My Experiances of Cardiac Emergancy at Workplace
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Transcript of My Experiances of Cardiac Emergancy at Workplace
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Cardiac emergencies at workplace
Dr S A MerchantInterventional Cardiologist
DM MD DNB FSCAILilavati, Saifee, Raheja fortis, Seven hills, BSES Hospitals
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Cardiac Symptoms at Work place
Chest pain
Breathlessness
Palpitations
Headache / Giddiness
Presyncope/syncope/sweats
Paraesthesia/weakness of limbs
General fatigue/weakness
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Keep Diagnosis in Mind
Acute myocardial infarction
Acute coronary syndrome
Heart failure
Pulmonary embolism Cardiac tachyarrhythmias
Hypertensive emergencies
Bradyarrhythmia vasovagal
TIA/Stroke
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Vitals in cardiac emergency at workplace
Level of Consciousness of patient
Pulse, heart rate and peripheral pulsations
Blood pressure
Oxygen saturation Auscultation of chest for heart sound and lungs for
rales / rhonchi
CNS evaluation for neurological deficits
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Basic cardiac emergency tray at workplace
Pulse oximeter
Stethoscope
BP intrument
ECG machine IV excess
IV fluids DNS, NS, Colloids
IV Atropine , adrenaline, NE, dopamine , xylocaine
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Drugs : Aspirin, clopidogrel , sorbitrate , SLNifedipine, NTG patch/spray, inj clexane,metoprolol, statins, Inj fortwin /phenergan, IV lasix
Monitor for heart rate , non invasive BP cuff,oxygen saturation
Oxygen, BIPAP
Foleys catheter for urine output
Defibrillator
TCP if possible
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Initial Diagnosis of STEMI
Dr S A Merchant
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Transport of Patients With STEMI and InitialReperfusion Treatment
J Am Col l Cardio l. 2004;44:671; Circulat ion. 2004;110:588.
EMS transport
Onset of
symptoms of
STEMI
9-1-1
EMS
dispatch
EMS on scene Encourage 12-lead ECGs
Consider prehospital fibrinolytic
if capable and EMStoneedle
within 30 min
GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Doortoneedle
30 min
Inter-
hospital
transfer
Golden Hour = 1st60 min Total ischemic time: within 120 min
Patient EMS Prehospital fibrinolysisEMStoneedle
30 min
EMS transportEMStoballoon 90 min
Patient self-transport
Hospital doortoballoon
90 min
Dispatch
1 min
5
min
8
min
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Complete
obstruction
Partial
flow
Full flow
Partial Successwith
pharmacologic
reperfusion
Rethrombosis:Prevented by antip latelet
and ant icoagulant Rx
PCI p lyticIdeal goal ofpharmacologicreperfusion
Pharmacoinvasive approach
Dr S A Merchant
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ECG changes in AMI
50% of pts have abn T wave that is prolonged or peaked followed by
STseg with reciprocal STseg in opp leads & followed by Q wave
formation
40% of pts develop T wave
or STseg depression
10% of pts with AMI have normal ECG
- sp posterolateral (high lateral) wall MI with acute occlusion of CX or OM
Diagnosis of Myocardial Infarction
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Thrombolytics : Streptokinase, urokinase, t PA
Sedation : Alprozalam, Diazepam, Fortwin, Fentanyl
Aspirin : 325 mg stat & one daily risk of MI &death
Clopidogril : 300 g loading dose & 1 tablet after lunch
IV heparin or LMWH : Inj Clexane or Inj arixta If pain still continues : add b-blocker (atenolol, Metoprolol) or
Diltiazem 3090 mg 8 hourly
If pain still persists : urgent angios, PTCA+stent to culprit lesion or CABGfor left main or multivessel disease.
IABP prior to angio helps to relieve rest pain by unloading action of IABP in LV, cor bl flow,
myo O2demand,
LVEDP, cor perfusion IV Reopro/Integrillin : given before PTCA/Stenting
ACE Inhibitor & Statins : Stabilizes plaque & improves endothelial function
MN of pts with unstable AnginaManagement of Myocardial Infarction
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Take Home Message:
Optimum management of STEMI
A PharmacoInvasive Approach
Initial Fibrinolysis with t-PA within 30-60 mins of chest pain inambulance, nursing home, non-PCI hospital
Endovascular cooling: Aspirin, loading dose clopidogril/prasugrel,
Inj Enoxyparin, GpIIb/IIIa Inhibitor, nitrates, Ace-Inhibitors, beta
blocker, diltiazem, high dose statins, trimatazione, sedation
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Transfer patient within 6 hours to PCI centre for
Cor angiography
Thrombectomy: Suction by Export Cath, AngioJet, M Guard
Direct stenting
Intracoro NTG/Nicorandil
This makes sense to everyone patient, relations, family doctor, consultant
physician, interventional cardiologist. Also, both short term & long term clinicaltrials show excellent result with pharmacoinvasive approach in terms of reduce
mortality, re-infarction & overall preservation of LV function
Management in Myocardial Infarction
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Vitals in cardiac EmergenciesMonitoring In ICU
Consists of :
ECG monitor
Arterial Saturation on oximeter
Non invasive BP cuff
Radial line for invasive arterial pressure
Central line/PA cather
Foleys catheter for hourly urine output
ABG
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h
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Occlusion of mid-RCA.
