CARDIOVASCULAR EMERGENCYEMERGENCY

Dr. Tri Wisesa Soetisna, SpB TKV (K)

Cardiovascular Emergency

Trauma - Penetrating - Blunt

Non Trauma - Congential Heart Disease - Acquired Heart

Disease

Penetrating trauma

Cardiac Wall Blood Vessel Rupture Cardiac Septum Cardiac Valve

Bleeding � TamponadeHemodinamic Disturbance

Shock

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Penetrating Heart Injury• Wilson et al 1975 : inhospital mortality rate > 50 %

• Bodai ( 1983) : prehospital mortality 38 – 83 %

• Paul Tahalele 1985 - 89: inhospital survival 91.2% (12)

• Wuryantoro ( 1989 ) : inhospital mortality 0% (6)• Djoko J : inhospital mortality 50 % (4)

Factor that contribute for the success in Management of Penetrating Heart Injury :

1. first aid in the location

1. Send patient to hospital with thoracic cardiovascular surgery fascility immediately

2. Definitive Treatment in Hospital

First Aid in Location Give a

• Nothing Per Oral• Don’t do external cardiac massage • Don’t draw a sharp matter from patient

Send Patient Imediately

HOSPITAL

Transportation to Hospital

• Placed the patient in supine position• Fluid Resuscitation Immediately (Electrolite Solution) • Contact the Hospital for Preparing

In Hospital In Hospital

1. Rapid and accurate diagnosis 2. Manage pericardial tamponade 3. Control the bleeding 4. Blood transfusion

High index of suspicion

• Trauma mark• Unstable condition• Tamponadefrom 200 cases : from 200 cases :

- 63 cases (31,5%) tamponade

- 26 cases (13%) complete Trias Beck

Cardiac Tamponade• Blood in the pericardial sac

• Most frequently penetrating injuries

• Shock, ↑JVP, PEA, pulsus paradoxus• Classically, Beck’s triad:• Classically, Beck’s triad:

– - distended neck veins– - muffled heart sounds– - hypotension

• Rx: Volume resuscitationPericardiostomy

Cardiac tamponadeCardiac tamponade

Cardiac Injuries

• The right ventricle is most commonly injured, followed by the left ventricle

Definitive Treatment

• Cardiac Tamponade � PericardiotomyThoracotomy

• Control a Bleeding

• Stop a Bleeding

* Sampai 1881 - 1897 hanya perikardiosentesisRobert, Wiliams, Rehn berhasil menjahit jantung yang luka

* Sampai 30 - 40 tahun kemudian kardiorapi banyak dianut.1930 Blalock & Ravitch melaporkan keberhasilan perikar-

diosentesis. Sejak itu terapi jadi kontroversial* Pengalaman Wilson, et al, 1975 dengan kardiorapi selama * Pengalaman Wilson, et al, 1975 dengan kardiorapi selama

20 tahun dengan survival rate: * 83% pada 173 penderita

luka tusuk dan * 74% pada 27 penderita luka tembak.

Ini menyokong tindakan torakotomi segera dan kardiorapi

Chest wall Incision for Emergency Thoracotomy

Finger pressureFoley Catheter

Bleeding controle

CARDIORRAPHY

Complication

• Coronary Laceration

• Septal Defect

• Conduction System Damage• Conduction System Damage

PITFALL8 :

Arrythmias could occured if large

coronary laceration is not repair

PITFALL8 :

Arrythmias could occured if large

coronary laceration is not repair

Blunt Cardiac/Great Vessel Injuries

• Myocardial contusion is the most common cardiac injury most common cardiac injury and is suspected with EKG changes and serial enzyme elevations

Blunt Cardiac/Great Vessel Injuries

• Coronary artery injury can result in thrombosisand myocardial infarction

• The patient should be monitored in the ICU and may require heparinization for coronary may require heparinization for coronary thrombosis and anti-arrhythmic therapy

• Echocardiography and angiography are indicated for tamponade and post-injury murmurs, which suggest valvular insufficiency or septal defect

Post Operative Management

* Broad Spectrum anti biotic* Standart elective post cardiac surgery* Chest physio therapy* Chest physio therapy* Early mobilisation* 24 % of reccurent pericardial effusion

Aortic rupture• Blunt trauma involving deceleration forces• 90% mortality on sites of accident• 90% mortality before optimal management at the ER (with in minutes)the ER (with in minutes)

• Most common site near ligamentum arteriosum

• Dx: clinical suspicion, CXR, aortography,contrast CT or TEE

Aortic rupture

• Weak leg pulses with hypertension in the arms, or a new murmur.

