CARDIAC EMERGENCIES: 12-YEAR-OLD BOY WITH COMMOTIO CORDIS
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A 12-year-old boy presented unresponsive after being struck in the chest by a baseball. Commotio cordis most commonly causes this and is associated with ventricular fibrillation. Commotio cordis occurs when an object strikes the chest and causes sudden death, most often in children aged 5 to 15 without known heart conditions. The document then discusses various cardiac conditions and emergencies including ischemic heart disease, ECG findings, treatments for acute coronary syndrome, and cardiomyopathies.
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CARDIAC EMERGENCIES: 12-YEAR-OLD BOY WITH COMMOTIO CORDIS
- 1. CARDIAC EMERGENCIES Andrew Crouch DO PGY-2
- 2. Question • A 12-year-old boy is brought to the ED after being struck in the chest by a baseball during a baseball game. He collapsed immediately upon impact and has been unresponsive since. Which of the following dysrhythmias is most commonly associated with this condition? • A Asystole • B Ventricular Tachycardia • C Ventricular Fibrillation • D PEA • E. SVT
- 3. Answer C (V-Fib) • Commotio cordis • occurs when an object such as a baseball strikes the chest and produces sudden death. It most commonly occurs in children between 5 and 15 years of age with no known predisposing cardiac conditions.
- 4. Ischemic Heart Disease • Leading cause of Death in USA • 30% all deaths • Etiology • Insufficient blood supply to myocardium • Risk factors • Family history, smoking, hypertension, diabetes, • cholesterol, male >55 years old • Global Hypotension • Fixed Lesion • Atherosclerosis • Stable Angina • Vasospasm • Prinzmetal angina • Drug induced • Ruptured Plaque • Leads to formation of clot • ACS
- 5. Coronary Anatomy • Left Main Coronary • LAD • Widowmaker • Anteroseptal • Left Circumflex • Anterolateral (if left dominant posterior) • Right Coronary Artery • Right ventricle • Inferior • SA node • Posterior descending artery • AV node • Lead to mitral regurgitation and bradycardia
- 6. TIMI Score • > 65 years old • (0-1) 4.7% • > = 3 cardiac risk (2) 8.3% • (3) 13.2% • (4) 19.9% (5) 26.2% • (6 to 7) 40.9% • Risk of death or MI • Note there is no 0% risk in this scale factors • Prior stenosis >50% • ST segment deviation • 2 anginal events in 24 hours • Aspirin use within last 1 week • Elevated CK
- 7. Chest Pain Atypical Chest Pain • Women Diabetic and Elderly • Fatique, nausea, epigastric pain, palpatations, chest wall pain, total body dolor • Chest pain absent in 18% of Mis • Account for 40-50% of cases Typical Chest pain • Crushing • Left chest • Radiate to left arm, jaw, back • Diaphoresis
- 8. Signs of ACS • Vitals • Tachycardia, Bradycardia (RCA) , hypertension, hypotension • Cardiac Exam • New S3 or S4 • New Murmur • Papillary muscle dysfunction • Wall rupture • Pulmonary crackles • New friction Rub
- 9. ECG • Initially abnormal in <50% of patients with ischemic chest pain • Meaning often it is perfectly normal
- 10. T wave morphology changes • Hyperacute T waves • Earliest sign • Prominent symmetrical, pointy • T wave flattening or inversion • Can be due to a S#*% ton of things
- 11. ST segment Changes • ST Elevation • Elevation >1mm in 2 contiguous leads • ST depression • Measured from the PR segment to the ST segment • Depression >1mm in 2 leads • New Bundle Branch Block or AV block • ST changes associated with increased mortality
- 12. QRS
- 13. Sgarbossa's criteria • Three criteria are included in Sgarbossa's criteria: • ST elevation ≥1 mm in a lead with a positive QRS complex (ie: concordance) - 5 points • ST depression ≥1 mm in lead V1, V2, or V3 - 3 points • ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex - 2 points • ≥3 points = 90% specificity of STEMI (sensitivity of 36%)
- 14. Arrhythmias of ACS • Bradycardia • SA or AV node involvement • Tachycardia • Reperfusion, autonomic tone, hemodynamic instability • V Fib • Indication for immediate cath • if not at ARMC • Accelerated Idioventicular Rhythms • Associated with reperfusion, Resemble V Tach with rate of 50-100 bpm • DO NOT USE Antiarrhythmics such as lidocaine
- 16. AnteroSeptal MI • Septal • ST elevations in V1 and V2 • Anterior • ST Elevations in V3 and V4 • LAD occlusion • High grade Heart Blocks
- 17. A little harder
- 18. Lateral Wall MI • ST elevations in I, aVL, V5 and V6 • Left Circumflex artery
- 19. Too Easy
- 20. Inferior • Inferior • ST elevations in II, III, aVF • Primary RCA occlusion • AV dysfunction • Up to 25% have right ventricular infarction • Do not give Nitro
- 21. Right sided ECG • ST elevations in V4R and V5R are diagnostic of Right ventricular infarct
- 22. WTF?
