Medical scenario

(Cardiac)
Scenario

Mr. Cheung, a 70-year-old man, attended A&E department complaining

persistence palpitation. On arrival, his BP was 103/65 mmHg. P 135/min, RR
20/min, SpO2 93% in room air. He was alert and conscious but appeared to be
diaphoretic. He also complained of chest discomfort and mild SOB for an hour.
Mr. Cheung PMH & social history:

NKDA, Ex-smoker, drinker. ADL-Partially dependent. Live alone.

HT on Norvasc, DM on Diamicron, COPD on Ventolin puff, CHF, CKD. Hx of inguinal hernia, OT repair
done 20 years ago.

He was then put to observation room for a 12 lead ECG & further observation.
Q1
Please interpret the following ECG for Mr. Cheung:

Rate:

Rhythm:
Q1.

Answer:

Rate: 22 x 6 = 132/min

Rhythm: Fast Atrial fibrillation

P wave indiscernible; PR interval not measurable. Narrow QRS complex (<0.12). For
irregular rhythm, count the number of R wave to calculate the Rate.
 2014 AHA/ACC/HRS
Guideline for the Management of
Patients With Atrial Fibrillation
Q2.
Regarding to Mr. Cheung’s current vitals signs, what will be the appropriate nursing
interventions?

I. Sit up to semi-fowler position

II. Administer O2 to keep SpO2 >=95%
III. Put on to Cardiac monitor
IV. Administer Pain-killer as per doctor order.

A. I & II
B. I & III
C. I, II & III
D. All of the above.
Q2.

Answer: B

In all patients presenting to AED with acute AF, immediate provision of

supplementary oxygen, establishment of an intravenous line and
continuous ECG monitoring is mandatory.

However, Mr. Cheung has a history of COPD, therefore keeping SpO2 >
90% will be fine.

Patient is not experiencing MI, not for MONA therapy.

Q3.

Which of the following is the most appropriate acute treatment?

A. Amiodarone
B. Adenosine
C. Diltiazem
D. Cardioversion
Q3.
Answer: A

Amiodarone is the first line treatment for Acute arrhythmia.

The principle of emergency management of AF are haemodynamic stabilisation, symptom relief and prevention of
thromboembolism.

Rate control vs Rhythm control?

Ventricular rate control vs Cardioversion?
According to 2 large clinical trials (AFFIRM & RACE), ventricular rate control as a primary strategy for the management of
acute AF. Death and disabling stroke or new arrhythmias are tended to be less common in rate control group. Rhythm control
group experienced more thromboembolic complications, heart failure and adverse effects.
Early cardioversion (<48 hrs after onset of new AF increase the rate of successful cardioversion, reduces the incidence of AF
recurrence and avoids the need for long term anticoagulation.
However, the duration of AF is an important consideration before cardioversion.
A&E Doctor reviewed the ECG and prescribed Amiodarone 150mg in 100ml D5 over 30
mins to Mr. Cheung and admitted him to Acute medical ward.
Mr. Cheung’s SpO2 dropped to 88% in RA. Doctor ordered 0-2L O2 NC.

Q4.
You need to escort Mr. Cheung to acute medical ward. What do you think you
need to prepare for the internal transportation?

SQ
Q4.
Answer:
- Ensure patient SpO2 > 90% before transport.
- Stretcher with O2 cylinder (check the O2 amount before leave)
- Cardiac Monitor with Cardiac, NIBP and SPO2 monitor
- Infusion pump with running Amiodarone
- A&E document
- +/- escort box
In medical ward, there was no improvement for Mr. Cheung after the amiodarone loading dose. Cardiac
monitor showed persistence AF with rate of 140/min, Mr. Cheung’s BP slightly dropped to BP 90/64
mmHg. SpO2: 95% in 2L O2 NC.
The doctor prescribed the following treatment:

Mx: NPO except Med (resume usual med)

Gelofusine 500ml FR x 1
BP/P Q1H
Blood x CBC, LRFT, CaPO4, Clotting, Trop T Q8H x 3
Cont’d Cardiac monitor
ECG x 1
Stat Clexane SC 60mg then Q12H
Continue Amiodarone maintenance @ 21ml/hr after loading dose
Consult Cardiac

Q5. How would you prepare Amiodarone infusion @21ml/hr (600mg in 500ml D5).
SQ.
Q5.

Answer:

Use infusion pump and PVC free set. (IV amiodarone has been found to leach out plasticisers,
such as DEHP from IV tubing, including PVC, which may lead to safety concerns for patients. )

Get 500ml D5, take out 12ml and add in 4 ampoules of Amiodarone
(150mg/3ml).
Mx: NPO except Med (resume usual med)
Gelofusin 500ml FR
BP/P Q1H
Blood x CBC, LRFT, CaPO4, Clotting, Trop T Q8H x 3
Cont’d Cardiac monitor
ECG x 1
Stat Clexane SC 60mg then Q12H
Continue Amiodarone maintenance @ 21ml/hr after loading dose
Consult cardiac

Q6.

