Cardiovascular Emergencies

Amal Mattu

• Publisher: American College of Emergency Physicians
• Year: 2017
• ISBN:
  9780998891224
• Edition: 1
• Topic: Medicina
• Subtopic: Cardiologia

Acute chest pain. Acute heart failure. Cardiac arrest. Tachycardia. Syncope.

If you take care of patients in an emergency department or some other "on-demand" facility, you have to be ready to identify and correctly treat cardiovascular emergencies any time – every time – they present.

So ARE you ready?

Learn now from the very best cardiovascular emergency medicine experts in the United States. Every one of the 21 chapters focuses on initial approach and evidence-based treatment -- all the info you need right away.

Read this book and you WILL save lives.

Published by the world's largest emergency medicine organization, the American College of Emergency Physicians, Cardiovascular Emergencies facilitates the efficient and cutting-edge delivery of care to patients who present with acute cardiovascular conditions. With more than 6 million people presented to U.S. emergency departments every year with chest pain, emergency physicians have the difficult task of differentiating life-threatening causes from more benign ones. And beyond chest pain, emergency physicians care for patients with other forms of cardiac disease—arrhythmias, infections, cardiovascular complications from other conditions, and they must be able to identify these conditions, assess their severity, and provide immediate, often lifesaving, interventions in the less-than-ideal conditions of a busy ED. This book teaches you the essentials of diagnosing and managing cardiovascular disorders from the experts.

Each of the 21 chapters focuses on an issue of critical importance in the care of patients with cardiovascular emergencies—emergencies that can present in any ED on any day in any community. The book includes hundreds of images, figures, and tables, and key points that you will use every time you treat a patient, brings together highly respected emergency physician educators to teach the essentials of diagnosing and managing cardiovascular disorders.

Key Elements:

• Approach to Acute Chest Pain
• The ECG in the Evaluation and Management of ACS
• Biomarkers and Imaging
• Bedside Ultrasound for Emergency Cardiovascular Disorders
• Modern Treatment of STEMI and NSTEMI
• Cardiogenic Shock
• Acute Heart Failure
• Bradyarrhythmias
• Narrow Complex Tachycardia
• Wide Complex Tachycardia
• Syncope
• Modern Management of Cardiac Arrest
• Post-Cardiac Arrest Syndrome
• Pericarditis, Myocarditis, and Endocarditis
• Hypertensive Emergencies and Elevated Blood Pressure
• Cardiac Disease in Special Populations: HIV, Pregnancy, and Cancer
• Special Populations: Pulmonary Hypertension and Cardiac Transplant
• Pharmacologic Approach to Emergency Cardia Patient
• Complications of Implanted Cardiac Devices
• Use of Emergency Depa

CHAPTER 1
Approach to Acute Chest Pain

Deborah B. Diercks and Nathan Parker

IN THIS CHAPTER

Initial approach

Acute coronary syndrome

Pulmonary embolism

Esophageal rupture

Tension pneumothorax

Aortic dissection

Cardiac tamponade

Ancillary tests

Advanced imaging

Clinical decision rules

More than 6 million Americans present to emergency departments every year with the chief complaint of acute chest pain.¹ The differential diagnosis is extremely broad (Table 1-1). Emergency physicians have the difficult task of differentiating life-threatening causes requiring immediate intervention from more benign causes. In this chapter, we focus on the presentation of the most common critical diagnoses, their initial workup, and the strategies employed to ensure a safe and successful disposition.

Initial Approach

All patients without an obviously benign cause of chest pain should have their vital signs assessed immediately, be connected to a monitor, and have intravenous access established. Ideally, an electrocardiogram (ECG) should be obtained in the prehospital setting. Recent data have shown that paramedics and nurses, given adequate training, can reliably diagnose ST-elevation myocardial infarction (STEMI) and subsequently alert destination hospitals.² Since it has been well established that early reperfusion reduces mortality and morbidity, a system should be in place to facilitate rapid percutaneous intervention or fibrinolysis once STEMI has been confirmed.³ A focused history and physical examination should be performed promptly by the emergency care provider because successful management of conditions such as tension pneumothorax depends on the provider’s acting within minutes of a patient’s presentation.

Key Point

Patients with chest pain should have an ECG obtained on arrival.

Acute Coronary Syndrome

Of the common presenting causes of chest pain, acute coronary syndrome (ACS) presents a particular challenge to emergency physicians. Defined as the syndrome resulting from acute cardiac ischemia, ACS encompasses stable angina, unstable angina, STEMI, and non-STEMI (NSTEMI).

Missed acute myocardial infarctions (AMIs) are frequent causes of litigation against medical providers. Emergency physicians disagree over the acceptable rate of missed acute MI; most accept a rate between 0.01% and 2%.⁴ Care providers in emergency departments with low patient volumes and limited resources face particularly difficult challenges in making the diagnosis; miss rates tend to be higher in these facilities.⁵

In the “classic” presentation of ACS, the patient usually describes the pain as pressure, squeezing, or crushing. The pain is located substernally or on the left, and it can radiate to the jaw, neck, or arms. Associated symptoms usually include diaphoresis, nausea, vomiting, weakness, and syncope.⁶ However, none of these signs and symptoms is sensitive or specific enough on its own to rule in or out ACS independent of an ECG, cardiac biomarkers, and other diagnostic tests.⁷ Similarly, the presence of traditional risk factors such as hypertension, hyperlipidemia, diabetes mellitus, family history of coronary artery disease (CAD), and history of smoking, although positively correlating with adverse events within 6 months, does not correlate with the incidence of acute MI in the emergency department.⁸ However, emergency care providers should be cautious about an initial impression of “noncardiac chest pain” if traditional risk factors are present because 3% of patients with those factors will experience an adverse cardiac event within 30 days.⁹

To further complicate the establishment of a diagnosis, many patients with an eventual diagnosis of acute MI present without chest pain at all.¹⁰ This presentation is more common among women than men (42% and 31%, respectively), but the difference decreases with increasing age.¹¹ Atypical presentation of acute MI is also associated with diabetes, heart failure, advanced age, and nonwhite races.¹²

Table 1-1.

Causes of Chest Pain

Cardiovascular

Acute MI

Aortic dissection

Cardiac tamponade

Coronary spasm

Pericarditis

Stable angina

Unstable angina

Pulmonary

Bronchitis

Pneumonia

Pneumothorax

Pulmonary embolus

Gastrointestinal

Cholecystitis

Esophageal reflux

Esophageal rupture

Esophageal spasm

Esophageal tear

Gastritis

Hepatitis

Pancreatitis

Peptic ulcer disease

Musculoskeletal

Costochondritis

Muscle strain

Rib fracture

Key Point

Many patients with ACS present without chest pain.

Pulmonary Embolism

Pulmonary embolism (PE) accounts for up to 200,000 deaths in the United States annually.¹³ Like ACS, PE represents a broad range of disease, from asymptomatic incidental findings to saddle embolus causing shock and sudden death. Among patients presenting in shock, the short-term mortality rate can reach as high as 50%.¹⁴

Reflecting this broad spectrum of disease, the clinical signs and symptoms are especially difficult to interpret. In a large, prospective study, the following symptoms were present in patients diagnosed with PE: dyspnea (79%), pleuritic pain (49%), cough (43%), wheezing (31%), calf or thigh s...