rosen's emergency

8/20/2019 Rosen's Emergency

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Rosen & Barkin's 5-Minute Emergency MedicineConsult, 3rd EditionCopyright Â!""# $ippincott %illiams & %ilkins

Acute Coronary Syndrome: Myocardial InfarctionShamai A. GrossmanLeon D. Sanchez

BasicsDescription

• Imbalance in myocardial blood supply and oy!en re"uirement

• Acute cardiac ischemia encompasses a spectrum of disease processes:

o #nstable an!ina pectoris

o Acute myocardial infarction $AMI%

o S& ele'ation myocardial infarction $S&(MI%

o )on*S&(MI

(tiolo!y

• Atherosclerotic narro+in! of coronary 'essels

• ,asospasm-/althou!h this is usually at rest and considered unstable if ne+ onset

• Micro'ascular an!ina or abnormal relaation of 'essels +ith diffuse 'ascular disease

• 0la"ue disruption

• &hrombosis

• Arteritis:

o Lupus

o &a1ayasu disease

o 2a+asa1i disease

o 3heumatoid arthritis

• 0rolon!ed hypotension


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• Anemia

o 4emo!lobin 56 !7dL

• 4yperbarism or ele'ations in carboyhemo!lobin

• Coronary artery !as embolus

• &hyroid storm

• Structural abnormalities of coronary arteries:

o 3adiation fibrosis

o Aneurysms

o (ctasia

• Cocaine* or amphetamine*induced 'asospasm

• Cardiac ris1 factors include:

o 4ypercholesterolemia

o Diabetes mellitus

o 4ypertension

o Smo1in!

o 8amily history in a first*de!ree relati'e less than 99 years old

o Men a!e ;99 years

o 0ostmenopausal +omen

Dia!nosisSi!ns and Symptoms

• Chest pain:

o Most common presentation of myocardial infarction $MI%

o Substernal pressure

o 4ea'iness

o S"ueezin!


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o Burnin! sensation

o &i!htness

• An!inal e"ui'alents $MI +ithout chest pain%:

o Abdominal pain

o Syncope

o Diaphoresis

o )ausea or 'omitin!

o ? minutes or more.

• Symptoms may occur +ith rest or durin! eertion.

• @ften preceded by crescendo an!ina

• May be impro'ed or relie'ed +ith rest or nitro!lycerin

• Symptoms !enerally unchan!ed +ith position or inspiration

• 0ositi'e Le'ine si!n or clenched fist o'er chest is su!!esti'e of an!ina.


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• Blood pressure $B0% is usually ele'ated durin! symptoms.

0hysical (am

• 0hysical eam is usually unre'ealin!.

• @ccasional physical findin!s include:

o S> or S due to left 'entricular systolic or diastolic symptoms

o 0apillary muscle dysfunction resultin! in mitral re!ur!itation

o Diminished peripheral pulses

(ssential


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• Mitral 'al'e prolapse

• Myocardial infarction

• 0anic disorder

• 0eptic ulcer disease

• 0neumonia

• 0sycho!enic

• 0ulmonary embolus

• #nstable an!ina

&reatment0re 4ospital

• I, access

• Aspirin

• @y!en

• Cardiac monitorin!

• Sublin!ual nitro!lycerin for symptom relief

• *lead (CG if possible +ith transmission or results relayed to recei'in! hospital

Alert

• All chest pain should be treated and transported as a possible life*threatenin!emer!ency.

• Do not administer thrombolytics or heparin if aortic dissection is suspected.

Initial Stabilization

• I, access

• @y!en


• @y!en saturation


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• Continuous B0 monitorin! and pulse oimetry

(D &reatment

• S&(MI re"uires reperfusion therapy as soon as possible:

o &hrombolytics should be used if percutaneous coronary inter'ention is notreadily a'ailable +ithin a ?*minute time frame $see 3eperfusion &herapyCardiac%.

