Cardiology
One of the most important topics in emergency medicine. Chest pain is one of the most common chief complaints in the emergency department and having a broad differential diagnosis and a methodical approach to your evaluation is critical. Thankfully, because it is such a common complaint usually emergency medicine physicians are comfortable and are well trained to appropriately manage emergent cardiac complaints. This section is lengthy but we tried to include some of the high yield material.
STEMI
Important to know criteria in males vs females.
Pay attention to V2-V3, these are the leads with exceptions.
1 mm elevation or more, in any contiguous leads, EXCEPT V2-V3
V2-V3 EXCEPTIONS:
1.5 mm elevation in FEMALES
2 mm elevation in MALES 40 y.o. and older
2.5 mm elevation in MALES less than 40 y.o.
ECG changes: early -> late
hyperacute T waves -> giant R waves -> ST elevation -> ST depression -> Q waves -> T wave inversions
Types:
Anterior (LAD) - elevation V1-V4, depression II, III, aVL
Lateral (LAD/Left Circumflex) - elevation I, aVL, V5-V6, depression V1
Inferior (posterior descending) - elevation II, III, aVF, depression V1-V4
Right ventricular (proximal right coronary) - elevation III > II, V1 > V2. Right sided leads w/ elevation in V4R, V5R.
Posterior (posterior descending) - depression in V1-V3, posterior leads w/ elevation of 0.5 mm
LBBB / Sgarbossa Criteria:
Concordant - 1 mm elevation (5pts) , 1 mm depression in V1-V3 (3pts)
Discordant - 5 mm elevation (2pts)
note, can be applied to paced rhythms
ST elevation ddx
acute MI
global ischemia (dissection, massive GI bleed, …)
early repol
myocarditis/pericarditis
vasospasm
ventricular aneurysm
LBBB/pacemaker
PE
high voltage (LVH, WPW, athletes…)
Na + channelopathies (TCA, hyperK, Brugada)
post cardioversion
hypothermia
takotsubo
intracranial abnormalities
hyperCalcemia
tPA
indications: PCI not available within 90 minutes or within 120 minutes with transfer
absolute contraindications: hx of brain bleed or known mass, ischemic stroke or TBI within 3 months, bleeding disorder, active bleeding, major surgery within 2 months, BP > 180/110 after treatment, suspect aortic dissection
tx: Over 67 kg: 100 mg administered as a 15 mg IV bolus followed by 50 mg infused over the next 30 minutes and then 35 mg infused over the next 60 minutes.
67 or less kg: 15 mg IV bolus, followed by 0.75 mg/kg (not to exceed 50 mg) infused over the next 30 minutes and then 0.5 mg/kg (not to exceed 35 mg) infused over the next 60 minutes.
Wellen’s Syndrome
early sign of proximal LAD lesion, may be asymptomatic, needs urgent cath
Type A
biphasic or deeply inverted T waves
Type B
symmetric T wave inversions in septal leads
De Winter pattern
STEMI equivalent, LAD/left anterior descending artery occlusion, needs emergent cath
upsloping ST elevation in aVR (0.5-1mm)
ST depressions and tall T waves in precordial leads
Post MI Complications
ruptured papillary muscle
Typically 2-7 days post MI, present with acute pulmonary edema, with new murmur. Tx nitroprusside, dobutamine, CT surgery
ventricular aneurysm
Persistent ST elevations > 2 wks after known MI and no reciprocal changes
dressler’s syndrome
2-10 wks post MI, low grade fever, chest pain, pericarditis/friction rub on exam, tx w/ ASA, ibuprofen, colchicine
Reading an ECG evaluate for all of the following
rate
Have a quick method of calculating the approximate heart rate. Rate of 300-150-100-75-60-50 corresponds to the number of large boxes between two consecutive QRS complexes, 1-2-3-4-5-6. If the rhythm is not regular then a quick method to get the approximate rate is to multiply the number of QRS complexes in a typical 10 second ECG by 6.
rhythm
Determine whether the rhythm is sinus, regular versus irregular. When a rhythm is initiated by the sinus node with every P wave followed by a QRS, it is known as sinus rhythm. Also, when the rhythm is initiated by the sinus node, the P wave will be upright in leads I, II, and III. P wave is usually best seen in lead II.
