هنتعامل ازاي مع مريض عده مشاكل في القلب بعد قبل و بعد عملية جراحية؟ والاهم ازاي نشخص ان مريض حصل له ازمة قلبية و هو محجوز في قسم الجراحة بعد عملية دي دردسة باستخدام الطريقة اللي ناقشناها في الفيديو دا https://www.youtube.com/watch?v=f6j4VQloB6k&t=1000s عن ازاي نتعامل مع المرضي دول الفيديو مناسب للزملاء المتقدمين لامتحان الMRCS و للزملاء اللي منتقلين حديثا للعمل بالمملكة المتحدة او بينو العمل فيها عنوان فيديو المحاضرة علي اليوتيوب https://youtu.be/V3nUgSzbf9w تابعونا علي الصفحة الجراح https://www.facebook.com/algarra7/

1. Cardiac
Disorders
Unwell Surgical Patient

2. Case Scenario
• 65 year-old male
• Uneventful elective anterior resection for rectal
carcinoma
• Post-op Day 1
• You have been informed by house officer at 4 pm,
that the patient is: Cold, clammy, P 124 & BP 90/50
What would you do for this patient?

3. Immediate
Management
• A
• B
• C
• D
• E
Full
Assessment
• Chart
• Sheet / History
and Examination
• Investigations /
Blood results
Plan
• Unstable/Unsure
• Stable
• Diagnosis required
• Definitive treatment
• Medical / high level care
• Surgical
• Radiological
• Daily management plan
• S
• O
• A
• P

4. ABCs
• A: Patent and talking
• B: RR 28, Basal Crepts.
• C: P 124, BP 90/50
• D: Alert, Oriented, Slightly Anxious
• E: NAD

5. Immediate
Management
• A
• B
• C
• D
• E
Full
Assessment
• Chart
• Sheet / History
and Examination
• Investigations /
Blood results
Plan
• Unstable/Unsure
• Stable
• Diagnosis required
• Definitive treatment
• Medical / high level care
• Surgical
• Radiological
• Daily management plan
• S
• O
• A
• P

6. Chart review
• Absolute values vs. trends
• Chart review
• vitals (P 120-130, BP 90/60, T 36, RR 25)
• fluids (2L i.v., 300 ml urine since operation and
<30ml last 2 hours)
• drugs (Furosimide, Amiloride, Enalapril, Aspirin)
• labs (within normal ranges)

7. History and Examination
• Known hypertensive, cardiac with previous MI
• Bilateral basal crepitations, Prominent neck viens
• Minimal ankle edema
• No signs of peritoneal irritation, Drains (Nil), Wound
Clean
• No other signs of sepsis or haemorrhage

8. Available Results
• Results:
• Biochemistry / Haematology /Microbiology /
Pathology
• Electro-Physiology (ECG)
• Radiology (Reports and films)
• Return to chart when in need
What will you do NOW?

9. Circulation
Shock Management Concepts
• Stop losses e.g. Bleeding (if present)
• Reestablishment of perfusion
• Establish suitable IV access (consider labs)
• Start IV crystalloids then think

10. Plan
• O2 mask, Start fluids with CAUTION
• ECG
• CXR (why?)
• Cardiac enzymes / Electrolytes??
• Cardiac/ICU Consultation??

11. Your Patient
• Enthusiastic house officer gives 1 L of RL in less
than one hour
• P 140, BP 100/70, urine output 20 ml in this hour
• Patient became more dyspneic
What will you do now?

12. Cardiac Failure

13. Cardiac Failure -
Causes in surgical patient
• MI
• Acute Arrhythmias
• Others: Cardiac Trauma, infective endocarditis,
prolonged cardiac surgery

14. Cardiac Failure - Clinically
• Symptoms and Signs of SHOCK. (What are they?)
• Elevated venous pressure:
• Pulmonary Edema
• Elevated jugular pressure
• Hepatomegaly and ankle edema
• On Auscultation (Galloping or bruit may me present)

15. Cardiogenic vs.
Other types of shock
• It may be difficult to distinguish clinically from the
shock of cardiac tamponade or pulmonary
embolism. However, in cardiogenic shock, the
dominant feature is the presence of acute
pulmonary oedema.
• In septic shock, the cardiac output is initially
increased, with presence of bounding pulses and
warm peripheries following a fall in the systemic
vascular resistance. The CVP is not elevated.