- 23. Posterior • Large R waves & ST depressions in V1 and V2
- 25. ECG changes correlate to Pathology • ST changes in V1-4 • Anteroseptal • V4-6, I, aVL • Anterolateral • I & aVL • Lateral • II, II, aVF • Inferior • II, III, aVF & V5-6 • Inferolateral • Small R waves V1-2 • Posterior • Depression II, III, aVF • Right Ventricular with ST elevation rV4
- 26. ECGs are not perfect • Normal ECGs are seen in • 1-5% of Acute MI • 4-23% of UA • Non diagnositic ECGs • 4-7% of Acute MI • 21-48% of UA • New ischemic changes • 25-73% of Acute MI • 14-34% of UA
- 27. Cardiac Enzymes • Troponin • Specific for Cardiac injury (Tt 94% and Ti 100%) • Positive 2 to 6hours and remain elevated foer up to 1 week • PE, Pericarditis, CHF, Shock, Renal failure, Remember it is a sign of injury not infarction • CK-MB • Positive 3 to 8 hours less specific than troponin • Useful for reinfarction due to shorter half life
- 28. Testing • ECHO • Regional wall abnormality • Poor correlation • Dobutamine Stress • Treadmill testing • Sensitivity 65% to 70% • Specificity 70 to 75% • SPECT • Nuclear imaging • 80-90% Sensitivity • 80-90% specificity • Stress ECHO • 80-85% sensitivity • 80-85% Specificty ECHO • 80-85% sensitivity • 85-90% Specificty
- 29. Treatment ACS • Oxygen • Antiplatelet • ASA 162 to 325mg, should be chewed • Do not use if possibly Aortic Dissection • Plavix, Clopidogrel • Can be given in addition to or instead aspirin • Nitroglycerin • Smooth Muscle Dilator • Dilate coronary arteries • Reduces preload and afterload • Do not give if taking viagra or if right ventricular infarction • Morphine • Block catacholamine surge • Reduce preload and afterload because of histamine response • Caution if right ventricular infarction or hypotensive • Beta Blockers • Use since COMMIT Trial • Decrease ventricular Arrhythmias in stable patients • Do not give if Meth or cocaine usage • Use with caution if asthma, hypotension, bradycardia
- 30. Anti Thrombotics • Heparin • Activates Antithrombin III • Bolus 60-70 U/kg • Then infuse 12-15 U/kg • Bivilirudin • Direct thrombin inhibitor • Useful if planning PTCA • Use if patient has HIT • Low Molecular weight • GP IIB IIIA inhibitor heparin • 16% relative risk reduction but increase risk bleed
- 31. Thrombolysis • Indicated if • ST Elevations >1mm in 2 contiguous limb leads • ST Elevation >2mm in 2 contiguous Chest Leads • New LBBB • High Suspicion for MR with pre-existing LBBB • Reciprocal ST segment depression V1 –V3 and posterior wall infarction
- 32. Thrombolysis Absolute Contraindication • Aortic Dissection • Active GI bleed or internal Bleed • Brain tumor, Bleed or AV fistula • Closed head trauma or facial trauma within 3 months • Allergy Relative Contraindication • Chronic Hypertension • BP >180/110 • Ischemic Stroke in last 3 • • • • • months Major surgery within 3 weeks Internal bleeding 2-4 weeks ago Noncompresable vascular punctures Peptic Ulcer Current use of anticoagulants
- 33. Question • Which of the following AV nodal blocks is most commonly • • • • associated with an acute inferior wall myocardial infarction? A First degree B Third degree C Type I second degree D Type II second degree
