Emergency management in cardiology

1. Emergency management in cardiology By C. Wongvipaporn Division of Cadiology in Medical Department Srinagaringe Hospital KhonKaen University

2. Objective • What are the emergency cardiac condition? • How to detection? • How to emergency management and monitoring?

3. Cardiac Emergency • Definition of emergency care and critical care • Symptomatic emergency: • CHF, Cardiogenic shock, Syncope, SCA • Arrhythmia: Tachy and Brady arrhythmia • Endocardial emergency: • valvular obstruction or regurgitation: CHF, Shock, Syncope • Myocardial emergency: • Coronary arterial disease, Myopathies: CHF, Shock, Syncope, Arrhythmia, SCA • Pericardial emergency: • Cardiac tamponade • Vascular disease: • Hypertensive emergency, Aortic dissection, Pulmonary emboli

4. CONGESTIVE HEART FAILURE

5. Definition • HF • Syndrome of abnormal cardiac functions in response to tissue requirement • CHF • Refractory CHF: Not improve or worsening in optimized medications • Intractable CHF: Not improve or worsening in full medications

6. Clinical manifestation

7. Physical examination • Left side • Pulsus alternans, Tachycardia • Cheyne-Stokes resp • Hypotensions • Gallop LV • Rales: Killips Class • Alteration, Renal failure • Right side • Engorged NV • HJR • Gallop RV • Dependent edema • Jaundice, Organomegaly, Ascites • Specific signs: Thyrotoxicosis, Beri beri

8. Killip’s Classification I . No crepitation , No S3 • Crepitation <1/2 Lung ; + S3 • Crepitation >1/2 Lung ; Pulmonary edema IV. Cardiogenic Shock

9. NYH Classification • FCI: No limitation of physical activity • FCII: Slight limitation of physical activity • FCIII: Marked limitation of physical activity • FCIV: Symptoms at rest

10. Etiology • Endocardium: Rheumatic heart disease • Myocardium: IHD, Cardiomyopathy, Hypertensive heart disease, Myocarditis • Pericardium: Constrictive pericarditis, Cardiac temponade • Vascular: Hypertensive emergency

11. Precipitating cause • Preload: Hypervolemia, Dietary • Contractility: ACS, Myocarditis • Afterload: HT • Others: Infection, Arrhythmias, Thyrotoxicosis, Anemia, Endocarditis, Inappropriate treatment

12. Principle of management • Clinical and Hemodynamic stabilization • Nonpharmacological • Pharmacological • Correct cause (Type of HF) and reversible precipitating factors • Awareness of treatment • Planing of long term treatment • Risk stratifications • Prevention

13. Nonpharmacological Rx. • Fluid; restrict • Diet; Low salt diet • Record V/S, BW • Activity • Position • Bed rest • Wandering tourniquet • Oxygination • Intubations • IABP • Cardioversion • Pacing

14. Pharmacological Rx. • Decrease preload • Diuretic • Nitroglycerine • Morphine sulfate • Increase contractility • Dobutamine • Dopamine • Adrenaline • Digoxin • Decrease afterload • Nitroprusside • Nitroglycerine • ACEI/ARB • ISDN+Hydralazine • Ca Blocker •  blocker • Antiarrhythmic drugs • Digoxin • Amiodarone

15. Correct cause & precipitation • Endocardium • Myxoma: Sx • IE: Sx, Abc • Myocardium • IHD: Thrombolytic, Revascularization • Beri beri: Thiamine • Myocarditis: Abc, steroid • Pericardium • Cardiac temponade: Sx • Constrictive: Sx • Other cause • High BP: iv control • Infection: Abc • Anemia: Transfusion • Thyrotoxicosis: PTU

16. Awareness of Treatment • Over diuresis; prerenal, hypovolemic shock • Electrolyte disturbance • Pharmacological side effects • Hypotension • MI • Inappropriate treatment

17. SHOCK

18. Shock -- Definition • Circulation inadequate to satisfy overall cellular metabolic requirement. • Hypotension • MAP decreased > 30 mmHg (< 60 mmHg) • SBP decreased > 40 mmHg (< 90 mmHg) • Hypoperfusion; clinical of vital organ dysfunctions

19. Shock -- Clinical manifestation I • Hypotension: At least one criteria. • MAP < 60 mmHg or • Decreased MAP > 30 mmHg or • SBP < 90 mmHg or • Decrease SBP > 40 mmHg

