0071643192.pdf

CARDIOVASCULAR EMERGENCIES

FIGURE 2.10. Osborn wave or J wave, indicating hypothermia.

(Reproduced, with permission, from Tintinalli JE, Kelen GD, Stapczynski JS. Emergency
Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill, 2004:1180.)

The charge nurse calls for you to examine a patient who was given sublin-

gual nitroglycerin 2 minutes earlier. The 49-year-old male presented with

acute onset of chest pain with shortness of breath and diaphoresis. His BP

is now 80/50 after the administration of the nitro (initial BP 110/70). Review of

the initial ECG reveals ST elevation in II, III, aVF and in lead V 4 on the R-sided

ECG (V 4 R). What is the most appropriate initial therapy for his hypotension?

The ST elevation in lead V 4 R indicates RV extension of his inferior MI. These

patients are often very preload dependent, so nitroglycerin will exacerbate the sit-

uation. Start a normal saline bolus to increase preload. Multiple fluid boluses may

be required.

ACUTE CORONARY SYNDROME (ACS)

ACS represents a spectrum of ischemic heart disease from stable angina to non-
ST segment MI (NSTEMI) and ST segment elevation myocardial infarction
(STEMI).

Stable angina--------------------Unstable Angina--------------------NSTEMI--------------------STEMI

ACS

Stable Angina

Stable angina represents the beginning of ACS, when a fixed coronary plaque
prevents sufficient blood supply through coronary artery at times of increased
O 2 demand. This results in ischemic symptoms, but does not cause infarction.

Stable angina is resolved by alleviating the increased O 2 demand (eg, resting,
blood transfusion) or increasing the blood supply through vasodilators such
as nitroglycerin. Symptoms usually last only a few minutesafter cessation of
activity or use of nitroglycerin.

Coronary heart disease is the

number one cause of death in

the United States, with over

500,000 victims annually.