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Cardiac emergencies 2 - CARDIOVASCULAR EMERGENCIES...

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CARDIOVASCULAR EMERGENCIES REVIEW REVIEW - - II II CORE CONTENT SYNTHESIS-BASED ON ABEM, SAEM, ACEP & ACLS OUTLINES O CLINICAL PEARLS O David Riley, MD David Riley, MD O Director of Ultrasound Training & Resident Didactics Director of Ultrasound Training & Resident Didactics O Department of Emergency Medicine Department of Emergency Medicine O St. Luke’s Roosevelt Hospital Center St. Luke’s Roosevelt Hospital Center O Columbia University College of Physicians & Surgeons Columbia University College of Physicians & Surgeons
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DISTURBANCES OF CARDIAC RHYTHM O MECHANISMS FOR ARRHYTHMIAS O 1. INCREASED AUTOMATICITY: INC. SLOPE OF PHASE 4 (Epi causes this & Lidocaine decreases phase 4 slope) O 2. TRIGGERED AUTOMATICITY: OSCILLATIONS OF PHASE 4 AMPLITUDE W/INC. CHANCE OF GETTING TO THRESHOLD O 3. CONDUCTION-DISTURBANCES AND RENTRY, IE PROL. QTc O MOST STABLE PATIENTS NEED MEDICINE O UNSTABLE PATIENTS NEED ELECTRICITY
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NORMAL ESCAPE RATES O SA NODE 80 BEATS/MIN O AV NODE 60 BEATS/MIN O VENTRICLES 40 BEATS/MIN
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AHA CLASSIFICATIONS OF INTERVENTIONS IN ACLS O Class I: Definitely Helpful O Class IIa: Acceptable, Probably Helpful O Class IIb: Acceptable, Possible Helpful O Class III: Not Indicated, May be Harmful
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A. ATRIAL FIBRILLATION 1. ATRIAL RATE IS 400 1. ATRIAL RATE IS 400 - 600, RHYTHM IS 600, RHYTHM IS IRREGULARLY IRREGULAR, can precipitate CHF IRREGULARLY IRREGULAR, can precipitate CHF - espec espec . w/LVEF < 50%, NO S4, CONSIDER CONSIDER THYROTOXICOSIS THYROTOXICOSIS 2. RAPID VENTRICULAR RESPONSE MAY OCCUR: 2. RAPID VENTRICULAR RESPONSE MAY OCCUR: MAX 200:> 200 MAX 200:> 200 = WPW: = WPW: Rx Rx - - procanamide procanamide 3.RX:HEMODYNAMICALLY UNSTABLE 3.RX:HEMODYNAMICALLY UNSTABLE - SYNC SYNC CARDIOVERSION WITH CARDIOVERSION WITH 200J: need big Joules to 200J: need big Joules to cardiovert cardiovert 4. 4. A FIB WITH RVR: USE A FIB WITH RVR: USE DILTIAZEM .25MG/KG IV .25MG/KG IV OVER 3 OVER 3 - 5 MIN TO SLOW THE VENT. RATE 1ST; 5 MIN TO SLOW THE VENT. RATE 1ST; IN ELDERLY GIVE IN 5MG IN ELDERLY GIVE IN 5MG INCREMENTS TO AVOID HYPOTENSION , LOAD W/DIGOXIN ALSO INCREMENTS TO AVOID HYPOTENSION , LOAD W/DIGOXIN ALSO 0.5mg IV 0.5mg IV THEN YOU HAVE 48 HRS TO CONVERT THE A FIB THEN YOU HAVE 48 HRS TO CONVERT THE A FIB TO NSR, WITH A TO NSR, WITH A IA IA - QUINIDINE QUINIDINE OR III CLASS DRUG OR III CLASS DRUG - Ilbutilide Ilbutilide OR CARDIOVERSION OR CARDIOVERSION 5. PTS WITH CHRONIC AFIB HAVE 60% STROKE REDUCTION WITH 5. PTS WITH CHRONIC AFIB HAVE 60% STROKE REDUCTION WITH COUMADIN RX(INR GOAL 2 COUMADIN RX(INR GOAL 2 - 3;3.5 3;3.5 - valves) valves)
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ATRIAL FIBRILLATION: New Onset O 50-70% convert to NSR spontaneously O 48 Hour Rule: New onset AF should be converted to normal sinus rhythm w/I 48 hours O Clot risk with embolic complications O >48 hrs=atrial stunning: lasts 3-6 weeks & need for anticoagulation O New Drugs:IV: amiadarone, ilbutilide (torsades 4-8%risk), PO only: propafanone
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New Onset Atrial Fibrillation O ADMIT ALL O 50-70% will convert to NSR spontaneously O R/O: thyrotoxicosis, pulmonary embolism, pericardial disease, carbon monoxide, lyme disease O Refractory AF/Aflutter: can be due to pericardial disease/effusion, or CO poison
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