CARDIAC EMERGENCY

1
(No Transcript)
2
CARDIAC EMERGENCY
?????? ???? ????? ????
??? ???? ???? ??????? ???? ????? ???? ????
3
Great Circulation of the Heart
4
Small Circulation of the Heart
5
The Heart Vessel
6
Electrical Conduction System

• SA node
• AV node
• Bundle of his
• Bundle branches
• Purkinje network

7
CARDIAC EMERGENCY

• Acute Coronary Syndrome
• unstable angina
• non-Q wave MI
• Q-wave MI
• Dangerous Cardiac Dysrhythmia
• Cardiogenic Shock
• Cardiac Tamponade
• Syncope
• Pulmonary Edema
• Cardiovascular Trauma
• Myocardial Contusion
• Traumatic Aortic Aneurysm

8
Acute Coronary Syndrome
( A.C.S )
9
Acute Coronary Syndrome

• The spectrum of clinical conditions ranging from
• unstable angina
• non-Q wave MI
• Q-wave MI
• characterized by the common pathophysiology of a
  disrupted atheroslerotic plaque

10
Coronary artery disease (CAD)
?????..........
1 - ???????????? 2 - ????????? 3 ?????? 4
??????? ????? 5 ?????? ?????????
???
11
????? ??? ????? ?? ???? ?????????????
1 Monoclonal hypothesis ?????? ??? ?????? 2
Response to injury
?????????? ?????????? ????? ???? ???????
??????? 1 - ??? ? ????? ????????? ????? ????
??????? ??????? 2 - ??? ? ????? ??????? ??????
???? ????? ???? ??????? ??????? 3 - ??? ? ?????
LDL ????? ???? ??????? ???????
12
Response to injury
???? ?? ???? ??????(??????? ????????????????..)
?? ???? LDL ????
?????? ????????? ?? ??? ??????
?????? ?????????? ?? ??? ?????? ???? ??? ?????????
?? ???? LDL ????
???? ?????? ??? ???? ??? ?????? ???? ??????????
??? LDL ???? ??????????
Foam cell
??? ??????? ?????? ????
Fatty streak
????? ??? (????? ????)
13
Fatty streak
?? ???? LDL ????
?????? ?? ???
?? ?? ?????? ?? ???(???? ?? ??????)
???? ???????
Fibrosis plaque
????? ??? (????? ?? ????)
14
Fibrosis plaque
??????????? ??? ???? ???????
?????? ????? ? ????? ...
?? ?? ?????? ??? ???? ???????
??????? ? ????? ????
???? ???? ???????? ???? ?????
????? ??? (????? ?? ????)
15
Age
Gender
??? ???? ?????
HTN
Race
Elevated serum lipids
Family
Cigarette smoking
Risk factors
diabetes mellitus
???? ?? ??? ? ????
???? ?????
Elevated homocysteine level
Metabolic syndrome
Obesity
Physical inactivity
Postmenopause
16
???? ????? ??????????? ????? ????? ?? ????? ??????
????? ?????? ??? ????????? ??? ????? ??? ????
????? ????
Supply
Demand
O2
17
????????????? ??? ?????? (Chest pain)
??? ????? ????? Demand ? Supply
?????? ???? ???????
?????? ????????? ?? ?????
????? ? ???? ?????? H ? K
?????? ???????? ????????? ? ????? ?????
?????? ?????? ????? ???????
?????? ?? ??? ?? ???? C7 ? T4 ?? ??? ???
??? ??? ?? ???? ????
18
??????? ??? ?????? (Chest pain)
??? ???
??? ???
?????? ???
????? ???
????? ??? ?? ????? ????
????
?????? ????
??? ????????
??? ?????
19
Levin Sign
20
Angina pectoris
Stable angina
Unstable angina
Noctural angina
Decubitus angina
Variant angina
Prinzmetal angina
21
????? ?????? ????? ????
??? ???? ???? ?????? ??????? ????????? ????
??? ???? ??????? ??? ?????? ???? ??? ?????
?????? ???? ?? S3,S4 ECG
22
????? ????? ????
1- ?????? ??????? ??????? 2- ???? ??? ??? 3-
??????? ?? ???? MI
????? ?????
????? ????? ????
laxative
CBR
O2
Anti platelet
Nitrates
???? ?? ?????? ????
????? ???
Anti anxiety
Beta blockers
Anticoagulant
Calcium blocker
23
?????? ??? ???????
???? ???
????? ?? ?????
???? ??????
??????? ?? ???? ??? ????? ? MI
24
Myocardial Infarction ( MI )
?????
????????????
????? ??????? ?????????????
?????? ?????
???????? MI
?????? ???
??????????? ????
???? ???????
25
????????????? MI

• ?? 6 ???? ??? ?? MI ?????? ?????? ???? ??????

