emergency cardiac care 2016
TRANSCRIPT
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EmergencyCardiacCareNovember10,2016UNIVERSITYOFNORTH DAKOTASCHOOLOFMEDICINE&HEALTH SCIENCES
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OutlineofThisAfternoon’sPresentation
• ManagementofAcuteCoronarySyndrome• ManagementofOtherImportantCausesofChestPain
• AorticDissection• Pericarditis/Tamponade• PulmonaryEmbolism
• ManagementofChestTrauma• CardiacInjury• AorticTransection
• ManagementofTachyarrhythmias• PSVT• VT/WideComplexTachycardia
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CoronaryArteryDisease
•Achronicdisorder• Thediseasetypicallycyclesinandoutofclinicallydefinedphases:
• asymptomatic• stableangina• unstableangina,non-STelevationMI,acuteSTelevationMI(“STEMI”)è AcuteCoronarySyndrome(ACS)
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Plaque fissuring and rupture (unstable plaque)èacute coronary thrombosis
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AlternativeDiagnosesforPatientswithChestPain• Non-Ischemic CV
– aortic dissection– pericarditis
• Pulmonary– pulmonary embolus– pneumothorax– pneumonia– pleuritis
• Chest Wall– costochondritis– fibrositis– rib fracture– sternoclavicular arthritis– herpes zoster
Gastrointestinal• Esophageal
– esophagitis– spasm– reflux
• Biliary– colic– cholecystitis– choledocholithiasis– cholangitis
• Peptic ulcer• Pancreatitis
Psychiatric• Anxiety disorders
– hyperventilation– panic disorder– primary anxiety
• Affective disorders– depression
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Electrocardiograms• ECGstakenintheabsenceofpaininpatientswithanginapectoris,andnohx ofMI,isnormalin50%ofcases
• Obtaininganelectrocardiogramwhileexperiencingchestpainismorerewarding
• Newhorizontalordown-slopingS-TsegmentsonECGishighlysuggestiveofmyocardialischemia;newT-waveinversionalsomayoccur,butthisfindingw/oS-Tdepressionislessspecific
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Acute Coronary Syndromes
Non-ST elevation MI or ACS
ST-elevation MI
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AcuteCoronarySyndrome(ACS)
•Unstableanginapectoris(UAP)•Non-STelevationmyocardialinfarction(Non-STEMI)•ST-elevationmyocardialinfarction(STEMI)
•DifferentiationofUAPfromNSTEMI:
+cardiacmarkers NSTEMI
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Cardiac TroponinsØExtremely specific for myocardial tissueØExtremely sensitive to even minute amounts of
myocardial damageØElevation parallels CK/CK-MB (3-6 hours) but
important to see rise and fallØElevations also found in chronic kidney disease,
cardiomyopathy, myocarditis, sepsis, pulmonary embolism
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Biomarkers of Myocyte DeathA. Myoglobin in AMIB. Troponin in AMIC. CK-MB in AMID. Troponin in unstable angina
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MEDICALTHERAPY
•Antiplateletagents• Aspirin,Clopidogrel,IIb/IIIa inhibitors
•Antithrombin therapy• Unfractionatedheparin,LMWH
•Antianginaltherapy• Betablockers,nitrates
•Reperfusiontherapy
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REPERFUSIONTHERAPY
• Higherinitialreperfusionrates
• Lowerrecurrenceratesofischemia/infarction
• Lessresidualstenosis• Lessintracranialbleeding• Utilitywhenfibrinolysiscontraindicated
• Moreuniversalaccess• Shortertimetotreatment• Resultslessdependentonphysicianexperience
• Lowersystemcosts
PTCA THROMBOLYSIS
Whichone?It’samatteroftime!
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Myocardial Reperfusion
Re-establishInfarct Vessel
Patency
Limit InfarctSize
¯ Mortality
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CoronaryAngiography
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Stent
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Evolution of ECG changes in STEMI
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Extension / Ischemia
ComplicationsofAcuteMI
Acute MI
Arrhythmia
Heart Failure
Expansion / Aneurysm RV Infarct
Pericarditis
Mechanical Mural Thrombus
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Take home concepts
Asymptomatic Stable angina USA/NSTEMI ST-elevation MI (STEMI)
Normal EKG
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OtherImportantCausesofChestPain• AorticDissection
• StigmataofMarfan’s Syndrome• Backpain• DoNOTgivethrombolytictherapy!
• Pericarditis/Tamponade• Pleuriticchestpain• DiffuseSTelevationonECG• Muffledheartsounds• Paradoxicalpulseonpalpation
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OtherImportantCausesofChestPain
• Pulmonaryembolism• Recentprolongedtravel/immobilization• Desaturation• Syncopalepisode
• Recentstudyfound1in6elderlypatientswithsyncopehadPEasthecause
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ManagementofChestTrauma
• Acutecoronarysyndromeduetocoronarydamage• Valvedamageè acuteregurgitation• Myocardialdamage
• Contusion• Freewallrupture/tamponade• Traumaticventricularseptaldefect
• Traumaticaortictransection(decelerationinjury)
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AorticTransection• Decelerationinjury(mobileascendingaortaandfixeddescendingaorta)• SurvivorstoEDshowtearatligamentumarteriosum• Mayhaveretrosternalorbackpain,dyspnea,stridor,dysphagia• Mayhaveharshsystolicmurmur• Mayhavepulsedifferencebetweenupperandlowerextremities• Needhighindexofsuspicion!
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ElectrocardiogramsandArrhythmias
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ECGLeads• II,III,AVF Inferiorwall
• V1-2 Septum
• V3-4 Anterior
• V5-6 Lateral
• I,AVL Highlateral
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LocalizationofMI
•AnteriorMI– LADand/ordiagonal•PosteriorMI– circumflexorRCA• InferiorMI– RCAorcircumflex
• Theapexreceivesbloodfromall3arteries
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LocalizationofMI
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AssessmentofTachyarrhythmia
•Hemodynamicallystableorunstable– “Whenindoubt,shockitout”
•RegularorIrregular– Ifirregularlyirregularprobablyatrialfibrillation(couldbechaoticormultifocalatrialtachycardia)
• Ifregular,isitnarroworwidecomplex(WCT)?
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DifferentialDiagnosisofRegularNarrowComplexTachycardia
• Sinustach– Trycarotidsinusmassage•Atrialflutter– canuseadenosinetounmask•PSVT
• AVNRT(dualAVpathways)• AVRT(bypasstract)• Ectopicatrialtachycardia
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DifferentialDiagnosisofWideComplexTachycardia
• SVTwithaberrancyorpre-existingbundlebranchblock–consideradenosine
•VT• LookfordissociatedPwaves• Rabbityearsize– Themoreitlookslikerightbundle,themorelikelythatit’sSVT
• Themorebizarre(e.g.,QSinV6),themorelikelyit’sVT• Ageofpatient
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ManagementofTachyarrhythmias