What about nearly arrest patient?

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

Reference: Harvard Shock symposium Sunday, August 9, 2009

Objective • Manage case that is nearly dead, guideline yet go there • Sunday, August 9, 2009

นาทีเฉียดตาย • Sunday, August 9, 2009

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

Sunday, August 9, 2009

What are you examining in AF patient? Sunday, August 9, 2009

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

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

Rapid AF • AHA guideline for management of a patient with hypotension and AF with RVR would be cardioversion • DC Cardioversion Sunday, August 9, 2009

Would you cardiovert the patient? Sunday, August 9, 2009

Rhythm Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009

Cardiovert Rhythm Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009

Cardiovert Rhythm Amiodarone Digoxin Rate Diltiazem/verapamil Sunday, August 9, 2009

What are you using? Amiodarone Diltiazem Adenosine Digoxin Beta blocker Sunday, August 9, 2009

What are you using? Digoxin Beta blocker 5 min Sunday, August 9, 2009

What are you using? Digoxin Cardiovert Beta blocker 5 min Sunday, August 9, 2009

What are you using? Digoxin Cardiovert Diltiazem Beta blocker 5 min Sunday, August 9, 2009

What are you using? Amiodarone Digoxin Cardiovert Diltiazem Beta blocker 5 min Sunday, August 9, 2009

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

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

Amiodarone Sunday, August 9, 2009

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

Maintain sinus Rate + anticoag ⇑Hemodynamic Avoid pro Pro ⇓Thromboembolic arrhythmia ⇓Hemodynamic Pro arrhythmic Bleeding Con Fatality Residual embolic Sunday, August 9, 2009

RV LV Loss of atrial kick sign? Sunday, August 9, 2009

•LV systolic function looks depressed (subcostal long axis view) RV LV Loss of atrial kick sign? Sunday, August 9, 2009

•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

•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

•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

What does it cause? Sunday, August 9, 2009

Loss of atrial kick What does it cause? Sunday, August 9, 2009

Blood don’t go into Loss of atrial kick atrium What does it cause? Sunday, August 9, 2009

Blood don’t go into Loss of atrial kick It reﬂux into neck vein atrium What does it cause? Sunday, August 9, 2009

• 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

• Patient was treated with Nicardipine IV • He feel less lightheadeness still chest discomfort • Old ECG show no atrial ﬁbrillation Sunday, August 9, 2009

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

Case II • BP=110/60 HR=130 RR=20 T=37.3 • Complaint of chest tightness, Sunday, August 9, 2009

What would you do? • Any reason to change rhythm? • Dead now or later? • Sunday, August 9, 2009

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

What is your diagnosis? Next Management? Sunday, August 9, 2009

What will you do in this patient? • Physical examinaiton • Further investigation? • Further Management Sunday, August 9, 2009

สักพัก... Sunday, August 9, 2009

What would you do in this patient? • Atropine • Epinephrine • Dopamine • Transcutaneous pacing Sunday, August 9, 2009

เจ็บแปลบ ... • The patient is so painful when you put on pacemaker • Will atropine cause more infarct? Sunday, August 9, 2009

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

campaign Sunday, August 9, 2009

What about nearly arrest patient?

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