cathlab emergencies - bcisbcis.org.uk/wp-content/uploads/2017/01/cathlab_emergencies_1.pdf · cath...

Cathlab Emergencies

Tom Johnson Consultant Cardiologist

Hon. Senior Lecturer

Sarah Carson Senior Nurse

Cathlab Manager

Outline

Cathlab team courtesy of Google Images

Cardiac Radiographer



Cardiac Physiologist

Cathlab Nurses




Cathlab Nurses

Cardiologist

Teamwork key to success courtesy of Google Images



Cathlab Nurses

Interventional Cardiologist

Cathlab Environment

Cathlab Emergency

Additional staff • Anaesthetists • ODPs • Resus team • Porters

+++ Stressful Coordination

Panic

Cathlab Emergencies

Complications & Emergencies

BCIS 2013 Data

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

%

2009

2010

2011

2012

Peri-procedural Complications

2012 data: Ludman

Cath Lab Emergencies: Vessel Closure

• Sidebranch occlusion • Coronary dissection • No-flow / Slow flow

Slow flow/No reflow

Peri-procedural Complications

2012 data: Ludman No flow / Slow flow by syndrome

Angio of occluded vessel

Pathophysiology of No flow

Thrombotic Emboli

Plaque Debris

Capillary Plugging & Vasoconstriction

Ischaemia

PCI

Endothelial Swelling

No Reflow

Predictive Factors: Acute Myocardial Infarction

Vein graft disease Thrombotic lesions

Rotational Atherectomy

Case 1 A Rescue Situation

73 yr old ♂

Anterolateral STEMI → Thrombolysis

6hrs post lysis – recurrent pain & ST↑

Transferred to BHI

Clexane

Tirofiban

ASA & Clopidogrel

Angio ‘pain free with resolved STs’

PCI

Radial Approach

EBU3.5 guide

Balance Wire

5000iu heparin

Lesion Predilatation

Persisting No Reflow EXPORT aspiration

Stent deployment 2.75x23 Vision

No Flow

No flow

Obstruction of Flow

Consider differentials

• Edge dissection

• Air embolus

• Residual thrombus

Angio of occluded vessel

Treatment Re-consider pathophysiology

Thrombotic Emboli

Plaque Debris

Capillary Plugging & Vasoconstriction

Ischaemia

PCI

Endothelial Swelling

No Reflow

Treating No Reflow Pharmacology

Always attempt to deliver drug to distal vessel

Drug choice varies enormously but tend to be directed at microvascular circulation

Verapamil 50-900μg

Adenosine 100μg

Nitroprusside 50 -200μg

Nicorandil 2μg

Epinephrine 50-200μg

Abciximab

Post i.c. GTN & Adenosine

Final Result

Strategies to Prevent No reflow

Mechanical

• Thrombectomy

• Thromboaspiration

• Direct Stenting

• Distal Protection

• Proximal Protection

PPCI

SVGs

Strategies to Prevent Mechanical

• Thrombectomy




• Direct Stenting

AngioJet®

• 6F compatible • 4F shaft • 135cm length • 3 high-velocity saline jets • 0.014” guide wire compatible


• Thrombectomy




• Direct Stenting

Lancet 2008; 371: 1915–20


• Thrombectomy




• Direct Stenting


• Thrombectomy




• Direct Stenting

• ↓ procedural time • ↓ radiation exposure • ↓ costs • ↑ resolution of STs • No impact on TIMI-3 rate

JACC 2002: 39(1);15-21

No flow Lessons

• Patient comfort - communicate - analgesia - sedation

• iv fluids

• Be ready with drugs

• Consider high-care

Cath Lab Emergencies:

Hypotension

Hypotension: Definition

• Generally a BP < 90 mmHg which is causing inadequate organ perfusion

• Often less when major problems going on!

• Important to know the starting BP

What do you need?

• Fully equipped room / WHO checklist

• IV access

• Know where all the key emergency kit is (Pericardiocentesis, Defib, IABP) and how to use it / what is expected of you

• Useful to mentally run through what you would have to do for a particular emergency situation … or practice with the team

Hypotension Management

• All staff in the room to be “on the ball” and aware of what is going on

• Be prepared to immediately “change gear” and be absolutely focussed to the emergency situation… but always stay calm

• Treat the underlying cause

• Support the haemodynamics in the meantime

• Recognition: Rash, itching, wheezing

• Adrenaline

• Piriton, Hydrocortisone

• Salbutamol nebuliser

• Fluids

• Stop giving the allergen! (often contrast)

• Anticipate if: Severe coronary disease with large territory ischaemia Acute presentation with pulmonary oedema

• Exclude other causes of cardiogenic shock with echo (tamponade, valve problem etc)

• Support the circulation: IABP (covered later today) Inotropes

• Urgent revascularisation • May need to consider GA

• MV rupture septal or free wall rupture

cardiogenic shock

• Early echo needed

• Support the circulation

– IABP

– Inotropes

• Emergency surgery??