• ??? ?? 6 ???? ????? ??? ???????? ???? ??? ?????
  ?? ???

• ??? ?? 24 ???? ????? ????? ???? ??????? ?? ???

• ??? ?? 4-3 ??? ???? ??????? ??? ?? ???

• ??? ???? ? ??? ??????? ?????? ????? ??? ????
  ?????????? ???? ???????

• ?? ????? ???? ??? ????? ???? ??????? ???? ??? 6
  ???? ??? ?? ???

26
Transmural
???? ???? MI
Nontransmural
Good prognosis
???? ???? MI
poor prognosis
27
I , AVL .. HIGH .LAT I , AVL , V5 ,
V6 .. LAT I , AVL ,V3 , V4 , V5 , V6
.. .. ANT.LAT I , AVL ,V1 , V2 , V3 , V4 , V5
, V6 EXT.ANT II , III , AVF .. .
INF V1 , V2 SEPTAL V1 , V2 , V3 ,
V4 ANT.SEPTAL V1 , V2 , V3 , V4 , V5 , V6
. ANT V1 , V2 (Mirror test ) true.
Posterior V3R , V4R, V5R... . RV . INFARCTION
????? MI ?? ECG
MSSHERMEH_at_YAHOO.COM
28
???????? ???? ???? ????? ???? ?? ???

• ???????? ????? 80 ??? (60 ???? ?? ????? )

• ????? ???? ???? ???????? (????? ? ????????? ?????
  ?....)

• ????MI ????

• ???? ????????? ??? ????? ??? ( 30 ???? ?? ????? )

• ???? ??? ???????? ?????? 55 ???? ??? ???? ?????
  ????? ???

??? ??? ??? ?? MI
1- ??? ????? ????
4- ????? ???
3- ?????????? ???
2- ??????? ????
29
????? ?????? MI
??? ???? ???? ?????? ???? ??? ?????????-?????????
?? ?? ??????????- ??????????? ???? ? ??????? ????
??? ??? ??? ????? ?????? ??? ?????? ??????? ?
??????? ??????? ? ????? ???? ??? ????? ?????? ?
???? ?? S3,S4 ECG
30
Hyper acute
Acute
????? MI
Recent
Old
MSSHERMEH_at_YAHOO.COM
31
????? ??????????? MI
?????? ????????? ((Mgb
?????? ????????
?????? ???????? ????
???? ??? ???? ??? ?????
4-3 ??? 36-24 ???? 6-3 ???? CPK(total)
4-3 ??? 24-12 ???? 8-4 ???? CPK(mb)
12 ???? 12-4 ???? 3-1 ???? Myoglobin
3-1 ???? 24-4 ???? 4-3 ???? Troponin(I)
32
???? ???? ??????? ???
??? ??? ???
????????????
?????????? ???
???????
?????????(?????? ?????)
????? ???
????? MI
????? ??????? ????
??????? ????
VSD
??? ?????
????????
??????? ????
33
????? MI
1- ??? ????? ??????? 2- ????? ??? 3- ??????? ?
????? ?????
????? ?????
????? MI
Thrombolitic therapy
CBR
GIK
O2
laxative
Nitrates
Anti platelet
????? ???
???? ?????
Beta blockers
Anticoagulant
Anti anxiety
ACE inhibitors
Calcium blocker
34
Thrombolitic therapy Streptokinase (SK)
?????? ??? ?? ?????
???????
?????? ??? ?????
Indication
?????? ??? ?? ?????
Contraindications
Dose
?????
????? ?????? ?????
35
?????? ??? ???????
???? ???
????? ?? ?????
???? ??????
???? ?????? ?? ????
??????? ?? ???? ????? ????
??????? ?? ???? ??? ????? ? MI
36
Cardiac dysrhythmia
37
??? ????? ??? ?????? ????
Sinus bradycardia Mobitz type 2 Complete heart
block
1- ????? ??? ????? ??
PAT Atrial flutter Atrial fibrillation Ventricu
lar tachycardia Ventricular fibrillation
2- ???? ??? ????? ??
38
SINUS BRADYCARDIA
39
HEART RATE
1 - ??? ??? 2 - ??? ??? 3 - ??? ??? 4 - ??? ?????
MSSHERMEH_at_YAHOO.COM
40
300
????? ??????? ????