• 0atients +ith non*S&(MI if started on !lycoprotein IIb7IIIa inhibitors and if theysubse"uently recei'e a stent benefit from a 0CI +ithin a 6*hour time frame.

• Aspirin should be administered first to all patients +ith suspected MI unless the patient has a 1no+n aller!y.

• If B0 is ;?-E?? mm 4! systolic administer sublin!ual nitro!lycerin nitropasteor I, nitro!lycerin assumin! no (CG criteria of ri!ht 'entricular infarct:

o Symptoms that persist after three sublin!ual nitro!lycerin tablets are stron!lysu!!esti'e of AMI or noncardiac etiolo!y

• Beta*bloc1ers should be administered if no contraindications $e.!. bradyarrhythmiasheart rate 5F? con!esti'e heart failure hypotension or obstructi'e pulmonarydisease% are present.

• Morphine may be !i'en to relie'e pain and increase oy!en carryin! capacity.

• (noaparin or heparin is !enerally appropriate as the net line of therapy.

• An!iotensin*con'ertin! enzyme inhibitors may effect a small decrease in mortality+hen !i'en acutely.

• If non*S&(MI is clearly the clinical dia!noses a !lycoprotein IIb7IIIa inhibitor should be started.

0.>>

• Clopido!rel may be of benefit acutely +hen added to standard therapy by reducin!the odds of AMI patients ha'in! another occluded artery or a second heart attac1 ordeath by >F after +ee1 of hospitalization.

• Statin therapy reduces clinical e'ents in patients +ith stable coronary artery disease.

this may also etend to patients eperiencin! an acute ischemic coronary e'ent.


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• If patient is in cardio!enic shoc1 patient should be transported to a cardiaccatheterization laboratory for an!ioplasty and intra*aortic balloon pump as soon as

possible $see Con!esti'e 4eart 8ailure%.

• ,entricular dysrhythmias:

o See ,entricular &achycardia

• Bradydysrhythmia associated +ith hypotension should be treated +ith atropine oreternal pacin!:

• Conduction disturbances:

o 8irst*de!ree aortic 'al'e $A,% bloc1 and Mobitz I $9 m! 0@

• Clopido!rel $0la'i%: >?? m! 0@ load H9 m! 0@ per day

• (noaparin $Lo'eno%: m!71! SC "h

• Glycoprotein IIb7IIIa inhibitors:

o (ptifibatide $Inte!rilin% 6? J!71! I, o'er -E minutes follo+ed bycontinuous infusion of J!71!7min up to H hours

o Irofiban $A!!rastat% ?. J!71!7min for >? minutes then ?. J!71!7min for6-E?6 hours

o Abciimab $3eo0ro% for use prior to 0CI only: ?.9 m!71! I, bolus

• 4eparin 6? units71! I, bolus then 6 units71!7h

• Lidocaine: .9 m!71! I, bolus infusion of -E m!71!7min

• Ma!nesium: ! bolus I,


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• Metoprolol: 9 m! I, "9min-E"9min follo+ed by 9-E9? m! 0@ startin! dose astolerated $note: beta*bloc1ers contraindicated in cocaine chest pain%

• Morphine: m! I, may titrate up+ard in *m! increments for relief of painassumin! no respiratory deterioration and SB0 ;? mm 4!

• )itro!lycerin: ?. m! sublin!ual

• )itro!lycerin: I, drip at 9-E? J!7min

• )itropaste: -E inches transdermal

• &hrombolytics: see 3eperfusion &herapy Cardiac for dosin!

8ollo+*#p

DispositionAdmission Criteria

• 0atients +ith an AMI re"uire hospital admission.

• If the dia!nosis is unclear admission to the hospital or an (D obser'ation unit may beuseful for serial cardiac enzymes (CGs and eercise stress testin! and7or cardiaccatheterization.

