Category: Cardiovascular

Podcast: Play in new window | Download

• “Sympathetic Crashing Acute Pulmonary Edema”
• Pathophysiology – Rapid onset of pulmonary edema caused by sudden hypertension
  • Triggers- Missed Medication, Cocaine, Stress/Anxiety
    • Increase in BP = Increase in afterload
    • Increased afterload causes acute pulmonary edema (in patients with CHF)
    • The worsening pulmonary edema causes shortness of breath which worsens blood pressure and further increases afterload
• Presentation- Sudden, severe respiratory distress AND hypertension
  • Different than CHF exacerbation
    • Not necessarily caused by hypervolemia
    • More rapid in onset
  • Typically crackles/rales on exam or diffuse B-Lines on POCUS
• Treatment
  • BiPAP/CPAP
  • High Dose Nitroglycerin
  • Diuretics IF Hypervolemic

Podcast: Play in new window | Download

Mnemonic: DARTH VADER

Death

Arrhythmia

• ACS patients need to be placed on cardiac monitor
• Frequently degenerate into non-perfusing rhythms

Rupture of Ventricle

• Occur within a few days of myocardial infarction
• Rapid decompensation
• Bedside ultrasound will show pericardial effusion and tamponade

Tamponade

• Multiple etiologies
  • Rupture of ventricle (see above)
  • Pericarditis
• Becks Triad
  • Jugular vein distension
  • Muffled heart sounds
  • Hypotension
• Diagnosed with bedside ultrasound
• Treatment is pericardiocentesis

Heart Failure

• Occurs in approximately 1/3 post-MI patients
• Leads to cardiogenic shock
• Treatment
  • Fluid bolus
  • Vasopressors (esp. norepinephrine)
  • Inotropes (milrinone, dobutimine)
  • Left ventricular assist devices
  • Intra-aortic balloon pumps

Valve Failure/Rupture

• Rapid decompensation (similar to ventricular wall rupture)
• PLUS
• New heart murmur
• Surgical emergency

Aneurysm

• A classic STEMI mimic
• Large Q waves with ST segment elevation (IN ASYMPTOMATIC PATIENT)

Dresslers Syndrome/Pericarditis

• Rule out cardiac tamponade
• Treatment
  • NSAIDS/colchicine

Embolism

• Occur in damaged ventricles and in cardiac aneurysms
• Require anticoagulation

Recurrence

• Emphasize lifestyle management

Additional Reading

• Approach to STEMI (EM Clerkship)

Podcast: Play in new window | Download

Always remember…1, 2, 3, get an old EKG!!!

Step 1: Identify the Rate and Rhythm

• Is it sinus rhythm?
  • P wave before every QRS
• Is it one of the tachycardias? (Refer to THIS episode)
• Is it one of the bradycardias? (Refer to THIS episode)

Step 2: Look for Signs of Ischemia

• Most consistent way is to examine by anatomic region of the heart
  • II, III, and aVF are “inferior” leads
  • I, aVL, V5, V6 are “lateral” leads
  • V1 and V2 are “septal” leads
  • V3 and V4 are “anterior” leads
• Check for Q waves
• Check for ST segment elevation or depression
  • Compare the J point with baseline (TP segment)
• Check for peaked T waves and T wave inversions
  • T wave inversions in V1 and aVR are normal

Step 3: Look at Intervals

• PR interval
  • Wolf-Parkinson White Syndrome
  • 1st degree heart block
• QRS interval
  • Left bundle branch block
  • Right bundle branch block
  • Sodium channel blockade
• QT interval
  • Long QT syndrome
  • Hypokalemia
  • Risk of torsades de pointes

Step 4: Get an Old EKG

• If you find anything abnormal looking, compare to an old EKG

Bonus: Scarbossa Criteria

• Identifies ischemia in patients with a left bundle branch block
  • 1 lead with concordant ST elevation
  • 1 lead with concordant ST depression (V1-V3)
  • Severely discordant ST elevation (>25% preceding S wave)