• Wire perforation (can be subtle)

• Coronary perforation (less so!)

• Ventricular Rupture

Case 2

84year old lady

• Acute pulmonary oedema

• Troponin positive

• Anaemia (Hb 8.0)

• ? Lower GI/ovarian mass & recent pelvic collection treated conservatively

• Angio = heavily calcified LAD & Cx disease

• MDT = trial of DAPT & then PCI

PCI to LAD

LAD OCT

Omega 2.75x16mm

PCI to Cx

Difficult Cx delivery

Anchor Balloon

6F guide

Guideliner

Buddy wire 2.5x24 Omega 2.75x24 Omega

Post-stent result

2.75 NC balloon 12A

2.75 NC balloon 12A

Cx OCT

Further Post-dilatation

What next?

Coronary Perforation Immediate Steps

• Balloon tamponade

Coronary Perforation Immediate Steps

• Balloon tamponade

• Pericardial drain set ready

• Communicate - call for echo & team support

• Group & Save

• Analgesia for ischaemia

• If available, ask for Cell Saver

• Locate covered stents

Post balloon tamponade

Guideliner to facilitate covered stent placement

Jo-stent GRAFTMASTER

Convert to 8F RFA

2.75x26 Graftmaster

Distal 2.75x16 Graftmaster

Outcome

• 700ml blood drained from pericardium

• 380ml PRB infused + 1unit blood

Hb pre-procedure 10.3g/dl

Hb 24hrs post procedure ?

Discharged 7days later & doing well

11.4g/dl

• Know where your pericardial drain set lives

• Get echo machine/operator

• Correct hypotension fluid/blood

• Ensure patient comfort

• Recognition of the problem

• Femoral access… flank pain? (RPH)

• GI bleed?

• Give rapid fluids and address the cause

• Cross match

• Does anticoagulation need to be reversed?

• Surgery?

Arrhythmias

Different Types…

• Tachy

– VT

– VF

– (AF, Flutter, SVTs etc – but less critical)

• Brady

– Profound sinus brady

– Long pauses… asystole

– CHB

Causes

• STEMI – i.e. during primaries (& re-perfusion)

• Ischaemia during procedure

• RCA lesions (NB RCA supplies SA & AV nodes) • RCA ischaemia can cause AV block (e.g. RCA ACS)

• Also with RCA Rota cases (TPW available!)

• Injection into the Conus branch of the RCA

• Pigtail in the LV (esp. if pre-existing BBB) or catheter in RVOT

• But… potentially with any intervention

Be aware of resources

• Resus council UK

– Tachy and Brady algorithms

Important Arrhythmias 1

• VT

• How is the patient / BP

• Drugs vs DC Shock


• VF

• DC Shock (once patient unconscious!)


• Very slow!! – doesn’t matter what the precise rhythm is – again, patient & BP??

• Atropine vs TPW (some will spontaneously recover)

Need to be on the ball…

• All team members should be aware of what is going on in the case

– Be ready to step up a gear and focus

• Need to know where all the kit is e.g. Atropine and TPW

• Any of these situations could lead on to full arrest…

Cardiac Arrest

• Shockable VF/VT DC shock

• Asystole/extreme brady Pace

• PEA: Need to establish mechanism, e.g.

– Tamponade Pericardiocentesis

– Global ischaemia IABP/Inotropes

• Be aware of Cath Lab specific guidelines

• Know how to call for an Anaesthetist

– Do not usually want the whole crash team!

LUCAS or Autopulse Device?

• Know how to use it

• Practise attaching it

• Know which angio views can be used

Stay focussed and work together!

Afterwards…

• Often useful to de-brief, particularly if it didn’t feel “smooth” or if you didn’t follow what was going on

– Make sure you understand what happened, why, and how it was treated

– Its OK not to understand everything at first… but make sure you learn from your experiences

Summary

• Be aware of the common important arrhythmias seen in the Cath Lab

– What causes them

– What they look like

– How they are treated

• Be aware of the Cath Lab Resus guidelines, and how they will be implemented in your Lab

• Always stay calm and stay focussed!

Cathlab Emergencies

• Focus • Know where the kit is • Communicate • Call for help • Reassure

& …

Any Questions?

Coffee

cathlab emergencies - bcisbcis.org.uk/wp-content/uploads/2017/01/cathlab_emergencies_1.pdf · cath...

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