give drugs, perform chest compressions Anesthetist \200\223 airway and breathing, they may choose to bag-and-mask ventilate the patient, insert a laryngeal mask or intubate (b p542) Nurses \200\223 provide BLS, defi brillate if trained, give drugs, perform chest compressi ons, record observations, note time points, and take ECGs. Needle-stick injuries (b p106) a re commonest in times of emer- gency. Have the sharps box nearby and never leave sharps on the bed. Cannulation can be very diffi cult during a cardiac arrest. The ante- cubital foss a is the best place to look fi rst; alternatively try feet, hands, forearms, or consider ex ternal jugular if all else fails. Take bloods if you are successful, but don \200\231t allo w this to delay the giving of drugs. Blood tests are occasionally useful in cardiac arrests , especially K+ which can often be measured by arterial blood gas machines. Use a blood gas syringe to obtain a sample (the femoral artery with a green needle (21G) is often easiest \200\223 NAVY, b p516) and ask a nurse to take the sample to the machine. Other blood test s depend on the clinical scenario; if in doubt fi ll all the common blood bottles. De \201 brillation is taught on specifi c courses (eg ILS, ALS) and must not be undertaken unless trained. The use of automated external defi brilla- tors or AEDs (b p532) is becoming routi ne. Cardiac arrest drugs are now prepared in pre-fi lled syringes: adrena- line (epinephrin e) 1mg in 10ml (1:10,000), atropine (several preparations available), amiodarone 300mg in 1 0ml. Always give a large fl ush (20ml saline) after each dose to encourage it into the cent ral circulation. See b inside back cover for further emergency drug doses. Cardiac arrest t rolleys are found in most areas of the hospital. Know where they are for your wards. Ask th e ward sister if you can open the trolley and have a good look at the equipment within it a s they diff er between hospitals. They are often arranged so the top drawer contains Airway equipment, the second contains Breathing equipment, the third contains Circulation equipme nt and the lower drawer contains the drugs and fl uids. You \200\231ll seldom need anything that isn \200\231t on the trolley. OHFP.indb 228 OHFP.indb 228 30/05/2014 16:18 30/05/2014 16:18 229 ADVANCED LIFE SUPPORT (ALS) Unresponsive? Not breathing or only occasional gasps Call resuscitation team CPR 30:2 Attach defibrillator/monitor Minimize interruptions Assess rhythm Shockable (VF/Pulseless VT) Non-shockable (PEA/Asystole) Return of spontaneous circulation 1 Shock Immediately resume CPR for 2 min Minimize interruptions Immediately resume CPR for 2 min Minimize interruptions Immediate post cardiac arrest treatment \200 Use ABCDE approach \200 Controlled oxygena tion and ventilation \200 12-lead ECG \200 Treat precipitating cause \200 Temperature control/ therapeutic hypothermia Reversible Causes During CPR Hypoxia \200 Hypovolaemia \200 Hypo-/hyperkalaemia/metabolic \200 Hypothermia Ensure high-quality CPR: rate, depth, recoil \200 Plan actions before interrupting CPR \200 Give oxygen \200 Consider advanced airway and capnography \200 Continuous chest c ompressions when advanced airway in place \200 Vascular access (intravenous, intraosseous ) \200 Give adrenaline every 3 \200\2235 min \200 Correct reversible causes Thrombosis - coronary or pulmonary \200 Tamponade - cardiac \200 Toxins \200 Tension pneumothorax Fig. 6.2 Adult Advanced Life Support algorithm; 2010 guidelines. Reproduced with the kind p ermission of the Resuscitation Council (UK). _OHFP.indb 229 _OHFP.indb 229 30/05/2014 16:18 30/05/2014 16:18 230 CHAPTER 6 Resuscitation Arrest equipment and tests Airway Jaw thrust Pull the jaw forward with your index and middle fi ngers at the angle of each mandible. Pull hard enough to make your fi ngers ache. Head tilt Gently extend the neck, avoid if C-spine injury risk. Chin lift Pull the chin up with two fi ngers, avoid if C-spine injury risk. Oropharyngeal airway (Guedel) A rigid, curved plastic tube; choose the size that reaches th e angle of the mouth from the tragus of the ear. Insert upside down to avoid pushing the to ngue back, then rotate 180 when inside the mouth (do not insert upside down in children). Nasopharyngeal airway A fl exible, curved plastic tube, not to be used with signifi cant he ad injury. Choose the size that will easily pass through the nose (size 6 \200\2237mm in mo st adults); insert by lubricating and pushing horizontally into the patient \200\231s nostr il (not upwards). Use a safety pin through the end to prevent the tube being lost. Suction Cover the hole on the side of a wide-bore suction catheter to cause suction at the tip. Secretions in the parts of the oropharynx