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T eachingseries1: CardiologyEmergencies Delivered by: Dr Alireza Sherafat Academic Foundation Doctor (SFP doctor)Disclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.SFP series • You can be asked about common clinical emergencies • Your approach must be safe • Use A-E assessment • Escalate appropriatelyCardiology emergencies • ACS (STEMI, NSTEMI, Unstable angina) • Tachycardia • Bradycardia • Heart failure • ShockCase 1 • 76-year-old gentleman • Asian origin • PC: Central chest pain • HPC: pain started at 5 pm while driving back home. No similar pain in the past • Previous history of Hypertension on Ramipril OD 10 mg , Amlodipine 10 mg OD • Social Hx: works as a manager, smoker (10 cigarettes/day for 40 years), drinks two pints of beer per dayACS • Acute Coronary syndrome can be seen as STEMI, NSTEMI or Unstable angina • Assess patients by history, examination and investigations • Ask them their symptoms (chest pain), use SOCRATES, explore ICE, ask about PMHx, FHx, Social Hx, medications and allergies • Observations • O/E Cardiorespiratory system (Scars, Pacemakers, ICD, check JVP, look for signs of CCF, check B/L pulses, listen to HS, ?murmurs, auscultate lungs) • Use A-E approach • Use risk calculators like T-MACS • Look at their medical records (previous cardiovascular problems) • ?D-Dimer, ?other electrolytes) ECG (12-lead), CXR, Bloods (FBC, U&Es, LFT, CRP, Troponin, • Get IV access and send bloodsSTEMI • ST elevation MI • Central crushing chest pain radiating to neck, jaw and left arm in a patient with risk factors (age, sex, lifestyle, smoking, obesity, family history, etc). • ECG and troponin • CXR • Consider differentials such as PE and aortic dissection • Refer to PCI centre as an emergency for stent or CABG if three vessel disease. • 300 mg Aspirin + 300 mg Clopidogrel (can consider ticagrelor 180 mg). Morphine (5-10 mg IV), Give anti-emetics (Cyclize 50 mg IV), GTN , O2 if sats<95% , can give b-blockers • If PCI not available locally use anti-coagulation like fondaparinux 2.5 mg SC (remote and rural settings) and then transfer.ECG examples (Life in the Fastlane) Figure 1) ECG for Anteroseptal MI (1).ECG examples (Life in the Fastlane) Figure 2) Anterolateral MI (1). ECG examples (Clinical Junior .com) Figure 3) ECG leads and various types of MI (2).NSTEMI • Non-ST elevation MI • Same history, examination and investigations as ACS • Troponin is raised but no ST elevation seen on ECG • Less area of infarction • Does not require PCI (usually) • 300 mg Aspirin and 300 mg Clopidogrel or 180 mg Ticagrelor • Can be managed with anticoagulation with Fondaparinux • Calculate GRACE Score (Prognostic): History of unstable angina, ST depression or T-wave inversion, Trop, Age> 70, cardiovascular history and comorbidities) . Plan intervention if high risk according to GRACE score • Manage risk factors (e.g. Atorvastatin 80 mg OD)ECG examples (Life in the Fastlane) Figure 4) NSTEMI with U-wave inversion (V5-V6) on ECG (3).Unstable Angina • MI symptoms • Defined as myocardial ischaemia and anginal pain at rest when there is no myocardial infarction • Same history, examination and investigations (ECG, Trop, CXR) • ECG: no evidence of STEMI, may show ST segment depression or T- wave inversion • Aspirin 300 mg, Clopidogrel 300 mg, GTN • Discuss with Cardiology • May need further investigations with Invasive Angiography or CT AngiographyCase 2 • 45-year-old gentleman • Unknown background • Found collapsed on the street • Brought in Resus by ambulance • Observations: HR 131, RR 18, BP 105/76 mmHg temp:36.9 O2 Sat: 89% • ECG : Broad-complex tachycardiaA-E assessment • A: patient is responsive to pain only. Bleep anaesthetist to intubate • B: Low saturation 89%. B/L equal air entry. No added sounds. Do ABG. Put 15 L RM. Request CXR. • C: HS I+II+0 . BP 105/76 mmHg. Cap refill> 3s. Pulse present centrally. No pedal oedema. Get IV access and send bloods (FBC, U&Es, LFT, Lactate, CRP, Trop and D-dimer). Do an ECG. Give stat 500 ml NaCl. • D: GCS 8. Only responsive to pain. No evidence of focal neurology deficit or head injury. PEARL. • E: Abdo SNT. No evidence of rash or haemorrhage seen ECG examples (Life in the Fastlane) Figure 5) Ventricular tachycardia on ECG (4).VT management • Patient not in shock and has Regular VT : give 300 mg IV Amiodarone over 20 min, then 900 mg slow IV infusion over 24 hours (via central line) • Check and Correct electrolytes (K, Mg, Ca) • If patient is in shock, Syncope or heart failure, sedation and 3 synchronised DC shocks (150 J for first then 150-360 J). Then, give 300 mg IV Amiodarone over 20 min, then 900 mg slow IV infusion over 24 hours (via central line) • Always get senior helpCase 3 • 48-year-old female patient presents with severe palpitation and HR of 168 • Shortness of breath and palpitation • Previous history of MI and stent • Smokes 5 cigarettes per day since 25 years ago • Drinks 20 units of alcohol per week • History of Depression and anxiety, not on medicationNarrow Complex tachycardia • DDx 1. Sinus tachycardia :normal P wave followed by normal QRS (might be physiological or seen in PE) 2. AF : P-wave is absent and QRS is irregular (unknown AF or new onset?) 3. Atrial Flutter : Sawtooth appearance due to a re-entrant circuit (2:1 block). 4. SVT (Supraventricular tachycardia): Junctional (re-entry) tachycarida and atrial tachycardia . Abnormal P-wave or buried in QRS complexECG examples (Life in the Fastlane) Figure 6) sinus tachycardia on ECG (5).ECG examples (Life in the Fastlane) Figure 7) AF ECG (6).ECG examples (Life in the Fastlane) Figure 8) Atrial flutter with 4:1 block (7).ECG examples (Life in the Fastlane) Figure 9) Narrow complex tachycardia (SVT) (8).Management of Narrow complex tachycardia • A-E approach • If low sats, 15 L RM O2, Get IV access and 12-lead ECG • If patient is unstable (shock/syncope) : sedate and give DC 120 J shock and repeat up to IV amiodarone over 20 min, then 900 mg IV infusion through central line in 24 hours00 mg • Cardioversion with synchronised DC shock under sedation or chemical cardioversion withh) : Flecainide 300 mg PO or Amiodarone 300 mg IV in 20 min, then 900 mg IV infusion in 24 hours. • If patient is stable and rhythm is regular : do vagal manouveres while patient is on cardiac monitoring. If it fails, give IV 6 mg Adenosine. Warn them about impending is asthmatic or other contra-indications present for adenosine, give Verapamil 2.5-5 mgent stat over 2 min). You can also give verapamil if adenosine does not work. • Always get senior/cardiology help.Case 4 • 55 year-old gentleman with history of previous MI when he was 39 presents to GP with fatigue and dizziness • GP does a set of observations and records the following values: HR 34, BP 112/65 mmHg, Temp 36.9 C, Sats 96% • GP refers the patient to ED • Next slide you can see the ECG in EDECG examples (Life in the Fastlane) Figure 10) Sinus bradycardia (9).Bradycardia management • A-E assessment. Give O2 15 L RM.ECG. Get IV access. Fluid resus • Check and treat electrolyte imbalances • If recent asystole, Mobitz type 2 AV block, Complete Heart block, shock, syncope, signs of cardiac ischaemia and heart failure present: give Atropine 500 mcg IV. You can