Complications of Acute MI ‘My patient just had an MI, what do I need to worry about?’ Adam Watchorn Oct THANKS TO IAN RIGBY

Arrhythmias Cooling Shock

55F CP 3hr duration Afebrile 95 86/48 94% 2L NP Diaphoretic & Pale Cool extremities JVP normal

1)LYTICS or transfer to Cath lab (Rockyview)? 2)LYTICS or transfer to Cath lab (Golden)? 1)What PRESSOR would you use and why? What dose would you start at?

My hospital has PCI Easy choice: PCI > LYTICS (6-month mortality benefit) My hospital does NOT have PCI Tough choice: Risk vs. Benefits of LYTICS ?

Cardiogenic Shock Subset N=280 Mortality 28 day Dopamine 52% Norepinephrine 48.6% P = 0.03 Arrhythmic Events Dopamine 24% Norepinephrine 12% P < 0.001

How would you INTUBATE ? Awake vs. RSI? Induction agent and dose? Paralytic agent and dose? How would you prepare?

CHANGE IT UP A LITTLE Same Patient 86/ % 2L NP

What’s Your DDx? 1L Fluids Acute CHF Murmur

Papillary Muscle Rupture (MR) 7% of CS Inferior – Posterior 2-7d (can be acute) Acute Pulmonary Edema > 50% Mortality

Septal Rupture 4% of CS Anterior-Lateral 1d Sudden badness Holosystolic murmur Mortality > 80%

Free Wall Rupture 1.4% Anterior 1d Pericardial effusion/Tamponade > 86% Mortality

Case Summary Normal ECG excludes Cardiogenic Shock Center without PCI = Lytics on case by case basis NE > Dopamine (MAP 65) Reduce Induction doses / Pressors on board

58M 2 hr CP after hockey game Feels like old MI 2 years ago PMHx: Ischemic cardiomyopathy (EF = 30), DM, GERD Meds: ASA, Metoprolol, ACEI, Statin, Pantoprazole 110 NSR 172/92 98% 2L NP

Would you give LYTICS? (No old ECGs)

Bottom Line (non-sustained VT, PVCs, AIVR) Very Common (>50%) Does not lead to worse outcomes (VF/Mortality) No role for prophylactic treatment

Palpable pulse. Ischemic pain returns /82

What would you use to prevent another episode of VT or VF? 1)Amiodarone 150 mg IV over 10 min 2)Metoprolol 5 mg IV 3)Lidocaine 40 mg IV

Arrhythmias associated with higher Mortality (CO = SV + HR) Any Tachycardia (TOO FAST) Sinus Tachy SVT AF VT VF Blocks (TOO SLOW) 2 nd AV Block Mobitz II Complete BOTTOM LINE Fix the arrhythmia to maintain adequate CO

Develops another run of sustained VT Ischemic pain returns and he becomes altered 205, 172/76, 96% 4L NP

100J

200J

Amiodarone

360J Mg

STILL in VT: What’s your next step? 1)Shock him again at 360J 1)Repeat Amiodarone 150 mg 2)Consult Electrophysiologist 1)Amiodarone 150 mg + Metoprolol 5 mg 2)Procainamide 1000 mg

BETA BLOCKER

Case Summary Common Benign: non-sustained VT, PVC, AIVR Bad: Tachy and Brady Ventricular storm = Add a little Metoprolol to your Amiodarone

All right stop collaborate and listen Ice is back with my brand new invention Something grabs a hold of me tightly Flow like a harpoon daily and nightly Will it ever stop yo I don’t know Robert Matthew Van Winkle aka Vanilla Ice, 1989

43M White Rapper According to witnesses: ‘CP then collapsed‘ No pulse CPR by groupies at scene Rushed to FMC

PEA ROSC after 35 min. Still Unresponsive

Who should I consider for cooling? 1)43M witnessed arrest, PEA, CPR immediately, ROSC 35 min, unresponsive 2)70M witnessed pulseless VT arrest after MVA, ROSC 25 minutes, unresponsive 1)55M witnessed arrest VF, ROSC 25min, CPR within 5 min, uncontrolled VT, cardiogenic shock, unresponsive

Indications for Cooling Witnessed arrest & patient remains unresponsive CPR within 15 min ROSC < 60 min

HACA 2002 NNT 6

What about PEA & Asystole? ROSC > 25 min only 3% survive Studies show: PEA/Asystole associated with longer ROSC (32 min versus 20 min) Bottom Line: We need larger studies but for now talk to ICU/CCU

Absolute Contraindications Responds to verbal commands after ROSC Initial Temp < 30 on admission Comatose prior to arrest Pregnant Coagulopathic

Fastest method for cooling? NS Fridge 30ml/kg (2L) Pressure Bag 1C with every 1L ICE Axilla and Groin Goal 1)Start ASAP 2)33C in 6 hours

Shivering Fentanyl 50 mcg bolus then infusion AND/OR Midazolam 2-5 mg bolus then infusion Roc 0.6 mg/kg then 0.2 mg/kg PRN

How do we monitor in ED? MAP > 65 Temperature = Esophageal probe (EMcrit) VS q15min Glucose q1h ABG q2h Lytes q6h

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