that can be seen directly can be cleared. A thinner catheter can be used to clear secretions in the airway of an intubated patient. Breathing Non-rebreather mask (trauma mask) A plastic mask with a fl oppy bag attached; use d in acutely ill patients to give 780% O2 with a 15l/min fl ow rate. Standard mask (Hudson mask) A plastic mask that connects directly to O2 tubing; delivers 75 0% O2 with a 15l/min fl ow rate. Venturi A mask that connects to the O2 tubing via a piece of colored plastic, delivering either 24%, 28%, 35%, 40%, or 60% O2. Adjust the fl ow rate according to the instructions on the colored plastic con- nector, eg 4l/min with the 28% Ve nturi connection. Bag and mask (Ambu bag) A self-infl ating bag and valve that allows you to force O2 into an inadequately ventilating patient. Attach the O2 tubing to the bag with a 15l/min fl ow rat e then seal the mask over the patient \200\231s nose and mouth. Easiest with two people; on e person stands at the head to get a fi rm seal with both hands whilst the other squeezes t he bag. The mask can be removed to attach the bag to an ETT or LMA (b p544). Pulse oximeter Plastic clip with a red light that measures blood O2 satura- tions. Clip ont o the patient \200\231s index fi nger. Do not rely on the reading unless there is an even t race on the monitor and the patient has a pulse; use on the diff erent arm from the BP cuff . Nebuliser This is a 3cm-high cylinder that attaches beneath a mask. The cylinder is made of two halves that can be untwisted so that the fl uid to be nebulised can be inserted. The n ebuliser can be connected to a pump or directly to an O2 or medical air supply. OHFP.indb 230 OHFP.indb 230 30/05/2014 16:18 30/05/2014 16:18 231 ARREST EQUIPMENT AND TESTS Circulation De \201 brillation (b p532) Successful defi brillation requires ECG monitoring to identify a shockable rhythm, and delivery of current through elec- trodes attached to t he chest wall. Previously, monitoring was performed using ECG leads: red to right shoulder, yellow to left shoulder and green to apex (b p528). Separate paddles were applied to deliv er current. Most NHS trusts now use hands-free adhesive defi brillation electrodes which ar e safer and also double as monitoring leads (b p533). Only defi brillate if you have been t rained: \200 Check the adhesive electrodes are correctly applied to the chest \200 Swit ch the defi brillator to \200\230monitor \200\231 mode \200 If a shockable rhythm is ide ntifi ed, select required defi brillation energy using the circular dial, then charge defi brillator using \200\230charge \200\231 button \200 Tell staff to stand clear and stand clear yourself - try to minimize the interruption of chest compressions which should contin ue until the latest possible moment Check the O2, staff and you are clear (O2, top, middle, bottom, self ) \200 Check the rhy thm is still shockable then press the \200\230shock \200\231 button to deliver the charge. Resume CPR, without pausing to check rhythm. Blood pressure Attach the cuff to the patient \200\231s left arm so it is out of the way and leave in place. If it does not work or is n ot believable (eg irregular or tachyarrhythmia) then obtain a manual reading. Venous access Ideally a brown/gray venfl on in each antecubital fossa; however, get the best available ( biggest and most central). Remember to take bloods but don \200\231t let this delay giving drugs. Disability Glucose Use a spot of blood from the venous sample or a skin prick to get a capillary sample; clean skin fi rst with water to avoid false readings. Examination GCS, pupil size and reactivity to light, posture, tone of all four limbs, plantar refl exes. Ex posure Get all the patient \200\231s clothes off ; have a low threshold for cutting them of f . Inspect the patient \200\231s entire body for clues as to the cause of the arrest, eg r ashes, injuries. Measure temp. Remember to cover the patient with a blanket to prevent hypo thermia and for dignity. Other investigations Arterial blood gas Attempts to sample radial artery blood in a patient in extremis may be futile and waste valuable time. Instead, attac h a green (21G) needle to a blood gas syringe, feel for the femoral pulse ( to 2 \201\204 3 between superior iliac spine and pubic symphysis) and insert the needle ver- tically unti l you get blood. Press hard after removal. Even if the sample is venous it can still off er useful information. Femoral stab (b p516) If no blood has been taken you can insert a gree n needle into the femoral vein which is medial to the artery (NAVY). Feel for the artery th en aim about 1cm medially. If you hit the artery take 20ml of blood anyway and send for art erial blood gas and normal blood tests, but