This document provides guidance on evaluating and managing common cardiovascular emergencies. It outlines the leading causes of cardiovascular emergencies, including acute chest pain, dyspnea, syncope, and hemodynamic instability. For patients presenting with chest pain, the priority is to differentiate life-threatening etiologies like pulmonary embolism, acute coronary syndrome, and aortic dissection from less serious conditions. The initial evaluation involves vital signs, ECG, CXR, labs including cardiac enzymes and D-dimer, and potentially CT imaging. Prompt diagnosis and treatment are essential given the high mortality associated with cardiovascular emergencies like out-of-hospital cardiac arrest.
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Brief Overview – ACLS Algorithm
Rhythm Based Management of Cardiac Arrest.
Monitoring during CPR.
Access for Parenteral Medications during Cardiac Arrest.
Advanced Airway.
Medications for Arrest Rythms.
Interventions Not Recommended for Routine Use During Cardiac Arrest.
A great tutorial from Dr Alistair Jones NHS medical educator (http://www.yorkshiremedicaleducation.co.uk/about-us) on ECG syndromes. Beyond the basics (but essential knowledge for training emergency physicians)
Cardiogenic shock is a rare condition .in this heart unable to pump an adequate amount of blood flow. types coronary cardiogenic shock and noncoronary cardiogenic shock.causes include any rupture of the in the ventricles .mi condition, any infectious condition,any medication that is a rare condition of the heart Are older
Have a history of heart failure or heart attack
Have blockages (coronary artery disease) in several of your heart's main arteries
Have diabetes or high blood pressure
Are female, Race or ethnicity
Cardiogenic shock signs and symptoms include:
Rapid breathing
Severe shortness of breath
Sudden, rapid heartbeat (tachycardia)
Loss of consciousness
Weak pulse
Low blood pressure (hypotension)
Sweating
Pale skin
Cold hands or feet
Urinating less than normal or not at all
treatment like emergency medication,dopamine ,doputamine ,adrenaline also given as a treatment to the patent. some other surgical procedure is there like cabg , heart transplantationmetc. preventionj oxf this avoid smoking,control alcohol,avoid stress etc
-
Cardiac arrhythmias occur frequently in ICU patients.
12% incidence of ventricular plus supra ventricular arrhythmias for a general icu population.
The most common arrhythmia is sinus tachycardia. Atrial arrhythmias also occur with some frequency , where as ventricular arrhythmias are less common but usually more ominous.
Not all arrhythmias seen in the ICU are of new onset , some patients have preexisting arrhythmias that can be exacerbated by their critical illness
When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?
Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may require more than an advanced life support (ALS) algorithm to effectively treat and suppress.
The mainstay of therapy for our patients in ICU is pharmacotherapy, usually with amiodarone or diltiazem, however specific circumstances may dictate the use of other antiarrhythmic drugs. Ablation therapies may offer effective treatment for ICU patients, however have risks specific to ICU patients, associated with transport, procedural risk, delay of ongoing therapies, requirement for personnel, and isolated location.
This session will outline a practical approach to diagnosis and management of common and important arrhythmias in the ICU, and will include case and ECG discussions.
Brief Overview – ACLS Algorithm
Rhythm Based Management of Cardiac Arrest.
Monitoring during CPR.
Access for Parenteral Medications during Cardiac Arrest.
Advanced Airway.
Medications for Arrest Rythms.
Interventions Not Recommended for Routine Use During Cardiac Arrest.