ST
Don’t miss the STEMI.
intervals
Look at PR, QRS, and QT intervals in order. If any abnormalities are seen, think about the clinical picture, whether your patient has an AV block, electrolyte abnormalities, reason for syncope, WPW etc. A quick way to determine if QT interval is normal is to see if it is less then half the interval between two consecutive QRS complexes. This method can be used when rate is normal 60-100 bpm.
killers
HCOM - LVH, need-like Q waves
Brugada - pseudo RBBB, STE V1-V3, down sloping ST elevation followed by T wave inversion, or “saddle back” ST elevation. A sodium channelopathy.
WPW - delta wave, wide QRS, short PR
Prolonged QT - QTc is prolonged if > 440ms in men or > 460ms in women, QTc > 500 is associated with increased risk of torsades de pointes
ARVD - arrythmogenic right ventricular displaisa - epsilon wave in 30%, T wave inversions in V1-V3
atypical
Wellen’s
DeWinter
Posterior MI
Endocarditis
ss:
osler nodes, janeway lesions, roth spots, splinter hemorrhages, petechiae, new murmur
dx:
blood cx x3, echo/TEE is best, duke criteria
tx:
abx: vancomycin + gentamicin
Heart Failure
ss
cardiomegally
fluffy infiltrate
kerly B lines
pleural effusions
tx
BiPAP - start first
nitro
furosemide - diuresis
inotropes - norepinephrine, dobutamine
dx
diagnose with ECHO
S3 heart sound - 99% specific
JVD - 70% specific, 50% sensitive
dyspnea - 50% sensitivity and specificity
orthopnea - 80% specificity
misc
BiPAP - decreases work of breathing, decreases preload by positive pressure which increases intrathoracic pressure, decreases venous return
Murmurs
systolic
HOCM - probably most commonly tested, mid systolic, murmur increases valsalva/standing due to decrease in venous return/preload. Murmur decreases with increase in preload/venous return such as leg raise/squat, and also decreases with increased afterload such as hand grip.
MVP- mitral valve prolapse, mid systolic click with late systolic murmur. Maneuvers have same effect on murmur as with the HOCM murmur.
MR - mitral regurgitation, holosystolic murmur. Maneuvers have opposite effects on murmurs as with the HOCM murmur. (Therefore learn the HOCM murmur). MR decreases with valsalva/standing, increases with leg raise/squatting, and hand grip.
AS- aortic stenosis, crescendo-decrescendo systolic murmur. Same response to maneuvers as with MR, EXCEPT with HANDGRIP/increased afterload. With increased afterload, AS decreases, but MR increases.
diastolic
MS- mid diastolic murmur, loud at the apex, can be 2/2 rheumatic fever
AR- early diastolic murmur, wide pulse pressure, head bobbing, can be 2/2 rheumatic fever, bicuspid valve, endocarditis
Syncope
consider San Francisco Syncope Rules - admit pts w/ CHF, Hct < 30, EKG abnormal, SOB, SBP < 90, fam hx of sudden death, syncope w/ exertion, structural heart disease.
arrhythmias
consider arrhythmias, AV blocks, a-fib, VT, etc
structural
hypertrophic cardiomyopathy, aortic stenosis - especially when syncope with exertion
electrical
WPW, QT, Brugada, ARVD
PE
1/6 patient’s admitted for first episode of syncope workup found to have PE. (NEJM 10.1056/NEJMoa1602172) History, clinical judgement and ECG changes are key in considering PE as cause of syncope (S1Q3T3, new RBBB, ST wave changes/depressions/elevation, TWI).