press hard after removal. ECG Attach the leads as shown on b p529. CXR Alert the radiographer early so that they can bring the X-ray machi ne for a portable CXR. _OHFP.indb 231 _OHFP.indb 231 30/05/2014 16:18 30/05/2014 16:18 232 CHAPTER 6 Resuscitation Advanced Trauma Life Support (ATLS) ATLS is designed to quickly and safely stabilize the in jured patient. The purpose of ATLS is not to provide defi nitive care of all injuries, but to recognize the immediate threats to life and to address these. As with ALS, in ATLS the p atient \200\231s care is delivered by a team which will consist of a leader and various mem bers. Details of how to undertake an ATLS course are given in the box. The primary survey allows a rapid assessment and relevant man- agement to be undertaken. If a life-threatening issue is found this must be treated before moving on to the next step o f the primary survey. The primary survey is as follows: Airway with cervical spine protec- tion; Breathing: ventilation and oxygenation; Circulation with haemor- rhage control; Disab ility: brief neurological examination; Exposure/ Environment; Adjuncts to primary survey; R eassess patient \200\231s ABCDE and consider need for patient transfer. The secondary survey follows once all life-threatening issues have been identifi ed and dea led with; the secondary survey is a top-to- toe examination looking for secondary injuries which are unlikely to be immediately life-threatening. The secondary survey is as follows: AMPLE history (Allergies, Medications, Past medical history, Last meal, Events leading to p resentation) and mechanism of injury; Head and maxillo- facial; Cervical spine and neck; Ch est; Abdomen; Perineum/rectum/ vagina; Musculoskeletal; Neurologic; Adjuncts to the seconda ry survey. ATLS and the F1 doctor it is highly unlikely the foundation doctor will be the fi rst perso n to attend to a major trauma patient, though ATLS can be applied in principle to any patie nt who has sustained an injury. Having a logical, step-wise approach to injured patients mi nimizes the risk of missing life-threatening complications or injuries which subse- quently may become debilitating if left unrecognized and untreated. ATLS course In the UK, ATLS courses are coordinated by the Royal College of Surgeons. The c ourse is currently 3 days long, and details of where and when courses are run can be obtain ed from the College (see b p600 for contact details). There is usually a long waiting list for places as this is a popular course; the cost for the 3-day course is around 600. OHFP.indb 232 OHFP.indb 232 30/05/2014 16:18 30/05/2014 16:18 This page intentionally left blank 234 CHAPTER 6 Resuscitation Pediatric Basic Life Support pp Check airway is patent; consider maneuvers/adjuncts If poor respiratory eff ort \200\223 C ALL ARREST TEAM If HR <60bpm \200\223 CALL ARREST TEAM If unresponsive to voice \200\223 CALL ARREST TEAM Airway Breathing Circulation Disability 3Call the arrest team if severely unwell; call senior help early (Fig. 6.3). Airway \200 \223 if irreversibly obstructed CALL ARREST TEAM \200 Airway maneuvers: (head tilt), chin lift, jaw thrust (see Table 6.2) \200 Oropharyngeal or nasopharyngeal airway if respondi ng only to pain \200 If still impaired CALL ARREST TEAM. If you suspect epiglottitis (stridor, drooling, septic) do not look in the mouth, but give O2 call your senior help urgently and an anaesthe- tist and ENT surgeon. Breathing \200\223 if poor or absent respiratory eff ort CALL ARREST TEAM \200 Bag and m ask with 15l/min O2 if poor or absent breathing eff ort \200 Non-rebreather mask and 15l/ min O2 in all other patients \200 Monitor pulse oximeter \200 Eff ort stridor, wheeze, RR, intercostal recession, grunting, accessory muscle use (head bobbing in infants), nasal fl aring Effi cacy chest expansion, air entry (does R=L?), O2 sats \200 Eff ects HR, pallor, cyano sis (late sign), agitation, drowsiness. Circulation \200\223 if HR absent or <60bpm and un responsive CALL ARREST TEAM \200 Start CPR if HR absent or <60bpm and unresponsive \200 Monitor defi brillator ECG leads \200 Status HR + rhythm, pulse volume, cap refi ll ( \211 2s normal), BP \200 Eff ects RR, mottled/pale/cold skin, urine output, agitation, dr owsiness \200 Venous access (consider intraosseous) check glucose and send blds \200 Co nsider \202 uid bolus (20ml/kg IV 0.9% saline STAT) if shocked \200 Exclude heart failu re iJVP, gallop rhythm, crepitations, large liver. Disability \200\223 if unresponsive to voice CALL ARREST TEAM \200 Assess AVPU (Alert, responds to Voice, responds to Pain, Unresponsive); check glucose if not already done Look for pupil size and refl exes; assess posture and tone \200 See b p346 for seizures. Exposure \200 Look all over body for rashes, check temp, cover with a blanket. Look all o ver body for rashes, check temp, cover with a blanket. Life-threatening causes Croup (exclude epiglottitis) \200 Inhaled foreign body \200 Bronchiolitis \200 Asthma Dehydration (DKA) \200 Sepsis, meningitis, pneumonia \200 Anaphylaxis \200 Heart fail ure (especially infants) OHFP.indb 234 OHFP.indb 234 30/05/2014 16:18 30/05/2014 16:18 235 pediatric BASIC LIFE SUPPORT Pediatric Basic Life Support (Healthcare professionals with a duty to respond) UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? 