CARDIAC AND CARDIAC AND RESPIRATORY RESPIRATORY EMERGENCIESEMERGENCIES

MOSHE WEIZBERG, MDMOSHE WEIZBERG, MD

BEEP!!!BEEP!!! ANY ES UNITS AVAILABLEANY ES UNITS AVAILABLE CHEST PAIN DIFFICULTY BREATHINGCHEST PAIN DIFFICULTY BREATHING

You gotta know these coldYou gotta know these cold

CARDIACCARDIAC

CHEST PAINCHEST PAIN CHFCHF ARRHYTHMIASARRHYTHMIAS

TACHYCARDIATACHYCARDIA

Usually due to underlying conditionUsually due to underlying condition May be due to arrhythmiaMay be due to arrhythmia >150 more likely to be arrhythmia>150 more likely to be arrhythmia

TACHYCARDIATACHYCARDIA

Treat underlying conditionTreat underlying condition Arrhythmia may require specific Arrhythmia may require specific

treatmenttreatment

BRADYCARDIABRADYCARDIA

More concerningMore concerning Inadequate cardiac outputInadequate cardiac output May lead to hypotensionMay lead to hypotension

BRADYCARDIABRADYCARDIA

OxygenOxygen Monitor BP closelyMonitor BP closely TransportTransport Definitive management depends on Definitive management depends on

causecause

CHEST PAINCHEST PAIN

MI/ANGINAMI/ANGINA PULMONARY EMBOLISMPULMONARY EMBOLISM AORTIC DISSECTIONAORTIC DISSECTION PNEUMOTHORAXPNEUMOTHORAX

CHEST PAINCHEST PAIN

MI/ANGINAMI/ANGINA– Most commonMost common

PULMONARY EMBOLISMPULMONARY EMBOLISM AORTIC DISSECTIONAORTIC DISSECTION PNEUMOTHORAXPNEUMOTHORAX

MIMI

Blockage in a coronary arteryBlockage in a coronary artery Inadequate blood flow to that area of Inadequate blood flow to that area of

the heartthe heart Inadequate oxygenation to that area Inadequate oxygenation to that area

of the heartof the heart Necrosis of myocardial cellsNecrosis of myocardial cells

MI RISK FACTORSMI RISK FACTORS

AgeAge GenderGender HypertensionHypertension HypercholesterolemiaHypercholesterolemia SmokingSmoking Family historyFamily history

MI SYMPTOMSMI SYMPTOMS

Chest painChest pain– Pressure, tightnessPressure, tightness– ““something is sitting on my chest”something is sitting on my chest”– Radiates to left arm, neckRadiates to left arm, neck

Shortness of breathShortness of breath Nausea/vomitingNausea/vomiting Dizziness/lightheadednessDizziness/lightheadedness

MI SIGNSMI SIGNS

AnxiousAnxious DiaphoreticDiaphoretic Ashen grayAshen gray Vital signs can be completely normalVital signs can be completely normal Levine’s signLevine’s sign Lungs for CHFLungs for CHF

MI TREATMENTMI TREATMENT

OxygenOxygen Assist with nitroglycerinAssist with nitroglycerin

– If systolic >120If systolic >120– Vasodilation Vasodilation

ASPIRINASPIRIN

Decreases mortality by 23%Decreases mortality by 23% Platelet inhibitionPlatelet inhibition

ASPIRINASPIRIN

IndicationsIndications– If >35 y/o or cardiac historyIf >35 y/o or cardiac history

DoseDose– 162 mg (2 baby aspirin)162 mg (2 baby aspirin)

ASPIRINASPIRIN

ContraindicationsContraindications– Aspirin allergyAspirin allergy– Recent GI bleedRecent GI bleed– Bleeding disorderBleeding disorder– On coumadinOn coumadin

MI TREATMENTMI TREATMENT

Monitor vital signsMonitor vital signs– Can develop V-fibCan develop V-fib

TransportTransport

MI WARNING SIGNSMI WARNING SIGNS

HypotensionHypotension CHFCHF Persistent painPersistent pain

ANGINAANGINA

Brief episode of chest painBrief episode of chest pain Goes awayGoes away Partial blockage in a coronary arteryPartial blockage in a coronary artery Much more commonMuch more common Treat the sameTreat the same

CHEST PAINCHEST PAIN MI/ANGINAMI/ANGINA

PULMONARY EMBOLISMPULMONARY EMBOLISM AORTIC DISSECTIONAORTIC DISSECTION PNEUMOTHORAXPNEUMOTHORAX

PULMONARY EMBOLISMPULMONARY EMBOLISM

Clot in pulmonary arteryClot in pulmonary artery Begins as DVTBegins as DVT HypoxiaHypoxia Necrosis of lung tissueNecrosis of lung tissue Decreased cardiac outputDecreased cardiac output

