EmergencyCardiacCareNovember10,2016UNIVERSITYOFNORTH DAKOTASCHOOLOFMEDICINE&HEALTH SCIENCES

OutlineofThisAfternoon’sPresentation

• ManagementofAcuteCoronarySyndrome• ManagementofOtherImportantCausesofChestPain

• AorticDissection• Pericarditis/Tamponade• PulmonaryEmbolism

• ManagementofChestTrauma• CardiacInjury• AorticTransection

• ManagementofTachyarrhythmias• PSVT• VT/WideComplexTachycardia

CoronaryArteryDisease

•Achronicdisorder• Thediseasetypicallycyclesinandoutofclinicallydefinedphases:

• asymptomatic• stableangina• unstableangina,non-STelevationMI,acuteSTelevationMI(“STEMI”)è AcuteCoronarySyndrome(ACS)

Plaque fissuring and rupture (unstable plaque)èacute coronary thrombosis

AlternativeDiagnosesforPatientswithChestPain• Non-Ischemic CV

– aortic dissection– pericarditis

• Pulmonary– pulmonary embolus– pneumothorax– pneumonia– pleuritis

• Chest Wall– costochondritis– fibrositis– rib fracture– sternoclavicular arthritis– herpes zoster

Gastrointestinal• Esophageal

– esophagitis– spasm– reflux

• Biliary– colic– cholecystitis– choledocholithiasis– cholangitis

• Peptic ulcer• Pancreatitis

Psychiatric• Anxiety disorders

– hyperventilation– panic disorder– primary anxiety

• Affective disorders– depression

Electrocardiograms• ECGstakenintheabsenceofpaininpatientswithanginapectoris,andnohx ofMI,isnormalin50%ofcases

• Obtaininganelectrocardiogramwhileexperiencingchestpainismorerewarding

• Newhorizontalordown-slopingS-TsegmentsonECGishighlysuggestiveofmyocardialischemia;newT-waveinversionalsomayoccur,butthisfindingw/oS-Tdepressionislessspecific

Acute Coronary Syndromes

Non-ST elevation MI or ACS

ST-elevation MI

AcuteCoronarySyndrome(ACS)

•Unstableanginapectoris(UAP)•Non-STelevationmyocardialinfarction(Non-STEMI)•ST-elevationmyocardialinfarction(STEMI)

•DifferentiationofUAPfromNSTEMI:

+cardiacmarkers NSTEMI

Cardiac TroponinsØExtremely specific for myocardial tissueØExtremely sensitive to even minute amounts of

myocardial damageØElevation parallels CK/CK-MB (3-6 hours) but

important to see rise and fallØElevations also found in chronic kidney disease,

cardiomyopathy, myocarditis, sepsis, pulmonary embolism

Biomarkers of Myocyte DeathA. Myoglobin in AMIB. Troponin in AMIC. CK-MB in AMID. Troponin in unstable angina

MEDICALTHERAPY

•Antiplateletagents• Aspirin,Clopidogrel,IIb/IIIa inhibitors

•Antithrombin therapy• Unfractionatedheparin,LMWH

•Antianginaltherapy• Betablockers,nitrates

•Reperfusiontherapy

REPERFUSIONTHERAPY

• Higherinitialreperfusionrates

• Lowerrecurrenceratesofischemia/infarction

• Lessresidualstenosis• Lessintracranialbleeding• Utilitywhenfibrinolysiscontraindicated

• Moreuniversalaccess• Shortertimetotreatment• Resultslessdependentonphysicianexperience

• Lowersystemcosts

PTCA THROMBOLYSIS

Whichone?It’samatteroftime!

Myocardial Reperfusion

Re-establishInfarct Vessel

Patency

Limit InfarctSize

¯ Mortality

CoronaryAngiography

Stent

Evolution of ECG changes in STEMI

Extension / Ischemia

ComplicationsofAcuteMI

Acute MI

Arrhythmia

Heart Failure

Expansion / Aneurysm RV Infarct

Pericarditis

Mechanical Mural Thrombus

Take home concepts

Asymptomatic Stable angina USA/NSTEMI ST-elevation MI (STEMI)

Normal EKG

OtherImportantCausesofChestPain• AorticDissection

• StigmataofMarfan’s Syndrome• Backpain• DoNOTgivethrombolytictherapy!

• Pericarditis/Tamponade• Pleuriticchestpain• DiffuseSTelevationonECG• Muffledheartsounds• Paradoxicalpulseonpalpation

OtherImportantCausesofChestPain

• Pulmonaryembolism• Recentprolongedtravel/immobilization• Desaturation• Syncopalepisode

• Recentstudyfound1in6elderlypatientswithsyncopehadPEasthecause

ManagementofChestTrauma

• Acutecoronarysyndromeduetocoronarydamage• Valvedamageè acuteregurgitation• Myocardialdamage

• Contusion• Freewallrupture/tamponade• Traumaticventricularseptaldefect

• Traumaticaortictransection(decelerationinjury)

AorticTransection• Decelerationinjury(mobileascendingaortaandfixeddescendingaorta)• SurvivorstoEDshowtearatligamentumarteriosum• Mayhaveretrosternalorbackpain,dyspnea,stridor,dysphagia• Mayhaveharshsystolicmurmur• Mayhavepulsedifferencebetweenupperandlowerextremities• Needhighindexofsuspicion!

ElectrocardiogramsandArrhythmias

ECGLeads• II,III,AVF Inferiorwall

• V1-2 Septum

• V3-4 Anterior

• V5-6 Lateral

• I,AVL Highlateral

LocalizationofMI

•AnteriorMI– LADand/ordiagonal•PosteriorMI– circumflexorRCA• InferiorMI– RCAorcircumflex

• Theapexreceivesbloodfromall3arteries

LocalizationofMI

AssessmentofTachyarrhythmia

•Hemodynamicallystableorunstable– “Whenindoubt,shockitout”

•RegularorIrregular– Ifirregularlyirregularprobablyatrialfibrillation(couldbechaoticormultifocalatrialtachycardia)

• Ifregular,isitnarroworwidecomplex(WCT)?

DifferentialDiagnosisofRegularNarrowComplexTachycardia

• Sinustach– Trycarotidsinusmassage•Atrialflutter– canuseadenosinetounmask•PSVT

• AVNRT(dualAVpathways)• AVRT(bypasstract)• Ectopicatrialtachycardia

DifferentialDiagnosisofWideComplexTachycardia

• SVTwithaberrancyorpre-existingbundlebranchblock–consideradenosine

•VT• LookfordissociatedPwaves• Rabbityearsize– Themoreitlookslikerightbundle,themorelikelythatit’sSVT

• Themorebizarre(e.g.,QSinV6),themorelikelyit’sVT• Ageofpatient

ManagementofTachyarrhythmias