Here we will discuss some common disease that required urgent care in emergency setup while there are many diseases that need urgent treatment in an emergency;
- Acute Coronary Syndrome (ACS).
- Myocardial Infarction.
- Ischemic heart Disease.
- Hypertensive Emergencies.
1- Acute Coronary Syndrome (ACS):
It is Produce due to the mismatches of oxygen supply and demand.
* Rupture or fissuring of atherosclerotic plaque resulting in thrombus formation and vessel occlusion is the cause of unstable angina (ACS).
* Incomplete occlusion is the cause of unstable angina while complete occlusion is the cause of MI.
Investigations:
Serial ECGs.
Serial Cardiac enzymes (Including Trop. T and Trop. I).
Findings:
ACS can be due to unstable angina and due to Non.elevated MI.
ECG shows NSTEMI i.e. ST inversion or ST flatten
If cardiac enzyme -ve it is unstable angina.
If cardiac enzyme +ve it is NSTEMI.
Management:
1- Anticoagulant.
2- Anti-platelet.
3- No role of SK.
4- Nitrates.
5- Beta blockers.
6- Ca+ Channel blockers.
7- Ace Inhibitors.
8- Revascularization.
2- Myocardial Infarction:
Definition:
Acute Ischemic necrosis of an area of myocardium is known as myocardial infarction.
OR
Myocardial necrosis occurring as a result of critical imbalance between coronary blood supply and myocardial demand is called as myocardial infarction.
Sign & Symptoms:
Symptoms:Chest pain that radiate to the left side of the chest and retrosternal.
Shortness of the breath for few hours.
Nausea and vomiting.
These symptoms lead to the infarction off or angina.
Sings:
On the examination of patient;
Vitals:
Pulse;
Bradycardia- that can lead to the heart blocks i.e. more common is III degree of heart block.
Tachycardia- that can lead to heart failure i.e. SVT, VT, AF.
Respiratory Rate;
Tachypnea i.e. Increased RR.
Investigations:
Electrocardiography (ECG);
V1-V6 Anterior wall MI
II,III & AVF Inferior wall MI
I, AVL, V5,V6 Lateral wall MI
I, AVL High lateral wall MI
V5-V6 Lower lateral wall MI
V1-V4 Antroseptal wall MI
Diagnostic criteria of Acute Myocardial Infarction (AMI):
Chest pain- It can be AMI.
ECG- Changes ST elevation > 1 mm.
Cardiac Enzymes- positive shows the unstable angina (MI).
Management:
A-Initial management OR prehospital management of AMI;
Two IV lines.
Cardiac monitoring (It can be done in CPC, CCU, ICU).
Oxygen inhalation.
Aspirine 320 mg.
Clopidogrel 300 mg.
Morphine as pain killer.
Angised- Sublingual Nitrates.
B-Reperfusion Therapy;
Thrombolytics.
Primary PCI.
Urgent CABG.
Thrombolytics Therapy OR Fibrinolysis:
(Thrombus breakdown)
Red thrombus; Fibrin deposition common.
White thrombus; Platelet clump.
* For the Treatment of Red thrombus we use Streptokinase (SK).
* For the Treatment of White thrombus we use Tissue plasminogen Activator (tPA).
3- Ischemic heart Disease:
Myocardial Ischemia develops when there is an imbalance between supply of oxygen and the myocardial demand.
Etiology:
1- Decreased coronary blood flow due to mechanical obstruction i.e. Atheroma, Spasm of coronary artery, Thrombosis, Coronary arteritis and congenital abnormalities of coronary artery.
2- Increased myocardial oxygen requirement i.e. increased cardiac output (in thyrotoxicosis), Myocardial hypertrophy (in AS or HTN).
3- Decreased flow of oxygenated blood to myocardium i.e. Anemia, Hypotension (decreased coronary perfusion pressure).
4- Cardiac Syndrome X (Micro vascular angina).
Risk Factors:
Non-modifying Risk factors:
Age (more occur in old age).
Sex (more common in males rather than females).
Family history (Congenital Heart disease).
Modifying Risk factors:
(Those they are changeable with treatment)
Hyperlipidemia (Obesity).
Hypertension.
Cigarette smoking.
Diabetes mellitus.
Investigations:
ECG.
Cardiac Enzymes.
CBC.
PT, APTT and BT.
Management:
Heparin as anticoagulant.
Anti-platelet therapy i.e. Aspirine, clopidogrel, Glycoprotein inhibitor: IIb and IIIa (Abciximab).
Beta blockers.
Nitrates (Isoket).
Calcium blockers (Verapamil).
ACE inhibitors.
4- Hypertensive Emergencies:
Hypertensive Emergencies/ Crisis is the Condition, when rapid reduction of blood pressure is required.
It is Produce due to the mismatches of oxygen supply and demand.
* Rupture or fissuring of atherosclerotic plaque resulting in thrombus formation and vessel occlusion is the cause of unstable angina (ACS).
* Incomplete occlusion is the cause of unstable angina while complete occlusion is the cause of MI.
Investigations:
Serial ECGs.
Serial Cardiac enzymes (Including Trop. T and Trop. I).
Findings:
ACS can be due to unstable angina and due to Non.elevated MI.
ECG shows NSTEMI i.e. ST inversion or ST flatten
If cardiac enzyme -ve it is unstable angina.
If cardiac enzyme +ve it is NSTEMI.
Management:
1- Anticoagulant.
2- Anti-platelet.
3- No role of SK.
4- Nitrates.
5- Beta blockers.
