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 |(100%) |

| |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:

[pic]

His ECG demonstrates third degree atrioventricular block.

Question

| |Describe your management |(100%) |

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:

1. IV Fluids

2. Atropine

3. Pacing (transcutaneous or transvenous)

4. 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 – B-blocker 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. |(100%) |

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.

| |(100%) |

|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. | |(100%) |

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:

[pic]


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. |(100%) |

Answer

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 4th 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° to infection

Chylothorax – 2° to thoracic duct injury

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° to tension hemothorax/effusion

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° to coagulopathy

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° to congestion

- 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 3rd degree heart block at a rate of 24 /min.

(a) Outline the investigations you would perform (30%)

(b) Discuss the options for increasing his heart rate. (70%)

2 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. (50%)

(b) Outline a protocol for a patient referred to this unit (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 antero-lateral 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

| |(100%) |

| | |

|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.

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