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Emergency management in cardiology. By C. Wongvipaporn Division of Cadiology in Medical Department Srinagaringe Hospital Khon Kaen University. Objective. What are the emergency cardiac condition? How to detection? How to emergency management and monitoring?. Cardiac Emergency.

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Emergency management in cardiology

By C. Wongvipaporn

Division of Cadiology in Medical Department

Srinagaringe Hospital KhonKaen University


Objective

  • What are the emergency cardiac condition?

  • How to detection?

  • How to emergency management and monitoring?


Cardiac Emergency

  • Definition of emergency care and critical care

  • Symptomatic emergency:

    • CHF, Cardiogenic shock, Syncope, SCA

    • Arrhythmia: Tachy and Brady arrhythmia

  • Endocardial emergency:

    • valvular obstruction or regurgitation: CHF, Shock, Syncope

  • Myocardial emergency:

    • Coronary arterial disease, Myopathies: CHF, Shock, Syncope, Arrhythmia, SCA

  • Pericardial emergency:

    • Cardiac tamponade

  • Vascular disease:

    • Hypertensive emergency, Aortic dissection, Pulmonary emboli


CONGESTIVE HEART FAILURE


Definition

  • HF

    • Syndrome of abnormal cardiac functions in response to tissue requirement

    • CHF

  • Refractory CHF: Not improve or worsening in optimized medications

  • Intractable CHF: Not improve or worsening in full medications


Clinical manifestation


Physical examination

  • Left side

    • Pulsus alternans, Tachycardia

    • Cheyne-Stokes resp

    • Hypotensions

    • Gallop LV

    • Rales: Killips Class

    • Alteration, Renal failure

  • Right side

    • Engorged NV

    • HJR

    • Gallop RV

    • Dependent edema

    • Jaundice, Organomegaly, Ascites

  • Specific signs: Thyrotoxicosis, Beri beri


Killip’s Classification

I . No crepitation , No S3

  • Crepitation <1/2 Lung ; + S3

  • Crepitation >1/2 Lung ; Pulmonary edema

    IV. Cardiogenic Shock


NYH Classification

  • FCI: No limitation of physical activity

  • FCII: Slight limitation of physical activity

  • FCIII: Marked limitation of physical activity

  • FCIV: Symptoms at rest


Etiology

  • Endocardium: Rheumatic heart disease

  • Myocardium: IHD, Cardiomyopathy, Hypertensive heart disease, Myocarditis

  • Pericardium: Constrictive pericarditis, Cardiac temponade

  • Vascular: Hypertensive emergency


Precipitating cause

  • Preload: Hypervolemia, Dietary

  • Contractility: ACS, Myocarditis

  • Afterload: HT

  • Others: Infection, Arrhythmias, Thyrotoxicosis, Anemia, Endocarditis, Inappropriate treatment


Principle of management

  • Clinical and Hemodynamic stabilization

    • Nonpharmacological

    • Pharmacological

  • Correct cause (Type of HF) and reversible precipitating factors

  • Awareness of treatment

  • Planing of long term treatment

    • Risk stratifications

    • Prevention


Nonpharmacological Rx.

  • Fluid; restrict

  • Diet; Low salt diet

  • Record V/S, BW

  • Activity

    • Position

    • Bed rest

  • Wandering tourniquet

  • Oxygination

  • Intubations

  • IABP

  • Cardioversion

  • Pacing


Pharmacological Rx.

