what about the "nearly arrest" patients?
DESCRIPTION
Where evidence based medicine has yet to go but where we often find ourselvesTRANSCRIPT
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What about the nearlyarrest patient?
Where evidence based medicine has yet to go but where we often find ourselves
SP-ER conference 9 Aug 2009Suthaporn Lumlertgul M.D.
King Chulalongkorn Memorial hospital
Sunday, August 9, 2009
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Reference:Harvard Shock symposium
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Reference:Harvard Shock symposium
Sunday, August 9, 2009
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Objective
• Manage case that is nearly dead, guideline yet go there
•
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นาทีเฉียดตาย
•
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Example case
• A 60 year old woman with complaint lightheadness, chest tightness
• HR= 150/min, BP=200/110 RR=36/min O2 Sat 96% Temp=37.4
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What are you examining in AF patient?
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What are you examining in AF patient?
• A 60 year old woman with complaint lightheadness, chest tightness
• HR= 150/min, BP=200/110
• RR=36/min O2 Sat 90% Temp=37.4
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Define Unstable
• Patients as those with ventricular rates 150,
• ongoing chest pain, or with evidence of critical perfusion:
• systolic BP 90 mm Hg, heart failure, or reduced
consciousness.
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Rapid AF
• AHA guideline for management of a patient with hypotension and AF with RVR would be cardioversion
• DC Cardioversion
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Would you cardiovert the patient?
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Would you cardiovert the patient?
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Rate
Rhythm
Digoxin
Diltiazem/verapamil
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Rate
Rhythm
Cardiovert
Digoxin
Diltiazem/verapamil
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Rate
Rhythm
Cardiovert
Amiodarone
Digoxin
Diltiazem/verapamil
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What are you using?DiltiazemAdenosine Amiodarone
DigoxinBeta blocker
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What are you using?
Digoxin
Beta blocker
5 min
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What are you using?
Digoxin
Beta blocker
Cardiovert
5 min
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What are you using?
Diltiazem
Digoxin
Beta blocker
Cardiovert
5 min
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What are you using?
Diltiazem
Amiodarone Digoxin
Beta blocker
Cardiovert
5 min
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What are you using?
Diltiazem
Amiodarone Digoxin
Beta blocker
Cardiovert
5 min
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Diltiazem
• Schreck et al compared the effectiveness of IV
diltiazem with digoxin. In this open-label RCT,consecutive patients with acute AF were assigned toreceive either diltiazem (0.25 mg/kg initial bolusfollowed by 0.35 mg/kg 15 min after, and then aninfusion of 10 to 20 mg/h to maintain a heart rate 100), digoxin (0.25-mg boluses at 0 and 30 min),or both digoxin and diltiazem. Follow-up was for 180min. Treatment with diltiazem achieved a rapidreduction in ventricular rate compared to digoxin,the results becoming statistically significant by 5 min
Diltiazem receive more rapid rate control in 5 minthank digoxin
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Diltiazem
• Rate-limiting calcium channel antagonists have
therefore been shown to be effective in ventricularrate reduction in acute AF. The major adverse eventreported from the RCTs was the precipitation ofsymptomatic hypotension (18% of patients)
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Amiodarone
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Digoxin
• Double-blind RCT recruited 40 patients to receive either digoxin (total IVdose of 1.25 mg in divided doses) or placebo.
• At 12 h posttherapy, there was no significant difference between the rates of conversion between the digoxin• Ventricular rate reduction was 30 min
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Maintain sinus Rate + anticoag
Pro⇑Hemodynamic⇓Thromboembolic
Avoid pro arrhythmia
Con Pro arrhythmicFatality
⇓HemodynamicBleeding
Residual embolic
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Loss of atrial kick sign?
LV
RV
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•LV systolic function looks depressed (subcostal long axis view)
Loss of atrial kick sign?
LV
RV
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•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
Loss of atrial kick sign?
LV
RV
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•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
•In this patient with acute onset of FA and subsequent hypotension .
Loss of atrial kick sign?
LV
RV
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•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
•In this patient with acute onset of FA and subsequent hypotension .
•After prompt cardioversion, sinus rhythm is restored and LV systolic function looks now much better
Loss of atrial kick sign?
LV
RV
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What does it cause?
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Loss of atrial kick
What does it cause?
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Loss of atrial kickBlood don’t go into
atrium
What does it cause?
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Loss of atrial kickBlood don’t go into
atriumIt reflux into neck vein
What does it cause?
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• Patient was administered Digoxin IV
• After not improving the clinical patient was administered Diltiazem IV
• Patient has less lightheadesness but still have chest tightness
• Heart rate was slower from 170 to 130/min but BP still 200/100
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• Patient was treated with Nicardipine IV
• He feel less lightheadeness still chest discomfort
• Old ECG show no atrial fibrillation
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Take home message
• Remember for the unstable signs in limited time Heart failure, poor perfusion
• How fast do you think the patient will survive on this rhythm
• Pick the choice of treatment from that
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Case II
• BP=110/60 HR=130 RR=20 T=37.3
• Complaint of chest tightness,
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What would you do?
• Any reason to change rhythm?
• Dead now or later?
•
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Case III
• A man with acute dyspnea come in ER with expiratory wheezing and sound of secretion, profound sweating
• Switching Taxi driver to passenger
• RR=35 PR=130/min BP=220/110 T=37 StO2=70%
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What is your diagnosis?Next Management?
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What will you do in this patient?
• Physical examinaiton
• Further investigation?
• Further Management
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สักพัก...
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What would you do in this patient?
• Atropine
• Epinephrine
• Dopamine
• Transcutaneous pacing
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เจ็บแปลบ ...
• The patient is so painful when you put on pacemaker
• Will atropine cause more infarct?
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Take home message
• Don’t be afraid to use adjuncts in life threatening patients
• This is 2009, ER is all about proove it and treat it.
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campaign
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