Recognising the deteriorating patient: avoiding catastrophe

Cardiovascular emergencies: what to do and when to refer

Dr David Gray Reader in Medicine and Consultant Cardiologist

(recently retired and highly recommended)

Who am I? Academic post –

research

–

teaching

Hands-on clinician Author/Editor of several books including

Essentials of Physical Health in Psychiatry

What is an emergency? Life-threatening situation Requires immediate action

What is an emergency? Life-threatening situation Requires immediate action IF YOU DO NOT KNOW WHAT TO DO,

IT IS AN EMERGENCY

Cardiovascular emergencies Cardiopulmonary arrest Chest pain

Fast or slow pulse and long QT

Syncope

Breathlessness

Cardiopulmonary arrest Daily checks on defibrillator Resuscitation protocols '999' Transfer patient to hospital for investigation

Normal ECG

Ventricular fibrillation

*

Cardiopulmonary arrest Survival figures best in

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Seattle

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Coronary Car Unit

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hospital

Cardiovascular emergencies Cardiopulmonary arrest

Chest pain Fast or slow pulse and long QT

Syncope

Breathlessness

Chest pain ? cardiac ●

Many causes –

Cardiac

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GI

–

Pulmonary

–

chest wall

–

somatisation

–

and others

Is it cardiac? –

Know your patient- whinger or stoic?

Cardiac chest pain ●

'crushing, heavy, pressure on chest, tight band'

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located anywhere in chest

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radiation = 'hurt elsewhere?' –

Left arm common

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what brings pain on?

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eased by GTN?

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anything else –

Feeling of doom

Chest pain Record an ECG Should show –

regular rhythm

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'normal' heart rate

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should be reported as 'normal' ●

or no different from admission ECG

Chest pain known angina –

Usually activity-induced chest pain

–

GTN (1-2) and check ECG

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Often tachycardia

Known angina ECG shows –

INFARCTION

–

ISCHAEMIA

ECG showing acute changes of infarction

ECG showing ischaemia

Action to take if chest pain and known angina If chest pain a 'one off' –

No need to refer

If chest pain recurrent –

Routine referral

–

May just need medication adjustment/change

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May need further investigation/treatment

If chest pain does not settle with (at most) two GTN

OR If ECG shows ischaemia or infarction –

'999'

Action to take while awaiting paramedics aspirin pain control reassurance continued observation monitor ECG cannula if possible make sure defibrillator available

What is happening inside if ECG shows acute changes

Chest pain and not known angina Need to know your patient Take a history if you can/patient able sounds cardiac: –

GTN

–

ECG

–

Aspirin

–

If first event ●

Arrange routine hospital referral for assessment

Chest pain- some other causes Pericarditis –

Usually better sitting up

–

fever

Pneumonia –

Usually respiratory symptoms/fever

GI ulcer –

Abdo tenderness/sickness/dark stool

Aortic dissection –

Usually history of poorly controlled BP

–

Different pulse and BP in each arm

Chest painunlikely to be cardiac If occurs on –

Bending or flexing spine

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Mimicked by pressure on chest

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Localised 'finger pointing sign'

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Severe on lying but eased by sitting up

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Can be difficult to recognise sham patient

–

Reliant on good history.....

Chest painlikely to be cardiac If associated with 'flight or fight' signs –

Pallor, nausea, tachycardia, sweating

–

ECG shows

–

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Abnormal rhythm

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ST depression/elevation

Reliant on good history.....

Chest pain ●

Safest action–

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Assume cardiac until proven otherwise

Record an ECG –

Normal does not exclude cardiac cause

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ST segment depression = ISCHAEMIA

–

ST segment elevation

= INFARCTION

ISCHAEMIA and INFARCTION ●

Both MEDICAL EMERGENCIES

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EASILY managed in hospital

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CANNOT be managed in psychiatric unit

Cardiovascular emergencies Cardiopulmonary arrest

Chest pain

Fast or slow pulse and long QT Syncope

Breathlessness

Fast or slow pulse rate Can be associated with serious heart disease –

Bradycardia ●

–

Heart block

Tachycardia●

Ventricular tachycardia

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Ventricular fibrillation

Many psychotropic drugs affect pulse –

Memory enhancers ●

–

bradycardia

Antipsychotics ●

Orthostatic hypotension …....syncope

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Prolonged Qtc interval

…...cardiac dysrhythmia

Take pulse change seriously if Accompanied by –

chest pain

–

breathlessness

–

dizziness- suggests cardiac output low

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pulse is erratic

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change in pulse cannot be explained by change in medication

Prolonged QT interval Prolonged = risk of cardiac dysrhythmia Some inherited forms of 'long QT syndrome' Many antipsychotics prolong QTc Normally corrected to heart rate of 60 bpm Measurement usually printed on ECG Ignore QT interval Look at QTc Normal value of QTc –

400 msec in man

–

430 msec in woman

What can you do about prolonged QTc? Before starting antipsychotics –

Know what you are dealing with

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ECG

–

Serum potassium/magnesium

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Cardiac risk factors and history

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Once on antipsychotic at steady state

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Keep doses as low as possible

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try to avoid second drug/combinations

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try to avoid PRN doses

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Monthly ECG

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Check any new drug for interactions

When to consult a cardiologist about chest pain Recurrent episodes –

known angina and not controlled with usual medication

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Not known angina= needs diagnosis

When to consult a cardiologist about abnormal ECG Any change since original ECG

Auto interpretation shows –

QTc > 500msec

–

Atrial fibrillation

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Ischaemia or infarction

When to consult a cardiologist about syncope or presyncope Known cardiac history –

Angina

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Heart failure

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Heart murmur

–

Cardiac arrhythmia

'999' on first presentation A&E should initiate referral/investigations

When to consult a cardiologist about palpitations If atrial fibrillation

if previously regular pulse becomes irregular If medication with antipsychotic –

Especially high dose/combination

If occurs with –

chest pain

–

breathlessness

–

dizziness

When to consult a cardiologist about breathlessness If likely to be heart failure on blood tests –

Raised BNP

If likely to be heart failure clinically –

Swollen ankles

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Raised JVP

When to worry about patient on antipsychotic If develops –

Collapse

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Dizzy

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Palpitations

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Fast or erratic heart beat

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Breathlessness

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Increase in QTc > 25%

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Serum potassium or magnesium low

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Urgent cardiology review

Cardiologists ARE –

really very nice people

LIKE TO HELP –

especially those who really need it

–

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