andrew crouch, do- cardiac emergencies...emergency medicine board review 2014, armc emergency...
TRANSCRIPT
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CARDIAC EMERGENCIESAndrew Crouch DO PGY-2
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Question• A 12-year-old boy is brought to the ED after being struck
in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition?
• A Asystole• B Ventricular Tachycardia• C Ventricular Fibrillation • D PEA• E. SVT
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Answer C (V-Fib)• Commotio cordis
• occurs when an object such as a baseball strikes the chest and produces sudden death. It most commonly occurs in children between 5 and 15 years of age with no known predisposing cardiac conditions.
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Ischemic Heart Disease
• Leading cause of Death in USA• 30% all deaths
• Etiology • Insufficient blood supply
to myocardium
• Risk factors • Family history, smoking,
hypertension, diabetes,• cholesterol, male >55
years old
• Global Hypotension• Fixed Lesion
• Atherosclerosis• Stable Angina
• Vasospasm• Prinzmetal angina• Drug induced
• Ruptured Plaque• Leads to formation of clot• ACS
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Coronary Anatomy• Left Main Coronary
• LAD• Widowmaker • Anteroseptal
• Left Circumflex• Anterolateral (if left dominant posterior)
• Right Coronary Artery• Right ventricle • Inferior• SA node
• Posterior descending artery• AV node• Lead to mitral regurgitation and bradycardia
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TIMI Score
• > 65 years old• > = 3 cardiac risk factors
• Prior stenosis >50%• ST segment deviation• 2 anginal events in 24 hours
• Aspirin use within last 1 week
• Elevated CK
• (0-1) 4.7%(2) 8.3%
• (3) 13.2%• (4) 19.9%(5) 26.2%
• (6 to 7) 40.9% • Risk of death or MI• Note there is no 0% risk in this scale
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Chest Pain
Atypical Chest Pain
• Women Diabetic and Elderly
• Fatique, nausea, epigastric pain, palpatations, chest wall pain, total body dolor
• Chest pain absent in 18% of Mis
• Account for 40-50% of cases
Typical Chest pain
• Crushing• Left chest • Radiate to left arm, jaw,
back• Diaphoresis
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Signs of ACS • Vitals
• Tachycardia, Bradycardia (RCA) , hypertension, hypotension
• Cardiac Exam• New S3 or S4• New Murmur
• Papillary muscle dysfunction• Wall rupture
• Pulmonary crackles• New friction Rub
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ECG• Initially abnormal in <50% of patients with ischemic chest
pain • Meaning often it is perfectly normal
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T wave morphology changes• Hyperacute T waves
• Earliest sign • Prominent symmetrical, pointy
• T wave flattening or inversion • Can be due to a S#*% ton of things
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ST segment Changes• ST Elevation
• Elevation >1mm in 2 contiguous leads
• ST depression • Measured from the PR segment to the ST segment • Depression >1mm in 2 leads
• New Bundle Branch Block or AV block• ST changes associated with increased mortality
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QRS
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Sgarbossa's criteria• Three criteria are included in
Sgarbossa's criteria:• ST elevation ≥1 mm in a lead
with a positive QRS complex (ie: concordance) - 5 points
• ST depression ≥1 mm in lead V1, V2, or V3 - 3 points
• ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex - 2 points
• ≥3 points = 90% specificity of STEMI (sensitivity of 36%)
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Arrhythmias of ACS• Bradycardia
• SA or AV node involvement
• Tachycardia• Reperfusion, autonomic tone, hemodynamic instability
• V Fib• Indication for immediate cath • if not at ARMC
• Accelerated Idioventicular Rhythms• Associated with reperfusion, Resemble V Tach with rate of 50-100
bpm• DO NOT USE Antiarrhythmics such as lidocaine
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AnteroSeptal MI• Septal
• ST elevations in V1 and V2
• Anterior • ST Elevations in V3 and V4• LAD occlusion • High grade Heart Blocks
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A little harder
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Lateral Wall MI• ST elevations in I, aVL, V5 and V6• Left Circumflex artery
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Too Easy
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Inferior • Inferior
• ST elevations in II, III, aVF• Primary RCA occlusion• AV dysfunction
• Up to 25% have right ventricular infarction• Do not give Nitro
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Right sided ECG
• ST elevations in V4R and V5R are diagnostic of Right ventricular infarct
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WTF?