5 rescue breaths NO SIGNS OF LIFE? 15 chest compressions 2 rescue breaths 15 compressions Call resuscitation team Fig. 6.3 Pediatric Basic Life Support algorithm; 2010 guidelines. Reproduced with the kind permission of the Resuscitation Council (UK). Table 6.2 Main age-related diff erences in pediatric life support Feature Infant <1yr Child >1yr Post-puberty Airway position Breaths Neutral Mouth and nose Mouth, 9nose Brachial 1 fi nger above xiphisternum 1 fi nger Slightly extended Slightly extended Mouth only Pulse CPR position Carotid 1 fi nger above xiphisternum 1 or 2 hands 15:2 Carotid 2 fi ngers above xiphisternum 2 hands 15:2 For CPR use Compressions:breaths 15:2 Common emergency drug doses \200 Diazepam 0.5mg/kg PR \200 Fluid bolus 20ml/kg 0.9% sal ine IV \200 Glucose 2ml/kg 10% glucose IV \200 Lorazepam 0.1mg/kg IV \200 Adrenaline (arrest) 0.1ml/kg 1:10,000 IV \200 Ceftriaxone 80mg/kg IV \200 Adrenaline (anaphylaxis) 0.01ml/kg 1:1,000 IM. Table 6.3 Normal range for observations by age Age <1yr 2 \200\2235yr 6 \200\22312yr >12yr RR (/min) 30 \200\22340 20 \200\22330 12 \200\22320 12 \200\22316 HR (/min) 110 \200\223160 95 \200\223140 80 \200\223120 60 \200\223100 Systolic BP (mmHg) 70 \200\22390 80 \200\223100 90 \200\223110 100 \200\223120 _OHFP.indb 235 _OHFP.indb 235 30/05/2014 16:18 30/05/2014 16:18 236 CHAPTER 6 Resuscitation ) Newborn Life Support (NLS) If no improvement after 2min (earlier if you are concerned) of resuscita- tion then fast bleep a senior or CALL THE NEONATAL ARREST TEAM (Fig. 6.4). pp ( Preparation \200 Put non-sterile gloves on \200 Turn on the heater and place warm towel s on the resuscitaire \200 Turn on O2/air and check pressure, set PIP/PEEP to 30/10cmH2O for term babies Turn on suction and check it works \200 Get the laryngoscope and size 3.5 and 4.0 (term b abies) ETT ready \200 Check gestation, estimated birth weight and history. Drying \200 Post-delivery start the clock and place the baby on the resuscitaire \200 Dry vigorously with a warm towel and cover \200 Babies <30/40 gestation should be placed directly in a p lastic bag. g g p y p Meconium delivery if the baby is not breathing suck out meco- nium from the mouth and benea th the vocal cords under direct vision with a laryngoscope before drying; if the baby breat hes then stop and resuscitate as usual. Airway and breathing \200 Assess RR and HR, if either impaired and not improving: place the baby \200\231s head in the neutral position \200 place Neopuff over nose and mo uth, jaw thrust; give 5 in \202 ation breaths: cover the Neopuff hole for 2 \200\2233s then uncover for 2 \200\2233s \200 look for chest movement, improved HR, color If unsuccessful reposition head and give a further 5 in \202 ation breaths \200 If unsuc cessful CALL ARREST TEAM and consider intubation \200 Look for oropharynx obstruction and consider a Guedel airway \200 Continue Neopuff breaths at lower pressures (eg 20/5, 1s o n 1s off ). Circulation \200\223 if HR <100bpm after breaths CALL ARREST TEAM \200 Asses s the HR by gripping the umbilicus or listening to the heart \200 Start CPR if HR <60bpm/ absent despite infl ation breaths: grip round the chest and use both thumbs over lower sternum \200 aim for a rate of 120 (t wice a second) \200 ratio of 3:1 compressions to breaths Attempt to get IV access eg umbilical venous catheter, check glucose. Drugs \200\223 if ne eded CALL ARREST TEAM \200 Adrenaline 0.1 \200\2230.3ml/kg of 1:10,000 IV if HR not impro ving \200 Na+ bicarbonate 4.2% 2 \200\2234ml/kg IV if acidotic and not improving \200 G lucose 10% 2.5ml/kg IV if hypoglycaemic \200 0.9% saline 10ml/kg IV if large blood loss s uspected. 