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CARDIOVASCULAR URGENCIES & EMERGENCIES

Steven Ganzberg, DMD, MS Director of Anesthesiology,

Century City Outpatient Surgery Center Clinical Professor of Anesthesiology,

UCLA School of Dentistry sganzberg@ucla.edu

MEDICATIONS Disclaimer:

Specific Required Medications May Vary Among States Use Only Those Medications With Which You Are Familiar

Cardiovascular Emergency Medications

• Dysrythmias • Ventricular

• Amiodarone 150 mg Vials** • Cardiac Lidocaine 1%/2% Syringes??

• Supraventricular • Esmolol 10mg/ml**; 10ml Vial • Diltiazem 5mg/ml; 5ml Vial • Adenosine 3mg/ml; 2ml Vial

Cardiovascular Emergency Medications

• Bradycardia • Atropine** 0.4mg/ml or 1mg/10ml Syringe • Glycopyrrolate 0.2mg/ml

• Tachycardia • Esmolol 10mg/ml** • Metoprolol 1mg/ml ? • Labetalol 5mg/ml ?

Cardiovascular Emergency Medications • Hypertension

• Beta Blockers • Esmolol 10mg/ml** • Metoprolol 1mg/ml • Labetolol 5mg/ml**

• Vasodilating Agents • Nitroglycerin SL 0.3/0.4 mg/dose**

•  IV 5mg/ml?? • Hydralazine 20mg/ml • Nicardipine 2.5mg/ml • Enalaprilat 1.25mg/ml

Cardiovascular Emergency Medications • Hypotension

• Ephedrine 50 mg/ml** • Requires 1:10 Dilution to 5 mg/ml • Both α and β Effects

• Phenylephrine 10 mg/ml** • Requires “Double 1:10” Dilution to 100 mcg/ml • Primarily α Effect

• Epinephrine 1:1000 (Multiple Vials)** • Cardiac Arrest/Anaphylactic Shock (Bronchospasm)

• Dopamine 40 mg/ml (Dilution & Infusion)? • Vasopressin 40 U (For Pulselessness)?

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Cardiovascular Emergency (Medications)

• AED? • Manual Defibrillator? • Cardioverter? • Transcutaneous Pacer?

General Principles For Sedated Patients If Persistent CV Urgency/Emergency •  If Patient Is Conscious, Ask Them How They Feel •  If Very Sedated, Consider Making Them Less Sedated

•  If Not Conscious, Consider Making Them Conscious • Evaluate Multiple Indicators

REVIEW OF THE ELECTROCARDIOGRAM Electrical

Conduction System

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Cardiac Pacemakers • SA Node 60 -100 BPM • AV Node 40 - 60 BPM • Ventricular 20 - 40 BPM

LEAD PLACEMENT

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Lead + ― •  I LA RA •  II LL RA •  III LL LA • aVL LA LL/RA • aVR RA LL/LA • aVF RF LA/RA

Anterior

Basics of the EKG

Heart Rate • Normal 60-100 BPM • Bradycardia = HR < 60 • Tachycardia = HR > 100 • Physiologic Bradycardia • Relative Bradycardia

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ECG Interpretation • Rate • Rhythm • Axis • Hypertrophy • Infarction

Rhythm

• Identify Basic Rhythm • Abnormal Waveforms • Pauses • Premature Beats • Irregularity

Rhythm • ü P Before Each QRS & QRS After Each P • ü PR Intervals • ü QRS Interval • ü PVCs

SINUS RHYTHM

SELECTED RHYTHM EMERGENCIES

Too Slow Irregular Rhythms Too Fast Wide Complexes

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SELECTED RHYTHM EMERGENCIES

Too Slow Irregular Rhythms Too Fast Wide Complexes

What About Bradycardia? • Physiologic Bradycardia/Reflex Bradycardia/↑ Age • Hypoxia/Hypercarbia • Drug Induced:

•  Beta Blockade/Ca++ Channel Blockade/Excess Digoxin /α2’s /Li++

•  Opioid Effect •  Anesthetic Overdose

• Primary Conduction Defect (MI?) •  Sick Sinus Syndrome •  Junctional Rhythm •  2nd and 3rd Degree Heart Block

• Decompensation/20% Acute MI, Esp. Inferior Wall • Pharyngeal and Oculocardiac Reflexes • Hypothyroidism/SLE/Collagen Vascular Disease

Respiratory Arrhythmia • Increase in heart rate during inspiration • Exaggerated in children, young adults and athletes • Decreases with age

• Usually asymptomatic, no treatment or referral • Can be non-respiratory

• Both in normal or diseased heart • Referral may be necessary if not clearly respiratory, history of heart disease

IF YOU DROP BEATS, YOU END UP WITH A BRADYCARDIA

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2nd & 3rd Degree Heart Blocks Bradycardia What is the Cause AND

Is It Hemodynamically Significant??? •  If Symptomatic

• Atropine 0.5 – 1mg •  3mg Full Adult Vagolytic Dose • No Help In 2nd Degree, Type II or 3rd Degree Heart Blocks

• Glycopyrrolate? •  0.1 - 0.2 mg Initially

• Ephedrine? • Consider If Both BP and HR Low

• For Select Heart Blocks (Discussed Later) • Dopamine? Epinephrine? Transcutaneous Pacing??