Regarding the above management and Mr Cheung’s condition, as a nurse,

what would you check as well?

SQ.
Q6.

Answer:

- Whether patient has two IV access sites for two drips

- H’stix frequency
- Double confirm if resume usual med except Norvasc & Diamicron (as
patient now NPO and low BP)
- Assess ongoing need for amiodarone (whether SR is returned)
- Clarify with Dr whether to give Gelofusine FR to a CHF patient.
- Clarify that is a urgent or semi urgent Cardiac consult ( you will need to
inform H.O. If it is a semi-urgent consult)
After consulting cardiac team, cardiac MO suggested the following treatment:
- Book TEE
- Prepare for Cardioversion if no improvement

Q7. What would you prepare if Mr. Cheung need to undergo cardioversion?
I. Transesophogeal echocardiogram (TEE)
II. Consent for procedure (not requiring Anaesthetist)
III. IV midazolam
IV. Defibrillator
V. Femoral Skin preparation

A. I, II, III & IV

B. II, III, IV & V
C. II, III, IV & V
D. All of the above
Q7.
Answer: A

TEE: According to AHA guideline 2019, patient with AF > = 48 hrs or unknown duration, has to take anticoagulant at least 3 weeks
before and 4 weeks after cardioversion.
If immediate cardioversion is required, anticoagulate as soon as possible and continue for at least 4 weeks
For emergency case, it is recommended to perform TEE before cardioversion to exclude presence of LA Thrombus before
cardioversion.
TEE provides the best look at the heart chambers

Explain and sign the consent without Anaes with patient

- complications: Dislodged blood clots (MI, Stroke, Pulmonary embolism), abnormal heart rhythm (rare), skin burn

Skin Prep (shave the chest area if necessary)

Defibrillator and act as cardiac monitor

E-trolley standby

Deep sedation is desirable. Optimal sedation would include quick onset, low cardiopulmonary depression and rapid recovery
Q8.

Doctor ordered Clexane 60 mg SC, what do you need to alert

before administer?

SQ.
Q8.

Answer:

- Mr Cheung’s BW
Recommended dosage of clexane is 1mg/kg BW twice daily subcutaneously
- Allergy history
- Medication record
- Skin condition for SC injection
- Clotting profile - Just to alert whether patient has poor blood coagulation, no specific monitoring is needed to INR or
APTT for LMWH (anti-factor Xa)
- No need to expel the air bubbles from the syringe before administration. When the quantity of drug
to be injected requires to be adjusted based on patient’s BW, use the graduated marking of the pre-
filled syringe to reach the required volume by discarding the excess before injection
Do not expel the air
bubble
After cardioversion, Mr Cheung return to NSR. Post ECG done as followed, the CBC and
LRFT also result available.

5.1 H
Q9.

What abnormal findings you observed? Can you explain the possible reason for
the corresponding findings?

SQ.
Q9. Answer:

CBC: Low Hb: Anemia commonly occurs in people with chronic kidney disease (CKD)—the
permanent, partial loss of kidney function. Anemia might begin to develop in the early stages of CKD,
when someone has 20 to 50 percent of normal kidney function. Anemia tends to worsen as CKD
progresses. Healthy kidneys produce a hormone called erythropoietin (EPO). A hormone is a
chemical produced by the body and released into the blood to help trigger or regulate particular body
functions. EPO prompts the bone marrow to make red blood cells, which then carry oxygen
throughout the body) Tx: SC Mircera (Haematopoetic growth factor )

LRFT:

High Cr: Creatinine (cree-A-ti-neen) is a waste you make each time you move a muscle. Those
with more muscle make more creatinine. Healthy kidneys remove creatinine from your blood. This
means that a high serum (blood) level may be due to kidney damage.

Low eGFR: GFR is a formula that uses your creatinine, age, race, and sex. GFR is used to divide
chronic kidney disease into five stages. The result is about the same as your percent kidney function.
So, a GFR of 60 means you may have function that is 60% of normal, 15 indicate Kidney failure

High K: When kidneys fail they can no longer remove excess potassium, so the level builds up in
the body. High potassium in the blood is called hyperkalemia, which may occur in people with
advanced stages of chronic kidney disease (CKD) —> PVC/ AF. —> Can further elaborate
CHF also high risk of High
serum K, due to Medication
like diuretic, ACEI.
Q10.

What is the most acute situation to fix?

Can you suggest a treatment of treating this situation?

