LGI_2.2_Cardiovascular

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2 Emergency Medicine

2.2 Cardiovascular

2.2.1 Acute Coronary Systems
Authors : Taj Hassan, Ramzi Khamis

Date : Jan 2002, Revised 2005

Management of acute cardiac pain is the commonest presentation in the Resuscitation Room. It is important thatyou are able to assess these patients and categorise them appropriately.

Aim: To provide the optimal initial management for patients with acute coronary syndromes In the A&E Department.

Acute myocardial infarction (AMI)

Definition:

Chest pain (which may be atypical) with or without radiation which usually lasts for more than 30 mins.

Sequential ECG changes which usually follow the pattern of ST elevation, T wave inversion and then Q waves.

A rise in cardiac enzymes. Cardiac enzymes have no part to play in the routine assessment of these patients in the A&E dept.

Some patients may not present with the typical picture, particularly the elderly and diabetics, who may present with LVF, unexplained hypotension, distal embolus, collapse or stroke. Management, (see thrombolysis).

It is vitally important that you use the A&E chest pain chart to assess all patients in the Resus Room. The chart will help you to record vital data and make an appropriate decision.
The patients have been divided into four broad categories.

Category 1: Cardiac type pain and definite ST elevation or acute LBBB.

Aspirin 300 mg O stat.
Oxygen
Primary Percutaneous Intervention

(If fits criteria PTCA /Stent rather then thrombolysis is available

(See below)

Thrombolysis–

(if PCI not available/suitable)

If in doubt ask senior/Cardiology ASAP

USE THE CHEST PAIN CHART. Make sure to complete it fully.

Analgesia and management of nausea and vomiting. (Diamorphine and Metaclopramide or/and cyclizine)
Oral Beta blocker on CCU.
Intravenous nitrates if prolonged or recurrent pain
Referral to the cardiology SHO and further management on CCU.

Initial Investigations in the A+E should include :

FBC, U&Es, Random Glucose and CXR. Investigations including fasting cholesterol, triglycerides, LFT’s, should be done the next day.

Category 2. Suspected Cardiac Pain with suspected acute ST depression or T inversion:

Aspirin 300mg po stat.
Sublingual GTN.
Oxygen
Enoxaparin mg/kg twice daily for 3 days.
Clopidogrel 300mg stat
Oral Beta blocker if necessary.
Intravenous nitrates if prolonged or recurrent pain
Analgesia as above.
Referral to the cardiology SHO and subsequent management on the ward depending on the investigations and serial ECG’s.

Category 3. Possible Cardiac Pain with ECG Changes, which may be chronic:

As per Category 2 but no clopidogrel.

Category 4. Possible cardiac pain and a normal or non diagnostic ECG.

This group of patients have a low risk (1%-10%) for having had an acute coronary syndrome (ACS). The chest pain may be typically cardiac or have a number of atypical features (often dyspepsia). Discuss with a SENIOR. These patients should ideally be managed on the CDU according to the protocol.

Refer the patient to the CDU Clinical Fellow

Delivering rapid, safe thrombolysis for patients with AMI.

The “door to needle” times (door = arrival of ambulance at A&E, needle = started thrombolysis) for patients with acute MI are a major issue for us in terms of standards to attain in Leeds. The National Service Framework for Coronary Heart Disease has set tough standards: 75% of eligible patients receiving thrombolysis within 20 minutes of arrival to A&E. Minutes mean myocardium! To achieve this:

1/ An ECG is performed on patients with cardiac sounding pain as soon as possible after presentation to A&E.

2/ Patients with obvious MIs are evaluated for thrombolysis and this is instituted as an absolute priority for the department.

3/ Patients with a good history for MI, and for “evolving” changes on their ECG, or LBBB, are assessed by a senior doctor ASAP.

4/ The chest pain form is completed properly and fully on all these patients. This aspect is particularly important now and failure to document your name (doctor co-ordinating thrombolysis) and if it falls outside 30 mins WHY this happened is particularly important. In future, these cases may end up as being classified as a critical incident. PLEASE make sure you complete the first AND second page of the form and pay particular heed to state WHY it was not possible to thrombolyse in 30 mins. This is valuable information which will allow us to improve weaknesses in the system. Please be honest.If the form is not filled in fully we will seek to give you individual feedback.

