Emergency conditions emergency conditions .pptx

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1. Emergency conditions Dept. of Primary Care & General Practice Kazan State Medical University

2. CRT - Cardiac resynchronization therapy

3. EMERGENCY THERAPY IN PAROXYSM OF ATRIAL FIBRILLATION ECG signs of AF 1. The absence of a P wave on the ECG; 2. RRs are not equal to each other; 3. Waves f in V1 (frequency within 350-600 per min);

4. Acute causes of paroxysms of AF: taking large doses of alcohol (“holiday heart syndrome”); surgical intervention; early postoperative complication of surgical operations on the heart or chest; electric shock; myocardial infarction, pericarditis, myocarditis; pulmonary embolism; acute severe lung diseases; hyperthyroidism and other metabolic disorders; other supraventricular tachycardia; WPW syndrome or AV nodal re-entry tachycardia.

5. At the stage of the first contact with a patient with this or that form of AF, a doctor needs to solve several rather complex issues: • Does this patient need to restore sinus rhythm or does he need medical correction of the ventricular rate. • Assess the safety of sinus rhythm restoration and the risk of normalizing thromboembolism, which is based on a number of factors: - the duration of the paroxysm is more than 24 hours, - dimensions of the atria - the presence of a thrombus in the cavity of the heart - the presence of valvular heart disease, severe organic lesions of the myocardium - thyroid diseases, presence and severity of chronic heart failure. • If the patient needs to be restored to sinus rhythm, should this be done in the pre-hospital setting, or should this procedure be done routinely in the hospital after the necessary preparation. • If the patient has bradysystolic AF, what is the risk that after the arrest of the paroxysm there will be an urgent need to install a pacemaker.

6. Cardioversion is not recommended if AF duration is longer than 24 hours, unless the patient has already received at least 3 weeks of therapeutic anticoagulation or a TOE is performed to exclude intracardiac thrombus. 2024 ESC Guidelines for the management of atrial fibrillation (European Heart Journal; 2024 – doi: 10.1093/eurheartj/ehae176) Approaches for cardioversion in patients with AF Figure 12 Approaches for cardioversion in patients with AF. AF, atrial fibrillation; CHA 2 DS 2 -VA, congestive heart failure, hypertension, age ≥75 years (2 points), diabetes mellitus, prior stroke/transient ischaemic attack/arterial thromboembolism (2 points), vascular disease, age 65–74 years; h, hour; LMWH, low molecular weight heparin; DOAC, direct oral anticoagulant; OAC, oral anticoagulant; TOE, transoesophageal echocardiography; UFH, unfractionated heparin; VKA, vitamin K antagonist. Flowchart for decision-making on cardioversion of AF depending on clinical presentation, AF onset, oral anticoagulation intake, and risk factors for stroke.

7. In patients with AF, both electrical and medical cardioversion can be used. Electrical cardioversion. In patients with severe hemodynamic disorders, D . C . synchronized electrical cardioversion is the method of choice for the relief of paroxysmal AF. With a two-phase (bipolar) discharge, start with 100 J, if necessary, increase the strength of each subsequent discharge by 50 J. A single-phase discharge requires 2 times more energy, that is, start with 200 J, followed by an increase of 100 J until the maximum is reached level 360 J. Exposure to a bipolar pulse is more effective and less damaging to the myocardium than to a monopolar one. The interval between two successive discharges must not be less than 1 minute. It is important to conduct continuous monitoring of blood pressure and pulse oximetry in such patients. Skin burns may occur. To mitigate the effect of transient bradycardia after cardioversion, intravenous atropine or isoproterenol, or temporary transcutaneous pacing, may be considered.

8. Anteroposterior positioning of the electrodes creates a stronger shock field in the left atrium than anterolateral positioning and contributes to a more effective restoration of sinus rhythm.

9. Pill-in-pocket cardioversion by patients. For some patients with infrequent symptomatic paroxysms of AF, after initial confirmation of the absence of contraindications, restoration of SR is possible with oral propafenone (450-600 mg) in the patients themselves at home (pill-in-pocket therapy). The rhythm is restored within 2-6 hours.

10. Early cardioversion. If the duration of an AF episode is < 24 hours, then one of the antiarrhythmic drugs is used: • Propafenone 450-600 mg orally or 2-4 mg/kg IV over 10 minutes. • Amiodarone 5-7 mg/kg over 30-60 minutes mg IV drip In patients with severe structural pathology of the heart (myocardial infarction, chronic heart failure with reduced ejection fraction, myocardial hypertrophy of more than 14 mm, coronary heart disease), the administration of amiodarone is optimal. However, a quick recovery of the rhythm does not occur, and one must be prepared for this. In other patients, propafenone should be preferred. After its parenteral application, the rhythm is usually restored within 30-120 minutes.

