CARDIOLOGY EMERGENCIES ON CALL DR. ALI ROOMI CARDIOLOGY ST3 23RD JULY 2016
+ OBJECTIVES Diagnosis and management of ACS When to liaise with tertiary centre Complications of ACS Tachyarrhythmias Bradyarrhythmias
+ WHAT TO DO WHEN YOUR BLEEP GOES OFF? Stay calm! Clarify patient observations with nursing staff Prioritise tasks Interim management? ABCDE review Peri-arrest?
+ SCENARIO 1 Bleeped at 1am by nursing staff 63M, admitted 2/7 diabetic foot infection On IV antibiotics, awaiting surgical debridement Patient is complaining of chest pain Afebrile, HR 74, BP 159/81, RR 18, sats 95% RA
+ WHAT WILL YOU DO? 1. Stop what you re doing and urgently review the patient 2. Advise nursing staff to administer simple analgesia - day team to review in the morning 3. Request a 12 lead ECG whilst you make you way to the ward 4. Put out a peri-arrest call Answer: 3
Lateral TWI + ECG 1
+ HISTORY Cardiovascular risk factors? Sudden onset? Heavy/tight? Any radiation - jaw/arm? Associated symptoms? SOB? Diaphoresis? Ongoing pain?
+?LATERAL NSTEMI Dynamic changes? Serial ECGs!! Compare to admission ECG Known IHD? Previous intervention? hstroponin 0 and 6 hrs
+ INITIAL MANAGEMENT GTN spray IV/oral morphine Aspirin 300 mg + Clopidogrel 300 mg Fondaparinux 2.5 mg
+ ADDITIONAL MANAGEMENT Beta blocker/acei/statin - can normally wait till morning BM monitoring +/- sliding scale (dry) GRACE score FBC, U&E, coagulation screen, CXR GRACE score - predictor of in-hospital and 6-month mortality
+ WHAT NEXT? Re-review Ongoing chest pain - GTN infusion, repeat ECG Stable - handover to morning team/cardiology
When to refer to tertiary centre?
+ CONSIDER IF Pain refractory to GTN infusion High risk NSTEMI STEMI Cardiogenic shock
Wellen Syndrome - prox LAD disease + ECG 2
Wellen Syndrome - biphasic T waves + ECG 3
Benign early repolarisation + ECG 4
+ ECG 5 LMS/ostial LAD disease STE avr
+ ECG 6 Pericarditis Concave STE PR depression ST depression avr
+ ECG 7 PE Sinus tachycardia RBBB RAD S1 Q3 T3
+ ECG 8 Hyperacute anterior STEMI Q waves anteriorly Peaked T waves Reciprocal ST depression III
Evolving anterior STEMI + ECG 9
+ PATIENT IS NOW BREATHLESS Afebrile, HR 110, BP 161/93, RR 29, sats 89% 15L Diaphoretic ABG: ph 7.43, pco2 5.3, po2 8.2, BE -1.3, Lac 1.7 ECG unchanged Diffuse coarse crackles and wheeze
+ CXR
+ IMMEDIATE NEXT MANAGEMENT? 1. 2.5 mg salbutamol nebuliser 2. 5 mg metoprolol IV 3. GTN infusion 4. IV furosemide 40 mg Avoid beta blockers in acute pulmonary oedema Answer: 3
+ PULMONARY OEDEMA GTN Infusion - titrate to SBP (aim > 110 mmhg) IV morphine IV furosemide 40-80 mg High flow O2/CPAP/optiflow Catheterise Senior help!