Dischar!e Criteria

)o patient +ith an AMI should be dischar!ed from the (D.Issues for 3eferralIf 0CI is una'ailable in the treatin! institution and particularly if the patient is in cardio!enicshoc1 patients should be transported to another hospital if 0CI can be under+ay in less than? minutes.

Acute Coronary Syndrome: )on-EK*


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o (ndothelial disruption eposes subendothelial colla!en and other platelet*adherin! li!ands 'on


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• Dyspnea

• Aniety

• Li!ht*headedness

• Syncope

0hysical (am

• 4ypertension

• 4ypotension

• Arrhythmias

• S heart sound

(ssential


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• (CG:

o S&*se!ment depression or transient ele'ation indicates increased ris1

o &*+a'e in'ersion in re!ional patterns does not increase ris1 but helps

differentiate cardiac pain from non cardiac pain

• Chest radio!raph:

o &o assess heart size pulmonary edema7con!estion or identify other causes ofchest pain

• (chocardio!raphy:

o &o identify +all motion abnormalities and assess left 'entricular function

• 3adionuclide studies:

o &hallium or sestamibi scannin!: identifies 'iable myocardium

o &echnetium : identifies recently infarcted myocardium

Differential Dia!nosis

• S&*ele'ation myocardial infarction


• Aortic dissection

• Acute pericarditis

• 0neumothora

• 0ancreatitis

• 0neumonia

• (sopha!eal spasm7!astroesopha!eal reflu

• (sopha!eal rupture

• Musculos1eletal pain $dia!nosis of eclusion%

&reatment

0re 4ospital


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• I, access

• @y!en administration

• Cardiac monitorin! and treatment of arrhythmias

• Aspirin anal!esia aniolytics


• @y!en administration

• I, access

• Cardiac monitorin! and treatment of arrhythmias

(D &reatment

• Anti*ischemic therapy to reduce myocardial demand and increase myocardial supplyof oy!en:

o Beta*bloc1ers

o )itrates

o @y!en

o Morphine sulfate

o Calcium channel bloc1ers $nondihydropyridines-/e.!. diltiazem 'erapamil%may be used in patients +ith on!oin! ischemia and contraindications to beta*

bloc1ade.

• Antiplatelet therapy to decrease platelet a!!re!ation:

o Aspirin

o Clopido!rel

o G0 IIb7IIIa inhibitors $eptifibatide tirofiban%:


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o Lo+ molecular +ei!ht heparin $specifically enoaparin% preferred o'erunfractionated heparin

• Aniolytics to suppress sympathomimetic release

Medication $Dru!s%

• Aspirin F-E>9 m! 0@ per day

• Beta*bloc1ers:

o Atenolol: Start 9 m! I, o'er 9 minutes then 9 m! I, ? minutes later then9?-E?? m! 0@ per day $-E hours after I, doses%.

o (smolol: ?? mc!71!7min I, infusion $titrate by increasin! 9? mc!71!7min

"9min until effect-/to ma dose >?? mc!71!7min%

o Metoprolol: Start 9 m! I, "9min OP > after 9 minutes be!in 9-E9? m!0@ "Fh.

o 0ropranolol: ?.9-E m! I, then ?-E6? m! 0@ "Fh-E"6h

0.>9

• Calcium channel bloc1ers

o Diltiazem: start ?.9 m!71! I, bolus then ?.>9 m!71! I, after 9 minutes ifneeded then >? m! 0@ "Fh

o ,erapamil: start 9-E? m! I, repeat after >? minutes if needed then6?-EF? m! 0@ "6h

• Clopido!rel: >??-EF?? m! 0@ OP then H9 m! per day

• G0 IIb7IIIa inhibitors:

o Abciimab: $only =ust prior to 0CI%: ?.9 m!71! I, bolus then ?.9mc!71!7min infusion $ma ? mc!7min% for -E hours

o (ptifibatide: 6? mc!71! I, bolus then mc!71!7min infusion for H-EFhours

o &irofiban: ?. mc!71!7min I, OP >? min then ?. mc!71!7min infusion for

6-EF hours


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• 4eparins:

o (noaparin: m!71! SC "h can !i'e >? m! I, bolus before SC dose$be+are of enoaparin in patients +ith renal dysfunction%

or

o #nfractionated heparin: F?-EH? units71! I, bolus then -E9 units71!7hrinfusion $ma bolus 9??? units ma infusion rate ??? units7hr $!oal is a 0&&9?-EH9 seconds%

