What about the "nearly arrest" patients?

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Where evidence based medicine has yet to go but where we often find ourselves

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What about the "nearly arrest" patients?

  1. 1. What about the nearly arrest patient? Where evidence based medicine has yet to go but where we often find ourselves SP-ER conference 9 Aug 2009 Suthaporn Lumlertgul M.D. King Chulalongkorn Memorial hospital Sunday, August 9, 2009
  2. 2. Reference: Harvard Shock symposium Sunday, August 9, 2009
  3. 3. Reference: Harvard Shock symposium Sunday, August 9, 2009
  4. 4. Objective • Manage case that is nearly dead, guideline yet go there • Sunday, August 9, 2009
  5. 5. นาทีเฉียดตาย • Sunday, August 9, 2009
  6. 6. Example case • A 60 year old woman with complaint lightheadness, chest tightness • HR= 150/min, BP=200/110 RR=36/min O2 Sat 96% Temp=37.4 Sunday, August 9, 2009
  7. 7. Sunday, August 9, 2009
  8. 8. What are you examining in AF patient? Sunday, August 9, 2009
  9. 9. What are you examining in AF patient? • A 60 year old woman with complaint lightheadness, chest tightness • HR= 150/min, BP=200/110 • RR=36/min O2 Sat 90% Temp=37.4 Sunday, August 9, 2009
  10. 10. Sunday, August 9, 2009
  11. 11. Define Unstable • Patients as those with ventricular rates 150, • ongoing chest pain, or with evidence of critical perfusion: • systolic BP 90 mm Hg, heart failure, or reduced consciousness. Sunday, August 9, 2009
  12. 12. Rapid AF • AHA guideline for management of a patient with hypotension and AF with RVR would be cardioversion • DC Cardioversion Sunday, August 9, 2009
  13. 13. Sunday, August 9, 2009
  14. 14. Would you cardiovert the patient? Sunday, August 9, 2009
  15. 15. Would you cardiovert the patient? Sunday, August 9, 2009
  16. 16. Rhythm Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009
  17. 17. Cardiovert Rhythm Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009
  18. 18. Cardiovert Rhythm Amiodarone Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009
  19. 19. What are you using? Amiodarone Diltiazem Adenosine Digoxin Beta blocker Sunday, August 9, 2009
  20. 20. What are you using? Digoxin Beta blocker 5 min Sunday, August 9, 2009
  21. 21. What are you using? Digoxin Cardiovert Beta blocker 5 min Sunday, August 9, 2009
  22. 22. What are you using? Digoxin Cardiovert Diltiazem Beta blocker 5 min Sunday, August 9, 2009
  23. 23. What are you using? Amiodarone Digoxin Cardiovert Diltiazem Beta blocker 5 min Sunday, August 9, 2009
  24. 24. What are you using? Amiodarone Digoxin Cardiovert Diltiazem Beta blocker 5 min Sunday, August 9, 2009
  25. 25. Diltiazem • Schreck et al compared the effectiveness of IV Diltiazem receive diltiazem with digoxin. In this open-label RCT, consecutive patients with acute AF were assigned to more rapid rate receive either diltiazem (0.25 mg/kg initial bolus followed by 0.35 mg/kg 15 min after, and then an control in 5 min infusion of 10 to 20 mg/h to maintain a heart rate thank digoxin 100), digoxin (0.25-mg boluses at 0 and 30 min), or both digoxin and diltiazem. Follow-up was for 180 min. Treatment with diltiazem achieved a rapid reduction in ventricular rate compared to digoxin, the results becoming statistically significant by 5 min Sunday, August 9, 2009
  26. 26. Diltiazem • Rate-limiting calcium channel antagonists have therefore been shown to be effective in ventricular rate reduction in acute AF. The major adverse event reported from the RCTs was the precipitation of symptomatic hypotension (18% of patients) Sunday, August 9, 2009
  27. 27. Amiodarone Sunday, August 9, 2009
  28. 28. Digoxin • Double-blind RCT recruited 40 patients to receive either digoxin (total IVdose of 1.25 mg in divided doses) or placebo. • At 12 h posttherapy, there was no significant difference between the rates of conversion between the digoxin • Ventricular rate reduction was 30 min Sunday, August 9, 2009
