Emergency in CV

Aortic dissection.
 Aortic dissection
• Type A: ascending
aortic dissection
surgery
• Type B medication.
 Symptoms.
• Symptoms: suddenly onset chest pain,
radiation to back.
• Proximal: STEMI, cardiac tamponate.
• Aortic arch: stroke
• Descending: ischemia bowel, ant. spinal
infarction, ischemia limb.
 Physical exam
• AR widen pulse pressure, diastolic
decrescendo murmur
• Cardiac tamponate: JVE, distension heart
sound, hypotension
• Vascular unequal pulse, cold limb
• Neurologic  stroke.
 Therapy for Type B aortic
dissection
• Control BP100-120mmHg, HR 60, MAP
60-75 mmHg.
• Beta block+ sodium nitroprusside/NTG
• If hypotension, norepinephrine are
preferred.
 Surgery
• Type A
• Type B, if
• Vital organ or limb ischemia
• Retrograde extension into the ascending aorta
• Rupture or impending rupture
• Uncontrolled pain or hypertension
• Rapid expansion in aortic size or extension of
dissection.
Cardiac tamponate
 Cause? Pericardiac effusion
• Infection
• Uremia
• Collagen vascular disease
• MI, acute or subacute (dressler’s syndrome)
• Aortic dissection
• Post-cardiac surgery
• Trauma
• Cancer
• Drug
• Hypothyroidism
 Clinical presentation
• Dyspnea, cough, extreme fatique,
presyncope
 Physical exam
• Pulsus paradoxus>10 mmHg, hypotension,
tachycardia
• JVE
• Decreasing heart sound
CXR
Measurement and Mechanism of Pulsus
Paradoxus
Pulsus Paradoxus
EKG
RV diastolic compression
 Therapy
• Resucitated with volume-expanding agent
to delay RV diastolic collapse
• Percutaneous needle pericardiocentesis.
Tachycardia
Paroxysmal Supraventricular
Tachycardia (PSVT)
 Management
• Valsalva maneuver, carotid massage.
• Adenosin 61212mg (contraindication,
asthma and AV block)
• Theophylline block adenosine receptor
and antagonized the action of adenosine.
Atrial Fibrillation (AF, A-fib)
 Predispose AF (Pirates)
• Pericarditis, pulmonary disease, pulmonary
embolism
• Ischemia, infection
• Rheumatic heart disease
• Alcoholism
• Thyrotoxicosis, theophylline
• Enlagement(LA)
• Systemic hypertension, sick sinus syndrome
 Atrial fibrillation
• Rate control: beta-blcok, CCB, digoxin
• Rhythm control
• Anticoagulation: CHADS2
Atrial fibrillation medication
• AF in the setting of WPW syndome: AV
nodal agent are contraindication in WPW
• Patient with AF associated with SSS:
using AV nodal agents to control the rate
of AF is difficulty, in some case, a
permanent pacemaker may be needed.
Tachycardia (VT):
Monomorphic
Tachycardia (VT):
Polymorphic
Torsades de Pointes
(TdP)
• QT normal:
• ischemia or infarction, E-, reduce beta agonist exposure.
• Amiodorone or lidocaine.
• QTC prolongation.
• Antiarrhythmic: Ia and III
• Psychiatric drug, antimicorbials
• Elecytrocyte: hypoCa, hypoK, hypoMg
• hypothyroidism,CAB.
• Long QTc syndrome
• MgSO4, Lidocaine
END.