SELECTED RHYTHM EMERGENCIES

Too Slow Irregular Rhythms Too Fast Wide Complexes

What About Sinus Tachycardia? • Hypoxia/Hypercarbia • Surgical Stimulation/Inadequate Local Anesthesia •  Intravascular Epinephrine Injection From LA • Severe Pre-operative Anxiety • Full Bladder • Hypotension/Hypovolemia (Reflex Tachycardia) • Medication Related: Pre-Operative & Intraoperative

• Albuterol • Ketamine/High Concentrations of Potent Inhaled Anesthetics • Amphetamines, Atomoxetine, Tricyclic Antidepressants, SNRIs • Rebound From Beta Blocker/Clonidine

• Anemia • Decreased Cardiac Output (e.g., CHF/MI/PE) • Hyperthyroidism/Hypermetabolic State/Pheo.

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OTHER TACHYCARDIAS Primary Conduction Defects

Supraventricular Dysrythmias

Supraventricular Dysrythmias Why, Why, Why ?? • Primary Conduction Abnormality • Sympathetic Nervous System Activation

• Hypoxia/Hypercarbia • Atrial Volume Overload

Supraventricular Dysrythmias

• Treat Underlying Cause If Possible • Treat Rate Before Rhythm!!

• Vagal Stimulation? • Beta Blockers Acceptable First Line Treatment in All Supraventricluar Dysrythmias • Esmolol 10mg/ml

•  Rule of Thumb → 1mg Decreases Heart Rate 1 Beat/Min (e.g. 10mg Decreases 10 Beats/Min)

•  Exception: CHF → Consider Amiodarone

• Other Beta Blockers? Calcium Channel Blockers? • Adenosine??? Cardioversion???

What is the Cause AND Is It Hemodynamically Significant???

Early Cardioversion Should Be Considered • For All Primary Tachyarrythmias With Serious Signs & Symptoms

• Because.... • Antiarrhythmics Are Also Proarrythmics •  If Impaired Myocardial Function, Antiarrythmics

Decrease Cardiac Function • Arrive At a Specific Diagnosis

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SELECTED RHYTHM EMERGENCIES

Too Slow Irregular Rhythms Too Fast Wide Complexes

Irregular Rhythm • Narrow Complex or Wide Complex? • Regularly Irregular or Irregularly Irregular? •  Is My Patient Hemodynamically Stable?

Irregular Rhythms – Narrow QRS • Primary Conduction Defects

• Sick Sinus Syndrome • Pre-Atrial Contractions (PACs) • Atrial Fibrillation • 2nd and 3rd Degree Heart Block

Irregular Rhythms – Wide QRS • Pre-Ventricular Contractions (PVCs) • PACs With RBBB

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SICK SINUS SYNDROME

Treatment?

PRE-ATRIAL CONTRACTIONS:

PACs

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So What About PACs • Can be Caused By:

• Anxiety/Caffeine • Excessive Alcohol • Sympathetic Stimulation/Drugs • Cardiac Disease/MVP • Congenital

• Treatment: • Usually Benign Without Hemodynamic

Significance

ATRIAL FIBRILLATION IRREGULARLY, IRREGULAR

Atrial Fibrillation • Epidemiology

•  1% Incidence; 2.2 Million Americans •  160,000 New Cases Per Year •  Double Mortality Risk vs. Normal Sinus Rhythm •  5-Fold Increase in Stroke Risk: Cause in 20%

• Pathophysiology •  Uncoordinated Atrial Rhythm •  Four Types:

•  Lone, Paroxysmal, Persistent, Permanent •  Irregularly, Irregular Ventricular Rhythm •  Possible Embolus with Conversion to Normal Sinus Rhythm

• Treatment •  Control Ventricular Response To Prevent A-Fib with RVR •  Anticoagulation (Prevents Mural Thrombus) •  Cardioversion •  Ablation

Atrial Fibrillation With RVR • Control Rate, Then Rhythm

• Beta Blockers •  Esmolol, 0.5mg/kg and titrate •  Metoprolol, Titrate 2.5mg q10 – 15 minutes

• Calcium Channel Blockers •  Diltiazem, 5mg q10 – 15 min

• Amiodarone in CHF → ED Titration? • Caution!! Cardioversion - Unless Onset Less Than 48 Hours (and you really want to) • Risk of Pulmonary Embolus/Stroke

HEART BLOCKS Another Irregular Rhythm

2nd & 3rd Degree Heart Blocks

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Electrical Conduction System

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10 AV Block + Wenckebach

Electrical Conduction System

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20 AV Block, Type 2

& 30 Block

Questions: Heart Blocks •  Is My Patient Hemodynamically Stable? • Onset?

