Intensive Cardiac Care and Emergency Cardiology
The exam tests resuscitation sequences, shock management, and the emergency treatment of pulmonary oedema, pulmonary embolism, and right ventricular infarction, always in a time-critical format.
Cardiac arrest and post-arrest care
- VF or pulseless VT: immediate defibrillation, CPR, epinephrine every 3-5 minutes, amiodarone or lidocaine after the third shock.
- Asystole and PEA: epinephrine and reversible-cause search.
- Post-arrest: targeted temperature control avoiding fever, oxygen saturation 92-96%, normocapnia, and early coronary angiography when the arrest was cardiac in origin.
Cardiogenic shock
- Signs: hypotension, cold peripheries, lactate rise, oliguria; SCAI stages A to E describe progression.
- Treat with urgent revascularisation, norepinephrine first-line, and dobutamine added for low output; routine intra-aortic balloon pumping is not supported by trial evidence in myocardial infarction shock.
Pulmonary oedema
- Non-invasive ventilation, nitrates, and diuretics; treat the precipitant (arrhythmia, ischaemia, hypertensive crisis).
Pulmonary embolism and right ventricular infarction
- High-risk PE with hypotension: systemic thrombolysis or embolectomy.
- Right ventricular infarction with inferior STEMI: fluids for preload, avoid nitrates and aggressive diuresis, and avoid excessive vasodilation.
Worked example
A 70-year-old with syncope, BP 80/50, sinus tachycardia, and CT-proven bilateral pulmonary embolism is high risk and receives alteplase 100 mg over 2 hours, unless contraindicated, with heparin stopped during infusion.
Traps
- Nitrates in right ventricular infarction cause profound hypotension.
- Permissive hypotension in trauma does not apply to cardiogenic shock.
- Do not delay defibrillation for drug administration in shockable rhythms.