  • Decrease preload

    • Diuretic

    • Nitroglycerine

    • Morphine sulfate

  • Increase contractility

    • Dobutamine

    • Dopamine

    • Adrenaline

    • Digoxin

  • Decrease afterload

    • Nitroprusside

    • Nitroglycerine

    • ACEI/ARB

    • ISDN+Hydralazine

    • Ca Blocker

    •  blocker

  • Antiarrhythmic drugs

    • Digoxin

    • Amiodarone


Correct cause & precipitation

  • Endocardium

    • Myxoma: Sx

    • IE: Sx, Abc

  • Myocardium

    • IHD: Thrombolytic, Revascularization

    • Beri beri: Thiamine

    • Myocarditis: Abc, steroid

  • Pericardium

    • Cardiac temponade: Sx

    • Constrictive: Sx

  • Other cause

    • High BP: iv control

    • Infection: Abc

    • Anemia: Transfusion

    • Thyrotoxicosis: PTU


Awareness of Treatment

  • Over diuresis; prerenal, hypovolemic shock

  • Electrolyte disturbance

  • Pharmacological side effects

    • Hypotension

    • MI

  • Inappropriate treatment


SHOCK


Shock -- Definition

  • Circulation inadequate to satisfy overall cellular metabolic requirement.

    • Hypotension

      • MAP decreased > 30 mmHg (< 60 mmHg)

      • SBP decreased > 40 mmHg (< 90 mmHg)

    • Hypoperfusion; clinical of vital organ dysfunctions


Shock -- Clinical manifestation I

  • Hypotension: At least one criteria.

    • MAP < 60 mmHg or

    • Decreased MAP > 30 mmHg or

    • SBP < 90 mmHg or

    • Decrease SBP > 40 mmHg


Shock -- Clinical manifestation II

  • Hypoperfusion (at least one system involvement)

    • CNS: Agitation, anxiety, confusion, alteration of consciousness, unconscious COMA

    • CVS: Hypotension, tachycardia, dysrhythmias, thready pulse, new murmurs or valvular regurgitation or dysfunction, capillary refill > 3 sec

    • RS: Tachypnea, dyspnea, cyanosis

    • Renal: Oliguria, anuria

    • Skin: Paleness, dusky skin, cool, clammy skin, profuse sweating, bluish lips and fingernils

    • Other: Lactic acidosis


By pathophysiology (New categories)

Hypovolemic

Cardiogenic

Obstructive

Distributive

Hyperdynamic

By site of origin dysfunction (Previous)

Hypovolemic

Cardiogenic

Vasogenic (anaphylactic)

Septic

Shock -- Classification

  • Overlap exists, and also concomitant categories exist


Shock -- Classification -- Cardiogenic

  • Endocardium

    • Valvular: stenosis, regurgitation

    • Septal defects

  • Myocardial

    • Infarction, contusion, myocarditis, cardiomyopathy, pharmacologic, depressant factors

  • Pericardium (Hemodynamic likely to Obstructive)

    • Constrictive pericarditis, Cardiac tamponade

  • Arrhythmogenic


Extrinsic causes

Pericardial tamponade

Constrictive pericarditis

Tension pneumothorax

High PEEP, High alveolar pressure

Obstructive intrathoracic tumors

Intrinsic causes

PE

Pulmonary vascular disease

Hypoxic pul vasoconstriction

Atrial myxoma (R)

Atrial thrombus (R)

Metastatic tumors

Endocarditis (R)

Shock -- Classification --Obstructive


Shock -- Management

Five major principles

  • Prompt recognition.

  • Initial supportive management.

    • Airway

    • Volume replacement

    • Cardiovascular drugs

  • Determine & management primary problem leading to shock.

  • Management of complications.


Shock – Volume replacement

  • Position:

    • FEET UP / HEAD FLAT OR 30 DEGREES

    • Not use Trendelenberg position

  • Vascular access

  • If no evidence of cardiogenic pulmonary edema, trial of volume expansion.

  • Initially, 500-750 of colloid or 1-2 litres crystalloid during the first hour.


Shock – Volume replacement

  • Rate and type of on-going fluid administration depends on:

    • Clinical scenario - Clinical response

  • Presence of pulmonary edema (cardiac or non-cardiac) is strong contraindication to more fluid admin without more hemodynamic info.