Additional Reading

• Basic Approach to Tachycardias (EM Clerkship)
• Basic Approach to Bradycardias (EM Clerkship)
• EKGs for the Emergency Physician (Amazon)

Podcast: Play in new window | Download

Differential Diagnosis

• Mnemonic: HE DIES
  • Hypothyroidism
  • Elevated intracranial pressure (ICP)
    • Cushings reflex
      • Bradycardia
      • Increased blood pressure
      • Irregular breathing
  • Drugs
    • Beta blockers
    • Calcium channel blockers
    • Digoxin
  • Ischemia
  • Electrolytes
    • Especially potassium!!!
  • Sick Sinus Syndrome

Approach to Bradycardia

• Step 1: Get an EKG
  • Ischemia?
  • Heart block?
    • 1st degree = PR interval >200ms (5 small boxes)
    • 2nd degree type 1 = PR gradually prolongs until dropped beat
    • 2nd degree type 2 = Intermittent dropped beats
    • 3rd degree = None of the atrial beats result in a ventricular beat
  • Evidence of hyperkalemia?
• Step 2: Determine if patient is SYMPTOMATIC
  • Hypotension
  • Chest Pain
  • Syncope
  • Lightheadedness
  • Note: Many patients have benign and asymptomatic resting bradycardia (I’ve seen as low as 30s!) and this does not necessarily require aggressive treatments/IV medications
• Step 3: If patient is having symptoms… Give atropine!
  • Typical dose is 0.5mg IV atropine
• Step 4: If patient still having symptoms… Give epinephrine!
• Step 5: If patient still having symptoms… Cardiac pacing!
  • If symptoms are minimal or resolved, patient can sometimes wait for permanent pacemaker with cardiology
  • Transcutaneous pacing
    • Sometimes difficult to get mechanical capture
  • Transvenous pacing
    • Place through the right internal jugular vein

Additional Reading

• How to Read an EKG (EM Clerkship)
• Transcutaneous Pacing Procedure (EM Clerkship)

Podcast: Play in new window | Download

Basic Approach

• Step 1: Is this SINUS tachycardia?
  • P before every QRS?
  • Treat the underlying condition
• Step 2: Is this a NARROW and REGULAR rhythm?
  • SVT
    • Treat with vagal maneuvers or adenosine
    • Another new trend is treating with calcium channel blockers!!
  • ORTHOdromic Wolf Parkinson White
    • Treat with adenosine
  • Atrial flutter with fixed block
    • Treat with AV blockers (diltiazem)
      • Slows the heart rate
• Step 3: Is this a NARROW and IRREGULAR tachycardia?
  • Almost always atrial fibrillation
    • Treat with AV blockers (diltiazem)
  • Other (less common) diagnoses
    • Atrial flutter with variable block
    • Multifocal atrial tachycardia
• Step 4: Is this a WIDE and REGULAR tachycardia?
  • Assume ventricular tachycardia until proven otherwise
    • Treatment is immediate cardioversion if unstable
    • May try chemical cardioversion if stable
      • Procainamide
      • Amiodarone
      • Lidocaine
  • Other diagnoses
    • ANTIdromic Wolf Parkinson White
    • Narrow complex tachycardias PLUS aberrancy
• Step 5: Is this a WIDE and IRREGULAR tachycardia?
  • Atrial fibrillation with bundle branch block
    • Extremely fast and bizarre in appearance?
      • Consider atrial fibrillation with Wolf Parkinson White

Additional Reading

• Calcium Channel Blockers for Stable SVT (ALiEM)
• Atrial Fibrillation in WPW – Pearls and Pitfalls (County EM)

Podcast: Play in new window | Download

6 EKG Findings. 6 Risk Factors. 6 Mimics.

Step 1: Get an EKG

• This is the only “required” test for a patient with syncope
• Other common tests
  • CBC
    • Evaluate for anemia
  • hCG
    • If patient might be pregnant

