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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

Emergency management in cardiology

By C. Wongvipaporn

Division of Cadiology in Medical Department

Srinagaringe Hospital KhonKaen University

objective
Objective
  • What are the emergency cardiac condition?
  • How to detection?
  • How to emergency management and monitoring?
cardiac emergency
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
definition
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
physical examination
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
Killip’s Classification

I . No crepitation , No S3

  • Crepitation <1/2 Lung ; + S3
  • Crepitation >1/2 Lung ; Pulmonary edema

IV. Cardiogenic Shock

nyh classification
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
Etiology
  • Endocardium: Rheumatic heart disease
  • Myocardium: IHD, Cardiomyopathy, Hypertensive heart disease, Myocarditis
  • Pericardium: Constrictive pericarditis, Cardiac temponade
  • Vascular: Hypertensive emergency
precipitating cause
Precipitating cause
  • Preload: Hypervolemia, Dietary
  • Contractility: ACS, Myocarditis
  • Afterload: HT
  • Others: Infection, Arrhythmias, Thyrotoxicosis, Anemia, Endocarditis, Inappropriate treatment
principle of management
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
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
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
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
Awareness of Treatment
  • Over diuresis; prerenal, hypovolemic shock
  • Electrolyte disturbance
  • Pharmacological side effects
    • Hypotension
    • MI
  • Inappropriate treatment
shock definition
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
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
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
shock classification
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
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
shock classification obstructive
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
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
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 replacement26
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
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 management use of vasopressors
Shock -- ManagementUse of vasopressors
  • Dopamine
  • Norepinephrine
  • Dobutamine
  • Epinephrine (anaphylactic shock)
  • Dopexamine (dopa 1,2, and beta 2)
slide29

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 definition
Syncope Definition
  • Collapse,Blackout
  • A sudden, transient loss of consciousness and postural tone, with spontaneous recovery
syncope diagnostic objectives
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
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...
syncope evaluation and differential diagnosis
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
what is sca
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
Management
  • Cardiac life support
    • Airway
    • Breathing
    • Circulation
    • Defibrillation
  • Get rid of cause
    • Metabolic: electrolyte, drugs
    • Organic: structural heart (ACS is common)
slide38

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
slide39

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

slide40

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
symptoms of arrhythmia
Symptoms of arrhythmia
  • Asymptomatic
  • Symptomatic
    • Palpitation
    • Low output syndrome: dyspnea, fatigue, fainting, syncope, shock, CHF
managements
Managements
  • Get rid of precipitating factors
  • Nonpharmacological treatment
      • Maneuvers
      • Pacing
      • Cardioversion
      • AICD
      • RF ablation
  • Pharmacological treatment
      • Antiarrhythmic drugs
carotid sinus massage
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 massage45
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
slide46

Bradycardia

Symptomatic

Stable

Unstable

(shock, angina, CHF)

EKG 12 leads

  • High risk
  • Mobitze II
  • Third degree

Low risk

slide47

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

slide48

VT

Stable

Monophasic

Polymorphic VT

QT normal

QT prolong

slide49

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

slide50

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)
slide51

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)
slide53

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
classification of acs
Classification of ACS

HistoryPhysical Exam

ACUTE CORONARY SYNDROME

No ST Elevation

ST Elevation

ECG

NSTEMI

Manangement

QMI

Unstable Angina

NQMI

pathogenesis of acs

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 of acs management
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 management58
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

pericardium
Pericardium
  • Visceral pericardium
  • Parietal pericardium
  • Pericardial space and fluid 15-50 ml
pericardial effusion
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
Causes of cardiac tamponade
  • Cardiac trauma
  • Aortic dissection
  • Cardiac rupture after AMI
  • Inflammatory pericarditis
  • Neoplasia
treatment of cardiac tamponade
Treatment of cardiac tamponade
  • Relieve pericardial pressure ;

Pericardiocenthesis (contraindication in aortic dissection, cardiac rupture)

  • Volume loading
  • Treat underlying cause
  • Avoid vasodilator
definitions
Definitions
  • Hypertensive Urgency
  • Hypertensive Emergency
    • Accelerated Hypertension
    • Malignant Hypertension
    • Accelerated-Malignant Hypertension
  • Hypertensive Crisis
    • Urgency or Emergency
hypertensive urgency
Hypertensive Urgency
  • “Severe elevation of blood pressure”
    • Generally DBP >115-130
    • No progressive end organ damage
hypertensive emergency70
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 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
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
pharmacotherapy73
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
clinical manifestion pe
Clinical of DVT

Shortness of breath

Rapid pulse

Sweating

Fainting

Sharp chest pain

Bloody sputum (coughing up blood)

Cardiogenic shock

Clinical manifestion PE
aim of pe management
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
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

incidence
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
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
take home massages
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 massages83
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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