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EMRAM ITE

Must Know Cardio

ANGELA PUGLIESE MD

DEPARTMENT OF EMERGENCY MEDICINE

HENRY FORD HOSPITAL

Outline

Dysrhythmias

Pacemakers/AICD

ACS

CHF/Cardiogenic Pulmonary Edema

Cardiomyopathies

Congenital Heart Disease

DVT

PE

Pericardial Disorders

Myocarditis/Pericarditis

Aortic Dissection/AAA

HTN Emergency/Urgency

Valvular Heart Disease

First and Foremost

KNOW ACLS

Meds that can be given through the ET tube - LEAN

L - lidocaine

E - epinephrine

A – atropine

N – nalaxone

Give 2 times normal dose diluted in normal saline

Dysrhythmias

Always assess hemodynamics…….

SHOCK THE UNSTABLE PATIENT

Dysrhythmias

Narrow Complex

SVT

Afib

WPW

A-flutter

MAT

Tachy Brady (Sick Sinus)

Wide Complex

Vtach

Torsades de pointes

Vfib

Dysrhythmias

AV Blocks

1st – prolonged PR, no treatment if no symptoms

3rd – AV dissociation, requires pacing

2nd

Mobitz 1 (Wenckebach) – no treatment is no symptoms

Mobitz 2 – avoid atropine, needs pacing

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Pacemakers

Pacemakers

KNOW WHEN TO PACE

Unstable bradycardias

Unstable blocks

Overdrive pacing for torsades

Temporary Options

Magnet doesn’t deactivate

Just turns off sensing and converts to demand mode

Tips for Transvenous Pacing

Ideal placement location

Tip of catheter at apex of right ventricle

Access Site

Right Internal Jugular

Back up Left subclavian

Pacemaker Failure

EKG and CXR for initial evaluation

Look for pacer lead fracture and placement

Failure to Sense

Pacer spikes at wrong time

Failure to Capture

Pacer spikes without associated QRS

Failure to Pace

Absent pacer spikes

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AICD

AICD Basics

Know Indications

Brugada

Prolonged QT syndrome

Low EF

Pay attention to Mag levels

Low levels frequently cause dysrhythmias

Magnet Deactivates

Watch out for the iphone 12

ACS

Continuum

Angina – Unstable Angina – NSTEMI - STEMI

AMI – STEMI or CP with elevated markers

Treatment –

ASA, Plavix/Brilinta, heparin, nitro

Thrombolytics – TPA

Give within 30 minutes if PCA > 60 min away

Complications

Vfib highest in first hour

LV failure

>20 % loss = pulm edema

> 40% loss = shock

CHF/Cardiogenic Pulm Edema

Left sided

Ischemic heart disease, HTN

Aortic/mitral valvular disease

Right sided

Left sided failure, pulm HTN, tricuspid/pulmonic disease

Signs and symptoms

SOB, ‘cardiac asthma’

Pleural effusions

S3, JVD, dependent edema

CHF/Cardiogenic Pulm Edema

CXR/Symptom progression

Stage 1 – cephalization, dyspnea

Stage 2 – interstitial edema (Kerley B lines), dry cough

Stage 3 – alveolar edema (butterfly pattern), wet cough

pink frothy sputum

Lab – BNP <100 excludes

Treatment

OXYGEN

BIPAP

Afterload reduction, diuresis

Think pressors for shock (dopamine, dobutamine)

Cardiomyopathies

Idiopathic Dilated – most common

Restrictive

Hypertrophic

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Dilated Cardiomyopathies

All four chambers, systolic pump failure

Have signs of left and right failure

Afib most common dysrhythmia

Tx – vasodilators, diuretics

Restrictive Cardiomyopathies

Diastolic restrictive of ventricular filling

Mimics constrictive pericarditis

Right sided symptoms predominate

Exercise intolerance

Tx – diuretics, AVOID vasodilators

Hypertrophic Cardiomyopathy

LVH without dilation (septum greater)

50% inherited

DOE, syncope or pre-syncope with exertion

Sudden death with exercise induced dysrhythmias

Tx

Propanolol

Avoid increasing myocardial contractility

Septal myomectomy for severe cases

Abx prophylaxis for dental procedures

Congenital Heart Disease

Cyanotic vs Acyanotic

Tetralogy of Fallot

Transposition of the great

vessels

Total anomalous pulmvenous return

Tricuspid atresia

Pulmonary atresia

Ebstein’s anomaly of the

tricuspid valve

Aortic Stenosis

VSD

ASD

Patent ductus arteriosus

Coarctation of the aorta

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Tetralogy of Fallot

Most common cyanotic CHD

Four components

VSD, pulmonic stenosis, dextroposition and overriding aorta,

right ventricular hypertrophy

2 major hemodynamic problems

Pulmonary stenosis and VSD

“Tet” Spells

First 3 years of life, brought on by exertion

Place in knee prone position

Give oxygen and morphine

If still having problems given propranolol or phylephrine

Increases PVR

Increases blood flow to the lungs

DVT

Virchow’s Triad

Venostasis, hypercoagulability, vessel wall injury

Presentation

Unilateral pain, swelling and edema (>3cm difference)

Diagnosis

Duplex US (repeat testing in 7 days)

