cardiology emergencies on-call

C A R D I O L O G Y E M E R G E N C I E S O N C A L L

D R . A L I R O O M I C A R D I O L O G Y S T 3

2 3 R D J U LY 2 0 1 6

+ O B J E C T I V E S

• Diagnosis and management of ACS

• When to liaise with tertiary centre

• Complications of ACS

• Tachyarrhythmias

• Bradyarrhythmias

+ W H AT T O D O W H E N Y O U R B L E E P G O E S O F F ?

• Stay calm!

• Clarify patient observations with nursing staff

• Prioritise tasks

• Interim management?

• ABCDE review

• Peri-arrest?

+ S C E N A R I O 1

• Bleeped at 1am by nursing staff

• 63M, admitted 2/7 diabetic foot infection

• On IV antibiotics, awaiting surgical debridement

• “Patient is complaining of chest pain”

• Afebrile, HR 74, BP 159/81, RR 18, sats 95% RA

+ W H AT W I L L Y O U D O ?

1. Stop what you’re doing and urgently review the patient

2. Advise nursing staff to administer simple analgesia - day team to review in the morning

3. Request a 12 lead ECG whilst you make you way to the ward

4. Put out a peri-arrest call

Answer: 3

+ E C G 1

Lateral TWI

+ H I S T O R Y

• Cardiovascular risk factors?

• Sudden onset? Heavy/tight? Any radiation - jaw/arm?

• Associated symptoms? SOB? Diaphoresis?

• Ongoing pain?

+ ? L AT E R A L N S T E M I

• Dynamic changes? Serial ECGs!!

• Compare to admission ECG

• Known IHD? Previous intervention?

• hsTroponin 0 and 6 hrs

+ I N I T I A L M A N A G E M E N T

• GTN spray

• IV/oral morphine

• Aspirin 300 mg + Clopidogrel 300 mg

• Fondaparinux 2.5 mg

+ A D D I T I O N A L M A N A G E M E N T

• Beta blocker/ACEi/statin - can normally wait till morning

• BM monitoring +/- sliding scale (dry)

• GRACE score

• FBC, U&E, coagulation screen, CXR

GRACE score - predictor of in-hospital and 6-month mortality

+ W H AT N E X T ?

• Re-review

• Ongoing chest pain - GTN infusion, repeat ECG

• Stable - handover to morning team/Cardiology

When to refer to tertiary centre?

+ C O N S I D E R I F…

• Pain refractory to GTN infusion

• High risk NSTEMI

• STEMI

• Cardiogenic shock

+ E C G 2

Wellen Syndrome - prox LAD disease

+ E C G 3

Wellen Syndrome - biphasic T waves

+ E C G 4

Benign early repolarisation

+ E C G 5

LMS/ostial LAD disease STE aVR

+ E C G 6

Pericarditis Concave STE PR depression ST depression aVR

+ E C G 7

PE Sinus tachycardia RBBB RAD S1 Q3 T3

+ E C G 8

Hyperacute anterior STEMI Q waves anteriorly Peaked T waves Reciprocal ST depression III

+ E C G 9

Evolving anterior STEMI

+ “ PAT I E N T I S N O W B R E AT H L E S S ”

• Afebrile, HR 110, BP 161/93, RR 29, sats 89% 15L

• Diaphoretic

• ABG: pH 7.43, pCO2 5.3, pO2 8.2, BE -1.3, Lac 1.7

• ECG unchanged

• Diffuse coarse crackles and wheeze

+ C X R

+ I M M E D I AT E N E X T M A N A G E M E N T ?

1. 2.5 mg salbutamol nebuliser

2. 5 mg metoprolol IV

3. GTN infusion

4. IV furosemide 40 mg

Avoid beta blockers in acute pulmonary oedema Answer: 3

+ P U L M O N A R Y O E D E M A

• GTN Infusion - titrate to SBP (aim > 110 mmHg)

• IV morphine

• IV furosemide 40-80 mg

• High flow O2/CPAP/optiflow

• Catheterise

• Senior help!

+ “ PAT I E N T I S N O W L I G H T H E A D E D ”


• Denies any chest pain

• GCS 15

+ E G G 1 0

Monomorphic VT


1. Synchronised DC Cardioversion

2. Adenosine 12 mg IV

3. Metoprolol 10 mg IV

4. Amiodarone 300 mg IV

Answer: 4

+ V E N T R I C U L A R TA C H Y C A R D I A

• Any signs of compromise?• Chest pain • Shock • Heart Failure • Syncope

Synchronised DCCV

• Stable? IV Amiodarone 300 mg

+ S C E N A R I O 2

• 77F

• Known COPD admitted with infective exacerbation

• Not on any home nebs/LTOT

• Afebrile, HR 180, BP 103/60, RR 24, sats 93% 2L O2

• WCC 16, CRP 140, Cr 145 (baseline 93), Troponin 68

+ E C G 1 1

AF with RVR





4. Synchronised DCCV

Answer: 1

+ AT R I A L F I B R I L L AT I O N

• Paroxysmal/persistent/permanent

Acute onset?