Shock – Cardiovascular drugs

  • Severe BP drop is disasterous to brain and heart. Use vasopressor initially, even in hypovolemic shock, in order to keep MAP >50-60 until caught up withvolume.

  • Dopamine is initially used often.

  • Switch early to norepinphrine or even start with it. Some studies show greater benefit in renal perfusion and cardiac function that with dopamine.


Shock -- ManagementUse of vasopressors

  • Dopamine

  • Norepinephrine

  • Dobutamine

  • Epinephrine (anaphylactic shock)

  • Dopexamine (dopa 1,2, and beta 2)


SHOCK

Hypoperfusion

Hypotension

Suspected shock

JVP CVP

  • Hypovolemic

  • Hyperdynamic

  • Distributive

  • Cardiogenic

  • Obstructive

High

Low

Clinical of CHF

> Crackle > Gallop

> Edema

  • Cardiac output

  • Fever

CO 

CO 

Fever

Y

N

  • Hypovolemic

  • GI bleed

  • Trauma

  • Burn

  • DI

  • DKA

  • Distributive

  • Anaphylaxis

  • Narcotics

  • Drugs

  • Hyperdynamic

  • Sepsis

  • SIRS

  • Pancreatitis

  • Cirrhosis

  • Thyroid strom

  • Cardiogenic

  • AMI

  • CM

  • AV block

  • AR

  • Obstructive

  • PE

  • Tamponade

  • Myxoma


Syncope


Syncope Definition

  • Collapse,Blackout

  • A sudden, transient loss of consciousness and postural tone, with spontaneous recovery


Syncope Diagnostic Objectives

  • Distinguish ‘True’ Syncope from other ‘Loss of Consciousness’ spells:

    • Seizures

    • Psychiatric disturbances

  • Establish the cause of syncope with sufficient certainty to:

    • Assess prognosis confidently

    • Initiate effective preventive treatment


Syncope Basic Diagnostic Steps

  • Detailed History & Physical

    • Document details of events

    • Assess frequency, severity

    • Obtain careful family history

  • Heart disease present?

    • Physical exam

    • ECG: long QT, WPW, conduction system disease

    • Echo: LV function, valve status, HOCM

  • Follow a diagnostic plan...


SyncopeEvaluation and Differential Diagnosis

History – What to Look for

  • Complete Description

    • From patient and observers

  • Type of Onset

  • Duration of Attacks

  • Posture

  • Associated Symptoms

  • Sequelae


Sudden cardiac arrest


What Is SCA?

  • Electrical system in heart malfunctions

  • Heart unexpectedly, abruptly stops beating

  • Often caused by an abnormal heart rhythm called ventricular fibrillation (VF)

    • VF accounts for half of all cardiac deaths

      • Rapid, chaotic heartbeat

      • Lower heart chambers, or ventricles, spasm

      • Heart functioning stops

      • Lack of oxygen in body, brain is dead


Management

  • Cardiac life support

    • Airway

    • Breathing

    • Circulation

    • Defibrillation

  • Get rid of cause

    • Metabolic: electrolyte, drugs

    • Organic: structural heart (ACS is common)


Unconcious pts

  • Check of conciousness

  • Syncope

  • Seizure

  • SCD

  • Call for help

  • Call defibrillator

  • Call first

  • Call fast

Management

  • Special situation

  • Airways obstruction

  • Accident

  • Toxic agent

  • Drowning

  • Position

  • Supine position

  • Recovery position


Primary Survey

  • Airway

  • Remove FB

    • Heimlich maneuver

    • Back blow

    • Chest thrust

  • Maintain airway

    • Head tilt-chin left

    • Jaw thrust

  • Defibrillation

  • EKG analysis

  • Defibable (VF/VT)

  • : Defib 3 time/CPR 1 min

  • : Monophasic 200/300/360

  • Nondefibable

  • : CPR 3 min and reevaluate EKG

  • Circulation

  • Check circulation

    • Pulse

    • Breathing

    • Movement

  • No circulation/Inadequate

    • Perform CPR

    • Commpressions (100/min)

