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Matters of the HeartMatters of the Heart

Troy W. Pennington DO, MSHPE, FAAEMEMS Director- ARMC, SBCFD, Mercy Air,

BFD

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WHY HOLD THE LASIX?

AMR 713 Victorville

85 y/o male SOB x 1 day

3-4 word dyspnea

Warm to touch

Cough

Pedal edema

Sats 89% …stach 120…RR 28

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Acute SOB

66 y/o man presents with acute sob developing over the last 8 hours

History of HTN, and tobacco use

Diaphoretic, normal mental status

Afebrile, HR 110, BP 180/110, RR30, pulse ox. 86%

Lungs crackles, JVD, pedal edema

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Acute SOB

What is the optimal treatment in the next 5-10 minutes?

A. morphine

B. Lasix

C. Morphine + lasix

D. Ntg + (morphine +- Lasix)

E. Nesertide + (morphine + Lasix)

F. None of the above

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Acute SOB

What is the optimal treatment in the next 5-10 minutes?

A. Nice try :0

B. Nope

C. Better luck next Time!

D. Sounded Good didn’t it

E. Maybe you consider another career choice

F. Ahh YES! None of the above

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Acute Pulmonary Edema

Preload…tries to fill lungs

LV Function…emptys heart

Afterload…size of hose to empty heart

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Acute Pulmonary Edema

What do you do if the Bathtub is overflowing?

Turn off water….Preload

Pump it out…LV Function

Drain it….Afterload

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Preload Reduction

MS

Lasix

Nitrates

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Morphine as Preload Reducer

Disadvantges

May increase catecholimines

Respiratory depression

Direct myocardial depressant…decreased SV

No good evidence that it is a central preload reducer

Trunk Monkeyand Dating

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Morphine Swan Studies

Preload increased

Worsening cardiac index

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Lasix

Increased catecholine output… activates renin..angiotensin system early on

Dieuresis is delayed…at least 90 minutes

Decrease stroke volume and cardiac output drop

Increases afterload

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Nitroglyercin

Better than morphine or lasix for preload reduction

Safer than morphine or lasix

Rapid effective iniation of treatment

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NitroglyercinHow do our treatments Stack up?

What do you normally start a Nitro Drip at?

10-40mcg/kg/min

How much NTG is in one sl tablet

0.4mg = 400 micrograms nitro

How much ntg is in 1” nitro Paste

20 micrograms

Safer than morphine or lasix

Rapid effective iniation of treatment

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Ace Inhibitors

Reduces afterload & some preload benefits

Works within 15 minutes

Decreases intubation and ICU admission rates

Combined ith NTG exceeds benefit of either alone

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WHY HOLD THE LASIX?

Top Articles in 2006

Evaluation of Prehospital use of Furosemide in patients with Respiratory Distress

Use of Lasix prior to adequate preload and afterload reduction can be harmful

Jaronik J. Mikkelson P, Fales W, et al. Prehosp Emerg Care 2006; 10:194-197

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WHY HOLD THE LASIX?

Lasix given improperly up to 30% of the time

Patients that received lasix and/or morphine had increased mortality 2.2 to 22%

Use of NTG not associated with worse outcome even if given inappropriately

Wuerz (Ann Emerg Med 1992)

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What about CPAP or BIPAP?

Non-Invasive Positive Pressure Ventilation

In an Austrialian meta-analysis 23 trials were reviewed

They found that when either CPAP or BiPAP were used there was decreased mortality

Decreased need for mechanical ventilation

Peter JV, Moran JL, Phillips-Hughes J, et al. Lancet 2006;367:1155-1163

Trunk Monkeyand ticket advice

What am I?

• Giant cell arteritis is a cause in the young

• Most patients that have it are old with long-standing hypertension

He died from this

This is what I Look Like

• I am seen in up to 44% of patients with Marfan sydrome which represent 5% of all cases of this condition

• Congential bicuspid aortic valve is seen in about 14% of the cases

Answer: Aortic Dissection

• John Ritter- You might know him as: Jack Tripper from Three's Company ,

• Born September 17, 1948 in Burbank, CA Died: September 11, 2003 in Burbank, CA

• Cause of Death: Undetected tear in his aorta

(Aortic Dissection)

• Henry Winkler on John's passing: It is like there is a big tear in the heart of the world.

