EMERGENCY MANAGEMENT OF
CARDIAC DISEASE
Cassidy Sedacca, MS, DVM, DACVIM (Cardiology)
Upstate Veterinary [email protected]
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Know how to treat congestive heart failure in the emergency situation
Know how to treat life threatening arrhythmias in the emergency situation
Know how to treat pericardial effusion/cardiac tamponade in the emergency situation
OBJECTIVES
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Signalment
Previous cardiac history?
Onset and duration?
Breathing difficulties?
Cough?
Abdominal distension?
HISTORY
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
… with a cardiac focus
Exercise intolerance?
Weakness/collapse/syncope?
Appetite?
Current medications?
Heartworm status?
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General patient condition
BCS, attitude, posture
MM color; CRT
Pink, pale, cyanotic
Rectal temperature
Fever, hypothermic
Jugular Veins
Normal, distended, pulsating
Femoral pulses
Normal, hypodynamic, hyperdynamic
Abdominal palpation
Distended, organomegaly, ballotable fluid wave
CARDIOVASCULAR EXAMINATION
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Respiratory rate and effort
Dyspnea, tachypnea, orthopnea
Pulmonary auscultation
Dull, quiet sounds
Increased bronchovesicular sounds
Crackles, wheezes
CARDIOVASCULAR EXAMINATION
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Cardiac auscultation
Quality (precordial impulse, muffled)
Rate (slow, appropriate, fast)
Rhythm (regular, regularly irregular, irregularly irregular)
Murmur (grade, location, phase)
Gallop sounds (systolic click, S3, S4)
CARDIOVASCULAR EXAMINATION
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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1) Indirect estimates of cardiac output
MM color, CRT, pulse quality, temperature, blood pressure, lactate
2) Focused ultrasound (TFAST, AFAST)
Pericardial fluid
Pleural fluid
Abdominal fluid
+/- B-lines or “lung rockets”
DIAGNOSTICS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Lisciandro GR, JVECC 2017
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3) Thoracic Radiographs
Heart size
Pulmonary vasculature
Caudal vena cava
Pulmonary parenchyma
Pleural effusion
Diagnosis of CHF or other?
4) Electrocardiogram
Heart rate and rhythm
DIAGNOSTICS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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5) CBC, biochemistry panel, U/A ideal
Baseline renal function – BUN, creatinine, USG
Electrolytes – arrhythmias
CBC – pneumonia
6) SNAP NTproBNP test
Respiratory vs. cardiac dyspnea
DIAGNOSTICS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
SNAP® Feline Cardiopet® proBNP Test
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TREATMENT STRATEGIES
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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OXYGEN THERAPY
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
FiO2 ~40%
Minimal restraint
Quiet
+/- sedation
Time to think
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TREATMENT STRATEGIES
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Determinants of cardiac output
Preload
Afterload
Contractility
Heart rate
Stroke Volume
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Stretch of the cardiomyocytes prior to contraction
Ventricular end-diastolic volume
Frank-Starling mechanism
Changes in ventricular preload directly affect stroke volume
PRELOAD
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Preload
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WHICH PATIENTS HAVE EXCESSIVE
PRELOAD?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Almost all cardiac diseases, except …
Pericardial Effusion
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Diuretics
Furosemide IV or IM PRN (2-4 mg/kg q 1-6 hr)
Furosemide CRI (0.5-1 mg/kg/hr)
Centesis (thorax, abdomen)
Venodilators
Furosemide, nitroglycerine (pinna), nitroprusside CRI
No IV fluids!
TREATMENT OF EXCESSIVE
PRELOAD
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Goal = lose 5-7%body weight
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Pressure that ventricle must generate to eject blood
Tension produced by ventricle in order to contract
Increased when aortic pressure or SVR are increased
Shifts Frank-Starling curve
AFTERLOAD
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Afterload
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HOW DO WE ASSESS AFTERLOAD IN
THE CLINICAL SETTING?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Measure systemic blood pressureMeasure systemic
blood pressure
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NEGATIVE EFFECTS OF INCREASED
AFTERLOAD
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Increased resistance to ejection leading to decreased SV and CO
Increased cardiac “work” and thus myocardial O2 demands
Increased regurgitant fraction in patients with mitral insufficiency
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Nitroprusside CRI
1-5 mcg/kg/min
Titrate to desired blood pressure
Hydralazine PO
1-3 mg/kg BID (but dose must be titrated)
Amlodipine PO
0.1-0.2 mg/kg SID
Pimobendan PO
0.2-0.3 mg/kg BID-TID
TREATMENT OF EXCESSIVE
AFTERLOAD
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Goal: Systolic BP = 100-130 mmHg
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The degree to which cardiomyocytes can shorten when activated by a stimulus
Independent of preload and afterload
“Inotropic state” of the myocardium
CONTRACTILITY
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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WHICH PATIENTS CAN HAVE A
DECREASE IN INOTROPIC STATE?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Almost all cardiac diseases, except …
Pericardial effusion
