CARDIAC EMERGENCIES
for Interns
Sheilah Bernard, MD
7/1/13
Pt HC
• 65 yo female hospital day #2 admitted for
untreated hypertension is currently on
labetalol 200 tid, hctz 25 qd, and captopril
25 tid
• You are called for BP of 200/110 with new
chest pain going to left scapula
• You ask for a 12-lead EKG and go to the
bedside to examine her while reviewing her
medications
Review of meds/labs
• Admission BP 230/120 R and 220/110 L
• In the ED pertinent labs included a Cr of 1.8
with a BUN of 22, RBS 132, TnI 0.051,
BNP of 312
• CXR shows mild cardiomegaly, mild
pulmonary venous redistribution
• EKG is unchanged:
What do you focus your PE on?
• Repeat BP’s manually, R + L arm, femoral
pulses, carotid pulses
• Appearance (uncomfortable, diaphoretic)
• CV system: ?new murmur of AI, S4, S3
• Lungs: Pulmonary edema
• CNS: Neurologic signs
• TREATMENT
Who do you call for help?
• Resident
• Rapid Response: Get a RN who can push
meds
• ICU resident for transfer to ICU for
parenteral agents
• CT surgery, Vascular Medicine
Acute management
• Control BP first with parenteral agents!
–
–
–
–
Labetalol infusion
Nitroprusside infusion
Nicardipine infusion
AVOID HYDRALAZINE
Blood Pressure Classification JNC 7
BP Classification
SBP mmHg
DBP mmHg
Normal
<120
and
<80
Prehypertension
120–139
or
80–89
Stage 1
Hypertension
140–159
or
90–99
Stage 2
Hypertension
>160
or
>100
Distribution of hypertensive
emergencies
•
•
•
•
•
•
•
Acute pulmonary edema/CHF
Cerebral infarction (stroke team)
Hypertensive encephalopathy
Acute coronary syndrome
Intracerebral or SA hemorrhage
Eclampsia
Aortic dissection
35%
25%
16%
12%
5%
5%
2%
Definitions of hypertensive crisis
• Hypertensive urgency: Acute rise in BP without acute endorgan damage; diastolic BP usually >120
 Patients with markedly elevated BP but without acute TOD
usually do not require hospitalization, but should receive
immediate combination oral antihypertensive therapy.
 Hypertensive emergency: Acute rise in BP with acute endorgan damage, diastolic BP usually >120
 Patients with marked BP elevations and acute Target Organ
Damage (e.g., encephalopathy, myocardial infarction,
unstable angina, pulmonary edema, eclampsia, stroke, head
trauma, life-threatening arterial bleeding, or aortic
dissection) require hospitalization and parenteral drug
therapy
Hypertensive Emergencies
Hypertensive Encephalopathy
– Headache, nausea/vomiting, change in mental
status, neuromuscular irritability
– Normal cerebral autoregulation of blood flow is
maintained at mean pressure 60-125 mmHg
– Goal is to reduce DBP 10-15% or 20-25%
reduction in MAP within 30-60 minutes, and to
160/100-110 within 2 hours
– http://internal.bmc.org/pharmacy/guidelines/doc
uments/mdg_hypertensive_crises.pdf
Parenteral treatment of
hypertensive emergencies
• Labetalol (B-blocker with a-blocker activity)
– 20 mg IV/2 min then after 15 min 20-80 mg q 15 bolus
or 0.5-2 mg/min infusion
– Contraindicated with SB, 2oAVB, CHF, bronchospasm
• Esmolol (B1>B2 blockade)
– 500 mcg/kg/min for 1 min then 4 min infusion of 50
mcg/kg/min; repeat cycle increasing by 50 mcg/kg/min
– Contraindicated with CHF, bronchospasm, 2oAVB
– Duration of action 4-16 minutes
Parenteral treatment of
hypertensive emergencies
• Nitroprusside (vasodilator)
– 0.25-10 mcg/kg/min to total <3.5 mg/kg
– Monitor thiocyanate in CRI, cyanide in liver failure
– Caution with high intracranial pressure,
phosphodiesterase inhibitors
• Nitroglycerin (veno>>vasodilator)
– 0.2 mcg/kg/min
– Higher dosage often necessary to decrease BP
– Caution with high intracranial pressure
Parenteral treatment of
hypertensive emergencies
• Nicardipine (dihydropyridine CCB)
– 5.0-7.5 mg/h, slow offset of action (30-40 min)
– Contraindicated with advanced AS, caution with ACS
– Risk of infusion phlebitis
• Enalaprilat (ACE-I)
– 1.25 mg IV over 5 min followed by 1.25 mg q 6 h (to
max 5 mg q 6 h)
– Reduce initial dose to 0.625 mg if patient receiving
diuretics, creat elevated
– Avoid with AMI, Slow onset of action (hours)
Parenteral treatment of
hypertensive emergencies
