Common cases seen on the acute take - cardiac
I am going to share my experience of management of common emergencies I see on the acute take.
This is no way an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Other useful websites:
http://www.bcs.com/pages/default.asp
https://www.escardio.org/
https://www.gov.uk/guidance/cardiovascular-disorders-assessing-fitness-to-drive
ACS:
This may be STEMI/NSTEMI
Every trust has its own guidelines so please follow them when it comes to this.
Tips:
Learn basic interpretation of ECGs here:https://litfl.com/ecg-library/
Patients with a new left bundle branch block, ST elevation/depression, T wave changes, dynamic ECG changes, active chest pain who are high risk need to be discussed with the PPCI center. There might be other criteria as well and follow your local guidelines.
Learn your local protocols ASAP. Whatever they are, ALWAYS call the PPCI reg/consultant and then ALWAYS chase it up
If the PPCI team asks you fax the referrals, ECGs, etc - ALSO ask them if you could have the work email address of the relevant team and email it as well - fax machines fail all the time. Follow up with a call.
STEMI patients should be transferred directly from ED to the PPCI center.
If they are for admission locally ( NSTEMI patients usually), ensure they are admitted to CCU so that they are seen by the appropriate specialists.
ALWAYS look at ECGs. Silent MIs in diabetic patients are quite common and may not always come in with chest pain.
Check previous ECGs as well - some changes might be chronic - old left bundle branch block.
NEVER delay treatment if you suspect ACS - you DO NOT have to wait for a troponin result if the history, clinical picture and EXG is convincing.
Remember common differentials - especially P.E.
If the patient is on a NOAC ( apixaban, rivaroxaban, dabigatran, etc), follow your trusts guidelines on ACS treatment in these cases.
MANAGEMENT POST PPCI
If you work in a trust where PPCIs and even regular diagnostic PCIs are done, I am sure you have come across complications. These are rare but can be potentially fatal.
If concerned, always call the cardiology consultant.
There can be a variety of complications ranging from stent occlusion to VT/VF in the cath lab to increased bleeding from guide wire insertion site.
Either way, these patients need careful monitoring- at least in the first 12 to 24 hours.
Tips:
The cardiology nurses are excellent at picking these up and managing acutely unwell patients. I have personally learnt a lot from them and continue to do so, even as a registrar.
Every trust has its own policy and when confused, contact the on call cardiology team ( even if they are located in a different trust).
PERICARDITIS:
https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Management-of-acute-pericarditis-treatment-and-follow-up
Young patient, which chest pain, ECG: low voltage, high trop, recent viral infection is usually pericarditis/myocarditis.
They have invariably received ACS treatment ( and I guess this is appropriate given that the cardiologists usually make this diagnosis and the ED team do not want to miss the obvious). Every trust manages this differently - in my trust, these patients are admitted to CCU, we do a bedside ECHO ( formal ECHO if there is availability), then discharge the patients on high dose NSAIDs with O/P follow up once they are feeling better.
PERICARDIAL EFFUSION
This could be an emergency especially if the patient is unstable. The ED team is very good at picking this up and they can even do a quick focussed ECHO to determine this. Some ED registrars/consultants can insert a pericardial drain but if they cannot the cardiology team or on call duty radiologist can also do this.
Remember to send the fluid off for analysis and monitor the drain output very carefully.
Tips:
There is always someone to insert a drain. Please ask and never assume that if you cannot do it, no one else can. Some district hospitals even transfer patients to specialist cardiology centres if necessary.
INFECTIVE ENDOCARDITIS
Ever thought how silly and non relevant PACES exam was? This condition will prove that wrong! People have been diagnosed with this condition ( correctly) by an ED doctor/ FY1/SHO on the medical take just by picking up subtle signs like splinter hemorrhages and microscopic haematuria.
Tips:
Always take blood cultures - there is a local protocol for this in each trust ( ie 3 sets, one hour apart from different peripheral regions).
Take a detailed history and do a thorough examination.