repeat atropine as well every 3-5 min. Max amount of atropine you can give is 3 mg. If bradycardia still persists : transcutaneous bradycardia is caused due to beta-blocker or Calcium-channel blocker, If glucagon can be given. It can be seen in patients with overdose, refer to Toxbase. • If adverse signs (as above) not present, continue cardiac monitorting • Always get senior help. Refer to cardiology urgently.Case 5 • 72-year-old lady presents to ED with difficulty breathing • She has history of IHD MI 5 years ago. She had CABG. • She has noticed she uses more pillows to sleep recently.CXR (Radiopaedia) Figure 11) pleural effusion on CXR (10).Management of heart failure • Take history and do physical examination with emphasis on cardioResp • Do ABG • Do ECG , Send Bloods (FBC, U&Es, Trop) • Get IV access. Input/output chart and daily weights. • Sit patient upright, Give Oxygen . You can consider CPAP. • Give IV morphine and IV furosemide 40 mg. You can repeat furosemide. • GTN spray (not in Systolic BP <90 mmHg) • Other DDx to consider: PE, Pneumonia, Aortic dissection • Get cardiology advice, refer to heart failure nurses.Shock • Inadequate tissue perfusion • Cardiogenic, Hypovolemic, Anaphylactic, Septic, Neurogenic • Causes of cardiogenic shock: MI, Tamponade, Aortic dissection, Arrhythmias, PE, Pneumothorax and drugs • Give O2 if hypoxic • Check Acid-base (ABG) and U&Es • Treat arrhythmias • (ITU care)uids and Inotropes like adrenaline, dopamine and dobutamine • Escalate urgently • Look for other causes and treatReferences 1. https://www.facebook.com/Medical.Blog. Anterior Myocardial Infarction • LITFL • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2019. Available from: https://litfl.com/anterior-myocardial-infarction-ecg-library/ 2-clinical junior.com - ECG EKG Interpretation basics how to read MI myocardial infarction angina AF atrial fibrillation ST elevation depression [Internet]. www.clinicaljunior.com. Available from: http://www.clinicaljunior.com/cardiologyecg.html 3- https://www.facebook.com/Medical.Blog. Myocardial Ischaemia • LITFL • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2018. Available from: https://litfl.com/myocardial-ischaemia-ecg-library/ 4-https://www.facebook.com/Medical.Blog. Ventricular Tachycardia – Monomorphic VT • LITFL • ECG Library [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2019. Available from: https://litfl.com/ventricular-tachycardia-monomorphic-ecg-library/ 5-Sinus tachycardia • LITFL • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2018. Available from: https://litfl.com/sinus-tachycardia-ecg-library/ 6-Burns E, Buttner R. Atrial Fibrillation • LITFL Medical Blog • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2018. Available from: https://litfl.com/atrial-fibrillation-ecg-library/ 7-https://www.facebook.com/Medical.Blog. Atrial Flutter • LITFL Medical Blog • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2019. Available from: https://litfl.com/atrial-flutter-ecg-library/ 8-Burns E, Buttner R. Supraventricular Tachycardia (SVT) • LITFL • ECG Library Diagnosis [Internet]. Life in the Fast Lane • LITFL • Medical Blog. 2018. Available from: https://litfl.com/supraventricular-tachycardia-svt-ecg-library/ 9- Burns E, Buttner R, Buttner EB and R. Sinus Bradycardia [Internet]. Life in the Fast Lane • LITFL. 2018. Available from: https://litfl.com/sinus- bradycardia-ecg-library/ 10-Jones J. Pleural effusion | Radiology Reference Article | Radiopaedia.org [Internet]. Radiopaedia. Available from: https://radiopaedia.org/articles/pleural-effusion?lang=gbFOR FEEDBACK AND QUERIES: Email @ info@bidasw.com
