CP presentation

Question 1

Initial Management of CP w/o trauma hx

Answer 1

airway, breathing, circulation

1. Begin supplemental O2
   
   • O2 via NC or face mask
2. Begin continuous cardiac monitoring
   
   • pulse ox
   • treat life-threatening arrythmias
3. look for markedly abNL hemodynamics
   
   • shock signs
   • altered sensorium, clammy skin, oliguria, resp distress from arterial HoTN and poor peripheral perfusion

Question 2

AbNL Hemodynamic management

Answer 2

immediate measures:

• insert 2 large bore IV catheters
  
  • CBC, markers of cardiac injury, and BMP (electroytes, glc, renal fxn)
  • IV bolus based on estimate of intravascular fluid V

hypovolemic shock:

• infuse IV crystalloid solns (NS)
• monitor response (BP, urine output, sensorium)

central venous hypervolemia (w/ or w/o shock or HoTN):

• infuse NS to keep IV catheter patent ot placec saline lock IV
• examine pulm and CV and palpate abd for pulsatile mass presence
• obtain ECG
• blood gas and pH determinations from arterial blood
• portable CXR
• urinary catheter insertion

Question 3

Central venous hypovolemia

Answer 3

clinical manifestations:

• collapsed neck veins
• clear lung fields on PE or CXR
• no peripheral edema

most common conditions causing CP w/ HoTN and central venous hypovolemia

• MI w/ vagotonia
  
  • crushing CP, N; bradycardia, stable HoTN; acute infarction pattern and bradycardiaon ECG, NL CXR
• aortic dissection
  
  • tearing CP, back pain, h/o HTN; tachycardia, pulse deficits, progressive HoTN; may show ischemia or infarction pattern, LVH; widened mediastinum, pleural fluid on CXR
• leaking upper abdominal aortic aneurysm
  
  • CP and epigastric pain; tachycardia, pulsatile epigastric mass; nonspecific ECG

DX and TX:

• if DX uncertain. TX oriented primarily toward aortic dissection
  
  • 6-10 units of packed RBCs
  • expand intravascular V w/ IV crystalloid soln
    
    • for severe shock + hypovolemia = up to 3 L crystalloid soln may be given rapidly (over 30 min -60 min) to restore NL hemodynamics until crossmatched blood is available
    • if no response to saline, O can be given pending crossmatched blood
  • consider vental venous cath
  • maintain BP w/ continued infusion of blood and crystalloid soln
  • obtain emergency vascular or thoracic sx consult
• pulse deficits, abd mass, or occult hematuria = aortic dissection or aneurysm
• get portable CXR and consider chest CT or abd and pelvis
• bedside US helpful

management:

• thoracic aortic dissection
  
  • beta-blockade (esmolol) to maintain HR less than 60-80 bpm and vasodilators (nitroprusside) to maintain systolic BP < 120 mmHg
  • dissections of ascending aorta managed w/ surgery while those not are managed medically
  • hospitalize in ICU immediately

Question 4

Central Venous Hypervolemia

Answer 4

clinical maifestations:

• superficial veins are distended (esp neck veins)
• pulm or peripheral edema may be present

DDX:

• tension pneumothorax
• cardiac tamponade
  
  • Beck triad = HoTN, jugular venous distension, muffled heart sounds
  • narrow pulse pressure and pulsus paradoxus
• cardiogenic shock (arrythmogenic)
• cardiogenic shock (myocardial)
• PE (massive)

Question 5

NL Hemodynamic management

Answer 5

DDX: (by location and quality of pain)