…more patients survive with severe, diffuse CAD that is no longer amenable to additional mechanical revascularization. Despite treatment with antianginal drugs and PCI or CABG…

…severe symptoms New confusion Severe headache Persistent nausea Moderately reduced consciousness Marked gait instability The specificity of the symptoms is limited. In a patient with…

…with or without diagnostic electrocardiographic abnormalities and with or without an acute rise in cardiac troponin. The spectrum ranges from symptom free presentation to persistent…

…than persistent obstruction of the treated epicardial segment. The phenomenon occurs in approximately 2%–3% of PCI procedures overall. It is particularly associated with intervention…

…elevation myocardial infarction (STEMI) is an acute coronary syndrome characterized clinically by acute myocardial ischaemic symptoms or equivalent presentations together with persistent ST segment elevation…

…with symptomatic HFrEF. The guideline defined population includes: LVEF ≤35%; sinus rhythm; resting heart rate ≥70 beats/min; persistent symptoms despite evidence based therapy with…

…segment elevation myocardial infarction (STEMI) is an acute myocardial infarction associated with a working diagnosis of persistent ST segment elevation or an accepted equivalent in…

…adequate. For example, a patient with acute graft occlusion may report an abrupt reduction in walking distance before claudication, accompanied by moderate pain or paresthesia…

…respond to medication Visual disturbance Persistent severe epigastric pain Pulmonary oedema Thrombocytopenia, with platelets <100 × 10⁹/L Renal insufficiency, with creatinine 1.1 mg/dL…

…Patients with hypotension, marked low output, or persistent severe symptoms require close monitoring and consideration of invasive haemodynamic assessment when precise measurements are needed to…

…abscess, hidradenitis abscess and paronychia with a collection of pus. Persistent painful induration after a few days of antibiotics — suggests that an abscess has formed…

…Silent or nearly silent chest Very severe airflow obstruction pH below 7.35 with raised pCO₂ Acute or acute on chronic hypercapnic respiratory failure Rapidly…

…triggers it [1,2]. The single most important practical rule is: Continuous acute dizziness with spontaneous nystagmus: consider HINTS plus, but only if the examiner…

…acute troponin elevation without evidence of ischaemia represents acute myocardial injury rather than MI. Persistent elevation without a significant dynamic change is consistent with chronic…

…or electrical instability in advanced or acute presentations Left main disease may be clinically silent, and revascularisation recommendations are not restricted to patients with symptoms…

…defining electrocardiographic feature is the absence of persistent ST segment elevation. This does not imply low risk: patients with NSTE ACS may have substantial myocardial…

…ACS is broad. Patients may be asymptomatic at presentation, have persistent chest discomfort, or present with cardiac arrest, electrical or haemodynamic instability, or cardiogenic shock…

…a genetic mutation in the RYR1 receptor, resulting in persistent muscle contraction upon administration of halogenated anesthetic agents. As an idiosyncratic response to substances such…

…Important presentations include: Hypotension or shock Acute severe aortic regurgitation with heart failure Cardiac tamponade from haemopericardium Myocardial ischaemia from coronary ostial compromise Focal neurological…

…Severe coronary artery or structural heart disease High risk features on examination include: Unexplained systolic blood pressure < 90 mmHg Suggestion of gastrointestinal hemorrhage Persistent…

…with severe symptoms, provided that first line therapies have failed and the patient does not have structural heart disease or reduced left ventricular function. Persistent…

…myocardium: a persistently dysfunctional but potentially recoverable state. The chronically dysfunctional myocardium in ischemic cardiomyopathy is therefore heterogeneous. Irreversibly scarred regions may alternate with viable…

…coronary arterial obstruction that has persisted for at least 30 days. CTOs are common among patients undergoing coronary angiography, with reported prevalence ranging from 18…

…more severe clinical disease. HeFH affects approximately 1 in 250–300 people and is the most common inherited metabolic disorder associated with premature cardiovascular disease…

…sometimes longer Persisting withdrawal, particularly after previous severe episodes, with concurrent physical illness or after prolonged very high intake More than 90 percent of withdrawal…

…when prolonged or severe, myocardial necrosis. It most commonly reflects atherothrombosis: disruption of an atherosclerotic plaque followed by platelet activation and coagulation, with formation of…

…adrenaline never replace intramuscular adrenaline [1,2]. Delayed administration of adrenaline is associated with more severe and more protracted reactions, biphasic courses and fatal outcome…

…severe frailty, or very old or frail patients who may not tolerate rapid blood pressure reduction. Initial Combination Therapy General Strategy For most adults with…

…of breathing, level of consciousness and PEF improve at the same time. Acute severe asthma is characterised by bronchospasm, mucosal oedema and mucus plugging. Expiratory…

…is made without reduction for incomplete cross tolerance. Indications Acute severe nociceptive pain where paracetamol and a COX inhibitor are not enough: fracture, renal colic…

Pulmonary valve regurgitation Mild regurgiation Moderate regurgitation Severe regurgitation Pulmonary valve morphology normal normal/abnormal abnormal Density CW Doppler weak, slow deceleration variable dense, steep…

