Presentation on theme: "Cardiovascular Emergencies By Dr. Z. Samarrae FRCS, FICS,CABS, DS, MB CHB."— Presentation transcript:
Cardiovascular Emergencies By Dr. Z. Samarrae FRCS, FICS,CABS, DS, MB CHB
ACUTE CORONARY SYNDROMES ACS encompass the following Stable angina USA Myocardial infarction What is the basic pathology?
coronary occlusion Atherosclerosis- a plaque causing gradual narrowing rupture of the plaque- rough surfaces exposed-platelets adhere-clot formation- resulting in partial or complete occlusion So what is the sequence? Plaque narrowing-plaque rupture-clot Can u relate each one to ACS spectrum?
Coronary occlusion Plaque narrowing---stable angina Plaque rupture(sudden)—either USA or MI (sudden rupture leads to sudden change in pattern of symptoms. Symptoms, ECG,&enzymes changes can be correlated to above 2 pathlogies,can u?
Approach to the patient Listen,lissten,lisssten, lissssssssssssssten Active listening---- donot interrupt Listen to a story,not scattered bits.. err on the worst side: donot be fooled by: Patient is young She is female She is obese ---reflux oesophagitis He is labourer-----it is musculoskeletal Listen to the patient 1 st,then to relatives
Ischemia– visceral pain What does it mean? Diffuse(not submammary)-note how he used his hands. Nausea, vomiting, and dizziness---if present will add more to the suspicion Ask how severe pain is, but indirectly, donot be fooled by: mild pain in ….? Elderly, and diabetics. Continuos pain---unlikely to be ischemic, but good listening to story,not direct,how u ask?
Physical exam Usually normal..but look for complications LVF Arrythmia New murmurs---papillary muscle rupture ---VSD
ECG-what it can show? 50% diagnostic.in MI may see ST elevation In angina-may see ST كابة during pain It may show arrythmias (fast or slow) May see old ischemia, or LVH what type of MI ? Is it important ?..yes. How ? ليس العاقل من احتاط للامر اذا وقع ولكن العاقل من احتاط للامر حتى لا يقع MAY SEE NOTHING ABSOLUTELY NOTHING-normal ECG does not exclude ischemia وماذا بعد؟
Cardiac enzymes CK-MB,and the more specific Troponin They are normal in stable angina. May be elevated in USA & MI. If ECG showed MI, do I need Troponin? Those with +ve troponin do worse Again a normal enzymes does not exclude ischemia وماذا بعد ؟ Serial reading- mind time since pain onset Now ECG &enzymes are normal, والحين؟ Admit.
Other investigations LDH-not specific Hb Creatinine, sugar, lipids…PT, PTT.. Any need for CXR? To screen for alternative Dx.e.g dissection of aorta –wide mediastinum,how history can help? Onset &response
Treatment MONA Reperfusion (PCI & Thrombolytics) B- blockers—reduce infarct size ACE—stabilize the plaque. Be ready for complicationليس العاقل من احتاط للامر اذا وقع ولكن العاقل من احتاط للامر حتى لايقع What is MONA?
MONA A :150 A spirin N :SL GTN 3 times-consider then IV O 2 NASAL CANNULA 4 L If still pain – M orphin 2-4 q 5min titrate to response and side effects. Heparin
Reperfusion therapy PCI SUPERIOR TO THROMBOLYSIS But PCI need a cath lab, trained staff>75/y, and a high volume centre>200 /year. esp. useful in cardiogenic shock When thrombolytics are contraind or failed Door to balloon should be 90 min. Thrombolytics : door to needle 30 min, but best given within 3hrs, but can be given up to 12 hrs.
Thrombolytics Consider contraindication before Watch for any bleeding esp in elderly ECG indications for thrombolysis: ST elevationin 2 contiguos leads New BBB esp LBBB How much elevation? 1mm in standard leads, 2mm in chest leads. Long term secondary prevention
ARRYTHMIAS Fast rhythm---tachycardias(AF/Aflutter,VT) Slow rhythm---bradycar(sinus&AV blocks) Treat patient NOT the ECG, many arrythmias donot need treatment. Tachycardias <150 generally no Rx. How tachycar & bradycar give symptoms? Reduction of cardiac output. Dizziness, chest pain,weakness,exertional dyspnea
Management Fast rythm----slow it by drugs & electricity Slow rythm---push it by drugs & electricity what medicines for fast rhythm? depend on? Narrow or wide complex tachycardia. For narrow complex—CCB For wide complex tachycar----Amiodarone For unstable tachycardia---cardioversion
Management of slow rythm Atropine for sinus bradycardia Pacing for blocks-mobitz 2,complete block In emergency —percutaneous pacing Later on -----transvenous pacing Again treat patient not an ECG
Hypertensive emergencies HTN emergency—target organ damage HTN urgency-----no target organ damage HTN emergency---Bp reduced min-hrs HTN urgency Bp reduced in24-48hrs Marked reductions should be avoided.
Patient approach Place patient in a quiet room. Repeat Bp at the end of interview: 27% show reduction
Patient evaluation CNS: focality…papilloedema.altered level of conciosness…CT scan… Renal : creatinine, urine test: RBC, cast, protienuria..oliguria Remember : donot treat Bp reading only Drug screen Pregnancy tests
Treatment Labetolol ----steady drop in Bp, iv small boluses, or drip titrate to response---in encephalopathy reduce MAP by 25%only and diastolic should be between GTN ND choice Trimethaphan(ganglionic blocker) ---for aortic dissection
Conclusions Mind white coat HTN Determine target organ Damage Donot treat numbers Overzealous Bp reduction to be avoided Mind the false concept ---a patient should have a normal Bp before leaving ED.