    • Combine comprssions

  • and ventilations (15 compressions/

  • 2 breaths)

  • Breathing

  • Breathing in 10 sec

  • Inadequate Breathing

    • Rescue breathing (1 breath/5 sec)

    • Monitor signs of circulation

  • (every 30-60 sec)

  • No breathing:

    • Provide 2 slow breaths (2 sec/ breath)

    • Mouth to mouth, Mouth to nose,

      Mouth to instrument


Secondary survey

  • Differential

  • Clinical setting

  • 5 H

  • 5 T

  • Airway

  • Invasive instrument

    • ET tube, laryngeal mask

  • Check position

  • Circulation

  • Access iv

  • Monitor EKG

  • Pacing, Defibrillation

  • Medications

    • Inotropic

    • Vasodilator

    • Antiarrhythmic

    • Diuretic

  • Breathing

  • Oxygen Rx

  • Check adequate breathing

    • Oxygen sat


CARDIAC ARRHYTHMIA


Symptoms of arrhythmia

  • Asymptomatic

  • Symptomatic

    • Palpitation

    • Low output syndrome: dyspnea, fatigue, fainting, syncope, shock, CHF


Managements

  • Get rid of precipitating factors

  • Nonpharmacological treatment

    • Maneuvers

    • Pacing

    • Cardioversion

    • AICD

    • RF ablation

  • Pharmacological treatment

    • Antiarrhythmic drugs


  • Carotid Sinus Massage

    • Site:

      • Carotid arterial pulse just below thyroid cartilage

    • Method:

      • Right followed by left, pause between

      • Massage, NOT occlusion

      • Duration: 5-10 sec

      • Posture – supine & erect


    Carotid Sinus Massage

    • Outcome:

      • 3 sec asystole and/or 50 mmHg fall in systolic blood pressure with reproductionof symptoms =

        Carotid Sinus Syndrome (CSS)

    • Contraindications

      • Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months

    • Risks

      • 1 in 5000 massages complicated by TIA


    Bradycardia

    Symptomatic

    Stable

    Unstable

    (shock, angina, CHF)

    EKG 12 leads

    • High risk

    • Mobitze II

    • Third degree

    Low risk


    Tachycardia

    Stable

    VT

    WCT (?)

    NCT(SVT)

    AF/Af

    • Clinical setting

    • Ix: EKG 12 leads

    • Esophageal leads

    • Clinical setting

    • Ix: EKG 12 leads

    • Vagal maneuvers

    • Adenosine

    Unknown type

    • JT

    • PSVT

    • Ectopic, MAT

    Lidocaine/

    Amiodarone

    • Convert sinus

    • Control rate

    • Embolic

    • prevention

    Cardioversion

    Rx as VT

    Rx as SVT

    Procainamide


    VT

    Stable

    Monophasic

    Polymorphic VT

    QT normal

    QT prolong


    • Clinical setting

    • Ix: EKG 12 leads

    • Vagal maneuvers

    • Adenosine

    • (6 mg iv over 1-3 sec, can repeated

    • 12 mg over 1-3 sec in 1-2 min)

    SVT

    Junctional Tach

    PSVT

    Ectopic/MAT


    VF/Pulseless VT

    Rx cuase

    CPR

    Repeat shock

    360 J  3 time

    in 30-60 sec

    Cardioversion

    (200, 300, 360 J)

    Persist arrhythmia

    • Adrenalin 1 mg iv q 3-5 min or

    • Vasopressin 40 U iv single dose

    • Consider antiarrhythmics

    • Amiodarone (IIb)

    • Lidocaine (Ind)

    • Procainamide (Ind)


    PEA

    (EMD)

    CPR

    • Hypovolemia

    • Hypoxia

    • Hydrogen ion (acidosis)

    • Hyper/Hypokalemia, other metabolic

    • Hypothermia

    • Tablets (over dose, accidents)

