Cardiovascular Emergencies
Acute coronary syndromes
Obtain a 12-lead ECG within 10 minutes of arrival and repeat it if the first is non-diagnostic. STEMI: primary PCI if achievable within 120 minutes, otherwise fibrinolysis within 30 minutes with subsequent transfer. Give aspirin 300 mg chewed, a P2Y12 inhibitor, anticoagulation and titrated analgesia; oxygen only if hypoxic.
Trap: inferior STEMI with hypotension may be a right ventricular infarct, which is preload dependent. Give a 250–500 mL fluid bolus and avoid nitrates and high-dose morphine, which can precipitate catastrophic hypotension.
Aortic dissection: sudden tearing pain radiating to the back, pulse deficit, inter-arm blood pressure difference, widened mediastinum. Control heart rate with a beta-blocker first (target below 60 bpm), then blood pressure, before definitive imaging or surgery.
Arrhythmias: unstable tachycardia gets synchronised cardioversion; regular narrow-complex SVT gets vagal manoeuvres then adenosine 6 mg, then 12 mg; atrial fibrillation gets rate control unless unstable; VT with a pulse gets amiodarone or cardioversion. Symptomatic bradycardia gets atropine 500–1000 µg, then pacing.
Pulmonary oedema: sit up, oxygen or CPAP, nitrates if systolic pressure allows, and diuretics only when genuinely volume overloaded - vasodilatation, not diuresis, is the priority in hypertensive flash oedema.
Rule of thumb: tachycardia is never a diagnosis - ask why the patient is fast (fever, pain, bleeding, hypoxia, sepsis, withdrawal).