Step 2: Look For 6 High Risk EKG Patterns

• Mnemonic: QT-BRIDE
  • QT prolongation
    • Especially QTc >500
  • Brugada pattern
  • Right heart strain
    • Tachycardia
    • S1Q3T3
    • Inverted T waves precordial leads
  • Ischemic changes
    • ST segment elevation/depression
    • T wave inversion
  • Delta waves
    • Seen in Wolf-Parkinson White (WPW)
  • Epsilon waves
    • Seen in arrhythmogenic right ventricular dysplasia (ARVD)

Step 3: Ask the 6 High Risk Historical Questions

• Mnemonic: CHESS +1
  • Cardiac history
    • CHF
    • Structural heart disease
  • Hematocrit <30%
  • “Elderly”
  • Shortness of Breath
  • Systolic BP <90
  • (+1) Family history of sudden cardiac death

Step 4: Consider 6 Deadly Syncope Mimics

• 15% of the following diseases reportedly present as “syncope”
  • AKA “Rule of 15s”
• Subarachnoid hemorrhage
• Myocardial infarction
• Pulmonary embolism
• Aortic dissection
• Abdominal aortic aneurysm
• Perforated GI
  • Ulcers
  • Ectopics

Additional Reading

• QT Intervals (LITFL)
• Brugada Syndrome (LITFL)
• Right Heart Strain (LITFL)
• Delta Wave (LITFL)
• Epsilon Wave (LITFL)

Podcast: Play in new window | Download

You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

• This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

• Dual anti-platelet therapy
  • Aspirin 325mg chewed (or PR)
  • Plavix 600mg (not usually given in ED)
    • Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

• Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

• If you DON’T have cath lab
  • Option 1: 30 minutes to give thrombolytics
  • Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

• Left bundle branch block (LBBB)
• PLUS
• Concordant ST elevation (>1mm) in leads with positive QRS
• OR
• Concordant ST depression (>1mm) in leads with negative QRS
  • Typically V1-V3
• OR
• Severely discordant ST elevation (>5mm) in leads with negative QRS

“MONA”

• Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain
• Oxygen has been shown to worsen outcomes if given indiscriminately
  • Not ideal to be giving supplemental O2 when SaO2 is 100%
• Nitroglycerine
  • Nitroglycerine 0.4 mg SL q5min
  • OR
  • Nitroglycerin 10mcg/min drip (will need to be titrated UP)
    • For comparison…
      • 0.4 mg SL nitroglycerine releases approximately 80mcg/min
  • Contraindications
    • Inferior/Right heart infarction
      • Patients usually preload dependent
      • Nitro drops preload
    • Sildenafil (Viagra)
      • Can cause sudden/severe drop in blood pressure
    • Hypotension

Additional Reading

• Round 3 – Chest Pain (EM Clerkship)
• The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)
• The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)
• The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)
• The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)

Podcast: Play in new window | Download

There are six cardiopulmonary causes of chest pain that you need to know.

The SIX Causes

• Cardiac
  • Acute coronary syndrome (ACS)
  • Pericarditis with tamponade
• Pulmonary
  • Pneumonia
  • Pneumothorax
• Vascular
  • Pulmonary embolism
  • Aortic dissection

Step 1: Core Measures

• Aspirin
• EKG

Step 2: Look for the “King” (Acute Coronary Syndrome)

• Four high yield symptoms
  • Radiation to the RIGHT shoulder
  • Vomiting
  • Worsens with exertion
  • Diaphoresis

Step 3: Look for the “Queen” (Pulmonary Embolism)

• Wells score
• PERC rule

Step 4: Print a Previous Cath Report

• Major bonus points with attending!
• Other useful information
  • Previous echocardiograms
  • Previous stress tests
  • Previous CTAs for PE

Step 5: Basic Testing Plan

• If concerned for cardiac causes
  • Troponin
• If concerned for pulmonary causes
  • Chest x-ray
• If concerned for vascular causes
  • CTA of the chest

Additional Reading

• STEMI (EM Clerkship)
• Pulmonary Embolism (EM Clerkship)