0.9% saline 10ml/kg IV if large blood loss suspected. Life-threatening causes \200 Prematurity \200 Hypoxia Meconium aspiration \200 Congenital abnormality OHFP.indb 236 OHFP.indb 236 30/05/2014 16:18 30/05/2014 16:18 237 NEWBORN LIFE SUPPORT (NLS) Dry the baby Remove any wet towels and cover Start the clock or note the time AT Birth ALL Assess (tone), breathing and heart rate 30 s If gasping or not breathing: Open the airway Give 5 inflation breaths Consider SpO2 monitor ing STAGES 60 s Re-assess If no increase in heart rate look for chest movement ASK: If chest not moving: Recheck head position Consider 2-person airway control and other airwa y maneuvers Repeat inflation breaths Consider SpO2 monitoring Look for a response Acceptable1 pre-ductal SpO2 2 min 3 min 4 min 5 min 10 min 60% 70% 80% 85% 90% If no increase in heart rate look for chest movement DO When the chest is moving: If heart rate is not detectable or slow (<60 min-1) Start chest c ompressions 3 compressions to each breath YOU NEED Reassess heart rate every 30 s If heart rate is not detectable or slow (<60 min-1) consider venous access and drugs HELP? Fig. 6.4 Newborn Life Support algorithm; 2010 guidelines. Reproduced with the kind permissi on of the Resuscitation Council (UK). 1 Dawson J.A., Kamlin C.O., Vento M., et al. (2010). Defi ning the reference range for oxyg en saturation for infants after birth. Pediatrics 125:e1340 \200\2237. _OHFP.indb 237 _OHFP.indb 237 30/05/2014 16:18 30/05/2014 16:18 238 CHAPTER 6 Resuscitation Obstetric arrest Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM If no palpable pulse \200\223 CALL ARREST TEAM If GCS \211 8 \200\223 CALL OBSTETRIC ARREST TEAM Airway Breathing Circulation Disability Staff \200 Standard arrest team along with obstetrician and neonatologist. Position \200 Left lateral position (>15 ) using a Cardiff Wedge, pillows or your knees to take the pr essure of the uterus off the vena cava and aorta Push the uterus to the left and up to further relieve pressure. Airway \200 Look inside t he mouth, remove obvious objects/dentures \200 Wide-bore suction under direct vision if s ecretions present \200 Jaw thrust/head tilt/chin lift; laryngeal mask if available \200 Early intubation to prevent gastric aspiration. Breathing \200 Look/listen/feel for resp iratory eff ort \200 Bag and mask if poor or absent respiratory eff ort \200 Monitor O2 sats and RR. Circulation \200 Feel for a central pulse (carotid/femoral) \200\223 HR an d rhythm \200 Mid-sternal chest compression (30:2) if pulse absent \200 Arrhythmias \200\223 use a defi brillator/drugs as usual (b p532) \200 Venous access, send bloods and give IV fl uids STAT \200 Monitor defi brillator ECG leads and BP. Disability \200 Ass ess GCS and check glucose \200 Look/feel for pupil refl exes, limb tone and plantar refl exes. Surgery \200 Emergency Cesarean if resuscitation is not successful by 5min: improves maternal chest compliance and venous return The mother \200\231s needs take priority in all decisions. Causes of obstetric arrest, see also b p226 b p478 b p504 Hemorrhage/ hypovolaemia Excess magnesium sulfate Acute coronary syndrome Aortic dissection b p247 Pre-eclampsia/ eclampsia Pulmonary embolism Amniotic fl uid embolism Stroke b OHCM9 p693 b p243 b p278 b OHCM9 p89 b p351 OHFP.indb 238 OHFP.indb 238 30/05/2014 16:18 30/05/2014 16:18 Chapter 7 Cardiovascular 239 Chest pain emergency 240 Chest pain 241 Tachyarrhythmia emergency 248 Tachyarrhythmias 250 Bradyarrhythmia emergency 256 Bradyarrhythmias 258 Hypertension emergency 262 Hypertension 263 Heart failure 267 _OHFP.indb 239 _OHFP.indb 239 30/05/2014 16:18 30/05/2014 16:18 240 CHAPTER 7 Cardiovascular y Chest pain emergency p g Check airway is patent; consider maneuvers/adjuncts If no respiratory eff ort \200\223 CAL L ARREST TEAM Airway Breathing Circulation If no palpable pulse \200\223 CALL ARREST TEAM 3Call for senior help early if patient unwell or deteriorating. \200 Sit patient up \200 15l/min O2 if SOB or sats <94% \200 Monitor pulse oximeter, BP, defi brillator ECG lead s if unwell \200 Obtain a full set of observations including BP in both arms and ECG \200 Take brief history if possible/check notes/ask ward staff \200 Examine patient: con densed CVS, RS, abdo exam \200 Establish likely causes and rule out serious causes: consider percutaneous coronary intervention (PCI) or thrombolysis (b p536) consider giving aspirin 300mg PO STAT \200 consider needle decompression (b p279) Initiate further treatment, including analgesia, see following pages \200 Venous access, take bloods: FBC, U+E, LFT, CRP, glucose, cardiac markers, D-dimer Request urgent CXR, portable if too unwell \200 Call for senior help if no improvement or worsening \200 Repeat ECG after 20min if no improvement \200 Reassess, starting with A , B, C \200 Life-threatening causes Myocardial infarction \200 (Tension) pneumothorax \200 Acute coronary syndrome \200 P ericardial eff usion/cardiac tamponade Aortic dissection \200 Pulmonary embolism \200 Sickle-cell crisis OHFP.indb 240 OHFP.indb 240 30/05/2014 16:18 30/05/2014 16:18 241 CHEST PAIN Chest painp Worrying features idHR, dBP, iRR, dGCS, sudden onset, sweating, nausea, vomitin g, pain