??? ???
????? ???? ??? ????
????? ??????? ????

????? ???? ??? ????
MSSHERMEH_at_YAHOO.COM
41
1500
??? ???
????? ??????? ????

????? ???? ??? ????
MSSHERMEH_at_YAHOO.COM
42
??? ???
300 - 150 - 100 - 75 - 60 - 50
300
150
100
75
60
MSSHERMEH_at_YAHOO.COM
43
??? ????? ??? ?? ??????? ?? ????
????? ??????? ????

????? ??????QRS??6 ?????
10
1S
2S
3S
4S
5S
6S
MSSHERMEH_at_YAHOO.COM
44
Atropine

• ?????????? ??? ?????????? ????? ???? ??????
  ???????????
• ?????? ???? ????? ?? ????? ?????? ???(A.V.N
  ?S.A.N)
• ??????? ?????????? ?????? ??? .
• ????? ??? ?????? ?? ??? .
• ?????? ??????? ????
• ?????? ????? ???? ?? ???? ?????? ??????? ????
• ????? 2 ????? ??? ??? ?? ?? ????? .

45

Atropine Dosage and special considereation

• ????? 1mg????? - ????? ??2-3 min ?? ??? ( 3mg)
  
• ?????? ???? ????? ???? ??? ?? 10cc????? ?????
  ?????? ???.
• ???? ?? 0.5mg ??? ????? ?? ?????.
• ?????? ?????? ?? 1mg????? ???????? .
• ??????????????? ???? ?????????? ???? ???? .

46

Dopamine

• ??? ???? Vasopresor?? ?? ????.
• ????? ??? ????? ??????? ???? ????? ?????????? ??
  ????.
• ?? ????? ???? ??????? ???? ???? ??????? ??????
  ????.
• ????? ?????? ?? ??????) (high dose - mid
  dose - low dose
• Low dose ???? ????? ????? ????? ??????? ? ??????
  ? ????? ?? ??? ( ???????????)
• Mid dose ???? ?????? ???? ??????? ??????
  ??????? ??? ?????.( ????? ???????)
• High dose ???? ?????? ???? ????? -???????? ????
  ??????? ??????? (????????????(

47
Dopamine Dosage and special consideration

• Low does 2 -4 mic /Kg /min
• Mid does 5 - 10 mic /Kg /min
• High does 10 - 20 mic /kg /min
• ?????? ????? ???? ? ????? ???? ???.
• ????? ??????? ?? ????? ??? .
• ?? ???????? ???? ?????? ?? ?? ?? ???? ???? .
• ???? ?????? ?? ??? ????? ???? ??? ???????
  ??????????? ?? ??? .

48


Epinephrine

• ???? ?????? ??? ????( ????? ??? ??????? ?????)
  ??????? ???
• ??? ( ?????? ???? ??????? ??? ? ??????
  ??????? ????) ?? ????.
• ?? ?????????? ????? ??? ??? ?? ??????? ? ???????
• ?? ??????????? ???? ??????? ??????? ? ??? ????
  ???? ??????.
• ??????? ?????????? ??? ???? ??????
  ????????????????? ????? ????????
• ?? ??????? ???? ?? ??? ??????? ? ????? ???????

49


Epinephrine Dosage and special consideration

• ???????? ???1- 10mic/min
• ?????? ???? ????? ?????? 2-2.5mg ???? ??? ??
  10cc????? ????? ???
• ?????? ?????????? ???? ? ????? ???? ?? ?????
  ???.