A great tutorial from Dr Alistair Jones NHS medical educator (http://www.yorkshiremedicaleducation.co.uk/about-us) on ECG syndromes. Beyond the basics (but essential knowledge for training emergency physicians)
Cardiogenic shock is a rare condition .in this heart unable to pump an adequate amount of blood flow. types coronary cardiogenic shock and noncoronary cardiogenic shock.causes include any rupture of the in the ventricles .mi condition, any infectious condition,any medication that is a rare condition of the heart Are older
Have a history of heart failure or heart attack
Have blockages (coronary artery disease) in several of your heart's main arteries
Have diabetes or high blood pressure
Are female, Race or ethnicity
Cardiogenic shock signs and symptoms include:
Rapid breathing
Severe shortness of breath
Sudden, rapid heartbeat (tachycardia)
Loss of consciousness
Weak pulse
Low blood pressure (hypotension)
Sweating
Pale skin
Cold hands or feet
Urinating less than normal or not at all
treatment like emergency medication,dopamine ,doputamine ,adrenaline also given as a treatment to the patent. some other surgical procedure is there like cabg , heart transplantationmetc. preventionj oxf this avoid smoking,control alcohol,avoid stress etc
-
Cardiac arrhythmias occur frequently in ICU patients.
12% incidence of ventricular plus supra ventricular arrhythmias for a general icu population.
The most common arrhythmia is sinus tachycardia. Atrial arrhythmias also occur with some frequency , where as ventricular arrhythmias are less common but usually more ominous.
Not all arrhythmias seen in the ICU are of new onset , some patients have preexisting arrhythmias that can be exacerbated by their critical illness
Cardiology 1.1. Chest pain - by Dr. Farjad IkramFarjad Ikram
Introduction to one of the most common symptoms that can represent a wide range of diseases, from benign to life-threatening, covering number of systems including gastrointestinal, cardiovascular, pulmonary, musculoskeletal and psychiatric. Includes a brief explanation of anti-anginal therapy.
Template design credits - http://www.slidescarnival.com
Chronic Stable Angina- Diagnosis & management
By Dr Awadhesh Kumar Sharma
Dr. Awadhesh kumar sharma is a young, diligent and dynamic interventional cardiologist. He did his graduation from GSVM Medical College Kanpur and MD in Internal Medicine from MLB Medical college jhansi. Then he did his superspecilisation degree DM in Cardiology from PGIMER & DR Ram Manoher Lohia Hospital Delhi. He had excellent academic record with Gold medal in MBBS,MD and first class in DM.He was also awarded chief ministers medal in 2009 for his academic excellence by former chief minister of UP Smt Mayawati in 2009.He is also receiver of GEMS international award.He had many national & international publications.He is also in editorial board of international journal- Journal of clinical medicine & research(JCMR).He is also active member of reviewer board of many journals.He is also trainee fellow of American college of cardiology. He is currently working in NABH Approved Gracian Superspeciality Hospital Mohali as Consultant Cardiologist.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. Introduction
• Cardiovascular disease is the most prevalent
disease worldwide.
• It is the leading global cause of death, accounting
for 15 million deaths in 2015 .
• Cardiovascular disease often presents in
emergency situations; prompt treatment is
essential to reduce mortality.
3. • Out-of-hospital cardiac arrest is one of the most
dreadful conditions leading to over 90% mortality
rate
• “Time is gold” has always been The cornerstone
of cardiovascular emergency management ;For
example in patients with STEMI, every 30-minute
delay in door to balloon time translates into 7.5%
relative increase in mortality
14. Case scenario
• A 68- year -old obese man is brought in by ambulance
to the emergency room complaining of abrupt onset
of chest discomfort for the past hour .
• He describes “severe aching ” under the distal aspect
of his sternum with radiation into the inferior left side
of his chest.
• His symptoms started at rest, have been constant, an
worsen when he takes a deep breath.
• He has a history of acid reflux disease, alcoholism,
hyperlipidemia, hypertension, prostate cancer, and
strong family history of myocardial infarction
15. • On examination, the patient appears restless and in
modest distress.
• Vital signs are temperature 37°c, heart ate 112 bpm,
blood pressure 80/ 60 mmHg in the left arm and 85/
65mmHg in the right arm, respirations 26 breaths/min,
and oxygen saturation 90% on room air .
• The patient’s breathing is labored , with normal breath
sounds.
