What about the "nearly arrest" patients?

What about the nearlyarrest patient?

Where evidence based medicine has yet to go but where we often find ourselves

SP-ER conference 9 Aug 2009Suthaporn Lumlertgul M.D.

King Chulalongkorn Memorial hospital

Sunday, August 9, 2009

Reference:Harvard Shock symposium


Reference:Harvard Shock symposium


Objective

• Manage case that is nearly dead, guideline yet go there

•


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•


Example case

• A 60 year old woman with complaint lightheadness, chest tightness

• HR= 150/min, BP=200/110 RR=36/min O2 Sat 96% Temp=37.4



What are you examining in AF patient?


What are you examining in AF patient?

• A 60 year old woman with complaint lightheadness, chest tightness

• HR= 150/min, BP=200/110

• RR=36/min O2 Sat 90% Temp=37.4



Define Unstable

• Patients as those with ventricular rates 150,

• ongoing chest pain, or with evidence of critical perfusion:

• systolic BP 90 mm Hg, heart failure, or reduced

consciousness.


Rapid AF

• AHA guideline for management of a patient with hypotension and AF with RVR would be cardioversion

• DC Cardioversion



Would you cardiovert the patient?


Would you cardiovert the patient?


Rate

Rhythm

Digoxin

Diltiazem/verapamil


Rate

Rhythm

Cardiovert

Digoxin

Diltiazem/verapamil


Rate

Rhythm

Cardiovert

Amiodarone

Digoxin

Diltiazem/verapamil


What are you using?DiltiazemAdenosine Amiodarone

DigoxinBeta blocker


What are you using?

Digoxin

Beta blocker

5 min


What are you using?

Digoxin

Beta blocker

Cardiovert

5 min


What are you using?

Diltiazem

Digoxin

Beta blocker

Cardiovert

5 min


What are you using?

Diltiazem

Amiodarone Digoxin

Beta blocker

Cardiovert

5 min


What are you using?

Diltiazem

Amiodarone Digoxin

Beta blocker

Cardiovert

5 min


Diltiazem

• Schreck et al compared the effectiveness of IV

diltiazem with digoxin. In this open-label RCT,consecutive patients with acute AF were assigned toreceive either diltiazem (0.25 mg/kg initial bolusfollowed by 0.35 mg/kg 15 min after, and then aninfusion of 10 to 20 mg/h to maintain a heart rate 100), digoxin (0.25-mg boluses at 0 and 30 min),or both digoxin and diltiazem. Follow-up was for 180min. Treatment with diltiazem achieved a rapidreduction in ventricular rate compared to digoxin,the results becoming statistically significant by 5 min

Diltiazem receive more rapid rate control in 5 minthank digoxin


Diltiazem

• Rate-limiting calcium channel antagonists have

therefore been shown to be effective in ventricularrate reduction in acute AF. The major adverse eventreported from the RCTs was the precipitation ofsymptomatic hypotension (18% of patients)


Amiodarone


Digoxin

• Double-blind RCT recruited 40 patients to receive either digoxin (total IVdose of 1.25 mg in divided doses) or placebo.

• At 12 h posttherapy, there was no significant difference between the rates of conversion between the digoxin• Ventricular rate reduction was 30 min


Maintain sinus Rate + anticoag

Pro⇑Hemodynamic⇓Thromboembolic

Avoid pro arrhythmia

Con Pro arrhythmicFatality

⇓HemodynamicBleeding

Residual embolic



Loss of atrial kick sign?

LV

RV


•LV systolic function looks depressed (subcostal long axis view)


LV

RV



•Reduce SV by reducing diastolic time / by absence of atrial kick).


LV

RV




•In this patient with acute onset of FA and subsequent hypotension .


LV

RV




•In this patient with acute onset of FA and subsequent hypotension .

•After prompt cardioversion, sinus rhythm is restored and LV systolic function looks now much better


LV

RV


What does it cause?


Loss of atrial kick

What does it cause?


Loss of atrial kickBlood don’t go into

atrium

What does it cause?


Loss of atrial kickBlood don’t go into

atriumIt reflux into neck vein

What does it cause?


• Patient was administered Digoxin IV

• After not improving the clinical patient was administered Diltiazem IV

• Patient has less lightheadesness but still have chest tightness

• Heart rate was slower from 170 to 130/min but BP still 200/100



• Patient was treated with Nicardipine IV

• He feel less lightheadeness still chest discomfort

• Old ECG show no atrial fibrillation



Take home message

• Remember for the unstable signs in limited time Heart failure, poor perfusion

• How fast do you think the patient will survive on this rhythm

• Pick the choice of treatment from that


Case II

• BP=110/60 HR=130 RR=20 T=37.3

• Complaint of chest tightness,





What would you do?

• Any reason to change rhythm?

• Dead now or later?

•


Case III

• A man with acute dyspnea come in ER with expiratory wheezing and sound of secretion, profound sweating

• Switching Taxi driver to passenger

• RR=35 PR=130/min BP=220/110 T=37 StO2=70%


What is your diagnosis?Next Management?


What will you do in this patient?

• Physical examinaiton

• Further investigation?

• Further Management








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What would you do in this patient?

• Atropine

• Epinephrine

• Dopamine

• Transcutaneous pacing


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• The patient is so painful when you put on pacemaker

• Will atropine cause more infarct?





Take home message

• Don’t be afraid to use adjuncts in life threatening patients

• This is 2009, ER is all about proove it and treat it.


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What about the "nearly arrest" patients?