Cardiogenic Emergencies

Acute ST Elevation MI

1. ECG monitor
2. High flow oxygen by face mask (caution if COPD)
3. IV access. Bloods: FBC, U+E (is troponin not being excreted, and hence is it falsely high?), glucose, lipids, cardiac enzymes
4. Brief assessment:hx of CV disease, RFs,
   Contraindications to thrombolysis
   Ex: pulse, BP, JVP, murmurs, heart failure, peripheral pulses, cardiac scars
5. Morphine (5-10mg IV + metoclopramide 10mg IV), Oxygen, Nitrates (2 puffs of GTN s/l), Aspirin (300mg)
6. Atenolol, ACE inhibitor, Atorvastatin, anti-ADP receptor (clopidogrel)
7. CXR
8. Thrombolysis or cardiac catheterisation if indicated
9. Consider gluscose+insulin infusion for DM
10. Consider DVT propylaxis

Indications for thrombolysis

Presentation within 3h of pain with:

1. ST elevation >2 mm in 2 or more chest leads or
2. ST elevation >1 mm in 2 or more limb leads or
3. Posterior infarction (dominant R waves and ST depression in V1-V3)
4. New onset LBBB

Contraindications to thromboloysis

• Internal bleeding, vaginal bleeding
• Prolonged or traumatic CPR
• Acute pancreatitis
• Recent trauma or surgery < 2w
• Cerebral neoplasm
• Severe hypotension
• Suspected aortic dissection
• Previous allergic
• Pregnancy or <19w postpartum
• Severe liver disease
• Oesophageal varices
• Recent head trauma
• Recent haemorrhagic stroke

Indications for angiography

After 3h, or continuing pain, or contraindication

Acute coronary syndrome without ST elevation

1. Same as above
2. Brief assessment: previous angina, relief with rest/nitrates, CVS hx, RFs
   Ex: Pulse, BP...
   Ix: ECG (ST depression, flat or inverted T waves, can be normal.)
   Bloods (FBC, U+E, glucose, lipids, cardiac enzymes, CXR)
   
3. Except heparin instead of thrombolysis
4. Tirofiban
5. Optimise drugs: beta-blocker, calcium channel antagonist, ACEI, nitrates, intensive statins
6. Angioplasty

Pulmonary Oedema

1. Sit the patient upright
2. 100% oxygen
3. IV access and monitor ECG. Treat any arrhythmias.
4. Start Ix whilst continuing treatment (ie don't wait for results): CXR (cardiomegaly, oedema, effusions, fluid in lung fissures, kerley B lines)
   ECG (signs of MI)
   Bloods: U+E (renal cause?), cardiac enzymes, ABG
   Consider echo
   
5. Diamorphine 2.5-5mg IV slowly (caution in liver failure and COPD)
6. Furosemide 40-80mg IV slowly
7. GTN spray 2 puffs SL
8. If systolic BP>100mmHg start a nitrate infusion
9. If the patient is worsening give a further dose of furosemide
10. Consider ventilation/CPAP
11. Once Improving
    • Daily weighing, BP and pulse, repeat CXR
    • Change to oral furosemide, or bumetanide
    • Consider an additional thiazide if ↑doses of furosemide
    • ACEI if LVF. Consider beta-blocker, spironolactone
    • Consider digoxin, warfarin, especially if AF

Differential Diagnosis

Asthma/COPD, pneumonia and oedema often co-exist, so can treat for all 3 (eg salbutamol nebs, furosemide IV, diamorphine, amoxicillin)

Symptoms

Dyspnoea, orthopnoea, pink frothy sputum

Signs

Distressed, pale, sweaty, tachycardia tachypnoea, pulsus alternans, raised JVP, fine lung crackles, triple/gallop rhythm, wheeze (“cardiac asthma”)