• Phentolamine (a1 blocker)
– Drug of choice for pheochromocytoma
– 1-5 mg IV/IM 1-2 hrs preop, repeat as
necessary
• Furosemide (Loop-acting diuretic)
– Rapid acting, initial venodilator
Parenteral treatment of
hypertensive emergencies
• Alpha-methyldopa (a-adrenergic inhibitor)
– Use in preeclampsia
– 250-1000 mg bolus IV q 6 hr
• Hydralazine (arteriolar vasodilator)
– Use “limited to” preeclampsia
– Can cause sudden, uncontrolled drop on BP
– 10-20 mg IV q 4-6 hours
Parenteral treatment of hypertensive
emergencies (Elsewhere)
• Fenoldopam (dopamine D1 receptor agonist)
– 0.1 mcg/kg/min then tititrate at 0.05 to 0.10 mcg/kg/min
increments q 15 min
– Caution with hypokalemia or glaucoma
– No negative inotropic or chronotropic effects (tachycardia)
– Flushing common
Special hypertensive situations
• Aortic dissection
– Sodium nipride with b-blockers, labetalol
• Acute ischemic stroke
– Labetalol or nitroprusside
• Cardiac Ischemia
– Nitroglycerin with beta blocker
• Catecholamine Surge
– Phentolamine
Chest Pain in the Emergency Department
–
Aortic dissection
• Classification
– DeBakey Type I = II + III
– Stanford Type A = Type I + II
Type B = Type III
– Proximal Type A; Distal Type B
• DX - Physical exam
– Appear shocky with
frequently elevated BP
– Pulse deficits (25-30%)
– AI (30%)
– Neurologic manifestation
• Imaging techniques (sens % IRAD)
– TEE - Unstable pt, if AI or EKG changes (88%)
– CT - If no MI/EKG changes; if MRI n/a or CI (93%)
– MRI/MRA - Hemodynamically stable (100%)
– Angiography - Gold Standard (87%)
Pt AF
• You are called to the bedside for your patient
who c/o PND
• The nurse tells you that the monitor has been
alarming for HR > 150 for the past 15
minutes, and she is getting an EKG
• Patient was admitted for ATCP with negative
enzymes, and is awaiting an ETT due to CV
risks of Fam hx, HTN, obesity and HL
At bedside you find:
• BP 165/70 R=L, HR 167 irreg irreg
• JVP 9 cm difficult to assess due to obesity,
lungs with bibasilar rales and end expiratory
wheezing
• CV irreg irreg, 2/6 HSM of MR at apex
previously known
• 1+ LE edema
What do you do?
• Call resident
• Initiate parenteral agents:
–
–
–
–
IV lopressor 5 mg q 10 min x 3 to slow HR
IV lasix to reduce pulmonary congestion
Goal HR < 100, goal SBP < 120
Consider IV diltiazem with infusion if poor
response to metoprolol
• Start PO agents
– Start or intensify metoprolol PO
How would treatment change if:
•
•
•
•
•
•
Pt hypotensive?
Pt with Acute MI by EKG with STE?
Pt had hemiplegia new onset?
RATE CONTROL
CARDIOVERSION
ANTICOAGULATION
Pt ACS
A 54-year-old woman is evaluated in the emergency department for jaw and shoulder pain that has occurr
Electrocardiogram shows 1.0-mm ST-segment depression in leads V1 through V4 with T-wave inversions.
The patient is given aspirin, intravenous nitroglycerin, low-molecular-weight heparin, metoprolol, and atorv
• A 54-year-old woman is evaluated in the
emergency department for jaw and shoulder
pain that has occurred intermittently for the
past week
• The symptoms occur with activity and are
relieved by rest
• Physical examination shows a blood
pressure of 130/68 mm Hg and a pulse of
90/min
Lab data
• Labs are normal except for TnI 0.851 (nl <
0.033 ng/ml)
• CK’s 133 normal
• BNP normal
• CXR normal
EKG
Hospital course
• The patient is given aspirin, intravenous
nitroglycerin, low-molecular-weight heparin,
metoprolol, clopidogrel and atorvastatin
• The pain subsides after approximately 20
minutes, and she is admitted to the coronary
care unit
• One hour later, she has recurrent jaw and
shoulder pain. She denies chest pain. A repeat
electrocardiogram is unchanged
Now what?
• Which of the following is the most
appropriate immediate treatment for this
patient?
• A. DC metoprolol and start verapamil
• B. DC low-molecular-weight heparin and
start unfractionated heparin
• C. Start enalapril
• D. Start glycoprotein IIb/IIIa inhibitor
Pt ACS
• UA/NSTEMI pts who have high risk features
with recurrent ischemia while on ASA,
thienopyridine and anticoagulant should be
started on GP2b/3A inhibitor—31-PTCA!