We are also fortunate to have a senior nurse (Acute Coronary Syndromes nurse- Carol Hague) who will help in terms of education and quality assurance on these issues as well as help in the thrombolysis procedure (available on bleep 1291) .

KEY MESSAGES

Get an ECG ASAP.

PCI (See below)/ Thrombolyse (if appropriate) ASAP
Get a senior to assess the patient if you are uncertain ASAP.

Fill in the chest pain form FULLY detailing why the target was not met if that was the case.

2.2.2 Acute Left Ventricular Failure

Author: Steve Crane Jan 2002

Typical presentation

An elderly or middle aged patient with a previous history of ischaemic heart disease, hypertension or congestive heart failure attends with acute onset dyspnoea.
They may also describe chest pain. Patients will typically be very pale and clammy.
Examination will reveal raised jugular venous pulse, tachycardia and tachypnoea. There will be crepitations on auscultation of the chest.

Differential diagnosis Bronchopneumonia, (exacerbation of COPD)

* IMPORTANT – CONSIDER ACUTE MYOCARDIAL INFARCTION*

Observations/Monitoring Oxygen saturations, ECG monitoring, blood pressure, urine output

Investigations 12 lead ECG, Arterial blood gases, Chest x-ray, U&E1

2.2.3 Cardiac Arrhythmias

ALS guidelines adapted Jan 2002

Authors Taj Hassan and Amjid Mohammed

Background :

Dysrhythmias are common in the A&E department. Some patients tolerate them well and others become acutely unwell due to a poor cardiac output.
It is important to differentiate those that need emergent treatment from those in whom treatment can be delayed until expert advice is sought.
Call for senior help early , particularly if your patient is hypotensive or has chest pain.

Key Points

Always assess the patient first. Treat the patient and NOT the monitor.
A patient who is talking is usually tolerating their rhythm.
Perform simple manoeuvres first (give oxygen, get an IV line and perform vagal interventions if you suspect SVT)
Analyse the ECG methodically.
Get a SENIOR early if your patient is compromised. Do not try to treat it yourself.

Bradycardia

Note: Sinus bradycardia may be physiological in hypothermia or in very fit athletes

1.Heart block

Management depends on the underlying cause.

a)Acute myocardial infarction

Inferiors:- heart block rarely needs to be treated with an inferior AMI. Complete heart block may be symptomatic and should initially be treated with Atropine and then by transcutaneous pacing.

Anterior:- temporary pacing is indicated for complete heart block with anterior AMI as this is associated with ventricular standstill. Again initial management should be with Atropine and / or temporary pacing but always transfer the patient with the external pacer available.

b)Chronic conduction diseases

Complete heart block and high grade second degree block usually require permanent pacing. Atropine and transcutaneous pacing can be used as a temporising manoeuvre

Syncopal patients should be treated as soon as possible which in A & E means transcutaneous pacing.

Broad complex tachycardia:

This may be due to Ventricular Tachycardia or a Supraventricular Tachycardia with aberrant conduction (which is quite rare).
VT is characterised by AV dissociation, concordance, capture and fusions beats on the 12 lead ECG.
It is a malignant rhythm usually occurring in patients with coexisting ischaemic heart disease and there is usually systemic upset secondary to a poor cardiac output.
SVT can be tolerated much better unless the rate is such that myocardial perfusion is impaired.
Adenosine can be used to distinguish SVT with aberrant conduction from VT if the patient is stable in many cases .

Always treat the patient not the monitor; if in doubt its safer to treat as VT.

Key points

Get senior help early
Use the ALS guidelines for the management of Broad Complex Tachycardias
Patients with signs of cardiovascular compromise require cardioversion
Check Potassium on the blood gas analyser

Supraventricular Arrhythmias

Supraventricular tachycardias

a. Sinus tachycardia is usually not of abrupt in onset and has a rate of <150, always check for underlying problem, eg hypoxia, pyrexia etc. Treatment is that of the underlying cause .

b.Paroxysmal atrial tachycardia (SVT) is usually abrupt in onset and rate >150. These patients may have chest pain and be hypotensive if the rate impairs myocardial perfusion. The rate may be slowed by vagal manoeuvrers eg valsalva against a closed glottis or CSM, always check for a bruit before trying this.

