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Cardiovascular Emergencies
1. Unconscious
Cardiac Arrest
- Ventricular Fibrillation / Pulseless Ventricular
Tachycardia
- Asystole
- Pulseless Electrical Activity (PEA)
2. Conscious
Acute Coronary Syndrome (ACS)
- Unstable Angina Pectoris (UAP)
- Acute Non ST-Elevation Myocardial infarction
(NSTEMI)
- Acute ST-Elevation Myocardial infarction
(STEMI)
Cardiac Arrest
Cardiac arrest is characterized by
abrupt loss of heart function
Main sign of cardiac arrest :
loss of consiousness + pulseless
Can be resuscitated within few
minutes (4-5m) if CPR is initiated
ETIOLOGY
Acute coronary ischemia:
Primary dysrhythmia(Cardiomyophaty and
myocarditis)
Cardiac rupture
Pericardial tamponade
Metabolic abnormalities
Noncardiac etiologies(Tension pneumothorax,
sepsis, etc):
Drugs(Cocaine and Heroin,etc)
Pathophysiology of Cardiac
Arrest
3 basic mechanism :
1.Ventricular Fibrillation / Pulseless
Ventricular Tachycardia
2.Asystole
3.Pulseless Electrical Activity
* Asystole and PEA are not
shockable.
Ventricular Fibrillation
Occur in 30% of in-hospital cardiac arrest
More common in ischemic and infarction heart
disease
More likely to respond to treatment
Clinical Manifestations:
Etiologies:
Acute coronary syndromes leading to ischemic
areas of myocardium
Stable-to-unstable VT, untreated
PVCs with R-on-T phenomenon
Multiple drug, electrolyte, or acid-base
abnormalities
Coarse VF
Fine VF
Treatment:
Early defibrillation is essential
Agents given to prolong period of reversible
death (oxygen, CPR, intubation,
epinephrine,vasopressin)
Agents given to prevent refibrillation after a
shock causes defibrillation (lidocaine,
amiodarone, procainamide, -blockers)
Agents given to adjust metabolic milieu
(sodium bicarbonate, magnesium)
ALGORITH
M
FOR
VF / VT
14
Clinical Manifestations:
Collapse; unconscious
Agonal respirations or apnea
No pulse detectable by arterial palpation
Etiologies
Hypovolemia
Tablets (drug OD, ingestions)
Tamponade, cardiac
Treatment:
Per PEA algorithm
Primary ABCD (basic CPR)
Secondary
AB (advanced airway and ventilation);
C (IV, epinephrine, atropine if electrical
activity <60 complexes per minute);
D (identify and treat reversible causes)
ASYSTOLE
Occur in 25% of in-hospital cardiac arrest
Occur 10% of out-side hospital cardiac arrest
Characterized by ventricular standstill due
to suppression of the cardiac peacemaker by
myocardial disease, anoxia, electrolyte
imbalance,or drugs
Clinical Manifestations:
Early may see agonal respirations; unconscious;
unresponsive
No pulse; no blood pressure
Cardiac arrest
Etiologies:
End of life (death)
Ischemia/hypoxia from many causes
Acute respiratory failure (no oxygen; apnea;
asphyxiation)
Massive electrical shock: electrocution; lightning strike
Postdefibrillatory shocks
Treatment:
Always check for status
Primary ABCD survey (basic CPR)
Secondary ABCD survey
ALGORYTH
M
FOR
BRADYCAR
DIA OR
ASYSTOLE
21
ACUTE CORONARY
SYNDROME
Initial Assessment
Acute myocardial
infarction(STEMI)
MI when arterial blood flow to the
myocardium is suddenly decreased /
interrupted.
Its usually due to atherosclerotic occlusion
by thrombus / emboli.
