emergency management of cardiac disease
TRANSCRIPT
EMERGENCY MANAGEMENT OF
CARDIAC DISEASE
Cassidy Sedacca, MS, DVM, DACVIM (Cardiology)
Upstate Veterinary [email protected]
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Know how to treat congestive heart failure in the emergency situation
Know how to treat life threatening arrhythmias in the emergency situation
Know how to treat pericardial effusion/cardiac tamponade in the emergency situation
OBJECTIVES
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Signalment
Previous cardiac history?
Onset and duration?
Breathing difficulties?
Cough?
Abdominal distension?
HISTORY
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… with a cardiac focus
Exercise intolerance?
Weakness/collapse/syncope?
Appetite?
Current medications?
Heartworm status?
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General patient condition
BCS, attitude, posture
MM color; CRT
Pink, pale, cyanotic
Rectal temperature
Fever, hypothermic
Jugular Veins
Normal, distended, pulsating
Femoral pulses
Normal, hypodynamic, hyperdynamic
Abdominal palpation
Distended, organomegaly, ballotable fluid wave
CARDIOVASCULAR EXAMINATION
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Respiratory rate and effort
Dyspnea, tachypnea, orthopnea
Pulmonary auscultation
Dull, quiet sounds
Increased bronchovesicular sounds
Crackles, wheezes
CARDIOVASCULAR EXAMINATION
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Cardiac auscultation
Quality (precordial impulse, muffled)
Rate (slow, appropriate, fast)
Rhythm (regular, regularly irregular, irregularly irregular)
Murmur (grade, location, phase)
Gallop sounds (systolic click, S3, S4)
CARDIOVASCULAR EXAMINATION
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1) Indirect estimates of cardiac output
MM color, CRT, pulse quality, temperature, blood pressure, lactate
2) Focused ultrasound (TFAST, AFAST)
Pericardial fluid
Pleural fluid
Abdominal fluid
+/- B-lines or “lung rockets”
DIAGNOSTICS
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Lisciandro GR, JVECC 2017
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3) Thoracic Radiographs
Heart size
Pulmonary vasculature
Caudal vena cava
Pulmonary parenchyma
Pleural effusion
Diagnosis of CHF or other?
4) Electrocardiogram
Heart rate and rhythm
DIAGNOSTICS
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5) CBC, biochemistry panel, U/A ideal
Baseline renal function – BUN, creatinine, USG
Electrolytes – arrhythmias
CBC – pneumonia
6) SNAP NTproBNP test
Respiratory vs. cardiac dyspnea
DIAGNOSTICS
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SNAP® Feline Cardiopet® proBNP Test
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TREATMENT STRATEGIES
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OXYGEN THERAPY
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FiO2 ~40%
Minimal restraint
Quiet
+/- sedation
Time to think
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TREATMENT STRATEGIES
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Determinants of cardiac output
Preload
Afterload
Contractility
Heart rate
Stroke Volume
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Stretch of the cardiomyocytes prior to contraction
Ventricular end-diastolic volume
Frank-Starling mechanism
Changes in ventricular preload directly affect stroke volume
PRELOAD
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Preload
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WHICH PATIENTS HAVE EXCESSIVE
PRELOAD?
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Almost all cardiac diseases, except …
Pericardial Effusion
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Diuretics
Furosemide IV or IM PRN (2-4 mg/kg q 1-6 hr)
Furosemide CRI (0.5-1 mg/kg/hr)
Centesis (thorax, abdomen)
Venodilators
Furosemide, nitroglycerine (pinna), nitroprusside CRI
No IV fluids!
TREATMENT OF EXCESSIVE
PRELOAD
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Goal = lose 5-7%body weight
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Pressure that ventricle must generate to eject blood
Tension produced by ventricle in order to contract
Increased when aortic pressure or SVR are increased
Shifts Frank-Starling curve
AFTERLOAD
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Afterload
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HOW DO WE ASSESS AFTERLOAD IN
THE CLINICAL SETTING?