Mr. Davies48 yrs. Dr S A Merchant
i 8 S h
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Dr S A MerchantMr. Davies48 yrsMr. Davies48 yrs. Dr S A Merchant
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M D i 48 D S A M h t
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Direct stenting complicated by distal embolization
of posterolateral branch.
Dr S A MerchantMr. Davies48 yrsMr. Davies48 yrs. Dr S A Merchant
M D i 48 D S A M h t
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Successful aspiration of the distal thrombus with
the Export catheter.
Dr S A MerchantMr. Davies48 yrsMr. Davies48 yrs. Dr S A Merchant
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Angiography:
LM thrombotic occlusion; 75% ostium of RCA.
Procedure:
IABP. LM aspiration thrombectomy. Predilatation and
DES of LM-LAD; final kiss balloon.
Dr S A Merchant
Cardiogenic shock in AMI
Mr Mishra 60 yrs Dr S A Merchant
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LM occlusion.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
Mr Mishra 60 yrs Dr S A Merchant
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RCA ostium severe stenosis.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
Mr Mishra 60 yrs Dr S A Merchant
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Final kiss balloon after thrombectomy and
stenting.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
Mr Mishra 60 yrs Dr S A Merchant
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After kiss balloon post-dilation.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
Mr Mishra 60 yrs Dr S A Merchant
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RCA stenting.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
Mr Mishra 60 yrs Dr S A Merchant
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Six-month F-U.
Dr S A MerchantMr. Mishra60 yrsMr. Mishra60 yrs. Dr S A Merchant
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Basic Life Support (BLS)consists of ABCAirway, Breathing &
Circulation.
Advance Cardiac Life Support (ACLS) Emphasize the interact of
CPR with emergency stabilization & transport, ventillatory
support, IV access, pharmacotherapy and electrical Rx.
Delay in initiation of either BLS or ACLS resultsin low survival rates.
CPR in ICCUABC in cardiac Emergencies
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Electric therapy using defibrillators orPrecordial thump.
Correct Hypoxaemia O24-6 L/min, Airway patency,
BIPAP, intubation, ventillator
Correct Acidosis - IV NaHCO3 Volume Replacement - IV crystalliods (normal saline,
DNS, RL, colloid, blood) Inotropes - Dobutamine, Dopamine,
Adrenaline, IABP
AAD - Xylocaine, Mexiletine,
Amiadarone, Bretelyliun
Tosylate, Procainamide,
Adenosine, Verapamil/Diltiazem, Mg, Atropine
Circulatory support during CPRICU Management in Cardiac Emergencies
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Sustained V. TACH
HYPOTENSION NO HYPOTENSION
DC Shock
(50-150 J-250 J)
and then prophylactic
IV Xylocaine drip afterconversion
Give IV xylocaine 50 mg bolus & repeat 50 mg IV
bolus within 10 mins if patient has not converted to
NSR
After reversal, start maintance drip 2-4 mg/min If xylocaine fails - give inj mexiletene in a dose of 100-
150 mg at rate of 25 mg/min followed by an infusion in
5% dextrose at a rate 2-4 mg/min for the first 3 hrs,
then maintance at a infusion rate of 0.5 mg./min.
Miss Snehal Patil 29 yrs Dr S A Merchant
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Miss. Snehal Patil29 yrs. Dr S A Merchant
Miss. Snehal Patil 19 yrs. Dr S A Merchant
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Miss. Snehal Patil19 yrs. Dr S A Merchant
Miss. Snehal Patil 19 yrs. Dr S A Merchant
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Miss. Snehal Patil 19 yrs. Dr S A Merchant
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Mn of V FIBS & Pulseless VT in ICCU
Persistent VT/VF Return of spon rhythm EMD Asystole
Continue CPR
Intubation at once
Obtain IV access
Adr 1mg push repeat
Defrillation 360J
with 30-60 sec.
