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CARDIAC
EMERGENCIES
Andrew Crouch DO PGY-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. H...
Answer C (V-Fib)
• Commotio cordis
• occurs when an object such as a baseball strikes the

chest and produces sudden death...
Ischemic Heart Disease
• Leading cause of

Death in USA
• 30% all deaths

• Etiology
• Insufficient blood supply
to myocar...
Coronary Anatomy
• Left Main Coronary
• LAD
• Widowmaker
• Anteroseptal

• Left Circumflex
• Anterolateral (if left domina...
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....
Chest Pain
Atypical Chest Pain

• Women Diabetic and

Elderly
• Fatique, nausea,
epigastric pain,
palpatations, chest wall...
Signs of ACS
• Vitals
• Tachycardia, Bradycardia (RCA) , hypertension, hypotension
• Cardiac Exam
• New S3 or S4
• New Mur...
ECG
• Initially abnormal in <50% of patients with ischemic chest

pain
• Meaning often it is perfectly normal
T wave morphology changes
• Hyperacute T waves
• Earliest sign
• Prominent symmetrical, pointy
• T wave flattening or inve...
ST segment Changes
• ST Elevation
• Elevation >1mm in 2 contiguous leads
• ST depression
• Measured from the PR segment to...
QRS
Sgarbossa's criteria
• Three criteria are included in

Sgarbossa's criteria:
• ST elevation ≥1 mm in a lead

with a positi...
Arrhythmias of ACS
• Bradycardia
• SA or AV node involvement
• Tachycardia
• Reperfusion, autonomic tone, hemodynamic inst...
AnteroSeptal MI
• Septal
• ST elevations in V1 and V2
• Anterior
• ST Elevations in V3 and V4
• LAD occlusion
• High grade...
A little harder
Lateral Wall MI
• ST elevations in I, aVL, V5 and V6
• Left Circumflex artery
Too Easy
Inferior
• Inferior
• ST elevations in II, III, aVF
• Primary RCA occlusion
• AV dysfunction
• Up to 25% have right ventri...
Right sided ECG
• ST elevations in V4R

and V5R are
diagnostic of Right
ventricular infarct
WTF?
Posterior
• Large R waves & ST

depressions in V1
and V2
ECG changes correlate to Pathology
• ST changes in V1-4

• Anteroseptal

• V4-6, I, aVL

• Anterolateral

• I & aVL

• Lat...
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
...
Cardiac Enzymes
• Troponin
• Specific for Cardiac injury (Tt 94% and Ti 100%)
• Positive 2 to 6hours and remain elevated f...
Testing
• ECHO
• Regional wall
abnormality
• Poor correlation

• Dobutamine Stress

• Treadmill testing
• Sensitivity 65% ...
Treatment ACS
• Oxygen
• Antiplatelet
• ASA 162 to 325mg, should be
chewed
• Do not use if possibly Aortic

Dissection
• P...
Anti Thrombotics
• Heparin
• Activates Antithrombin III
• Bolus 60-70 U/kg
• Then infuse 12-15 U/kg

• Bivilirudin
• Direc...
Thrombolysis
• Indicated if
• ST Elevations >1mm in 2 contiguous limb leads
• ST Elevation >2mm in 2 contiguous Chest Lead...
Thrombolysis
Absolute Contraindication

• Aortic Dissection
• Active GI bleed or internal

Bleed
• Brain tumor, Bleed or A...
Question
• Which of the following AV nodal blocks is most commonly

•
•
•
•

associated with an acute inferior wall myocar...
Answer C
• Type I
• Type II more likely with anterior not inferior MI
PCI
• Gold Standard
• Door to Balloon <90 Min
• Presentation > 3hours
• Thrombolysis should be performed over PCI if prolo...
Question

• A 62-year-old man presents to the ED with a mild cough and

URI symptoms. He was discharged from the hospital ...
• A Pericarditis
• B Postmyocardial infarction syndrome

Pulmonary embolism
D Ventricular aneurysm


C
Congestive Heart Failure
• 3.4 million ED visits per year
• 70-80% of patients with CHF die within 8 years
• Left vs Right...
Left vs Right
Right Heart failure

Left Sided Heart failure

• JVD

• Pulmonary Edema

• Dependent Edema

• Orthopnea

• L...
Pathophysiology
Hemodynamic Model

• Left Ventriclar pressure

increases leading to high
end diastolic filling
pressure
• ...
New York Heart Association (NYHA)
• Class I : No limitation
• Class II : Slight limitation at high exertion
• Class III: M...
Symptoms
• Exertional Dyspnea
• Orhtopnea
• Dimished Pulse pRessure
• Pulsus Alterans
• Bilateral Rales

• Pitting Edema
•...
Diagnosis
• CXR
• can show congestion
• Cardiomegally
• Kerly B Lines
• Pleural effusion R>L
• Interstitial Hilar infiltra...
Kerley B lines
Bat Wigging out
Sorry… Bat winging
Management
• Oxygen
• CPAP and BIPAP
• Decrease work of
breathing
• Decreased mortality
• Contraindicated if Altered
• Int...
Management
• Afterload reduction
• Nitates
• NTG
• Nitroprusside

• ACE inhibitors and

ARBS
• Decrease afterload and

inc...
Dilated Cardiomyopathy
Causes
• Infection
• Idiopathic
• Familial diseases
• (Pompe’s Disease)
• Pregnancy
• Sarcoidosis
•...
Dilated Cardiomyopathy
• In the US Viral illness is the most common cause
• World Wide the most common cause is

