26 Questions
What is the primary concern for patients with severe coronary artery disease?
CABG surgery may be required
What is typically observed on an ECG for a patient with Wellens' Syndrome?
Biphasic or deeply inverted T waves in V2-3
What is the significance of a Type A pattern on an ECG?
Sign of reperfusion
What is the significance of a patient's cardiac enzymes being normal or minimally elevated?
Does not necessarily rule out a cardiac event
What is the recommended management for patients with Wellens' Syndrome?
PCI or CABG
What is the significance of psychological stress in cardiac patients?
Can cause tachyarrhythmias
What is the goal of electrical cardioversion?
To restore a normal heart rhythm
Why may patients with Wellens' Syndrome be at high risk for anterior wall MI?
Due to the critical stenosis of the LAD
What is a potential cause of delayed deterioration in a patient with a myocardial infarction?
Retroperitoneal hemorrhage
What is a common investigation performed in the case of delayed deterioration in a patient with a myocardial infarction?
EKG
What is a potential diagnosis in a patient with a myocardial infarction and a new murmur?
Ventricular septal defect
What is the management of Type I MI in a patient presenting with chest pain?
Treat medically for MI and pursue prompt catheterization
What is a complication of myocardial infarction that can cause delayed deterioration?
Ventricular free wall rupture
What is a sign of pericarditis on physical examination?
Pericardial friction rub
What is a potential cause of delayed deterioration in a patient with a myocardial infarction?
In-stent thrombosis
What is a potential diagnosis in a patient with a myocardial infarction and a new murmur?
Mitral regurgitation
What is the definition of concordant ST elevation in ECG?
≥1 mm and proportionally excessive (≥25% of depth of preceding S-wave)
In which leads is ST elevation typically seen in an anteroseptal myocardial infarction?
V1-V4
What is the indication for urgent echocardiography in a patient with LBBB?
To detect wall motion abnormalities
What is the target temperature for avoiding hypothermia in trauma patients?
> 36°C
What is the goal of 'damage control surgery' in trauma patients?
To control haemorrhage, decompress, decontaminate, and splint
What is the indication for performing regular blood gas analysis in trauma patients?
To monitor base excess
What is the recommended target for platelet transfusion in trauma patients?
> 100x10^9/L
What is the consequence of inappropriate use of vasoconstrictors in trauma patients?
Doubled mortality
What is the recommended target for INR in trauma patients?
< 1.8
What is the recommended goal for surgery time in trauma patients?
< 90 minutes
Study Notes
Clinical Causes of Delayed Deterioration Post-MI
- Deterioration post-MI can be caused by Left main coronary artery (LMCA) stenosis, Proximal left anterior descending artery (LAD) stenosis, Severe triple vessel disease, Reinfarction, and Hypoxia or hypotension.
- Rupture can also cause delayed deterioration, including ventricular free wall rupture, ventricular septal defect (VSD), and mitral valve chordae tendinae rupture.
- Post-MI Pericarditis and Hemorrhage (e.g., retroperitoneal hemorrhage) can also contribute to delayed deterioration.
Differential Diagnosis
- Investigation of delayed deterioration includes review of recent interventions, EKG (new ischemia), Auscultation (new murmur), and Pericardial friction rub.
Management of Delayed Deterioration
- Management depends on the clinical context: if Type I MI, treat medically for MI and pursue prompt catheterization; if Type-2 MI, treat the underlying cause of stress and follow EKGs carefully.
Wellens Syndrome
- Wellens Syndrome is a clinical syndrome characterized by biphasic or deeply inverted T waves in V2-3, plus a history of recent chest pain now resolved.
- It is highly specific for critical stenosis of the left anterior descending artery (LAD) and indicates high risk for extensive anterior wall MI.
Psychological Stress and Tachyarrhythmias
- Psychological stress can trigger tachyarrhythmias, and dexmedetomidine should be considered.
Electrical Cardioversion
- Synchronized cardioversion is recommended, with a dose of 25-50 J/kg.
Management of Cardiac Arrest
- Aim to avoid hypothermia, with a target temperature > 36°C.
- Remove wet clothing and sheets, and use warm blood products, fluids, and warming blankets/mattresses.
- Perform damage control surgery, including hemorrhage control, decompression, decontamination, and splintage.
- Aim for surgery time < 90 minutes and conduct regular 'surgical pauses'.
Metabolic Management
- Perform regular blood gas analysis, and use base excess to guide resuscitation.
- If lactate > 5mmol/L or rising, consider stopping surgery, splinting, and transferring to ICU.
Avoiding Vasoconstrictors
- Inappropriate use of vasoconstrictors doubles mortality, but may be required in cases of spinal cord or traumatic brain injury.
Coagulation Management
- Check clotting regularly and target transfusion, aiming for platelets > 100x10^9/L, INR ≤ 1.8, and fibrinogen > 2g/L.
Pediatric Doses
- Pediatric doses are not specified in the text.
Cardiology
- Diagnose acute coronary syndrome (ACS) using ECG, clinical symptoms, and biomarkers.
Thoracic Pain
- Thoracic pain can be a symptom of ACS.
Acute Coronary Syndrome (ACS)
- ACS is defined as a clinical syndrome characterized by symptoms of myocardial ischemia, with or without ST elevation.
ECG Diagnosis
- ECG diagnosis includes concordant ST elevation, concordant ST depression, and discordant ST elevation.
- In cases of LBBB, urgent echocardiography may be useful to detect wall motion abnormalities.
- Repeat ECG if uncertain.
- Anatomical localization of ST elevation can help identify the affected coronary artery.
Identify the clinical causes of cardiac issues, including post-MI deterioration, left main coronary artery stenosis, and proximal left anterior descending artery stenosis. Differential diagnosis and investigation methods are also discussed.
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