MEDICATIONS CARDIOVASCULAR URGENCIES & EMERGENCIES 12/29/14. Cardiovascular Emergency Medications. Cardiovascular Emergency Medications

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1 CARDIOVASCULAR URGENCIES & EMERGENCIES Steven Ganzberg, DMD, MS Director of Anesthesiology, Century City Outpatient Surgery Center Clinical Professor of Anesthesiology, UCLA School of Dentistry MEDICATIONS Disclaimer: Specific Required Medications May Vary Among States Use Only Those Medications With Which You Are Familiar Cardiovascular Emergency Medications Dysrythmias Ventricular Amiodarone 150 mg Vials** Cardiac Lidocaine 1%/2% Syringes?? Supraventricular Esmolol 10mg/ml**; 10ml Vial Diltiazem 5mg/ml; 5ml Vial Adenosine 3mg/ml; 2ml Vial Cardiovascular Emergency Medications Bradycardia Atropine** 0.4mg/ml or 1mg/10ml Syringe Glycopyrrolate 0.2mg/ml Tachycardia Esmolol 10mg/ml** Metoprolol 1mg/ml? Labetalol 5mg/ml? Cardiovascular Emergency Medications Hypertension Beta Blockers Esmolol 10mg/ml** Metoprolol 1mg/ml Labetolol 5mg/ml** Vasodilating Agents Nitroglycerin SL 0.3/0.4 mg/dose** IV 5mg/ml?? Hydralazine 20mg/ml Nicardipine 2.5mg/ml Enalaprilat 1.25mg/ml Cardiovascular Emergency Medications Hypotension Ephedrine 50 mg/ml** Requires 1:10 Dilution to 5 mg/ml Both α and β Effects Phenylephrine 10 mg/ml** Requires Double 1:10 Dilution to 100 mcg/ml Primarily α Effect Epinephrine 1:1000 (Multiple Vials)** Cardiac Arrest/Anaphylactic Shock (Bronchospasm) Dopamine 40 mg/ml (Dilution & Infusion)? Vasopressin 40 U (For Pulselessness)? 1

2 Cardiovascular Emergency (Medications) AED? Manual Defibrillator? Cardioverter? Transcutaneous Pacer? General Principles For Sedated Patients If Persistent CV Urgency/Emergency If Patient Is Conscious, Ask Them How They Feel If Very Sedated, Consider Making Them Less Sedated If Not Conscious, Consider Making Them Conscious Evaluate Multiple Indicators REVIEW OF THE ELECTROCARDIOGRAM Electrical Conduction System Cardiac Pacemakers SA Node BPM AV Node BPM Ventricular BPM LEAD PLACEMENT 2

3 Lead + I LA RA II LL RA III LL LA avl LA LL/RA avr RA LL/LA avf RF LA/RA Anterior Basics of the EKG Heart Rate Normal BPM Bradycardia = HR < 60 Tachycardia = HR > 100 Physiologic Bradycardia Relative Bradycardia 3

4 ECG Interpretation Rate Rhythm Axis Hypertrophy Infarction Rhythm Identify Basic Rhythm Abnormal Waveforms Pauses Premature Beats Irregularity Rhythm ü P Before Each QRS & QRS After Each P ü PR Intervals ü QRS Interval ü PVCs SINUS RHYTHM SELECTED RHYTHM EMERGENCIES Too Slow Too Fast Irregular Rhythms Wide Complexes 4

5 What About Bradycardia? SELECTED RHYTHM EMERGENCIES Too Slow Too Fast Irregular Rhythms Wide Complexes Physiologic Bradycardia/Reflex Bradycardia/ Age Hypoxia/Hypercarbia Drug Induced: Beta Blockade/Ca ++ Channel Blockade/Excess Digoxin /α2 s /Li ++ Opioid Effect Anesthetic Overdose Primary Conduction Defect (MI?) Sick Sinus Syndrome Junctional Rhythm 2 nd and 3 rd Degree Heart Block Decompensation/20% Acute MI, Esp. Inferior Wall Pharyngeal and Oculocardiac Reflexes Hypothyroidism/SLE/Collagen Vascular Disease Respiratory Arrhythmia Increase in heart rate during inspiration Exaggerated in children, young adults and athletes Decreases with age Usually asymptomatic, no treatment or referral Can be non-respiratory Both in normal or diseased heart Referral may be necessary if not clearly respiratory, history of heart disease IF YOU DROP BEATS, YOU END UP WITH A BRADYCARDIA 5

