Evidence of elevated pericardial pressure manifested as elevated systemic venous pressure . Decreased cardiac output and hypotension; evidence of decreased peripheral perfusion.
Echocardiography : large pericardial effusion; RV early diastolic collapse, RA diastolic collapse, LA diastolic collapse; etc.
Right heart catheterization: Equalization of RA pressure, LA pressure, PCWP, and Ventricular EDP.
Initial treatment / Medical therapy : Rapid intravenous fluid loading and dopamine Avoidance diuretics or vasodilators.
Priority of therapy (percutaneous or surgical therapy) : Drainage (Tapping)--- needle pericardiocentesis Surgical drainage : subxiphoid pericardioectomy, pericardial window, and subtotal pericardiectomy Percutaneous balloon pericardiotomy
HYPERTENSIVE CRISIS ANDMALIGNANT HYPERTENSION
Hypertensive crisis : Systemic BP > 240/130 mmHg without symptoms, or elevated BP with chest pain, headache, or heart failure. May have intracranial hemorrhage, aortic dissection, pulmonary edema, myocardial infarction, or unstable angina. Hypertensive crisis traditionally has been classified as:
- Emergency and- Urgency
Malignant hypertension : Severe hypertension associated with encephalopathy, renal failure, or papiledema.
In general, diastolic BP >120 mmHg Malignant htn with papiledema Hypertensive encephalopathy Severe htn in the setting of stroke, subarachnoid hemorrhage, head trauma Acute aortic dissection Htn and LV failure Htn and myocardial ischemia/infarction Htn after CABG operation Pheocromocytoma crisis Food and drug interactions with MAO inhibitors Cocain abuse Rebound htn after sudden drug withdrawal (clonidine) Idiosyncratic drug reactions ( atropin) Eclampsia
(Rapid decompensation of vital organ function)
Diastolic BP > 120 mmHg, but no symptoms and sign of tissue damage Severe htn, accelerated htn Pheochromocytoma crisis Food and drug interactions with MAO inhibitors Rebound htn after sudden drug withdrawal Idiosyncratic drug reactions Preoperative htn Postoperative htn
(Marked elevations of BP without acute or progressive target organ )
The goal therapy : immediate, controlled reduction in BP. BP initially be reduced by no more than 25% of MAP (diastolic pressure + 1/3 pulse pressure) over minutes to hours. (exception : aortic dissection, LV failure, and pulmonary edema.
Medical therapy : Nitroprusside (drug of choice), Glyceryl trinitrate, Labetalol ( contraindicated for patients with CHF, bradycardia, heart block, reactive airway disease), Nicardipine, Enalapril, Phentolamine, Hydralazine, Fenoldopam.
Nifedipine (Sublingual nifedipine should not be used in the treatment of patients with htn).
EVALUATION OF CHEST PAIN IN THE EMERGENCY DEPARTMENT
Chest pain : substernal pressure, squeezing, or sensation of suffocation. Some patients describe aching, burning, tightness. The pain radiate to the shoulder, neck, jaw, left or right arm and the fingertips. Occasionally the pain predominantly epigastric or intrascapular.
Dyspnea may also be the only major presenting symptom in about 10% patients wit AMI (atypical presentation)
Other atypical : fatigue, syncope, altered sensorium, stroke, nausea, vomiting and lethargy
Atypical presentations: More common in elderly, diabetics, women
NON ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (NSTEMI)
Upon diagnosis of UAP or NSTEMI, level of risk for death & nonfatal cardiac ischemic events must be assessed. Treatment is based on this risk level.
Patients considered HIGH RISK if one or more of the following are present: 1. Recurrent ischemia (ST-depression/ST elevation). 2. Ongoing chest pain at rest >20 min. 3. Elevated cardiac marker levels (CK-MB, Troponin T, CRP). 4. Developing hemodynamic instability. 5. Major arrhythmias (VF, VT) or LV dysfunction. 6. Early post-infarction UAP 7. Thrombus on angiography.
Low risk patients : 1. No recurrent chest pain 2. No evidence of angina at rest 3. No elevation of troponin or other biochemical markers 4. Norma or unchanged ECG during chest discomfort
• Aspirin & clopidogrel/ticlopidine• Nitrates (sublingual/spray or IV)• Oral beta-blocker (if not contraindicated)• Calcium antagonists (diltiazem)• Lipid lowering agent (statin/ fibrate/niacin)• Heparin (Low molecular weight heparin-LMWH)• Stress test (Treadmill test) recommended either during hospitalization or within 72 hr.
Bed rest with continuous ECG monitoring Supplemental O2 to maintain O2 saturation>90%
Treatment of ischemic pain• Nitrates (sublingual/spray/IV) :
- contraindicated in patients who have taken sildenafil within the past 24 hr - Use with caution in patients with RV failure
• Beta-blockers• Morphine sulfate - May be administered with nitrates. - may need concomitant administration of anti emetic • Calcium antagonists (CCB)• ACE inhibitors