الاسعافات القلبية الدكتور احمد جميل الغوطاني كلية الطب – جامعة دمشق فندق داما روز - دمشق الاثنين 29 شباط 2016

Cardiovascular Emergencies …time is myocardium!

Statistics CVD has been the leading cause of death for Americans since Sudden cardiac death accounts for over 40% of these deaths. The majority of our 911 responses are for chest pain.

Controllable Risk Factors Smoking High blood pressure Elevated cholesterol levels Elevated blood glucose levels Diet Lack of exercise Stress

Uncontrollable Risk Factors Age Family history Race Sex

All chest pain is considered to be an AMI until proven otherwise!

Coronary Arteries

8 Atherosclerosis: Build up of plaque in the arteries

9 Angina Pectoris “A choking in the chest” Myocardial oxygen demand exceeds supply during periods of increased activity, exercise, or stressful event The muscle becomes starved for oxygen, causing pain

Angina

Angina Pectoris Chest pain caused when heart tissues do not get enough oxygen for a brief period of time. Typically crushing or squeezing. Usually resolves with rest or meds. May be difficult to diagnose from AMI

12 Angina Pectoris Following an angina attack there is no residual damage to the myocardium

13 Symptoms -Angina Pectoris Pain – Retrosternal – Squeezing/Crushing/Heaviness – May radiate to arms, shoulders, jaw, upper back, upper abdomen – May be associated with shortness of breath, nausea, sweating

14 Symptoms -Angina Pectoris Pain seldom lasts > 30 minutes Pain relieved by – Rest – Nitroglycerin

15 Forms of Angina Pectoris Stable Angina – Occurs with exercise – Predictable – Relieved with rest or Nitroglycerin

16 Forms of Angina Pectoris Unstable Angina – More frequent/severe – Can occur during rest – May indicate impending MI – Requires immediate treatment and transport to appropriate facility

17 A cute M yocardial I nfarction (Heart Attack) - leading cause of death in U.S. 1.5 million Americans will have AMI’s this year – Of these.5 million will die! – 350,000 will die in first 2 hours!

AMI

19 Acute Myocardial Infarction “Heart Attack” Inadequate perfusion of myocardium – Death of myocardium Infarct – Damage to myocardium Ischemia

Acute Myocardial Infarct Usually caused by the same mechanism as angina only with resulting tissue death. Time is myocardium: Consequences can be serious: Congestive heart failure Cardiogenic shock Sudden death

21 Symptoms - AMI Chest Pain – Unrelieved by rest/nitroglycerin – Pain lasts longer than angina pain (up to 12 hours) – “Silent” MI 15% of patients with MI, particularly common in elderly and diabetics

22 Symptoms - AMI – 50% of deaths occur in first two hours – Average patient waits 3 hours before seeking help

23 Symptoms - AMI Shortness of breath Weakness, dizziness, syncope Nausea, vomiting Pallor and diaphoresis (heavy sweating)

24 Symptoms - AMI Chest Pain - cardinal sign of myocardial infarction – Occurs in 85% of MI’s – Retrosternal – “Crushing,” “squeezing,” “tight,” “heavy” – May radiate to arms, shoulders, jaw, upper back, upper abdomen – May vary in intensity

Acute Coronary Syndrome Used to describe the range of conditions from unstable angina to AMI. Signs and symptoms usually caused by acute myocardial ischemia.

26 Management of Cardiac Chest Pain Position of Comfort Patent Airway High concentration O 2 – non-rebreather mask lpm

27 Management of Cardiac Chest Pain Nitroglycerin 0.4mg tablet sublingual – Patient should be sitting or lying down – Has Pt. Taken nitroglycerin in last 10 minutes? Is pain relieved? Headache? – Is BP 120 systolic or are there clinical signs of shock? – May take every 5 minutes until pain relieved or 3 tablets have been administered

28 Management of Cardiac Chest Pain Do not walk patient to the ambulance Monitor vital signs every 5 minutes The purpose of NTG is to dilate the coronary arteries and increase the amount of oxygen getting to the myocardium

Bradycardia Atropine, 0.5 mg, up to a total of 3 mg IV Transcutaneous pacing, if available Dopamine, 5 to 20 µg/kg/min Epinephrine, 2 to 10 µ/min Isoproterenol, 2 to 10 µ/min Consider glucagon for beta-blocker toxicity, calcium infusion for calcium channel blocker toxicity.

30 Sudden Death A cardiac arrest that occurs within 2 hours of onset of symptoms. Nearly 25% of these have no previous history of cardiac problems

Start chest compressions as early as cardiopulmonary arrest is identified. Place airway device as soon as possible and confirm oxygenation and ventilation. Establish IV access, identify rhythm, and administer drugs appropriate for rhythm and condition.

Hypertensive emergency

Aortic dissection

Thoracic Dissection

Signs & Symptoms Sudden and severe chest or upper back discomfort. “Pain shoots to the shoulder blades.” Anxiety Diaphoresis Nausea

Treatment Surgery Surgical therapy is the best option for acute aortic dissection involving the ascending aorta. Studies have shown that delaying surgical intervention, even to carry out left heart catheterization, aortography, or both, results in worse outcomes. Mortality increases by 1% per hour while waiting for surgery

Surgical repair in patients with type B dissection is generally reserved for: those with end-organ compromise or those who do not respond to medical therapy.

Medical therapy Medical therapy should be initiated in all patients with acute dissection. Reductions of shear force and blood pressure should be the primary goals.

Beta-blockers should be given intravenously and titrated to the desired effect. typically start by using boluses of IV metoprolol to achieve a heart rate of 50 to 60 beats/min, which may require very high doses of 200 to 1,000 mg. then add SNP if needed because of its rapid onset and ease of titration, aiming for a MAP of 65 to 75 mm Hg.

Acute pulmonary edema The pharmacologic agents most commonly used in the treatment of acute pulmonary edema are nitroglycerin, SNP, and diuretics.

Nitroglycerin acts immediately to decrease preload and afterload. It should be used for the management of patients with pulmonary edema who are not hypotensive. Sublingual administration allows rapid delivery, which is often required to decrease preload.

IV administration of nitroglycerin also should be used in the nonhypotensive patient and, based on symptoms,

Congestive Heart Failure Occurs when the ventricles are damaged. Heart tries to compensate with increased heart rate. Enlarged, ineffective left ventricle Fluid builds up into lungs or body as “pump” fails.

CHF

Signs & Symptoms

Cardiac Tamponade Trauma induced, filling of the pericardial sac with blood. Signs of shock JVD Decrease pulse pressures

Pericarditis Inflammation of the pericardium caused by infection. Usually presents as sharp discomfort. Changes with breathing and movement.

Listen to the patient… …he will tell you exactly what is wrong!

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