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Acute myocardial infarct Acute coronary syndrome Aortic dissection Pulmonary embolism Life threatening arrhythmias

Acute Coronary Syndrome

A spectrum of diseases
On one end is ST segment elevation MI (STEMI), on the other unstable angina (UA). In between is Non-ST segment elevation MI (NSTEMI) (previously known as non-Q MI) Difference between UA and NSTEMI is that cardiac enzymes are elevated in the latter.

Acute Myocardial Infarction

Diagnosis if 2 out of 3 criteria fulfilled
Chest Pain or Equivalent ECG changes Enzyme Changes

Diagnosis Clinical ECG Enzymes Complications Management


Acute Myocardial Infarction Chest Pain

Chest Pain Angina Equivalent - SOB - Syncope - Shock - Depressed Conscious Level Silent MI

Acute Myocardial Infarction ECG Changes

New onset Bundle Branch Block

ST elevation in
Ant leads V1-3 Lat leads V4-6; I AVL Inf leads II,III, AVF Rt sided leads Posterior wall

Anterior Myocardial Infarct

Inferior Myocardial Infarct

Acute Myocardial Infarction Enzyme Changes

CKMB Troponin T, Troponin I

Elevation 3-6 hrs post MI Troponin remains elevated for 2 weeks Elevation 1 hr post MI However nonspecific

Acute Myocardial Infarction Acute Complications

Arrhythmia Tachyarrhythmia Bradyarrhythmia e.g. heart block Cardiogenic Shock Acute Vulvular dysfunction Wall perforation acute VSD free wall perforation

Thrombolytic for STEMI patients

Criteria for use of Thrombolytics

Typical chest pain of AMI ST segment elevation of at least 1mm in 2 limb leads and 2mm in at least 2 contiguous chest leads. Less than 12 hours from onset of chest pain Less than 75 years of age.

Duties of the medical officer

Upon recognition of a STEMI, the medical officer will: -inform senior ED physician on duty -send patient to resus room for initial stabilisation -ascertain if the patient has any contraindications to the use of thrombolytics -book a bed in CCU.

Duties of the senior ED physicians

Once informed of a patient with STEMI in the resus room, the senior ED physician will: -ensure no contraindications to iv thrombolytics -take consent for iv thrombolytics -ensure that the iv thrombolytic is safely delivered to the patient

Acute Myocardial Infarction Management

ABC O2 supplement Analgesia IV morphine, nitrates Antiplatelet Aspirin
Beta Blocker Continuous Monitoring

Acute Myocardial Infarction Management

Reperfusion Therapy Thrombolytics ( only for STEMI) PTCA E-CABG Early ACE inhibitors Use of heparin Glycoprotein IIb/IIIa inhibitors (adjunct to PTCA)

Cardiogenic Shock Management

LV infarct Inotropes IABP
RV infarct Fluids 1st line

Caution in use of nitrates

Diagnosis of AMI require high index of suspicion
Early diagnosis and appropriate treatment + monitoring crucial in ensuring a good outcome

SUSPECTED CARDIAC-ORIGIN CHEST PAIN PROTOCOL Chest pain or Chest pain equivalent *

*Ischemic Chest Pain - tight, crushing - radiating to neck/ arm - diaphoresis - SOB Chest Pain Equivalent - chest discomfort - diaphoresis - SOB - giddiness/syncope

Hx, Ex, ECG

STEMI New BBB Unstable Angina

Ongoing ischemic CP >20min Hemoydynamically unstable Pulmonary edem ECG changes of ST depression, T inversion

Unable to rule out ACS

Non-cardiac CP

Pulmonary embolism Aortic dissection Pneumothorax Pneumonia Musculoskeletal

To Resus

Treat Accordingly


Unable to rule out ACS

High Risk **

Low Risk

Treat & Admit

Evaluate in ED

** High Risk Subgroup - middle aged male - Indian - pain similar to previous documented angina - Known CAD - Prev PTCA/CABG - Multiple risk factors


Give Aspirin/GTN Repeat ECG CK/CKMB on arrival in ED Repeat ECG CK/CKMB/Trop I 4h fr first sample
(at least 6h from onset of chest pain)


Both sets normal TCU CVM

Acute Coronary Syndrome (NSTEMI & Unstable angina)

ECG - ST depression or T inversion Cardiac enzymes raised in NSTEMI Management
Oxygen IV GTN IV heparin

CCU for monitoring coronary angiogram

acute tearing chest pain radiating to inter-scapular region. sudden death from rupture or cardiac tamponade, CCF

hypertension pulse deficits, neurological deficits, pericardial rub

AMI - dissection into coronary artery Renal failure Gut ischaemia - mesenteric artery occlusion Paraplegia - spinal artery occlusion Acute limb ischaemia - subclavian artery occlusion

Associations with Aortic Dissection

Hypertension Marfans syndrome Ehlers-Danlos syndrome Bicuspid aortic valve Coarctation of aorta Chest trauma Iatrogenic - instrumentation of aorta