    • Tamponade

    • Tension pneumothorax

    • Thrombosis; coronary (ACS)

    • Thrombosis; pulmonary (PE)


    CPR

    Asystole

    • Adrenalin 1 mg iv q 3-5 min

    • Atropine 1 mg iv q 3-5 min

    • (max 0.04 mg/K)

    • Pace maker

    • Transcutaneous

    • Transvenous


    Concepts of Acute Coronary Syndrome


    Classification of ACS

    HistoryPhysical Exam

    ACUTE CORONARY SYNDROME

    No ST Elevation

    ST Elevation

    ECG

    NSTEMI

    Manangement

    QMI

    Unstable Angina

    NQMI


    Acute MI

    • Platelet aggregation

    • Thrombus

      formation

    • Vasospasm

    Complete occlusion

    Plaque rupture

    (55-80%)

    Spontaneous lysis

    Exertion

    BP, HR

    Vasoconstriction

    Healing plaque

    Incomplete occlusion

    Distal embolization

    Vulnerable Plaque

    Unstable angina

    Non-Q MI

    Pathogenesis of ACS


    Principle ofACS management

    • Revascularization

      • Medical

      • Balloon

      • CABG

    • Medication for ischemia

    • Modified risk factors

    • Treatment of complication

    TIME IS MUSCLE AND

    MUSCLE IS TIME

    • decrease area infarction

    • prevent LV dysfunction

    • decrease mortality

    Factor of revascularization

    • Timing of symptoms

    • Timing of treatments

    • Patient condition

    • Medical limitation

    • Instrument limitation

    • Personal limitation


    Principle of ACS management

    • Early Invasive

    • Primary PCI

    • Facilitate PCI

    • Rescue PCI

    • CABG

    Adjuvant Rx

    • Aspirin

    • Nitrates

    • Mo

    • Beta blockers

    • ACEI

    • Antithrombin

    • Clopidogrel

    • GPII/IIIa

    • Hemodynamic

    • stabilization

    • Medical

    • Ventilator

    • IABP

    • Pace maker

    ACS

    • Early Conservative

    • Fibrinolytic drugs

    • Risk stratification

    Elective CAG

    +/- PCI or CABG


    Cardiac tamponade


    Pericardium

    • Visceral pericardium

    • Parietal pericardium

    • Pericardial space and fluid 15-50 ml


    Pericardial effusion

    • Fluid accumulates in pericardial cavity

    • Complication: Cardiac tamponade is the pressure compression of heart

    • Often secondary to an underlying condition.

      • Uremia

      • Radiation

      • Post cardiac surgery

      • Drugs: procainamide, minoxidil


    Causes of cardiac tamponade

    • Cardiac trauma

    • Aortic dissection

    • Cardiac rupture after AMI

    • Inflammatory pericarditis

    • Neoplasia


    Treatment of cardiac tamponade

    • Relieve pericardial pressure ;

      Pericardiocenthesis (contraindication in aortic dissection, cardiac rupture)

    • Volume loading

    • Treat underlying cause

    • Avoid vasodilator


    Hypertensive emergency


    Definitions

    • Hypertensive Urgency

    • Hypertensive Emergency

      • Accelerated Hypertension

      • Malignant Hypertension

      • Accelerated-Malignant Hypertension

    • Hypertensive Crisis

      • Urgency or Emergency


    Hypertensive Urgency

    • “Severe elevation of blood pressure”

      • Generally DBP >115-130

      • No progressive end organ damage


    Hypertensive Emergency

    • “Severe elevation of blood pressure”

      • Generally occurs with DBP >130

      • WITH significant orprogressive end organ damage

        • Hypertensive Encephalopathy

        • CVA – Ischemic versus hemorrhagic

        • Acute Aortic Dissection

        • Acute LVF with Pulmonary Edema

        • Acute MI / Unstable Angina

        • Acute Renal Failure

        • Eclampsia


    Urgency vs. Emergency

    • Urgency

      • No need to acutely lower blood pressure

      • May be harmful to rapidly lower blood pressure

      • Death not imminent

    • Emergency

      • Immediate control of BP essential

      • Irreversible end organ damage or death within hours


    Pharmacotherapy

    • Nitroprusside

      • Arterial & venous dilator

        • Decreases afterload and preload

      • No direct negative inotropy or chronotropy

      • Kinetics

        • Onset: seconds

        • Duration: 1-2 min

        • 1/2 life: 3-4 min

      • Increased ICP (?)