6 2 nd & 3 rd Degree Heart Blocks Bradycardia What is the Cause AND Is It Hemodynamically Significant??? If Symptomatic Atropine 0.5 1mg 3mg Full Adult Vagolytic Dose No Help In 2 nd Degree, Type II or 3 rd Degree Heart Blocks Glycopyrrolate? mg Initially Ephedrine? Consider If Both BP and HR Low For Select Heart Blocks (Discussed Later) Dopamine? Epinephrine? Transcutaneous Pacing?? SELECTED RHYTHM EMERGENCIES Too Slow Too Fast Irregular Rhythms Wide Complexes What About Sinus Tachycardia? Hypoxia/Hypercarbia Surgical Stimulation/Inadequate Local Anesthesia Intravascular Epinephrine Injection From LA Severe Pre-operative Anxiety Full Bladder Hypotension/Hypovolemia (Reflex Tachycardia) Medication Related: Pre-Operative & Intraoperative Albuterol Ketamine/High Concentrations of Potent Inhaled Anesthetics Amphetamines, Atomoxetine, Tricyclic Antidepressants, SNRIs Rebound From Beta Blocker/Clonidine Anemia Decreased Cardiac Output (e.g., CHF/MI/PE) Hyperthyroidism/Hypermetabolic State/Pheo. 6

7 OTHER TACHYCARDIAS Primary Conduction Defects Supraventricular Dysrythmias Supraventricular Dysrythmias Why, Why, Why?? Primary Conduction Abnormality Sympathetic Nervous System Activation Hypoxia/Hypercarbia Atrial Volume Overload Supraventricular Dysrythmias What is the Cause AND Is It Hemodynamically Significant??? Treat Underlying Cause If Possible Treat Rate Before Rhythm!! Vagal Stimulation? Beta Blockers Acceptable First Line Treatment in All Supraventricluar Dysrythmias Esmolol 10mg/ml Rule of Thumb 1mg Decreases Heart Rate 1 Beat/Min (e.g. 10mg Decreases 10 Beats/Min) Exception: CHF Consider Amiodarone Other Beta Blockers? Calcium Channel Blockers? Adenosine??? Cardioversion??? Early Cardioversion Should Be Considered For All Primary Tachyarrythmias With Serious Signs & Symptoms Because... Antiarrhythmics Are Also Proarrythmics If Impaired Myocardial Function, Antiarrythmics Decrease Cardiac Function Arrive At a Specific Diagnosis 7

8 SELECTED RHYTHM EMERGENCIES Too Slow Too Fast Irregular Rhythms Wide Complexes Irregular Rhythm Narrow Complex or Wide Complex? Regularly Irregular or Irregularly Irregular? Is My Patient Hemodynamically Stable? Irregular Rhythms Narrow QRS Primary Conduction Defects Sick Sinus Syndrome Pre-Atrial Contractions (PACs) Atrial Fibrillation 2 nd and 3 rd Degree Heart Block Irregular Rhythms Wide QRS Pre-Ventricular Contractions (PVCs) PACs With RBBB 8

9 SICK SINUS SYNDROME Treatment? PRE-ATRIAL CONTRACTIONS: PACs 9

10 So What About PACs Can be Caused By: Anxiety/Caffeine Excessive Alcohol Sympathetic Stimulation/Drugs Cardiac Disease/MVP Congenital Treatment: Usually Benign Without Hemodynamic Significance ATRIAL FIBRILLATION IRREGULARLY, IRREGULAR Atrial Fibrillation Epidemiology 1% Incidence; 2.2 Million Americans 160,000 New Cases Per Year Double Mortality Risk vs. Normal Sinus Rhythm 5-Fold Increase in Stroke Risk: Cause in 20% Pathophysiology Uncoordinated Atrial Rhythm Four Types: Lone, Paroxysmal, Persistent, Permanent Irregularly, Irregular Ventricular Rhythm Possible Embolus with Conversion to Normal Sinus Rhythm Treatment Control Ventricular Response To Prevent A-Fib with RVR Anticoagulation (Prevents Mural Thrombus) Cardioversion Ablation Atrial Fibrillation With RVR Control Rate, Then Rhythm Beta Blockers Esmolol, 0.5mg/kg and titrate Metoprolol, Titrate 2.5mg q10 15 minutes Calcium Channel Blockers Diltiazem, 5mg q10 15 min Amiodarone in CHF ED Titration? Caution!! Cardioversion - Unless Onset Less Than 48 Hours (and you really want to) Risk of Pulmonary Embolus/Stroke 2 nd & 3 rd Degree Heart Blocks HEART BLOCKS Another Irregular Rhythm 10

