Download CVS I: Chest Pain, IHD, CCF

SAQ CVS 1
A 55 year old man is brought to hospital by ambulance
complaining of severe headache, vomiting and blurred vision.
On initial examination his BP is 260 / 145, similar in both arms.
His Glasgow Coma Score is 14.
CT scan reveals no
abnormality.
Question
Discuss the pharmacological treatment options for the treatment
of his hypertension.
Answer
Answer and Interpretation
FACEM SAQ Exam 2009.1 – Question 4
The overall pass rate for this question was 63/81
(78%).
Pass Criteria
The examiner pair felt that this was an
excellent question on a core EM presentation.
Pass criteria included nominating an
appropriate range of medications with appropriate
dosages and routes of administration within the
context of close physiological monitoring and safe
BP reductions.
Features of unsuccessful answers
Inadequate answers suggested oral administration
or inappropriate dosages.
An 82 year old man is brought to the emergency department
following a brief collapse at home. He has a history of chronic
renal failure and hypertension. His medications include an
angiotensin converting enzyme inhibiting agent (ACEI),
frusemide and metoprolol. He has no traumatic injuries from
this episode.
Examination reveals:
His ECG demonstrates third degree atrioventricular block.
Question
Describe your management
Answer
Answer and Interpretation
FACEM SAQ Exam 2010.1 – Question 6
The overall pass rate for this question was 45/70
(64.3%)
Pass Criteria
Recognition of shock
Consideration of all of:
IV Fluids
Atropine
Pacing (transcutaneous or transvenous)
Use of inotropes/chronotropes
Discussion of disposition to appropriately
monitored bed.
Better answers described above in context of
possible causes of collapse in this patient – Bblocker toxicity, ACS, electrolyte imbalance, head
injury, hypothermia.
Features of unsuccessful answers
Failure to recognise shock
Failure to take steps to correct rate
A 47 year old man with a history of hypertension and
depression has presented to your emergency department
following deliberate self poisoning approximately 3hrs ago
with 20 x 240mg slow release verapamil tablets.
Question
Describe your management of this patient.
Answer
Answer and Interpretation
FACEM SAQ Exam 2009.1 – Question 3
The overall pass rate for this question was 62/81
(76.5%).
Pass Criteria
The examiners felt that this was a good
toxicology question.
Comprehensive answers took into context the
time of presentation and utilized whole bowel
irrigation as the decontamination method of choice
plus discussed the evidence for other therapies
such as activated charcoal, glucose/insulin and
glucagon.
Appropriate disposition, including
psychiatric assessment, was deemed mandatory
also.
Features of unsuccessful answers
Poor answers failed to address the critical nature of
this presentation and the indication for whole bowel
irrigation.
Discuss the investigations for a suspected pulmonary embolus
in a 24 year old woman who is 10 weeks pregnant.
Answer
Answer and Interpretation
FACEM SAQ Exam 2010.1 – Question 4
The overall pass rate for this question was 47/70
(67.1%)
Pass Criteria
Discussion of supportive tests, definitive tests,
risk benefit analysis
Rational approach to reducing radiation risk
(when discussing the definitive tests)
Features of unsuccessful answers
Clear statement showing lack of
understanding of radiation risk (CTPA and V/Q)
Algorithm using both VQ and CTPA
Stating that CTPA was not indicated in
pregnancy
Not “discussing” question
A 67 year old male presents to your urban district emergency
department 1 hour post onset of chest pain. His ECG reveals
acute ST segment elevation of 3mm in leads V3, V4 and V5.
He is treated with aspirin (300mg), reteplase (two 10 unit
boluses 30 minutes apart), and unfractionated heparin (5000
unit bolus and 1000 units/hr infusion). Sixty minutes after the
thrombolysis is administered the patient complains of
increasing left sided chest discomfort and shortness of breath.
A repeat CXR reveals a new large left-sided collection in the
pleural space. His vital signs are currently heart rate 100, BP
85/55, RR 26 and O2 sat 92% on 6L per minute via Hudson
mask..