Duration unknown?

IV Amiodarone 300 mg

Stable BP?

Labile BP?

Beta blocker Calcium channel blocker

Digoxin

Compromised? Synchronised DCCV

Caveat - digoxin not useful in the longterm with paroxysmal AF or non-sedentary patients

+ A N T I C O A G U L AT I O N

Warfarin/NOAC - if CHADSVASc > 1

+ S C E N A R I O 3

• 42M

• Sudden onset palpitations and chest pain

• No CVRF


• Troponin 37

+ E C G 1 2

SVT - likely AVRT/AVNRT. No discernible p waves






Answer: 3

+ E C G 1 3

Pre-excitation Delta waves Short PR interval Orthodromic AVRT (because narrow complex QRS during SVT phase)

+ E C G 1 4

SVT with ventricular rate 250-300 ?Atrial Flutter with 1:1 block ?AVRT/AVNRT

+ A D E N O S I N E

+ TA C H Y C A R D I A A L G O R I T H MAdult Tachycardia (with pulse) Algorithm

Is QRS narrow (< 0.12 s)?

Adverse features? Shock Syncope

Myocardial ischaemia Heart failure

Regular

Narrow QRSIs rhythm regular?

Broad QRSIs QRS regular?

Vagal manoeuvres Adenosine 6 mg rapid IV bolus

if no effect give 12 mgif no effect give further 12 mg

Monitor/record ECG continuously

Probable AF: Control rate with beta-blocker or

diltiazem If in heart failure consider digoxin or

amiodarone Assess thromboembolic risk and

consider anticoagulation

Probable re-entry paroxysmal SVT: Record 12-lead ECG in sinus rhythm If SVT recurs treat again and consider

anti-arrhythmic prophylaxisPossible atrial flutter:

Control rate (e.g. with beta-blocker)

Possibilities include: AF with bundle branch block

treat as for narrow complex Pre-excited AF

consider amiodarone

If VT (or uncertain rhythm): Amiodarone 300 mg IV over 20-

60 min then 900 mg over 24 h

If known to be SVT with bundle branch block:

Treat as for regular narrow-complex tachycardia

Synchronised DC Shock*Up to 3 attempts

Amiodarone 300 mg IV over 10-20 min Repeat shock Then give amiodarone 900 mg over 24 h

Assess using the ABCDE approach Monitor SpO2 and give oxygen if hypoxic Monitor ECG and BP, and record 12-lead ECG Obtain IV access Identify and treat reversible causes (e.g. electrolyte abnormalities)

Yes - Unstable

No - Stable

Broad Narrow

Irregular Regular

Irregular

Yes No

*Conscious patients require sedation or general anaesthesia for cardioversion

Sinus rhythm achieved?

Seek expert help !

Seek expert help !Seek expert help !

+ S C E N A R I O 4

• 83F

• Admitted with 5/7 dizziness and syncope

• HTN, T2DM, OA, prev R NOF #


• Currently denies any presyncope

+ E C G 1 5

Complete Heart Block Junctional escape - 42 bpm



2. Transcutaneous pacing

3. Atropine 500 mcg IV

4. Monitored bed and observe

Answer: 4

+ E C G 1 6

Complete Heart Block Broad complex ventricular escape - rate 27 bpm High risk of asystole

+ B R A D Y C A R D I A A L G O R I T H MAdult Bradycardia Algorithm

* Alternatives include: Aminophylline Dopamine Glucagon (if bradycardia is caused by beta-blocker or calcium channel blocker) Glycopyrrolate (may be used instead of atropine)

Assess using the ABCDE approach Monitor SpO2 and give oxygen if hypoxic Monitor ECG and BP, and record 12-lead ECG Obtain IV access Identify and treat reversible causes (e.g.

electrolyte abnormalities)

Adverse features? Shock Syncope

Consider interim measures: Atropine 500 mcg IV repeat to

maximum of 3 mgOR

Transcutaneous pacingOR

Isoprenaline 5 mcg min-1 IV Adrenaline 2-10 mcg min-1 IV Alternative drugs*

Seek expert helpArrange transvenous pacing

Satisfactory response?

Continue observation

Atropine 500 mcg IV

NoYes

YesNo

Yes

No

!

Myocardial ischaemia Heart failure

Risk of asystole? Recent asystole Mobitz II AV block Complete heart block with

broad QRS Ventricular pause > 3 s

+ C O N C L U S I O N

• Stay calm!

• ABCDE

• If in doubt, seek senior help

• Enjoy yourselves!

+ R E F E R E N C E S

• www.lifeinthefastlane.com

• www.resus.org.uk

• www.chadsvasc.org

http://www.lifeinthefastlane.com

http://www.resus.org.uk

http://www.chadsvasc.org

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cardiology emergencies on-call

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