PE RISK FACTORSPE RISK FACTORS

Cancer Cancer Prolonged immobilizationProlonged immobilization

– Casted legCasted leg– Airplane flightAirplane flight

PregnancyPregnancy Recent surgeryRecent surgery Hypercoagulable stateHypercoagulable state

PE SYMPTOMSPE SYMPTOMS

Sudden deathSudden death Abrupt onset SOBAbrupt onset SOB Chest painChest pain

– PleuriticPleuritic

PE SIGNSPE SIGNS

Appearance variableAppearance variable TachycardiaTachycardia TachypneaTachypnea BP may be normalBP may be normal When severe – hypotensionWhen severe – hypotension

PE SIGNSPE SIGNS

Clear lungsClear lungs Swollen legSwollen leg

PE TREATMENTPE TREATMENT

OxygenOxygen TransportTransport CT scanCT scan HeparinHeparin

PE WARNING SIGNSPE WARNING SIGNS

Respiratory distressRespiratory distress HypotensionHypotension

CHEST PAINCHEST PAIN MI/ANGINAMI/ANGINA PULMONARY EMBOLISMPULMONARY EMBOLISM

AORTIC DISSECTIONAORTIC DISSECTION PNEUMOTHORAXPNEUMOTHORAX

AORTIC DISSECTIONAORTIC DISSECTION

AortaAorta– Large blood vesselLarge blood vessel

Tear in aortaTear in aorta Massive hemorrhageMassive hemorrhage John RitterJohn Ritter

DISSECTION RISK FACTORSDISSECTION RISK FACTORS

Prolonged hypertensionProlonged hypertension SmokingSmoking Post-partumPost-partum Marfan’s syndromeMarfan’s syndrome

– Abe LincolnAbe Lincoln

DISSECTION SYMPTOMSDISSECTION SYMPTOMS

Abrupt onset chest painAbrupt onset chest pain Radiates to backRadiates to back Described as tearing sensationDescribed as tearing sensation

DISSECTION SIGNSDISSECTION SIGNS

Look sickLook sick TachycardiaTachycardia HypertensionHypertension Unequal pulsesUnequal pulses

DISSECTION TREATMENTDISSECTION TREATMENT

OxygenOxygen NO ASPIRINNO ASPIRIN Rapid transportRapid transport SurgerySurgery High mortalityHigh mortality

DISSECTION WARNING DISSECTION WARNING SIGNSSIGNS

HypotensionHypotension

CHEST PAINCHEST PAIN MI/ANGINAMI/ANGINA PULMONARY EMBOLISMPULMONARY EMBOLISM AORTIC DISSECTIONAORTIC DISSECTION

PNEUMOTHORAXPNEUMOTHORAX– Pulmonary sectionPulmonary section

CHFCHF

Left ventricle failsLeft ventricle fails Pressure backs up to lungsPressure backs up to lungs Leakage of fluid into lungsLeakage of fluid into lungs Pulmonary edemaPulmonary edema Trying to breathe air through fluidTrying to breathe air through fluid

CHF CAUSESCHF CAUSES

IschemiaIschemia– MIMI

Prolonged hypertensionProlonged hypertension Excessive salt intakeExcessive salt intake Didn’t take medsDidn’t take meds

CHF SYMPTOMSCHF SYMPTOMS

SOBSOB CongestionCongestion Drowning Drowning

CHF SIGNSCHF SIGNS

Look sickLook sick DiaphoreticDiaphoretic Laboring to breatheLaboring to breathe Difficulty speakingDifficulty speaking Gurgling respirationsGurgling respirations

CHF SIGNSCHF SIGNS

TachycardiaTachycardia TachypneaTachypnea Hypertension Hypertension

CHF SIGNSCHF SIGNS

Rales bilaterally Rales bilaterally JVDJVD Pedal edemaPedal edema

CHF TREATMENTCHF TREATMENT

Sitting positionSitting position– Gravity brings fluid downGravity brings fluid down

OxygenOxygen

CHF TREATMENTCHF TREATMENT

Monitor respiratory statusMonitor respiratory status Monitor mental statusMonitor mental status

– If decreasing If decreasing may need to assist may need to assist ventilations with BVMventilations with BVM

Rapid transportRapid transport

CHF WARNING SIGNSCHF WARNING SIGNS

Worsening respiratory distressWorsening respiratory distress Decreasing mental statusDecreasing mental status