Who Am I?

Jonathan Larson

• American Composer & Playwright

• Died Jan. 1996

• The night before the opening of RENT

He had presented to the ED twice in the week before his

death

The most effective medication to lower blood pressure in a patient with an aortic dissection is:

• A. Fentanyl

• B. Labetalol

• C. Metoprolol

• D. Nitroglycerin

• E. Sodium nitroprusside

Answer: E

•The most specific diagnostic test that can be obtained most rapidly for an emergency department patient to make the diagnosis of aortic dissection is?

•A. 12 lead ECG

•B. Aortic angiography

•C. Helical CT chest scan

•D. Portable chest x-ray

•E. Transesophageal echocardiography

Answer:

C- Helical CT chest scan

Imaging

Ct with contrast is Ideal (can try without if unstable or renal insuffiency)

TEEAngiography

No longer gold standard- only looks at changes atInside lumen…CT is better

• Chest Pain + Old + HTN

• Chest Pain + Marfan’s

• Chest Pain + Bicuspid Aortic valve

• Chest Pain + Tearing / Back Pain

• Chest Pain + Gi Symptoms

• Chest Pain + African American

• Chest Pain + Very Tall

• Chest Pain + Aortic Regurgitation

• Chest Pain + Collagen Vascular Disease

• Chest Trauma

• Chest Pain + Unequal Pulses

• =Aortic Dissection

Always Consider Aortic Dissection

Recognizing Aortic Dissection

Trunk Monkeypediatrics edition

CXR How Sensitive is it?

• In pooled Data From several recent studies CXR is on 67-70% sensitive for making the diagnosis of Dissection

CXR Classic Findings• Abnormal Mediastinum

• Too wide or funny looking

• L pleural Effusion

• Calcification of the internal rim of the aorta (5-10mm of soft tissue beyond calcification)

CXR Dissection

CXR Dissection

CXR Dissection

EKG

• Non-discriminatory

• Rare- but a Aortic dissection that presents with MI most commonly presents with dissection into R coronary will show inferior st elevation

• Only 1/100 dissections present with STEMI

Incidence

• 5-30 cases per 1 million people

• Much Less common than ACS but more common the AAA

• Somewhere between 100 to 1000 Mi’s for every dissection

Mortality increases 1-2% per hour if unrecognized

Always Think about the 6 Major causes of Chest

Pain Badness!• ACS: MI / Angina

• PE

• Aortic Dissection

• Boerhave’s (Esophageal Rupture)

• Tension Pneumothorax

• Pericardial Tamponade / Myocarditis

Risk Factors

• Male

• Hypertension

• Marfan’s, Ehler’s Danlos

• Cocaine

• Pregnancy

• Polycystic Kidney Disease

• Increasing Age

• Turners Syndrome

• Sleep Apnea

• Family History

Fast Facts About Dissection

• Difficult DX to make

• Delay of >24 hours occurred in 31% of proximal Dissection and 53% of distal dissections

• Frequently delays in dx for some = days

• Newer studies are showing we may miss >50% of dissections on initial visit

• Painless dissection: 15% had a painless presentation

(Mayo Clin Proc. 2002 Mar;77(3):296. )

Fast Facts• The most common site of dissection is

the first few centimeters of the ascending aorta, with 90% occurring within 10 centimeters of the aortic valve.

• The second most common site is just distal to the left subclavian artery. Between 5% and 10% of dissections do not have an obvious intimal tear

Atypical / Subtle Presentations

• Abdominal Pain

• An Aneurysm and dissection may coexist

• Abdominal pain + Chest Pain

• Be highly suspicious in pain above and below the diaphragm

• Isolated neurologic symptoms: altered, seizure, unable to move legs

• Chest Pain and Leg pain

D-dimer to r/o dissection?

