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Matters of the Heart Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, SBCFD, Mercy Air, BFD
WHY HOLD THE LASIX? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute SOB ,[object Object],[object Object],[object Object],[object Object],[object Object]
Acute SOB ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute SOB ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Acute Pulmonary Edema ,[object Object],[object Object],[object Object]
Acute Pulmonary Edema ,[object Object],[object Object],[object Object],[object Object]
Preload Reduction ,[object Object],[object Object],[object Object]
Morphine as Preload Reducer ,[object Object],[object Object],[object Object],[object Object],[object Object]
Trunk Monkey and Dating
Morphine Swan Studies ,[object Object],[object Object]
Lasix ,[object Object],[object Object],[object Object],[object Object]
Nitroglyercin ,[object Object],[object Object],[object Object]
Nitroglyercin How do our treatments Stack up? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ace Inhibitors ,[object Object],[object Object],[object Object],[object Object]
WHY HOLD THE LASIX? ,[object Object],[object Object],[object Object],[object Object]
WHY HOLD THE LASIX? ,[object Object],[object Object],[object Object],[object Object]
What about CPAP or BIPAP? ,[object Object],[object Object],[object Object],[object Object],[object Object]
Trunk Monkey and ticket advice
[object Object],[object Object],[object Object]
He died from this
This is what I Look Like
[object Object],[object Object]
Answer: Aortic Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object]
Who Am I?
Jonathan Larson ,[object Object],[object Object],[object Object],He had presented to the ED twice in the week before his death
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Answer:  E
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Answer:    C- Helical CT chest scan
Imaging Ct with contrast is Ideal (can try without if unstable or renal insuffiency) TEE Angiography No longer gold standard- only looks at changes at Inside lumen…CT is better
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Always Consider Aortic Dissection
Recognizing Aortic Dissection
Trunk Monkey pediatrics edition
CXR How Sensitive is it? ,[object Object]
CXR Classic Findings ,[object Object],[object Object],[object Object],[object Object]
CXR Dissection
CXR Dissection
CXR Dissection
EKG ,[object Object],[object Object],[object Object]
Incidence ,[object Object],[object Object],[object Object],[object Object]
Always Think about the 6 Major causes of Chest Pain Badness! ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fast Facts About Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Fast Facts ,[object Object],[object Object]
Atypical / Subtle Presentations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
D-dime r to r/o dissection? ,[object Object],[object Object],[object Object],[object Object]
Atypical / Subtle Presentations ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Myth ,[object Object],[object Object]
34 year old construction worker with sudden onset back pain - discharged home with motrin Tall 28 year old with Chest Pain as he is being discharged the attending happens to ask have you had any surgery before… prior eye surgery
 
[object Object]
Trunk Monkey chasing bad eggs
[object Object]
[object Object],Classification
[object Object],Classification
Classification of Aortic Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Class 1: Classic dissection
Aortic Dissection
    Intramural Hematoma ,[object Object],[object Object]
Intramural Hematoma
Class 2: Intramural hematoma
Initial Medical Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object]
Trunk Monkey delivers first aid
Intial Treatment Type A Urgent surgical intervention is required in type A dissections The area of the aorta with the intimal tear usually is  resected and replaced with a Dacron graft The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased Dissections involving the arch are more complicated that those involving only the ascending aorta because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10% Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future
Initial Treatment of Type B Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Initial Treatment of Type B Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Mechanisms Involved in Aortic Dissection Type B ,[object Object],[object Object],[object Object],[object Object],[object Object]
Prognosis ,[object Object]
Trunk Monkey encounters aliens
THANK YOU   ,[object Object],[object Object],[object Object],[object Object]

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Matters heart armc 7 11-2011

  • 1. Matters of the Heart Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, SBCFD, Mercy Air, BFD
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  • 19. Trunk Monkey and ticket advice
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  • 21. He died from this
  • 22. This is what I Look Like
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  • 30. Answer: C- Helical CT chest scan
  • 31. Imaging Ct with contrast is Ideal (can try without if unstable or renal insuffiency) TEE Angiography No longer gold standard- only looks at changes at Inside lumen…CT is better
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  • 50. 34 year old construction worker with sudden onset back pain - discharged home with motrin Tall 28 year old with Chest Pain as he is being discharged the attending happens to ask have you had any surgery before… prior eye surgery
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  • 58. Class 1: Classic dissection
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  • 65. Intial Treatment Type A Urgent surgical intervention is required in type A dissections The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with this highly invasive surgery have decreased Dissections involving the arch are more complicated that those involving only the ascending aorta because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10% Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future
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Notas do Editor

  1. Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
  2. Figure 2a.    (a) Schematic of aortic layers in typical aortic dissection shows a tear of the intimal layer, which has resulted in the formation of two lumina (one false, one true). (b) Photograph of an autopsy specimen shows a Stanford type B aortic dissection. An intimal tear (arrows) and intimal calcifications (arrowheads) are clearly visible in the descending aorta.
  3. Figure 10a.    (a) Schematic of aortic layers in IMH shows a hemorrhage within the media but no intimal tear. Red dots inside the media represent the vasa vasorum. (b) Photograph of an autopsy specimen reveals hematoma (*) within the media, between the intima (held in place by a surgical clamp) and the adventitia (arrow). There is no evidence of intimal tear.