- 34. Answer C • Type I • Type II more likely with anterior not inferior MI
- 35. PCI • Gold Standard • Door to Balloon <90 Min • Presentation > 3hours • Thrombolysis should be performed over PCI if prolonged time to cath lab or no capability
- 36. Question • A 62-year-old man presents to the ED with a mild cough and URI symptoms. He was discharged from the hospital 2 weeks ago after undergoing percutaneous intervention for an acute myocardial infarction. You obtain an ECG (seen above) and compare the current ECG to the ECG obtained when he was admitted 2 weeks ago. You note that the morphologies are similar. Which of the following is the most likely diagnosis?
- 37. • A Pericarditis • B Postmyocardial infarction syndrome Pulmonary embolism D Ventricular aneurysm C
- 38. Congestive Heart Failure • 3.4 million ED visits per year • 70-80% of patients with CHF die within 8 years • Left vs Right • High output vs low output • High output due to metabolic demand (Hyperthyroid, beriberi, AV fistula, Pagets disease, Anemia, Pregnancy) • Low output (Decreased Ejection Fraction) • Systolic vs Diastolic • Systolic • Poor Contractility of left ventricle • Ejection fraction on ECHO < 40% • Diastolic • Poor Compliance • Systolic function preserved • 20-50% of patients with heart failure
- 39. Left vs Right Right Heart failure Left Sided Heart failure • JVD • Pulmonary Edema • Dependent Edema • Orthopnea • Liver congestion • Paroxysmal noctural (hepatojuglar reflex) • Causes dyspnea • Causes • Left sided heart failure #1 • Systemic HTN cause • MR, COPD, Pulmonary Stenosis • Cardiomyopathy • AS/AR • Cardiomyopathy • MI
- 40. Pathophysiology Hemodynamic Model • Left Ventriclar pressure increases leading to high end diastolic filling pressure • Leads to Pulmonary congestion Neurohormonal Model • Inadequate end-organ • • • • perfusion Increased sympathetic nervous system and renin-angiotensinaldosterone axis Vasoconstriction/ fluid retention Increasing afterload Increasing workload
- 41. New York Heart Association (NYHA) • Class I : No limitation • Class II : Slight limitation at high exertion • Class III: Marked Limitation with no symptoms at rest • Class IV : Symptoms at Rest
- 42. Symptoms • Exertional Dyspnea • Orhtopnea • Dimished Pulse pRessure • Pulsus Alterans • Bilateral Rales • Pitting Edema • Hepatomegally • Acities • JVD • S3 gallop • Loud P2
- 43. Diagnosis • CXR • can show congestion • Cardiomegally • Kerly B Lines • Pleural effusion R>L • Interstitial Hilar infiltrates (bat winging) • Cephalization • BNP • <50pg/ml negative predictive value 98% • >100 pg/ml has 83% sensitivity • ECHO • EF > 40% • High EF with thick walls • Valvular abnormalities
- 44. Kerley B lines
- 45. Bat Wigging out
- 47. Management • Oxygen • CPAP and BIPAP • Decrease work of breathing • Decreased mortality • Contraindicated if Altered • Intubation • When all else fails tube them • Preload reduction • Diuretics • Furosemide • Bumex • Morphine • Decrease Pulmonary congestion by vasodilation • Nitrates • Can be given sublingual or as gtt • Doses as high as 2mg IV every 3 minutes can be given
