高血压英文ppt精品课件emergency management in

Emergency management in cardiology By C. Wongvipaporn Division of Cadiology in Medical Department Srinagaringe Hospital Khon Kaen University Objective What are the emergency cardiac condition? How to detection? How to emergency management and monitoring? Cardiac Emergency Definition of emergency care and critical care Symptomatic emergency: CHF, Cardiogenic shock, Syncope, SCA Arrhythmia: Tachy and Brady arrhythmia Endocardial emergency: valvular obstruction or regurgitation: CHF, Shock, Syncope Myocardial emergency: Coronary arterial disease, Myopathies: CHF, Shock, Syncope, Arrhythmia, SCA Pericardial emergency: Cardiac tamponade Vascular disease: Hypertensive emergency, Aortic dissection, Pulmonary emboli CONGESTIVE HEART FAILURE Definition HF Syndrome of abnormal cardiac functions in response to tissue requirement CHF Refractory CHF: Not improve or worsening in optimized medications Intractable CHF: Not improve or worsening in full medications Clinical manifestation Mechanical maifestation Left side Pulmonary edema Low output syndrome Cardiogenic shock Right side Visceral congestion Edema Electrical manifestation: Tachycardia Specific manifestation: Angina, Thyrotoxicosis, Beri beri Physical examination Left side Pulsus alternans, Tachycardia Cheyne-Stokes resp Hypotensions Gallop LV Rales: Killips Class Alteration, Renal failure Right side Engorged NV HJR Gallop RV Dependent edema Jaundice, Organomegaly, Ascites Specific signs: Thyrotoxicosis, Beri beri Killips Classification I . No crepitation , No S3 II. Crepitation 1/2 Lung ; Pulmonary edema IV. Cardiogenic Shock NYH Classification FCI: No limitation of physical activity FCII: Slight limitation of physical activity FCIII: Marked limitation of physical activity FCIV: Symptoms at rest Etiology Endocardium: Rheumatic heart disease Myocardium: IHD, Cardiomyopathy, Hypertensive heart disease, Myocarditis Pericardium: Constrictive pericarditis, Cardiac temponade Vascular: Hypertensive emergency Precipitating cause Preload: Hypervolemia, Dietary Contractility: ACS, Myocarditis Afterload: HT Others: Infection, Arrhythmias, Thyrotoxicosis, Anemia, Endocarditis, Inappropriate treatment Principle of management 1. Clinical and Hemodynamic stabilization Nonpharmacological Pharmacological 2. Correct cause (Type of HF) and reversible precipitating factors 3. Awareness of treatment 4. Planing of long term treatment Risk stratifications Prevention Nonpharmacological Rx. Fluid; restrict Diet; Low salt diet Record V/S, BW Activity Position Bed rest Wandering tourniquet Oxygination Intubations IABP Cardioversion Pacing Pharmacological Rx. Decrease preload Diuretic Nitroglycerine Morphine sulfate Increase contractility Dobutamine Dopamine Adrenaline Digoxin Decrease afterload Nitroprusside Nitroglycerine ACEI/ARB ISDN+Hydralazine Ca Blocker blocker Antiarrhythmic drugs Digoxin Amiodarone Correct cause prerenal, hypovolemic shock Electrolyte disturbance Pharmacological side effects Hypotension MI Inappropriate treatment SHOCK Shock - Definition Circulation inadequate to satisfy overall cellular metabolic requirement. Hypotension MAP decreased 30 mmHg ( 40 mmHg ( 30 mmHg or SBP 40 mmHg Shock - Clinical manifestation II Hypoperfusion (at least one system involvement) CNS: Agitation, anxiety, confusion, alteration of consciousness, unconscious COMA CVS: Hypotension, tachycardia, dysrhythmias, thready pulse, new murmurs or valvular regurgitation or dysfunction, capillary refill 3 sec RS: Tachypnea, dyspnea, cyanosis Renal: Oliguria, anuria Skin: Paleness, dusky skin, cool, clammy skin, profuse sweating, bluish lips and fingernils Other: Lactic acidosis Shock - Classification By pathophysiology (New categories) Hypovolemic Cardiogenic Obstructive Distributive Hyperdynamic By site of origin dysfunction (Previous) Hypovolemic Cardiogenic Vasogenic (anaphylactic) Septic l Overlap exists, and also concomitant categories exist Shock - Classification - Cardiogenic Endocardium Valvular: stenosis, regurgitation Septal defects Myocardial Infarction, contusion, myocarditis, cardiomyopathy, pharmacologic, depressant factors Pericardium (Hemodynamic likely to Obstructive) Constrictive pericarditis, Cardiac tamponade Arrhythmogenic Shock - Classification - Obstructive Extrinsic causes Pericardial tamponade Constrictive pericarditis Tension pneumothorax High PEEP, High alveolar pressure Obstructive intrathoracic tumors Intrinsic causes PE Pulmonary vascular disease Hypoxic pul vasoconstriction Atrial myxoma (R) Atrial thrombus (R) Metastatic tumors Endocarditis (R) Shock - Classification Hyperdynamic Shock SIRS-related (any shock can end up w/SIRS) Sepsis (infectious); pancreatitis; trauma; burns. Toxic shock syndrome Thyrotoxicosis, Cardiac beriberi, Pagets disease Cirrhosis AV shunt/fistula Ovarian hyperstimulation syndrome Drugs toxicity; Salicylate, Tricyclic antidepressant, Trmethoprim-sulfamethoxazole Vasoplegic syndrome Shock - Classification - Distributive Anaphylactic/anaphylactoid IgE mediated Non-IgE mediated Neurogenic shock; Spinal Trauma (low pulse, SVR low) Adrenal insufficiency Narcotic Drugs: Nitrates, Nitroglycerine, Viagra Shock - Management Five major principles 1. Prompt recognition. 