Download Cardiology in the ED

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Cardiology in the ED
Dr Jessica Spedding StR BRI September 2014
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Cardiology in ED
What comes in:
Chest pain
C?C
Palpitations
Breathlessness due to cardiac causes
What ENPs see:
All of the above!
Minors BRI = Majors anywhere else!
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Today’s session
Cases to cover patients who often present to Minors
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Case 1
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84y woman
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Presents following collapse on way to bathroom at 6am
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Brief LOC without features of seizure
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In ED – had breakfast and feels ‘back to normal’
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What is important history?
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More history
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HPC:
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No CP, SOB, palpitations, headache immediate pre or post faint
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No recent illness, no hosp admissions for >10y
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PMH – HTN, hypothyroid (last check 3m ago), breast cancer 14y ago
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DH: amlodipine, bendroflumethazone, ramipril (started 4d ago),
levothyroxine
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SH: lives with husband, both well, independent, stairs at home,
family supportive
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Examination
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Looks well
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Afeb, BP 120/76, HR 72, sats 99 RR 12
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CVS N HS, JVP normal, minimal ankle pitting oedema
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RS Abdo Neuro grossly normal
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What else do you want?
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Syncope: ED investigation
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Postural BP – 120/76 lying stand up then wait 2 mins, 91/70
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BM – 6.1
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FBC U&E TFT all normal
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ECG…
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ECG interpretation:
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Differential diagnosis in C?C
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Differential diagnosis in C?C
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Vasovagal – secondary to:
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hunger, dehydration, intercurrent illness, stress, micturition
and…
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Postural hypotension:
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Recognised complication of ACE-I (and all BP lowering meds)
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Increased likelihood with autonomic dysfunction of age
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Can also indicate acute bleed – think occult GI bleed (Hb, Ur)
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Differential diagnosis
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Arrhythmia (brady or tachy) – not always persistent on ECG,
look for clues (PR, QTc)
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Heart failure – CCF / HOCM
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ACS
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Neuro – seizure, SAH
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AAA / thoracic aortic dissection
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Hypoglycaemia
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Other metabolic causes (Na, Ca… which can contribute to an
arrhythmia or a seizure)
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American College of Physicians
Guidelines
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Admit:
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Usually admit:
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Hx Coronary Artery Disease, CCF, VT
Chest pain
Signs of CCF, valve dis, stroke, focal neuro
ECG ischaemia, arrhythmia, long QTc or BBB
Sudden LOC with injury, palpns, exertional syncope
Frequent episodes
Suspicion of arrhythmia or CAD
Mod to sev postural hypotension
Over 70y
Don’t need to admit:
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The rest!
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Course of action for Case 1
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Admit
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Stop ramipril
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Watch BPs
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ECHO
Home after 24h
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What we must do
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Thorough history ruling out each potential serious diagnosis
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Exam focussing on evidence of arrhythmia, heart failure, BP,
aorta assessment and neuro concerns
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Focussed ix: ECG, post BP, bloods
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If home – consider GP ref for ECHO
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Case 2
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43y man
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Chest pain – severe for 20 mins but by arrival resolved
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ECG and obs at triage normal
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HTN for past 5y
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Smoker
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More info?
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Pain was chest and between shoulder blades, very sharp,
10/10 then settled
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Pain in right arm earlier
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Hasn’t been taking BP meds as thought caused impotence
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Examination
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normal except for BP 160/100
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What do you do?
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Investigations?
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ECG
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Aortic dissection
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Rare
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Fatality high (80%) if unrecognised, mortality 1% per hour
whilst untreated
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What is it?
+Tear in intima =>
False lumen =>
tracking of blood into false lumen =>
limits blood flow down branching arteries
coronary – MI
carotid – dense stroke
renals – renal failure
coeliac / mesenterics – gut ischaemia
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Management
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Think of it… then CT aortogram
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Get into resus
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2 large lines
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Xm blood
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Call cardiothoracics
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theNNT.com
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Case 3
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22y male
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Out jogging in icy conditions
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Slipped and banged head with brief LOC
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Ongoing severe headache, otherwise well and felt well prior
to fall
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No PMH
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What else do you want to know?
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Investigation
CT head normal
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ECG
+ QT interval:
beginning of QRS complex to end of T wave
most machines will calculate the QTc
= the QT length corrected to a rate of 60bpm
normal = less than 450 (or thereabouts!)
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Young fit collapses
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Most are vasovagal…. Less common in males….
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Just think of
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1. Arrhythmias – familial sporadic or iatrogenic long QT
predisposes to ventricular arrythmias and cardiac arrestr
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2. Cardiomyopathies
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HOCM:
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Young fit men/boys
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Sudden collapse whilst
exercising
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Due to obstructed outflow
of blood from LV to aorta
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Demand exceeds supply
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Syncope
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May present as VF or PEA
arrest
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Summary
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Thought about 3 cases that may walk in to minors
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That may not ring alarm bells
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Need to:
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Have an open mind
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Know differential diagnosis
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Know the ED tests that will rule out the rare and serious diagnoses
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ANY QUESTIONS?