ARRHYTHMIASARRHYTHMIAS

Electrical wires in heartElectrical wires in heart OverdriveOverdrive Supraventricular vs ventricularSupraventricular vs ventricular

ARRHYTHMIA CAUSESARRHYTHMIA CAUSES

IschemiaIschemia Heart diseaseHeart disease CaffeineCaffeine Stimulants Stimulants Congenital Congenital

ARRHYTHMIA SYMPTOMSARRHYTHMIA SYMPTOMS

PalpitationsPalpitations– Abrupt onsetAbrupt onset

Light-headednessLight-headedness Syncope Syncope

ARRHYTHMIA SIGNSARRHYTHMIA SIGNS

TachycardiaTachycardia Blood pressure can be normalBlood pressure can be normal Hypotension is a bad signHypotension is a bad sign

ARRHYTHMIA TREATMENTARRHYTHMIA TREATMENT

OxygenOxygen Monitor heart rateMonitor heart rate Monitor blood pressureMonitor blood pressure Monitor mental statusMonitor mental status Transport Transport

ARRHYTHMIA WARNING ARRHYTHMIA WARNING SIGNSSIGNS

HypotensionHypotension Worsening mental statusWorsening mental status

RESPIRATORYRESPIRATORY

SOBSOB ASTHMAASTHMA COPDCOPD PNEUMONIAPNEUMONIA PTXPTX

SHORTNESS OF BREATHSHORTNESS OF BREATH

CardiacCardiac RespiratoryRespiratory

SHORTNESS OF BREATHSHORTNESS OF BREATH

CardiacCardiac– CHFCHF– Pulmonary EmbolismPulmonary Embolism– MIMI

SHORTNESS OF BREATHSHORTNESS OF BREATH

RespiratoryRespiratory– Asthma exacerbationAsthma exacerbation– COPD exacerbationCOPD exacerbation– PneumoniaPneumonia– Pneumothorax Pneumothorax

SHORTNESS OF BREATHSHORTNESS OF BREATH

Recognize the sick patientRecognize the sick patient Labored respirationsLabored respirations Accessory muscle useAccessory muscle use Speak full sentencesSpeak full sentences Mental statusMental status

ASTHMAASTHMA

Reactive airwaysReactive airways Inflammation Inflammation Mucous plugsMucous plugs BronchospasmBronchospasm

ASTHMAASTHMA

ChildhoodChildhood Young adultYoung adult Rare in elderlyRare in elderly

– New wheezing likely not asthmaNew wheezing likely not asthma

ASTHMA EXACERBATIONASTHMA EXACERBATION

ExerciseExercise ColdCold Ran out of medicinesRan out of medicines

ASTHMA SYMPTOMSASTHMA SYMPTOMS

CoughCough DyspneaDyspnea WheezingWheezing

ASTHMA SIGNSASTHMA SIGNS

Appearance variableAppearance variable– Stable to severe distressStable to severe distress

ASTHMA SIGNSASTHMA SIGNS

Vital signs variableVital signs variable– Usually tachypneicUsually tachypneic– May be tachycardicMay be tachycardic– Blood pressure should be normalBlood pressure should be normal

May be elevatedMay be elevated

ASTHMA SIGNSASTHMA SIGNS

LungsLungs– TachypneaTachypnea– Labored respirationsLabored respirations– WHEEZINGWHEEZING

bronchospasmbronchospasm

ASTHMA TREATMENTASTHMA TREATMENT

OxygenOxygen Nebulized albuterolNebulized albuterol Transport Transport

ALBUTEROLALBUTEROL

ββ22 agonist agonist BronchodilationBronchodilation Side effectsSide effects

– Tachycardia (Tachycardia (ββ1 1 effects)effects)

– JiterrinessJiterriness– Lightheadedness Lightheadedness

ALBUTEROLALBUTEROL

IndicationsIndications– >1y/o>1y/o– Previous history of asthmaPrevious history of asthma

Up to 3 dosesUp to 3 doses

WARNING SIGNSWARNING SIGNS

Respirations slowingRespirations slowing Decreasing breath soundsDecreasing breath sounds TiredTired

COPDCOPD

Chronic obstructive pulmonary Chronic obstructive pulmonary diseasedisease

ChronicChronic ObstructiveObstructive

COPDCOPD

Older patientsOlder patients SmokingSmoking

COPD EXACERBATIONSCOPD EXACERBATIONS

Upper respiratory infectionsUpper respiratory infections Ran out of meds Ran out of meds

