CARDIAC EMERGENCIESAndrew Crouch DO PGY-2

Question• A 12-year-old boy is brought to the ED after being struck

in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition?

• A Asystole• B Ventricular Tachycardia• C Ventricular Fibrillation • D PEA• E. SVT

Answer C (V-Fib)• Commotio cordis

• occurs when an object such as a baseball strikes the chest and produces sudden death. It most commonly occurs in children between 5 and 15 years of age with no known predisposing cardiac conditions.

Ischemic Heart Disease

• Leading cause of Death in USA• 30% all deaths

• Etiology • Insufficient blood supply

to myocardium

• Risk factors • Family history, smoking,

hypertension, diabetes,• cholesterol, male >55

years old

• Global Hypotension• Fixed Lesion

• Atherosclerosis• Stable Angina

• Vasospasm• Prinzmetal angina• Drug induced

• Ruptured Plaque• Leads to formation of clot• ACS

Coronary Anatomy• Left Main Coronary

• LAD• Widowmaker • Anteroseptal

• Left Circumflex• Anterolateral (if left dominant posterior)

• Right Coronary Artery• Right ventricle • Inferior• SA node

• Posterior descending artery• AV node• Lead to mitral regurgitation and bradycardia

TIMI Score

• > 65 years old• > = 3 cardiac risk factors

• Prior stenosis >50%• ST segment deviation• 2 anginal events in 24 hours

• Aspirin use within last 1 week

• Elevated CK

• (0-1) 4.7%(2) 8.3%

• (3) 13.2%• (4) 19.9%(5) 26.2%

• (6 to 7) 40.9% • Risk of death or MI• Note there is no 0% risk in this scale

Chest Pain

Atypical Chest Pain

• Women Diabetic and Elderly

• Fatique, nausea, epigastric pain, palpatations, chest wall pain, total body dolor

• Chest pain absent in 18% of Mis

• Account for 40-50% of cases

Typical Chest pain

• Crushing• Left chest • Radiate to left arm, jaw,

back• Diaphoresis

Signs of ACS • Vitals

• Tachycardia, Bradycardia (RCA) , hypertension, hypotension

• Cardiac Exam• New S3 or S4• New Murmur

• Papillary muscle dysfunction• Wall rupture

• Pulmonary crackles• New friction Rub

ECG• Initially abnormal in <50% of patients with ischemic chest

pain • Meaning often it is perfectly normal

T wave morphology changes• Hyperacute T waves

• Earliest sign • Prominent symmetrical, pointy

• T wave flattening or inversion • Can be due to a S#*% ton of things

ST segment Changes• ST Elevation

• Elevation >1mm in 2 contiguous leads

• ST depression • Measured from the PR segment to the ST segment • Depression >1mm in 2 leads

• New Bundle Branch Block or AV block• ST changes associated with increased mortality

QRS

Sgarbossa's criteria• Three criteria are included in

Sgarbossa's criteria:• ST elevation ≥1 mm in a lead

with a positive QRS complex (ie: concordance) - 5 points

• ST depression ≥1 mm in lead V1, V2, or V3 - 3 points

• ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex - 2 points

• ≥3 points = 90% specificity of STEMI (sensitivity of 36%)

Arrhythmias of ACS• Bradycardia

• SA or AV node involvement

• Tachycardia• Reperfusion, autonomic tone, hemodynamic instability

• V Fib• Indication for immediate cath • if not at ARMC

• Accelerated Idioventicular Rhythms• Associated with reperfusion, Resemble V Tach with rate of 50-100

bpm• DO NOT USE Antiarrhythmics such as lidocaine

AnteroSeptal MI• Septal

• ST elevations in V1 and V2

• Anterior • ST Elevations in V3 and V4• LAD occlusion • High grade Heart Blocks

A little harder

Lateral Wall MI• ST elevations in I, aVL, V5 and V6• Left Circumflex artery

Too Easy

Inferior • Inferior

• ST elevations in II, III, aVF• Primary RCA occlusion• AV dysfunction

• Up to 25% have right ventricular infarction• Do not give Nitro

Right sided ECG

• ST elevations in V4R and V5R are diagnostic of Right ventricular infarct

WTF?

Posterior • Large R waves & ST

depressions in V1 and V2

ECG changes correlate to Pathology

• ST changes in V1-4• V4-6, I, aVL• I & aVL• II, II, aVF• II, III, aVF & V5-6• Small R waves V1-2• Depression II, III, aVF with ST elevation rV4

• Anteroseptal• Anterolateral• Lateral• Inferior• Inferolateral• Posterior• Right Ventricular

ECGs are not perfect • Normal ECGs are seen in

• 1-5% of Acute MI• 4-23% of UA

• Non diagnositic ECGs• 4-7% of Acute MI • 21-48% of UA

• New ischemic changes• 25-73% of Acute MI• 14-34% of UA

Cardiac Enzymes • Troponin

• Specific for Cardiac injury (Tt 94% and Ti 100%)• Positive 2 to 6hours and remain elevated foer up to 1 week• PE, Pericarditis, CHF, Shock, Renal failure, Remember it is a sign

of injury not infarction

• CK-MB• Positive 3 to 8 hours less specific than troponin• Useful for reinfarction due to shorter half life

