTEMI Unstable angina
Chest pain ?ACS
ECG Troponin T
STEMI ST elevation Positive
NSTEMI +/- ST depression Positive
Unstable angina - Negative
Remember posterior infarcts can cause ST depression
Risk factors
MODIFIABLE Smoking Obesity Diet No exercise Hypercholesterolaemia Hypertension Diabetes?
UNMODIFIABLE Increased age Gender (male) Ethnicity Family Hx Diabetes?
Signs and symptoms
Signs Pallor Tachycardia Pulmonary
crepitations Raised JVP Murmurs
Symptoms Pain SOB Sweating Syncope N&V
History
Chest pain?
Brief PMH – why?
Risk factors?
Allergies?
Current meds?
Differential diagnosis
Cardiac•MI•Angina•Pericarditis•Aortic dissection
Respiratory
•Pulmonary embolism•Pneumothorax•Pneumonia
GI•Oesophageal spasm•GORD•Pancreatitis
Investigations
Bedside ECG, obs
Blood FBC, U+E, clotting screen, Trop T, glucose, lipids
Imaging ?CXR
Special tests
Diagnosis (2/3):- Convincing MI history- ECG with ST changes- Cardiac enzymes raised
Management
A – airway
B – breathing
O2, aim sats > 95%
C – circulation
Sats probe, BP, HR, IV access
D – disability
E – exposure
ECG
MONA
Morphine
Oxygen
Nitrates
Aspirin
Clopidogrel
Beta blocker (not in asthma, or with heart failure)
Antiemetic
Time is muscle…
Percutaneous coronary intervention (angioplasty)
Thrombolysis (beware CI)
CABG
Subacute management
Bed rest 48 hours
Gradual build up in activity over 1-2 months
Thromboprophylaxis
Job?
Secondary prevention
Statins ACE inhibitors Beta blocker Life style advice Aspirin/clopidogrel
MODIFIABLE Hypercholesterolaemia Hypertension Diabetes? Smoking Obesity Diet No exercise
UA/NSTEMI
Oxygen
Nitrates
Clopidogrel
Aspirin
LMWH
Risk assess (TIMI score) ?intervention
Complications
Sudden death
PE
Rupture of ventricle
Arrythmia/aneurysm
Emboli
Dressler’s syndrome (AI pericarditis)
ECG quizThis shows posterior infarct?
ECG quiz
This only shows evidence of an old infarct?
LBBB indicating STEMI?
Anterior MI?
Scenario 2
It’s 23:15, you’re on nights.
You’re about to take some bloods, for gentamicin levels, for a patient due to have their next dose at 24:00.
You’ve just been bleeped by a nurse because a patient on another ward has developed chest pain...
What do you do next?
Take home message
ECG as soon as possible, repeat often
ABCDE + structured approach
Know your acute management – MONA ABCE
Senior review if unsure what’s happening
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