Question
a. Outline your management of this situation.
Answer
Answer and Interpretation
Facem Vaq Exam 2003.1 – Question 8
The overall pass rate for this question was 56 / 83
(67.5%).
Examiners considered this a good question that
covered a relevant scenario but included many issues
other than just basic resuscitation to cover.
These included an appreciation of alternate
diagnoses to AM1 (such as aortic dissection), reversal of
anticoagulation (prior to), insertion of an ICC, likely
need for transfer.
Failures tended not to cover these and ‘consider’
rather than say what
they would do.
A 53 year old previously well man presents with a 6 hour
history of palpitations. He is otherwise asymptomatic.
His
vitals signs are:
ECG reveals atrial fibrillation with a rate of 130 /minute. His
assessment does not reveal a cause for his arrhythmia.
Question
Discuss the management options for this patient.
Answer
(100
%)
Answer and Interpretation
FACEM SAQ Exam 2009.1 – Question 7
The overall pass rate for this question was 60/81
(74.1%).
Pass Criteria
Pass criteria were addressing the options of
no treatment, rate control,
cardioversion
(chemical/electrical) and
anticoagulation.
Features of unsuccessful answers
Poor answers failed to discuss these issues in the
context of this presentation or missed a major criterion
altogether.
5. An elite athlete has presented with chest discomfort after training. He has a family history of
HOCM and is concerned that he may also have it. Your findings on physical examination include: BP
110/70, pulse rate 40/min, displaced apex beat, prominent 4 th heart sound, systolic ejection murmur,
otherwise unremarkable. His ECG shows Mobitz Type 1 block, incomplete RBBB, LVH and ST
elevation in the chest leads. CXR shows CT ratio of 0.6 and prominent upper lobe veins. Discuss
these findings. Are any other investigations justifiable?
HOCM – asymmetrical LV/RVOT hypertrophy and mitral valve problems
SOB, angina, syncope, sudden death, a wave, double apex beat
S4, pansystollic murmur if MR, louder with valsalva, last 2 important
differentiating features
LVH, LAH, septal Q waves
CXR usually normal, can have venous congestion
Athlete – benign ’s reverse on cessation training, 40% male elite athletes
must rule out IHD, HOCM, pericarditis
Signs – bradycardia, displaced apex beat, ejection systolic murmur, no failure
ECG – sinus brady, incomplete RBBB, 1O or Mobitz I common,
LVH and ST repolarisation ’s common
CXR – can have prominent pulmonary vasculature due to CO
Echo – uniform hypertrophy and normal mitral valve
This fellow has features mainly suggestive of benign cardiac hypertrophy of the elite athlete, BUT need
to investigate further if :
family history HOCM/sudden death at young age (30’s and 40’s)
hypertension or heart failure
murmur accentuates with valsalva
develops Mobitz II, 3O block or long QT
This fellow
1. Rule out acute event now (IHD, pericarditis) troponins and ECG, CXR
2. Confirm family history HOCM
3. Echo indicated semi-urgently – avoid strenuous exercise until done
4. Cardiologist review
5. Consider other causes of his pain
SAQ 336
A 65 year old female presents 10 days following coronary artery bypass surgery at your
regional referral hospital. She is complaining of lightheadedness and sharp chest pain.
On examination, she has a clean median sternotomy wound, pulse rate 105/min, blood
pressure 145/90, respiratory rate 24/min, SaO2 94% (room air). There is dullness to
percussion and reduced breath sounds at the left lung base. ECG shows sinus
tachycardia with ST-T changes present on her pre-discharge ECG. Chrst xray shows a
moderate left pleural effusion.
a) Outline your assessment of this patient (50%)
b) Outline your management of this patient (50%)
ISSUES
Left pleural effusion 10d post-CABG, mild tachycardia and hypoxia with tachypnoea.
