Cardiovascular emergencies: what to do and when to refer

Transcription

1 Recognising the deteriorating patient: avoiding catastrophe Cardiovascular emergencies: what to do and when to refer Dr David Gray Reader in Medicine and Consultant Cardiologist (recently retired and highly recommended)

2 Who am I? Academic post research teaching Hands-on clinician Author/Editor of several books including Essentials of Physical Health in Psychiatry

3 What is an emergency? Life-threatening situation Requires immediate action

4 What is an emergency? Life-threatening situation Requires immediate action IF YOU DO NOT KNOW WHAT TO DO, IT IS AN EMERGENCY

5 Cardiovascular emergencies Cardiopulmonary arrest Chest pain Fast or slow pulse and long QT Syncope Breathlessness

6 Cardiopulmonary arrest Daily checks on defibrillator Resuscitation protocols '999' Transfer patient to hospital for investigation

7 Normal ECG

8 Ventricular fibrillation *

9 Cardiopulmonary arrest Survival figures best in Seattle Coronary Car Unit hospital

10 Cardiovascular emergencies Cardiopulmonary arrest Chest pain Fast or slow pulse and long QT Syncope Breathlessness

11 Many causes Cardiac GI Pulmonary chest wall somatisation and others Chest pain? cardiac Is it cardiac? Know your patient- whinger or stoic?

12 Cardiac chest pain 'crushing, heavy, pressure on chest, tight band' located anywhere in chest radiation = 'hurt elsewhere?' Left arm common what brings pain on? eased by GTN? anything else Feeling of doom

13 Chest pain Record an ECG Should show regular rhythm 'normal' heart rate should be reported as 'normal' or no different from admission ECG

14 Chest pain known angina Usually activity-induced chest pain GTN (1-2) and check ECG Often tachycardia

15 Known angina ECG shows INFARCTION ISCHAEMIA

16 ECG showing acute changes of infarction

17 ECG showing ischaemia

18 Action to take if chest pain and known angina If chest pain a 'one off' No need to refer If chest pain recurrent Routine referral May just need medication adjustment/change May need further investigation/treatment If chest pain does not settle with (at most) two GTN OR If ECG shows ischaemia or infarction '999'

19 Action to take while awaiting paramedics aspirin pain control reassurance continued observation monitor ECG cannula if possible make sure defibrillator available

20 What is happening inside if ECG shows acute changes

21 Chest pain and not known angina Need to know your patient Take a history if you can/patient able sounds cardiac: GTN ECG Aspirin If first event Arrange routine hospital referral for assessment

22 Chest pain- some other causes Pericarditis Usually better sitting up fever Pneumonia Usually respiratory symptoms/fever GI ulcer Abdo tenderness/sickness/dark stool Aortic dissection Usually history of poorly controlled BP Different pulse and BP in each arm

23 Chest pain- unlikely to be cardiac If occurs on Bending or flexing spine Mimicked by pressure on chest Localised 'finger pointing sign' Severe on lying but eased by sitting up Can be difficult to recognise sham patient Reliant on good history...

24 Chest pain- likely to be cardiac If associated with 'flight or fight' signs Pallor, nausea, tachycardia, sweating ECG shows Abnormal rhythm ST depression/elevation Reliant on good history...

25 Chest pain Safest action- Assume cardiac until proven otherwise Record an ECG Normal does not exclude cardiac cause ST segment depression = ISCHAEMIA ST segment elevation = INFARCTION

26 ISCHAEMIA and INFARCTION Both MEDICAL EMERGENCIES EASILY managed in hospital CANNOT be managed in psychiatric unit

27 Cardiovascular emergencies Cardiopulmonary arrest Chest pain Fast or slow pulse and long QT Syncope Breathlessness

28 Fast or slow pulse rate Can be associated with serious heart disease Bradycardia Heart block Tachycardia- Ventricular tachycardia Ventricular fibrillation Many psychotropic drugs affect pulse Memory enhancers bradycardia Antipsychotics Orthostatic hypotension...syncope Prolonged Qtc interval...cardiac dysrhythmia

29 Take pulse change seriously if Accompanied by chest pain breathlessness dizziness- suggests cardiac output low pulse is erratic change in pulse cannot be explained by change in medication

30 Prolonged QT interval Prolonged = risk of cardiac dysrhythmia Some inherited forms of 'long QT syndrome' Many antipsychotics prolong QTc Normally corrected to heart rate of 60 bpm Measurement usually printed on ECG Ignore QT interval Look at QTc Normal value of QTc 400 msec in man 430 msec in woman

31 What can you do about prolonged QTc? Before starting antipsychotics Know what you are dealing with ECG Serum potassium/magnesium Cardiac risk factors and history Once on antipsychotic at steady state Keep doses as low as possible try to avoid second drug/combinations try to avoid PRN doses Monthly ECG Check any new drug for interactions

32 When to consult a cardiologist Recurrent episodes about chest pain known angina and not controlled with usual medication Not known angina= needs diagnosis

33 When to consult a cardiologist about abnormal ECG Any change since original ECG Auto interpretation shows QTc > 500msec Atrial fibrillation Ischaemia or infarction

34 When to consult a cardiologist about syncope or presyncope Known cardiac history Angina Heart failure Heart murmur Cardiac arrhythmia '999' on first presentation A&E should initiate referral/investigations

35 When to consult a cardiologist about palpitations If atrial fibrillation if previously regular pulse becomes irregular If medication with antipsychotic Especially high dose/combination If occurs with chest pain breathlessness dizziness

36 When to consult a cardiologist about breathlessness If likely to be heart failure on blood tests Raised BNP If likely to be heart failure clinically Swollen ankles Raised JVP

37 When to worry about patient on antipsychotic If develops Collapse Dizzy Palpitations Fast or erratic heart beat Breathlessness Increase in QTc > 25% Serum potassium or magnesium low Urgent cardiology review

38 Cardiologists ARE really very nice people LIKE TO HELP especially those who really need it Get one on your CONTACT lists