Cardiac emergencies at workplace

Dr S A Merchant
Interventional Cardiologist DM MD DNB FSCAI
Lilavati, Saifee, Raheja fortis, Seven hills, BSES Hospitals

Cardiac Symptoms at Work place

Chest pain

Breathlessness
Palpitations Headache / Giddiness Presyncope/syncope/sweats Paraesthesia/weakness of limbs General fatigue/weakness

Keep Diagnosis in Mind

Acute myocardial infarction Acute coronary syndrome Heart failure

Pulmonary embolism
Cardiac tachyarrhythmias Hypertensive emergencies Bradyarrhythmia vasovagal TIA/Stroke

Vitals in cardiac emergency at work place

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

Basic cardiac emergency tray at work place

Pulse oximeter Stethoscope BP intrument

ECG machine
IV excess IV fluids DNS, NS, Colloids IV Atropine , adrenaline, NE, dopamine , xylocaine

 Drugs : Aspirin, clopidogrel , sorbitrate , SL

Nifedipine, 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

Initial Diagnosis of STEMI

Dr S A Merchant

Transport of Patients With STEMI and Initial Reperfusion Treatment

Hospital fibrinolysis: Doortoneedle 30 min

Not PCI capable

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

Interhospital transfer

PCI capable

5 min
Patient

GOALS

8 min

EMS transport
Prehospital fibrinolysis EMS transport EMStoneedle EMStoballoon 90 min 30 min Patient self-transport Hospital doortoballoon 90 min

EMS

Dispatch 1 min

Golden Hour = 1st 60 min

Total ischemic time: within 120 min

J Am Coll Cardiol. 2004;44:671; Circulation. 2004;110:588.

Pharmacoinvasive approach
Complete obstruction Partial Success with pharmacologic reperfusion

Partial flow

Rethrombosis:
Prevented by antiplatelet and anticoagulant Rx

Full flow Ideal goal of pharmacologic reperfusion

PCI p lytic
Dr S A Merchant

Diagnosis of Myocardial Infarction 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

Management of Myocardial MN of pts with unstable Angina

Infarction

Thrombolytics Sedation

: Streptokinase, urokinase, t PA : Alprozalam, Diazepam, Fortwin, Fentanyl

Aspirin
Clopidogril IV heparin or LMWH If pain still continues

:
: : :

325 mg stat & one daily risk of MI &death

300 g loading dose & 1 tablet after lunch Inj Clexane or Inj arixta add b-blocker (atenolol, Metoprolol) or Diltiazem 30 90 mg 8 hourly

If pain still persists

urgent angios, PTCA+stent to culprit lesion or CABG for 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 O2 demand, LVEDP, cor perfusion IV Reopro/Integrillin : given before PTCA/Stenting

ACE Inhibitor & Statins

Stabilizes plaque & improves endothelial function

Take Home Message:

Optimum management of STEMI A PharmacoInvasive Approach
Initial Fibrinolysis with t-PA within 30-60 mins of chest pain in ambulance, 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

Management in Myocardial Infarction

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 clinical trials show excellent result with pharmacoinvasive approach in terms of reduce mortality, re-infarction & overall preservation of LV function

Vitals in cardiac Emergencies Monitoring 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

PAMI
Inferior AMI.
Direct RCA stenting complicated by distal macroembolization.

Use distal filter or M guard

Mr. Davies 48 yrs.

Dr S A Merchant

Occlusion of mid-RCA.

Mr. Davies 48 yrs.

Mr. Davies 48 yrs

Dr S A Merchant

Dr S A Merchant

Mr. Davies 48 yrs.

Mr. Davies 48 yrs

Dr S A Merchant

Dr S A Merchant

After wiring, evidence of massive thrombosis of RCA.

Mr. Davies 48 yrs.

Mr. Davies 48 yrs

Dr S A Merchant

Dr S A Merchant

Direct stenting complicated by distal embolization of posterolateral branch.

Mr. Davies 48 yrs.

Mr. Davies 48 yrs

Dr S A Merchant

Dr S A Merchant

Successful aspiration of the distal thrombus with the Export catheter.

Cardiogenic shock in AMI

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

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

LM occlusion.

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

RCA ostium severe stenosis.

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

Final kiss balloon after thrombectomy and stenting.

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

After kiss balloon post-dilation.

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

RCA stenting.

Mr. Mishra 60 yrs.

Mr. Mishra 60 yrs

Dr S A Merchant

Dr S A Merchant

Six-month F-U.