50
????? ??? ????
??? - ????? Internal
1- ???? Temporary
? ????? (T.C.P) External
2- ????? Permanent
51
External Temporary Pacemaker
(T.C.P)
52
Internal Temporary Pacemaker
???? ???
??? ???
???????
53
MOBITZ TYPE 2
54
COMPELET HEART BLOCK
55

Isoproterenol

• ?? ??????? ?????? ???? ?? ????? ????
• ?? ??? ???? ? ????? ??? ????
• ?? Torsade des point ?? ?? ?????? ??????? ????
  ????? ???.
• ????????? ?? ??? ???????
• ???????? 2-10mic/min ?? ????? ?? HR ?????

56
Paroxysmal Atrial Tachycardia
57
Adenosine

• ??????? PAT?? ????? ???.
• ???? ?? ????? A.fl , AF ??? ????.
• ?? ???? ?????? ???? ? ???? ???.
• ???? ????? ???? ? ???? ??? ??? ?? ???.

58
Adenosine Dosage and special consideration

• ??? ????? 6 ??????? ?? ??? ???? ?? 2 ????? ???
  ????? 20 ?? ?? ??????? ?????
• ?? ????? ????? ?????? ????? ???? ?????? ???? ?
  ??? ?? ?? ???? ???? ????? ???.
• ????? ?? 2????? ? 12-6 ???? ??? ?? ??? 30 ???????
• ????? CPR ????? ????.
• ????? ??????????? ????? ?????

59


Verapamil

• ?????? ???? ????? ??? ???????? ?????? ???????? .
• ???? ???? ????? ????? AV ????? ???? ??????? ???
  ? ??????? ??? ?? ???...
• ???? ????? ???? ????? ? ??????? ????? ? ????
  After load ?? ??? .
• ??????? PAT ?? ????? QRS ???? ?? ??????? ?????
  ????? ????? ?? ????? ???.

60


Verapamil Dosage and special consideration

• ????? 2.5 - 5 mg ????? ????? 2 min
• ?????? ???? ????? 5-10 mg?? 15 - 30 min?????
• ????? ??? 20 mg
• ????????? ?? ??????? ???? ? ??? ???? ? ???????
  ?? ????? ????? ???? ? ??????? ?????? 90
  mmHg ????? ??? .
• ?????? ?? ??????? ?? ??????? ???? ???? ????
  ??????? ?? ???
• ??????? ??? ????? ???? ????? ????? ??? (
  ???????3 ?????).

61
Atrial flutter
62
Atrial Fibrilation (AF)
63
Amiodaron

• ??????? ??? ????? ??? ??? ???? ????? ?? ??? ??
  ???.
• ????? ????? ??????? ???? ???? ?? ?????? ?? ???.
• ????? ?? ??? AV?? ??? ?? ???.
• ???? ????? ???? ? ???? ??? ??? ?? ???.

64

Amiodaron Dosage and special consideration

• 150mg????? ????? ?????15????? - ???????10?????
• ????? ??? ??24???? 2.2g????? ?? ???? ?? ???????
  ?????.
• ??? ?????????0.5-1mg/min ?? ????? 150mg??
  100cc???????
• (1mg/min ?? 6 ???? ????? 0.5mg/min ?? 18
  ???? ???)
• ???? ?????? ?? ????? ????? ?? ? ?????????? ????
  ??? ?????????? ???? ??????
• ? ???? ?????? ???? ????.

65

Digoxin

• ???? ???? ?????? ??? SA ?? ??? .
• ???? ?????? ????? ??????? ??? AV ?? ???.
• ???? ????????? ???? ?????? ????? ??? ?? ???.
• ?? ????? ????? ?????? ? AF? PSVT ?? ??? ?? ???

66

Digoxin Dosage and special consideration

• 0.5 - 1.5 mg ????? ????? ???? ????? ???? ???
  ????????
• ????? 0.25mg ??20 ????? ?????
• ?? ?? ???? ???????? ?? ???? ??? ?? ?????
  ???????? ??????? ????
  ??? ????? ( 20-10 ???) ???? ??? .
• ?? ??????? ???? ?? ?? ?? ???? ???? .
• ???? ?????? ?? ???????? ?????????? ???? ??????
  ??? ???????? ????? ?? ??? .