A. Hyperkalemia
B. PVC
C. Low Hb
D. High Creatinine
Q10. Answer: A. Hyperkalemia.

● Check if the sample is haemolyzed

○ blood sample contamination :red blood cells burst and cause the release of contents for example potassium due to improper specimen
collection or poor sample handling techniques.
Recollection of blood sample is needed
● Insulin administered with glucose (DI Drip)
○ Insulin drives potassium into the cells by stimulating the uptake of the electrolyte by the cell membrane. This process begins within twenty to
thirty minutes of the start of insulin treatment. Glucose is administered to facilitate this process and also to maintain glucose level in the
bloodstream, as insulin can cause hypoglycemia, or low blood sugar.
○ Serum K+ starts trending down within 10-20 min after DI drip with max effect in 60min and effect lasts for 2-6 hours
○ Common practice: 6-8 units Actrapid in 50ml D50 over 30 mins
● Resonium C/A
○ artificial resins that exchange bound cations (Ca2+ or Na+) for K+ in the large intestine. K+ adhering to the resin are excreted with faeces
● Calcium gluconate/chloride(injected by MO)
○ First line treatment for severe hyperK+ when ECG shows significant abnormalities
to increase threshold potential thus restoring the normal gradient between threshold potential and resting membrane potential → stabilizing
cardiac cell membrane against undesirable depolarization
○ Common practice: 10ml 10% calcium gluconate IVI over 3 mins (slow injection)
● Consult ICU for CRRT.
● Continue on Cardiac Monitoring
Recheck blood x LRFT and it was found that the previous result was hemolyzed, the latest
serum potassium level should be 4.3mmol/L.
Mr Cheung’s vital signs was finally stabilised, no more chest discomfort was reported, but
ECG showed on and off AF. The doctor suggested to start Apixaban for Mr. Cheung.

Q11.
Which drug group does Apixaban belong to?

A. Anti-platelet
B. Anti-arrhythmic
C. Anti-coagulant
D. Anti-hypertensive
Q11.

Answer: C

Anticoagulant.

—> Follow up: other kind of Anticoagulant? E.g. Dabigatran, warfarin

Q12.

What is the purpose of starting Apixaban to Mr. Cheung?

Hint: Prelim Diagnosis

SQ.
Q12.

Answer:
AF, whether paroxysmal, persistent or permanent and whether symptomatic or silent, significantly increases
the risk of thromboembolic ischemic stroke.
Thromboembolism occurring with AF is associated a greater risk of recurrent stroke.

Antithrombotic agents routinely used for the prevention of thromboembolism in patients with AF include
anticoagulant drugs (UFH and LMWH, warfarin, and direct thrombin and factor Xa inhibitors) and
antiplatelet drugs (aspirin and clopidogrel)
To reduce the formation of platelet-rich or thrombotic clots in the LA or LAA

Although anticoagulants have been effective in reducing ischemic stroke in multiple randomized controlled
trials (RCTs), their use is associated with an increased risk of bleeding, ranging from minor bleeding to fatal
intracranial or extracranial hemorrhage

Careful consideration is required to balance the benefits and risks of bleeding in each individual patient
Left atrial appendage
Apixaban is an Non-vitamin K oral anticoagulant approved for prevention of stroke and systemic
embolism in patients with nonvalvular atrial fibrillation.
Common dosage: 5mg PO BD

According to AHA 2019, RCTs show that most NOACs represent an advance in therapeutic safety
when compared with warfarin for prevention of thromboembolism in patients with AF. NOACs are
noninferior or superior to warfarin in preventing stroke or thromboembolism. NOACs reduce
intracranial bleeding as compared with warfarin

Apixaban may be a reasonable treatment option for patients with atrial fibrillation who also have renal
disease and are receiving hemodialysis, according to late-breaking clinical trial results
Q13.
What do you need to alert if a patient is on Apixaban?

I. Monitor platelet level

II. Monitor INR
III. Prevent intake of Vitamin K1 rich food
IV. Prevent fall

A. I only
B. II only
C. II, III
D. IV only
Q13.

Answer: D.

Since patient will be on anticoagulant, the clotting ability will be lowered, have to remind patient to be
careful of injury or fall and prevent from getting injury or bruises.