11. Delayed cardioversion. If the duration of AF is > 24 hours, then anticoagulant preparation is necessary (warfarin (with target values of INR 2.0-3.0), apixaban, dabigatran, rivaroxaban, edoxaban ) for 3 weeks, then elective cardioversion (200 J electrically synchronized cardioversion is preferred), after which anticoagulants are again prescribed for at least 4 weeks. If the rhythm has recovered on its own, then it is necessary to warn the patient in advance about the importance of anticoagulation even in sinus rhythm. Early cardioversion is acceptable in patients with AF paroxysm > 24 hours and hemodynamic disorders (myocardial ischemia, shock, loss of consciousness, acute cardiovascular failure, stroke) provided that there are no blood clots in the heart cavities according to transesophageal echocardioscopy . In this case, intravenous infusion of heparin is also mandatory until an increase in activated partial thromboplastin time (APTT) by 1.5-2.0 times compared with the control value.

12. Supraventricular paroxysmal tachycardia- paroxysmal Supraventricular paroxysmal tachycardia- paroxysmal increase in heart rate over 100/min (140-250) while maintaining the correct rhythm, due to pathological circulation of excitation through the myocardium or activation of pathological foci of high automatism. Supraventricular tachycardia: atrial, AV-paroxysmal.

13. With severe hemodynamic disorders - emergency ECV 100J or emergency stimulation. Uncomplicated paroxysm. Valsalva vagal test (straining with holding the breath for 20-30 seconds) or deep breathing. in case of inefficiency: Adenosine - 6-12 mg or ATP 5-10 mg bolus under the control of the monitor. Repeat after 2 minutes if there is no effect. Contraindications: SA block 2- 3rd degree, AV block 2- 3rd degree. in case of inefficiency: Verapamil 5-10 mg bolus, slowly. Contraindicated in WPW. In case of therapeutic failure - synchronized ECV.

14. Ventricular paroxysmal tachycardia Ventricular paroxysmal tachycardia - an accelerated rhythm (at least 3 QRS complexes with a heart rate of more than 100/min), the source of which is in the legs or branches of the His bundle, Purkinje fibers or the working myocardium of the ventricles. Diagnostics: - ECG - ECG monitoring - EchoCG (with the secondary nature of the gastrointestinal tract) Help 1. Emergency electrical defibrillation 150-360 J. 2. If three shocks are ineffective - amiodarone IV bolus 300 mg against the background of cardiac massage.

15. PULMONARY EMBOLISM Clinic - pain, shortness of breath, fainting, hemoptysis. Hemodynamics does not always suffer, but its change is evidence about the massiveness of thrombotic lesions with the involvement of large branches of the pulmonary artery and a decrease in hemodynamic reserve. Hypoxemia is rare. ECG - T inversion in V1-V4, QR pattern in V1, S1Q3T3 pattern are more characteristic of RV overload and are found in severe cases. More often - sinus tachycardia or atrial arrhythmia.

16. Emergency medical care: 1. Call an ambulance! 2. Lay the patient down. With hypotension - in a supine position with a raised leg end, turn his head to the side, remove dentures, push the lower jaw. 3. Provide fresh air, loosen tight clothes. 4. Monitor blood pressure, pulse, respiratory rate, oxygenation level, ECG. 5. Administer humidified oxygen via nasal cannula to maintain SpO2 >95%. 6. In case of hypotension (BP < 90 mmHg), inject 0.1% epinephrine solution 0.3-0.5 ml IM into the middle of the anterolateral thigh. 7. In case of hypotension (BP < 90 mmHg), establish intravenous access. Connect 0.9% sodium chloride solution. The rate of infusion depends on the level of blood pressure. The introduction of a significant amount of fluid can lead to pulmonary edema. 8. Be prepared to perform CPR. For adults, chest compressions (chest compressions) should be performed at a frequency of 100-120 per minute to a depth of 5-6 cm. The ratio of breaths to chest compressions is 2:30. Further actions - emergency hospitalization only by the ambulance team. CPR - С ardiopulmonary resuscitation

17. Aortic dissection Aortic dissection destruction of the middle layer of its wall, provoked by intraparietal blood ingress, with the resulting separation of the layers of the aortic wall.

