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CARDIOVASCULAR SYSTEM
Management guidelines (pp. 2–8)
Anaphylactic shock
Dysrhythmias
Bradycardia
Atrial fibrillation (AF)
Paroxysmal
Persistent
Permanent
Atrial flutter
Paroxysmal supraventricular tachycardia (PSVT)-(narrow complex tachycardia)
Ventricular fibrillation (VF)
Ventricular tachycardia
Heart failure
Acute
Chronic
Hyperlipidaemia
Hypertension
Ischaemic heart disease
Stable angina
Acute coronary syndromes
Unstable angina
Non-ST elevation myocardial infarction (MI)
ST elevation MI
Post MI
Thromboembolism
Deep vein thrombosis (DVT)
Pulmonary embolism
Drug types (pp. 9–11)
Beta blockers
Calcium-channel blockers
Diuretics
Drugs (pp. 12–40)
Angiotensin-converting enzyme (ACE) inhibitors
Adenosine, alpha1 blockers, amiodarone, amlodipine, angiotensin-receptor blockers (ARBs), aspirin, atenolol, atropine
Bendroflumethiazide, bezafibrate
Clopidogrel
Digoxin, diltiazem, dobutamine, dopamine
Epinephrine, ezetimibe
Furosemide
Heparin
Methyldopa
Nicorandil, nitrates (glyceryl trinitrate [GTN], isosorbide dinitrate
[ISDN], isosorbide mononitrate [ISMN])
Sildenafil, simvastatin, spironolactone
Tenecteplase
Verapamil
Warfarin
Management Guidelines
ANAPHYLACTIC SHOCK
- Give 0.5 mg (0.5 ml of 1:1000) epinephrine intramuscular (IM) (given intravenous [IV] if there is no central pulse or if severely unwell) if any compromise in airway (stridor, tongue swelling), breathing (low oxygen saturations, wheeze) or circulation (hypotensive, pale, clammy).
- Most ideal site to inject IM epinephrine is the middle third of thigh on the anterolateral aspect.
- Give high-flow oxygen through face mask.
- Gain IV access.
- Give 10 mg of IV chlorpheniramine.
- Give 100–200 mg IV hydrocortisone.
- Consider salbutamol nebulizer and IV aminophylline if bronchospasm present.
- Administer IV fluids if required to maintain blood pressure (BP).
- Repeat IM epinephrine every 5 minutes if no improvement, as guided by BP, pulse and respiratory function.
- If still no improvement, consider intubation and mechanical ventilation.
- Follow-up:
- Suggest a medic alert bracelet naming culprit allergen.
- Identify allergen with skin prick testing and consider referral to an allergy clinic at a later stage.
- Self-injected epinephrine may be necessary for the future.
DYSRHYTHMIAS
Bradycardia
- Look for and treat underlying cause (e.g. drugs, hypothyroidism, post MI).
- If pulse rate <40 bpm and patient symptomatic, give IV atropine up to a maximum dose of 3 mg.
- If no response, consider external, percussion or temporary venous pacing until underlying cause corrected or permanent pacemaker inserted.
Atrial fibrillation (AF)
- Look for and treat any underlying cause.
- Antiarrhythmic agents are used to restore sinus rhythm or control ventricular rate.
- Consider anticoagulation with warfarin (aspirin if warfarin contraindicated or inappropriate) to prevent thromboembolic events. The CHAD score can help in making a decision however all those with valvular heart disease should be anticoagulated
- Paroxysmal AF:
- Self-terminating, usually lasts less than 48 hours.
- If recurrent, consider warfarin and antiarrhythmic drugs (e.g. sotalol, amiodarone).
- Persistent AF:
- Lasts more than 48 hours and can be converted to sinus rhythm either chemically (amiodarone, beta blocker or flecainide) or with synchronized direct current (DC) shock.
- In cases of synchronized DC shock, administer warfarin for 1 month, then give DC shock under general anaesthetic to revert to sinus rhythm (only if no structural heart lesions are present) and continue warfarin for 1 month thereafter. If haemodynamically unstable, DC cardiovert with IV heparin or LMWH.
- Permanent AF:
- To control the ventricular rate use digoxin, a rate-limiting calcium-channel blocker, beta blocker or amiodarone as monotherapy or in combination.
- Warfarin for anticoagulation (give aspirin if warfarin is contraindicated or inappropriate) if risk of emboli is high
- Consider pacemaker or radiofrequency ablation if all else fails.
Atrial flutter
- Look for and treat any underlying cause.
- Treat as for acute AF.
- In chronic atrial flutter, maintain on warfarin to prevent thromboembolic events and antiarrhythmic medication (e.g. sotalol, amiodarone) and consider radiofrequency ablation.
Paroxysmal supraventricular tachycardia (PSVT)
- Most terminate spontaneously, if not perform vagal manoeuvres (e.g. carotid sinus massage if no bruits, Valsalva manoeuvre), which transiently increase atrioventricular (AV) block.
- If this fails, give IV adenosine in incremental doses.
- If this fails, or adenosine is contraindicated, give IV verapamil.
- If the patient is haemodynamically compromised, give synchroniz...
