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
+
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
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