Look for needle injection marks in IVDUs - especially in the groin. However some IVDUs find atypical sites to inject. Also send a swab from the site if it looks infected.
Discuss this with the on call microbiologist and start on appropriate antibiotics if there is no standard protocol. The microbiologist will decide based on your history.
It is worth getting an urgent ECHO - some registrars are ECHO trained and can do a quick bedside ECHO to confirm the diagnosis.
Remember your local sepsis management guidelines.
Do not forget that patients can have septic emboli in any organ - I have seen intracranial, splenic, renal septic emboli.
ALWAYS listen for a murmur when you have a septic patient and check the peripheries for subtle signs.
These patients need antibiotics for upto 6 weeks and hence may benefit from a PICC line - be aware of IVDUs who leave the ward - they are very high risk and can inject IV drugs through their PICC lines hence constant vigilance is very important.
Some patients may be a candidate for valve replacement. Specialist centres have their own criteria hence it might be helpful to get in touch with them early/look at their referral proformas and request the necessary investigations early if the cardiology team think they are a candidate for valve replacement. They are discussed in a MDT first and this is an excellent opportunity for junior doctors to present such cases to cardiology and cardiothoracic consultants.
VENTRICULAR TACHYCARDIA
These patients are naturally very unwell and even if they are stable, they can deteriorate rapidly. Hence, prompt treatment is very important as per ALS guidelines and local trust policy.
Some stable patients on CCU who have been admitted due to another reason ( ie ACS), can have runs of VT as well.
Tips:
Remember your A to E assessment and ALS algorithms.
Connect defib pads.
Check electrolytes - especially magnesium, potassium, bone profile and phosphate.
Hypomagnesaemia is a common cause so replace it ASAP - be aware of torsades.
Listen to your cardiology nurses.
Call for help early!
If they need amiodarone, remember that they will need a central line hence let the ITU registrar know ( and try to observe, then assist and maybe ask if you could insert it next time under their supervision). Remember the contraindications of amiodarone. If confused, talk to your friendly on call cardiology team.
If indicated, these patients end up having an ICD device.
ICD FIRING
Some patients come in with repeated episodes of chest discomfort who have an ICD. They are put on telemetry ASAP and sometimes a run of VT is captured. They are admitted to CCU.
Tips:
ICDs can be interrogated by the cardio-physiology team ( who are usually not available out of hours - especially if you are in a district hospitals). They can even come to ED with their equipment to do an ICD check. They can usually identify the make and model by looking at the chest X ray however it can help if you can ask the patient to give you a leaflet which they usually carry with them at all times - it has the details of the make and model.
Always do a CXR to rule out a lead fracture.
Check for features of infection at the ICD site
Do the basic blood tests and check electrolytes, replace as necessary.
These patients still need telemetry as you can capture a VT episode and treat it appropriately.
ICD/CRT/PACEMAKER INFECTION
As device insertions are becoming more common, the number of device infections are also increasing.
Patients are usually very good at picking up soreness at the insertion site however they can be profoundly septic on arrival.
Tips:
Follow the sepsis guidelines and do blood cultures.
The device may need removing and then reinsertion and usually these patients are transferred to tertiary centres for further management.
They may need telemetry especially if there is a concern about the device not functioning properly.
HEART BLOCK
This can be of various types from the benign type 1 to the very worrying complete heart block.
Again as above, remember your basics and try to find out a cause. Remember that RCA occlusion ( supplying the AV node) leading to an inferior STEMI/NSTEMI which can result in a complete heart block so have a low threshold of doing a troponin.
Tips:
Always discuss such patients with the cardiology team ASAP if an urgent pacemaker is indicated.
There are other modalities available as well - ie external pacing, isoprenaline infusion after discussion with the cardiology team.
Try to find out a cause - MI being one of the common causes.
CONGESTIVE CARDIAC FAILURE
This is very common on the acute take.