Protozoan...
Hypertrophic cardiomyopathy
• Asymetrical Septal Hypertorphy
• Hypertrophic Obstructive cardiomyopathy
• Idiopathic Subaor...
Epidemiology
• Common Cause death in young athletes
• Mortality 4% if untreated
• Autosomal Dominant
• Mutation leading to...
Diagnosis
• Murmur
• Harsh Systolic Murmur
• Increase with Valsalva, Amyl nitrate
• Decrease with Squatingm Leg raise, han...
Management
• Beta Blockers
• Verapamil
• Disopyramide (Class Ia anti-arrhythmic)
• NO Diuretics
• AICD

• Pacemaker
• Sept...
Pericardial Tamponade
• Fluid in pericardial space
• Normal 15-30ml effusions

can get >1L if occur slowly
but in cases of...
Tamponade
• Becks triad
• Hypotension
• JVD
• Distant heart sounds
• Kussmal sign
• Paradoxical jugular venous distention ...
Electrical Alternans
Treatment
• Fluids
• Pressors
• If hemodynamic compromise do pericardiocentsis
• Pericardial window is definitive treatmen...
Pericarditis
• Idiopathic #1 Cause
• Infectious
• Viral
• Bacterial
• Tuberculosis
• Fungal
• Malignancy
• Drug-induced (p...
Diagnosis
• Blood
• CBC
• Elevated WBC could point to

infection

• BUN
• Uremia
• Serology
• Rheumatoid arthritis and lup...
Treatment
• #1 treat underlying cause if can be found
• Viral or Idiopathic Pericarditis
• NSAIDs
• Bacterial
• Antibiotic...
Andrew Crouch, DO- Cardiac Emergencies...Emergency Medicine Board Review 2014, ARMC Emergency Medicine
Andrew Crouch, DO- Cardiac Emergencies...Emergency Medicine Board Review 2014, ARMC Emergency Medicine
Andrew Crouch, DO- Cardiac Emergencies...Emergency Medicine Board Review 2014, ARMC Emergency Medicine
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Andrew Crouch, DO- Cardiac Emergencies...Emergency Medicine Board Review 2014, ARMC Emergency Medicine

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Andrew Crouch, DO- Cardiac Emergencies...Emergency Medicine Board Review 2014, ARMC Emergency Medicine

  1. 1. CARDIAC EMERGENCIES Andrew Crouch DO PGY-2
  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. 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. 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. 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. 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. 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. 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. 9. ECG • Initially abnormal in <50% of patients with ischemic chest pain • Meaning often it is perfectly normal
  10. 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. 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. 12. QRS
  13. 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. 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
  15. 15. AnteroSeptal MI • Septal • ST elevations in V1 and V2 • Anterior • ST Elevations in V3 and V4 • LAD occlusion • High grade Heart Blocks
  16. 16. A little harder
  17. 17. Lateral Wall MI • ST elevations in I, aVL, V5 and V6 • Left Circumflex artery
  18. 18. Too Easy
  19. 19. Inferior • Inferior • ST elevations in II, III, aVF • Primary RCA occlusion • AV dysfunction • Up to 25% have right ventricular infarction • Do not give Nitro
  20. 20. Right sided ECG • ST elevations in V4R and V5R are diagnostic of Right ventricular infarct
  21. 21. WTF?
  22. 22. Posterior • Large R waves & ST depressions in V1 and V2
  23. 23. 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
  24. 24. 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
  25. 25. 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
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. Answer C • Type I • Type II more likely with anterior not inferior MI
  33. 33. 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
  34. 34. 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?
  35. 35. • A Pericarditis • B Postmyocardial infarction syndrome Pulmonary embolism D Ventricular aneurysm 
C
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. Symptoms • Exertional Dyspnea • Orhtopnea • Dimished Pulse pRessure • Pulsus Alterans • Bilateral Rales • Pitting Edema • Hepatomegally • Acities • JVD • S3 gallop • Loud P2
  41. 41. 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
  42. 42. Kerley B lines
  43. 43. Bat Wigging out
  44. 44. Sorry… Bat winging
  45. 45. 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
  46. 46. 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
  47. 47. 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
  48. 48. Dilated Cardiomyopathy • In the US Viral illness is the most common cause • World Wide the most common cause is Protozoan, Trypanosoma Cruzi “Chagas Disease”
  49. 49. Hypertrophic cardiomyopathy • Asymetrical Septal Hypertorphy • Hypertrophic Obstructive cardiomyopathy • Idiopathic Subaortic Stenosis
  50. 50. Epidemiology • Common Cause death in young athletes • Mortality 4% if untreated • Autosomal Dominant • Mutation leading to dysfunctional cardiac sarcomere production • Leads to Diastolic dysfunction
  51. 51. 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
  52. 52. Management • Beta Blockers • Verapamil • Disopyramide (Class Ia anti-arrhythmic) • NO Diuretics • AICD • Pacemaker • Septal Ablation • Myomectomy
  53. 53. 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
  54. 54. 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
  55. 55. Electrical Alternans
  56. 56. Treatment • Fluids • Pressors • If hemodynamic compromise do pericardiocentsis • Pericardial window is definitive treatment
  57. 57. Pericarditis • Idiopathic #1 Cause • Infectious • Viral • Bacterial • Tuberculosis • Fungal • Malignancy • Drug-induced (procainamide) • Miscellaneous: connective tissue disease or • autoimmune • Uremia • Postradiation • Dressler syndrome • Myxedema
  58. 58. 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
  59. 59. 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

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