• He has a tachycardic regular rhythm without
murmurs, rubs, o gallops.
• The epigastrium is mildly tender to palpation, and his
stool is negative for occult blood.
16. • What are the priority diagnosis to evaluate?
• What are your next diagnostic steps?
18. Summary:
• This 68-year-old man presents with vague
substernal and left-sided chest pain for 1 hour.
• His pain is associated with dyspnea, tachypnea,
and unstable vital signs, including hypotension,
tachycardia, and relative hypoxia.
• He is currently in respiratory distress, and triage
should focus on differentiating between possible
life threatening etiologies of his symptoms that
require urgent attention.
19. This patient has Risk factors for:
• 1-Thromboembolic disease (obesity and
malignancy).
• 2-Cardiovascular disease (obesity, age, gender,
hypertension, hyperlipidemia, and a strong family
history).
• 3-Peptic ulcer disease (acid reflux and
alcoholism).
• As such, the differential should initially be kept
broad, and narrowed once life- threatening
causes are ruled out.
20. Priority differential diagnosis:
• “Can’t miss” diagnoses include:
1- Pulmonary embolism (PE),
2-Acute coronary syndrome (ACS),
3-Aortic dissection
4-Tension pneumothorax
since these are potentially fatal conditions.
21. Next diagnostic steps:
• ECG
• CXR
• Labs (including cardiac biomarkers and ABG)
• Consider contrast enhanced CT of the chest.
22. Approach for Chest Pain
DEFINITIONS:
ACUTE CORONARY SYNDROME (ACS):
• 1-Unstable angina
• 2-Non-ST elevation MI
(NSTEMI)
• 3-ST elevation MI (STEMI)
23. Approach for Chest Pain
DEFINITIONS:
Percutaneous coronary intervention
Catheter-based therapy by
which blood flow is restored
to an occluded coronary artery
by balloon angioplasty or
stenting
24. Differential Diagnosis
• The differential diagnosis of chest pain is
extensive, and although it is usually due to
benign causes, some causes of chest pain may
be life-threatening.
• As such, for each patient presenting with
chest pain, serious causes should be ruled out
before less dangerous conditions are
considered
25.
26. • Non-emergent chest pain evaluated in the primary
care office is most often due to musculoskeletal pain
followed by gastrointestinal issues and is less
commonly due to cardiac causes (most of which are
stable angina).
• Acute chest pain in patients with risk factors for
coronary artery disease will be more likely to be
cardiac in origin (in patients older than 40, up to 50%
of cases will be due to a cardiac cause) .
27. History
Chest pain analysis
• Onset, course duration
• Site and radiation
• Character and duration
• Precipitating and relieving
factors
• Associated symptoms
• Severity
Risk factors and type of patient
• DM
• Hypertension
• Smoking
• Obesity
• Family history
• Age
• Prior similar attacks
• Prolonged Immobilization
• Recent surgery
• Oral contraceptive pills
28. History suggestive of MI
Chest pain analysis
• Site: Retrosternal
• Radiation :left or right shoulder or both ,back,
lower jaw, epigastrium
• Character: Compressing, heaviness, Burning
• Duration: More than 20 minutes
• Precipitating factors: Physical or emotional stress
• Relieving factors: Rest or SL nitrates
• Associated symptoms: Vomiting, sweating
dyspnea and syncope
29. History suggestive of MI
Risk factors and type of patient
• DM
• Hypertension
• Smoking
• Obesity
• Family history
• Age
• Prior similar attacks
30. Important tips
• Normal ECG does not rule out ACS
• Do not allow patient presenting to ER at night with
acute chest pain to go home
• Presentations may be atypical in the elderly, women,
and diabetics.
• Up to one-third of these patients may not experience
classic ischemic chest pain with myocardial infarction
(MI).
• They can present with dyspnea(angina equivalent) or
fatigue, syncope, arrhythmia, acute HF or even silent
infarction.