Remember the basics - doing bloods including a BNP if it has never been done before ( https://pathways.nice.org.uk/pathways/acute-heart-failure ), CXR and giving a stat of diuretics after inserting a catheter.
The management of chronic heart failure is mentioned here:
https://pathways.nice.org.uk/pathways/chronic-heart-failure
Tips:
Think about causes - MI, valve stenosis could be a possible cause. Flash pulmonary oedema due to ACE inhibitors is another differential.
Remember other differentials like bilateral CAP, pulmonary fibrosis
Right heart failure and left heart failure have different presentations - so if the patient does not have pulmonary oedema, do not assume it is not heart failure.
Think about catheterizing patients - I have seen patients fall because they want to rush to the toilet for a wee and they feel dizzy because of getting up suddenly - hence have a low threshold to catheterize if you think a bottle/ bedside commode might be difficult.
Read the old letters - you might find helpful information like the patient tolerated continuous infusion of diuretics with a baseline blood pressure of 90mmhg systolic.
Request daily U and E's and daily weights. A fluid restriction can also help.
If they are elderly, frail think about escalation plans - https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
In some cases, CPAP may help with symptoms. The medical registrar, with ITU/outreach nurses' input and cardiology nurses may think that it will help oxygenation coupled with diuretics. The policies vary from trust to trust.
There are some very promising treatments for heart failure management- eg: sacubitril and valsartan, devices which can help the ejection fraction of the heart.
Heart failure nurses are very helpful in managing patients like these - seek their advice early ( although their criteria to review patients may vary from trust to trust).
VALVE STENOSIS/REGURGITATION
This can be chronic / acute.
There are loads of differentials and this is an excellent opportunity to brush up on clinical knowledge.
Tips
Remember the most common causes - aortic stenosis is very common.
This is an excellent opportunity to brush up on your CVS examination skills for PACES.
Think about infective endocarditis with a new murmur- especially regurgitation, features of infection with no clear cause.
If they meet the criteria, as per cardiology MDT, they can be for valve replacement. As mentioned above, if this is the case, ensure that they have had the relevant investigations once they have been accepted.
CARDIAC SYNCOPE
This can due to various reasons - arrhythmias being on top of the list. If telemetry, ECHO, bloods of these patients are normal, they may end up having a reveal device inserted- which is a small USB like device inserted subcutaneously over the left pectoral region to monitor any arrhythmias. They are given a device with a button to press whenever they become symptomatic - the device then saves the ECG over the past few minutes-hour and it can be electronically transferred/ interrogated by the cardio-physiologists.
Tips:
Never take syncopal episodes lightly if there is no clear cause identifiable.
A referral to the cardiology team for a reveal device insertion in such cases can be life saving.
CARDIOLOGY MDTs
These are held every week with a variety of team members - including cardiology consultants, cardiothoracic consultants, heart failure nurses, ECHO technicians, CCU nurses, doctors and other specialist nurses.
They discuss a variety of cases like
- Atypical ECHO findings
- Atypical angiogram findings
- Whether surgical management of occluded coronaries, valve dysfunction is indicated.
- Discussion about specialist tests interpretation like cardiac MRIs, etc.
This is an excellent opportunity for doctors to present their cases as well, even if they saw them on the acute take and the cardiology consultant want to discuss further management in a MDT.
Points to remember:
1. Bring the patients notes if possible
2. Summarize the case beforehand - have a basic idea of their mobility, functional status.
3. Discuss cases in a SBAR format explained here:https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html#!/2019/12/handing-over-patients-in-different.html
This list is no way complete. Please read up on management of whatever condition you see on your local trust website and on NICE, BSC and ESC.
Some cases are very interesting and it might be worth asking your cardiology consultants if you can do a case study on them and publish it/present it in your local grand rounds/conferences.
Overall, cardiology is complex but a lot of fun. The cardiology team is very helpful- even if they are based in another tertiary centre.
This is no way an official guideline and is just my experience. Please refer to your local guidelines and always escalate if you are not sure.