6- Ca+ Channel blockers.
7- Ace Inhibitors.
8- Revascularization.
2- Myocardial Infarction:
Definition:
Acute Ischemic necrosis of an area of myocardium is known as myocardial infarction.
OR
Myocardial necrosis occurring as a result of critical imbalance between coronary blood supply and myocardial demand is called as myocardial infarction.
Sign & Symptoms:
Symptoms:Chest pain that radiate to the left side of the chest and retrosternal.
Shortness of the breath for few hours.
Nausea and vomiting.
These symptoms lead to the infarction off or angina.
Sings:
On the examination of patient;
Vitals:
Pulse;
Bradycardia- that can lead to the heart blocks i.e. more common is III degree of heart block.
Tachycardia- that can lead to heart failure i.e. SVT, VT, AF.
Respiratory Rate;
Tachypnea i.e. Increased RR.
Investigations:
Electrocardiography (ECG);
V1-V6 Anterior wall MI
II,III & AVF Inferior wall MI
I, AVL, V5,V6 Lateral wall MI
I, AVL High lateral wall MI
V5-V6 Lower lateral wall MI
V1-V4 Antroseptal wall MI
Diagnostic criteria of Acute Myocardial Infarction (AMI):
Chest pain- It can be AMI.
ECG- Changes ST elevation > 1 mm.
Cardiac Enzymes- positive shows the unstable angina (MI).
Management:
A-Initial management OR prehospital management of AMI;
Two IV lines.
Cardiac monitoring (It can be done in CPC, CCU, ICU).
Oxygen inhalation.
Aspirine 320 mg.
Clopidogrel 300 mg.
Morphine as pain killer.
Angised- Sublingual Nitrates.
B-Reperfusion Therapy;
Thrombolytics.
Primary PCI.
Urgent CABG.
Thrombolytics Therapy OR Fibrinolysis:
(Thrombus breakdown)
Red thrombus; Fibrin deposition common.
White thrombus; Platelet clump.
* For the Treatment of Red thrombus we use Streptokinase (SK).
* For the Treatment of White thrombus we use Tissue plasminogen Activator (tPA).
3- Ischemic heart Disease:
Myocardial Ischemia develops when there is an imbalance between supply of oxygen and the myocardial demand.
Etiology:
1- Decreased coronary blood flow due to mechanical obstruction i.e. Atheroma, Spasm of coronary artery, Thrombosis, Coronary arteritis and congenital abnormalities of coronary artery.
2- Increased myocardial oxygen requirement i.e. increased cardiac output (in thyrotoxicosis), Myocardial hypertrophy (in AS or HTN).
3- Decreased flow of oxygenated blood to myocardium i.e. Anemia, Hypotension (decreased coronary perfusion pressure).
4- Cardiac Syndrome X (Micro vascular angina).
Risk Factors:
Non-modifying Risk factors:
Age (more occur in old age).
Sex (more common in males rather than females).
Family history (Congenital Heart disease).
Modifying Risk factors:
(Those they are changeable with treatment)
Hyperlipidemia (Obesity).
Hypertension.
Cigarette smoking.
Diabetes mellitus.
Investigations:
ECG.
Cardiac Enzymes.
CBC.
PT, APTT and BT.
Management:
Heparin as anticoagulant.
Anti-platelet therapy i.e. Aspirine, clopidogrel, Glycoprotein inhibitor: IIb and IIIa (Abciximab).
Beta blockers.
Nitrates (Isoket).
Calcium blockers (Verapamil).
ACE inhibitors.
4- Hypertensive Emergencies:
Hypertensive Emergencies/ Crisis is the Condition, when rapid reduction of blood pressure is required.
Usually the diastolic BP is > 130 mm Hg that associated with vascular damage.
There are two type of Hypertensive crisis;
- Hypertensive Urgency.
- Hypertensive Emergency.
1. Hypertensive Urgency:(Accelerated Hypertension)
In this condition Blood pressure is controlled slowly by oral agents within few hours.
In this condition Blood pressure is controlled slowly by oral agents within few hours.
HTN Severe, when systolic pressure is > 220 mm Hg and diastolic is > 125 mm Hg.
Patient may be Asymptomatic or minimal symptoms.
In this case, Although BP is very high but have no risk of organ damage.
2. Hypertensive Emergency:
Immediate reduction in BP is required within one hour with Parenteral drugs.
It can cause end organ damage, Avoid the serious morbidity or death.
It is associated with the sudden increase BP that can cause acute injury to target organ.
BP is usually > 130 mm Hg diastolic.
Target organ damage;
- Brain.
- Kidney.
- Heart.
- Retina.
Brain:
HTN Encephalopathy ( Headache, Confusion, Irritability, Altered mental status and ICH-Intra cranial Hemorrhage )
Kidney:
HTN neuropathy (Hematuria, Proteinuria and progressive renal function)
HTN neuropathy (Hematuria, Proteinuria and progressive renal function)
Heart:
Angina, Pulmonary Edema or Myocardial Infarction.
Retina:
Angina, Pulmonary Edema or Myocardial Infarction.
Retina:
Hemorrhage Exudates and papilliedema.
Management:
These are the following drugs that uses in the management of Hypertension.
Management:
These are the following drugs that uses in the management of Hypertension.
- Sodium Nitroprusside (Nipride) IV infusion.
- Nitroglycerin (Isoket) IV infusion.
- Hydralazine IV bolus.
- Diazoxide.
- Labetalol IV bolus.
- Diuretics.
- Nifedipine (Adalat).
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