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Measure systemic blood pressureMeasure systemic
blood pressure
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NEGATIVE EFFECTS OF INCREASED
AFTERLOAD
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Increased resistance to ejection leading to decreased SV and CO
Increased cardiac “work” and thus myocardial O2 demands
Increased regurgitant fraction in patients with mitral insufficiency
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Nitroprusside CRI
1-5 mcg/kg/min
Titrate to desired blood pressure
Hydralazine PO
1-3 mg/kg BID (but dose must be titrated)
Amlodipine PO
0.1-0.2 mg/kg SID
Pimobendan PO
0.2-0.3 mg/kg BID-TID
TREATMENT OF EXCESSIVE
AFTERLOAD
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Goal: Systolic BP = 100-130 mmHg
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The degree to which cardiomyocytes can shorten when activated by a stimulus
Independent of preload and afterload
“Inotropic state” of the myocardium
CONTRACTILITY
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WHICH PATIENTS CAN HAVE A
DECREASE IN INOTROPIC STATE?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Almost all cardiac diseases, except …
Pericardial effusion
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Signs of forward/low-output heart failure
Inappropriate mentation
Severe generalized weakness
Poor femoral pulse quality
Hypotension
Hypothermia
Elevated lactate
CLINICAL ASSESSMENT OF
CONTRACTILITY
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Pimobendan PO
0.2-0.3 mg/kg TID
Milrinone CRI
1-10 mcg/kg/min
Dobutamine CRI (dogs)
2-10 mcg/kg/min
Dopamine CRI (cats)
2-10 mcg/kg/min
Digoxin PO
0.005 mg/kg BID
Loading dose: double maintenance dose for 24 hours
POSITIVE INOTROPIC AGENTS
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HEART RATE
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Effects of HR on cardiac output
Cardiac output directly proportional to HR …
… until a point when HR become too fast
Tachyarrhythmias and bradyarrhythmias are detrimental to cardiac output
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WHICH PATIENTS MIGHT HEART RATE
IMPACT CLINICAL SIGNS?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Atrial fibrillation/flutter
Sustained tachyarrhythmia
Ventricular tachycardia (VT)
Supraventricular tachycardia (SVT)
Bradyarrhythmias
3rd degree AV block
Sick Sinus Syndrome
Treatment of a sinus tachycardia or sinus
bradycardia is almost never necessary
HR = 50 bpm
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ATRIAL FIBRILLATION
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SUPRAVENTRICULAR
TACHYCARDIA
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VENTRICULAR TACHYCARDIA
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SINUS NODE DYSFUNCTION (SSS)
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3RD DEGREE AV BLOCK
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Vagal maneuver
Ocular pressure, carotid massage
Diltiazem (Ca+2 blocker)
0.1-0.25 mg/kg IV slow bolus (3 min)
2-6 mcg/kg/min CRI
Esmolol (beta-blocker)
50-500 mcg/kg IV bolus
50-200 mcg/kg/min CRI
TREATMENT OF SVT
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Procainamide (Na+ blocker)
6-10 mg/kg IV slow bolus (3-5 min)
20-50 mcg/kg/min CRI
Amiodarone (K+ blocker)
Bolus followed by CRI
DC electrical cardioversion
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Diltiazem (class IV)
0.1-0.25 mg/kg IV slow bolus (3 min)
2-6 mcg/kg/min CRI
0.5-2 mg/kg PO TID
Digoxin PO
0.005 mg/kg BID
Loading dose: double maintenance dose for 24 hours
TREATMENT OF ATRIAL
FIBRILLATION
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Rate control, not rhythm control
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Lidocaine (Na+ bloacker)
Dog: 2 mg/kg IV bolus
Cat: 0.2 mg/kg IV bolus
Repeat up to 3 total times 5 min apart
50-80 mcg/kg/min CRI (dog only)
Procainamide (Na+ blocker)
6-10 mg/kg IV slow bolus (3-5 min)
20-50 mcg/kg/min CRI
TREATMENT OF VT
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE
Esmolol (beta-blocker)
50-500 mcg/kg IV bolus
50-200 mcg/kg/min CRI
MgCl
0.1-0.2 ml/kg IV slow bolus (3 min)
Sotalol (K+ blocker)
1-2 mg/kg PO BID
Amiodarone (K+ blocker)
Bolus followed by CRI
DC electrical cardioversion
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Atropine Response Test
0.04 mg/kg IV (wait 3 min)
Can initially make AV block worse
0.04 mg/kg IM (wait 20 min)
If AV block/sinus arrest eliminated
High resting vagal tone
Search for underlying cause
TREATMENT OF
BRADYARRHYTHMIAS
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If no response or partial response,
Temporary/permanent pacemaker ultimately required
Glycopyroolate 0.02 mg/kg SQ or IM q 4-6 hr
Aminophylline 5-10 mg/kg slow IV (30-60 min) q 6-8 hr
Terbutaline 0.01 mg/kg SQ or IM q 8 hr
Dopamine/dobutamine CRIs
Theophylline, terbutaline, or hyoscyamine PO
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Simple to diagnose but easy to miss
Presents with signs of low-output heart failure or R-CHF
Cardiac tamponade = intrapericardial pressure > right atrial pressure
“Decrease in preload”
PERICARDIAL EFFUSION
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Acute: collapse, severe weakness, unable to rise, vomiting
Chronic: Anorexia, lethargy, exercise intolerance, abdominal distension
Pale mucous membranes
Muffled heart sounds
Hypokinetic femoral pulses, pulsus paradoxus
Jugular venous distension/pulsation
Signs of R-CHF (pleural effusion, ascites)
Hypotension
ECG
Tachyarrhythmias
Low voltage R waves, electrical alternans
CXR
“Globoid” cardiomegaly
TFAST/AFAST
Pericardial fluid
Pleural fluid
Abdominal fluid
CARDIAC TAMPONADE: DIAGNOSIS
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Pericardiocentesis!
Ultrasound-guided or “blind”
Right side: 4th – 6th intercostal space, just dorsal to costochondral junction
Local block with lidocaine
Small stab skin incision (#11 blade)
14-16 gauge over-the-needle catheter
Advance catheter needle slowly until flash of fluid in hub
Advance catheter off of stylet
Use 3-way valve and syringe to remove fluid
CARDIAC TAMPONADE:
TREATMENT
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Pericardiocentesis “tricks of the trade”
IV fluids/boluses okay
Diuretics contraindicated
Sedation frequently required
Butorphanol +/- midazolam
Always have continuous ECG monitoring
Place sample in EDTA tube and plain tube (cytology, check for clotting)
Caution if coagulopathy or ruptured atrium
CARDIAC TAMPONADE:
TREATMENT
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Oxygen therapy … may give you time to think
Determinates of cardiac output will help you guide treatment
Preload
Afterload
Contractility
Heart rate
Pericardiocentesis … you can do it!
SUMMARY OF KEY POINTS
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QUESTIONS ?
11/14/2017CE FALL 2017 | EMERGENCY MANAGEMENT OF CARDIAC DISEASE