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    Emergency

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    medstudy123
    This document discusses several cardiovascular emergencies including: 1. Acute myocardial infarction is diagnosed when two of three criteria are met - chest pain, ECG changes, and elevated cardiac enzymes. Early diagnosis and treatment are crucial. 2. Acute coronary syndrome ranges from unstable angina to STEMI and NSTEMI depending on ECG changes and elevated cardiac enzymes. 3. Aortic dissection presents with acute tearing chest pain and requires urgent diagnosis and treatment to prevent complications like rupture or cardiac tamponade. 4. Pulmonary embolism is also a life-threatening condition that requires rapid diagnosis and stabilization with oxygen, IV access, and anticoagulation therapy.

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    Emergency

    Uploaded by

    medstudy123
    66 views47 pages
    This document discusses several cardiovascular emergencies including: 1. Acute myocardial infarction is diagnosed when two of three criteria are met - chest pain, ECG changes, and elevated cardiac enzymes. Early diagnosis and treatment are crucial. 2. Acute coronary syndrome ranges from unstable angina to STEMI and NSTEMI depending on ECG changes and elevated cardiac enzymes. 3. Aortic dissection presents with acute tearing chest pain and requires urgent diagnosis and treatment to prevent complications like rupture or cardiac tamponade. 4. Pulmonary embolism is also a life-threatening condition that requires rapid diagnosis and stabilization with oxygen, IV access, and anticoagulation therapy.

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    This document discusses several cardiovascular emergencies including: 1. Acute myocardial infarction is diagnosed when two of three criteria are met - chest pain, ECG changes, and elevated cardiac enzymes. Early diagnosis and treatment are crucial. 2. Acute coronary syndrome ranges from unstable angina to STEMI and NSTEMI depending on ECG changes and elevated cardiac enzymes. 3. Aortic dissection presents with acute tearing chest pain and requires urgent diagnosis and treatment to prevent complications like rupture or cardiac tamponade. 4. Pulmonary embolism is also a life-threatening condition that requires rapid diagnosis and stabilization with oxygen, IV access, and anticoagulation therapy.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    66 views47 pages

    Emergency

    Uploaded by

    medstudy123
    This document discusses several cardiovascular emergencies including: 1. Acute myocardial infarction is diagnosed when two of three criteria are met - chest pain, ECG changes, and elevated cardiac enzymes. Early diagnosis and treatment are crucial. 2. Acute coronary syndrome ranges from unstable angina to STEMI and NSTEMI depending on ECG changes and elevated cardiac enzymes. 3. Aortic dissection presents with acute tearing chest pain and requires urgent diagnosis and treatment to prevent complications like rupture or cardiac tamponade. 4. Pulmonary embolism is also a life-threatening condition that requires rapid diagnosis and stabilization with oxygen, IV access, and anticoagulation therapy.

    Copyright:

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    Download as PPT, PDF, TXT or read online from Scribd
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    of 47

    CARDIOVASCULAR EMERGENCIES

    CARDIOVASCULAR EMERGENCIES
    Acute myocardial infarct Acute coronary syndrome Aortic dissection Pulmonary embolism Life threatening arrhythmias

    Acute Coronary Syndrome


    A spectrum of diseases
    On one end is ST segment elevation MI (STEMI), on the other unstable angina (UA). In between is Non-ST segment elevation MI (NSTEMI) (previously known as non-Q MI) Difference between UA and NSTEMI is that cardiac enzymes are elevated in the latter.

    Acute Myocardial Infarction


    Diagnosis if 2 out of 3 criteria fulfilled
    Chest Pain or Equivalent ECG changes Enzyme Changes

    Diagnosis Clinical ECG Enzymes Complications Management

    ACUTE MYOCARDIAL INFARCTION Objectives

    Acute Myocardial Infarction Chest Pain


    Chest Pain Angina Equivalent - SOB - Syncope - Shock - Depressed Conscious Level Silent MI

    Acute Myocardial Infarction ECG Changes


    New onset Bundle Branch Block

    ST elevation in
    Ant leads V1-3 Lat leads V4-6; I AVL Inf leads II,III, AVF Rt sided leads Posterior wall

    Anterior Myocardial Infarct

    Inferior Myocardial Infarct

    Acute Myocardial Infarction Enzyme Changes


    CKMB Troponin T, Troponin I
    Myoglobin

    Elevation 3-6 hrs post MI Troponin remains elevated for 2 weeks Elevation 1 hr post MI However nonspecific

    Acute Myocardial Infarction Acute Complications


    Arrhythmia Tachyarrhythmia Bradyarrhythmia e.g. heart block Cardiogenic Shock Acute Vulvular dysfunction Wall perforation acute VSD free wall perforation

    Thrombolytic for STEMI patients

    Criteria for use of Thrombolytics


    Typical chest pain of AMI ST segment elevation of at least 1mm in 2 limb leads and 2mm in at least 2 contiguous chest leads. Less than 12 hours from onset of chest pain Less than 75 years of age.