• No well defined cut off

• Cut off for PE 500ng/dl 98% at 500

• For Dissection 100ng/dl sensitivity 100% r/o for dissection

• Does not r/o intramural hematoma

Atypical / Subtle Presentations

• Paralysis

• No pain and presents like spinal cord injury

• Compromise of spinal artery

• Syncope- IRAD Study (JAMA 2000;283:897-903)

• 13% of patients with aortic dissection had syncope as their only symptom

• Many with no CP/back pain/abdominal pain

Myth

• ALL Patients with Aortic

Dissection Look Ill

34 year old construction worker with sudden onset

back pain- discharged home with motrin

Tall 28 year old with Chest Pain as he is being

discharged the attending happens to ask have you had

any surgery before… prior eye surgery

There is a tear (arrow) located 7 cm above the aortic valve and proximal to the great vessels in this aorta with marked atherosclerosis. This is an aortic dissection.

Trunk Monkeychasing bad eggs

• This aorta has been opened longitudinally to reveal an area of fairly limited dissection that is organizing. The red-brown thrombus can be seen in on both sides of the section as it extends around the aorta. The intimal tear would have been at the left. This creates a "double lumen" to the aorta. This aorta shows severe atherosclerosis which, along with cystic medial necrosis and hypertension, is a risk factor for dissection.

• Stanford Type A / DeBakey Type II

Classification

• Stanford Type B / DeBakey III

Classification

Classification of Aortic Dissection

1. Classic with true and false lumens separated by intimal flap

2. Medial disruption with intramural hematoma or hemorrhage

3. Discrete/subtle aortic dissection bulge at tear site with no hematoma

4. Plaque rupture/penetrating aortic ulcer

5. Iatrogenic and traumatic dissection

Task force on aortic dissection, European Society of Cardiology, Eur Heart J 2001;22: 1642-81

Class 1: Classic dissection

Aortic Dissection

   Intramural Hematoma

In contrast to typical aortic dissection, in which there is an intimal tear, IMH is caused by a spontaneous hemorrhage of the vasa vasorum of the medial layer, which weakens the media without an intimal tear.

Clinical manifestations and the risk factors in IMH are similar to those in typical aortic dissection. IMH accounts for approximately 13% of the prevalence of acute aortic dissection .

Intramural Hematoma

Class 2: Intramural hematoma

Initial Medical Therapy

• Pain control: opiates

• Heart Rate control: Labetalol (bolus & maintenance) vs Titrate- Esmolol

• Heart Rate < 70

• BP control: Nipride (Target SBP< 110, DBP<70)

• Monitor hemodynamics, pulses

Trunk Monkeydelivers first aid

Intial Treatment Type A

Urgent surgical intervention is required in type A dissections

The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft

The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic

dissections

With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated

with this highly invasive surgery have decreased

Dissections involving the arch are more complicated that those involving only the ascending aorta because the innominate, carotid, and subclavian vessels

branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system

complications is less than 10%

Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable

alternative in high-risk patients in the near future

Initial Treatment of Type B Dissection

• Initial treatment: hypotensive medication

• Reserve intervention for 30-40% with:

• Rupture

• End-organ ischemia / malperfusion

• Localized false aneurysm

• Refractory hypertension

• Continuing pain

Initial Treatment of Type B Dissection

• Initial treatment: hypotensive medication

• Reserve intervention for 30-40% with:

• Rupture

• End-organ ischemia / malperfusion

• Localized false aneurysm

• Refractory hypertension

• Continuing pain

Mechanisms Involved in Aortic Dissection

Type B• Primary tear: usually close to the aortic

isthmus

• End-organ ischemia:

• Static obstruction from extension of dissection into side branches

• Dynamic obstruction from the intimal flap bowing into the true lumen

• Combination of static and dynamic obstruction

Prognosis

• Poor-1/3 of patients with h/o dissection will re-dissect, rupture or extend their dissection in the next 5 years

Trunk Monkeyencounters aliens

THANK YOU

Questions?

You can contact me at:

troypenn@aol.com

1-951-544-5433