DDx pleural effusion
Transudate
- cardiac failure
- other: hepatic/renal failure/hypoalbunimea (unlikely)
Exudate
- infection eg community acquired pneumonia
- inflammatory eg pleuritis secondary to pleural irritation
- PE
- other: autoimmune (SLE), pancreatitis, malignancy (less likely)
Empyema
Hemothorax - ?2
Chylothorax –
a) ASSESSMENT
Aims:
- look for cause
- assess severity/complications
1. History
HPC
- duration of symptoms – CP, lightheadedness
gradual – slow accumulation of fluid
sudden – hemothorax
- associated symptoms –
infective: fever, productive cough, malaise
PE: pleuritic CP, SOB, palpitation, presyncope
CCF: SOB/orthopnoea/PND, peripheral edema
PMHx
RF for DVT/PE: recent OT, immobilisation, ?DVT prophylaxis, PHx/FHx DVT, hormonal Rx,
smoking
Underlying malignancy, autoimmune d/o
Cardiorespiratory reserve
Meds
Antiplatelets
Anticoagulants
Immunosuppressants
Allergies, Alcohol
SHx
ADLs, supports
2. Examination
Immediate life threats:
A,B airway patency and protection wrt GCS
RR, sats ?hypoxia
?respiratory mm. fatigue
C monitor for tachycardia, hypotension (postural) , cap refil
?mediastinal (tracheal) shift 2
D GCS
E BSL, temp.
Systems examination:
Lungs AE, creps ?pulmonary edema ?consolidation
Cardiac HS, added sounds, murmur (new or old)
?pericardial effusion
signs of failure – pulmonary edema, elevated JVP, peripheral edema
Abdo congested liver, ascites
Neuro GCS, ?focal neurology (thromboembolism)
Skin ?bruising 2
3. Investigations
Bedside:
- ECG no new changes
- ABG PaO2 ?hypoxemia
pH ?acidosis (resp or metabolic)
Laboratory:
- FBE ?anemia ?raised WCC in infection ?low platelets (?HITS)
- U&E renal function, hypoalbuminemia
- LFT ?hepatitis 2
- TnI compare to discharge Tn
- coags ?warfarin/heparin
- G&H may need BTF
- ?sternotomy wound swab
- Pleural fluid tap:
m/c/s WCC, RCC
protein
glucose
LDH
- BC if febrile > 38.5
Imaging:
Repeat CXR
CT chest/CTPA ?PE
Echo cardiac contractility, RWMA, pericardial collection, valves
b) MANAGEMENT
Acute area, full non-invasive monitoring
Treatment
1. Stabilisation
A,B consider NIPPV/IPPV if:
Hypoxic
Respiratory mm. fatigue
GCS < 9
Otherwise high flow O2 via NRB
C 18g canula
Tachycardic – 500ml n/saline, assess response
Aim – PR < 100, SBP > 100, CR < 3 sec
Watch for pulmonary edema
Packed cells if Hb < 110 (transfusion guidelines)
If collection is causing hemodynamic compromise via mediastinal shift – ICC, 30F, light
sedation, underwater seal drain
D monitor GCS, pupils
2. Specific treatment
Optimise hemodynamics
Drain pleural effusion as above
Watch for reflex pulmonary edema
Infective IV antibiotics: empiric – iv ceftriaxone + erythromycin – modify according to micro
Cardiac failure Diuretics, ACE-inhibitors, +/- inotropes
Hemothorax 30F ICC
If unstable (>1.5L stat or > 500ml/h) urgent thoracic surgery
3. Treat complications
Acute lung injury – supportive
Sepsis – iv antibiotics, +/- inotropes
Coagulopathy – FFP, platelets, cryoprecipitate as per guidelines
Renal failure – fluid balance, +/- dialysis
Supportive care
Sit up
Analgesia - iv morphine 2.5mg doses – titrate
Antiemetic – iv metoclopramide 10mg
Educate and support patient and family
Disposal
Unstable HDU/ICU
Consider OT for formal drainage
Stable CCU
Telemetry bed
Monitor gas exchange, hemodynamics, fluid balance
Involve cardiologist, cardiothoracic surgeon +/- intensivist
1
A 76 year old man presents to the ED after becoming light-headed at church that
morning. He has not experienced any chest pain, and his ECG reveals 3 rd degree
heart block at a rate of 24 /min.