• Lorazepam: -E m! I, 03) aniety

• Morphine sulfate -E9 m! I, "9min-E">?min 03) pain

• )itro!lycerin: ?.>-E?.F m! SL or ?. m! by spray "9min follo+ed by I, infusion be!innin! at ?-E? mc!7min if pain persists $ma. dose ?? mc!7min%

8ollo+*#pDispositionAdmission Criteria

• All patients +ith positi'e cardiac mar1ers or si!nificant clinical probability of acutecoronary syndrome

• Intensi'e care unit for monitorin! unstable patients

Dischar!e Criteria@nly those +ho are ruled out for acute coronary syndrome7non-EK*+a'e infarction can besafely sent home.

Acute Coronary Syndrome: Stable An!inaShamai Grossman&arina Lee 2an!

Basics

Description• Chest discomfort that is predictable in nature occurs +ith eertion and impro'es +ith

rest

• Imbalance in myocardial blood supply and oy!en re"uirements

• Canadian Cardio'ascular Classification-/class I: ordinary physical acti'ity does notcause symptoms.

• Canadian Cardio'ascular Classification-/class II: symptoms that sli!htly limitnormal acti'ity such as:


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o 9 years


• Atherosclerotic narro+in! of coronary 'essels

• ,asospasm althou!h this is usually at rest and considered unstable if ne+ onset


• Arteritis:

o Lupus

o &a1ayasu disease

o 2a+asa1i disease


• Anemia: hemo!lobin 56 !7dL




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o Aneurysms

o (ctasia


Dia!nosisSi!ns and Symptoms

• Chest pain:


o 4ea'iness

o S"ueezin!

o Burnin! sensation

o &i!htness

• May localize or radiate to arms shoulders bac1 nec1 or =a+

•

May be associated +ith dyspnea syncope fati!ue diaphoresis nausea or 'omitin!

• #sually reproduced by eertion eatin! eposure to cold or emotional stress

• Symptoms last less than ? minutes but more than a fe+ seconds.

• 3ecurrent symptoms of months duration or more

• #sually relie'ed +ith rest or nitro!lycerin

•

Symptoms !enerally unchan!ed +ith position or inspiration

• )o chan!es in pattern or fre"uency of symptoms

• @ccasional an!inal e"ui'alents include:

o Abdominal pain

o Syncope

o Diaphoresis


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o or S due to left 'entricular systolic or diastolic symptoms

o Mitral re!ur!itation or pansystolic murmur

o Diminished peripheral pulses

(ssential


18/28

&estsLabCardiac enzymes should not be ele'ated and are not indicated unless the history is suspiciousfor acute myocardial infarction $AMI%.Ima!in!

• Chest radio!raph:

o #sually normal

o May sho+ cardiome!aly

o Con!esti'e heart failure is su!!esti'e of unstable an!ina.

o May identify other etiolo!ies of chest pain such as pneumonia

• (ercise stress testin! may help establish the dia!nosis of stable an!ina and pro'ide pro!nostic information.

o *mm depression of the S& se!ment belo+ the baseline 6? msec from the point in three consecuti'e beats and t+o consecuti'e leads is characteristic ofcardiac ischemia

o (arly positi'e $+ithin > minutes% stress tests are +orrisome for unstablean!ina.

o Si minutes of eercise utilizin! a standard Bruce protocol su!!ests anecellent pro!nosis.

o (ercise stress testin! +ith (CG alone has a sensiti'ity of F6 and specificityof HH.

o (ercise stress testin! +ith echocardio!raphy has a sensiti'ity of 69 andspecificity of HH.

o (ercise stress testin! +ith thallium*? or technetium &c*m sestamibi has

a sensiti'ity of 6H and specificity of F.

