Complications of Acute MI‘My patient just had an MI, what do I need to worry about?’

Adam WatchornOct 6 2011

THANKS TO IAN RIGBY

Arrhythmias

Cooling

Shock

55FCP 3hr duration

Afebrile9586/4894% 2L NP

Diaphoretic & PaleCool extremitiesJVP normal

1) LYTICS or transfer to Cath lab (Rockyview)?

2) LYTICS or transfer to Cath lab (Golden)?

3) What PRESSOR would you use and why? What dose would you start at?

My hospital has PCI• Easy choice: PCI > LYTICS (6-month mortality benefit)

My hospital does NOT have PCI• Tough choice: Risk vs. Benefits of LYTICS?

Cardiogenic Shock SubsetN=280

Mortality 28 day• Dopamine 52%• Norepinephrine 48.6% P = 0.03

Arrhythmic Events• Dopamine 24%• Norepinephrine 12% P < 0.001

How would you INTUBATE ?

• Awake vs. RSI?• Induction agent and dose?• Paralytic agent and dose?• How would you prepare?

CHANGE IT UP A LITTLE

Same Patient86/485096% 2L NP

What’s Your DDx?

1L FluidsAcute CHFMurmur

Papillary Muscle Rupture (MR)

7% of CSInferior – Posterior2-7d (can be acute)Acute Pulmonary Edema> 50% Mortality

Septal Rupture4% of CSAnterior-Lateral1dSudden badnessHolosystolic murmurMortality > 80%

Free Wall Rupture

1.4%Anterior1dPericardial effusion/Tamponade> 86% Mortality

Case Summary

• Normal ECG excludes Cardiogenic Shock• Center without PCI = Lytics on case by case

basis• NE > Dopamine (MAP 65) • Reduce Induction doses / Pressors on board

58M2 hr CP after hockey gameFeels like old MI 2 years agoPMHx: Ischemic cardiomyopathy (EF = 30), DM, GERDMeds: ASA, Metoprolol, ACEI, Statin, Pantoprazole

110 NSR172/9298% 2L NP

Would you give LYTICS?(No old ECGs)

Bottom Line (non-sustained VT, PVCs, AIVR)

Very Common (>50%)

Does not lead to worse outcomes (VF/Mortality)

No role for prophylactic treatment

Palpable pulse. Ischemic pain returns.175130/82

What would you use to prevent another episode of VT or VF?

1) Amiodarone 150 mg IV over 10 min

2) Metoprolol 5 mg IV

3) Lidocaine 40 mg IV

Arrhythmias associated with higher Mortality(CO = SV + HR)

Any Tachycardia (TOO FAST)• Sinus Tachy• SVT• AF• VT• VF

Blocks (TOO SLOW) • 2nd AV Block Mobitz II• Complete

BOTTOM LINEFix the arrhythmia to maintain adequate CO

Develops another run of sustained VTIschemic pain returns and he becomes altered

205, 172/76, 96% 4L NP

100J

200J

200JAmiodarone

360JMg

STILL in VT: What’s your next step?

1) Shock him again at 360J

2) Repeat Amiodarone 150 mg

3) Consult Electrophysiologist

4) Amiodarone 150 mg + Metoprolol 5 mg

5) Procainamide 1000 mg

BETA BLOCKER

Case Summary

• Common• Benign: non-sustained VT, PVC, AIVR• Bad: Tachy and Brady• Ventricular storm = Add a little Metoprolol to

your Amiodarone

All right stop collaborate and listenIce is back with my brand new inventionSomething grabs a hold of me tightlyFlow like a harpoon daily and nightlyWill it ever stop yo I don’t know

Robert Matthew Van Winkle aka Vanilla Ice, 1989

43M White Rapper

According to witnesses: ‘CP then collapsed‘

No pulse

CPR by groupies at scene

Rushed to FMC

PEA

ROSC after 35 min. Still Unresponsive

Who should I consider for cooling?

1) 43M witnessed arrest, PEA, CPR immediately, ROSC 35 min, unresponsive

2) 70M witnessed pulseless VT arrest after MVA, ROSC 25 minutes, unresponsive

3) 55M witnessed arrest VF, ROSC 25min, CPR within 5 min, uncontrolled VT, cardiogenic shock, unresponsive

Indications for Cooling

• Witnessed arrest & patient remains unresponsive• CPR within 15 min• ROSC < 60 min

HACA 2002NNT 6

What about PEA & Asystole?

ROSC > 25 min only 3% survive

Studies show: PEA/Asystole associated with longer ROSC (32 min versus 20 min)

Bottom Line: We need larger studies but for now talk to ICU/CCU

Absolute Contraindications

• Responds to verbal commands after ROSC• Initial Temp < 30 on admission• Comatose prior to arrest• Pregnant• Coagulopathic

Fastest method for cooling?

NS Fridge30ml/kg (2L)Pressure Bag1C with every 1L

ICEAxilla and Groin

Goal1) Start ASAP2) 33C in 6 hours

Shivering

• Fentanyl 50 mcg bolus then infusion AND/OR

• Midazolam 2-5 mg bolus then infusion

• Roc 0.6 mg/kg then 0.2 mg/kg PRN

How do we monitor in ED?

• MAP > 65• Temperature = Esophageal probe (EMcrit)• VS q15min• Glucose q1h• ABG q2h• Lytes q6h

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