Apixaban (Factor Xa inhibitor) is a non-vitamin K oral anticoagulant, act by inhibiting factor Xa and
block the propagation phase of the coagulation cascade, thereby decreasing the conversion of
prothrombin to thrombin.
In rivaroxaban- and apixaban-treated patients, a normal PT/INR and aPTT may be found at trough
despite the presence of therapeutic levels of the drug.
Commercially available tests for PT or INR are not appropriate for monitoring factor Xa inhibitors
No routine coagulation test can reliably exclude a residual anticoagulant effect.
Unlike Warfarin, apixaban dose not require routine laboratory monitoring of INR

HA leaflet on DOAC:

http://www.ha.org.hk/hadf/hadf/Portals/0/Docs/Leaflets/Eng/Direct%20Oral%20Anticoagulant%20(DOAC).pdf
Doctor allowed patient DAT after stabilisation. Mr. Cheung was feeling so hungry and thirsty
after NPO for a day and drank 3L of water.
One day later, Mr. Cheung experience SOB & dyspnea, he insisted a sit up position, but
SpO2 further decreased to 85% in 2L O2 NC, Bilateral lower limb Edema was noted, CXR
showed Bat-wing opacity.

Q14.
What do you think Mr. Cheung is experiencing?
What is the possible treatment for this?

SQ.
Q14.
Answer: APO - Acute Pulmonary Edema

- Lasix IVI +/- infusion

- Strict IO, +/- foley
- NPO
- Nitrates infusion
- Give 100% O2 via mask or even Put on NIPPV ( BiPAP)
- Prop up
- Blood x ABG (determine if there is acidosis and titrate O2)
- Bedside Echo
APO has a high morality and characterises by dyspnoea and hypoxia secondary to fluid
accumulation in the lungs which impairs gas exchange and lung compliance
The most common causes of APO include MI, arrhythmias (AF), acute valvular
dysfunction and fluid overload.
The goals of therapy are to 1) provide symptomatic relief, 2) improve oxygenation, 3)
maintain cardiac output & perfusion of vital organs and 4) reduce excess
extracellular fluid.

IV Diuretics are indicated for patients with fluid overload with the dose of Lasix ranging
from 40-80mg. After the bolus IV injection, continuous IV infusion may be considered,
commencing at a rate of 5-10mg per hr.

Low dose Nitrates cause smooth muscle relaxation, causing venodilatation and
consequent preload reduction. IV infusion is preferred due to the speed of onset and the
ability to titrate the dose

Inotropic drugs should only be started when there is hypotension and evidence of reduced
organ perfusion. Dobutamine is usually first-line treatment.
Ventilatory Support
- Prop up could reduce the ventilation-perfusion mismatch and assist with their work of
breathing
- Oxygen should be administered to achieve a target SpO2 92-96% but for COPD
case, the target SpO2 is 88-92%
- If patient has respiratory distress, acidosis or hypoxia, despite supplemental O2, non-
invasive ventilation is indicated, such as bi-level positive airway pressure ventilation
(BiPAP)
- BiPAP maintains the patency of the fluid-filled alveoli and prevents them from
collapsing during exhalation
- BiPAP also increases intrathoracic pressure with reduction in preload and afterload of
heart
- BiPAP should be commenced at 100% O2 with recommended initial setting of 10/4
cm water pressure (inspiratory positive airway pressure /expiratory positive airway
pressure)
- If despite non-invasive ventilation, there is persistent hypercapnia, hypoxaeia or
acidosis, then intubation should be considered. Other indications for intubation
include signs of physical exhaustion, decreasing level of consciousness or
cardiogenic shock.
After IV lasix and BiPAP support, Mr Cheung recovered from APO. Now his SpO2 regain to
93% in Room air. BP/P stabilized. Here are the following management:
Mx: Home
FU GOPC x 1/52
+ Apixaban P.O. x 1/52 Q15.
+ Lasix 20mg P.O. BD x 1/52
What discharge nursing care do you think is applicable?

I. Reinforce fluid restriction

II. Consult Dietitian for Renal and DM diet
III. Book GOPC FU
IV. Arrange NEATS
V. Get medication from pharmacy
VI. Inform close relative for his discharge

A. I, III, IV & V
B. I, III, IV, V & IV
C. II, III, IV, V & IV
D. All of the above
Q15.
Answer: D
Reinforce fluid restriction
Prevent APO again, esp Mr. Cheung has CHF and CKD
Consult Dietitian for Renal and DM diet
For Mr. Cheung‘s high protein, low GI index. Diet can help control his disease.
Book GOPC FU
You should book the FU in advance and give the FU slip to Mr. Cheung when discharge.
Note any prescription of blood taking before follow -up, instruct patient go blood taking 1 wk before FU
Arrange NEATS
In social history, Mr. Cheung live alone and ADL-PD. Should help Mr Cheung arrange NEATS to discharge and
FU transport.
Get medication from pharmacy
Since Mr. Cheung is not fit to get medication from pharmacy by himself, we could arrange porter to take the
discharge medication and double check before discharge.
Provide education of medications
Inform close relative for his discharge
If it is possible, inform Mr. Cheung’s close relative for his discharge so at least one relative will be able to check
on his Post-hospitalized condition.