(a) Outline the investigations you would perform
(b) Discuss the options for increasing his heart rate.
2
(30%)
(70%)
The hospital executive in your large urban district hospital has asked you to introduce
a chest pain unit, to reduce the work of the frequently full coronary care unit. It is
willing to provide you with appropriate resources.
(a) Outline the steps you would take in planning this unit.
(b) Outline a protocol for a patient referred to this unit
(50%)
(50%)
3
Describe the role of anti-platelet drugs in the treatment of acute coronary syndromes
in the ED.
4.
Discuss the pharmacological options that you would consider for the treatment
of a hypertensive emergency in the ED.
1.
A 72 yo woman presents with a 24 hour history of palpitations. It is her first episode. She
reports no other symptoms.
Her only past history is hypertension, treated with irbesartan.
Examination reveals an alert lady with a BP of 135 /80; ECG shows atrial fibrillation with a
rate of 145.
Discuss the management options.
7. A 35 year old man complains of calf pain after exercise. He is asymptomatic when you see him.
You note that he is hypertensive (160/70 in both arms). He has an ejection systolic murmur plus
clinical and ECG signs of moderate LVH. The pulses in his legs are weak. What is the differential
diagnosis? What further investigations and treatment does he need?
Story suggests vascular insufficiency to legs.
Could just be musculo-skeletal strain
Differential diagnosis
Most likely given story is coarctation aorta
Others:
Central vascular occlusion eg abdo mass
Embolism
Peripheral vascular disease – atheroma, Raynaud’s, arteritis
Examination
Radio-femoral delay, ankle/brachial index
Upper and lower limb hypertension
Document all peripheral pulses
Assoc with bicuspid aortic valve - ?opening snap or ESM?
Flow murmur heard over back
Exclude AAA
Investigations
ECG – hypertrophy
CXR – notching of ribs by collateral intercostals
Echo – TOE only likely to be sensitive enough
Peripheral vascular Doppler studies
Subtraction angiography of iliacs and lower limbs
Arch aortogram
Pressure gradient across coarctation
Complications if untreated
Of peripheral vascular disease
limb ischaemia, ulcers and loss
Of coarctation
Dissection, IHD/CAD, LVF, CVA, endocarditis
Treatment choices
Balloon dilatation – risk dissection/recurrence
Surgical correction if pressure gradient >30mmHg
8. A patient with a prosthetic heart valve has collapsed. Outline how you would assess the patient to
determine if the collapse was the result of a complication of the prosthetic valve.
History
Of collapse event – CVS/neuro symptoms, ?LOC etc, ?previous collapses
Of prosthetic valve – when/why/which/where placed? On Warfarin? IVDU?
Any previous valve complications? – endocarditis? valve/heart failure?, AMI, CVA,
Other co-morbidities?
Generic collapse FI questions
Examination
Vital signs, ABC, GCS, temperature
signs SBE
thorough neuro and CVS exam
other exam
Investigations
General collapse invx – usual bloods, INR, blood cultures
ECG, CXR, infection screen,
CT brain if suspect SOL, ICH, trauma, abscess, cerebral event
Specific to valve
Multiple blood cultures (3+) if SBE suspected
Echo – TTE easier but TOE better
Bottom line – Echo will give best info on functional status of valve, but other causes collapse need to
be ruled out
1.) A 75 year old man is brought into your tertiary level emergency department
by ambulance. The ambulance officers tell you he had a sudden onset of
severe, sharp chest and back pain 2/24 ago followed by a syncopal episode.
When they arrived he was sweaty and agitated and had a paraplegia which
resolved 20 minutes later. He has a past history of hypertension but is non
compliant with medications.
His BP is 180/85 in the right arm and 140/65 in the left arm pulse 80. He
remains agitated.