      • Toxic metabolites

        • Takes days to accumulate


    Pharmacotherapy

    • Nitroglycerine

      • Weak anti-hypertensive

      • Vasodilator

        • At high doses dilates arteriolar smooth muscle

        • Better dilation of coronary conductance arteries

      • Kinetics

        • Onset: 1-2 min

        • Duration: 3-4 min

      • Tolerance

      • Headache, Tachycardia, Nausea, Vomiting, Hypotension


    PULMONARY EMBOLI


    Clinical of DVT

    Shortness of breath

    Rapid pulse

    Sweating

    Fainting

    Sharp chest pain

    Bloody sputum (coughing up blood)

    Cardiogenic shock

    Clinical manifestion PE


    Symptomatic Rx

    Analgesic, Bed rest

    Oxygen Rx, Respirator Rx

    Specific Rx

    Risk reduction

    Prevent clot propagration

    Clot removal

    Medical Rx

    Catherter Rx

    Surgical Rx

    Prevention

    Primary

    Secondary

    Anticoagulant

    Thrombolysis

    Catheter embolectomy

    Surgical embolectomy

    Aim of PE Management

    • Primary prevention

    • Anticoagulant

      • Heparin, warfarin, xymelagatran

    • Secondary prevention

    • Anticoagulant

      • Heparin

      • warfarin, xymelagatran

    • IVC filter


    Recommended Treatment of Acute PE

    • Massive PE with shock or syncope

      • Thrombolysis or surgery

    • Major PE with right-ventricular dysfunction

      • Anticoagulants (Dalen)

      • Thrombolysis (Goldhaber)

    • Major PE without right-ventricular dysfunction

      • Anticoagulants

    • Minor PE

      • Anticoagulants

    Hyers et al, 1998

    Goldhaber, 1999Goldhaber, 1998

    Dalen et al, 1997

    Nass et al, 1999


    AORTIC DISSECTION


    Incidence

    • Primarily occurs in two distinct populations--

      • Middle aged men (age 40-60 years) with hypertension ( accounts for 90% of pts)

      • Younger people with connective tissue defect of Aorta (e.g. Marfan’s syndrome)

    • Can also be iatrogenic-- arterial cannulation (catheter) diagnostic or therapeutic

    • Other risk factors-- Pregnancy, bicuspid aortic valve, aortic coarctation


    Clinical presentation and course

    • Sudden onset of excruciating pain with a “tearing” quality in the anterior chest and extending into the back. Pain extends lower as dissection progresses

    • Clinical signs--

      • Signs of ischemia-- with involvement of carotids, or vertebrals see CNS ischemic sx’s, MI if coronaries involved...

      • Diminished carotid or upper extremity pulses

      • Aortic insufficiency murmur


    • Commonly used classification systems for aortic dissection


    Take Home Massages

    • Emergency condition need to

      • Early detection

      • Early recognition (cause)

      • Early management

    • CHF is the most condition of emergency condition.

    • Syncope (arrhythmia) require EKG interpretation.

    • Shock must be immediate response especially in cardiogenic shock.


    Take Home Massages

    • ACS is the most common of SCA.

    • Complicated ACS is emergency condition.

    • Hypertensive emergency must be monitor target organ damage.

    • Aortic dissection is emergency surgical condition.

    • Pulmonary emboli must be early recognize, investigation and

      management


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