Testing

• ECHO• Regional wall

abnormality• Poor correlation

• Treadmill testing• Sensitivity 65% to 70%• Specificity 70 to 75%

• Stress ECHO• 80-85% sensitivity• 80-85% Specificty

• Dobutamine Stress ECHO• 80-85% sensitivity • 85-90% Specificty

• SPECT• Nuclear imaging• 80-90% Sensitivity• 80-90% specificity

Treatment ACS

• Oxygen• Antiplatelet

• ASA 162 to 325mg, should be chewed• Do not use if possibly Aortic

Dissection

• Plavix, Clopidogrel• Can be given in addition to or

instead aspirin

• Nitroglycerin • Smooth Muscle Dilator• Dilate coronary arteries

• Reduces preload and afterload

• Do not give if taking viagra or if right ventricular infarction

• Morphine• Block catacholamine surge• Reduce preload and afterload

because of histamine response• Caution if right ventricular

infarction or hypotensive

• Beta Blockers• Use since COMMIT Trial • Decrease ventricular

Arrhythmias in stable patients • Do not give if Meth or cocaine

usage • Use with caution if asthma,

hypotension, bradycardia

Anti Thrombotics

• Heparin • Activates Antithrombin III• Bolus 60-70 U/kg • Then infuse 12-15 U/kg

• Low Molecular weight heparin • 16% relative risk

reduction but increase risk bleed

• Bivilirudin• Direct thrombin inhibitor • Useful if planning PTCA• Use if patient has HIT

• GP IIB IIIA inhibitor

Thrombolysis• Indicated if • ST Elevations >1mm in 2 contiguous limb leads• ST Elevation >2mm in 2 contiguous Chest Leads• New LBBB• High Suspicion for MR with pre-existing LBBB• Reciprocal ST segment depression V1 –V3 and posterior

wall infarction

Thrombolysis

Absolute Contraindication

• Aortic Dissection• Active GI bleed or internal

Bleed• Brain tumor, Bleed or AV

fistula• Closed head trauma or

facial trauma within 3 months

• Allergy

Relative Contraindication

• Chronic Hypertension• BP >180/110• Ischemic Stroke in last 3

months • Major surgery within 3 weeks• Internal bleeding 2-4 weeks

ago• Noncompresable vascular

punctures• Peptic Ulcer• Current use of anticoagulants

Question• Which of the following AV nodal blocks is most commonly

associated with an acute inferior wall myocardial infarction?

• A First degree• B Third degree • C Type I second degree• D Type II second degree

Answer C• Type I

• Type II more likely with anterior not inferior MI

PCI• Gold Standard

• Door to Balloon <90 Min• Presentation > 3hours

• Thrombolysis should be performed over PCI if prolonged time to cath lab or no capability

Question

• A 62-year-old man presents to the ED with a mild cough and URI symptoms. He was discharged from the hospital 2 weeks ago after undergoing percutaneous intervention for an acute myocardial infarction. You obtain an ECG (seen above) and compare the current ECG to the ECG obtained when he was admitted 2 weeks ago. You note that the morphologies are similar. Which of the following is the most likely diagnosis?

• A Pericarditis• B Postmyocardial infarction syndrome C Pulmonary embolism

D Ventricular aneurysm

Congestive Heart Failure • 3.4 million ED visits per year• 70-80% of patients with CHF die within 8 years• Left vs Right • High output vs low output

• High output due to metabolic demand (Hyperthyroid, beriberi, AV fistula, Pagets disease, Anemia, Pregnancy)

• Low output (Decreased Ejection Fraction)

• Systolic vs Diastolic • Systolic

• Poor Contractility of left ventricle • Ejection fraction on ECHO < 40%

• Diastolic• Poor Compliance • Systolic function preserved • 20-50% of patients with heart failure

Left vs Right

Right Heart failure

• JVD• Dependent Edema• Liver congestion

(hepatojuglar reflex)• Causes

• Left sided heart failure #1 cause

• MR, COPD, Pulmonary Stenosis

• Cardiomyopathy

Left Sided Heart failure

• Pulmonary Edema• Orthopnea• Paroxysmal noctural

dyspnea• Causes

• Systemic HTN• AS/AR• Cardiomyopathy• MI

Pathophysiology

Hemodynamic Model

• Left Ventriclar pressure increases leading to high end diastolic filling pressure

• Leads to Pulmonary congestion

Neurohormonal Model

• Inadequate end-organ perfusion

• Increased sympathetic nervous system and renin-angiotensin-aldosterone axis

• Vasoconstriction/ fluid retention

• Increasing afterload• Increasing workload

New York Heart Association (NYHA)• Class I : No limitation• Class II : Slight limitation at high exertion• Class III: Marked Limitation with no symptoms at rest• Class IV : Symptoms at Rest