Classification of Aortic Dissection

Type 1 - ascending limb Type 2 - ascending and descending limb Type 3 - descending limb

Type A - DeBakey 1 & 2 Type B - DeBakey 3

Investigation of Aortic Dissection

ECG - look for inferior MI (RCA occlusion) CXR - widened mediastinum, abnormal aortic knuckle, calcium sign > 5mm, pericardial or pleural effusion, displacement of trachea to right Transoesophageal echocardiography Spiral CT with contrast - intimal flap Angiography

Management of Aortic Dissection

Stablise patient in resus - IV access, supplemental O2, GXM BP control - IV labetalol - reduce heart rate to 60-70 bpm, reduce SBP 100-120 mm Hg, add nitroprusside if necessary Urgent cardiothoracic consult Surgery indicated for
involvement of ascending aorta rupture arterial compromise (ARF, limb ischaemia)

Acute Pulmonary Embolism

High index of suspicion History
Pleuritic chest pain, dyspnoea, syncope, cough, haemoptysis Risk factors of DVT - immobility, post-op, malignant disease, previous DVT/PE, obesity, pelvic mass, pregnancy

mild fever, HR, RR, pleural rub, JVP , lower limb thrombophlebitis

Investigations for Pulmonary Embolism

ABG - hypoxia, resp. alkalosis, normal ABG does not exclude PE CXR - usually normal. Pulm. oligaemia, raised hemidiaphragm, small effusion Ventilation / Perfusion scan problem with indeterminate probability scans Pulmonary Angiography - Gold standard Helical CT scan Investigate for underlying cause of PE eg. ultrasound legs, abdomen, pelvis

ECG showing PE

Stablize patient
supplemental O2, IV access, cardiac monitor, IV heparin

Cardiac arrest
CPR may dislodge clot

fluid resus to increase right sided filling pressure. Inotropes

Anti-coagulation Thrombolysis

Pulmonary embolectomy
thrombolysis contraindicated or patient in shock

Inferior vena cava filter

Use if anti-coagulation contraindicated; persistent embolism

ARRHYTHMIA General Approach

Assess haemodynamic stability Assess ECG/ rhythm Diagnosis Decide need to treat Appropriate Treatment Look for underlying cause/ precipitant

ARRHYTHMIA Serious haemodynamic Effect

Chest Pain Dypsnoea Depressed Conscious Level

Low BP Shock Pulmonary Oedema


Tachy (>120) or Brady (< 60)
QRS narrow ( <= 120 ms or 3 small sq) or broad Regular vs irregular

Supra-ventricular Tachycardia

Ventricular Tachycardia

TACHYARRHYTHYMIA VF Torsades Approach to ECG Polymorphic VT


Wide Complex

Narrow Complex

VT SVT + aberrancy Electrolyte abnormalities Drugs

AF + aberrancy MAT + aberrancy Atrial Flutter + varying block + aberrancy

Sinus Tachycardia SVT Atrial Tachycardia Atrial Flutter

Sinus Arrhythmia

Atrial Flutter+ varying block MAT

Tachyarrhythmia Principles of Rx
Assess pt stability ABC, monitoring Diagnosis Need to Rx
Pt unstable Specific arrhythmia VF, VT SVT, fast AF, new onset AF

Appropriate Rx

Tachyarrhythmia Clinical Management

Patient Stable?

ABC Monitoring

Unstable/ Serious signs or symptoms ABC Monitoring 12 Lead ECG Cardioversion

VF/ Pulseless VT Immediate Defibrillation

12 lead ECG
Evaluate ECG Specific Rx

Resus as per ACLS protocol

Tachyarrhythmia Clinical Management

Stable Pt
Narrow Complex Tachycarrhythmia SVT Vagal maneuvres Pharmacological adenosine verapamil others

Broad Complex Tachyarrhythmia Pharmacological Suspected VT-- lignocaine amiodarone Unsure-- consider trial of adenosine Synchornised Cardioversion

Synchronised cardioversion AF If chronic, aim to slow rate for fast AF If acute ( <72 hrs) convert

Absolute: HR < 60 min Relative : HR < expected
Sinus Bradycardia Heart Blocks Sick Sinus Syndrome

Evaluate Pt Stability ABC Monitor Rhythm strip 12 lead ECG Need to Rx?


Unstable Pt Type II 2nd Degree AV Block 3rd Degree AV Block

Bradycardia Treatment
Pharmacologcial Atropine Dopamine Infusion Adrenaline Infusion Pacing Transcutaneous Transvenous

ARRHYTHMIA Underlying Causes/ Precipitant

Underlying Cardiac Disease
IHD, inflammation, Vulvular Hear Disease Congenital Heart Disease, tumours Abnormal of Resting ECG e.g. bypass tract, prolonged QT Post cardiac surgery

Drugs Metabolic Endocrine Underlying Pulmonary Disease Misc

e.g. fever, stress, smoking

Not all require Treatment Need to evaluate Patient Status Type of Arrhythymia
( be it tachy or brady)

Need to Recognise Arrhythymia that require immediate Rx


Thank you!