Administir Medicat-(Xylocaine, Mexiletine, Bretylium, Mg So4
Procainmide if persist or recurrent VT / Fib
Defrillation 360J, 30-60 sec. after each dose of medication
Pattern should be drug-shock, drug-shock
Defrillation 200J, 200-300J, 360J
ABC
Perform CPR until defibrillator attached
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Management of Congestive Heart failure
Connect to ECG monitor, NIBP, SAT probe,
radial art pr, foleys, central line, ABG, ECG, X-
ray chest
Propped up position
Oxygen 6-8 litres/min thronasal prong/mask
Inj Fentanyl : 50 mgm IV bolus, 50 mgm/hr for
pts on ventillator, adv over morphine short
acting, pain relief, does not cause hypotension orhypoxia, vasodilator
Loop diuretics : inj Frusemide 40120 mg bolus,
repeat if reqd.
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Preload reduction : vasodilator IV NTG/Patch/Spray
Afterload reduction : Captopril/ramipril/losartan keep sys pr > 100mmHg.
Inotropes:
IV Dopamine/Dobutamine/Amrinone/IABP
Ventillator: PO2< 45mmHg, PCO2>50 mmHg
Vol-cycle ventillator with an FIO2of 100%
Management of Congestive Heart failure
Mr. Peter Gomes 44 yrs. Dr S A Merchant
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y
Mr. Peter Gomes
44 yrs. Dr S A Merchant
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y
Mr. Peter Gomes
44 yrs. Dr S A Merchant
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y
Mr. Peter Gomes
44 yrs. Dr S A Merchant
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y
MN OF BRADYCARDIA
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MN OF BRADYCARDIA
Access ABC
Secure Airway
Give O2
IV access
Attach pulse oximeter & sphygmomanometer
SymptomsCP, SOB, consciousness
SignsLow BP, shock, PE, CHF, AMI
Type II second degree AV block or third degree AV block
Observe Prepare for TV pacing
Use TCP as bridge device
Atropine - 0.61.2 mg
Fluid infusion - RL, DNSTCP - If available
Dopamine - 520 g/kg/min
Adr - 210 g/min
Isoproterenol - 210 g/min
Transvenous pacing
HR < 60/mm
NO YES
NO YES
Dr S A MerchantMr Rai 60 yrsDr S A Merchant
Mr. Roy
58 yrs. Dr S A Merchant
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Dr S A MerchantMr. Rai60 yrs
Mr. Roy
58 yrs. Dr S A Merchant
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Management of H pertensi e emergencies
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Definition:
Systolic BP > 220 mmHg or diastolic BP > 125mmHg with end organ
damage involving heart, brain, kidneys &/or retina
Treatment:
ICCU admission and monitor BP
Observe symptoms of neurological deficits, chest pain, dyspnoe or
signs of papilledema, hematuria, renal dysfunction or ECG changes
Rx goal is to reduce arterial pressure by 25% in 1 to 2 hrs, then toreduce BP to 160/100 over next 6 to 12 hrs.
IV nitroprusside, NTG & labetolol commonly used.
Some prefer oral/SL Nifedipine, nicardipine & fenoldopam
Management of Hypertensive emergencies
Mr. Das
60 yrs. Dr S A Merchant
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Mr. Das
60 yrs. Dr S A Merchant
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Mr. Das
60 yrs. Dr S A Merchant
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Mr. Das
60 yrs. Dr S A Merchant
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Mr. Das
60 yrs. Dr S A Merchant
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Mr. Das
60 yrs. Dr S A Merchant
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Repeated TIA/Acute Stroke management
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Repeated TIA/Acute Stroke management
Aspirin, Clopidogril, LMHW, Stiloz
Control BP with SL nefidipine, NTG IV/Spray, Do not drop
BP
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Mr. Choudhary
60 yrs. Dr S A Merchant
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Mr. Choudhary
60 yrs. Dr S A Merchant
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Mr. Choudhary
60 yrs. Dr S A Merchant
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Mr. Choudhary
60 yrs. Dr S A Merchant
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DVT with pulmonary embolism
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DVT with pulmonary embolism
Sitting for long hours on computers at office
Sudden acute breathlessness with sweat, fatigue and giddiness
Oxygen, bipap, ventilator,
LMWH, IV Heparin, Aspirin
Thrombolytics in cathlab (tpa, uk), mechanical breaking of
thrombi, IVC filter implant
Mr. Patel
40 yrs. Dr S A Merchant
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Mr. Patel
40 yrs. Dr S A Merchant
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Mr. Patel
40 yrs. Dr S A Merchant
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Mr. Patel
40 yrs. Dr S A Merchant
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Thank you