20. Shock -- Clinical manifestation II • Hypoperfusion (at least one system involvement) • CNS: Agitation, anxiety, confusion, alteration of consciousness, unconscious COMA • CVS: Hypotension, tachycardia, dysrhythmias, thready pulse, new murmurs or valvular regurgitation or dysfunction, capillary refill > 3 sec • RS: Tachypnea, dyspnea, cyanosis • Renal: Oliguria, anuria • Skin: Paleness, dusky skin, cool, clammy skin, profuse sweating, bluish lips and fingernils • Other: Lactic acidosis

21. By pathophysiology (New categories) Hypovolemic Cardiogenic Obstructive Distributive Hyperdynamic By site of origin dysfunction (Previous) Hypovolemic Cardiogenic Vasogenic (anaphylactic) Septic Shock -- Classification • Overlap exists, and also concomitant categories exist

22. Shock -- Classification -- Cardiogenic • Endocardium • Valvular: stenosis, regurgitation • Septal defects • Myocardial • Infarction, contusion, myocarditis, cardiomyopathy, pharmacologic, depressant factors • Pericardium (Hemodynamic likely to Obstructive) • Constrictive pericarditis, Cardiac tamponade • Arrhythmogenic

23. Extrinsic causes Pericardial tamponade Constrictive pericarditis Tension pneumothorax High PEEP, High alveolar pressure Obstructive intrathoracic tumors Intrinsic causes PE Pulmonary vascular disease Hypoxic pul vasoconstriction Atrial myxoma (R) Atrial thrombus (R) Metastatic tumors Endocarditis (R) Shock -- Classification --Obstructive

24. Shock -- Management Five major principles • Prompt recognition. • Initial supportive management. • Airway • Volume replacement • Cardiovascular drugs • Determine & management primary problem leading to shock. • Management of complications.

25. Shock – Volume replacement • Position: • FEET UP / HEAD FLAT OR 30 DEGREES • Not use Trendelenberg position • Vascular access • If no evidence of cardiogenic pulmonary edema, trial of volume expansion. • Initially, 500-750 of colloid or 1-2 litres crystalloid during the first hour.

26. Shock – Volume replacement • Rate and type of on-going fluid administration depends on: • Clinical scenario - Clinical response • Presence of pulmonary edema (cardiac or non-cardiac) is strong contraindication to more fluid admin without more hemodynamic info.

27. Shock – Cardiovascular drugs • Severe BP drop is disasterous to brain and heart. Use vasopressor initially, even in hypovolemic shock, in order to keep MAP >50-60 until caught up withvolume. • Dopamine is initially used often. • Switch early to norepinphrine or even start with it. Some studies show greater benefit in renal perfusion and cardiac function that with dopamine.

28. Shock -- ManagementUse of vasopressors • Dopamine • Norepinephrine • Dobutamine • Epinephrine (anaphylactic shock) • Dopexamine (dopa 1,2, and beta 2)

29. SHOCK Hypoperfusion Hypotension Suspected shock JVP CVP • Hypovolemic • Hyperdynamic • Distributive • Cardiogenic • Obstructive High Low Clinical of CHF > Crackle > Gallop > Edema • Cardiac output • Fever CO  CO  Fever Y N • Hypovolemic • GI bleed • Trauma • Burn • DI • DKA • Distributive • Anaphylaxis • Narcotics • Drugs • Hyperdynamic • Sepsis • SIRS • Pancreatitis • Cirrhosis • Thyroid strom • Cardiogenic • AMI • CM • AV block • AR • Obstructive • PE • Tamponade • Myxoma

30. Syncope

31. Syncope Definition • Collapse,Blackout • A sudden, transient loss of consciousness and postural tone, with spontaneous recovery

32. Syncope Diagnostic Objectives • Distinguish ‘True’ Syncope from other ‘Loss of Consciousness’ spells: • Seizures • Psychiatric disturbances • Establish the cause of syncope with sufficient certainty to: • Assess prognosis confidently • Initiate effective preventive treatment

33. Syncope Basic Diagnostic Steps • Detailed History & Physical • Document details of events • Assess frequency, severity • Obtain careful family history • Heart disease present? • Physical exam • ECG: long QT, WPW, conduction system disease • Echo: LV function, valve status, HOCM • Follow a diagnostic plan...