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Posterior • Large R waves & ST
depressions in V1 and V2
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ECG changes correlate to Pathology
• ST changes in V1-4• V4-6, I, aVL• I & aVL• II, II, aVF• II, III, aVF & V5-6• Small R waves V1-2• Depression II, III, aVF with ST elevation rV4
• Anteroseptal• Anterolateral• Lateral• Inferior• Inferolateral• Posterior• Right Ventricular
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ECGs are not perfect • Normal ECGs are seen in
• 1-5% of Acute MI• 4-23% of UA
• Non diagnositic ECGs• 4-7% of Acute MI • 21-48% of UA
• New ischemic changes• 25-73% of Acute MI• 14-34% of UA
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Cardiac Enzymes • Troponin
• Specific for Cardiac injury (Tt 94% and Ti 100%)• Positive 2 to 6hours and remain elevated foer up to 1 week• PE, Pericarditis, CHF, Shock, Renal failure, Remember it is a sign
of injury not infarction
• CK-MB• Positive 3 to 8 hours less specific than troponin• Useful for reinfarction due to shorter half life
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Testing
• ECHO• Regional wall
abnormality• Poor correlation
• Treadmill testing• Sensitivity 65% to 70%• Specificity 70 to 75%
• Stress ECHO• 80-85% sensitivity• 80-85% Specificty
• Dobutamine Stress ECHO• 80-85% sensitivity • 85-90% Specificty
• SPECT• Nuclear imaging• 80-90% Sensitivity• 80-90% specificity
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Treatment ACS
• Oxygen• Antiplatelet
• ASA 162 to 325mg, should be chewed• Do not use if possibly Aortic
Dissection
• Plavix, Clopidogrel• Can be given in addition to or
instead aspirin
• Nitroglycerin • Smooth Muscle Dilator• Dilate coronary arteries
• Reduces preload and afterload
• Do not give if taking viagra or if right ventricular infarction
• Morphine• Block catacholamine surge• Reduce preload and afterload
because of histamine response• Caution if right ventricular
infarction or hypotensive
• Beta Blockers• Use since COMMIT Trial • Decrease ventricular
Arrhythmias in stable patients • Do not give if Meth or cocaine
usage • Use with caution if asthma,
hypotension, bradycardia
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Anti Thrombotics
• Heparin • Activates Antithrombin III• Bolus 60-70 U/kg • Then infuse 12-15 U/kg
• Low Molecular weight heparin • 16% relative risk
reduction but increase risk bleed
• Bivilirudin• Direct thrombin inhibitor • Useful if planning PTCA• Use if patient has HIT
• GP IIB IIIA inhibitor
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Thrombolysis• Indicated if • ST Elevations >1mm in 2 contiguous limb leads• ST Elevation >2mm in 2 contiguous Chest Leads• New LBBB• High Suspicion for MR with pre-existing LBBB• Reciprocal ST segment depression V1 –V3 and posterior
wall infarction
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Thrombolysis
Absolute Contraindication
• Aortic Dissection• Active GI bleed or internal
Bleed• Brain tumor, Bleed or AV
fistula• Closed head trauma or
facial trauma within 3 months
• Allergy
Relative Contraindication
• Chronic Hypertension• BP >180/110• Ischemic Stroke in last 3
months • Major surgery within 3 weeks• Internal bleeding 2-4 weeks
ago• Noncompresable vascular
punctures• Peptic Ulcer• Current use of anticoagulants
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Question• Which of the following AV nodal blocks is most commonly
associated with an acute inferior wall myocardial infarction?
• A First degree• B Third degree • C Type I second degree• D Type II second degree
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Answer C• Type I
• Type II more likely with anterior not inferior MI
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PCI• Gold Standard
• Door to Balloon <90 Min• Presentation > 3hours
• Thrombolysis should be performed over PCI if prolonged time to cath lab or no capability
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Question
• A 62-year-old man presents to the ED with a mild cough and URI symptoms. He was discharged from the hospital 2 weeks ago after undergoing percutaneous intervention for an acute myocardial infarction. You obtain an ECG (seen above) and compare the current ECG to the ECG obtained when he was admitted 2 weeks ago. You note that the morphologies are similar. Which of the following is the most likely diagnosis?
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• A Pericarditis• B Postmyocardial infarction syndrome C Pulmonary embolism
D Ventricular aneurysm
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Congestive Heart Failure • 3.4 million ED visits per year• 70-80% of patients with CHF die within 8 years• Left vs Right • High output vs low output
• High output due to metabolic demand (Hyperthyroid, beriberi, AV fistula, Pagets disease, Anemia, Pregnancy)
• Low output (Decreased Ejection Fraction)
• Systolic vs Diastolic • Systolic
• Poor Contractility of left ventricle • Ejection fraction on ECHO < 40%
• Diastolic• Poor Compliance • Systolic function preserved • 20-50% of patients with heart failure
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Left vs Right
Right Heart failure
• JVD• Dependent Edema• Liver congestion
(hepatojuglar reflex)• Causes
• Left sided heart failure #1 cause
• MR, COPD, Pulmonary Stenosis
• Cardiomyopathy
Left Sided Heart failure
• Pulmonary Edema• Orthopnea• Paroxysmal noctural
dyspnea• Causes
• Systemic HTN• AS/AR• Cardiomyopathy• MI
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Pathophysiology
Hemodynamic Model
• Left Ventriclar pressure increases leading to high end diastolic filling pressure