ABC in cardiac Emergencies CPR in ICCU

Basic Life Support (BLS) consists of ABC Airway, 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 results

in low survival rates.

Circulatory support during CPR

Electric therapy Correct Hypoxaemia Correct Acidosis Volume Replacement Inotropes AAD -

ICU Management in Cardiac Emergencies

using defibrillators or Precordial thump. O2 4-6 L/min, Airway patency, BIPAP, intubation, ventillator IV NaHCO3 IV crystalliods (normal saline, DNS, RL, colloid, blood) Dobutamine, Dopamine, Adrenaline, IABP Xylocaine, Mexiletine, Amiadarone, Bretelyliun Tosylate, Procainamide, Adenosine, Verapamil/ Diltiazem, Mg, Atropine

Sustained V. TACH

HYPOTENSION DC Shock (50-150 J-250 J) and then prophylactic IV Xylocaine drip after conversion

NO HYPOTENSION 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 100150 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

Miss. Snehal Patil 19 yrs.

Dr S A Merchant

Miss. Snehal Patil 19 yrs.

Dr S A Merchant

Mn of V FIBS & Pulseless VT in ICCU

ABC Perform CPR until defibrillator attached

Defrillation 200J, 200-300J, 360J

Persistent VT/VF

Return of spon rhythm

EMD

Asystole

Continue CPR Intubation at once Obtain IV access Administir Medicat-(Xylocaine, Mexiletine, Bretylium, Mg So4 Procainmide if persist or recurrent VT / Fib

Adr 1mg push repeat

Defrillation 360J with 30-60 sec.

Defrillation 360J, 30-60 sec. after each dose of medication Pattern should be drug-shock, drug-shock

Management of Congestive Heart failure

Connect to ECG monitor, NIBP, SAT probe, radial art pr, foleys, central line, ABG, ECG, Xray chest Propped up position Oxygen 6-8 litres/min thro nasal 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 or hypoxia, vasodilator Loop diuretics : inj Frusemide 40 120 mg bolus, repeat if reqd.

Management of Congestive Heart failure

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 FIO2 of 100%

Mr. Peter Gomes 44 yrs.

Dr S A Merchant

Mr. Peter Gomes 44 yrs.

Dr S A Merchant

Mr. Peter Gomes 44 yrs.

Dr S A Merchant

Mr. Peter Gomes 44 yrs.

Dr S A Merchant

MN OF BRADYCARDIA

Access ABC Secure Airway Give O2 IV access Attach pulse oximeter & sphygmomanometer

HR < 60/mm
Symptoms CP, SOB, consciousness Signs Low BP, shock, PE, CHF, AMI

NO
Type II second degree AV block or third degree AV block Atropine Fluid infusion TCP Dopamine Adr Isoproterenol Transvenous pacing -

YES

NO
Observe

YES
Prepare for TV pacing Use TCP as bridge device

0.6 1.2 mg RL, DNS If available 5 20 g/kg/min 2 10 g/min 2 10 g/min

Mr. Roy 58 yrs.

Mr. Rai 60 yrs

Dr S A Merchant

Dr S A Merchant

Mr. Roy 58 yrs.

Dr S A Merchant

Management of Hypertensive emergencies

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 to reduce BP to 160/100 over next 6 to 12 hrs. IV nitroprusside, NTG & labetolol commonly used. Some prefer oral/SL Nifedipine, nicardipine & fenoldopam

Mr. Das 60 yrs.

Dr S A Merchant

Mr. Das 60 yrs.

Dr S A Merchant

Mr. Das 60 yrs.

Dr S A Merchant

Mr. Das 60 yrs.

Dr S A Merchant

Mr. Das 60 yrs.

Dr S A Merchant

Mr. Das 60 yrs.

Dr S A Merchant

Repeated TIA/Acute Stroke management

Aspirin, Clopidogril, LMHW, Stiloz Control BP with SL nefidipine, NTG IV/Spray, Do not drop BP <140 mm/hg

Medical Treatment for 5-7 days.

4 vessel DSA with carotid stenting.

Mr. Choudhary 60 yrs.

Dr S A Merchant

Mr. Choudhary 60 yrs.

Dr S A Merchant

Mr. Choudhary 60 yrs.

Dr S A Merchant

Mr. Choudhary 60 yrs.

Dr S A Merchant

Mr. Choudhary 60 yrs.

Dr S A Merchant

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

Mr. Patel 40 yrs.

Dr S A Merchant

Mr. Patel 40 yrs.

Dr S A Merchant

Mr. Patel 40 yrs.

Dr S A Merchant

Thank you

I am Open to Questions