radiating to jaw, left arm or back, ECG changes. Think about common myocardial infarction, acute coronary syndromes, angina, pulmonary embol ism, musculoskeletal, pneumonia, pneumothorax (tension or simple), pericarditis, refl ux an d peptic ulcer disease; uncommon aortic dissection, cardiac tamponade, sickle-cell crisis ( Table 7.1). Ask about site of onset and radiation, quality (heavy, aching, sharp, tearing), intensity ( scale of 1 \200\22310), time of onset, duration, associated symptoms (sweating, nausea, pal pitations, breathlessness), exacerbating/ relieving factors (breathing, position, exertion, eating), recent trauma/ exertion, similarity to previous episodes; PMH cardiac or respirat ory problems, DM, GORD; DH cardiac or respiratory medications, antacids; FH IHD, premature cardiac death; SH smoking, exercise tolerance. Risk factors \200 IHD iBP, icholesterol, FH, smoking, obesity, DM, previous IHD \200 PE /DVT previous PE/DVT, immobility, ioestrogens, recent surgery, FH, pregnancy, hypercoagulab le states, smoking, long distance travel GI known GORD (b p294), known peptic ulcer, alcohol binge. Obs HR, BP (both arms), RR, sats , temp. Look for pulse rate/rhythm/volume, sweating, pallor, dyspnoea, cyanosis, iJVP, asymmetric c hest expansion/percussion/breath sounds, chest wall tenderness, mediastinal shift, tracheal tug, swollen ankles, calf pain/swelling/ erythema. Investigations ECG (b p528/572 for proc edure/interpretation); blds FBC, U+E, LFT, D-dimer, cardiac markers;1 consider ABG taken on O2 if patient acutely unwell (b p522/584 for procedure/interpretation); CXR if you suspect a tension pneumothorax clinically perform imme- diate needle decompression (b p279), other wise request a portable CXR if the patient is severely ill (poorer image quality) or standa rd CXR (b p582 for interpretation); urgent echo/CT if large proximal PE or aortic root diss ection suspected (discuss with cardiologist on-call). Treatment 15l/min O2 in everyone initially. Consider IV opioids (and an antiemetic) if pain is severe. Diagnoses to exclude If you are unable to confi rm a diagnosis imme- diately, consider life -threatening causes and investigate until excluded: \200 Cardiac ischaemia: abnormal ECG, typical history, icardiac markers1 \200 PE: dsats, abnormal ECG, clinical risk (b p278), iD-dimer, CT-PA \200 Pneumothorax: mediastinal shift, dbreath sounds, review CXR \200 Aortic dissection: evidence of shock, left and right systolic BP diff er by >15mmHg, medias tinal widening on CXR, abnormal CT/echo. Contact cardiology/medical registrar on-call for advice if necessary. 1 Various cardiac markers rise at diff erent times, so check locally which you should send and at what time-point after onset of chest pain (b p243). _OHFP.indb 241 _OHFP.indb 241 30/05/2014 16:18 30/05/2014 16:18 242 CHAPTER 7 Cardiovascular Table 7.1 Common causes of chest pain History Examination Investigations 22ACS (STEMI) Sudden onset pain, radiating to left arm/jaw, >20min, breathlessness, sweating, nausea Dyspnoea, arrhythmia, sweating, non- tender ST elevation or new LBBB, icardiac markers. Cardiac markers are not needed to make the diag nosis of STEMI ST depression, T wave inversion; itroponin 22ACS (NSTEMI) Sudden onset pain, radiating to left arm/jaw, >20min, breathlessness, sweating, nausea Dyspnoea, arrhythmia, sweating, non-tender 22ACS (Unstable angina) Anginal pain at rest or with ifrequency, severity or duration Dyspnoea, arrhythmia, sweating, non-tender ST depression, T wave inversion, troponin not elevated Angina (stable) Exertional pain, radiating to left arm/jaw, <20min, breathlessness, dby rest/GTN Dyspnoea, tachycardia, non- tender, may be normal after pain resolves Transient ECG changes, troponin not elevated, +ve stress ECG, + coronary angiography Pericarditis History of viral-like illness, pleuritic pain, ion lying, dsitting forwards Pericardial rub, otherwise normal CVS and RS examinations Tachycardia, dBP, diff erence in brachial pulses and pressures, iRR. Limb weakness or paraesthesia Saddle-shaped ST segments on most ECG leads, iCRP/ ESR 22Aortic dissection Sudden onset severe interscapular pain, tearing in nature, breathlessness. Limb weakness/nu mbness Widened mediastinum on CXR, aortic dilatation on echo/CT, aortic leak on angiogram ABG: PaO 2n/d, CO2d, clear CXR, iD-dimer, sinus tachycardia, S1Q3T3 (rare), thrombus on echo Pulmonary embolism Breathlessness, PE risk factors (b p278), may have pleuritic chest pain and haemoptysis Often normal, may have evidence of DVT (swollen red leg), tachycardia, dyspnoea, dBP Pneumothorax Sudden onset pleuritic pain trauma; tall and thin; COPD Mediastinal shift, unequal air entry and expansion, hyperresonance Pleura separated from