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Cathlab Emergencies
Tom Johnson Consultant Cardiologist
Hon. Senior Lecturer
Sarah Carson Senior Nurse
Cathlab Manager
Cathlab team courtesy of Google Images
Cardiac Radiographer
Cardiac Physiologist
Cathlab Nurses
Cardiologist
Teamwork key to success courtesy of Google Images
Cardiac Radiographer
Cardiac Physiologist
Cathlab Nurses
Interventional Cardiologist
BCIS 2013 Data
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
%
2009
2010
2011
2012
Peri-procedural Complications
2012 data: Ludman
Cath Lab Emergencies: Vessel Closure
• Sidebranch occlusion • Coronary dissection • No-flow / Slow flow
Angio of occluded vessel
Pathophysiology of No flow
Thrombotic Emboli
Plaque Debris
Capillary Plugging & Vasoconstriction
Ischaemia
PCI
Endothelial Swelling
No Reflow
Predictive Factors: Acute Myocardial Infarction
Vein graft disease Thrombotic lesions
Rotational Atherectomy
Case 1 A Rescue Situation
73 yr old ♂
Anterolateral STEMI → Thrombolysis
6hrs post lysis – recurrent pain & ST↑
Transferred to BHI
Clexane
Tirofiban
ASA & Clopidogrel
No flow
Obstruction of Flow
Consider differentials
• Edge dissection
• Air embolus
• Residual thrombus
Angio of occluded vessel
Treatment Re-consider pathophysiology
Thrombotic Emboli
Plaque Debris
Capillary Plugging & Vasoconstriction
Ischaemia
PCI
Endothelial Swelling
No Reflow
Treating No Reflow Pharmacology
Always attempt to deliver drug to distal vessel
Drug choice varies enormously but tend to be directed at microvascular circulation
Verapamil 50-900μg
Adenosine 100μg
Nitroprusside 50 -200μg
Nicorandil 2μg
Epinephrine 50-200μg
Abciximab
Strategies to Prevent No reflow
Mechanical
• Thrombectomy
• Thromboaspiration
• Direct Stenting
• Distal Protection
• Proximal Protection
PPCI
SVGs
Strategies to Prevent Mechanical
• Thrombectomy
• Thromboaspiration
• Distal Protection
• Proximal Protection
• Direct Stenting
AngioJet®
• 6F compatible • 4F shaft • 135cm length • 3 high-velocity saline jets • 0.014” guide wire compatible
Strategies to Prevent Mechanical
• Thrombectomy
• Thromboaspiration
• Distal Protection
• Proximal Protection
• Direct Stenting
Lancet 2008; 371: 1915–20
Strategies to Prevent Mechanical
• Thrombectomy
• Thromboaspiration
• Distal Protection
• Proximal Protection
• Direct Stenting
Strategies to Prevent Mechanical
• Thrombectomy
• Thromboaspiration
• Distal Protection
• Proximal Protection
• Direct Stenting
Strategies to Prevent Mechanical
• Thrombectomy
• Thromboaspiration
• Distal Protection
• Proximal Protection
• Direct Stenting
• ↓ procedural time • ↓ radiation exposure • ↓ costs • ↑ resolution of STs • No impact on TIMI-3 rate
JACC 2002: 39(1);15-21
No flow Lessons
• Patient comfort - communicate - analgesia - sedation
• iv fluids
• Be ready with drugs
• Consider high-care
Hypotension: Definition
• Generally a BP < 90 mmHg which is causing inadequate organ perfusion
• Often less when major problems going on!
• Important to know the starting BP
What do you need?
