Pre-hospital management of Cardiovascular disorders in

our perspective

Prof A.K.M. Rafique uddin Professor and Head

Department of Medicine Enam Medical College and Hospital

Our perspective

• Population density : 964/km2

• M:F – 100.3: 100

• Population 14 crore 79 lac (2010 – 2011)

• Current national population growth 1.35%

• Hospital bed 1 for 1860

• Registered doctors - 1 for 2785

• Per capita income – 818 US dollar

• Per head GDP – 692 US dollar

Our perspective Continued..

The proposed Tk 8889 crore in national health

budget 2011 is too little for over 150 million of people.

The per capita allocation in healthcare is Tk 590 or

$7.5 per year per person.

In USA, health budget is 8,047 US dollar per person

& In UK, 3713 US dollar per capita per year.

Our perspective Continued..

• The media of education is English.

• Their education and management level is much advanced which is beyond the reach of our poor people.

• Our doctors are even unable to understand many of the symptoms which are expressed in colloquial language .

Cont.

• The majority of deaths from coronary disease occur in the pre-hospital phase and most victims do not get any medical support.

Cont.

• In the western countries every citizen is trained with Basic Life Support(BLS)

• But in Bangladesh , even the graduate physicians are not well trained with this BLS.

Cont.

Pre-hospital personnel

Physician

Paramedical staff

Non-trained personnel

Presentation of CV Disorders

• Sudden cardiac Death

• Acute Chest Pain

• Angina

• MI

• Syncopal attack

• Shock

• Dyspnoea

• Passive Venous Congestion(CCF)

• Palpitation

• Peripheral Thrombo-embolism

• Vasculitis

• Congenital Heart Disease

• Rheumatic fever

• Haemoptysis

• Prolonged pyrexia

• Thrombophlebitis

• Cardiac Neurosis

• Asymptomatic

Presentation of CV Disorders Continued..

Sudden cardiac Death

• Sudden and complete loss of cardiac function in apparently healthy person.

• Diagnosed by- Loss of consciousness Cessation of respiration Absence of pulse

Management

• Should be started very promptly within minutes. If delayed by more than 3 minutes, there will be permanent brain damage.

In abroad

In Bangladesh

Pre-hospital Management

• Precordial Thump

• A- Airway clearance

• B- Breathing

• C- Cardiac message

• D- Drip, Drug and Defibrillation

Cardio-pulmonary Resuscitation………Continue

Acute Chest Pain (Angina/MI/Angina equivalent)

Chest pain or discomfort in or around the chest due to myocardial hypoxia secondary to inadequate coronary blood flow which usually aggravates by exercise and relieved by rest or GTN.

Diagnosis

• Any symptoms over chest, neck or upper abdomen

• Nausea, vomiting related with exertion

• Features of sympathetic over-activity e.g sweating, palpitation and breathlessness

• Features persisting more than 20 minutes considered as serious cardiac damage i.e MI

Drugs

Sublingual nitroglycerine

Aspirin

Iso-sorbide mono and di-nitrate

Negative inotropic drugs e.g beta –blockers ,calcium channel blockers

• After amelioration of the symptoms patient should be transferred to hospital for further evaluation and management.

Myocardial Infarction

• Absolute bed rest

• High flow oxygen ?

• Analgesic e.g. pethedine (should be avoided)

• Thrombolytic agents if the patient encounters within 6 hrs

Continued..

Continued..

• Aspirin

• Coronary vasodilators

• IV channels

• Treatment of complications

Syncopal attack

Transient loss of consciousness due to inadequate cerebral blood flow.

D/D

• True Syncope

• Hysterical Conversion Reaction

• Malingering

Pre-hospital management

• Lying down the patient with raising the foot-end

• Majority patients specially younger and in situational syncope , do not require any evaluation.

• For other patients, specially elderly and recurrent attack further evaluation should be done and referred to specialized centre for better management.

Shock(Acute Circulatory Failure)

Inadequate tissue perfusion due to disproportional distribution of circulatory volume and circulatory bed characterized by restlessness, confusional state, profused sweating ,low thready rapid pulse and unrecordable BP.

Pre hospital Management

• If hypovolaemic- fluid is mandatory

• JVP should be the guideline

– If supraclavicular fossa full

– then possibility of cardiogenic shock

• Give pressure amine

• Transfer to hospital in a proper way.

Cont.

• Treatment of underlying causes e.g. control of haemorrhage, control of infection by antibiotics

• Treatment of complications

Renal failure

Dyspnoea

• One of the principal presentation of Left Ventricular failure , acute pulmonary edema and ARDS.

• Diagnosed by Short history Known cardiovascular disorders e.g. Myocardial infarction , Hypertension, Valvular

disease

DIAGNOSIS

Pulsus alternans or arrhythmias

BP - hypertension

Shifting of apex beat

Bilateral basal crepitation

Gallop rhythm

Cardiac murmurs

Management

• Propped up posture

• O2 inhalation !

• Sedation

• Diuretics - frusemide

• Salbutamol inhaler or nebuliser if associated brochospasm

• Vasodilators

• Beta blockers

• Digoxin …?

After amelioration of the symptoms patient should be transferred to hospital for further evaluation and management.

Passive venous congestion(CCF)

• Oedema

• Ascites

• Hepatomegaly

Diagnosed by History of-

• Known cardiovascular disorders

• Breathing difficulties prior to presenting features

Signs

• Dependent oedema

• Enlarged tender liver

• JVP

• Pulse abnormalities

• Apex

• Cardiac murmur

• Exclusion of other causes e.g ascites and oedema

Management

• Diuretics

• Vasodilators

• Digoxin

• Treatment of primary cause

• Further evaluation by ECG, X-Ray, Echo cardiogram etc.