• Leads to Pulmonary congestion
Neurohormonal Model
• Inadequate end-organ perfusion
• Increased sympathetic nervous system and renin-angiotensin-aldosterone axis
• Vasoconstriction/ fluid retention
• Increasing afterload• Increasing workload
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New York Heart Association (NYHA)• Class I : No limitation• Class II : Slight limitation at high exertion• Class III: Marked Limitation with no symptoms at rest• Class IV : Symptoms at Rest
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Symptoms• Exertional Dyspnea• Orhtopnea• Dimished Pulse pRessure• Pulsus Alterans• Bilateral Rales• Pitting Edema• Hepatomegally• Acities• JVD• S3 gallop• Loud P2
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Diagnosis
• CXR• can show congestion• Cardiomegally• Kerly B Lines• Pleural effusion R>L• Interstitial Hilar infiltrates
(bat winging)• Cephalization
• BNP• <50pg/ml negative
predictive value 98%• >100 pg/ml has 83%
sensitivity
• ECHO• EF > 40% • High EF with thick walls• Valvular abnormalities
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Kerley B lines
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Bat Wigging out
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Sorry… Bat winging
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Management
• Oxygen• CPAP and BIPAP
• Decrease work of breathing
• Decreased mortality • Contraindicated if
Altered
• Intubation • When all else fails tube
them
• Preload reduction• Diuretics
• Furosemide • Bumex
• Morphine• Decrease Pulmonary
congestion by vasodilation
• Nitrates • Can be given sublingual or
as gtt• Doses as high as 2mg IV
every 3 minutes can be given
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Management
• Afterload reduction• Nitates
• NTG• Nitroprusside
• ACE inhibitors and ARBS• Decrease afterload and
increase renal perfusion
• Inotropic agents (can increase contractility but at a price)• Dobutamine
• Beta agonist
• Amrinone and Milrinone• Phosphodiesterase
inhibitors
Intraaortic Balloon pump
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Dilated Cardiomyopathy
Causes
• Infection• Idiopathic• Familial diseases
• (Pompe’s Disease)
• Pregnancy • Sarcoidosis• Muscular dystrophy • Hypothyroidism• Chronic low phosphate or calcium• Meth or Cocaine• Chronic Alcohol usage• Heavy metal toxicity
ECG
• Similar to congestive heart failure • Mural thrombus formation
• Can embolize
• Syncope• Death
Symptoms
• A fib• Poor R wave progression• Blocks• Large P waves
– In lead II• Double hump = Left atrial• Peaked Right Atrial
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Dilated Cardiomyopathy • In the US Viral illness is the most common cause • World Wide the most common cause is Protozoan,
Trypanosoma Cruzi “Chagas Disease”
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Hypertrophic cardiomyopathy• Asymetrical Septal Hypertorphy • Hypertrophic Obstructive cardiomyopathy• Idiopathic Subaortic Stenosis
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Epidemiology• Common Cause death in young athletes• Mortality 4% if untreated • Autosomal Dominant • Mutation leading to dysfunctional cardiac sarcomere
production• Leads to Diastolic dysfunction
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Diagnosis • Murmur
• Harsh Systolic Murmur • Increase with Valsalva, Amyl nitrate• Decrease with Squatingm Leg raise, hand grip, beta blocker
• ECG• LVH• Q waves in inferior or lateral leads
• ECHO• Septum thicker than wall• Systolic anterior motion of mitral valve
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Management • Beta Blockers• Verapamil• Disopyramide (Class Ia anti-arrhythmic)• NO Diuretics• AICD• Pacemaker• Septal Ablation• Myomectomy
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Pericardial Tamponade• Fluid in pericardial space• Normal 15-30ml effusions
can get >1L if occur slowly but in cases of rapid expansion there will be myocardial compression
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Tamponade• Becks triad
• Hypotension• JVD• Distant heart sounds
• Kussmal sign• Paradoxical jugular venous distention with inspiration
• Pulsus paradoxus• Decrease systolic blood pressure >10mmHg with inspiration• Also seen with PE, COPD
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Electrical Alternans
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Treatment• Fluids• Pressors• If hemodynamic compromise do pericardiocentsis • Pericardial window is definitive treatment
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Pericarditis• Idiopathic #1 Cause • Infectious
• Viral• Bacterial • Tuberculosis • Fungal
• Malignancy • Drug-induced (procainamide) • Miscellaneous: connective tissue disease or • autoimmune • Uremia• Postradiation• Dressler syndrome• Myxedema
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Diagnosis
• Blood• CBC
• Elevated WBC could point to infection
• BUN • Uremia
• Serology• Rheumatoid arthritis and lupus
• TSH• Thyroid disease
• Cardiac Enzymes• Dressler Syndrome
• CXR• Bottle Shaped heart
• ECHO• CT or MRI
• ECG (4 Satges)• Stage I
• PR Depression (II, aVF, V4-V6)
• Diffuse ST Elevation • PR elevation aVR
• Stage II• Flattening of ST wave
• Stage III• Inverted T waves
• Stage IV • Normal
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Treatment • #1 treat underlying cause if can be found
• Viral or Idiopathic Pericarditis • NSAIDs
• Bacterial• Antibiotics and drainage if purulent
• 100% mortality without treatment
• TB• INH, Rifampin, Ethanbutol, Pyrazinamide
• Dressler’s Syndrome• ASA (avoid NSAID)
• Autoimmune• Steroids + NSAID