Symptoms• Exertional Dyspnea• Orhtopnea• Dimished Pulse pRessure• Pulsus Alterans• Bilateral Rales• Pitting Edema• Hepatomegally• Acities• JVD• S3 gallop• Loud P2

Diagnosis

• CXR• can show congestion• Cardiomegally• Kerly B Lines• Pleural effusion R>L• Interstitial Hilar infiltrates

(bat winging)• Cephalization

• BNP• <50pg/ml negative

predictive value 98%• >100 pg/ml has 83%

sensitivity

• ECHO• EF > 40% • High EF with thick walls• Valvular abnormalities

Kerley B lines

Bat Wigging out

Sorry… Bat winging

Management

• Oxygen• CPAP and BIPAP

• Decrease work of breathing

• Decreased mortality • Contraindicated if

Altered

• Intubation • When all else fails tube

them

• Preload reduction• Diuretics

• Furosemide • Bumex

• Morphine• Decrease Pulmonary

congestion by vasodilation

• Nitrates • Can be given sublingual or

as gtt• Doses as high as 2mg IV

every 3 minutes can be given

Management

• Afterload reduction• Nitates

• NTG• Nitroprusside

• ACE inhibitors and ARBS• Decrease afterload and

increase renal perfusion

• Inotropic agents (can increase contractility but at a price)• Dobutamine

• Beta agonist

• Amrinone and Milrinone• Phosphodiesterase

inhibitors

Intraaortic Balloon pump

Dilated Cardiomyopathy

Causes

• Infection• Idiopathic• Familial diseases

• (Pompe’s Disease)

• Pregnancy • Sarcoidosis• Muscular dystrophy • Hypothyroidism• Chronic low phosphate or calcium• Meth or Cocaine• Chronic Alcohol usage• Heavy metal toxicity

ECG

• Similar to congestive heart failure • Mural thrombus formation

• Can embolize

• Syncope• Death

Symptoms

• A fib• Poor R wave progression• Blocks• Large P waves

– In lead II• Double hump = Left atrial• Peaked Right Atrial

Dilated Cardiomyopathy • In the US Viral illness is the most common cause • World Wide the most common cause is Protozoan,

Trypanosoma Cruzi “Chagas Disease”

Hypertrophic cardiomyopathy• Asymetrical Septal Hypertorphy • Hypertrophic Obstructive cardiomyopathy• Idiopathic Subaortic Stenosis

Epidemiology• Common Cause death in young athletes• Mortality 4% if untreated • Autosomal Dominant • Mutation leading to dysfunctional cardiac sarcomere

production• Leads to Diastolic dysfunction

Diagnosis • Murmur

• Harsh Systolic Murmur • Increase with Valsalva, Amyl nitrate• Decrease with Squatingm Leg raise, hand grip, beta blocker

• ECG• LVH• Q waves in inferior or lateral leads

• ECHO• Septum thicker than wall• Systolic anterior motion of mitral valve

Management • Beta Blockers• Verapamil• Disopyramide (Class Ia anti-arrhythmic)• NO Diuretics• AICD• Pacemaker• Septal Ablation• Myomectomy

Pericardial Tamponade• Fluid in pericardial space• Normal 15-30ml effusions

can get >1L if occur slowly but in cases of rapid expansion there will be myocardial compression

Tamponade• Becks triad

• Hypotension• JVD• Distant heart sounds

• Kussmal sign• Paradoxical jugular venous distention with inspiration

• Pulsus paradoxus• Decrease systolic blood pressure >10mmHg with inspiration• Also seen with PE, COPD

Electrical Alternans

Treatment• Fluids• Pressors• If hemodynamic compromise do pericardiocentsis • Pericardial window is definitive treatment

Pericarditis• Idiopathic #1 Cause • Infectious

• Viral• Bacterial • Tuberculosis • Fungal

• Malignancy • Drug-induced (procainamide) • Miscellaneous: connective tissue disease or • autoimmune • Uremia• Postradiation• Dressler syndrome• Myxedema

Diagnosis

• Blood• CBC

• Elevated WBC could point to infection

• BUN • Uremia

• Serology• Rheumatoid arthritis and lupus

• TSH• Thyroid disease

• Cardiac Enzymes• Dressler Syndrome

• CXR• Bottle Shaped heart

• ECHO• CT or MRI

• ECG (4 Satges)• Stage I

• PR Depression (II, aVF, V4-V6)

• Diffuse ST Elevation • PR elevation aVR

• Stage II• Flattening of ST wave

• Stage III• Inverted T waves

• Stage IV • Normal

Treatment • #1 treat underlying cause if can be found

• Viral or Idiopathic Pericarditis • NSAIDs

• Bacterial• Antibiotics and drainage if purulent

• 100% mortality without treatment

• TB• INH, Rifampin, Ethanbutol, Pyrazinamide

• Dressler’s Syndrome• ASA (avoid NSAID)

• Autoimmune• Steroids + NSAID