1. 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
2. Reference:
Harvard Shock symposium
Sunday, August 9, 2009
3. Reference:
Harvard Shock symposium
Sunday, August 9, 2009
4. Objective
• Manage case that is nearly dead, guideline
yet go there
•
Sunday, August 9, 2009
6. 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
8. What are you examining in AF patient?
Sunday, August 9, 2009
9. 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
11. 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
12. Rapid AF
• AHA guideline for management of a patient
with hypotension and AF with RVR would
be cardioversion
• DC Cardioversion
Sunday, August 9, 2009
19. What are you using?
Amiodarone Diltiazem
Adenosine
Digoxin
Beta blocker
Sunday, August 9, 2009
20. What are you using?
Digoxin
Beta blocker
5 min
Sunday, August 9, 2009
21. What are you using?
Digoxin
Cardiovert
Beta blocker
5 min
Sunday, August 9, 2009
22. What are you using?
Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
23. What are you using?
Amiodarone Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
24. What are you using?
Amiodarone Digoxin
Cardiovert
Diltiazem
Beta blocker
5 min
Sunday, August 9, 2009
25. 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
26. 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
28. 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
29. Maintain sinus Rate + anticoag
⇑Hemodynamic Avoid pro
Pro
⇓Thromboembolic arrhythmia
⇓Hemodynamic
Pro arrhythmic Bleeding
Con
Fatality Residual embolic
Sunday, August 9, 2009
31. RV
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
32. •LV systolic function looks
depressed (subcostal long axis
view)
RV
LV
Loss of atrial kick sign?
Sunday, August 9, 2009
33. •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
34. •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
35. •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
37. Loss of atrial kick
What does it cause?
Sunday, August 9, 2009
38. Blood don’t go into
Loss of atrial kick
atrium
What does it cause?
Sunday, August 9, 2009
39. Blood don’t go into
Loss of atrial kick It reflux into neck vein
atrium
What does it cause?
Sunday, August 9, 2009
40. • 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
42. • Patient was treated with Nicardipine IV
• He feel less lightheadeness still chest
discomfort
• Old ECG show no atrial fibrillation
Sunday, August 9, 2009
44. 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
45. Case II
• BP=110/60 HR=130 RR=20 T=37.3
• Complaint of chest tightness,
Sunday, August 9, 2009
49. What would you do?
• Any reason to change rhythm?
• Dead now or later?
•
Sunday, August 9, 2009
50. 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
51. What is your diagnosis?
Next Management?
Sunday, August 9, 2009
52. What will you do in
this patient?
• Physical examinaiton
• Further investigation?
• Further Management
Sunday, August 9, 2009
65. 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