Palpitation

• It is the awareness of heart beat.

• Very common presentation of cardiac as well as non-cardiac disorders.

Diagnosed by-

• cardiac disorders diagnosed on following basis-

Pulse e.g >140 beats/min Apex beat Cardiac murmurs

• Suddenness of appearance and disappearance

• Confusion with panic attack

Management

• Tachyarrythmias

Valsalva maneuver

Carotid massage ( uni -lateral)

Drugs e.g

b- blockers , verapamil , digoxin

Defibrillation

Brady-arrythmia

• Efforts should be made by- Anti- cholinergic drug e.g atropine,propantheline Sympathomimetic drugs e.g. aminophylline • Refer to hospital for further evaluation and

management

Peripheral Thrombo -embolism

Diagnosed by-

Sudden severe pain in limbs or in any target organs

Absence of pulse of involved regions having cardiac abnormalities

Management

• Rest

• Aspirin

• Low molecular wt. heparin(s/c)

• Avoidance of risk factors

• Transfer to hospital in a proper way.

Vasculitis

Diagnosed by

Intermittent claudication

Raynaud’s phenomenon

Ulceration

Gangrene

Treatment

• According to cause

• Symptomatic treatment

Vasodilators

Avoidance of preciptating

factors

Congenital heart disease

• Cyanotic spell

-Recurrent episodes of convulsion associated with cyanosis in case of congenital heart disease

• Recurrent Respiratory tract infection

• Failure to thrive

• Presence of murmur

Management

• Squatting posture

• Propranolol

• Treatment of recurrent RTI

• Refer to hospital

Surgical correction

Rheumatic fever

• 5 major criteria- Migratory polyarthritis

Carditis

Sydenhams chorea

Erythema marginatum

Rheumatoid nodules

• Minor criteria Arthralgia

High fever

High ESR

CRP

Prolongation of PR interval

Diagnosis

2 major criteria or 1 major and 2 minor criteria

plus

evidence of streptococcal infection e.g raised ASO titre ,positive throat swab culture

Management • Rest

• Aspirin

• Steroid, if there is carditis

• In acute case- Inj Benzyl Penicillin 1.2 Million unit single dose or Oral phenoxymythylpenicillin 250 mg 6 hourly for 10 days

Prophylaxis

• Benzathine penicillin

• Phenoxy methyl penicillin

Haemoptysis

• Could be a presentation of

Mitral Stenosis (MS)

Pulmonary infarction

Acute LVF

• Diagnosis

In case of Mitral stenosis, murmur

Presenting condition for Pulmonary infarction e.g prolonged immobilisation, post-operative state

• Treatment

Antibiotic

Treatment of cause

Prolonged pyrexia • One of the important presentations of

Bacterial endocarditis

• Diagnosis should be suspected in a patient having cardiac lesions

Not responding to conventional anti microbial treatment

Exclusion of other causes of PUO

Treatment

• Identification of bacteria by blood culture

• Administration of at least two antibiotics e.g Flucloxacillin and Gentamicin for 4-6 wks

• Treatment of complications and treat according to the patient’s symptom.

Thrombophlebitis

• Diagnosed by Unilateral leg oedema, pain,fever

• Management Antibiotics

Rest

Anti-coagulants

Asymptomatic Cardiovascular disorders(incidental findings)

• Hypertension

• Valvular lesions

• Cardiomegaly

• Radiological or ECG abnormalities

Management

If asymptomatic no treatment but

time to time observation for any complication but patient should be informed and reassured.

Asymptomatic hypertension

• Hypertension is a common incidental finding.

• Diagnosis should be established by recheck.

• Proper measurement of BP is essential for diagnosis and should be repeated 5-10 minutes apart in a single setting and should be recorded at the last phase of examination.

Management

• Non-pharmacological Weight reduction

Avoidance of smoking

Relaxation

Exercise

Salt restriction

Pharmacological

Depends on TOD and ACC

Diuretics e.g thiazides

B- blockers, Ca Channel blockers

Combination of above two

ACE inhibitors

Vasodilators

Centrally acting sympatholytic drugs

Cerebrovascular Accident

Sudden neurological deficit with or without loss of consciousness due to cardiovascular abnormalities.

Diagnosis • Suddenness

• Having known cardiovascular disorders e.g HTN, MI, Valvular diseases

Other risk factors

No other precipitating causes of neurological dysfunction e.g drug, head injury

Management • General management of an

unconscious patient

Care of mouth, eyes, skin

Care of pressure sore

Care of airway

Fluid balance

Cont..

Care of bowel and bladder

Physiotherapy to protect muscles and joints contractures.

Monitoring

Control of infection

• Specific treatment To control BP ,DM and other

precipitating causes

Cardiac Neurosis Patient used psedomedical terms as a

complain, like

Low pressure

Heart Attack

Heart Disease

Heart fail e.t.c.

Management:

A good rapport with the patient and Reassurance and explanation

Conclusion

• Teaching should be problem based not on topic based.

• Doctors must be competent enough to address the cardiac emergences like Sudden Cardiac Death, Syncope or Dyspnoea at local setup promptly.

• They must learn when, how, where to refer after settling the acute condition.

Conclusion

• Doctors should be capable enough to individualise each patient and their local clinical facilities and feasibility of transportation to higher centre.

• BLS management training should be compulsory to all Doctors, paramedics.

• We also recommend basic life support management training should be included in general education.