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Cardiac Emergencies made easy Dr. Akram Asi.pptx
- 1. “Saving One LifeIs As If Saving Whole Of Humanity” Quran 5:32 Cardiac Emergencies & Management
- 2. Dr. Muhammad AkramAsi Consultant Cardiologist FCPS Cardiology MD (GOLD Medalist)
- 3. Thanks Medicine Interest Group RawalpindiMedical University
- 4. OBJECTIVES 1. Acute CoronarySyndrome Management of STEMI 2. Dysarrythmias Simplified Classification Management of SVTAVNRT 3. Conclusion 4. Q/A Session
- 5. What is the leadingcause of death worldwide?
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- 7. • Smoking • Hypertension •Diabetes Mellitus • Dyslipidemia • Family History event in first degree relative 55 male/65 female • Chronic Kidney Disease • Lack of regular physical activity • Obesity • Lack of diet rich in fruit, veggies, fiber Expanding Risk Factors
- 8. At least 2of the following 1. Ischemic symptoms 2. Diagnostic ECG changes 3. Serum cardiac marker elevations How to diagnose?
- 9. Gradual onset ofsevere crushing retrosternal diffuse chest pain with gripping in character, radiating to jaw, neck and left arm, aggravating with exertion and associated with sweating and nausea/vomiting. Ischemic Symptoms
- 10. 1. ST-Segment ElevationMI (STEMI) 2. Non-ST-Segment Elevation MI (NSTEMI) 3. Unstable Angina TYPES
- 12. A 62 yearsold male with known history of Obesity, HTN, DM presented with gradual onset of severe crushing chest pain starting from last 2 hours, radiating to jaw, neck and left arm. Pain was associated with sweating. With these symptoms patient came to E/R and you quickly examined the patient. Pulse: 120 bpm BP: 150/90 mmHg RR: 18 breaths per minute. What is your provisional diagnosis..?
- 13. 1.Acute Coronary Syndrome. 2.AcuteAortic Dissection. 3.Pneumothorax. 4.Acute Pericarditis. 5.Acute Cholecystitis. Provisional Diagnosis
- 14. What should beyour next best step..? A 62 years old male with known history of Obesity, HTN, DM and presented with gradual onset of severe crushing chest pain starting from last 2 hours, radiating to jaw, neck and left arm. Pain was associated with sweating. With these symptoms patient came to E/R and you quickly examined the patient. Pulse: 120 bpm BP: 150/90 mmHg RR: 18 breaths per minute. Acute Coronary Syndrome
- 15. • ST-T: Elevationin V1-V6,I,avL and Depression in II,III & avF • Rhythm: Irregular, PVCs • Axis: LAD • Rate: 75bpm • P-Wave: Present and normal • PR: 0.18s • QRS: 0.10s+Normal morphology ECG
- 16. Acute Coronary Syndrome (STEMIOF ANTERIOR WALL WITH PVCs With possible etiology of Atherosclerosis) Definite Diagnosis History (Risk Factors) Clinical Manifestations. Physical Examination. ECG
- 17. MONAAAA MANAGEMENT Admit the Patientin ICU. Resuscitation A+B+C Attach Cardiac Monitor with Defibrillator.
- 18. MANAGEMENT MONAAAA M: Morphine. O: Oxygen. N:Nitrates. A: Antiplatelets: Aspirin and Clopidogrel. A: Anticoagulation. A: Antithrombotic and/or A: Angioplasty.