COPD SYMPTOMSCOPD SYMPTOMS

Similar to asthma exacerbationsSimilar to asthma exacerbations CoughCough

– PhlegmPhlegm DyspneaDyspnea

– May be worse with exertionMay be worse with exertion WheezingWheezing

COPD SIGNSCOPD SIGNS

Variable appearanceVariable appearance– Stable to sickStable to sick

Vital signsVital signs– TachypneaTachypnea– Pulse usually normalPulse usually normal– BP usually normalBP usually normal

COPD SIGNSCOPD SIGNS

Lung examLung exam– TachypneaTachypnea– Labored respirationsLabored respirations– Wheezing Wheezing

COPD TREATMENTCOPD TREATMENT

OxygenOxygen Monitor respiratory statusMonitor respiratory status Monitor mental statusMonitor mental status TransportTransport

WARNING SIGNSWARNING SIGNS

Decreasing respirationsDecreasing respirations Decreasing mental statusDecreasing mental status Getting tired Getting tired

PNEUMONIAPNEUMONIA

Infection in the lung tissueInfection in the lung tissue Bacteria, white blood cells, Bacteria, white blood cells,

inflammatory cells in the lunginflammatory cells in the lung Interfere with air exchangeInterfere with air exchange

PNEUMONIA SYMPTOMSPNEUMONIA SYMPTOMS

Gradual onset SOBGradual onset SOB FeverFever Generalized weaknessGeneralized weakness Cough productive of green/brown Cough productive of green/brown

sputumsputum

PNEUMONIA SIGNSPNEUMONIA SIGNS

Usually tachypneicUsually tachypneic May be tachycardicMay be tachycardic BP normal unless septicBP normal unless septic LungsLungs

– Rhonchi on one sideRhonchi on one side

PNEUMONIA vs CHFPNEUMONIA vs CHF

Difficult to differentiateDifficult to differentiate Fever suggests pneumoniaFever suggests pneumonia History of CHF suggests CHFHistory of CHF suggests CHF Can coexistCan coexist

– Pneumonia can exacerbate CHFPneumonia can exacerbate CHF

PNEUMONIA TREATMENTPNEUMONIA TREATMENT

Young healthy adultYoung healthy adult– If hemodynamically stable and not If hemodynamically stable and not

hypoxic, can manage as O/Phypoxic, can manage as O/P

PNEUMONIA TREATMENTPNEUMONIA TREATMENT

Most of our patientsMost of our patients– ElderlyElderly– ComorbiditiesComorbidities– Diagnosis may be unclearDiagnosis may be unclear

PNEUMONIA TREATMENTPNEUMONIA TREATMENT

OxygenOxygen Monitor vital signsMonitor vital signs

– Respiration rate, BPRespiration rate, BP Transport Transport

WARNING SIGNSWARNING SIGNS

Worsening respiratory distressWorsening respiratory distress Dropping blood pressureDropping blood pressure

– SepsisSepsis Decreasing mental statusDecreasing mental status

– Hypoxia, sepsisHypoxia, sepsis

PNEUMOTHORAXPNEUMOTHORAX

Collapsed lungCollapsed lung Air accumulates around lungAir accumulates around lung TraumaTrauma Blebs Blebs AsthmaticsAsthmatics COPD patientsCOPD patients

PNEUMOTHORAX PNEUMOTHORAX SYMPTOMSSYMPTOMS

Abrupt onset SOBAbrupt onset SOB Chest painChest pain

– PleuriticPleuritic Severity depends on sizeSeverity depends on size

PNEUMOTHORAX SIGNSPNEUMOTHORAX SIGNS

Usually tachypneicUsually tachypneic Pulse may be normalPulse may be normal BP normal unless tensionBP normal unless tension Decreased breath sounds on one sideDecreased breath sounds on one side

TENSION PNEUMOTHORAXTENSION PNEUMOTHORAX

Pneumothorax compresses trachea Pneumothorax compresses trachea to opposite sideto opposite side

Decreased venous returnDecreased venous return Decreased cardiac outputDecreased cardiac output HypotensionHypotension Life threatening emergencyLife threatening emergency

TENSION PNEUMOTHORAX TENSION PNEUMOTHORAX SIGNSSIGNS

Absent breath sounds on one sideAbsent breath sounds on one side Tracheal deviationTracheal deviation Hypotension Hypotension

PNEUMOTHORAX PNEUMOTHORAX TREATMENTTREATMENT

OXYGENOXYGEN TransportTransport Air must be drainedAir must be drained

כלכל המקייםהמקיים נפשנפש אחתאחת מישראלמישראל

כאילוכאילו קייםקיים עולםעולם מלאמלא KEEP UP THE AMAZING KEEP UP THE AMAZING

WORK!!!WORK!!!