Cardiovascular Emergencies
Domain focus
The Cardiovascular Emergencies domain tests rapid recognition of ACS, malignant arrhythmias, acute heart failure, and aortic dissection. Expect ECG interpretation, reperfusion timing, and drug safety.
Core rules
- STEMI: activate reperfusion. Primary PCI goal door-to-balloon ≤90 min at a PCI center; fibrinolysis within 30 min if PCI is unavailable and there is no contraindication. Give aspirin 162–325 mg chewed, a P2Y12 inhibitor, and anticoagulant.
- Inferior STEMI: obtain right-sided leads; avoid nitroglycerin if RV infarction with hypotension.
- Aortic dissection: control heart rate first with IV beta-blocker to <60/min, then add a vasodilator; give analgesia. Type A needs surgery.
- Acute pulmonary edema: oxygen for hypoxemia, NIV, nitrates if hypertensive, diuretic; avoid fluid bolus.
- Unstable tachycardia: synchronized cardioversion; unstable bradycardia: atropine then pacing.
Worked example
A 62-year-old smoker has crushing chest pain and ST elevation in II, III, aVF, with BP 82/50. Right-sided lead V4R shows elevation. The correct move is to avoid nitroglycerin and give a cautious fluid bolus, because inferior STEMI can involve the right ventricle, which is preload dependent. Activate PCI and give aspirin, anticoagulation, and antiplatelet therapy; treat hypotension.
Traps
Do not label every ST elevation as STEMI-pericarditis and early repolarization exist. Do not give nitrates in RV infarction or recent phosphodiesterase inhibitor use. Missing posterior MI (ST depression V1–V3) and treating dissection with thrombolysis are classic errors.