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Where evidence based medicine has yet to go but where we often find ourselves
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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
Sunday, August 9, 2009
Reference:Harvard Shock symposium
Sunday, August 9, 2009
Objective
• Manage case that is nearly dead, guideline yet go there
•
Sunday, August 9, 2009
นาทีเฉียดตาย
•
Sunday, August 9, 2009
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
Sunday, August 9, 2009
Sunday, August 9, 2009
What are you examining in AF patient?
Sunday, August 9, 2009
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
Sunday, August 9, 2009
Sunday, August 9, 2009
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.
Sunday, August 9, 2009
Rapid AF
• AHA guideline for management of a patient with hypotension and AF with RVR would be cardioversion
• DC Cardioversion
Sunday, August 9, 2009
Sunday, August 9, 2009
Would you cardiovert the patient?
Sunday, August 9, 2009
Would you cardiovert the patient?
Sunday, August 9, 2009
Rate
Rhythm
Digoxin
Diltiazem/verapamil
Sunday, August 9, 2009
Rate
Rhythm
Cardiovert
Digoxin
Diltiazem/verapamil
Sunday, August 9, 2009
Rate
Rhythm
Cardiovert
Amiodarone
Digoxin
Diltiazem/verapamil
Sunday, August 9, 2009
What are you using?DiltiazemAdenosine Amiodarone
DigoxinBeta blocker
Sunday, August 9, 2009
What are you using?
Digoxin
Beta blocker
5 min
Sunday, August 9, 2009
What are you using?
Digoxin
Beta blocker
Cardiovert
5 min
Sunday, August 9, 2009
What are you using?
Diltiazem
Digoxin
Beta blocker
Cardiovert
5 min
Sunday, August 9, 2009
What are you using?
Diltiazem
Amiodarone Digoxin
Beta blocker
Cardiovert
5 min
Sunday, August 9, 2009
What are you using?
Diltiazem
Amiodarone Digoxin
Beta blocker
Cardiovert
5 min
Sunday, August 9, 2009
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
Sunday, August 9, 2009
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)
Sunday, August 9, 2009
Amiodarone
Sunday, August 9, 2009
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
Sunday, August 9, 2009
Maintain sinus Rate + anticoag
Pro⇑Hemodynamic⇓Thromboembolic
Avoid pro arrhythmia
Con Pro arrhythmicFatality
⇓HemodynamicBleeding
Residual embolic
Sunday, August 9, 2009
Sunday, August 9, 2009
Loss of atrial kick sign?
LV
RV
Sunday, August 9, 2009
•LV systolic function looks depressed (subcostal long axis view)
Loss of atrial kick sign?
LV
RV
Sunday, August 9, 2009
•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
Loss of atrial kick sign?
LV
RV
Sunday, August 9, 2009
•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
•In this patient with acute onset of FA and subsequent hypotension .
Loss of atrial kick sign?
LV
RV
Sunday, August 9, 2009
•LV systolic function looks depressed (subcostal long axis view)
•Reduce SV by reducing diastolic time / by absence of atrial kick).
•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
Loss of atrial kick sign?
LV
RV
Sunday, August 9, 2009
What does it cause?
Sunday, August 9, 2009
Loss of atrial kick
What does it cause?
Sunday, August 9, 2009
Loss of atrial kickBlood don’t go into
atrium
What does it cause?
Sunday, August 9, 2009
Loss of atrial kickBlood don’t go into
atriumIt reflux into neck vein
What does it cause?
Sunday, August 9, 2009
• 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
Sunday, August 9, 2009
Sunday, August 9, 2009
• Patient was treated with Nicardipine IV
• He feel less lightheadeness still chest discomfort
• Old ECG show no atrial fibrillation
Sunday, August 9, 2009
Sunday, August 9, 2009
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
Sunday, August 9, 2009
Case II
• BP=110/60 HR=130 RR=20 T=37.3
• Complaint of chest tightness,
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
What would you do?
• Any reason to change rhythm?
• Dead now or later?
•
Sunday, August 9, 2009
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%
Sunday, August 9, 2009
What is your diagnosis?Next Management?
Sunday, August 9, 2009
What will you do in this patient?
• Physical examinaiton
• Further investigation?
• Further Management
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
สักพัก...
Sunday, August 9, 2009
What would you do in this patient?
• Atropine
• Epinephrine
• Dopamine
• Transcutaneous pacing
Sunday, August 9, 2009
เจ็บแปลบ ...
• The patient is so painful when you put on pacemaker
• Will atropine cause more infarct?
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
Sunday, August 9, 2009
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.
Sunday, August 9, 2009
campaign
Sunday, August 9, 2009
Sunday, August 9, 2009