- 48. Management • Afterload reduction • Nitates • NTG • Nitroprusside • ACE inhibitors and ARBS • Decrease afterload and increase renal perfusion • Inotropic agents (can increase contractility but at a price) • Dobutamine • Beta agonist • Amrinone and Milrinone • Phosphodiesterase inhibitors Intraaortic Balloon pump
- 49. Dilated Cardiomyopathy Causes • Infection • Idiopathic • Familial diseases • (Pompe’s Disease) • Pregnancy • Sarcoidosis • Muscular dystrophy • Hypothyroidism • Chronic low phosphate or calcium • Meth or Cocaine • Chronic Alcohol usage • Heavy metal toxicity Symptoms • Similar to congestive heart failure • Mural thrombus formation • Can embolize • Syncope • Death ECG • • • • A fib Poor R wave progression Blocks Large P waves – In lead II • • Double hump = Left atrial Peaked Right Atrial
- 50. Dilated Cardiomyopathy • In the US Viral illness is the most common cause • World Wide the most common cause is Protozoan, Trypanosoma Cruzi “Chagas Disease”
- 51. Hypertrophic cardiomyopathy • Asymetrical Septal Hypertorphy • Hypertrophic Obstructive cardiomyopathy • Idiopathic Subaortic Stenosis
- 52. Epidemiology • Common Cause death in young athletes • Mortality 4% if untreated • Autosomal Dominant • Mutation leading to dysfunctional cardiac sarcomere production • Leads to Diastolic dysfunction
- 53. Diagnosis • Murmur • Harsh Systolic Murmur • Increase with Valsalva, Amyl nitrate • Decrease with Squatingm Leg raise, hand grip, beta blocker • ECG • LVH • Q waves in inferior or lateral leads • ECHO • Septum thicker than wall • Systolic anterior motion of mitral valve
- 54. Management • Beta Blockers • Verapamil • Disopyramide (Class Ia anti-arrhythmic) • NO Diuretics • AICD • Pacemaker • Septal Ablation • Myomectomy
- 55. Pericardial Tamponade • Fluid in pericardial space • Normal 15-30ml effusions can get >1L if occur slowly but in cases of rapid expansion there will be myocardial compression
- 56. Tamponade • Becks triad • Hypotension • JVD • Distant heart sounds • Kussmal sign • Paradoxical jugular venous distention with inspiration • Pulsus paradoxus • Decrease systolic blood pressure >10mmHg with inspiration • Also seen with PE, COPD
- 58. Treatment • Fluids • Pressors • If hemodynamic compromise do pericardiocentsis • Pericardial window is definitive treatment
- 60. Pericarditis • Idiopathic #1 Cause • Infectious • Viral • Bacterial • Tuberculosis • Fungal • Malignancy • Drug-induced (procainamide) • Miscellaneous: connective tissue disease or • autoimmune • Uremia • Postradiation • Dressler syndrome • Myxedema
- 61. Diagnosis • Blood • CBC • Elevated WBC could point to infection • BUN • Uremia • Serology • Rheumatoid arthritis and lupus • TSH • Thyroid disease • Cardiac Enzymes • Dressler Syndrome • CXR • Bottle Shaped heart • ECHO • CT or MRI • ECG (4 Satges) • Stage I • PR Depression (II, aVF, V4-V6) • Diffuse ST Elevation • PR elevation aVR • Stage II • Flattening of ST wave • Stage III • Inverted T waves • Stage IV • Normal
- 62. Treatment • #1 treat underlying cause if can be found • Viral or Idiopathic Pericarditis • NSAIDs • Bacterial • Antibiotics and drainage if purulent • 100% mortality without treatment • TB • INH, Rifampin, Ethanbutol, Pyrazinamide • Dressler’s Syndrome • ASA (avoid NSAID) • Autoimmune • Steroids + NSAID