CARDIOVASCULAR

EMERGENCY
Dr. Tri Wisesa Soetisna, SpB TKV (K)
 Cardiovascular Emergency

Trauma Non Trauma

- Penetrating - Congential Heart Disease
- Blunt - Acquired Heart
Disease
Penetrating trauma

Cardiac Wall
Blood Vessel Rupture
Cardiac Septum
Cardiac Valve

Bleeding
Tamponade
Hemodinamic Disturbance

Shock

+
Penetrating Heart Injury
• Wilson et al 1975 : inhospital mortality rate > 50 %
• Bodai ( 1983) : prehospital mortality 38 – 83 %
• Paul Tahalele 1985 - 89: inhospital survival 91.2% (12)
• Wuryantoro ( 1989 ) : inhospital mortality 0% (6)
• Djoko J : inhospital mortality 50 % (4)

Factor that contribute for the success in Management of

Penetrating Heart Injury :
1. first aid in the location
1. Send patient to hospital with thoracic cardiovascular
surgery fascility immediately
2. Definitive Treatment in Hospital
 First Aid in Location Give a
• Nothing Per Oral
• Don’t do external cardiac massage
• Don’t draw a sharp matter from patient

Send Patient Imediately

HOSPITAL
 Transportation to Hospital
• Placed the patient in supine position
• Fluid Resuscitation Immediately (Electrolite Solution)
• Contact the Hospital for Preparing

In Hospital

1. Rapid and accurate diagnosis

2. Manage pericardial tamponade
3. Control the bleeding
4. Blood transfusion
High index of suspicion
• Trauma mark
• Unstable condition
• Tamponade
from 200 cases :
- 63 cases (31,5%) tamponade
- 26 cases (13%) complete Trias
Beck
 Cardiac Tamponade
• Blood in the pericardial sac
• Most frequently penetrating injuries
• Shock, ↑JVP, PEA, pulsus paradoxus
• Classically, Beck’s triad:
– - distended neck veins
– - muffled heart sounds
– - hypotension
• Rx: Volume resuscitation
Pericardiostomy
Cardiac tamponade
 Cardiac Injuries

• The right ventricle is most commonly injured,

followed by the left ventricle
 Definitive Treatment
• Cardiac Tamponade
Pericardiotomy
Thoracotomy
• Control a Bleeding

• Stop a Bleeding
* Sampai 1881 - 1897 hanya perikardiosentesis
Robert, Wiliams, Rehn berhasil menjahit jantung yang luka
* Sampai 30 - 40 tahun kemudian kardiorapi banyak dianut.
1930 Blalock & Ravitch melaporkan keberhasilan perikar-
diosentesis. Sejak itu terapi jadi kontroversial
* Pengalaman Wilson, et al, 1975 dengan kardiorapi selama
20 tahun dengan survival rate: * 83% pada 173 penderita
luka tusuk dan * 74% pada 27 penderita luka tembak.
Ini menyokong tindakan torakotomi segera dan kardiorapi
Chest wall Incision for Emergency Thoracotomy
 Bleeding controle

Foley Catheter Finger pressure

CARDIORRAPHY
 Complication

• Coronary Laceration
• Septal Defect
• Conduction System Damage

PITFALL8 :
Arrythmias could occured if large
coronary laceration is not repair
 Blunt Cardiac/Great Vessel
Injuries

• Myocardial contusion is the

most common cardiac injury
and is suspected with EKG
changes and serial enzyme
elevations
 Blunt Cardiac/Great Vessel
Injuries
• Coronary artery injury can result in thrombosis
and myocardial infarction

• The patient should be monitored in the ICU and

may require heparinization for coronary
thrombosis and anti-arrhythmic therapy

• Echocardiography and angiography are

indicated for tamponade and post-injury
murmurs, which suggest valvular
insufficiency or septal defect
Post Operative Management

* Broad Spectrum anti biotic

* Standart elective post cardiac surgery
* Chest physio therapy
* Early mobilisation
* 24 % of reccurent pericardial effusion
 Aortic rupture
• Blunt trauma involving deceleration forces
• 90% mortality on sites of accident
• 90% mortality before optimal management at
the ER (with in minutes)
• Most common site near ligamentum
arteriosum
• Dx: clinical suspicion, CXR,
aortography,contrast CT or TEE
Aortic rupture
 Aortic rupture
• Weak leg pulses with hypertension in
the arms, or a new murmur.