- 19. Inj Morphine x3mgx diluted x IV Can be repeated after 3-5 minutes Max Dose: 10mg Morphine
- 20. O2 Inhalation ifSPO2 is < 90 % Oxygen
- 21. Sub Lingual: glyceryltrinitrate (Angised) Intravenous: isosorbide dinitrate (Isoket infusion) Inhalation: Nitroglycerine Spray Nitrates
- 22. Tab Aspirin 300mg1 tab x PO x stat (chewing) Tab Clopidogrel 75mg x 4 tablets x PO x Stat Antiplatelets
- 23. Injection Heparin 1CCx (5000 IU) x IV x Stat Anticoagulation
- 24. Injection STREPTOKINASE 1.5 MUx IV x over 1 Hour Antithrombotics
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- 30. BRADYARRHYTHMIA HR <55bpm Look forPR Interval (0.12 to 0.20 Sec) If > 0.20 Sec AV Blocks • 1st degree • 2nd degree • 3rd degree If Normal Look for P-P interval If ≥ 3 Sec Sinus Node dysfunction/ Sick Sinus Syndrome If < 3 Sec Sinus Bradycardia
- 31. TACHYARRHYTHMIA HR >100bpm Look forQRS complexes (0.8 to 0.12 secs) If > 0.12 secs If < 0.12 Sec Broad Complex Tachycardia Narrow Complex Tachycardia Look for rhythm Irregular Regular V. Fib VT
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- 33. Narrow Complex Tachycardia Look forP wave If absent If present Look for rhythm Irregular Regular A. Fib SVT Look for P: QRS ratio 1:1 2:1, 3:1 A. Flutter S. Tachy
- 39. Supraventricular Tachycardias Atrioventricular NodeRe-Entrant Tachycardia (AVNRT) Atrioventricular Reciprocating Tachycardia (AVRT) Atrial Tachycardia Atrial Flutter Atrial Fibrillation Sinus Tachycardia
- 40. Introductio n AVNRT Usually paroxysmalin nature Most common of PSVTs, accounting for two- third of cases. Most common in women. Familial AVNRT has been reported
- 41. SYMPTOMS Palpitations Dyspnea Chest pain Dizziness Sweating Syncope Fatigue
- 43. ECG features AVNRT RegularNarrow complex tachycardia No Visible P waves P waves are retrograde and inverted in II, III and AVF P waves are buried in QRS complex (Descending limb of R wave) Pseudo S wave in Inf leads and Pseudo r wave in V 1
- 45. ECG features • RegularNarrow complex tachycardia • No Visible P waves • P waves are retrograde and inverted in II, III and AVF • P waves are buried in QRS complex (Descending limb of R wave) • Pseudo S wave in Inf leads and Pseudo r wave in V1
- 47. A 28 yearsold female, works in HBL. She presented with sudden onset of racing heart after taking half cup of Capuchino coffee. Moreover she feels dizziness associated with sweating. She has history of similar kind of event in last month but relieved spontaneously, but at this time she has these symptoms for an hour. She came to E/R and you quickly examined the patient. Pulse: > 150 bpm BP: 120/80 mmHg RR: 20 breaths per minute. CNS: Grossly intact What is your provisional diagnosis..?
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- 49. What should beyour next best step..? A 28 years old female, works in HBL. She presented with sudden onset of racing heart after taking half cup of Capuchino coffee. Moreover she feels dizziness associated with sweating. She has history of similar kind of event in last month but relieved spontaneously, but at this time she has these symptoms for an hour. She came to E/R and you quickly examined the patient. Pulse: > 150 bpm BP: 120/80 mmHg RR: 20 breaths per minute. CNS: Grossly intact Tachyarrhythmias
- 50. ECG • HR: 150 •Rhythm : Regular • Axis: Normal • No Visible P waves • P waves buried in QRS complex (Descending limb of R wave) • Pseudo S wave in Inf leads and Pseudo r wave in V1
- 51. Narrow Complex Tachycardia (SVTAVNRT) Definite Diagnosis History (Past History) Clinical Manifestations. Physical Examination. ECG
- 52. Look for signsof instability Acute MANAGEMENT Admit the Patient. Resuscitation A+B+C Attach Cardiac Monitor with Defibrillator.
- 53. Signs of instability Chest pain ASOC Hypotension Shock Shortness of breath pulmo Edema
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- 55. How to prepare? ChemicalCardioversion VAGAL MANEUVERS Valsalva maneuver Carotid Massage (always auscultate carotids) Pharmacotherapy/AV Blockers drugs 1. Adenosin: 6mg,12mg,12mg x iv x stat (if no CI) 2. CCB: Verapamil: 5mg x iv x stat (if no CI) 3. BB: Metoprolol: 5mg x iv x stat (if no CI) 4. Antiarrythmmic: Amiodaron 2
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- 57. Radiofrequency ablation of AP Definite MANAGEMENT Do all base line investigations Thyroid profile Echocardiography ETT/Stress MPI to rule out ischemia
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