• Before Case On Placement of ECG • During Case → Must Ask: Is This Presentation of MI?

• 10 AV Block → Minimal Issues • 20 Type I – Wenckebach

• Vagally Mediated During Case? •  If Pre-op, Cardio Consult?

• 20 Type II and 3rd Degree → ED Evaluation •  Is This Initial Presentation of Intraoperative MI?

PRE-VENTRICULAR CONTRACTIONS - PVCs

Yet Another Irregular Rhythm

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PVCs

SELECTED RHYTHM EMERGENCIES

Too Slow Irregular Rhythms Too Fast Wide Complexes

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Multifocal PVCs

Ventricular Dysrythmias – Why, Why, Why ?? • Likely Myocardial Ischemia

• Hypoxia/Hypercarbia** • Tachycardia/Hypertension • Valvular Disorder • Myocardial Infarction • Cardiomyopathy/Other Cardiac Disorder

• Primary Conduction Abnormality • Bradycardia?

Ventricular Dysrythmias • Considered Significant > 6 PVC’s/min

• But Is the Patient Hemodynamically Stable!!! • Treat Underlying Cause (Hypoxia/Hypercarbia?) • Consider Cardiac Lidocaine 1 – 1.5mg/kg

• Short Acting • Continue 0.75mg/kg X 2 • Maximum Bolus Dose = 3mg/kg •  If Maximum Reached → Infusion 1- 4mg/min

• Alternative • Amiodarone

•  With Pulse → 150mg Over 10 Minutes •  No Pulse → 300mg IV Push

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CAN YOU HAVE A P WAVE BEFORE A WIDE COMPLEX QRS????

RIGHT/LEFT BUNDLE BRANCH BLOCK

Another Wide Complex Rhythm

Yes!!

Electrical Conduction System - RBBB

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Electrical Conduction System - LBBB

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LBBB WPW Wolf-Parkinson-White

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Fusion activation of the ventricles

AP

Sinus beat Hybrid

QRS shape

Accessory Pathway with Ventricular Preexcitation- WPW

Varying Degrees of Ventricular Preexcitation

AND……….. THE ULTIMATE VENTRICULAR RHYTHM

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LASTLY, WHAT ABOUT MI? CHEST PAIN Is It Angina Pectoris Or

Myocardial Infarction???? Or Something Else???

Chest Pain - Angina Pectoris •  Increased O2 Demand Relative To Supply • Usually Exertional • Angina Pectoris Usually Resolves in Minutes With Rest or After Sublingual Nitroglycerin (NTG)

• Types of Angina • Stable Angina • Unstable Angina • Vasospastic (Prinzmetal’s) Angina

Chest Pain - Acute MI • Decreased O2 Supply to Myocardium • Chest Pain at Rest • Chest Pain Lasts Longer Than Angina • Crushing CP, Sense of ‘Impending Doom’ •  ↓ CO -Lightheadedness, Diaphoretic, Nausea, SOB, Weakness, Cool Skin

• Ashen, Gray Color, Cyanosis, Arrhythmias • No Response to NTG

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Under Sedation/GA?? • Evidence of Myocardial Ischemia?

• Downgoing ST Segment

Under Sedation/GA?? • Evidence of Myocardial Infarction?

• Elevated ST Segment

Under Sedation/GA?? • Onset of New Major Cardiac Dysrhytmias?

• Heart Blocks, Especially Advanced • PVCs • Runs of V-Tach • Unexplained Sinus Tachycardia OR Bradycadia • Pulseless Rhythms

Chest Pain - Treatment •  If + History of Angina & Pain Typical • Position to Comfort • Vital Signs • Yes → NTG 0.3 - 0.4mg Q 5 Min Sublingual Spray or Tablet X 2 to Decrease O2 Demand • Caution: Phosphodiesterase 5 Inhibitors

• Supplemental O2 • Resolution → ?? Continue Treatment • No Resolution → Activate EMS, Possible MI • NTG Again, BLS If Needed

Chest Pain - Treatment • No Hx of Angina or Atypical Chest Pain • BLS, Vital Signs, Loosen Clothing • Activate EMS - Assume MI • Consider Trendelenberg if ↓ BP • Treatment

• Morphine (N2O/O2?)

• Oxygen – How Much??? • Nitroglycerin sublingual (BP > 90 mmHg) • Aspirin – 160 - 325mg Chewable

•  If Sedation/GA → Wake Up Patient

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THANK YOU Questions????