My Experiances of Cardiac Emergancy at Workplace

8/12/2019 My Experiances of Cardiac Emergancy at Workplace

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Cardiac emergencies at workplace

Dr S A MerchantInterventional Cardiologist

DM MD DNB FSCAILilavati, Saifee, Raheja fortis, Seven hills, BSES Hospitals


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Cardiac Symptoms at Work place

Chest pain

Breathlessness

Palpitations

Headache / Giddiness

Presyncope/syncope/sweats

Paraesthesia/weakness of limbs

General fatigue/weakness


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Keep Diagnosis in Mind

Acute myocardial infarction

Acute coronary syndrome

Heart failure

Pulmonary embolism Cardiac tachyarrhythmias

Hypertensive emergencies

Bradyarrhythmia vasovagal

TIA/Stroke


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Vitals in cardiac emergency at workplace

Level of Consciousness of patient

Pulse, heart rate and peripheral pulsations

Blood pressure

Oxygen saturation Auscultation of chest for heart sound and lungs for

rales / rhonchi

CNS evaluation for neurological deficits


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Basic cardiac emergency tray at workplace

Pulse oximeter

Stethoscope

BP intrument

ECG machine IV excess

IV fluids DNS, NS, Colloids

IV Atropine , adrenaline, NE, dopamine , xylocaine


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Drugs : Aspirin, clopidogrel , sorbitrate , SLNifedipine, NTG patch/spray, inj clexane,metoprolol, statins, Inj fortwin /phenergan, IV lasix

Monitor for heart rate , non invasive BP cuff,oxygen saturation

Oxygen, BIPAP

Foleys catheter for urine output

Defibrillator

TCP if possible


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Initial Diagnosis of STEMI

Dr S A Merchant


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Transport of Patients With STEMI and InitialReperfusion Treatment

J Am Col l Cardio l. 2004;44:671; Circulat ion. 2004;110:588.

EMS transport

Onset of

symptoms of

STEMI

9-1-1

EMS

dispatch

EMS on scene Encourage 12-lead ECGs

Consider prehospital fibrinolytic

if capable and EMStoneedle

within 30 min

GOALS

PCI

capable

Not PCI

capable

Hospital fibrinolysis:

Doortoneedle

30 min

Inter-

hospital

transfer

Golden Hour = 1st60 min Total ischemic time: within 120 min

Patient EMS Prehospital fibrinolysisEMStoneedle

30 min

EMS transportEMStoballoon 90 min

Patient self-transport

Hospital doortoballoon

90 min

Dispatch

1 min

5

min

8

min


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Complete

obstruction

Partial

flow

Full flow

Partial Successwith

pharmacologic

reperfusion

Rethrombosis:Prevented by antip latelet

and ant icoagulant Rx

PCI p lyticIdeal goal ofpharmacologicreperfusion

Pharmacoinvasive approach

Dr S A Merchant


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ECG changes in AMI

50% of pts have abn T wave that is prolonged or peaked followed by

STseg with reciprocal STseg in opp leads & followed by Q wave

formation

40% of pts develop T wave

or STseg depression

10% of pts with AMI have normal ECG

- sp posterolateral (high lateral) wall MI with acute occlusion of CX or OM

Diagnosis of Myocardial Infarction


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Thrombolytics : Streptokinase, urokinase, t PA

Sedation : Alprozalam, Diazepam, Fortwin, Fentanyl

Aspirin : 325 mg stat & one daily risk of MI &death

Clopidogril : 300 g loading dose & 1 tablet after lunch

IV heparin or LMWH : Inj Clexane or Inj arixta If pain still continues : add b-blocker (atenolol, Metoprolol) or

Diltiazem 3090 mg 8 hourly

If pain still persists : urgent angios, PTCA+stent to culprit lesion or CABGfor left main or multivessel disease.