,
a.) Outline your management. (30%)
b.) Discuss investigations that may of benefit in the assessment of this man
(70%)
2.) You are asked to improve time taken to thrombolysis for patients with acute
myocardial infarction in your hospital. Outline the way that you would do this
2.) An 80 year old woman is brought to your ED after collapsing while on an organi~ThToui.On~iva1,
she is confused and dyspnoeic, with PR 50, BP 85/40, s~O29O%(r~~gen). ECG shows a narrow
complex bradycardia with no ~ ischaemic changes.
a.) outline your investigations
b.) describe your treatment options
A 52 year old man presents to the ED via ambulance. His wife reports that he has
had severe central chest pain for 6 hours. His EGG shows a large anterolateral AMI and a sinus rhythm of 110. He is agitated, with ~PO2 88% on 15
I/rn in 02 and a BP of 80/45. Examination reveals severe LVF.
Outline your management.
3.) Discuss the radiological investigations available for the assessment of a patient with
suspected pulmonary embolism.
The expectation of examiners was that answers to
this question would include a clinical risk stratification
to guide test selection, acknowledgement of the limited
utility of tests such as ABG/ECG/CXR & troponin and a
more detailed discussion of the important tests such as
D-dimer, V/Q scan, CTPA, echo, Doppler ultrasound
and angiography.
The better answers concentrated on the more
controversial areas with risk stratification as a prominent
part of their preferred approach.
Failing candidates tended to neglect the importance
of pretest risk stratification when deciding on the value or
otherwise of tests, did not provide sufficient detail in the
important areas or simply failed to “discuss” (and so did not
answer the question).
2.) A SQyear-oliLmDn_with a history of rheumatic heart disease dies of bacterial endocarditis after
an indwelling catheter insertion in your rgedi5ydbpartrnent.
-~
How would you reduce the risks of endocarditis after ED procedures in your department?
2008.2 SAQ 1
A 52 year old woman presents with atypical chest pain and a normal ECG.
What features on assessment would influence the disposition of this patient? (100%)
The overall pass rate for this question was 51/81
(63%).
Pass Criteria
The examiners felt that this was a good
question in that it tested a topical and common area
in Emergency Medicine.
Good answers suggested a structure for ACS
stratification and recognised the wide differential
of chest pain.
The best answers demonstrated knowledge of
recently published guidelines ( Cardiac Society,
TIMI).
Features of unsuccessful answers
Poor answers either failed to answer the question
or did not mention serial ECG/Cardiac Enzymes as part of the
risk stratification
Describe the use of amiodarone in the emergency department,
including its indications and limitations.
Answer
Answer and Interpretation
FACEM SAQ Exam 2006.2 – Question 3
The overall pass rate for this question was 37/57
(64.9%).
Pass Criteria
Examiners considered that this question
worked well as it tested a widely used Emergency
Department drug.
Candidates were expected to show good
knowledge of currently accepted indications and
acute toxicity.
Extra marks were allocated for those showing
knowledge of recent clinical trials and for
discussing areas of clinical controversy.
Features of unsuccessful answers
Candidates who failed the question did not
address all the standard indications, showed poor
knowledge of common problems with acute use
and did not state appropriate dosing schedules.
SAQ 165
A 65 year old woman presents to your ED with sudden onset of a painful, cold,
pulseless right leg. Outline your management.