Differential Dia!nosis

• Aniety


• Biliary colic

•

Costochondritis


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• (sopha!eal reflu

• (sopha!eal spasm

• 4erpes zoster

• 4iatal hernia


• Myocardial infarction

• 0anic disorder


• 0neumonia

• 0sycho!enic


• #nstable an!ina

&reatment

0re 4ospital

• I, access

• @y!en



• Aspirin


• I, access

• @y!en




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(D &reatment

• Aspirin

• Sublin!ual nitro!lycerin:

o Symptoms that persist after three sublin!ual nitro!lycerins are stron!lysu!!esti'e of unstable an!ina AMI or noncardiac etiolo!y.

• May re"uire ad=ustment of patientQs outpatient medical re!imen includin! addin! orchan!in! the dosa!e of a beta*bloc1er

0.>H

Medication $Dru!s%

• Aspirin: F?-E>9 m!


• Isosorbide mononitrate: ? m! 0@ b.i.d. or isosorbide dinitrate 9-E? m! 0@ t.i.d. or )itropatch -E inches ?-E hours daily

• Metoprolol: 9-E9? m! 0@ startin! dose: Clopido!rel in con=unction +ith standardtherapy for S&*se!ment ele'ation myocardial infarction +as sho+n to reduce theodds of AMI patients ha'in! another occluded artery or a second heart attac1 or death

by >F after one +ee1 of hospitalization.

• Statin therapy reduces clinical e'ents in patients +ith stable coronary artery diseasethis may also etend to patients eperiencin! an acute ischemic coronary e'ent.

8ollo+*#pDispositionAdmission Criteria

• 0atients +ith stable an!ina !enerally do not re"uire hospital admission.

• If the dia!nosis is unclear admission to the hospital or an (D obser'ation unit may beuseful for serial cardiac enzymes (CGs and eercise stress testin!.

• 0atients +ho re"uire additional ad=ustment of medication or an!ioplasty to reducesymptoms and impro'e "uality of life

Dischar!e CriteriaBy definition patients +ho meet dia!nostic criteria of stable an!ina are safe to dischar!e.

Acute Coronary Syndrome: #nstable An!ina


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Shamai A. GrossmanLeon D. Sanchez

BasicsDescription

• Imbalance in myocardial blood supply and oy!en re"uirement

• Canadian Cardio'ascular Classification Class III: se'ere limitations of ordinary physical acti'ity

• Class I,: inability to perform any acti'ity +ithout discomfort symptoms may be present at rest

(tiolo!y

•

Atherosclerotic narro+in! of coronary 'essels

• ,asospasm althou!h this is usually at rest and considered unstable if ne+ onset


• 0la"ue disruption

• &hrombosis

•

Arteritis:

o Lupus

o &a1ayasu disease

o 2a+asa1i disease


• Anemia:

o 4emo!lobin 56 !7dL


• Coronary artery !as embolus

• &hyroid storm



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o Aneurysms

o (ctasia


• Cardiac ris1 factors include:

o 4ypercholesterolemia

o Diabetes mellitus

o 4ypertension

o Smo1in!

o 8amily history in a first*de!ree relati'e less than a!e 99

o Men: a!e ;99 years


Dia!nosis

Si!ns and Symptoms

• #nstable an!ina is defined by either:

o )e+*onset symptoms

o Symptoms that occur at rest

o A chan!e in the patientQs usual pattern of an!ina

• Chest pain:

o Most common presentation of myocardial infarction


o 4ea'iness

o S"ueezin!

o Burnin! sensation

o &i!htness


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• @ccasional an!inal e"ui'alents:

o Abdominal pain

o Syncope

o Diaphoresis


o


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o


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o 4as a sensiti'ity of H? and specificity of 6H for ACI