Mitral valve regurgitation Primary parameters Mild regurgiation Moderate regurgitation Severe regurgitation Vena contracta (cm) < 0,3 0,3 0,69 0,69 EROA (cm²…

Tricuspid valve regurgitation Primary parameters Mild regurgiation Moderate regurgitation Severe regurgitation PISA radius < 0,6 0,6 0,9 0,9 Vena contracta (cm…

…abnormalities. Malignant hypertension may cause acute microangiopathy, with renal, retinal, and cerebral involvement. Catecholamine excess and drug related presentations Severe hypertension may result from phaeochromocytoma…

ECG Myocardial ischemia and infarction Acute Myocardial Infarction: Definition & Criteria Acute myocardial infarction is the most severe complication of coronary artery disease. The most common…

…in parallel with the investigation. 8. Document the diagnosis and communicate it at every handover. Recognise it Core criteria Core criterion Meaning : : Acute onset The…

…defect associated with anterior infarction. Ventricular free wall rupture Free wall rupture may be catastrophic or subacute. In the catastrophic form, an acute tear causes…

…acute mechanical complications—particularly ventricular septal defect (VSD) and papillary muscle rupture with acute severe mitral regurgitation—predominant right ventricular (RV) infarction, cardiac rupture with…

…workload. Levosimendan is used in severe acute or chronic heart failure. Consider urgent angiography in patients with unknown etiology for acute severe heart failure. A…

…exercise due to physical limitations. Contraindications to exercise, such as unstable angina, severe aortic stenosis, decompensated heart failure, or aortic aneurysm. Baseline ECG abnormalities rendering…

…ECG), Criteria & Management Acute ST Elevation Myocardial Infarction (STEMI) is the most severe manifestation of coronary artery disease. This chapter deals with the pathophysiology, definitions…

…Repeated blood gases, for example during mechanical ventilation or severe metabolic derangement. Major surgery with expected blood loss or large volume shifts. Patients in whom…

…A systolic blood pressure < 90 mmHg caused by the arrhythmia. Ongoing myocardial ischaemia with chest pain and ECG changes. Acute pulmonary oedema. Impaired consciousness…

…suspected granulomatous disease with marrow involvement. Work up of unexplained iron, B12 or folate deficiency when blood tests are insufficient. Contraindications Severe coagulopathy or ongoing…

…departments — follow local protocol. Severe lung disease or a contralateral pneumothorax: avoid the subclavian and jugular routes on the healthy side, since a pneumothorax there…

…from withdrawal of treatment to circulatory arrest Indications An intensive care patient with severe brain injury in whom total brain infarction is judged possible during…

…protocols. Children, pregnant women and patients with advanced renal failure, marked heart failure or circulatory shock require a specific protocol and early specialist involvement. DKA…

…is not a test for BPPV. It is used in the acute vestibular syndrome — continuous vertigo with spontaneous nystagmus, nausea and difficulty walking that has…

…treatment review. For a fuller account of two of the commonest acute drug problems, see Warfarin therapy and Opioid therapy in severe pain. Cardiac arrest…

…severe piperacillin–tazobactam 4 g × 4 IV Exacerbation of COPD with an indication for antibiotics amoxicillin 750 mg × 3 PO 5–7 days or doxycycline…

…on a clear indication and with full preparedness Moderate to severe aortic stenosis without symptoms Individual assessment Hypertrophic cardiomyopathy with outflow tract obstruction Caution Tachyarrhythmia…

…a dialysis patient, in severe acute kidney injury, in treatment failure or in ongoing massive potassium release. In cardiac arrest with suspected hyperkalaemia, advanced life…

…denotes severe hypertension with advanced hypertensive retinopathy, usually retinal haemorrhages, exudates, cotton wool spots or papilloedema. Intravenous treatment is required if there is concomitant acute…

…marked reflux. A need for high airway pressures, for example severe ARDS, marked obesity or a stiff chest wall. Glottic or subglottic obstruction — the mask…

…injury Peripheral neuropathy of other cause As above Severe pain Titrate the pressure up gradually Rheumatoid arthritis with vasculitis Individual assessment Repeat the ABI every…

…Procedure : : Acute paronychia with fluctuance or visible pus Incision and drainage Acute paronychia without pus formation Antibiotics and soaks alone Ingrown nail with mild inflammation…

…the tube is safe. A misplaced tube in the airway produces no reliable symptoms in a patient with an impaired cough reflex, and the first…

Procedurer In acute circulatory failure it is not the number of cannulae that matters but the flow per unit time . A large bore, short cannula…

…Marked atopic disease, particularly severe asthma and a history of anaphylaxis — a relative contraindication; the test is then performed with preparedness for anaphylaxis. An untreated…

…close to delivery (embryopathy and fetal bleeding respectively). Marked liver failure with coagulopathy. Severe uncontrolled hypertension. Recent intracranial haemorrhage without a fresh assessment of benefit…