• Epigastric pain may be sign of inferior infarction
31. History suggestive of aortic dissection
Chest pain analysis
• Sudden tearing chest
pain refer to the
back in interscapular
region
• Severe pain from
the start
Risk factors and type of patient
• Usually male patient
,smoker with
uncontrolled
hypertension
• Marfan syndrome
32. Important tip
• The possibility of aortic dissection should be
excluded in every patient with ACS as
antiplatelet and anticoagulant as well as
thrombolytic therapy are contraindicated and
will be catastrophic in patients with aortic
dissection
33. History suggestive of pneumothorax
Chest pain analysis
• Pleuritic chest pain:
stitching localized chest
pain that increase with
cough or deep
inspiration or positional
pain
• Associated with severe
dyspnea
Risk factors and type of patient
• Spontaneous
pneumothorax classically
occurs in tall patients,
those with cystic fibrosis,
α1-antitrypsin deficiency,
following trauma to the
chest, or iatrogenically
• Patient with long history
of chest problems(COPD,
BA)
34. Important tip
• Any patient with chest pain and normal ECG
should have a CXR to look for pneumothorax
or wide mediastinum
35. History suggestive of pulmonary
embolism
Chest pain analysis
• Typical chest pain
or
• Pleuritic chest pain:
stitching localized chest
pain that increase with
cough or deep inspiration
or positional pain
• Associated with severe
unexplained dyspnea
Risk factors and type of patient
• Prolonged
Immobilization
• Recent surgery
• Oral contraceptive
pills
• Malignancy
• Pregnancy
36. Important tip
• Any patient with unexplained dyspnea with
normal CXR should be considered pulmonary
embolism until proved otherwise
37. Less urgent causes of chest pain that
may mimic MI include the following
• Pericarditis (pain is typically better when leaning forward, and may
be pleuritic)
• Myocarditis (may be preceded by a recent flulike illness)
• Pneumonia (may be associated with fevers, chills, cough, and
leukocytosis)
• Peptic ulcer (pain is more epigastric, is reproducible, and may be
associated with peritoneal signs if perforated)
• Pancreatitis
• Cholecystitis
• Musculoskeletal pain (always a diagnosis of exclusion).
38. Physical Exam
1-Vital signs
• Assessment of the vital signs is essential in the early evaluation of
chest pain.
• Pulmonary embolism:
Tachycardia and tachypnea may be early signs of a pulmonary
embolism, even if the patient is not hypoxic.
• Aortic dissection:
• Blood pressure differential of >20 mmHg between the arms is
suggestive of an aortic dissection.
40. Chest examination
1-Acute coronary syndrome:
• Final bilateral basal crepitation if complicated
with heart failure
2-Pneumothorax:
• Unilateral bulge or limited chest expansion
• Hyper-resonance by percussion
• Diminished breath sounds
41. Important tips
• The physical examination may be completely
normal in a patient with life-threatening chest
pain.
• As such, a normal exam may be falsely
assuring, and diagnostic testing should be
done.
42. Diagnostic Testing
1-ECG:
• An ECG should be obtained within 10 minutes of arrival to
the ED to rule out acute MI
2-CXR:
(Wide mediastinum, pneumothorax)
3-Echocardiography:
(RWMAs or dissection flap)
4-CT:
(Triple rule out, CT aortography, CT pulmonary
angiography, CT coronary angiography)
5-Labs:
D-dimer and cardiac enzymes ,ABG
55. Important tips
• Do not wait for cardiac enzymes in patients
with STEMI
• D-dimer is a good negative test but it should
be only used in patients with low or
intermediate probability of pulmonary
embolism
• First set of cardiac enzymes may be normal
and you ask for serial cardiac enzymes
56. Management of ACS
• 1-Loading dose of dual antiplatelet therapy :
4 tablets Acetyl salicylic acid(4 tablet Aspocid 75mg)
and
4 tablets Clopidgrel ( 4 tablet Plavix 75 mg)
or
2 tablet Ticagrelor( 2 tablets of Birlique 90 mg)
• 2-Pain relief by morphia or SL nitrates(Dinitra 5 mg SL
tab)
57. Management of ACS
• 3-Reperfusion or revascularization
STEMI
Patients with STEMI should immediately proceed to PCI, and patients
with STEMI who cannot receive PCI within 120 minutes should be
considered for thrombolysis (with an agent such as streptokinase or
alteplase), whereas lytic agents are contraindicated in NSTEMI.