• &echnetium &c* sestamibi $rest%:

o 4as a sensiti'ity of 6 and specificity of H> for ACI

• (ercise stress testin! may help establish the dia!nosis of an!ina and pro'ide pro!nostic information +hen the clinical presentation is e"ui'ocal:

o (ercise stress testin! +ith (CG alone has a sensiti'ity of F6 and specificityof HH.

o (ercise stress testin! +ith echocardio!raphy has a sensiti'ity of 69 andspecificity of HH.

o (ercise stress testin! +ith thallium*? or technetium &c*m sestamibi hasa sensiti'ity of 6H and specificity of F.

o *mm depression of the S& se!ment belo+ the baseline 6? msec from the point in three consecuti'e beats and t+o consecuti'e leads is characteristic ofcardiac ischemia.

o (arly positi'e $+ithin > minutes% stress tests are +orrisome for unstablean!ina.

Dia!nostic 0rocedures7Sur!erySee Cardiac &estin!Differential Dia!nosis

• Acute MI

• Aniety


• Biliary colic

• Costochondritis

• (sopha!eal reflu

• (sopha!eal spasm

• 4erpes zoster

• 4iatal hernia



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• MI

• 0anic disorder


• 0neumonia

• 0sycho!enic


0.>

&reatment0re 4ospital

• I, access

• Aspirin

• @y!en



AlertAll chest pain should be treated and transported as a possible life*threatenin! emer!ency.Initial Stabilization

• I, access

• @y!en



• Continuous B0 monitorin! and pulse oimetry

(D &reatment

• Aspirin should be administered first to all patients +ith suspected unstable an!ina

• Sublin!ual nitro!lycerin nitro paste or I, nitro!lycerin


27/28

o Symptoms that persist after three sublin!ual nitro!lycerins are stron!lysu!!esti'e of unstable an!ina acute MI or noncardiac etiolo!y.

• Beta*bloc1ers should be administered if no contraindications $e.!. bradyarrhythmiasor obstructi'e pulmonary disease% are present.

• Morphine may be !i'en to relie'e pain and increase oy!en*carryin! capacity.

• (noaparin or heparin is !enerally appropriate as the net line of therapy.

• If unstable an!ina is clearly the clinical dia!noses a !lycoprotein IIb7IIIa inhibitorshould be started as +ell.

Medication $Dru!s%

• Aspirin: F?-E>9 m! 0@

• (noaparin $Lo'eno%: m!71! SC "h

• Glycoprotein IIb7IIIa inhibitors:

o (ptifibatide $Inte!rilin%: 6? J!71! I, o'er -E minutes follo+ed bycontinuous infusion of J!71!7min up to H hours

o &irofiban $A!!rastat%: ?. J!71!7min for >? minutes then ?. J!71!7min

for 6-E?6 hours

o Abciimab $3eo0ro%: for use prior to percutaneous coronary inter'ention only?.9 m!71! I, bolus

• 4eparin: 6? units71! I, bolus then 6 units71!7hr

• Metoprolol: 9 m! I, "9min-E"9min follo+ed by 9-E9? m! 0@ startin! dose astolerated $note: beta*bloc1ers contraindicated in cocaine chest pain%

• Morphine: m! I, may titrate up+ard in *m! increments for relief of painassumin! no respiratory deterioration and SB0 ;? mm 4!


• )itro!lycerin: I, drip at 9-E? J!7min

• )itropaste: -E inches transdermal

8ollo+*#pDisposition

Admission Criteria


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• 0atients +ith unstable an!ina re"uire hospital admission.

• If the dia!nosis is unclear admission to the hospital or an (D obser'ation unit may beuseful for serial cardiac enzymes (CGs and eercise stress testin! and7or cardiaccatheterization.

Dischar!e Criteria )o patient +ith unstable an!ina should be dischar!ed from the (D.

rosen's emergency

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