    Duties of the medical officer


    Upon recognition of a STEMI, the medical officer will: -inform senior ED physician on duty -send patient to resus room for initial stabilisation -ascertain if the patient has any contraindications to the use of thrombolytics -book a bed in CCU.

    Duties of the senior ED physicians


    Once informed of a patient with STEMI in the resus room, the senior ED physician will: -ensure no contraindications to iv thrombolytics -take consent for iv thrombolytics -ensure that the iv thrombolytic is safely delivered to the patient

    Acute Myocardial Infarction Management


    ABC O2 supplement Analgesia IV morphine, nitrates Antiplatelet Aspirin
    Beta Blocker Continuous Monitoring

    Acute Myocardial Infarction Management


    Reperfusion Therapy Thrombolytics ( only for STEMI) PTCA E-CABG Early ACE inhibitors Use of heparin Glycoprotein IIb/IIIa inhibitors (adjunct to PTCA)

    Cardiogenic Shock Management


    LV infarct Inotropes IABP
    RV infarct Fluids 1st line

    Caution in use of nitrates

    Summary
    Diagnosis of AMI require high index of suspicion
    Early diagnosis and appropriate treatment + monitoring crucial in ensuring a good outcome

    SUSPECTED CARDIAC-ORIGIN CHEST PAIN PROTOCOL Chest pain or Chest pain equivalent *

    *Ischemic Chest Pain - tight, crushing - radiating to neck/ arm - diaphoresis - SOB Chest Pain Equivalent - chest discomfort - diaphoresis - SOB - giddiness/syncope

    Hx, Ex, ECG

    STEMI New BBB Unstable Angina


    Ongoing ischemic CP >20min Hemoydynamically unstable Pulmonary edem ECG changes of ST depression, T inversion

    Unable to rule out ACS

    Non-cardiac CP

    Pulmonary embolism Aortic dissection Pneumothorax Pneumonia Musculoskeletal

    To Resus

    Treat Accordingly

    SUSPECTED CARDIAC-ORIGIN CHEST PAIN PROTOCOL

    Unable to rule out ACS

    High Risk **

    Low Risk

    Treat & Admit

    Evaluate in ED

    ** High Risk Subgroup - middle aged male - Indian - pain similar to previous documented angina - Known CAD - Prev PTCA/CABG - Multiple risk factors

    abnormal

    Give Aspirin/GTN Repeat ECG CK/CKMB on arrival in ED Repeat ECG CK/CKMB/Trop I 4h fr first sample
    (at least 6h from onset of chest pain)

    abnormal

    Both sets normal TCU CVM

    Acute Coronary Syndrome (NSTEMI & Unstable angina)


    ECG - ST depression or T inversion Cardiac enzymes raised in NSTEMI Management
    Oxygen IV GTN IV heparin

    Disposition
    CCU for monitoring coronary angiogram

    AORTIC DISSECTION
    Presentation
    acute tearing chest pain radiating to inter-scapular region. sudden death from rupture or cardiac tamponade, CCF

    Examination
    hypertension pulse deficits, neurological deficits, pericardial rub

    Complications
    AMI - dissection into coronary artery Renal failure Gut ischaemia - mesenteric artery occlusion Paraplegia - spinal artery occlusion Acute limb ischaemia - subclavian artery occlusion

    Associations with Aortic Dissection


    Hypertension Marfans syndrome Ehlers-Danlos syndrome Bicuspid aortic valve Coarctation of aorta Chest trauma Iatrogenic - instrumentation of aorta

    Classification of Aortic Dissection


    DeBakey
    Type 1 - ascending limb Type 2 - ascending and descending limb Type 3 - descending limb

    Stanford
    Type A - DeBakey 1 & 2 Type B - DeBakey 3

    Investigation of Aortic Dissection


    ECG - look for inferior MI (RCA occlusion) CXR - widened mediastinum, abnormal aortic knuckle, calcium sign > 5mm, pericardial or pleural effusion, displacement of trachea to right Transoesophageal echocardiography Spiral CT with contrast - intimal flap Angiography

    Management of Aortic Dissection


    Stablise patient in resus - IV access, supplemental O2, GXM BP control - IV labetalol - reduce heart rate to 60-70 bpm, reduce SBP 100-120 mm Hg, add nitroprusside if necessary Urgent cardiothoracic consult Surgery indicated for
    involvement of ascending aorta rupture arterial compromise (ARF, limb ischaemia)