• Eptifibatide 180 mcg/kg IV bolus followed by
2 mcg/kg/min (decrease to 1 mcg/kg/min if
CrCl < 50 ml/m)
• Contraindicated in ESRD
• Check plt count 4 hours later then daily
Cardiac pacemakers
1957
Pacer modes
Atrial pacing
Ventricular pacing
Pseudofusion pacing (atrial tracking)
Dual-chamber pacing (A-V)
Dual-chamber pacer leads
Implantable cardioverters/
defibrillators (ICD’s)
ICD’s--defibrillation
Cardiac resynchronization therapy
(CRT)
www.ccbm.jhu.edu/research
/cvs.php
CRT pacing
Pt with HTN and Stage 2 CKI on
ACEI has GI bleed HD #3
Alcoholic admitted with
withdrawal seizures on HCTZ
K+ up to 3.3
CARDIAC PACING
• External Heartstream XL pacing pads for
immediate pacing with EKG cable
– Atropine
– Dopamine
– Isoproterenol 2-10 mcg/min
• Contraindication
– Hypothermia (includes death!)
– Late pacing (brady-asystolic > 20 minutes)
– VF
ICD considerations
• Perform ACLS protocols as if patient did not have
ICD
• External defibrillation can be performed, avoid
placing pads over pulse generator
• Repetitive, appropriate shocks indicate electrical
storm—Call EP fellow:
– Active ischemia, lyte imbalance, deterioration of LVEF
– Deactivate ICD with magnet placement or
reprogramming
Defibrillation
– Current defibrillators set to pad default (hands-off)
– Defibrillation charge bleeds down if not
discharged within 15 secs
– No EKG cables necessary
Refractory Ventricular Defibrillation
– Alkalosis
– Respiratory acidosis (mechanical ventilation)
– Excessive parasympathetic stimulation
(atropine)
– Excessive catecholamine stimulation
– Hypokalemia
– Hypomagnesemia
– Hypothermia
Automatic External Defibrillators
• Definition
– Shockable rhythm
• VT >150/VF
– Non-shockable rhythm
• Asystole, paced, slow <100 VT/IVR, variable
ventricular ectopy, SVT QRS>120, agonal HR < 20
• 5-10 sec analyze/charge time; 1 shock/2
min CPR, biphasic joules
• Can be manually overridden (2 buttons in
middle push simultaneously)
AED FR2 vs Manual Heartstream
XL
• Defibrillate only, NO PACING, NO
SYNCHRONIZED CARDIOVERSION
• Leave pads in place, cable transfers to
manual Heartstream XL
• Manuals all have pad or paddle options, all
are biphasic technology
• All Heartstream XL have pacing option
59 yo F collapsed in choir Sun AM
•Call EMS 3431324 24/7 with
trip/EMT #
AED
AED2
Post-ACLS: Hypothermia?
• Indications
– S/p VT/VF arrest with <15 min time from collapse to
onset of resuscitation
– <60 minutes from collapse to restoration of circulation
• Contraindications
–
–
–
–
Trauma, recent surgery
Respiratory arrest, sepsis/infections
Coagulopathy, conditions predisposed to major bleeds
Pregnancy
Code Response at BMC
(ENC/HAC)
• Inpatient Code team (inpatients)
– CCU/ICU resident, ICU RN, Anesthesia,
Respiratory therapy, Transport, Security,
Central equipment
• Proceed-out team (non-inpatients)
– CCU resident, ICU RN/Resource RN,
Transport, Security to bring victim to ED
• Rapid Response team
– Respiratory therapy, resource RN/RN manager
Pericardial Chest Pain
– Pericarditis - Clinical diagnosis
– Pericardial effusion
– Pericardial tamponade
• Beck’s triad (1935) of arterial hypotension,
elevation of systemic venous pressure and small
quiet heart
Pericardial Tamponade
PE
– Elevated JVP with prominent X descent, absent Y descent
– Pulsus paradoxus (77%)
– Tachypnea (80%), Tachycardia (77%)
DX
– CXR
– EKG
– Echo/Doppler
• Pericardial effusion
• Diastolic RA, RV collapse
• Inspiratory reduction of MV early diastolic flows
– Swan Ganz/Cath
TX
– Pericardiocentesis
• EKG and Echo guidance
– Pericardiectomy/Pericardiotomy
Acute endocarditis
Fever, murmur, embolic manifestations (MI)
DX - Blood cultures (find source)
- Echocardiography
RX - Medical
-Surgical for CHF, persistent fever refractory
to therapy, major embolic events, abscess
formation, fungal infection, prosthetic
valves
An approach to the diagnostic use of echocardiography (echo)
Baddour, L. M. et al. Circulation 2005;111:3167-3184
Copyright ©2005 American Heart Association