  29. 29. Maintain sinus Rate + anticoag ⇑Hemodynamic Avoid pro Pro ⇓Thromboembolic arrhythmia ⇓Hemodynamic Pro arrhythmic Bleeding Con Fatality Residual embolic Sunday, August 9, 2009
  30. 30. Sunday, August 9, 2009
  31. 31. RV LV Loss of atrial kick sign? Sunday, August 9, 2009
  32. 32. •LV systolic function looks depressed (subcostal long axis view) RV LV Loss of atrial kick sign? Sunday, August 9, 2009
  33. 33. •LV systolic function looks depressed (subcostal long axis view) RV •Reduce SV by reducing diastolic time / by absence of atrial kick). LV Loss of atrial kick sign? Sunday, August 9, 2009
  34. 34. •LV systolic function looks depressed (subcostal long axis view) RV •Reduce SV by reducing diastolic time / by absence of atrial kick). •In this patient with acute onset of FA and subsequent hypotension . LV Loss of atrial kick sign? Sunday, August 9, 2009
  35. 35. •LV systolic function looks depressed (subcostal long axis view) RV •Reduce SV by reducing diastolic time / by absence of atrial kick). •In this patient with acute onset of FA and subsequent hypotension . LV •After prompt cardioversion, sinus rhythm is restored and LV systolic function looks now much better Loss of atrial kick sign? Sunday, August 9, 2009
  36. 36. What does it cause? Sunday, August 9, 2009
  37. 37. Loss of atrial kick What does it cause? Sunday, August 9, 2009
  38. 38. Blood don’t go into Loss of atrial kick atrium What does it cause? Sunday, August 9, 2009
  39. 39. Blood don’t go into Loss of atrial kick It reflux into neck vein atrium What does it cause? Sunday, August 9, 2009
  40. 40. • Patient was administered Digoxin IV • After not improving the clinical patient was administered Diltiazem IV • Patient has less lightheadesness but still have chest tightness • Heart rate was slower from 170 to 130/ min but BP still 200/100 Sunday, August 9, 2009
  41. 41. Sunday, August 9, 2009
  42. 42. • Patient was treated with Nicardipine IV • He feel less lightheadeness still chest discomfort • Old ECG show no atrial fibrillation Sunday, August 9, 2009
  43. 43. Sunday, August 9, 2009
  44. 44. Take home message • Remember for the unstable signs in limited time Heart failure, poor perfusion • How fast do you think the patient will survive on this rhythm • Pick the choice of treatment from that Sunday, August 9, 2009
  45. 45. Case II • BP=110/60 HR=130 RR=20 T=37.3 • Complaint of chest tightness, Sunday, August 9, 2009
  46. 46. Sunday, August 9, 2009
  47. 47. Sunday, August 9, 2009
  48. 48. Sunday, August 9, 2009
  49. 49. What would you do? • Any reason to change rhythm? • Dead now or later? • Sunday, August 9, 2009
  50. 50. Case III • A man with acute dyspnea come in ER with expiratory wheezing and sound of secretion, profound sweating • Switching Taxi driver to passenger • RR=35 PR=130/min BP=220/110 T=37 StO2=70% Sunday, August 9, 2009
  51. 51. What is your diagnosis? Next Management? Sunday, August 9, 2009
  52. 52. What will you do in this patient? • Physical examinaiton • Further investigation? • Further Management Sunday, August 9, 2009
  53. 53. Sunday, August 9, 2009
  54. 54. Sunday, August 9, 2009
  55. 55. Sunday, August 9, 2009
  56. 56. Sunday, August 9, 2009
  57. 57. Sunday, August 9, 2009
  58. 58. Sunday, August 9, 2009
  59. 59. สักพัก... Sunday, August 9, 2009
  60. 60. What would you do in this patient? • Atropine • Epinephrine • Dopamine • Transcutaneous pacing Sunday, August 9, 2009
  61. 61. เจ็บแปลบ ... • The patient is so painful when you put on pacemaker • Will atropine cause more infarct? Sunday, August 9, 2009
  62. 62. Sunday, August 9, 2009
  63. 63. Sunday, August 9, 2009
  64. 64. Sunday, August 9, 2009
  65. 65. Take home message • Don’t be afraid to use adjuncts in life threatening patients • This is 2009, ER is all about proove it and treat it. Sunday, August 9, 2009
  66. 66. campaign Sunday, August 9, 2009
  67. 67. Sunday, August 9, 2009

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