• 1st or 2nd rib fractures

• A widened upper mediastinum,
deviation of the trachea, a “pleural
cap,”
widening mediastinum
• Rx: surgical…poor prognosis
Aortic rupture
 Cardiac/Great Vessel Injuries
• Aortic rupture is also usually fatal, but can result
in formation of a false aneurysm, typically at the
aortic isthmus

• Patients with a widened mediastinum on CXR

should have prompt aortography, which will
demonstrate an intimal tear

• Surgical repair should be done promptly, as

fatal hemorrhage can occur at any time
Classification
 Cardiac/Great Vessel Injuries

• CXR, EKG, and echocardiography have little

diagnostic value in these patients

• Subxiphoid pericardiotomy is useful for diagnosis;

negative deflection of the QRS complex indicates
contact with the epicardium and a drain should be
left in place

• Subxiphoid pericardiotomy is preferred for

tamponade, however, and should be performed in
the operating room, as the patient may rapidly
exsanguinate
TAVARES

ERT mortality rate 43 % (37 )
1. No sign of life /
ERT no vital sign
2. Hypotensive / BP systolik < 90 mmHg, shock,
unconciousness, respiratory distress
ERT /OR
3. Normotensive ( BPs > 90 mmHg ) concious,
adequate breating
OR

Djoko J : thoracotomy:
1. Immediate ( emergency ) thoracotomy for
resusciatation
2. Early thoracotomy, first 24 hours
3. Late thoracotomy, > 24 hours
 Congenital Heart Disease
• Cyanotic
• Respiratory distraess
tachypnea
• Tachycardia
• Enlargement heart
• Systolik mur mur, thrill
• Sign of acute congestive heart failure

Hospital
 Hypoxic Spell
• Inadequate Pulmonary Blood Flow
• CHD :
– Tetralogy of Fallot
– Pulmonary Stenosis
– Pulmonary Atresia
• Sign of Severe Systemic Hypoxia
,Cyanosis, provoke by severe activity / cry
/ acidosis (severe diarrhea/dehidration)
 Hypoxic Spell
• Management :
– Stop activity that provoke hupoxic
spell
– Put the patient in knee chest
position
– Oxygen
– Rehidration (IV fluid)
– Medical
Surgical
 Congestive Heart Failure
• < 6 month of Live
• CHD :
– L
R shunt (ASD,VSD,PDA,AVSD,APVD)
– TGA, HLHS
– Coarctation
– Valvular (severe AS)
• Sign :
– Feeding difficulty
– Reccurent Respiratory Track Infection
– Failure to thrive
Heart Failure
PRE LOAD
- INTRAVASCULAR VOLUME

CONTRACTILITY
- CAD
- TAMPONADE
- CHRONIC / COMPLEX VALVULAR
(THROMBUS FORMATION)
- ARRYTHMIAS
- MYXOMA

AFTERLOAD
- HYPERTENSION

OTHER
- TENSION PNEUMOTHORAX
- ACUTE PULMONARY EMBOLISM
- CHRONIC LUNG DISEASE
 Heart Failure
CONSERVATIVE
-BEDREST
-OXYGEN
-LOW SALT DIET
-FLUID RESTRICTION

MEDICAL
-DIGITALS
-DIURETIC
-ACE inhibitor
-THROMBOLYSIS
- ANTIARRYTHMIAS

DEFINITIF / SURGICAL
-PERICARDIOTOMY
-CABG
-CARDIOMYOPLASTY
-VALVE REPLACE/REPAIR
-ARTERECTOMY
-ABLASION
ACS
 Acute Myocardial Infarction

Arrythmia Hemodynamic Complication Unstable Angina

- Sinus Tachycardia - myocardial rupture
- Bradycardia - ventricle aneurysm
- Block - septal rupture
- severe mitral regurg

Medical

Medical Therapy Emergency or IABP

Pace maker implantation Cito Operation

PTCA
Cito CABG
ST elevasion
 Acute Myocardial Infarction
16

14

12

10

0
<6h 6 – 23 h 1–3d 4–7d 8 – 14 d > 15 d
THANK YOU