    Acute Pulmonary Embolism


    High index of suspicion History
    Pleuritic chest pain, dyspnoea, syncope, cough, haemoptysis Risk factors of DVT - immobility, post-op, malignant disease, previous DVT/PE, obesity, pelvic mass, pregnancy

    Examination
    mild fever, HR, RR, pleural rub, JVP , lower limb thrombophlebitis

    Investigations for Pulmonary Embolism


    ABG - hypoxia, resp. alkalosis, normal ABG does not exclude PE CXR - usually normal. Pulm. oligaemia, raised hemidiaphragm, small effusion Ventilation / Perfusion scan problem with indeterminate probability scans Pulmonary Angiography - Gold standard Helical CT scan Investigate for underlying cause of PE eg. ultrasound legs, abdomen, pelvis

    ECG showing PE

    Management
    Stablize patient
    supplemental O2, IV access, cardiac monitor, IV heparin

    Cardiac arrest
    CPR may dislodge clot

    Hypotension
    fluid resus to increase right sided filling pressure. Inotropes

    Anti-coagulation Thrombolysis

    Management
    Pulmonary embolectomy
    thrombolysis contraindicated or patient in shock

    Inferior vena cava filter


    Use if anti-coagulation contraindicated; persistent embolism

    ARRHYTHMIA General Approach


    Assess haemodynamic stability Assess ECG/ rhythm Diagnosis Decide need to treat Appropriate Treatment Look for underlying cause/ precipitant

    ARRHYTHMIA Serious haemodynamic Effect


    Symptoms
    Chest Pain Dypsnoea Depressed Conscious Level

    Signs
    Low BP Shock Pulmonary Oedema

    ARRHYTHMIA Approach to ECG


    Tachy (>120) or Brady (< 60)
    QRS narrow ( <= 120 ms or 3 small sq) or broad Regular vs irregular

    Supra-ventricular Tachycardia

    Ventricular Tachycardia

    TACHYARRHYTHYMIA VF Torsades Approach to ECG Polymorphic VT


    Tachyarrhythmia
    Polymorphic

    Wide Complex
    Monomorphic

    Narrow Complex

    Regular
    VT SVT + aberrancy Electrolyte abnormalities Drugs

    Irregular
    AF + aberrancy MAT + aberrancy Atrial Flutter + varying block + aberrancy

    Regular
    Sinus Tachycardia SVT Atrial Tachycardia Atrial Flutter

    Irregular
    Sinus Arrhythmia

    AF
    Atrial Flutter+ varying block MAT

    Tachyarrhythmia Principles of Rx
    Assess pt stability ABC, monitoring Diagnosis Need to Rx
    Pt unstable Specific arrhythmia VF, VT SVT, fast AF, new onset AF

    Appropriate Rx

    Tachyarrhythmia Clinical Management


    Patient Stable?

    Stable
    ABC Monitoring

    Unstable/ Serious signs or symptoms ABC Monitoring 12 Lead ECG Cardioversion

    VF/ Pulseless VT Immediate Defibrillation

    12 lead ECG
    Evaluate ECG Specific Rx

    Resus as per ACLS protocol

    Tachyarrhythmia Clinical Management


    Stable Pt
    Narrow Complex Tachycarrhythmia SVT Vagal maneuvres Pharmacological adenosine verapamil others

    Broad Complex Tachyarrhythmia Pharmacological Suspected VT-- lignocaine amiodarone Unsure-- consider trial of adenosine Synchornised Cardioversion

    Synchronised cardioversion AF If chronic, aim to slow rate for fast AF If acute ( <72 hrs) convert

    Bradycardia
    Absolute: HR < 60 min Relative : HR < expected
    Sinus Bradycardia Heart Blocks Sick Sinus Syndrome

    Bradycardia
    Evaluate Pt Stability ABC Monitor Rhythm strip 12 lead ECG Need to Rx?

    Management

    Unstable Pt Type II 2nd Degree AV Block 3rd Degree AV Block

    Bradycardia Treatment
    Pharmacologcial Atropine Dopamine Infusion Adrenaline Infusion Pacing Transcutaneous Transvenous

    ARRHYTHMIA Underlying Causes/ Precipitant


    Underlying Cardiac Disease
    IHD, inflammation, Vulvular Hear Disease Congenital Heart Disease, tumours Abnormal of Resting ECG e.g. bypass tract, prolonged QT Post cardiac surgery

    Drugs Metabolic Endocrine Underlying Pulmonary Disease Misc


    e.g. fever, stress, smoking

    ARRHYTHMIA Summary
    Not all require Treatment Need to evaluate Patient Status Type of Arrhythymia
    ( be it tachy or brady)

    Need to Recognise Arrhythymia that require immediate Rx

    THE END

    Thank you!

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