• 1st or 2nd rib fractures

Aortic rupture

• A widened upper mediastinum, deviation of the trachea, a “pleural cap,”

• Rx: surgical…poor prognosis

widening mediastinumwidening mediastinum

Aortic ruptureAortic rupture

Cardiac/Great Vessel Injuries

• Aortic rupture is also usually fatal, but can result in formation of a false aneurysm, typically at the aortic isthmus

• Patients with a widened mediastinum on CXR • Patients with a widened mediastinum on CXR should have prompt aortography, which will demonstrate an intimal tear

• Surgical repair should be done promptly, as fatal hemorrhage can occur at any time

Classification

Cardiac/Great Vessel Injuries

• CXR, EKG, and echocardiography have little diagnostic value in these patients

• Subxiphoid pericardiotomy is useful for diagnosis; • Subxiphoid pericardiotomy is useful for diagnosis; negative deflection of the QRS complex indicates contact with the epicardium and a drain should be left in place

• Subxiphoid pericardiotomy is preferred for tamponade, however, and should be performed in the operating room, as the patient may rapidly exsanguinate

TAVARES � ERT mortality rate 43 % (37 )

1. No sign of life / � ERT no vital sign 2. Hypotensive / BP systolik < 90 mmHg, shock,

unconciousness, respiratory distress � ERT /OR 3. Normotensive ( BPs > 90 mmHg ) concious,

adequate breating � OR

Djoko J : thoracotomy: 1. Immediate ( emergency ) thoracotomy for

resusciatation 2. Early thoracotomy, first 24 hours3. Late thoracotomy, > 24 hours

Congenital Heart Disease

• Cyanotic• Respiratory distraess � tachypnea• Tachycardia • Enlargement heart • Enlargement heart • Systolik mur mur, thrill • Sign of acute congestive heart failure

Hospital

Hypoxic Spell

• Inadequate Pulmonary Blood Flow• CHD :

– Tetralogy of Fallot– Pulmonary Stenosis– Pulmonary Stenosis– Pulmonary Atresia

• Sign of Severe Systemic Hypoxia ,Cyanosis, provoke by severe activity / cry / acidosis (severe diarrhea/dehidration)

Hypoxic Spell

• Management :– Stop activity that provoke hupoxic

spell– Put the patient in knee chest – Put the patient in knee chest

position– Oxygen– Rehidration (IV fluid)– Medical � Surgical

Congestive Heart Failure

• < 6 month of Live• CHD :

– L � R shunt (ASD,VSD,PDA,AVSD,APVD)– TGA, HLHS– Coarctation– Valvular (severe AS)

• Sign :– Feeding difficulty– Reccurent Respiratory Track Infection– Failure to thrive

Heart FailurePRE LOAD

- INTRAVASCULAR VOLUME

CONTRACTILITY- CAD- TAMPONADE- CHRONIC / COMPLEX VALVULAR

(THROMBUS FORMATION) - ARRYTHMIAS- ARRYTHMIAS- MYXOMA

AFTERLOAD- HYPERTENSION

OTHER- TENSION PNEUMOTHORAX- ACUTE PULMONARY EMBOLISM- CHRONIC LUNG DISEASE

Heart FailureCONSERVATIVE

-BEDREST-OXYGEN-LOW SALT DIET-FLUID RESTRICTION

MEDICAL-DIGITALS-DIURETIC-DIURETIC-ACE inhibitor-THROMBOLYSIS- ANTIARRYTHMIAS

DEFINITIF / SURGICAL-PERICARDIOTOMY-CABG-CARDIOMYOPLASTY-VALVE REPLACE/REPAIR-ARTERECTOMY-ABLASION

ACS

Acute Myocardial Infarction

Arrythmia- Sinus Tachycardia- Bradycardia- Block

Hemodynamic Complication- myocardial rupture- ventricle aneurysm- septal rupture- severe mitral regurg

Unstable Angina

Medical TherapyPace maker implantation

Emergency orCito Operation

Medical

I A B P

PTCACito CABG

ST elevasion

Acute Myocardial Infarction16

14

12

10

8

< 6 h 6 – 23 h 1 – 3 d 4 – 7 d 8 – 14 d > 15 d

8

6

4

2

0

THANK YOU