Cardiac Emergencies Flashcards
Name the common cardiac emergencies?
- acute coronary syndrome
- cardiac tamponade
- aortic dissection
- severe arrhythmias
- cardiac arrest
What is acute coronary syndrome?
encompasses a spectrum of unstable coronary artery disease
Mechanism of ACS?
is a rupture or erosion of a fibrous cap of a coronary artery atheromatous plaque
Disease spectrum of ACS ranges from?
- Unstable angina
- Myocardial infarction
- NSTEMI
- STEMI
Criteria for unstable angina?
- troponin - negative
- ECG - normal
Criteria for non ST segment myocardial infarction?
- troponin - >x10 ULM
- ECG - ST segment depression
Criteria for ST segment elevation myocardial infarction?
- troponin - >x10 ULM
- ECG - ST elevation
ACS clinical features?
- Patient has a history of angina or presents with worsening chest pain on minimal exertion
- chest pain- discomfort, tightness, pressure or burning like
Describe the chest pain of ACS?
- Central or left sided
- Dull , pressing, burning on nature
- Radiates to the left shoulder or the left jaw or the occipital
- Relieved by rest or nitrates
- Associated with autonomic symptoms
- Nausea, heart palpitations or excessive sweating
Treatment options for ACS?
- Admit to HDU/ICU and put on continues cardiac monitor
- Pain relief
- antiplatelet
- anticoagulant
- thrombolysis
Pain relief treatment for ACS?
- Nitroglycerine o.5mg SL start
- Morphine 2.5-5mg iv start
Antipletelet treatment for ACS?
- Aspirin 300mg po chewed
- Clopidogrel 300mg po start
Anticoagulant treatment for ACS?
Low Molecular weight heparin - 1mg/kg sc q12hrly
Thrombolysis treatment for ACS?
If presented in less than 4hrs from onset of chest pains
1. Streptokinase 1.5MU in 100ml of N/S over 60minutes
2. Altepase
Describe altepase treatment for ACS?
- <67Kg
15mg iv push over 2 minutes
0.75mg/kg over 30minutes
0.5mg/Kg iv over 60minutes - > 67Kg
15mg iv push over 2 minutes
50mg iv over 30minutes
35mg iv over 60minutes
What is cardiac tamponade?
What does it result in?
- Rapid accumulation of pericardial fluid within the pericardial sac
- Impairs ventricular filling and therefore cardiac output leading to cardiogenic shock
Clinical features of cardiac tamponade?
- Elevated JVP
- Kussmaul’s signs
- Tachycardia
- Tachypnea
- Apex beat may not be palpable
- Becks triad
Becks triad?
clinical feature of cardiac tamponade
1. increased JVP
2. low systolic BP
3. diminished heart sounds
Treatment for cardiac tamponade?
- Urgent drainage under ultrasound scan guidance
- Pericardial window if chronic or recurrent
What is aortic dissection?
- Separation of layers of the aortic wall
- A tear within the intimal layer will propagate either distally or proximally
What are the 3 types of aortic dissection?
Type I - originates in the ascending aorta and to at least the aortic arch
Type II - originates in and is limited to the ascending aorta
Type III - begins in the descending aorta and extends distally above the diaphragm (3a) or below the diaphragm (3b)
Clinical features of dissecting aorta?
- sudden onset of sever chest pains
- Syncope
- Anxiety and prenomination of death
- Altered mental status
- Flank pain if the renal artery is involved
Severe chest pain in aortic dissection?
Tearing and ripping in nature
1. May be anterior if associated with aortic arch or aortic root
2. Posterior or intrascapular pain may suggest descending aorta involvement
- 10% are chest pain free
Diagnosis of aortic dissection?
- Inter-arm BP difference more than 20mmHg
- AR murmur
- Becks triad suggestive of possible cardiac tamponade
- CXR show a widened mediastinum
- Cardiac ECHO
Management of aortic dissection?
- Surgical
- Tear is repaired and replaced with a dacron graft - Medically
- BP lowering to SBP<100mmHg
> Beta blockers are the drug of choice
- Pain relief
> Morphine
Describe extreme tachycardia?
- Extreme tachycardia with heart rates of more than 150bpm impairs diastolic filling
- Lead to reduced cardiac output and cardiogenic shock
- Commonest arrhythmia is a supraventricular tachycardia, SVT
Clinical features of extreme tachycardia?
- Chest pains
- Low SBP
- Hypoxia
- Excessive sweating
Management of extreme tachycardia?
- If unstable, do electrical cardioversion
- Medically
* Vagal maneuvers
* Beta blockers
* calcium channel blockers
* Amiodarone
Amiodarone dose in tachycardia treatment?
- 150mg iv over 10min then
- 1mg/Kg iv over 6 hrs then
- 0.5mg/Kg iv over 18hrs
Cardiopulmonary resuscitation?
Pay attention to ABCs
1. Airway
2. Breathing
3. Circulation
- Current trend is to place more emphasis on Circulation
- Check for pulse and if absent, start chest compression immediately
Chest compressions?
30 chest compressions and then 2 breaths
When do we stop compressions?
only hands off time is for defibrillation and rhythm analysis
When to shock the patient?
Attach defribrillator and assess rhythm and if a shockable rhythm, please provide shock
When to apply definitive airway?
delay definitive airway management until after return of spontaneous circulation
NB : DO NOT stop compressions for airway
What to do when airway is secure?
provide adequate breaths after each compression
What to do when breathing is adequate?
give high- concentration oxygen by nonrebreather
What to do if breathing is inadequate?
ventilate with high-concentration oxygen
Compressions if patient is intubated?
continuous
Compressions if patient is not intubated?
rotate every 2 minutes at which point a resuscitation cycle is said to have been completed
Medication in CPR?
- adrenaline as bolus in between each cycle
- Establish venous access
- Put up two iv lines if possible
- One for fluids and the other for special drugs
How to establish underlying cause for cardiac arrest?
arterial blood gas
When to admit to ICU?
ICU for post resuscitation care once return of spontaneous circulation is achieved