Read the national NICE guidance here:
https://www.nice.org.uk/
Other useful websites:
http://www.bcs.com/pages/default.asp
https://www.escardio.org/
https://www.gov.uk/guidance/cardiovascular-disorders-assessing-fitness-to-drive
ACS:
This may be STEMI/NSTEMI
Every trust has its own guidelines so please follow them when it comes to this.
Tips:
Learn basic interpretation of ECGs here:https://litfl.com/ecg-library/
Patients with a new left bundle branch block, ST elevation/depression, T wave changes, dynamic ECG changes, active chest pain who are high risk need to be discussed with the PPCI center. There might be other criteria as well and follow your local guidelines.
Learn your local protocols ASAP. Whatever they are, ALWAYS call the PPCI reg/consultant and then ALWAYS chase it up
If the PPCI team asks you fax the referrals, ECGs, etc - ALSO ask them if you could have the work email address of the relevant team and email it as well - fax machines fail all the time. Follow up with a call.
STEMI patients should be transferred directly from ED to the PPCI center.
If they are for admission locally ( NSTEMI patients usually), ensure they are admitted to CCU so that they are seen by the appropriate specialists.
ALWAYS look at ECGs. Silent MIs in diabetic patients are quite common and may not always come in with chest pain.
Check previous ECGs as well - some changes might be chronic - old left bundle branch block.
NEVER delay treatment if you suspect ACS - you DO NOT have to wait for a troponin result if the history, clinical picture and EXG is convincing.
Remember common differentials - especially P.E.
If the patient is on a NOAC ( apixaban, rivaroxaban, dabigatran, etc), follow your trusts guidelines on ACS treatment in these cases.
MANAGEMENT POST PPCI
If you work in a trust where PPCIs and even regular diagnostic PCIs are done, I am sure you have come across complications. These are rare but can be potentially fatal.
If concerned, always call the cardiology consultant.
There can be a variety of complications ranging from stent occlusion to VT/VF in the cath lab to increased bleeding from guide wire insertion site.
Either way, these patients need careful monitoring- at least in the first 12 to 24 hours.
Tips:
The cardiology nurses are excellent at picking these up and managing acutely unwell patients. I have personally learnt a lot from them and continue to do so, even as a registrar.
Every trust has its own policy and when confused, contact the on call cardiology team ( even if they are located in a different trust).
PERICARDITIS:
https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-15/Management-of-acute-pericarditis-treatment-and-follow-up
Young patient, which chest pain, ECG: low voltage, high trop, recent viral infection is usually pericarditis/myocarditis.
They have invariably received ACS treatment ( and I guess this is appropriate given that the cardiologists usually make this diagnosis and the ED team do not want to miss the obvious). Every trust manages this differently - in my trust, these patients are admitted to CCU, we do a bedside ECHO ( formal ECHO if there is availability), then discharge the patients on high dose NSAIDs with O/P follow up once they are feeling better.
PERICARDIAL EFFUSION
This could be an emergency especially if the patient is unstable. The ED team is very good at picking this up and they can even do a quick focussed ECHO to determine this. Some ED registrars/consultants can insert a pericardial drain but if they cannot the cardiology team or on call duty radiologist can also do this.
Remember to send the fluid off for analysis and monitor the drain output very carefully.
Tips:
There is always someone to insert a drain. Please ask and never assume that if you cannot do it, no one else can. Some district hospitals even transfer patients to specialist cardiology centres if necessary.
INFECTIVE ENDOCARDITIS
Ever thought how silly and non relevant PACES exam was? This condition will prove that wrong! People have been diagnosed with this condition ( correctly) by an ED doctor/ FY1/SHO on the medical take just by picking up subtle signs like splinter hemorrhages and microscopic haematuria.
Tips:
Always take blood cultures - there is a local protocol for this in each trust ( ie 3 sets, one hour apart from different peripheral regions).
Take a detailed history and do a thorough examination.
Look for needle injection marks in IVDUs - especially in the groin. However some IVDUs find atypical sites to inject. Also send a swab from the site if it looks infected.