16. CXR finding
• Increased cardiothoracic ratio: reflecting a dilated, volume overloaded
ventricle
• Kerley B lines: short-line shadows above the costophrenic angle. They
reflect interstitial oedema of the septa
• Interstitial shadowing of pulmonary oedema
• Hilar ‘bat’s wing’ shadowing further evidence of oedema
• Prominent upper lobe pulmonary vessels indicating venous congestion
• Left atrial enlargement seen as double shadowing at the atrial position,
or prominence at the left heart border (due to enlargement of the left
atrial appendage)

17. ECG

24. Arrhythmias

25. Sinus Tachycardia
• Exercise
• Pain and anxiety
• Pyrexia
• Shock of any cause
• Hyperthyroidism
• Anaemia
• Drugs: Catacholamines, atropine, aminophylline

26. Sinus Bradycardia
• Athletes Heart
• Hypothyroidism
• Raised intracranial pressure (as part of the Cushing
reflex)
• Jaundice
• Drugs: Beta-blockers, digoxin

27. Supraventricular
Arrhythmias
• Atrial ectopics
• Supraventricular tachycardia
• Atrial flutter and fibrillation

28. Supraventricular tachycardia
• A heart rate in the order of 150–220 beats per minute
• The QRS complex duration is within normal limits
• P waves may be of abnormal shape, or absent altogether
• Management:
• simple measures to stimulate vagal activity, such as the valsalva manoeuvre,
or carotid sinus massage.
• Alternatively, by the use of i.v. adenosine, which transiently blocks AV
conduction. Verapamil has also been used.
• CALL FOR HELP??

29. Atrial Flutter
• Rapid tachycardia an atrial rate of 250–350 beats per minute
• ECG shows ‘sawtooth’-shape flutter waves
• Often seen with variable degrees of AV block, e.g. 2:1, 3:1 or
4:1
• The ventricular rate is correspondingly less in cases seen
with AV block
• QRS complexes are of normal morphology

30. Atrial Fibrillation

31. AF - Causes
• Multifactorial
• Sepsis
• Electrolyte disturbance (K & Mg)
• Hypoxia
• Hypovolemia
• Drugs (Theophylline, Adenosine & Digitalis)

32. AF - Risk Factors
• Hypertension
• Recent or Active MI
• Rheumatic heart disease
• Heart failure
• Obesity
• Binge drinkers

33. AF - Clinically
• Asymptomatic
• Dizziness, Weakness, Palpitation & Dyspnea
• Angina, Hypotension & Heart Failure

34. AF - Prevention
• Correct Anaemia, Hypoxia and Electrolytes (K >4 mmol & Mg)
• Control perioperative Pain
• Consider ECG and troponin in high risk patient
• Never stop preoperative B-blocker or nitrates without
alternatives
• Prophylactic medications in high risk operations (Cardiac &
Vascular): Amiodarone, B-blockers or CCB
• Consult.. Consult.. Consult..

35. AF - Treatment
• Haemodynamically
unstable patient
• Heparin (5000-10000 IU)
• Life-threatening (Electrical
Cardioversion Immediately)
• Non life-threatening unstable
patient (Electrical Cardioversion if
available or Amiodarone i.e
Rhythm control)
• Known AF or contraindication for
anticoagulation or anti-arrhythmic
drugs (Digoxin i.e. Rate control)
• Haemodynamically Stable patient
• Refer to Cardiology
• Correct underlying abnormality
• Anticoagulate if no sign of cardiac
thrombus
Call For Help

36. Cardiac Ischemia

38. MI - Clinically
• Non-specific complain (50%) keep high index of
suspicion in high risk patient (e.g. upper abdominal
pain, heartburn)
• Chest pain (15%)
• Heart Failure (dyspnea)

39. MI - Diagnosis
• Cardiac consultation in high risk patient
• ECG
• Troponin

40. MI - Treatment
• Consult Cardiology / ICU
• High flow O2
• Secure i.v. Access withdraw samples
• Aspirin 300 mg immediately
• Nitrate sublingual tablets or GTN 2 puffs
• Morphine 5-10 mg (+or- Metoclopramide)
Call For Help

41. Questions?

42. Conclusion
• Predict and appreciate risks
• Monitor appropriately and detect early
• Give routine medications
• Prevent and treat correctable factors
• Give O2 to the compromised patient
• Start Simple treatment immediately
• NEVER leave patient with inadequate CVS function
Call For Help

43. Immediate
Management
• A
• B
• C
• D
• E
Full
Assessment
• Chart
• Sheet / History
and Examination
• Investigations /
Blood results
Plan
• Unstable/Unsure
• Stable
• Diagnosis required
• Definitive treatment
• Medical / high level care
• Surgical
• Radiological
• Daily management plan
• S
• O
• A
• P

44. Summery
• CCrISP approach in Cardiac conditions
• Heart Failure
• Arrhythmias
• Cardiac Ischemia