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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Treatment, in the presence of hemodynamic stability and a pulse, is as follows:
(Amiodarone is the preferred drug when the ejection fraction is <40%.)
If unstable (defined as systolic BP <90 mm Hg, confusion, chest pain, or CHF):
CCS NOTE
A cardiology consult should be ordered with any serious rhythm disorder. In this case,
you will need cardiology to place an implantable defibrillator. Do not expect them to
actually say anything.
While electrical cardioversion must be performed immediately if the patient is unstable,
premedication is still preferable when possible. A sedative such as diazepam or midazolam
should be used prior to the cardioversion when time allows.
Pulseless ventricular tachycardia is managed the same way as ventricular fibrillation.
Oxygen, IV access1.
Amiodarone2.
Lidocaine3.
Procainamide4.
Synchronized cardioversion 100 J1.
Synchronized cardioversion 200 J2.
Synchronized cardioversion 360 J3.
Synchronized cardioversion 360 J4.
If persistent, use amiodarone followed by lidocaine or procainamide5.
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The most common side effect of lidocaine is confusion, particularly among the elderly. In the
short term, amiodarone has few adverse effects when used on a regular basis. Amiodarone can
lead to pulmonary fibrosis, thyroid disorders, and corneal deposits.
In those patients with a wide complex tachycardia of unknown type, procainamide or
amiodarone can be used; these agents are effective for both atrial and ventricular arrhythmias.
When ejection fraction is <40%, amiodarone is preferred.
Anyone with cardiac rhythm disturbances should have an echocardiogram. Cardiomyopathy is
often associated with arrhythmia. Ischemia should be excluded as a cause of ventricular
arrhythmias.
Follow-up Management and Prevention
Final Diagnosis
Ventricular tachycardia
Keep patient in ICU
Continue amiodarone
Do stress (exercise-tolerance) test once patient is stable
If stress test or catheterization is normal, arrange electrophysiology studies
—
Do echocardiography
Arrange cardiology consult
Consider automatic implantable cardioverter defibrillator (AICD) placement
Metoprolol
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133
Case 4
Chief Complaint
“My chest and stomach began to hurt as I was eating.”
History and Physical Examination
A 56-year-old man with diabetes mellitus and hypertension is brought to the emergency
department because of a 30-minute history of chest and epigastric pain which developed
while eating. He has had similar episodes that occur after walking for 1 to 2 blocks and
which are relieved by rest. He denies a history of myocardial infarction. He takes
diltiazem to control his BP. After arriving in the emergency department the pain starts
again.
Vital signs are T 37.2 C (98.9 F), BP 140/90 mm Hg, and pulse 110/min. Physical
examination shows no jugular venous distension, a clear chest bilaterally, and a benign
abdomen. Cardiovascular examination shows tachycardia with no murmurs or gallops.
The extremities are not edematous.
Differential Diagnosis
Unstable angina
1.
Myocardial infarction
2.
Dissecting aortic aneurysm
3.
Pericarditis
4.
Peptic ulcer disease
5.
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Initial Management
Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
Assessment
This patient has unstable angina and may be having a myocardial infarction. Unstable angina
means a ‘history consistent with MI but no ST segment elevation.’ In unstable angina, one can
have a normal electrocardiogram, ST depression, or T-wave inversion. The anginal pattern is
termed “unstable” because there is a worsening of the pattern characterized by pain occurring
at rest.
If the electrocardiogram were to have ST-segment elevation or if the CPK-MB became
significantly elevated, then the same pattern would be consistent with acute myocardial
infarction. This is an important distinction because the use of thrombolytic therapy such as tPA
Gastroesophageal reflux disease (GERD)6.
Aspirin oral, nitroglycerin sublingual, morphine
Electrocardiogram
Chest x-ray
CK-MB and troponin
EKG: 1 mm ST segment depression in leads II, III, and aVF
Chest x-ray normal
CK-MB and troponin normal
135
and streptokinase is predicated upon diagnosing an infarction by seeing ST segment elevation.
Thrombolytics are not indicated in the treatment of unstable angina alone.
Further Management Plan
Further Test Results
CCS NOTE
The order in which you type the medication or treatment names does not matter on the
CCS, as long as you write them in on the same screen. The CCS software has an
automatic spellcheck.