Discuss this with the on call microbiologist and start on appropriate antibiotics if there is no standard protocol. The microbiologist will decide based on your history.
It is worth getting an urgent ECHO - some registrars are ECHO trained and can do a quick bedside ECHO to confirm the diagnosis.
Remember your local sepsis management guidelines.
Do not forget that patients can have septic emboli in any organ - I have seen intracranial, splenic, renal septic emboli.
ALWAYS listen for a murmur when you have a septic patient and check the peripheries for subtle signs.
These patients need antibiotics for upto 6 weeks and hence may benefit from a PICC line - be aware of IVDUs who leave the ward - they are very high risk and can inject IV drugs through their PICC lines hence constant vigilance is very important.
Some patients may be a candidate for valve replacement. Specialist centres have their own criteria hence it might be helpful to get in touch with them early/look at their referral proformas and request the necessary investigations early if the cardiology team think they are a candidate for valve replacement. They are discussed in a MDT first and this is an excellent opportunity for junior doctors to present such cases to cardiology and cardiothoracic consultants.
VENTRICULAR TACHYCARDIA
These patients are naturally very unwell and even if they are stable, they can deteriorate rapidly. Hence, prompt treatment is very important as per ALS guidelines and local trust policy.
Some stable patients on CCU who have been admitted due to another reason ( ie ACS), can have runs of VT as well.
Tips:
Remember your A to E assessment and ALS algorithms.
Connect defib pads.
Check electrolytes - especially magnesium, potassium, bone profile and phosphate.
Hypomagnesaemia is a common cause so replace it ASAP - be aware of torsades.
Listen to your cardiology nurses.
Call for help early!
If they need amiodarone, remember that they will need a central line hence let the ITU registrar know ( and try to observe, then assist and maybe ask if you could insert it next time under their supervision). Remember the contraindications of amiodarone. If confused, talk to your friendly on call cardiology team.
If indicated, these patients end up having an ICD device.
ICD FIRING
Some patients come in with repeated episodes of chest discomfort who have an ICD. They are put on telemetry ASAP and sometimes a run of VT is captured. They are admitted to CCU.
Tips:
ICDs can be interrogated by the cardio-physiology team ( who are usually not available out of hours - especially if you are in a district hospitals). They can even come to ED with their equipment to do an ICD check. They can usually identify the make and model by looking at the chest X ray however it can help if you can ask the patient to give you a leaflet which they usually carry with them at all times - it has the details of the make and model.
Always do a CXR to rule out a lead fracture.
Check for features of infection at the ICD site
Do the basic blood tests and check electrolytes, replace as necessary.
These patients still need telemetry as you can capture a VT episode and treat it appropriately.
ICD/CRT/PACEMAKER INFECTION
As device insertions are becoming more common, the number of device infections are also increasing.
Patients are usually very good at picking up soreness at the insertion site however they can be profoundly septic on arrival.
Tips:
Follow the sepsis guidelines and do blood cultures.
The device may need removing and then reinsertion and usually these patients are transferred to tertiary centres for further management.
They may need telemetry especially if there is a concern about the device not functioning properly.
HEART BLOCK
This can be of various types from the benign type 1 to the very worrying complete heart block.
Again as above, remember your basics and try to find out a cause. Remember that RCA occlusion ( supplying the AV node) leading to an inferior STEMI/NSTEMI which can result in a complete heart block so have a low threshold of doing a troponin.
Tips:
Always discuss such patients with the cardiology team ASAP if an urgent pacemaker is indicated.
There are other modalities available as well - ie external pacing, isoprenaline infusion after discussion with the cardiology team.
Try to find out a cause - MI being one of the common causes.
CONGESTIVE CARDIAC FAILURE
This is very common on the acute take.
Remember the basics - doing bloods including a BNP if it has never been done before ( https://pathways.nice.org.uk/pathways/acute-heart-failure ), CXR and giving a stat of diuretics after inserting a catheter.