MI
history/chest pain, ECG, hx of CAD, troponin
other
AAA, CVA, SAH, seizure, ruptured ectopic, GI bleed, orthostatic/ meds, vasovagal. Do not forget to check glucose.
Consider CT head if neurologic complaint. SAH for example can cause syncope however pt usually will have persistent HA, AMS.
Admit pt’s for echo, cath/holter monitor, EP study.
Heart Blocks
first degree
Prolonged PR greater than 200.
second degree
Two types.
Mobitz Type I - increasing PR then dropped beat. Wenckebach.
Mobitz Type II - prolonged PR then sudden dropped beat. Needs pacemaker.
third degree
Complete heart block, dissociation of P from QRS. Needs pacemaker.
Transvenous pacer placement
Cordis placement
First place a 5 or 6 French cordis, into the right IJ or left subclavian.
Insertion
Sterile: Make sure swan sheath and white proximal hub of the sheath is on the pacer wire before insertion into the cordis. Thread the pacer wire to 20 cm into the cordis. Inflate balloon with 1.5cc of air. Have Distal/negative port of the pacer connected to the V2 lead on the chest (this will be done by a non sterile assistant). Advance the pacer wire and watch the monitor until ECG changes resemble ventricular lead placement (Widened QRS, with ST changes/elevations).
Once confirmed ventricular placement, deflate the balloon.
Pacer Setup
You will need an assistant to set up the pacer with non sterile hands. Insert the Distal/negative port into the V2 lead on the chest, this will allow you to monitor ventricular pacer placement described above.
Once confirmed ventricular placement per steps above, connect the pacer ports into the pacing device. Negative (-) to (-), positive (+) to (+).
Set rate at 100 bpm
A output rate to 0 bpm
V output to 25mAmp/Max
Decrease V output until lose pacing
Set/lock pacing at 2x minimum V output mAmp
tachycardia ddx
Can be split into narrow and wide qrs complex tachycardia, regular and irregular.
Narrow/Regular
Sinus tachycardia
Atrial tachycardia
Atrial flutter
SVT: AVNRT/ orthodromic AVRT
Narrow/Irregular
Atrial fibrillation
Multifocal atrial tachycardia
Atrial flutter with varied conduction (regularly irregular)
Wide/Regular
VT
SVT with BBB
Antidromic AVRT
Wide/Irregular
torsades, polymorphic VT
wide complex tachycardia
ventricular tachycardia
On ECG you can find AV dissociation, QRS > 120/ wide, Heart rate > 100, fusion beats and capture beats.
If unstable but with a pulse -> synchronized cardioversion at 100J
SVT with BBB
Difficult to distinguish from VT. Look for previous ECG with evidence of BBB or history of SVT terminated by adenoside/vagal maneuvers. If in doubt treat like VT. Consider using Brugada algorithm in distinguishing between VT and SVT with BBB.
antidromic AVRT/ WPW
DO NOT USE: adenosine, amiodarone, beta blockers, calcium channel blockers.
treatment
If unstable but with a pulse, -> synchronized cardioversion @ 100J
procainamide: 17 mg/kg at a rate of 25-50 mg/min
amiodarone - loading dose of 150 mg IV over 10 minutes, followed by an infusion 1mg/min for 6 hours, then 0.5 mg/min for 18 hours.
misc
avoid AV nodal blockers such as adenosine, digoxin, diltiazem, verapamil
the rest
Bidirectional ventricular tachycardia, caused by digoxin toxicity.
Other Tox/drugs can cause wide complex arrhythmia: TCA’s
bradycardia ddx
After considering ddx, treatment’s include:
atropine 0.5mg IV for max of 3mg.
epinephrine 2-10 mcg/min
transcutaneous pacing
transvenous pacing
Cause specific treatment:
athlete - sinus bradycardia, asymptomatic/HDS -> no treatment needed
hypothermia - rewarm
hypoglycemia - D50
hypothyroid/myxedema coma - tx hemodynamics/ABC’s, abx, hydrocortisone 100mg IV, levothyroxine
hyperkalemia- calcium gluconate/chloride, insulin/D50, albuterool, HCO3 1amp IV, dialysis.