ISSUES
Ischemic right lower limb
Sudden = probable embolus rather than thrombus ?source ?AF (90% cardiac, other – AAA)
Limb-threatening illness – needs urgent care and vascular referral
MANAGEMENT
Acute area. Full non-invasive monitoring
Call vascular surgeon and interventional radiologist early
Treatment
1. Stabilisation
High flow O2 to maximise O2 delivery to limb (15L via NRB)
Optimise hemodynamics with gentle fluid loading 250ml n/saline titrated to endpoint of PR
< 100, SBP > 100
Monitor GCS, BSL, temp
Check other limbs
2. Specific treatment
mild elevation of limb to prevent venous congestion, relieve pain
Anticoagulate: unfractionated heparin iv 60mg/kg load, then 12u/kg/hr infusion, monitor
aPTT
Definitive treatment: remove clot and reperfuse leg
a. Angiography intra-arterial thrombolysis with urokinase
embolectomy
b. Vascular surgery end-arterectomy
fem-pop bypass
3. Treatment of complications (monitor for:)
Compartment syndrome
Rhabdomyolysis
Emboli to other regions/trashing
Reperfusion injury eg hyperkalemia
Supportive Care
Prepare for sedation/GA:
ECG, CXR, coags (?spinal anaesthetic), G&H
Optimise lung and cardiac function within time limits
Analgesia – iv morphine 2.5mg doses – titrate
Antiemetic – iv metoclopramide 10mg
Pressure area care
Inform and support patient and family
Disposal
OT/Angiography suite for definitive care
Ix to find source of embolus: Echo, CT abdomen
Input from vascular surgeons, interventional radiologist, +/- anaesthetist
SAQ 319
(a) List the clinical signs that may be seen in thoracic aortic dissection (30%)
(b) List the diagnostic modalities that may be used in suspected thoracic aortic
dissection and comment on the advantages and disadvantages of each (70%)
(a) Clinical signs:
General signs:
• Distressed
• Diaphoretic
• Tachycardia
• Hypertensive / hypotensive (pre-terminal sign)
• Hypoxia
Specific signs associated with potential complications:
• Acute aortic incompetence – new murmur, LVF (pulmonary crepitations).
• Pericardial blood – tamponade – raised JVP, muffled heart sounds, hypotension.
• Extravascular free rupture – pre-terminal – signs of massive haemothorax.
• Aortic branch occlusions:
o Carotids – altered level of consciousness, hemiplegia, pulse deficits.
o Subclavian – pulse deficits, BP discrepancies.
o Renal – renal bruits.
o Lumbar / spinal – paraplegia, sensory changes.
o Femoral – pulse deficits, ischaemic lower limb.
• Pressure effects – Horner’s syndrome, superior vena caval syndrome.
(b) Diagnostic modalities:
CXR:
Advantages:
• Simple, rapid, readily available.
• Non-invasive.
• 85% sensitivity
Disadvantages:
• Non-specific, not diagnostic.
• Cannot be used to exclude dissection – as only 85% sensitivity.
CTA Chest:
Advantages:
• Relatively quick and available.
• Non-invasive.
• Sensitivity 80-90%
• Specificity 87-100%
• Identifies other causes of widened mediastinum or causes for the chest pain.
Disadvantages:
• Only for haemodynamically stable patients.
• Requires use of contrast – allergies, renal implications.
• Unable to demonstrate aortic valve involvement.
• May not be able to demonstrate site of intimal tear, or branch vessel involvement.
• Negative predictive value only 86% - potentially have to investigate further.
MRI:
Advantages:
• Non-invasive.
• No contrast or radiation
• Sensitivity 95-100%
• Specificity 94-100%
Disadvantages:
• Limited availability
• Long acquisition time
• Requires a haemodynamically stable patient.
• No information on coronary artery involvement.
Echocardiography:
Transthoracic:
• Advantages:
o Rapid, non-invasive, perform at bedside.
o Able to demonstrate aortic incompetence, myocardial function, pericardial blood /
tamponade.
o Sensitivity 60-85% / Specificity 63-96%.
• Disadvantages:
o Sensitivity only 60-85%
o Poor sensitivity for Type B dissections – difficulty imaging arch and descending aorta.
Transoesophageal:
• Advantages:
o Perform at bedside.
o Sensitivity 98-99%.
o Demonstrates aortic valve involvement, pericardial blood / tamponade, coronary artery
involvement.
• Disadvantages:
o Invasive.
o Requires patient to be sedated or intubated and ventilated.
o Not as sensitive for distal dissections.
Aortography:
Advantages:
• Sensitivity – 81-91% / Specificity 90-95%.
• Demonstrates aortic valve involvement, coronary artery and branch vessel involvement.
Disadvantages:
• Invasive.
• Use of contrast – allergic and renal implications.
• Time-intensive.
• Negative predictive value – 84% (may fail to demonstrate false lumen or intimal flap.