Post on 15-Jan-2016
Cardiovascular Cardiovascular EmergenciesEmergencies
ByBy
Dr. Z. SamarraeDr. Z. SamarraeFRCS, FICS ,CABS, DS, MB CHBFRCS, FICS ,CABS, DS, MB CHB
ACUTE CORONARY ACUTE CORONARY SYNDROMESSYNDROMES
• ACS encompass the following
• Stable angina
• USA
• Myocardial infarction
• What is the basic pathology?
coronary occlusioncoronary occlusion
• Atherosclerosis- a plaque causing gradual narrowing
• rupture of the plaque- rough surfaces exposed-platelets adhere-clot formation-resulting in partial or complete occlusion
• So what is the sequence?
• Plaque narrowing-plaque rupture-clot
• Can u relate each one to ACS spectrum?
Coronary occlusionCoronary occlusion
• Plaque narrowing---stable angina
• Plaque rupture(sudden)—either USA or MI (sudden rupture leads to sudden change in pattern of symptoms.
• Symptoms, ECG,&enzymes changes can be correlated to above 2 pathlogies,can u?
Approach to the patientApproach to the patient
• Listen,lissten,lisssten, lissssssssssssssten• Active listening---- donot interrupt• Listen to a story ,not scattered bits..• err on the worst side: donot be fooled by:• Patient is young• She is female• She is obese ---reflux oesophagitis• He is labourer-----it is musculoskeletal• Listen to the patient 1st ,then to relatives
Ischemia– visceral painIschemia– visceral pain
• What does it mean?• Diffuse(not submammary)-note how he used his
hands.• Nausea, vomiting, and dizziness---if present will
add more to the suspicion• Ask how severe pain is , but indirectly, donot
be fooled by: mild pain in ….?• Elderly, and diabetics.• Continuos pain---unlikely to be ischemic, but
good listening to story ,not direct,how u ask?
Physical examPhysical exam
• Usually normal..but look for complications
• LVF
• Arrythmia
• New murmurs---papillary muscle rupture
• ---VSD
ECG-what it can show?ECG-what it can show?
• 50% diagnostic.in MI may see ST elevation• In angina-may see ST كابة during pain• It may show arrythmias (fast or slow)• May see old ischemia, or LVH• what type of MI ? Is it important ?• ..yes. How ?• احتاط من العاقل ولكن وقع اذا لالمر احتاط من العاقل ليس
يقع ال حتى لالمر• MAY SEE NOTHING• ABSOLUTELY NOTHING-normal ECG does not exclude
ischemia• بعد؟ وماذا
Cardiac enzymesCardiac enzymes
• CK-MB,and the more specific Troponin• They are normal in stable angina.• May be elevated in USA & MI.• If ECG showed MI, do I need Troponin?• Those with +ve troponin do worse • Again a normal enzymes does not exclude
ischemia ؟ بعد وماذا• Serial reading- mind time since pain onset• Now ECG &enzymes are normal, والحين؟• Admit .
Other investigationsOther investigations
• LDH-not specific
• Hb
• Creatinine, sugar, lipids…PT, PTT..
• Any need for CXR?
• To screen for alternative Dx.e.g dissection of aorta –wide mediastinum,how history can help?
• Onset &response
Treatment Treatment
• MONA
• Reperfusion (PCI & Thrombolytics)
• B- blockers—reduce infarct size
• ACE—stabilize the plaque.
• Be ready for complication من العاقل ليساحتاط من العاقل ولكن وقع اذا لالمر احتاط
اليقع حتى لالمر• What is MONA?
MONAMONA
• A:150 Aspirin
•N :SL GTN 3 times-consider then IV
•O2 NASAL CANNULA 4 L
• If still pain –Morphin 2-4 q 5min titrate to response and side effects.
• Heparin
Reperfusion therapyReperfusion therapy
• PCI SUPERIOR TO THROMBOLYSIS• But PCI need a cath lab, trained staff>75/y , and
a high volume centre>200 /year.• esp. useful in cardiogenic shock• When thrombolytics are contraind or failed• Door to balloon should be 90 min. • Thrombolytics : door to needle 30 min, but best
given within 3hrs, but can be given up to 12 hrs.
Thrombolytics Thrombolytics
• Consider contraindication before • Watch for any bleeding esp in elderly• ECG indications for thrombolysis:• ST elevationin 2 contiguos leads• New BBB esp LBBB• How much elevation? 1mm in standard
leads, 2mm in chest leads.• Long term secondary prevention
ARRYTHMIASARRYTHMIAS
• Fast rhythm---tachycardias(AF/Aflutter,VT)• Slow rhythm---bradycar(sinus&AV blocks)• Treat patient NOT the ECG, many arrythmias
donot need treatment.• Tachycardias <150 generally no Rx.• How tachycar & bradycar give symptoms?• Reduction of cardiac output.• Dizziness, chest pain ,weakness,exertional
dyspnea
Management Management
• Fast rythm----slow it by drugs & electricity• Slow rythm---push it by drugs & electricity• what medicines for fast rhythm? depend
on?• Narrow or wide complex tachycardia.• For narrow complex—CCB• For wide complex tachycar----Amiodarone• For unstable tachycardia---cardioversion
Management of slow rythmManagement of slow rythm
• Atropine for sinus bradycardia
• Pacing for blocks-mobitz 2,complete block
• In emergency —percutaneous pacing
• Later on -----transvenous pacing
• Again treat patient not an ECG
Hypertensive emergenciesHypertensive emergencies
• HTN emergency—target organ damage
• HTN urgency-----no target organ damage
• HTN emergency---Bp reduced min-hrs
• HTN urgency-------Bp reduced in24-48hrs
• Marked reductions should be avoided.
Patient approachPatient approach
• Place patient in a quiet room. • Repeat Bp at the end of interview: 27% show
reduction <critical level at end.• If still high: determine target org.damage.• What is work up needed?• Clinical, lab ,radiological assessment for 3
systems---heart ,CNS,renal.• Heart: chest pain, heart failure, ECG,CXR• Why CXR?• LVF…aortic dissection
Patient evaluationPatient evaluation
• CNS: focality…papilloedema.altered level of conciosness…CT scan…
• Renal : creatinine, urine test: RBC, cast, protienuria..oliguria
• Remember : donot treat Bp reading only
• Drug screen
• Pregnancy tests
Treatment Treatment
• Labetolol ----steady drop in Bp, iv small boluses, or drip titrate to response---in encephalopathy reduce MAP by 25%only and diastolic should be between 100-110
• GTN ----2ND choice
• Trimethaphan(ganglionic blocker) ---for aortic dissection
Conclusions Conclusions
• Mind white coat HTN
• Determine target organ Damage
• Donot treat numbers
• Overzealous Bp reduction to be avoided
• Mind the false concept ---a patient should have a normal Bp before leaving ED.