NSTEMI
For NSTEMI, if not high-risk, PCI can be delayed for up to 72 hours,
and patients with high-risk NSTEMI (persistent chest pain, heart
failure, or electrical instability) should proceed immediately to PCI.
4-Anticoagulation,ACEI, Betablocker ,statins and PPI
58. Management of aortic dissection
• Patients with aortic dissection are typically emergently
treated with IV beta-blockers (which decrease heart rate,
blood pressure, and shear force of blood along the arterial
wall) and afterload reduction with nitroprusside.
• Type A dissections (involving the ascending aorta to the
left subclavian artery) are typically managed with
immediate surgery
• Type B dissections (involving the descending aorta distal to
the left subclavian artery) may be initially managed
medically with surgery reserved for patients with refractory
pain or evidence of end-organ hypoperfusion.
59. Management of pneumothorax
In the case of simple, uncomplicated pneumothorax:
• patients are typically monitored closely with serial
CXR, and 100% oxygen may be empirically
administered to increase the rate of absorption.
Patients with tension pneumothorax
• Usually unstable on presentation, and require a needle
thoracotomy to the 2nd intercostal space,
midclavicular line.
• This immediately relieves the pressure, and a chest
tube may be placed surgically immediately thereafter.
60. Management of pulmonary embolism
• Parenteral and oral anticoagulation
• Thrombolytic therapy(If there is hemodynamic
instability or shock)
• Ogygen
61. Tachyarrhythmia
• Any patient presenting with tachyarrhythmia
and hemodynamically unstable you must go
synchronized DC cardioversion
62. Bradyarrhythmia
• You can give up to 3 mg atropine(0.5mg every 5 minutes)
• Always suspect hyperkalemia and if so you should give
anti-hyperkalemic measures
Slow IV calcium gluconate over 15 minutes
100 cc glucose 25% with 10 units of rapid acting insulin)
Nebulizer with beta agonist (farcoline)
Lasix
Sodium bicarbonate if there is acidosis)
• Refer for possible temporary or permanent pacemaker
70. Important tips
• SL nifidipine (Epilat) is absolutely
contraindicated and no longer used as it can
lead to acute severe lowering of BP with
subsequent cerebral hypoperfusion and
stroke
• Lasix is not used in hypertensive urgency, it is
used only in hypertensive emergency in form
of acute pulmonary edema
72. Cardiac arrest
You should follow BLS and ALS algorithm
putting in mind the difference between:
• 1-Shockable rhythms(VF or pulseless VT):
you should give non-synchronized DC
cardioversion
• 2-Non-Shockable rhythms(Bardy-Asystole)
74. COMPREHENSION QUESTIONS
• 1-A 68-year-old man with no medical history presents
to a rural emergency department with chest pain for
the past 30 minutes.
• The ECG shows ST elevation in V3–V6 and I, and aVL.
• The hospital is not equipped for PCI, and the closest
hospital that performs PCI is 3 hours away.
• Vital signs are HR 110 bpm, BP 150/84 mmHg, RR 18
per minute, and O2 saturation 98% on room air (RA).
• In addition to aspirin and IV heparin, what is the most
appropriate next step?
