C: CARDIOVASCULAR

cardio

In working through your ABCs, the C is for circulation. In the ER we need a rapid and systematic way of thinking about the different components of the cardiovascular system and the different emergencies related to them. Think of the CARDIOVASCULAR system, a mnemonic that reinforces pathophysiology–including electrical rhythm (C), pump (ARDIO), volume (VASC), and vascular tone (ULAR).

Cardiac arrhythmia

  • brady-arrythmias: sinus bradycardia (treat underlying), 1-3 degree AV block, SSS (pacer for high degree block and SSS)
  • narrow complex tachycardia: sinus tach (treat underlying), MAT, AF (rate vs rhythm control), AVNRT (vagal/adenosine), WPW (cardiovert)
  • wide complex tachycardia: VT (amio vs cardiovert), TdP (Mg, pacing, cardiovert)

Around heart: pericardial disease

  • pericarditis: acute inflammation of pericardium, presenting with pleuritic/position chest pain, often viral prodrome
  • Dx: ECG diffuse concave-up ST elevation, PR depression in all leads except PR elevation in AvR
  • Tx: NSAIDS, cochicine
  • complications:
    • purulent pericarditis from bacterial infection –> pericardiectomy, antibiotics
    • pericardial effusion (especially uremic, neoplastic or hemorrhagic) –> ECG low voltage/alternans, POCUS effusion +/- tamponade
    • myocarditis, causing arrhythmias, heart failiure –> supportive
    • constrictive pericarditis, resulting in heart failure –> diuresis +/- pericardiectomy

RV strain: PE

  • Wells criteria: Embolism history, Malignancy, Bed-bound, Oral blood cough, Leg symptom, Increase HR, Sign DVT, Most likely
  • beside: clear chest, ECG RV strain or precordial flipped T, POCUS dilated RV if large
  • diagnosis: leg doppler, CT chest
  • treatment: anticoagulate; tPA if massive/unstable; filter if refractory

Dysfunctional LV

  • chronic cardiomyopathy: hypertrophic (exertional syncope, ECG LVH+dagger Q waves), dilated, restrictive
  • acute: ACS: STEMI (ECG –> cath lab), NSTEMI (+trop –> admit), UA (increase symptoms –> admit); oxygen, nitro, aspirin, plavix
  • acute with normal coronaries: vasospasm, Takatsubo cardiomyopathy (after stress)

Incompetent valve

  • mitral stenosis: caused by rheumatic fever, present with SOB/hemoptysis/AF, hear loud S1
  • mitral regurg: caused by acute MI, chronic from RHD/MI/MVP, present with CHF, hear holosystolic to axilla
  • mitral valve prolapse: congenital, present with CP/palpitation/SOB, hear mid S click
  • aortic stenosis: congenital/RHD/degenerative, present with syncope/SOB/CP, hear systolic ejection murmur
  • aortic insufficiency: caused by trauma/dissect (acute), RHD/IE (chronic), present with CHF, hear diastolic murmur
  • tricuspid regurg: caused by PHTN, IVDV endocarditis, present with right-sided failure

Outflow: aortic dissection

  • traumatic or spontaneous (elderlly/hypertensive, connective tissue, cocaine)
  • sudden sever chest/back pain +/- end organ (inferior MI, stroke, ischemic gut, ischemic limb)
  • POCUS can sometimes see intimal flap; CXR can see widened mediastinum, double knob
  • CT diagnosis and classification: Stanford A (ascending) surgical treatment, Stanford B (descending) medical +/- surgical

Volume depletion

  • vomiting, diarrhea, fever, lack of intake

Abdominal bleed

  • GI bleed –> coffee grounds emesis, melena stool
  • intra-abdominal bleed, eg liver/splenic/ovarian hemorrhage –> POCUS free fluid

Soft tissue bleed:

  • AAA: abdo/back pain +/- shock, POCUS 3cm AAA, usually bleed into retroperitoneum
  • retroperitoneal bleed, eg anticoagulated patient
  • pelvic/femur bleed, eg trauma patient

Child-bearing: ectopic

  • risk: tubal infections/surgeries
  • wide variety of presentations: +/- pain, vag bleed, syncope
  • POCUS free fluid, no IUP (unless heterotopic)
  • treatment: surgical vs medical if stable

Urticaria: anaphylactic

  • 2 systems: airway, breathing, circulation, GI, derm
  • treatment: epi, fluids, steroids, antihistamines

Lactate: septic

  • source: airway, chest, cardiac, neuro, renal/pelvic, gi, derm, ortho
  • treatment: antibiotics, fluids, underlying

Adrenal crisis

  • sudden loss cortisol (adrenal hemorrhage, stopping chronic steroids), sudden increased requirement (adrenal insufficient + sepsis)
  • treat with hydrocortisone 100mg

Rx

  • intoxicants that reduce tone

 

This approach to the CARDIOVASCULAR system can help you at the bedside to focus your history, physical, bedside tests (ECG and POCUS), and further investigations.

  • C: ECG assess arrhythmia
  • A: URTI/uremic/cancer/connective tissue; hear rub/reduced heart sounds, ECG for pericarditis, POCUS for effusion + increase IVC
  • R: PE risk; ECG for PE, POCUS for RV strain + increase IVC, CT chest
  • D: cardiac risk; ECG for STEMI, POCUS for reduced LV + pleural effusion + increase IVC; trop
  • I: valve history; listen for murmur, POCUS for valvulopathy
  • O: POCUS for flap, CXR for widened mediastinum, CT chest
  • V: fluid loss history; POCUS reduced IVC and hyperdynamic LV
  • A: POCUS for free fluid, DRE for blood
  • S: history trauma/anticoagulated, POCUS for AAA
  • C: LMP; POCUS for free fluid and lack IUP
  • U: anaphylaxis 2 systems
  • L: septic source
  • A: steroid use
  • R: tox

 

cardiovascular

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