IABP prior to angio helps to relieve rest pain by unloading action of IABP in LV, cor bl flow,

myo O2demand,

LVEDP, cor perfusion IV Reopro/Integrillin : given before PTCA/Stenting

ACE Inhibitor & Statins : Stabilizes plaque & improves endothelial function

MN of pts with unstable AnginaManagement of Myocardial Infarction


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Take Home Message:

Optimum management of STEMI

A PharmacoInvasive Approach

Initial Fibrinolysis with t-PA within 30-60 mins of chest pain inambulance, nursing home, non-PCI hospital

Endovascular cooling: Aspirin, loading dose clopidogril/prasugrel,

Inj Enoxyparin, GpIIb/IIIa Inhibitor, nitrates, Ace-Inhibitors, beta

blocker, diltiazem, high dose statins, trimatazione, sedation


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Transfer patient within 6 hours to PCI centre for

Cor angiography

Thrombectomy: Suction by Export Cath, AngioJet, M Guard

Direct stenting

Intracoro NTG/Nicorandil

This makes sense to everyone patient, relations, family doctor, consultant

physician, interventional cardiologist. Also, both short term & long term clinicaltrials show excellent result with pharmacoinvasive approach in terms of reduce

mortality, re-infarction & overall preservation of LV function

Management in Myocardial Infarction


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Vitals in cardiac EmergenciesMonitoring In ICU

Consists of :

ECG monitor

Arterial Saturation on oximeter

Non invasive BP cuff

Radial line for invasive arterial pressure

Central line/PA cather

Foleys catheter for hourly urine output

ABG


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h


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Occlusion of mid-RCA.

Mr. Davies48 yrs. Dr S A Merchant

i 8 S h


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Dr S A MerchantMr. Davies48 yrsMr. Davies48 yrs. Dr S A Merchant


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M D i 48 D S A M h t


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Direct stenting complicated by distal embolization

of posterolateral branch.


M D i 48 D S A M h t


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Successful aspiration of the distal thrombus with

the Export catheter.



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Angiography:

LM thrombotic occlusion; 75% ostium of RCA.

Procedure:

IABP. LM aspiration thrombectomy. Predilatation and

DES of LM-LAD; final kiss balloon.

Dr S A Merchant

Cardiogenic shock in AMI

Mr Mishra 60 yrs Dr S A Merchant


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LM occlusion.

Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant



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RCA ostium severe stenosis.




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Final kiss balloon after thrombectomy and

stenting.




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After kiss balloon post-dilation.




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RCA stenting.




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Six-month F-U.



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Basic Life Support (BLS)consists of ABCAirway, Breathing &

Circulation.

Advance Cardiac Life Support (ACLS) Emphasize the interact of

CPR with emergency stabilization & transport, ventillatory

support, IV access, pharmacotherapy and electrical Rx.

Delay in initiation of either BLS or ACLS resultsin low survival rates.

CPR in ICCUABC in cardiac Emergencies


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Electric therapy using defibrillators orPrecordial thump.

Correct Hypoxaemia O24-6 L/min, Airway patency,

BIPAP, intubation, ventillator

Correct Acidosis - IV NaHCO3 Volume Replacement - IV crystalliods (normal saline,

DNS, RL, colloid, blood) Inotropes - Dobutamine, Dopamine,

Adrenaline, IABP

AAD - Xylocaine, Mexiletine,

Amiadarone, Bretelyliun

Tosylate, Procainamide,

Adenosine, Verapamil/Diltiazem, Mg, Atropine

Circulatory support during CPRICU Management in Cardiac Emergencies


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Sustained V. TACH

HYPOTENSION NO HYPOTENSION

DC Shock

(50-150 J-250 J)

and then prophylactic

IV Xylocaine drip afterconversion

Give IV xylocaine 50 mg bolus & repeat 50 mg IV

bolus within 10 mins if patient has not converted to

NSR

After reversal, start maintance drip 2-4 mg/min If xylocaine fails - give inj mexiletene in a dose of 100-

150 mg at rate of 25 mg/min followed by an infusion in

5% dextrose at a rate 2-4 mg/min for the first 3 hrs,

then maintance at a infusion rate of 0.5 mg./min.

Miss Snehal Patil 29 yrs Dr S A Merchant


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Miss. Snehal Patil29 yrs. Dr S A Merchant

Miss. Snehal Patil 19 yrs. Dr S A Merchant


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Miss. Snehal Patil19 yrs. Dr S A Merchant



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Mn of V FIBS & Pulseless VT in ICCU

Persistent VT/VF Return of spon rhythm EMD Asystole

Continue CPR

Intubation at once

Obtain IV access

Adr 1mg push repeat

Defrillation 360J

with 30-60 sec.