The management of chronic heart failure is mentioned here:
https://pathways.nice.org.uk/pathways/chronic-heart-failure
Tips:
Think about causes - MI, valve stenosis could be a possible cause. Flash pulmonary oedema due to ACE inhibitors is another differential.
Remember other differentials like bilateral CAP, pulmonary fibrosis
Right heart failure and left heart failure have different presentations - so if the patient does not have pulmonary oedema, do not assume it is not heart failure.
Think about catheterizing patients - I have seen patients fall because they want to rush to the toilet for a wee and they feel dizzy because of getting up suddenly - hence have a low threshold to catheterize if you think a bottle/ bedside commode might be difficult.
Read the old letters - you might find helpful information like the patient tolerated continuous infusion of diuretics with a baseline blood pressure of 90mmhg systolic.
Request daily U and E's and daily weights. A fluid restriction can also help.
If they are elderly, frail think about escalation plans - https://omarsguidelines.blogspot.com/2020/02/teaching-session-ceiling-of-care-in-nhs.html
In some cases, CPAP may help with symptoms. The medical registrar, with ITU/outreach nurses' input and cardiology nurses may think that it will help oxygenation coupled with diuretics. The policies vary from trust to trust.
There are some very promising treatments for heart failure management- eg: sacubitril and valsartan, devices which can help the ejection fraction of the heart.
Heart failure nurses are very helpful in managing patients like these - seek their advice early ( although their criteria to review patients may vary from trust to trust).
VALVE STENOSIS/REGURGITATION
This can be chronic / acute.
There are loads of differentials and this is an excellent opportunity to brush up on clinical knowledge.
Tips
Remember the most common causes - aortic stenosis is very common.
This is an excellent opportunity to brush up on your CVS examination skills for PACES.
Think about infective endocarditis with a new murmur- especially regurgitation, features of infection with no clear cause.
If they meet the criteria, as per cardiology MDT, they can be for valve replacement. As mentioned above, if this is the case, ensure that they have had the relevant investigations once they have been accepted.
CARDIAC SYNCOPE
This can due to various reasons - arrhythmias being on top of the list. If telemetry, ECHO, bloods of these patients are normal, they may end up having a reveal device inserted- which is a small USB like device inserted subcutaneously over the left pectoral region to monitor any arrhythmias. They are given a device with a button to press whenever they become symptomatic - the device then saves the ECG over the past few minutes-hour and it can be electronically transferred/ interrogated by the cardio-physiologists.
Tips:
Never take syncopal episodes lightly if there is no clear cause identifiable.
A referral to the cardiology team for a reveal device insertion in such cases can be life saving.
CARDIOLOGY MDTs
These are held every week with a variety of team members - including cardiology consultants, cardiothoracic consultants, heart failure nurses, ECHO technicians, CCU nurses, doctors and other specialist nurses.
They discuss a variety of cases like
- Atypical ECHO findings
- Atypical angiogram findings
- Whether surgical management of occluded coronaries, valve dysfunction is indicated.
- Discussion about specialist tests interpretation like cardiac MRIs, etc.
This is an excellent opportunity for doctors to present their cases as well, even if they saw them on the acute take and the cardiology consultant want to discuss further management in a MDT.
Points to remember:
1. Bring the patients notes if possible
2. Summarize the case beforehand - have a basic idea of their mobility, functional status.
3. Discuss cases in a SBAR format explained here:https://omarsguidelines.blogspot.com/2019/12/handing-over-patients-in-different.html#!/2019/12/handing-over-patients-in-different.html
This list is no way complete. Please read up on management of whatever condition you see on your local trust website and on NICE, BSC and ESC.
Some cases are very interesting and it might be worth asking your cardiology consultants if you can do a case study on them and publish it/present it in your local grand rounds/conferences.
Overall, cardiology is complex but a lot of fun. The cardiology team is very helpful- even if they are based in another tertiary centre.
Comments
Post a Comment