75. • A. Administration of full-dose thrombolysis, and transfer to
the nearest PCI capable hospital for angiography
• B. Administration of full-dose thrombolysis, and
subsequent transfer only if patient is unstable
• C. Administration of half-dose thrombolysis, and transfer to
the nearest PCI capable hospital for immediate PCI
• D. Medical management with the addition of clopidogrel
76. • 1 A.
• Patients who present to a hospital not equipped
for PCI who are more than 120 minutes from the
nearest PCI-capable hospital should be given
thrombolysis unless contraindicated.
• Angiography can then be performed, and PCI
carried out if reperfusion is not complete.
• Trials of half-dose lytic and immediate PCI (called
“facilitated PCI”) have not shown favorable
results, and this strategy is not advocated.
77. • 2 -A 70-year-old woman with a history of hypertension,
coronary artery disease, and smoking presents with
tearing chest pain across the chest that radiates to the
back for the past 1 hour.
• Vitals are HR 100 bpm , BP 190/110 mmHg, RR 18 per
minute, and O2 saturation 97% on RA.
• A chest CT with contrast shows an aortic dissection
extending 1 cm distal to the left subclavian artery to 2
cm superior to the renal arteries.
• What is the most appropriate management strategy?
78. • A. Immediate surgery
• B. Administration of IV labetalol, nitroglycerine,
and surgery when stable
• C. Administration of IV heparin, IV metoprolol,
and continued monitoring
• D. Administration of IV heparin, IV nitroprusside,
IV metoprolol, and continued monitoring
• E. Administration of IV metoprolol, IV
nitroprusside, and continued monitoring
79. • 2 E.
• This patient has a type B aortic dissection, which may
be managed medically with IV metoprolol and IV
nitroprusside.
• Intravenous labetalol does not reduce shear force of
blood along the arterial wall as well as metoprolol, and
• nitroglycerine is generally considered inferior to
nitroprusside for afterload reduction.
• Surgery is not required unless the aneurysm continues
to extend or there are complications, and IV heparin is
contraindicated.
80. • 3 An 18-year-old man presents with chest pain
and dyspnea with deep breathing for the past
1 hour. Vitals are stable. CXR shows a small
pneumothorax involving 10% of area of the
left lung.
• What is the most appropriate management
strategy?
81. • A. Needle thoracotomy of the 2nd left
intercostal space, midclavicular line
• B. Placement of a chest tube
• C. 100% oxygen and serial CXR over the next
24 hours
• D. Albuterol inhaler, 100% oxygen, and chest
physical therapy
82. • 3 C.
• This young man has a simple, uncomplicated
pneumothorax, which may be monitored with
serial CXR for stability.
• No urgent intervention is required, and 100%
oxygen may help it resorb.
• Needle thoracotomy and chest tube are
therapies reserved for tension pneumothorax.
83. • 4 A 45-year-old man with a history of
hypertension and lung cancer presents with
pleuritic chest pain, and left calf swelling after
a 4-hour plane flight.
• He is tachycardic, hypoxic, but otherwise
stable.
• What is the most appropriate next step in
management?
84. • A. Obtain a left lower extremity venous
ultrasound
• B. Obtain a chest CT scan with contrast
• C. Obtain a bedside transthoracic
echocardiogram
• D. Check a d -dimer
• E. Empiric administration of IV unfractionated
heparin
85. • 21.4 B.
• This patient likely has a pulmonary embolism,
caused by a left lower extremity deep-vein
thrombosis (DVT).
• The next best step is to obtain a chest CT with
contrast to confirm the diagnosis.
• In patients with renal insufficiency, a venous
ultrasound to confirm a DVT may be sufficient
to infer a diagnosis, but is less ideal.
86. • A bedside echocardiogram is typically unnecessary
unless the right heart needs to be assessed in a patient
with signs of hemodynamic instability.
• A d-dimer is reasonable to rule out a PE in a patient
with low to intermediate probability for PE; however,
this may be falsely elevated in this patient with lung
cancer.
• IV heparin should not be administered without a
diagnosis if this can be avoided.