67
Ventricular tachycardia (V.tach)
68
Ventricular Fibrilation
69
Amiodaron

• ??????? ??? ????? ??? ??? ???? ????? ?? ??? ??
  ???.
• ????? ????? ??????? ???? ???? ?? ?????? ?? ???.
• ????? ?? ??? AV?? ??? ?? ???.
• ???? ????? ???? ? ???? ??? ??? ?? ???.

70

Amiodaron Dosage and special consideration

• 150mg????? ????? ?????15????? - ???????10?????
• ????? ??? ??24???? 2.2g????? ?? ???? ?? ???????
  ?????.
• ??? ?????????0.5-1mg/min ?? ????? 150mg??
  100cc???????
• (1mg/min ?? 6 ???? ????? 0.5mg/min ?? 18
  ???? ???)
• ???? ?????? ?? ????? ????? ?? ? ?????????? ????
  ??? ?????????? ???? ??????
• ? ???? ?????? ???? ????.

71
Lidocaine

• ??????? ???? ????? ???? ? ??????????? ???? ??????
  ???
• ????? ???? ????? ????? ????? ???? ??????? ??????
• ???? ????????????? ???????? ??????? ????
• ???? ??????????? ??????? ????

72
Lidocaine Dosage and special considereation
1-1.5mg/kg - ????? ????? - ????? ??? ??? ?????
?? 5-10min ????? - ????? ??? 3mg/kg?? ?? ????
- ???????? ??? 1-4mg/min(30-50mic/min). - ?????
????? ???????? ?????? ??????? ( ???? ????????
???? ? ???????????? ?????? ????? PR ? ??? ???
?????? QRS )?????. - ?????? ???? ????? ???????
???????? ???????? ???? ??? ????.
73
Cardiogenic Shock ??? ????
74
??? ????

• ?????
• ???? ??????? ??? ?? ????? ??? ?? ?? ????? ???????
  ?? ??? ?????? ??? ?? ?? ???? ? ??? ??????????
  ????? .
• ??????? ????? ??? ?? ???? ???? ????? ? ???? ??
  ??????? ?????? ?????? ?? ????.

75
??? ??? ??????????

• ???? ???? (??? ?? 40)
• ????? ???? ???
• ??????? ????
• ??????? ????? ??? ???
• ?????? ????

76
?????????????

• ?? ????? ???? ??????? ?? MI ,???? ?? ??? ???? ?
  ???? ??? ?????? ?? ????? ??? ????? ( ??? ? ??? ?
  ???? ?? ) ???? ?? ??? ? ???? ????? ??? ?? ?? ???
  .
• ??? ???? ?? ?? ???? ????? ( Vicious Cycle )
  ???? ???? ???????? ?? ??? ?? ??? .

77
?????? ??????
?????? ???????
???? ???? ??????? ???????
???? ????? ???
??? ???????
???? ??????? ???????
????? ?????? .........
78
????? ??? ????

• ???? ???? ??? ?? ???? ?? mm Hg 90 ?? ??? ?? 30
  ????? ???? ?????
• ???? ????? ?????? ? ???????
• ???? ??? ????? ?? ???? ?? 20 ?? ?? ?? ????
• ??? ??? ? ????
• ?????
• ?????? ???????
• ???? ??? ? ?????
• ????? ?????? ???? ??? ??????? ? ???? ?????? ?
  ???? ? ???

79
????? ?????? ??? ????

• ????? ???? ????????
• ?????? ???? ???( ??? ???? ???? ????? ???
  ?????? ? ?????? )
• ?????? ??????? ????? ???
• ????? ???? ???????
• ????? ?????? ??

80
???? ?????? ??? ????

• ???????
• ????????? ( Levophed )
• ????????? ( Dobutrex )
• ??? ??? ?????
• ?????
• ?????????????
• ????? ?????? ? ??????? ??
• ??????