Tx

Aimed at preventing PE

Anti-coagulation

Thrombolytics (vascular surgery consult

Cerulea Dolens

Alba Dolens

Pulmonary Embolism

Presentation

Dyspnea

Classic triad – dyspnea, pleuritic CP or tachypnea

CXR

Dyspnea, hypoxia and normal are very suggestive

Diagnostics

EKG, d-dimer, V/Q, CT, Angiography

Tx –

Anticoagulation

Thrombolytics

Hemodynamic instability

TPA, 100 mg over 2 hours

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PE – CXR FindingsPE - Diagnostics

EKG – sinus tach most common

S1, Q3, T3

D-dimer – know Well’s, low risk pt only

V/Q

Limited in lung disease

Needs clinical context

Low-mod pretest prob with normal study 98% exculsion

CTA

95% sensitive for segmental or large PE, 75% for subsegmental

Angiography

Gold standard

Pericardial Disorders

Pericarditis

Idiopathic and viral most common causes

Diagnosis

Hx – sharp precordial pain relieved by sitting up and leaning forward

PE – friction rub

EKG – diffuse concave ST elevation, PR depression

Echo – to look for effusion

BUN/Crt – look for uremia

Treatment

Outpatient NSAID for idiopathic/viral and reliable pts

Pericardial Disorders

Pericardial Tamponade

Becks Triad – hypotension, JVD, muffled heart tones

Tachycardia is earliest finding

Diagnosis

EKG – electrical alternans, low voltage

Echo – gold standard, large effusion, diastolic RV collapse

Treatment

Monitor, IV, O2

Aggressive volume resuscitation and pressors if needed

Cardio/CT surgery consult and pericardiocentesis (under US)

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Myocarditis

Presentation

Range from nonspecific fatigue to florid CHF

Watch for tachycardia out of proportion to fever

Diagnosis

Echo – dilated chambers with diffuse or focal hypokinesis

Labs – elevated ESR, trop rise and fall slowly

Biopsy for definitive

Etiology

Viral most common cause

Treatment

Supportive, treat like CHF

Avoid immunosuppressives and NSAIDs

IVIG for Kawasaki

Endocarditis

Localized infection of endocardium with hallmark vegetation

Causative Organisms

Native valve – non-viridan strep

Prosthetic valve – coag-neg strep (<60 day post op)

IVDA – staph aureus (found on right, ie pulmonic)

Presentation

Fever most common finding

Signs of metastatic infection

Roth spots

Splinter hemorrhages

Osler nodes – TENDER nodules on volar fingers

Janeway lesions – non tender macules on fingers, palms, soles

Endocarditis

Diagnosis

Positive blood cultures

Duke criteria

Treatment

Native valve – ampicillin + gent or vanc + gent

Prosthetic – vanc + gent + rifampin

Duke Criteria

Major

Positive blood culture

Evidence of endocardial involvement (TEE)

Minor

Predisposition

Fever

Vascular and/or immunologic phenomenon

Microbiology evidence

Echo evidence

Need 2 major or 1 major with 3 minor or 5 minor

Endocarditis Prophylaxis

Needed for procedures with significant manipulation of infected tissue

Not needed for foley, intubation, routine dental cleaning

Prosthetic valve

Hx of endocarditis

Cyanotic congenital heart lesions

Acquired valvular disease (ie rheumatic fever)

Hypertrophic cardiomyopathy

Aortic Dissection

Males age 50-70

HTN most common risk factor

Presentation

pain

Classification – type A vs B

Definitive Testing –

TEE – unstable patients

CTA – may miss rapid moving flap

Treatment –

10-15 units of blood on standby with surgical consultation

Control HR and BP, esmolol first then nipride

Treat pain with IV narcotics

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Aortic Dissection

EKG –

Usually abnormal

STEMI most common misdiagnosis (inferior)

CXR findings

Widened mediastinum

Right side

Tracheal deviation

Left side

Apical cap

Effusion

Depressed mainstem bronchus

Expanding/Ruptured AAA

> 95 % infrarenal

Males > 60

Presentation

Thing middle age male with syncope or near syncope and lower abdominal or back pain

PE classic pulsatile abdominal mass

Diagnosis and Management

Bedside echo

IV, O2, monitor

10 units of blood on standby

Surgical consultation

HTN Emergency/Urgency

End Organ Damage

Arrest and lower BP rapidly,

30% in first hour

DBP > 115

Asymptomatic pt discharge

to follow up with PCP

Oral agents to lower BP over 24-48 hours

ValvularDisorders

Mitral Valve Prolapse

Click murmur syndrome

High pitched late systolic murmur with mid-systolic click

Most common – 5-10% of population

Presentation

Young women – palpitations

Elderly – syncope

Treatment

Only symptomatic pts

Beta blockers for CP or dysrhythmias

ASA or anticoagulation with hx TIA/stroke

Mitral Regurgitation

Acute

Rupture chordae tendineae or papillary muscle after…

Presents with fulminant CHF

Apical systolic murmur

Tx- hemodynamic support and CT surgery consult

Chronic

Evolves slowly and usually coexists with mitral stenosis

High pitched holosystolic murmur

Afib in 75% of patients

Abx prophylaxis

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Aortic Stenosis

Etiology

<65 bicuspid valve

>65 calcification

Symptoms

Exertional dyspnea or syncope

Harsh crescendo-decrescendo murmur radiating to carotids

Treatment

Mild – d/c home avoid strenuous activity

CHF – admit, reduce preload/afterload

Refer all symptomatic patients for surgical therapy

EKG Trivia

The END

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