If the patient is compromised then cardiovert with a DC shock starting at 100J.

The best drug to use for chemical cardioversion is adenosine, start with 3mg iv, wait 2 min then repeat with 6 mg, followed by 12 mg. Don't forget to warn the patient that they may experience a heavy feeling in the arms and chest pain. If adenosine doesn't work then it probably isn't a SVT!

c. Atrial flutter The atrium always flutters at 300 bpm, the ventricles can't respond to this and there is always an element of block, so suspect it in rates that are approx 150 bpm(2:1 block).

Again if the patient is compromised then DC cardiovert.

d. Atrial fibrillation. This is very common affecting >10% in the over 70s. It may be a response to an underlying illness such as pneumonia, sepsis, neoplasm or ischaemic heart disease. It is important to ascertain how long the rhythm has been established for as this influences treatment. The decision is whether the patient requires rate control with digoxin or cardioversion chemically with amiodarone. At present this depends on individual clinical judgement. Guidelines are being developed to help in this process. As usual if the patient is hypotensive and unwell they should be considered for cardioversion.

Acute cardioversion whether chemical or electrical carries a risk of embolic phenomenon particularly if AF has been established for at least 48 hrs.

How to digitalise someone....0.5 mg of digoxin in 100 ml of normal saline over 30 mins, this can be repeated every 6 hrs to a total dose of 1.5-2.0 mg. Try and get a potassium before digitalisation, a low K potentiates digoxin induced arrhythmias.

Key points

Correct biochemical abnormality
If there is serious cardiovascular compromise then cardiovert
Use the ALS guidelines for the management of Narrow Complex tachycardias

2.2.4 Aortic Dissection

Author A Mohammed Jan 2002

This can be difficult to differentiate from AMI and other intrathoracic catastrophes in the ED .A high index of suspicion is required to avoid delay; it is essentials to get early senior help and radiology assistance.

Features in the history suggestive of Dissection:

Sudden onset of tearing inter-scapular pain +/- chest pain

Migratory pain

Difficult to control pain

Syncope

Presence Predisposing factors(hypertension, Marfans, Erlos-Danlos, pregnancy etc)

Features in the examination suggestive of Dissection:

Differential BP and pulses in the limbs

Severe hypertension/hypotension

New Aortic regurgitation

Features of cardiac tamponade

Neurological deficit

Investigations:

ECG (may show inferior injury),FBC,U&E,X-match,CXR (may be normal)

Aortography is the gold standard and is especially useful is surgery is planned.

Alternatively an ECHO(particularly TOE ) in the resus room may help

CT is also useful and may give alternative diagnoses as well.

Treatment:

INVOLVE CARDIOTHORACIC SURGEONS EARLY

A:Protect the airway

B: Free rupture in to the thoracic cavity is immediately life threatening and will lead to massive haemothorax

C: usually are hypertensive, but may be hypotensive due to free rupture or tamponade

Type A: Proximal dissection (Ascending Aorta) extends to varying degree

Majority require surgery if survive. Control hypertension/hypotension

Type B: distal (Descending Aorta) may not require surgery. Surgery is reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ.

Control hypertension/hypotension

2.2.5 Managing the hypertensive patient

Initial therapeutic goals include elimination of pain and reduction of systolic blood pressure to 100-120 mm Hg, or to the lowest level commensurate with adequate vital organ (cardiac, cerebral, renal) perfusion.

Antihypertensives -- These agents are used to reduce arterial BP. For acute reduction of arterial pressure, the potent vasodilator sodium nitroprusside is very effective. IV beta-blocker ( such as esmolol or labetalol) can also be used to acutely reduce BP acutely in incremental doses until a heart rate of 60-80 beats/min is attained. Expert advice is needed.

When beta-blockers are contraindicated, such as in second- or third-degree atrioventricular block, consider using calcium channel blockers. Sublingual nifedipine successfully treats refractory hypertension associated with aortic dissection.

Key messages

If you suspect the diagnosis – involve seniors early.
Control the blood pressure if the diagnosis is obvious. Insert an A line and involve ITU staff early
Involve cardiothoracic surgeons early