2. Initial supportive management. Airway Volume replacement Cardiovascular drugs 3. Determine coronary (ACS) Thrombosis; pulmonary (PE) Asystole Work up cause Adequate CPR Sign of terminate CPR Pace maker Transcutaneous Transvenous Adrenalin 1 mg iv q 3-5 min Atropine 1 mg iv q 3-5 min (max 0.04 mg/K) CPR * Concepts of Acute Coronary Syndrome ACUTE CORONARY SYNDROME No ST Elevation ST Elevation Unstable Angina NQMI NSTEMI Classification of ACS QMI ECG Manangement History Physical Exam Vulnerable Plaque Platelet aggregation Thrombus formation Vasospasm Plaque rupture (55-80%) Exertion BP, HR Vasoconstriction Pathogenesis of ACS Acute MI Complete occlusion Unstable angina Non-Q MI Incomplete occlusion Distal embolization Healing plaque Spontaneous lysis Treatment of ACS Acute Coronary Syndrome ST elevation MI Thrombolytic therapy Anticoagulation Antiplatelet Anti-ischemic Coronary revascularization Long term medical therapy (antiplatelet, betablocker, ACEI, Statin) Unstable angina/ Non ST elevation MI Antiplatelet Anticoagulation Anti-ischemic Coronary revascularization Principle of ACS management Revascularization Medical Balloon CABG Medication for ischemia Modified risk factors Treatment of complication Factor of revascularization decrease area infarction prevent LV dysfunction decrease mortality TIME IS MUSCLE AND MUSCLE IS TIME Timing of symptoms Timing of treatments Patient condition Medical limitation Instrument limitation Personal limitation Principle of ACS management ACS Aspirin Nitrates Mo Beta blockers ACEI Antithrombin Clopidogrel GPII/IIIa Early Invasive Primary PCI Facilitate PCI Rescue PCI CABG Early Conservative Fibrinolytic drugs Risk stratification Hemodynamic stabilization qMedical qVentilator qIABP qPace maker Elective CAG +/- PCI or CABG Adjuvant Rx Cardiac tamponade Pericardium Visceral pericardium Parietal pericardium Pericardial space and fluid 15-50 ml Pericardial effusion Fluid accumulates in pericardial cavity Complication: Cardiac tamponade is the pressure compression of heart Often secondary to an underlying condition. Uremia Radiation Post cardiac surgery Drugs: procainamide, minoxidil Causes of cardiac tamponade Cardiac trauma Aortic dissection Cardiac rupture after AMI Inflammatory pericarditis Neoplasia Treatment of cardiac tamponade Relieve pericardial pressure ; Pericardiocenthesis (contraindication in aortic dissection, cardiac rupture) Volume loading Treat underlying cause Avoid vasodilator Hypertensive emergency Definitions Hypertensive Urgency Hypertensive Emergency Accelerated Hypertension Malignant Hypertension Accelerated-Malignant Hypertension Hypertensive Crisis Urgency or Emergency Hypertensive Urgency “Severe elevation of blood pressure” Generally DBP 115-130 No progressive end organ damage Hypertensive Emergency “Severe elevation of blood pressure” Generally occurs with DBP 130 WITH significant or progressive end organ damage Hypertensive Encephalopathy CVA Ischemic versus hemorrhagic Acute Aortic Dissection Acute LVF with Pulmonary Edema Acute MI / Unstable Angina Acute Renal Failure Eclampsia Urgency vs. Emergency Urgency No need to acutely lower blood pressure May be harmful to rapidly lower blood pressure Death not imminent Emergency Immediate control of BP essential Irreversible end organ damage or death within hours Pharmacotherapy Nitroprusside Arterial & venous dilator Decreases afterload and preload No direct negative inotropy or chronotropy Kinetics Onset: seconds Duration: 1-2 min 1/2 life: 3-4 min Increased ICP (?) Toxic metabolites Takes days to accumulate Pharmacotherapy Nitroglycerine Weak anti-hypertensive Vasodilator At high doses dilates arteriolar smooth muscle Better dilation of coronary conductance arteries Kinetics Onset: 1-2 min Duration: 3-4 min Tolerance Headache, Tachycardia, Nausea, Vomiting, Hypotension PULMONARY EMBOLI Clinical manifestion PE Clinical of DVT Shortness of breath Rapid pulse Sweating Fainting Sharp chest pain Bloody sputum (coughing up blood) Cardiogenic shock Aim of PE Management Symptomatic Rx Analgesic, Bed rest Oxygen Rx, Respirator Rx Specific Rx Risk reduction Prevent clot propagration Clot removal Medical Rx Catherter Rx Surgical Rx Prevention Primary Secondary Anticoagulant Thrombolysis Catheter embolectomy Surgical embolectomy Primary prevention Anticoagulant Heparin, warfarin, xymelagatran Secondary prevention Anticoagulant Heparin warfarin, xymelagatran IVC filter Recommended Treatment of Acute PE Massive PE with shock or syncope Thrombolysis or surgery Major PE with right-ventricular dysfunction Anticoagulants (Dalen) Thrombolysis (Goldhaber) Major PE without right-ventricular dysfunction Anticoagulants Minor PE Anticoagulants Hyers et al, 1998 Goldhaber, 1999 Goldhaber, 1998 Dalen et al, 1997 Nass et al, 1999 AORTIC DISSECTION Incidence Primarily occurs in two distinct populations - Middle aged men (age 40-60 years) with hypertension ( accounts for 90% of pts) Younger people with connective tissue defect of Aorta (e.g. Marfans syndrome) Can a