Discussion
Admit to ICU (also known as special, coronary, and intensive)
Repeat electrocardiogram and CPK-MB or troponin at 6-hr intervals, though treatment
should not be delayed pending the result of any test with an anginal pattern such as this
Enoxaparin (low molecular weight heparin)
Clopidogrel (prasugrel or ticagrelor for those patients undergoing angioplasty and a stent)
Metoprolol IV, statin oral
Glycoprotein IIb and IIIa inhibitors (eptifibatide or tirofiban) if patient high-risk or
undergoing angioplasty cardiac catheterization
Repeat electrocardiogram every 15 min while pain is present
EKG: ST depression in II, III and aVF persists
CKMB and troponin: normal
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The most important part of the initial management with any form of angina is to stop the pain.
Nitroglycerin, oxygen, and morphine are the traditional treatments, though their effect on
lowering overall mortality has not been demonstrated.
Unstable angina should be thought of as ‘the result of a clot forming upon an underlying
atheromatous plaque.’ Hence, acute treatment is predominantly based on the prevention of
further clotting with aspirin and heparin. Low molecular weight heparin has a superior efficacy
compared with IV heparin. Thrombolytic therapy has not been found to decrease mortality
in unstable angina.
Glycoprotein IIb/IIIa inhibitors such as abciximab, eptifibatide, and tirofiban are useful adjunct
therapy to aspirin and heparin; they are indicated when the patient has a high risk for mortality.
These risks include elevated troponin or CK-MB, persistent pain, CHF, diffuse
electrocardiogram abnormalities, or decreased left ventricular function. In addition, these
inhibitors are useful when there has been prior stenting or revascularization.
Low molecular weight heparin prevents active clot formation. These drugs are enoxaparin,
dalteparin, and nadroparin. Urgent cardiac catheterization and angioplasty are useful in those
who have persistent pain through medical therapy. In other words, if the clot is worsening and
the medications can’t stop it, use a balloon and stent to mechanically open it. Abciximab should
be used any time a patient gets a stent with the angioplasty.
Drug-eluting stents reduce the rate of re-stenosis. The drugs are sirolimus and paclitaxel; they
reduce the rate of re-stenosis from a 30% frequency to <5%. All those with stents placed must
be on aspirin and a second anti-platelet drug such as clopidogrel, prasugrel or ticagrelor.
Follow-up Management and Prevention
ICU monitoring in those patients producing enzymes consistent with MI
Telemetry monitoring
Aspirin and a second anti-platelet agent for those undergoing angioplasty or with MI
137
Final Diagnosis
Angina pectoris, unstable
Statin, beta blockers, and ACE inhibitors
ACE inhibitor can stop at 6 wks if echocardiogram shows normal wall motion and
ejection fraction >40%
—
Stop diltiazem: diabetics with hypertension are best managed with ACE inhibitors
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Case 5
Chief Complaint
Hyperlipidemia management
History
A 58-year-old man has been referred to the office by his vascular surgeon for
preoperative evaluation prior to undergoing a femoral-popliteal bypass graft. He denies a
history of angina, though he does have a history of diabetes mellitus and hypertension.
There is no family history of coronary artery disease. He stopped smoking 6 months ago.
The initial electrocardiogram is normal.
Because of his multiple risk factors, you decide to perform a stress test. A dipyridamole
thallium test is performed because his claudication leaves him unable to exercise. The
stress test shows an area of reversible ischemia in the inferior wall. The surgeon is
concerned because the total cholesterol is elevated at 212 mg/dL. Vital signs are T 36.8
(98.2 F), BP 124/82 mm Hg, pulse 82/min, and respirations 14/min. Examination of the
head, eyes, ears, nose, and throat is normal except for arcus senilis. Peripheral pulses in
his extremities, which are smooth and shiny, are diminished.
Differential Diagnosis
No specific differential diagnosis; patient is evaluated because of PVD, HTN, diabetes,
and hyperlipidemia before surgery to exclude sub-clinical CAD and for the
management of dyslipidemia
1.
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Initial Management
Setting: outpatient
Diagnostic/Therapeutic Plan
CCS NOTE
Don’t forget to order the proper diet for each patient based on diabetes, hypertension,
hyperlipidemia, or obesity.
Test Results
Assessment
This patient has an elevated LDL cholesterol in the presence of coronary heart disease.
Although he has no history of angina, he does have multiple risk factors for coronary artery
disease. Even in the absence of symptoms, preoperative evaluation with a stress test may
Total cholesterol
LDL
Triglycerides
HDL
Total cholesterol: 212 mg/dL (normal <200 mg/dL)
LDL: 138 mg/dL
Triglycerides: 125 mg/dL (normal <150 mg/dL)
HDL: 52 mg/dL (normal 40–60 mg/dL)
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