Cardiovascular

  • Abdominal Aortic Aneurysm
  • Acute Coronary Syndrome
  • Aortic Dissection
  • Cardiac Tamponade
  • Heart Failure Exacerbation

Abdominal Aortic Aneurysm

  • Background
    • An abdominal aortic aneurysm (often referred to as a ‘triple A’), is an abnormal dilation of the abdominal segment of the aorta. Smoking is a significant risk factor for development of this condition. As the aneurysm grows, there is an increased risk of rupture, which can be life threatening.
  • Signs/Symptoms
    • “AAA Triad” (Abdominal pain, hypotension, pulsatile abdominal mass), syncope
  • Diagnosis 
    • Ultrasound useful for initial detection (abdominal aorta > 3.0 considered aneurysmal). CT is better at identifying potential ruptures.
  • Treatment
    • If ruptured: maintain targeted SBP of 70-90 mm Hg and prep for immediate surgery. If non-ruptured: consult vascular surgery
Video Credit: Zero To Finals

*Deep Dive: Abdominal Aortic Aneurysm (Core EM)



Acute Coronary Syndrome

  • Background:
    • Acute coronary syndromes result from acute obstruction of a coronary artery. Consequences depend on degree and location of obstruction and range from unstable angina to non–ST-segment elevation myocardial infarction (NSTEMI), ST-segment elevation myocardial infarction (STEMI), and sudden cardiac death.
  • Signs/Symptoms: 
    • Chest discomfort (+/- dyspnea), nausea, and diaphoresis.
  • Diagnosis: 
    • ECG (ST-segment elevation/depression)
    • Troponin
  • Treatment: 
    • Initial treatment includes antiplatelets (aspirin and clopidogrel), pain control (nitroglycerin/morphine), anticoagulation (Heparin), beta-blocker (if no signs of heart failure), statin (high-dose atorvastatin).
    •  For STEMI, fibrinolytics and PCI are needed.
Video Credit: Armando Hasudungan

*Deep Dive: Current ED Management of NSTEMI (emDocs)



Aortic Dissection

  • Background
    • The aorta is the largest blood vessel of the body and carries blood away from the heart. An aortic dissection occurs when the lining of the aorta begins to separate. Type A dissections move towards the heart and are a surgical emergency. Type B dissections move away from the heart and may be managed with medication to control blood pressure and heart rate.
  • Signs/Symptoms
    • “Ripping/tearing” sensation, asymmetric pulses/BP 
  • Diagnosis
    • CXR (show widened mediastinum). CT or transesophageal echo confirms diagnosis.
  • Treatment
    • “Anti-impulse therapy”. Reduce BP and HR as low as tolerable using IV beta-blockers (ex. esmolol, labetalol) and nitroprusside (after HR controlled). 
    • Provide analgesia
Video Credit: Osmosis

*Deep Dive: Acute Aortic Dissection (Life in the Fastlane)



Cardiac Tamponade

  • Background
    • Cardiac tamponade is accumulation of blood in the pericardial sac of sufficient volume and pressure to impair cardiac fillings
  • Signs/Symptoms: 
    • “Beck’s Triad” (hypotension, muffled heart tones, and distended neck veins).  May present with chest pain and dyspnea
  • Diagnosis
    • Clinical diagnosis; ECG may show low QRS voltage, CXR will show enlarged cardiac silhouette. Ultrasound will show RV diastolic collapse.
  • Treatment
    • Pericardiocentesis
Video Credit: Armando Hasudungan

*Deep Dive: Cardiac Tamponade (PubMed)



Heart Failure Exacerbation

  • Background
    • Broad disease characterized by inadequate blood flow to meet metabolic demands. Heart failure can be right-sided or left-sided. Left-side heart failure is further categorized into heart failure with reduced ejection fraction (HFrEF or “systolic failure) or heart failure with preserved ejection fraction (HFpEF or “diastolic failure”)
  • Signs/Symptoms
    • Largely depends on type of HF. Left-sided HF typically causes SOB, fatigue, orthopnea, rales/crackles on lung sounds. Right-side HF typically causes pitting edema, abdominal fluid accumulation, and JVD
  • Diagnosis
    • Mostly clinical; BNP will be elevated, CXR may show cardiomegaly and effusions. Cardiac ultrasound is the most useful diagnostic tool.  
  • Treatment
    • Fluid overload and pulmonary edema can be managed with CPAP/BPAP, nitroglycerin, and furosemide. Hypotension can be managed with norepinephrine
Video Credit: Osmosis

*Deep Dive: Acute Congestive Heart Failure (EM Cases)



Brandon Simpson, PA-S2
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