AV blocking meds - CCB OD: high dose insulin, Calcium gluconate/chloride. BB OD: Glucagon 3mg IV. Digoxin OD: Digibind
sick sinus syndrome - pace
OSA - hemodynamics
heart block - pace
MI/ischemia - treat MI/cath lab?
CHA2DS2VASc
Score used to determine need for anti-coagulation in patient’s with Atrial Fibrillation. If score of 0, start ASA or no AC at all. Score of 1, consider AC. Score of 2 start AC.
Low risk - 0, Medium risk - 1 , High risk - 2 or greater points. As you can see below, many people will need anti-coagulation.
CHF - 1
HTN - 1
Age >75 - 2
DM - 1
Stroke - 1
Female - 1
ACLS
Evaluate for pulse first. If no pulse, then look at the rhythm and determine if rhythm is shockable or not shockable.
Remember that good CPR is what saves lives.
200J for defibrillation of shockable rhythms.
asystole / PEA
not shockable
CPR pulse check q2 min, and epinephrine q3-5 min
evaluate reversible causes, H’s/T’s
VT / V-fib
shockable, defibrillate at 200J
CPR pulse check 2min, epinephrine q3-5 min
amiodarone 300mg -> 150mg or lidocaine 1-1.5mg/kg
tx for reversible causes
hypoglycemia
acidosis
hyperkalemia
hypomagnesemia
tPA
H’s and T’s
hypoxia
hypovolemia
hypo/hyperKalemia
hypo/hyperThermia
H+ acidosis
Thrombosis/ MI
Thromboembolism / PE
Tension PTX
Tamponade
Toxins
Hypertension treatment, JNC 8 Recommendations
Asymptomatic Hypertension
If a patient is symptomatic from hypertension, presenting with HA, blurred vision or other end organ damage, then a completely different approach is used and is not addressed here. However in patients with hypertension greater than 180 mm Hg systolic, and 120 mm Hg diastolic, who are NOT symptomatic i.e. no signs of end organ damage, starting someone on anti-hypertensives is recommended. If BP is less then 180/120 mm Hg in patient’s who are asymptomatic, it is reasonable to have then follow up with their PCP for management of their blood pressure.
Patient’s need to follow up with their PCP for further management, recheck renal function, electrolyte levels.
African Americans
Thiazide / HCTZ - start with 12.5 mg daily
Calcium channel blocker / amlodipine - start with 2.5 mg once daily
Non African Americans
Thiazide / HCTZ - start with 12.5 mg daily
ACE-i or ARB - lisinopril start with 10 mg daily (In all races start ACE-i or ARB as initial therapy in CKD patients)
CCB / amlodipine - start with 2.5 mg once daily
LVAD labs
LDH
free hemoglobin
haptoglobin
cbc, cmp
troponin, bnp
PT/PTT/INR
Pulmonary Embolism
Massive PE
Hypotension with SBP < 90 for at least 15 minutes. Hypotension not due to other causes such as sepsis, arrhythmia, hypovolemia.
Persistent bradycardia, HR < 40 with signs of sock.
Tx: with tPA
Submassive PE
Acute PE without hypotension, SBP > 90, but with RV strain or dysfunction. Elevated Troponin, BNP.
Tx: anticoagulation, consider embolectomy, consider tPA?
PE
HDS, normal BP, no RV strain, normal troponin/BNP.
Tx: anticoagulation
ddx list
Just a salad of tested diagnoses and key facts about each.
Ebstein anomaly
apical displacement of tricuspid valve
Commotio cordis
v-fib after getting struck in the chest by an object
Coarctation of the aorta
typically pediatric presentation, tx with prostaglandin E1. Remember PGE1 can cause apnea so you will need to intubate the pediatric patient first.
Eisenmenger syndrome
VSD/left to right shunting progressing to right to left shunting