81
??? ???? ???? ????? IABP (Intra Aortic Ballon
Pump)
82
????? ???? ??????? ??IABP

• ?? ???? ??? ?? ??? ?? ??? ?? ???.
• ???? ?? ??? ?? ?? ????? ???? ??? ???? ???????
  ????? ?? ????.
• ??????? ????? ?????? ?? ?????? ?? ?? ? ???? ????
  ?????? ??????? ?? ????.
• ???? ??????? ?? ?? ?? ???.
• ?? ????? ?? ????? ???? ??????? ???? ???
  (Revasularisation) ????? ???????????????? ??
  ????? ?? ???.

83
????? IABP

• ??????? ?????? (?????? ???????? ?????)????? ????
• ???? ???? ???? ?? ???? ?????? ?? ???.
• ????? ?????
• ?????? ??????
• ????? ??????? ???????? ???? ???
• ??????? ?? ??????? ??? ?? IABP (???????)
• ????? ?????? ?? ??? ???? ?????

84
????? ??? ???? IABP

• ???????
• ??????? ?????
• ?? ????
• ???????????
• ??????? ?? ??? ????? ???
• ???????? ??? ???? ?????
• ??????? ??????

85
?????? ??????? ?? ?????? ??? IABP

• ????? ?? ??????? ????? ?? ???? ???? ???? ????.
• ?? ???? ?????? ????? ??????? ????.
• ??? ???? ?? ??? ????? ???? ????? ?? ???? ?? ???
  ???? ????.
• ?????? ????? ???????? ?? ?? ???? ???? ???? ????.
• ????? ?? ?? ??? ??????? ? ????? ??????? ???????
  ??? ????? ??????.

86
???????? ????
87
Pericardial tamponade
88
(No Transcript)
89
???????? ????

• ???? ??? ???? ???? ??????? ?? ???????? ???? ??
  ????? ?
• ??? (100-200 ML) -???? ( L5.1-1)
• ???????? ???? ??? ?? ?????????? ??? ? ?? ?????
  ?????? ? ????? ?? ????.
• ??? ????? ?????? ????? ?? ??? ?? ??? ???? ?????
  ???? ???? ??????? ??? ???? ??? ??? ????? ?????
  ??? ?? ????? ??????? ???? ???.
• ??? ??? ??? ???? ???? ???? ?? ???? ?? ???? ?? ??
  ???? ??? ????? ???? ???? ?? ??? ? ??? ????? ??
  ???.

90
??? ???????? ????

• ????? ????
• ????????? (????? ?? ??????)
• ????? ????????
• ?????? ??????????
• ???????????
• ???????? ?????????
• ??? ???? ?? ???
• ????? ???? ?? ??? ?? ???????? ?????
• ????? ??? ????? ???

91
????? ?????? ???????? ????

• ???? ?????????? ( ???? ??????? ????????)
• ?????? ????????????? cvp
• ????????? ? ??? ????
• ???? ??? ? ???? ?????? ????
• Friction rub
• ??? ???????? ??????
• ????? ???? ??? ????? ??????
• ??? ???? ????
• ???? ??? ? ????? ? ??????? ???
• Cusmal respiration
• ???? ???
• ???? ??? ??????? ??? ?????
• ?????? ??? ? ???? ???? / ?????

92
?????

• ?????? ??????
• EKG (???? ????? )
• ?????????????? (???? ???? ?? ???? ???????)
• Chest-X-Ray

93
?? ?????????????? ???? ???? ?? ???? ???????
?????? ?? ??? .
94
????? ??????????? ??? ?? Chest-X-Ray
95
????? (??????? ????????)

• ????? ?????? 15 L/min
• ???????? ????? ??????
• ?????????? ????? ???? ????
• ????? ????? ????? ?????
• ????????? ????

???????? ?? ???? ???? ???? ???? ????? ???? ?
?????? ??? ???????? ???? ???? ????? ?? ????? ??
????? ?? ??????? ??????? ???? ????? ????? ????
??????? ????????? ?? ????.
96
????????? ????
97
?????? ???????
?????? ???? ????? ????? ???? ?? ???????? ???? ???
?? ????? ??????? ???? ?? ???? ?? ?? ???? ???
????? ???? ???? ?? ??? ????? ?? ???.

• ???????????? ?? ????? ??? ?????? ?? ??????
  ????????? ????? ?? ???????? ???????? ??? ????? ?
  ?????? ????? ???????? ???? ?? ????.

98
Good luck