ribs on CXR, other investigations often normal iWCC/iN \230/ iCRP, co nsolidation on CXR (b p582) Pneumonia Cough, productive with colored sputum, pleuritic pain, feels unwell Febrile, asymmetrical air entry, coarse creps (often unilateral), dull to percussion Musculoskeletal chest pain Lifting, impact injury, may be pleuritic, worse on palpation or movement Tender (presence does not exclude other causes), respiratory examination normal ECG to exclude cardiac cause, normal CXR Oesophageal refl ux or spasm Previous indigestion/ refl ux, known hiatus hernia, dby antacids May have upper abdo tenderness, normal CVS and RS examinations ECG to exclude cardiac cause, normal CXR, trial of antacids OHFP.indb 242 OHFP.indb 242 30/05/2014 16:18 30/05/2014 16:18 243 CHEST PAIN 3Acute coronary syndromes (ACS) (OHCM9 b p112) ACS is a general term referring to presentat ions of varying severities of myocardial ischaemia (Tables 7.2 and 7.3). The aim is to allo w a prospec- tive rather than a retrospective diagnosis to be made and so improve both acut e management and subsequent patient outcome. Table 7.2 Acute coronary syndrome (ACS) classi \201 cation in patients with typical cardia c-sounding chest pain lasting >20min ECG \201 ndings Troponin (12h post-pain) Diagnosis ST elevation or new LBBB Not needed to make a diagnosis, but will be i Trop T \211 0.1ng/ml or Trop I \211 1ng/ml Trop T <0.1ng/ml or Trop I <1ng/ml STEMI (b p244) NSTEMI (b p245) Unstable angina (b p246) Ischaemia (other than ST elevation), though may be normal Table 7.3 Serum cardiac markers in suspected ACS The term \200\230cardiac enzymes \200\231 is incorrect when referring to the troponins as these are structural/regulatory proteins a nd have no enzymatic activity Troponins (I or T) Identifi cation of these in the blood is highly suggestive of myocardial injury, though the y can be raised in PE, renal failure, septicaemia and following tachyarrhythmias (but CK is seldom concurrently raised in these conditions). Detection is usually possible 6h after my ocardial injury and levels remain elevated for up to 14d. Troponins are also used as a prog nostic indicator in NSTEMI/UA (b p245) Enzyme found in all muscle and released in muscle ce ll lysis; not specifi c for cardiac muscle. Peaks within 24h post-MI and usually returns to normal within 48 \200\22372h, so useful in detecting further infarction in patients with p ain 3 \200\22314 days post MI (Fig. 7.1) Cardiac isomer of CK enzyme, so more specifi c tha n total CK. Rises and falls in similar fashion to total CK These were once used to retrospe ctively aid in the diagnosis of acute MI but have been superseded in recent years Creatine kinase (CK) CK-MB AST LDH x50 l e v e Troponin l e m y z n e m u r e S x5 x4 x3 x2 x1 CK-MB 1 2 3 4 Days 0 5 6 7 8 Fig. 7.1 Typical changes in cardiac markers following an acute myocardial infarction. _OHFP.indb 243 _OHFP.indb 243 30/05/2014 16:18 30/05/2014 16:18 244 CHAPTER 7 Cardiovascular 22STEMI (ST Elevation MI)1 (OHCM9 b p114) Worrying signs features of LV failure, cardiac dy srhythmia. Symptoms central, crushing, heavy chest pain ( \211 20min), radiating to left arm/jaw, shortness of breath, nausea, sweating, palpitations, anxiety. Risk factors smoking , obesity, DM, iBP, icholesterol, FH, previous IHD. Signs tachycardia, cool and sweaty ( \200\230clammy \200\231), 9LV failure or hypotension. Investigations ECG ST elevation (>1mm in 2 or more contiguous limb leads or >2mm in chest leads) or new LBBB; subsequent Q waves (commonly) T wave inversion (Fig. 7.2); CXR cardiomegaly, signs of LV failure; cardiac m arkers will be raised but treatment should not be withheld as ECG fi ndings and history alo ne are suffi cient to make the diagnosis. Acute treatment The goal is for rapid reperfusion by percutaneous coro- nary intervention (PCI) in those presenting within 12h of symptom on set so seek senior help. O2 (15l/min), aspirin (300mg), clopidogrel (300mg), diamorphine (2 .5 \200\2235mg IV), antiemetic (b p185), GTN (two puff s SL/5min until pain free; infusion if ongoing pain after 3 SL doses, provided not hypotensive, b p201). Where PCI is not avail able within 3h, consider fi brinolysis (b p536). B-blockade (eg bisoprolol 10mg/PO STAT) li mits infarct size and dmortality, but avoid use in COPD, hypoten- sion and overt failure. C areful glycaemic control (eg insulin sliding scale b p327) may improve outcomes.2 Secondary prophylaxis dmodifi able risk factors (smoking, obesity, DM, iBP, icholesterol), B-blockad e, statin, anti-platelets (aspirin indefi nitely, clopidogrel for 1 year), ACEi, symptom ma nagement (nitrates, Ca2+ channel antagonists). Complications dysrhythmias (AV block, bradyc ardia, VF/VT), LVF, valve prolapse, ventricular