34. SyncopeEvaluation and Differential Diagnosis History – What to Look for • Complete Description • From patient and observers • Type of Onset • Duration of Attacks • Posture • Associated Symptoms • Sequelae

35. Sudden cardiac arrest

36. What Is SCA? • Electrical system in heart malfunctions • Heart unexpectedly, abruptly stops beating • Often caused by an abnormal heart rhythm called ventricular fibrillation (VF) • VF accounts for half of all cardiac deaths • Rapid, chaotic heartbeat • Lower heart chambers, or ventricles, spasm • Heart functioning stops • Lack of oxygen in body, brain is dead

37. Management • Cardiac life support • Airway • Breathing • Circulation • Defibrillation • Get rid of cause • Metabolic: electrolyte, drugs • Organic: structural heart (ACS is common)

38. Unconcious pts • Check of conciousness • Syncope • Seizure • SCD • Call for help • Call defibrillator • Call first • Call fast Management • Special situation • Airways obstruction • Accident • Toxic agent • Drowning • Position • Supine position • Recovery position

39. Primary Survey • Airway • Remove FB • Heimlich maneuver • Back blow • Chest thrust • Maintain airway • Head tilt-chin left • Jaw thrust • Defibrillation • EKG analysis • Defibable (VF/VT) • : Defib 3 time/CPR 1 min • : Monophasic 200/300/360 • Nondefibable • : CPR 3 min and reevaluate EKG • Circulation • Check circulation • Pulse • Breathing • Movement • No circulation/Inadequate • Perform CPR • Commpressions (100/min) • Combine comprssions • and ventilations (15 compressions/ • 2 breaths) • Breathing • Breathing in 10 sec • Inadequate Breathing • Rescue breathing (1 breath/5 sec) • Monitor signs of circulation • (every 30-60 sec) • No breathing: • Provide 2 slow breaths (2 sec/ breath) • Mouth to mouth, Mouth to nose, Mouth to instrument

40. Secondary survey • Differential • Clinical setting • 5 H • 5 T • Airway • Invasive instrument • ET tube, laryngeal mask • Check position • Circulation • Access iv • Monitor EKG • Pacing, Defibrillation • Medications • Inotropic • Vasodilator • Antiarrhythmic • Diuretic • Breathing • Oxygen Rx • Check adequate breathing • Oxygen sat

41. CARDIAC ARRHYTHMIA

42. Symptoms of arrhythmia • Asymptomatic • Symptomatic • Palpitation • Low output syndrome: dyspnea, fatigue, fainting, syncope, shock, CHF

43. Managements • Get rid of precipitating factors • Nonpharmacological treatment • Maneuvers • Pacing • Cardioversion • AICD • RF ablation • Pharmacological treatment • Antiarrhythmic drugs

44. Carotid Sinus Massage • Site: • Carotid arterial pulse just below thyroid cartilage • Method: • Right followed by left, pause between • Massage, NOT occlusion • Duration: 5-10 sec • Posture – supine & erect

45. Carotid Sinus Massage • Outcome: • 3 sec asystole and/or 50 mmHg fall in systolic blood pressure with reproductionof symptoms = Carotid Sinus Syndrome (CSS) • Contraindications • Carotid bruit, known significant carotid arterial disease, previous CVA, MI last 3 months • Risks • 1 in 5000 massages complicated by TIA

46. Bradycardia Symptomatic Stable Unstable (shock, angina, CHF) EKG 12 leads • High risk • Mobitze II • Third degree Low risk

47. Tachycardia Stable VT WCT (?) NCT(SVT) AF/Af • Clinical setting • Ix: EKG 12 leads • Esophageal leads • Clinical setting • Ix: EKG 12 leads • Vagal maneuvers • Adenosine Unknown type • JT • PSVT • Ectopic, MAT Lidocaine/ Amiodarone • Convert sinus • Control rate • Embolic • prevention Cardioversion Rx as VT Rx as SVT Procainamide

48. VT Stable Monophasic Polymorphic VT QT normal QT prolong

49. Clinical setting • Ix: EKG 12 leads • Vagal maneuvers • Adenosine • (6 mg iv over 1-3 sec, can repeated • 12 mg over 1-3 sec in 1-2 min) SVT Junctional Tach PSVT Ectopic/MAT

50. VF/Pulseless VT Rx cuase CPR Repeat shock 360 J  3 time in 30-60 sec Cardioversion (200, 300, 360 J) Persist arrhythmia • Adrenalin 1 mg iv q 3-5 min or • Vasopressin 40 U iv single dose • Consider antiarrhythmics • Amiodarone (IIb) • Lidocaine (Ind) • Procainamide (Ind)