• Fully equipped room / WHO checklist
• IV access
• Know where all the key emergency kit is (Pericardiocentesis, Defib, IABP) and how to use it / what is expected of you
• Useful to mentally run through what you would have to do for a particular emergency situation … or practice with the team
Hypotension Management
• All staff in the room to be “on the ball” and aware of what is going on
• Be prepared to immediately “change gear” and be absolutely focussed to the emergency situation… but always stay calm
• Treat the underlying cause
• Support the haemodynamics in the meantime
• Recognition: Rash, itching, wheezing
• Adrenaline
• Piriton, Hydrocortisone
• Salbutamol nebuliser
• Fluids
• Stop giving the allergen! (often contrast)
• Anticipate if: Severe coronary disease with large territory ischaemia Acute presentation with pulmonary oedema
• Exclude other causes of cardiogenic shock with echo (tamponade, valve problem etc)
• Support the circulation: IABP (covered later today) Inotropes
• Urgent revascularisation • May need to consider GA
• MV rupture septal or free wall rupture
cardiogenic shock
• Early echo needed
• Support the circulation
– IABP
– Inotropes
• Emergency surgery??
Case 2
84year old lady
• Acute pulmonary oedema
• Troponin positive
• Anaemia (Hb 8.0)
• ? Lower GI/ovarian mass & recent pelvic collection treated conservatively
• Angio = heavily calcified LAD & Cx disease
• MDT = trial of DAPT & then PCI
Coronary Perforation Immediate Steps
• Balloon tamponade
• Pericardial drain set ready
• Communicate - call for echo & team support
• Group & Save
• Analgesia for ischaemia
• If available, ask for Cell Saver
• Locate covered stents
Outcome
• 700ml blood drained from pericardium
• 380ml PRB infused + 1unit blood
Hb pre-procedure 10.3g/dl
Hb 24hrs post procedure ?
Discharged 7days later & doing well
11.4g/dl
• Know where your pericardial drain set lives
• Get echo machine/operator
• Correct hypotension fluid/blood
• Ensure patient comfort
• Recognition of the problem
• Femoral access… flank pain? (RPH)
• GI bleed?
• Give rapid fluids and address the cause
• Cross match
• Does anticoagulation need to be reversed?
• Surgery?
Different Types…
• Tachy
– VT
– VF
– (AF, Flutter, SVTs etc – but less critical)
• Brady
– Profound sinus brady
– Long pauses… asystole
– CHB
Causes
• STEMI – i.e. during primaries (& re-perfusion)
• Ischaemia during procedure
• RCA lesions (NB RCA supplies SA & AV nodes) • RCA ischaemia can cause AV block (e.g. RCA ACS)
• Also with RCA Rota cases (TPW available!)
• Injection into the Conus branch of the RCA
• Pigtail in the LV (esp. if pre-existing BBB) or catheter in RVOT
• But… potentially with any intervention
Important Arrhythmias 3
• Very slow!! – doesn’t matter what the precise rhythm is – again, patient & BP??
• Atropine vs TPW (some will spontaneously recover)
Need to be on the ball…
• All team members should be aware of what is going on in the case
– Be ready to step up a gear and focus
• Need to know where all the kit is e.g. Atropine and TPW
• Any of these situations could lead on to full arrest…
Cardiac Arrest
• Shockable VF/VT DC shock
• Asystole/extreme brady Pace
• PEA: Need to establish mechanism, e.g.
– Tamponade Pericardiocentesis
– Global ischaemia IABP/Inotropes
• Be aware of Cath Lab specific guidelines
• Know how to call for an Anaesthetist
– Do not usually want the whole crash team!
LUCAS or Autopulse Device?
• Know how to use it
• Practise attaching it
• Know which angio views can be used
Afterwards…
• Often useful to de-brief, particularly if it didn’t feel “smooth” or if you didn’t follow what was going on
– Make sure you understand what happened, why, and how it was treated
– Its OK not to understand everything at first… but make sure you learn from your experiences
Summary
• Be aware of the common important arrhythmias seen in the Cath Lab
– What causes them
– What they look like
– How they are treated
• Be aware of the Cath Lab Resus guidelines, and how they will be implemented in your Lab
• Always stay calm and stay focussed!
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