+ PATIENT IS NOW LIGHTHEADED Afebrile, HR 200, BP 103/50, RR 21, sats 93% RA Denies any chest pain GCS 15
Monomorphic VT + EGG 10
+ IMMEDIATE NEXT MANAGEMENT? 1. Synchronised DC Cardioversion 2. Adenosine 12 mg IV 3. Metoprolol 10 mg IV 4. Amiodarone 300 mg IV Answer: 4
+ VENTRICULAR TACHYCARDIA Any signs of compromise? Synchronised DCCV Chest pain Shock Heart Failure Syncope Stable? IV Amiodarone 300 mg
+ SCENARIO 2 77F Known COPD admitted with infective exacerbation Not on any home nebs/ltot Afebrile, HR 180, BP 103/60, RR 24, sats 93% 2L O2 WCC 16, CRP 140, Cr 145 (baseline 93), Troponin 68
AF with RVR + ECG 11
+ IMMEDIATE NEXT MANAGEMENT? 1. Metoprolol 10 mg IV 2. Amiodarone 300 mg IV 3. Adenosine 12 mg IV 4. Synchronised DCCV Answer: 1
+ ATRIAL FIBRILLATION Paroxysmal/persistent/permanent Acute onset? IV Amiodarone 300 mg Duration unknown? Stable BP? Labile BP? Beta blocker Calcium channel blocker Digoxin Compromised? Synchronised DCCV Caveat - digoxin not useful in the longterm with paroxysmal AF or non-sedentary patients
Warfarin/NOAC - if CHADSVASc > 1 + ANTICOAGULATION
+ SCENARIO 3 42M Sudden onset palpitations and chest pain No CVRF Afebrile, HR 230, BP 131/82, RR 19, sats 97% RA Troponin 37
+ ECG 12 SVT - likely AVRT/AVNRT. No discernible p waves
+ IMMEDIATE NEXT MANAGEMENT? 1. Synchronised DC Cardioversion 2. Amiodarone 300 mg IV 3. Adenosine 12 mg IV 4. Metoprolol 10 mg IV Answer: 3
+ ECG 13 Pre-excitation Delta waves Short PR interval Orthodromic AVRT (because narrow complex QRS during SVT phase)
+ ECG 14 SVT with ventricular rate 250-300?Atrial Flutter with 1:1 block?avrt/avnrt
+ ADENOSINE
+ TACHYCARDIA ALGORITHM Adult Tachycardia (with pulse) Algorithm Assess using the ABCDE approach Monitor SpO2 and give oxygen if hypoxic Monitor ECG and BP, and record 12-lead ECG Obtain IV access Identify and treat reversible causes (e.g. electrolyte abnormalities) Synchronised DC Shock* Up to 3 attempts Yes - Unstable Adverse features? Shock Myocardial ischaemia Syncope Heart failure Seek expert help Amiodarone 300 mg IV over 10-20 min Repeat shock Then give amiodarone 900 mg over 24 h! No - Stable Is QRS narrow (< 0.12 s)? Broad Narrow Broad QRS Is QRS regular? Regular Narrow QRS Is rhythm regular? Irregular Irregular Seek expert help Possibilities include: AF with bundle branch block treat as for narrow complex Pre-excited AF consider amiodarone! Regular If VT (or uncertain rhythm): Amiodarone 300 mg IV over 20-60 min then 900 mg over 24 h If known to be SVT with bundle branch block: Treat as for regular narrowcomplex tachycardia Vagal manoeuvres Adenosine 6 mg rapid IV bolus if no effect give 12 mg if no effect give further 12 mg Monitor/record ECG continuously Sinus rhythm achieved? Yes No Probable re-entry paroxysmal SVT: Record 12-lead ECG in sinus rhythm If SVT recurs treat again and consider anti-arrhythmic prophylaxis Probable AF: Control rate with beta-blocker or diltiazem If in heart failure consider digoxin or amiodarone Assess thromboembolic risk and consider anticoagulation Seek expert help! Possible atrial flutter: Control rate (e.g. with beta-blocker) *Conscious patients require sedation or general anaesthesia for cardioversion
+ SCENARIO 4 83F Admitted with 5/7 dizziness and syncope HTN, T2DM, OA, prev R NOF # Afebrile, HR 42, BP 161/75, RR 17, sats 96% RA Currently denies any presyncope
+ ECG 15 Complete Heart Block Junctional escape - 42 bpm
+ IMMEDIATE NEXT MANAGEMENT? 1. Synchronised DC Cardioversion 2. Transcutaneous pacing 3. Atropine 500 mcg IV 4. Monitored bed and observe Answer: 4
+ ECG 16 Complete Heart Block Broad complex ventricular escape - rate 27 bpm High risk of asystole
+ BRADYCARDIA ALGORITHM Adult Bradycardia Algorithm Assess using the ABCDE approach Monitor SpO2 and give oxygen if hypoxic Monitor ECG and BP, and record 12-lead ECG Obtain IV access Identify and treat reversible causes (e.g. electrolyte abnormalities) Shock Syncope Yes Adverse features? Myocardial ischaemia Heart failure No Atropine 500 mcg IV Satisfactory response? No Yes Consider interim measures: Atropine 500 mcg IV repeat to maximum of 3 mg OR Transcutaneous pacing OR Isoprenaline 5 mcg min -1 IV Adrenaline 2-10 mcg min -1 IV Alternative drugs* Seek expert help Arrange transvenous pacing! Yes Risk of asystole? Recent asystole Mobitz II AV block Complete heart block with broad QRS Ventricular pause > 3 s No Continue observation * Alternatives include: Aminophylline Dopamine Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker) Glycopyrrolate (may be used instead of atropine)
+ CONCLUSION Stay calm! ABCDE If in doubt, seek senior help Enjoy yourselves!
+ REFERENCES www.lifeinthefastlane.com www.resus.org.uk www.chadsvasc.org
Questions?