18. In most cases, the initiating condition is intimal rupture, as a result of which blood enters the plane of the dissection - the middle shell of the aorta. Then, the next step is either a rupture of the aorta in case of destruction of the adventitia, or re-entry of blood into the lumen of the aorta through the second intima rupture. Diagnostics - CT, MRI, PE- EchoCG . The main goal is to reduce the impact of deforming stress by decrease in blood pressure and contractile function of the heart. IV administration of B-AB up to BP 100-120 (propranolol 1 mg every 10 minutes up to 10 mg max.)- to reduce pressure, sodium nitroprusside 0.3-1.5 µg/kg/min can be used - emergency operation

19. Gastrointestinal bleeding 1. Control of pulse, blood pressure, clinical signs of hypoperfusion and shock. 2. Catheterization of 2 peripheral veins and stomach 3. Infusion of crystalloids 1000 ml. 4 . PPI - Omeprazole - 80 mg IV

20. Acute coronary syndrome Acute coronary syndrome (ACS) - any group of clinical signs or symptoms suggestive of acute myocardial infarction or unstable angina, indicates a period of exacerbation of coronary heart disease (CHD). Includes the concepts of “acute MI”, “MI with ECG ST segment elevation (STEMI)”, “MI without ECG ST segment elevation (NSTEMI )”, and ”unstable angina”. Acute coronary syndrome with persistent ST-segment elevations - recent clinical signs or symptoms of myocardial ischemia in combination with the presence of persistent (more than 20 minutes) ST-segment elevations in at least two adjacent ECG leads.

21. Clinical picture: С onstricting , pressing or burning pain behind the breastbone lasting >20 min at rest, with irradiation to the left shoulder, arm, under the left shoulder blade, back or neck; Pain may be accompanied by a feeling of suffocation, pallor of the skin, sweating, tachycardia (possible bradycardia); Blood pressure may increase or decrease up to collapse; nausea, abdominal pain ; loss of consciousness.

22. Medical emergency (simultaneously start steps 1, 2, 3, 4, 5): 1. Call an ambulance! 2. Lay the patient down, ensure complete rest, access to fresh air. 3. Monitor vital functions (consciousness, blood pressure, heart rate, pulse oximetry). 4. Continuous visual monitoring for timely detection of the need to start cardiopulmonary resuscitation. 5. Registration of an ECG on the spot. 6. Short-acting nitroglycerin sublingually 0.5 mg or 1 dose of Nitroglycerin sublingual spray (1 dose - 0.4 mg ) , if the blood pressure not lower than 90/60 mm Hg, can be repeated after 5 minutes, but no more than 3 times under the control of blood pressure (systolic blood pressure ≥100 mm Hg) and heart rate (≤ 100 bpm). If BP 90/60 mmHg nitrates are contraindicated!

23. 7. ½ tab. acetylsalicylic acid (ASA ) chew, swallow. For persons who have not regularly taken ASA before, the first dose is 150-325 mg (chew and swallow) + orally Clopidogrel 300 mg (4 tablets). For persons over 70 years old - no more than 150 mg. 8. Propranolol 10-40 mg orally in the absence of obvious clinical contraindications (atrioventricular block II and III degree, sinoatrial block, SSSU, blood pressure below 90/60 mm Hg, heart rate <50 beats per minute, congestive heart failure, BA , COPD) 9. In case of arterial hypotension (systolic blood pressure < 90 mm Hg. Art.) - 0.1% solution of epinephrine 0.3-0.5 ml / m in the middle of the anterolateral surface of the thigh. Provide venous access! 10. With obvious signs of hypoxemia (SpO2 less than 90%), especially in combination with shortness of breath, cyanosis and other manifestations of cardiopulmonary insufficiency - oxygen therapy with 40% humidified oxygen through nasal cannulas 11. With arterial hypertension (BP ˃ 140/90 mm Hg) - captopril 25 mg orally. Further actions - emergency hospitalization only by the ambulance team.

24. SPONTANEOUS PNEUMOTHORAX Providing emergency care for spontaneous pneumothorax. Prehospital stage: 1 Complete rest. 2 Elevated position of the head end. 3 Oxygen inhalation 2-4l/min 4 Pain relief - 50% solution of analgin 2 ml / m, diclofenac sodium 2% - 3 ml / m. 5 Antitussives - with a pronounced dry cough. - Lebiksin 100 mg 3-4 times a day. - Terpinkod 1 tab. 2-3 times a day