Cardio. 2 ~ Short Answer

Question 1.

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 beats/minute, blood pressure 85/55mmHg, respiratory rate 26 breaths/minute and an oxygen saturation of 92% on 6 litres of oxygen/minute via Hudson mask.

 A. What are the main issues that need to be addressed in this patient’s management?

Show Answer

  • Shock
    • Resuscitation with blood
  • Reversal of thrombolysis and heparin
  • Drainage of haemothorax to manage hypoxia
  • Definitive surgical management of haemothorax/bleeding

(4 marks)

B. List the immediate actions that you will undertake in this patients’ resuscitation and why.

Show Answer

A. Call for help

  • Urban district ED – likely only senior doctor present
  • Other DEM staff
  • Surgery
  • Haematology
  • Anaesthetics

B. O2 to achieve sats> 95%

  • To address hypoxia

C. Place large bore ICC in left chest

  • To address hypoxia

D. Place 2 x large IVCs

E. Transfuse with blood

  • To address hypotension & bleeding
  • If ? 4 units – massive transfusion protocol

(4 marks; bold needed)

 C. List the drugs and doses to reverse the thrombolysis and heparin?

Show Answer

Reversal of lytics

  • Aminocaproic Acid (plasminogen activator inhibitor)
    • 4-5g IV over 1 hour then 1g/hr until bleeding stops or 8 hours
  • Tranexamic Acid (plasminogen inhibitor)
    • 10 mg/kg over 20 mins IV every 6-8 hrs

Reversal of heparin

  • Protamine 1 mg for every 100U of UFH in last 15 minutes (Max 50 mg)

(3 marks)

 D. Describe a massive transfusion protocol and the biochemical goals

Show Answer

Massive transfusion = transfusion of half of one blood volume in 4 hours or more than one blood volume in 24 hours (adult blood volume 70 ml/kg).

Activated when transfused 4 units PRBCs with ongoing bleeding.

 

Ratios (no high level evidence for one particular ratio)

  • Ratio PRBC:FFP:platelets of 4:2:1 or 4:4:1
    • Assumes pooled platelets = 4 units of platelets
  • Cryoprecipitate based on fibrinogen levels
  • Ca replacement to maintain normal ionised Ca

 

Aims

  • Hb ? 80 g/dl
  • Plts ? 50 x 109/L
  • INR ?5
  • Fibrinogen ? 1.0 g/L
  • Ca2+ > 1.1 mmol/L
  • PT/APTT < 1.5 x normal
  • Temp > 35°C
  • pH > 7.2
  • lactate < 4 mmol/L
  • base excess < -6

(4 marks)

E. What are your options for organising surgical control of the bleeding?

Show Answer

  • Cardiothoracic surgery on site – unlikely to be available
  • Thoracotomy by general surgery – if available
  • Cardiothoracic surgeon to come to this hospital – would take time
  • Stabilise patient for transfer to site with cardiothoracic surgery – risky
  • Thoracotomy in ED to stop bleeding or cross-clamp aorta if arrests in ED

(3 marks; 3 out of 5)

Author: J Haire

 


 

Question 2.

A distressed 60 year old man from a nursing home is brought into the ED having ‘choked on his dentures’.

xray 2

A.)  List the abnormalities in this CXR

Show Answer

  • Denture/foreign body overlying mediastinum
  • Air in soft tissues of neck

(2 marks)

B.) What is major life-threatening complication that these abnormalities could indicate?

Show Answer

Perforated oesophagus and mediastinitis

(2 marks)

C.) What further investigations may be indicated?

Show Answer

  • Bedside
    • VBG
      • Acidosis/lactate –sepsis, baseline
    • Imaging
      • CT chest
        • perforation/mediastinitis
      • Bloods
        • FBC
          • WCC – infection/inflammation
        • U&Es
          • Renal
          • Electrolytes
          • Baseline

(2 marks bold + 1 other)

Author: J Haire

 


 

 

 

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