11 12/29/14 10 AV Block + Wenckebach Electrical Conduction System Electrical Conduction System 20 AV Block, Type 2 & 30 Block Questions: Heart Blocks Is My Patient Hemodynamically Stable? Onset? Before Case On Placement of ECG During Case Must Ask: Is This Presentation of MI? 10 AV Block Minimal Issues 20 Type I Wenckebach Vagally Mediated During Case? If Pre-op, Cardio Consult? 20 Type II and 3rd Degree ED Evaluation Is This Initial Presentation of Intraoperative MI? PRE-VENTRICULAR CONTRACTIONS - PVCs Yet Another Irregular Rhythm 11

12 PVCs SELECTED RHYTHM EMERGENCIES Too Slow Too Fast Irregular Rhythms Wide Complexes 12

13 12/29/14 Multifocal PVCs Ventricular Dysrythmias Why, Why, Why?? Likely Myocardial Ischemia Hypoxia/Hypercarbia** Tachycardia/Hypertension Valvular Disorder Myocardial Infarction Cardiomyopathy/Other Cardiac Disorder Primary Conduction Abnormality Bradycardia? Ventricular Dysrythmias Considered Significant > 6 PVC s/min But Is the Patient Hemodynamically Stable!!! Treat Underlying Cause (Hypoxia/Hypercarbia?) Consider Cardiac Lidocaine 1 1.5mg/kg Short Acting Continue 0.75mg/kg X 2 Maximum Bolus Dose = 3mg/kg If Maximum Reached Infusion 1-4mg/min Alternative Amiodarone With Pulse 150mg Over 10 Minutes No Pulse 300mg IV Push 13

14 CAN YOU HAVE A P WAVE BEFORE A WIDE COMPLEX QRS???? Yes!! RIGHT/LEFT BUNDLE BRANCH BLOCK Another Wide Complex Rhythm Electrical Conduction System - RBBB Electrical Conduction System - LBBB LBBB WPW Wolf-Parkinson-White 14

15 Accessory Pathway with Ventricular Preexcitation- WPW Varying Degrees of Ventricular Preexcitation Sinus beat AP Hybrid QRS shape Fusion activation of the ventricles AND.. THE ULTIMATE VENTRICULAR RHYTHM 15

16 LASTLY, WHAT ABOUT MI? CHEST PAIN Is It Angina Pectoris Or Myocardial Infarction???? Or Something Else??? Chest Pain - Angina Pectoris Increased O 2 Demand Relative To Supply Usually Exertional Angina Pectoris Usually Resolves in Minutes With Rest or After Sublingual Nitroglycerin (NTG) Types of Angina Stable Angina Unstable Angina Vasospastic (Prinzmetal s) Angina Chest Pain - Acute MI Decreased O 2 Supply to Myocardium Chest Pain at Rest Chest Pain Lasts Longer Than Angina Crushing CP, Sense of Impending Doom CO -Lightheadedness, Diaphoretic, Nausea, SOB, Weakness, Cool Skin Ashen, Gray Color, Cyanosis, Arrhythmias No Response to NTG 16

17 Under Sedation/GA?? Evidence of Myocardial Ischemia? Downgoing ST Segment Under Sedation/GA?? Evidence of Myocardial Infarction? Elevated ST Segment Under Sedation/GA?? Onset of New Major Cardiac Dysrhytmias? Heart Blocks, Especially Advanced PVCs Runs of V-Tach Unexplained Sinus Tachycardia OR Bradycadia Pulseless Rhythms Chest Pain - Treatment If + History of Angina & Pain Typical Position to Comfort Vital Signs Yes NTG mg Q 5 Min Sublingual Spray or Tablet X 2 to Decrease O 2 Demand Caution: Phosphodiesterase 5 Inhibitors Supplemental O 2 Resolution?? Continue Treatment No Resolution Activate EMS, Possible MI NTG Again, BLS If Needed Chest Pain - Treatment No Hx of Angina or Atypical Chest Pain BLS, Vital Signs, Loosen Clothing Activate EMS - Assume MI Consider Trendelenberg if BP Treatment Morphine (N 2 O/O 2?) Oxygen How Much??? Nitroglycerin sublingual (BP > 90 mmhg) Aspirin mg Chewable If Sedation/GA Wake Up Patient 17

18 THANK YOU Questions???? 18