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Signs of forward/low-output heart failure
Inappropriate mentation
Severe generalized weakness
Poor femoral pulse quality
Hypotension
Hypothermia
Elevated lactate
CLINICAL ASSESSMENT OF
CONTRACTILITY
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Pimobendan PO
0.2-0.3 mg/kg TID
Milrinone CRI
1-10 mcg/kg/min
Dobutamine CRI (dogs)
2-10 mcg/kg/min
Dopamine CRI (cats)
2-10 mcg/kg/min
Digoxin PO
0.005 mg/kg BID
Loading dose: double maintenance dose for 24 hours
POSITIVE INOTROPIC AGENTS
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HEART RATE
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Effects of HR on cardiac output
Cardiac output directly proportional to HR …
… until a point when HR become too fast
Tachyarrhythmias and bradyarrhythmias are detrimental to cardiac output
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WHICH PATIENTS MIGHT HEART RATE
IMPACT CLINICAL SIGNS?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Atrial fibrillation/flutter
Sustained tachyarrhythmia
Ventricular tachycardia (VT)
Supraventricular tachycardia (SVT)
Bradyarrhythmias
3rd degree AV block
Sick Sinus Syndrome
Treatment of a sinus tachycardia or sinus
bradycardia is almost never necessary
HR = 50 bpm
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ATRIAL FIBRILLATION
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SUPRAVENTRICULAR
TACHYCARDIA
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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VENTRICULAR TACHYCARDIA
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SINUS NODE DYSFUNCTION (SSS)
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3RD DEGREE AV BLOCK
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Vagal maneuver
Ocular pressure, carotid massage
Diltiazem (Ca+2 blocker)
0.1-0.25 mg/kg IV slow bolus (3 min)
2-6 mcg/kg/min CRI
Esmolol (beta-blocker)
50-500 mcg/kg IV bolus
50-200 mcg/kg/min CRI
TREATMENT OF SVT
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Procainamide (Na+ blocker)
6-10 mg/kg IV slow bolus (3-5 min)
20-50 mcg/kg/min CRI
Amiodarone (K+ blocker)
Bolus followed by CRI
DC electrical cardioversion
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Diltiazem (class IV)
0.1-0.25 mg/kg IV slow bolus (3 min)
2-6 mcg/kg/min CRI
0.5-2 mg/kg PO TID
Digoxin PO
0.005 mg/kg BID
Loading dose: double maintenance dose for 24 hours
TREATMENT OF ATRIAL
FIBRILLATION
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Rate control, not rhythm control
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Lidocaine (Na+ bloacker)
Dog: 2 mg/kg IV bolus
Cat: 0.2 mg/kg IV bolus
Repeat up to 3 total times 5 min apart
50-80 mcg/kg/min CRI (dog only)
Procainamide (Na+ blocker)
6-10 mg/kg IV slow bolus (3-5 min)
20-50 mcg/kg/min CRI
TREATMENT OF VT
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Esmolol (beta-blocker)
50-500 mcg/kg IV bolus
50-200 mcg/kg/min CRI
MgCl
0.1-0.2 ml/kg IV slow bolus (3 min)
Sotalol (K+ blocker)
1-2 mg/kg PO BID
Amiodarone (K+ blocker)
Bolus followed by CRI
DC electrical cardioversion
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Atropine Response Test
0.04 mg/kg IV (wait 3 min)
Can initially make AV block worse
0.04 mg/kg IM (wait 20 min)
If AV block/sinus arrest eliminated
High resting vagal tone
Search for underlying cause
TREATMENT OF
BRADYARRHYTHMIAS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
If no response or partial response,
Temporary/permanent pacemaker ultimately required
Glycopyroolate 0.02 mg/kg SQ or IM q 4-6 hr
Aminophylline 5-10 mg/kg slow IV (30-60 min) q 6-8 hr
Terbutaline 0.01 mg/kg SQ or IM q 8 hr
Dopamine/dobutamine CRIs
Theophylline, terbutaline, or hyoscyamine PO
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Simple to diagnose but easy to miss
Presents with signs of low-output heart failure or R-CHF
Cardiac tamponade = intrapericardial pressure > right atrial pressure
“Decrease in preload”
PERICARDIAL EFFUSION
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Acute: collapse, severe weakness, unable to rise, vomiting
Chronic: Anorexia, lethargy, exercise intolerance, abdominal distension
Pale mucous membranes
Muffled heart sounds
Hypokinetic femoral pulses, pulsus paradoxus
Jugular venous distension/pulsation
Signs of R-CHF (pleural effusion, ascites)
Hypotension
ECG
Tachyarrhythmias
Low voltage R waves, electrical alternans
CXR
“Globoid” cardiomegaly
TFAST/AFAST
Pericardial fluid
Pleural fluid
Abdominal fluid
CARDIAC TAMPONADE: DIAGNOSIS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Pericardiocentesis!
Ultrasound-guided or “blind”
Right side: 4th – 6th intercostal space, just dorsal to costochondral junction
Local block with lidocaine
Small stab skin incision (#11 blade)
14-16 gauge over-the-needle catheter
Advance catheter needle slowly until flash of fluid in hub
Advance catheter off of stylet
Use 3-way valve and syringe to remove fluid
CARDIAC TAMPONADE:
TREATMENT
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Pericardiocentesis “tricks of the trade”
IV fluids/boluses okay
Diuretics contraindicated
Sedation frequently required
Butorphanol +/- midazolam
Always have continuous ECG monitoring
Place sample in EDTA tube and plain tube (cytology, check for clotting)
Caution if coagulopathy or ruptured atrium
CARDIAC TAMPONADE:
TREATMENT
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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Oxygen therapy … may give you time to think
Determinates of cardiac output will help you guide treatment
Preload
Afterload
Contractility
Heart rate
Pericardiocentesis … you can do it!
SUMMARY OF KEY POINTS
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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QUESTIONS ?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
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