Complete occlusion (ST segment
elevation) 80-90% because of the
thrombus
Patophysiology
Unstable plaque
Plaque rupture
Unstable angina
Microemboli
Occlusive thrombus
Clinical finding
Chest discomfort typically
substernal radiate to the neck /
left arm
Pain classically oppresive or
squeezing
May associated with SOB(shortness of
breathing),dizziness,
syncope/presyncope, , nausea,
vomitting, dyspnea, and diaphoresis
ECG
Hyperacute T waves
Flipped T waves
Elevated ST segment
Abnormal Q waves
Normal ECG does not rule out the
possibility
of MI / ACS.
Laboratory findings
CK-MB less sensitive than Troponin
Troponin cTnt & cTni the most
cardiac specific biochemical marker.
Mioglobin marker for injured
cardiac sensitive early marker
Differential Diagnosis
Aortic dissection
Aneurysm
Pericarditis
GI bleeding
Killip Classification
Cardiac Biomarkers
Patients with NSTEMI who have
elevated biomarkers of necrosis, such
as CK-MB and troponin, are at
increased risk for death or recurrent
MI
Patients with UA who havent
elevated biomarkers of
necrosiscardiac biomarkers not
increased
Clinical Condition
Dosage
Nitrates
Beta
blockers
Unstable angina
Metoprolol 2550 mg
by mouth every 6 h
Calcium
channel
blockers
Dependent on specific
agent
Morphine
sulfate
25 mg IV dose May
be repeated every 5
CARDIOGENIC SHOCK
Description
Inadequate tissue perfusion due to
cardiac dysfunction
Underlying mechanisms in acute
myocardial infarction (AMI):
Pump failure:
left ventricle (LV) infarct
Infarct in pre-existing LV dysfunction
Reinfarction
Description
Mechanical complications:
Etiology
AMI
Sepsis
Myocarditis
Cardiomyopathy
Drug toxicity:
Beta-blocker
Calcium channel blocker
Adriamycin
etc
Systolic click:
Suggests rupture of the chordae tendinae
Abdominal:
Epigastric pain
Nausea and vomiting
Neurologic:
Obtundation
Test
Electrocardiogram
Normal ECG does not rule out AMI.
Findings of AMI (ST-elevations in two
or more contiguous leads)
May occur in non-ST-elevation acute
coronary syndrome
Dysrhythmias
LV hypertrophy
Test
Chest Radiography
Pulmonary congestion
Pleural effusion
Cardiomegaly
Pneumonia
Pneumothorax
Pericardial effusion
Test
Emergent Echocardiography
Transthoracic echocardiography (TTE) with color
Doppler
LV contractility looking for hypokinesis, akinesis
or dyskinesis
Acute mitral regurgitation or septal defects
RV dilatation, tricuspid insufficiency, high
pulmonary artery and RV pressures suggest
pulmonary embolism
RV hypokinesis or akinesis, RV dilatation, normal
pulmonary pressures suggest RV infarction
Pericardial effusion, right atrium or RV diastolic
collapse suggest cardiac tamponade
Lab
B-type natriuretic peptide (BNP):
Diagnostic and prognostic value
CBC:
Identify anemia or elevated WBC
Differential Diagnosis
Obstructive shock
Distributive shock
Hypovolemic shock
Treatment
Pre Hospital
ABCs, IV access, O2, monitor
Consider fluid bolus if no crackles.
Aspirin
Nitroglycerin or morphine sulfate for
chest pain in absence of hypotension
Transport AMI patients to facility with 24hour cardiac revascularization capability.
Treatment
Initial Stabilization
ABCs
Two large bore peripheral IV lines
Cardiac monitor
Endotracheal intubation for airway
compromise:
Consider etomidate for induction (minimal
effect on blood pressure)
Treatment
Medication (Drugs)
Dobutamine
Dopamine
Furosemide
Milrinone
Nitroglycerin
Nitroprusside
Norepinephrine
CPR
Definition
CPR is an organized, sequential response
to cardiac arrest, including
Recognition of absent breathing and circulation
Basic life support with chest compression and
rescue breathing
Advanced cardiac life support (ACLS) with
definitive airway and rhythm control
Postresuscitative care