septal rupture, ventricular aneurysm format ion, pericarditis, Dressler \200\231s syndrome (OHAM3 b p32), recurrent pain. Normal Hours Days Weeks Months Fig. 7.2 Typical sequential ECG changes following an acute STEMI. Fig. 7.2 Typical sequenti al ECG changes following an acute STEMI. Care after myocardial infarction (OHCM9 b p114) \200 Bed rest for 48h with continuous ECG monitoring \200 Daily 12-lead ECG and thorough clinical examination of CVS/RS \200 Thromboembolism prophylaxis (b p406) \200 B-blocka de unless contraindicated \200 ACEi/angiotensin II receptor antagonist \200 Statin \200 Discuss modifi able risk factors and arrange cardiac rehabilitation \200 Primary PC I patients are at lower risk of complications and have shorter stays; thrombolysis patients will require risk stratifi cation and consideration for in-patient angiography. Consider electrophysiological studies in those with new dysrhythmias \200 Review in out-p atients at 5wk and 3mth for symptoms and to check lipids+BP 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG167 2. Evidence low quality a nd confl icting. NICE review available at (cid:27)guidance.nice.org.uk/CG130 OHFP.indb 244 OHFP.indb 244 30/05/2014 16:18 30/05/2014 16:18 245 CHEST PAIN 22NSTEMI (Non-ST Elevation MI)1 (OHAM3 b p44) Diagnosis and intervention are often less \200\230dramatic \200\231 than for STEMI, requiring recognition of evolving ECG changes; ho wever, 1yr survival is poorer. Worrying signs features of LV failure, cardiac dysrhythmia. Symptoms, risk factors, and signs overlap with STEMI; patients typically tend to be older, with more co-morbidities. Investigations ECG ST depression, inverted T waves; subsequent ev olution of changes T wave inversion; CXR cardiomegaly, signs of LV failure; cardiac marke rs diff erentiate from UA by elevated troponin, taken according to local protocols (typical ly on presentation and 12h after worst pain). Acute treatment O2 (15l/min), aspirin (300mg) , clopidogrel (300mg), diamorphine (2.5 \200\2235mg IV), antiemetic (b p185), GTN (two puff s SL/5min until pain free; infusion if ongoing pain after 3 SL doses, pro- vided not hypot ensive, b p201) Anticoagulation with fondaparinux (b p407).2 B-blockade (eg bisoprolol 10mg STAT) but beware use in patients with COPD, hypotension or overt failure. Risk stratify (s ee below) and involve CCU+cardiologist early for high-risk patients for consideration of pr ompt catheterisation and glycoprotein IIb/IIIa inhibitors. Secondary prophylaxis and compli cations are broadly the same as in STEMI, though complications are less common. Risk strati \201 cation in ACS Estimation of the risk of death in ACS allows individualize d assessment of the risks and benefi ts of interventions and careful targeting of resources to those patients who stand to benefi t the most. A number of validated scoring algorithms have been developed from major clinical trial data. These include the pioneering Thromboly sis In Myocardial Infarction (TIMI) risk score3 still widely used in many hospitals. Howeve r, many such trials had restricted entry criteria, leading to under-representation of patie nts with renal or heart failure. The Global Registry of Acute Coronary Events (GRACE) algor ithms were developed from a multinational registry (94 hospitals, 14 countries, and 22,645 patients) involving patients with all subtypes of ACS (STEMI, NSTEMI, and UA).4 Risk scores may be cal- culated on admission (to predict in hospital and 6mth mortality) or on dischar ge (to predict 6mth mortality). A free online calculator is available at (cid:27)www.outcom es-umassmed.org/grace High-risk patients will need a CCU bed, and consideration for glycopr o- tein IIb/IIIa inhibitors and urgent catheterisation (within 96h). Low/intermediate-risk require observation to ensure pain free, then fur - ther stratifi cation using exercise ECG , coronary calcium scoring or stress imaging (echo or perfusion imaging) to determine need for catheterisation. 3 Antman, E.M. et al. JAMA 2000 284:835 available free online at (cid: 27)jama.ama-assn.org/cgi/ content/full/284/7/835 See also the excellent collection of resources available free at (ci d:27)www. timi.org 4 Granger, C.B. et al. Arch Intern Med 2003 163:2345 available free online at (cid:27)archi nte.ama- assn.org/cgi/content/full/163/19/2345 1 NICE guidelines available at (cid:27)guidance.nice.org.uk/CG94 2 Use unfractionated heparin infusion if angiography is planned within 24h, or if signifi c ant bleeding risk (consider in frail elderly, active/recent bleeding complications, signifi can t renal impairment or those with extreme low body mass). _OHFP.indb 245 _OHFP.indb 245 30/05/2014 16:18 30/05/2014 16:18 246 CHAPTER 7 Cardiovascular