Administir Medicat-(Xylocaine, Mexiletine, Bretylium, Mg So4

Procainmide if persist or recurrent VT / Fib

Defrillation 360J, 30-60 sec. after each dose of medication

Pattern should be drug-shock, drug-shock

Defrillation 200J, 200-300J, 360J

ABC

Perform CPR until defibrillator attached


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Management of Congestive Heart failure

Connect to ECG monitor, NIBP, SAT probe,

radial art pr, foleys, central line, ABG, ECG, X-

ray chest

Propped up position

Oxygen 6-8 litres/min thronasal prong/mask

Inj Fentanyl : 50 mgm IV bolus, 50 mgm/hr for

pts on ventillator, adv over morphine short

acting, pain relief, does not cause hypotension orhypoxia, vasodilator

Loop diuretics : inj Frusemide 40120 mg bolus,

repeat if reqd.


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Preload reduction : vasodilator IV NTG/Patch/Spray

Afterload reduction : Captopril/ramipril/losartan keep sys pr > 100mmHg.

Inotropes:

IV Dopamine/Dobutamine/Amrinone/IABP

Ventillator: PO2< 45mmHg, PCO2>50 mmHg

Vol-cycle ventillator with an FIO2of 100%

Management of Congestive Heart failure

Mr. Peter Gomes 44 yrs. Dr S A Merchant


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y

Mr. Peter Gomes

44 yrs. Dr S A Merchant


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y

Mr. Peter Gomes



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y

Mr. Peter Gomes



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y

MN OF BRADYCARDIA


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MN OF BRADYCARDIA

Access ABC

Secure Airway

Give O2

IV access

Attach pulse oximeter & sphygmomanometer

SymptomsCP, SOB, consciousness

SignsLow BP, shock, PE, CHF, AMI

Type II second degree AV block or third degree AV block

Observe Prepare for TV pacing

Use TCP as bridge device

Atropine - 0.61.2 mg

Fluid infusion - RL, DNSTCP - If available

Dopamine - 520 g/kg/min

Adr - 210 g/min

Isoproterenol - 210 g/min

Transvenous pacing

HR < 60/mm

NO YES

NO YES

Dr S A MerchantMr Rai 60 yrsDr S A Merchant

Mr. Roy



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Dr S A MerchantMr. Rai60 yrs

Mr. Roy



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Management of H pertensi e emergencies


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Definition:

Systolic BP > 220 mmHg or diastolic BP > 125mmHg with end organ

damage involving heart, brain, kidneys &/or retina

Treatment:

ICCU admission and monitor BP

Observe symptoms of neurological deficits, chest pain, dyspnoe or

signs of papilledema, hematuria, renal dysfunction or ECG changes

Rx goal is to reduce arterial pressure by 25% in 1 to 2 hrs, then toreduce BP to 160/100 over next 6 to 12 hrs.

IV nitroprusside, NTG & labetolol commonly used.

Some prefer oral/SL Nifedipine, nicardipine & fenoldopam

Management of Hypertensive emergencies

Mr. Das



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Mr. Das



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Mr. Das



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Mr. Das



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Mr. Das



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Mr. Das



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Repeated TIA/Acute Stroke management


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Repeated TIA/Acute Stroke management

Aspirin, Clopidogril, LMHW, Stiloz

Control BP with SL nefidipine, NTG IV/Spray, Do not drop

BP


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Mr. Choudhary



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Mr. Choudhary



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Mr. Choudhary



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Mr. Choudhary



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DVT with pulmonary embolism


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DVT with pulmonary embolism

Sitting for long hours on computers at office

Sudden acute breathlessness with sweat, fatigue and giddiness

Oxygen, bipap, ventilator,

LMWH, IV Heparin, Aspirin

Thrombolytics in cathlab (tpa, uk), mechanical breaking of

thrombi, IVC filter implant

Mr. Patel



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Mr. Patel



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Mr. Patel



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Mr. Patel



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Thank you

My Experiances of Cardiac Emergancy at Workplace

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