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Emergency Cardiac Care
November 10, 2016 UNIVERSITY OF NORTH DAKOTA SCHOOL OF MEDICINE & HEALTH SCIENCES
Outline of This Afternoon’s Presentation • Management of Acute Coronary Syndrome • Management of Other Important Causes of Chest Pain • Aortic Dissection • Pericarditis/Tamponade • Pulmonary Embolism
• Management of Tachyarrhythmias • PSVT • VT/Wide Complex Tachycardia
Coronary Artery Disease • A chronic disorder • The disease typically cycles in and out of clinically defined phases: • asymptomatic • stable angina • unstable angina, non-ST elevation MI, acute ST elevation MI (“STEMI”)è Acute Coronary Syndrome (ACS)
Plaque fissuring and rupture (unstable plaque)è acute coronary thrombosis
Alternative Diagnoses for Patients with Chest Pain •
Electrocardiograms • ECGs taken in the absence of pain in patients with angina pectoris, and no hx of MI, is normal in 50% of cases • Obtaining an electrocardiogram while experiencing chest pain is more rewarding • New horizontal or down-sloping S-T segments on ECG is highly suggestive of myocardial ischemia; new T-wave inversion also may occur, but this finding w/o S-T depression is less specific
Cardiac Troponins ØExtremely specific for myocardial tissue ØExtremely sensitive to even minute amounts of myocardial damage ØElevation parallels CK/CK-MB (3-6 hours) but important to see rise and fall ØElevations also found in chronic kidney disease, cardiomyopathy, myocarditis, sepsis, pulmonary embolism
Biomarkers of Myocyte Death A. Myoglobin in AMI B. Troponin in AMI C. CK-MB in AMI D. Troponin in unstable angina
MEDICAL THERAPY • Antiplatelet agents • Aspirin, Clopidogrel, IIb/IIIa inhibitors
• Antithrombin therapy
• Unfractionated heparin, LMWH
• Antianginal therapy • Beta blockers, nitrates
• Reperfusion therapy
REPERFUSION THERAPY PTCA • Higher initial reperfusion rates • Lower recurrence rates of ischemia / infarction • Less residual stenosis • Less intracranial bleeding • Utility when fibrinolysis contraindicated
THROMBOLYSIS • More universal access • Shorter time to treatment • Results less dependent on physician experience • Lower system costs
Which one? It’s a matter of time!
Re-establish Infarct Vessel Patency
Limit Infarct Size
Evolution of ECG changes in STEMI
Complications of Acute MI
Extension / Ischemia
Expansion / Aneurysm
Take home concepts
ST-elevation MI (STEMI)
Other Important Causes of Chest Pain • Aortic Dissection • Stigmata of Marfan’s Syndrome • Back pain • Do NOT give thrombolytic therapy!
• Pericarditis/Tamponade • • • •
Pleuritic chest pain Diffuse ST elevation on ECG Muffled heart sounds Paradoxical pulse on palpation
Other Important Causes of Chest Pain • Pulmonary embolism • Recent prolonged travel/immobilization • Desaturation • Syncopal episode • Recent study found 1 in 6 elderly patients with syncope had PE as the cause
Management of Chest Trauma • Acute coronary syndrome due to coronary damage • Valve damage è acute regurgitation • Myocardial damage • Contusion • Free wall rupture/tamponade • Traumatic ventricular septal defect
Aortic Transection • Deceleration injury (mobile ascending aorta and fixed descending aorta) • Survivors to ED show tear at ligamentum arteriosum • May have retrosternal or back pain, dyspnea, stridor, dysphagia • May have harsh systolic murmur • May have pulse difference between upper and lower extremities • Need high index of suspicion!
Electrocardiograms and Arrhythmias
ECG Leads • II, III, AVF
• I, AVL
Localization of MI • Anterior MI – LAD and/or diagonal • Posterior MI – circumflex or RCA • Inferior MI – RCA or circumflex • The apex receives blood from all 3 arteries
Localization of MI
Assessment of Tachyarrhythmia •Hemodynamically stable or unstable – “When in doubt, shock it out” •Regular or Irregular – If irregularly irregular probably atrial fibrillation (could be chaotic or multifocal atrial tachycardia) •If regular, is it narrow or wide complex (WCT)?
Differential Diagnosis of Regular Narrow Complex Tachycardia • Sinus tach – Try carotid sinus massage • Atrial flutter – can use adenosine to unmask • PSVT • AVNRT (dual AV pathways) • AVRT (bypass tract) • Ectopic atrial tachycardia
Differential Diagnosis of Wide Complex Tachycardia • SVT with aberrancy or pre-existing bundle branch block – consider adenosine • VT • Look for dissociated P waves • Rabbit year size – The more it looks like right bundle, the more likely that it’s SVT • The more bizarre (e.g., QS in V6), the more likely it’s VT • Age of patient