Cardiac causes of cardiac arrest Learning outcomes This

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Cardiac causes of cardiac arrest

Cardiac causes of cardiac arrest

Learning outcomes This lecture should enable you to: • describe the heart conditions that

Learning outcomes This lecture should enable you to: • describe the heart conditions that may cause cardiac arrest • explain the process that causes acute coronary syndromes (ACS) • describe the different types of ACS • explain how to recognise and assess an ACS • list the relevant immediate treatment for each type of ACS • discuss how to recognise and respond to other cardiac conditions that may cause cardiac arrest.

Acute coronary syndromes Spectrum of clinical presentation caused by: • atherosclerotic plaque rupture •

Acute coronary syndromes Spectrum of clinical presentation caused by: • atherosclerotic plaque rupture • thrombus formation • smooth muscle constriction

Fissured plaque

Fissured plaque

ABCDE Assessment • Use ABCDE to assess – treat immediate issues – blood sample

ABCDE Assessment • Use ABCDE to assess – treat immediate issues – blood sample in ‘C’ for enzymes – reassess • 12 lead ECG

Risk Stratification

Risk Stratification

Acute coronary syndromes Clinical syndromes caused by the same disease process: • unstable angina

Acute coronary syndromes Clinical syndromes caused by the same disease process: • unstable angina • non-ST-elevation myocardial infarction • ST-elevation myocardial infarction

Unstable angina 1. angina on exertion with increasing frequency over a few days, provoked

Unstable angina 1. angina on exertion with increasing frequency over a few days, provoked by less exertion or 2. angina occurring recurrently and unpredictably not specifically on exercise or 3. unprovoked and prolonged episode of chest pain ______________________ __ – ECG may be normal – No troponin release – ST segment depression suggests high risk

Acute ST depression

Acute ST depression

Non-ST-elevation myocardial infarction (NSTEMI) • symptoms suggest acute myocardial infarction • ECG findings non-specific:

Non-ST-elevation myocardial infarction (NSTEMI) • symptoms suggest acute myocardial infarction • ECG findings non-specific: – ST-segment depression – T-wave inversion – may be normal • troponin release

T-wave inversion in NSTEMI

T-wave inversion in NSTEMI

ST-elevation myocardial infarction (STEMI) • symptoms suggest acute myocardial infarction • ECG shows acute

ST-elevation myocardial infarction (STEMI) • symptoms suggest acute myocardial infarction • ECG shows acute ST-segment elevation • Q waves likely to develop • troponin release • early effective treatment may limit myocardial damage (and prevent Q wave development)

Anterolateral STEMI

Anterolateral STEMI

Immediate treatment for all acute coronary syndromes ABCDE approach • • • aspirin 300

Immediate treatment for all acute coronary syndromes ABCDE approach • • • aspirin 300 mg orally (crush/chew) consider other antiplatelet medication nitrate (GTN tablet or patients own spray) fentanyl/morphine oxygen - if hypoxic or signs of shock • (Sp. O 2 <94% or no measurement available)

Unstable angina and NSTEMI • anti-thrombotic – – aspirin clopidogrel or ticagrelor (or prasugrel)

Unstable angina and NSTEMI • anti-thrombotic – – aspirin clopidogrel or ticagrelor (or prasugrel) LMW heparin or fondaparinux If very high risk: glycoprotein IIb/IIIa inhibitor • pain relief – nitrate – fentanyl/morphine • oxygen if hypoxaemic • myocardial protection – beta blocker – coronary angiography/PCI in most patients

STEMI (or acute MI with new LBBB) Emergency reperfusion therapy: • optimal treatment -

STEMI (or acute MI with new LBBB) Emergency reperfusion therapy: • optimal treatment - primary percutaneous coronary intervention (PPCI) • fibrinolytic therapy if PPCI is not available • when given very early, similar outcomes • avoid delay “time is muscle”

Access to emergency reperfusion

Access to emergency reperfusion

Left bundle branch block

Left bundle branch block

Other cardiac causes of cardiac arrest • in any cardiac arrest look for evidence

Other cardiac causes of cardiac arrest • in any cardiac arrest look for evidence of the cause • not all cardiac arrests are due to ACS • other causes may be ‘structural’ or ‘electrical’ • some are inherited, some acquired, some congenital

Examples of other cardiac causes Condition Nature Causation Severe aortic stenosis Structural Mostly acquired

Examples of other cardiac causes Condition Nature Causation Severe aortic stenosis Structural Mostly acquired Sometimes congenital Hypertrophic cardiomyopathy Structural Inherited High-grade AV block Electrical Mostly acquired Occasionally congenital Long QT syndrome Electrical Inherited, but… there are other causes of a long QT interval Anomalous coronary anatomy Structural Congenital

Long QT syndrome

Long QT syndrome

Other cardiac causes: preventing cardiac arrest • be alert for warning symptoms (e. g.

Other cardiac causes: preventing cardiac arrest • be alert for warning symptoms (e. g. unexplained syncope) • arrange urgent specialist assessment and treatment (including genetic family) • with inherited conditions, don’t forget the family

Any questions?

Any questions?

Summary • • recognise the different presentations of ACS use the ABCDE approach start

Summary • • recognise the different presentations of ACS use the ABCDE approach start appropriate immediate treatment arrange immediate PPCI when appropriate be aware of other cardiac causes of arrest these require different management ‘warning’ symptoms need urgent referral

Advanced Life Support Level 2 Course Slide set All rights reserved © Australian Resuscitation

Advanced Life Support Level 2 Course Slide set All rights reserved © Australian Resuscitation Council (June 2016)