scenario 1scenario 1 58 year old man 30 minute history of severe chest pain, 10/10, radiating to...
TRANSCRIPT
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Acute coronary syndrome (ACS)
Dr Darren Reed FY1
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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?
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Atherosclerosis
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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.
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Terminology
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Differentiating ACS
ECG
No ST-elevationST-elevation
Troponin T
Raised Not raised
STEMI
NSTEMI Unstable angina
Chest pain ?ACS
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ECG Troponin T
STEMI ST elevation Positive
NSTEMI +/- ST depression Positive
Unstable angina - Negative
Remember posterior infarcts can cause ST depression
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Risk factors
MODIFIABLE Smoking Obesity Diet No exercise Hypercholesterolaemia Hypertension Diabetes?
UNMODIFIABLE Increased age Gender (male) Ethnicity Family Hx Diabetes?
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Signs and symptoms
Signs Pallor Tachycardia Pulmonary
crepitations Raised JVP Murmurs
Symptoms Pain SOB Sweating Syncope N&V
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History
Chest pain?
Brief PMH – why?
Risk factors?
Allergies?
Current meds?
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Differential diagnosis
Cardiac•MI•Angina•Pericarditis•Aortic dissection
Respiratory
•Pulmonary embolism•Pneumothorax•Pneumonia
GI•Oesophageal spasm•GORD•Pancreatitis
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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
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Management
A – airway
B – breathing
O2, aim sats > 95%
C – circulation
Sats probe, BP, HR, IV access
D – disability
E – exposure
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ECG
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MONA
Morphine
Oxygen
Nitrates
Aspirin
Clopidogrel
Beta blocker (not in asthma, or with heart failure)
Antiemetic
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Time is muscle…
Percutaneous coronary intervention (angioplasty)
Thrombolysis (beware CI)
CABG
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Subacute management
Bed rest 48 hours
Gradual build up in activity over 1-2 months
Thromboprophylaxis
Job?
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Secondary prevention
Statins ACE inhibitors Beta blocker Life style advice Aspirin/clopidogrel
MODIFIABLE Hypercholesterolaemia Hypertension Diabetes? Smoking Obesity Diet No exercise
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UA/NSTEMI
Oxygen
Nitrates
Clopidogrel
Aspirin
LMWH
Risk assess (TIMI score) ?intervention
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Complications
Sudden death
PE
Rupture of ventricle
Arrythmia/aneurysm
Emboli
Dressler’s syndrome (AI pericarditis)
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ECG quizThis shows posterior infarct?
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ECG quiz
This only shows evidence of an old infarct?
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LBBB indicating STEMI?
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Anterior MI?
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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?
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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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