cardiac_emergency_1

Max

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Hamsini YagneswarBVSc DVM DACVECC MRCVS

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5yr MN Mixed-Breed dogNo previous medical history.Emergency appointment for vomiting and breathing difficulty

Max

case-based simulation

Physical exam

Lab

Imaging

Therapeutics

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Admin

Carer

Procedures

Discharge

Treatment

1

2

3

Diagnostics

4

5

Clinical Exam

History

How should we start?

Discharge

Definitive care

Initial care

History

Triage

Physical exam

Lab

Imaging

Therapeutics

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Admin

Carer

Let's get an x-ray

What is his diet?

Let's do a physical exam

Procedures

And his breathing is very fast now. I though maybe he was feeling hot

Vomiting? Yes, I think he vomited at least two times

Something is very wrong with Max...

He hasn't eaten anything in 5 days. He's very weak.

Hello, doctor

Physical exam

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Imaging

Therapeutics

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Procedures

pale mucous membranes with a CRT ~2 sec

Difficult to hear heart sounds but sounds very fast

Cold extremities

Loud lung sounds, no crackles or other unusual bronchovesicular sounds

Pulses sometimes strong and synchronous with heart beats but sometimes difficult to palpate Pulse rate is very fast - more than 150 I think

Abdomen feels very distended. There is also a fluid thrill

Jugular veins look distended and seem to be pulsating

Physical exam

Lab

Imaging

Therapeutics

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Admin

He has a respiratory problem

Carer

He has a cardiovascular problem

Procedures

Is he ok, doctor?

I'm going to take him to the treatment room to check his vitals

Please make yourself comfortable here. I'll be back as soon as I can

T: 38.2C PR: 156 bpm RR: 60bpm (panting) BP: 90/62 (73) mmHg sPO2: 99% ECG:

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Lab

Imaging

Therapeutics

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Procedures

POCUS

X-ray

CT scan

MRI

Scope

What bloods do you want?

Blood gas

Chemistry

CBC

Blood smear

PCV/TS

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Lab

Imaging

Therapeutics

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What's your diagnosis?

Admin

Pericardial effusion with secondary right diastolic failure

Problem summary

• pleural, pericardial effusion
• GI, ALT, urea

Obstructive shock

• pulsus paradoxus
• panting?

Interventricular depedence

Physical exam

Lab

Imaging

• right chambers
• cardiac output
• chronic?

Therapeutics

Cardiac tamponade

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• Lethargy
• Vomiting

• Dyspnea

Admin

Presentation

Carer

Pericardial Effusion

Procedures

+ info

+ info

+ info

+ info

+ info

Physical exam

Lab

Imaging

Therapeutics

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Procedures

What is causing all this, doctor?

What is causing all this, doctor?

There are a few possibilities...

How can we find out what is going on?

Physical exam

Lab

Imaging

Therapeutics

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Admin

Carer

Procedures

I have a checklist to help you!

Sedation and emergency drugs

Culture

Cytology

PCV/TS

Physical exam

Lab

Imaging

Therapeutics

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Carer

Procedures

Physical exam

Lab

Therapeutics

Imaging

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Admin

Carer

Procedures

What is causing all this, doctor?

So, he doesn't have cancer right?

My recommendation is...

Based on the echo and the fluid...

What about a CT or MRI?

Physical exam

Lab

Imaging

Therapeutics

Get help

Admin

Carer

Procedures

Bye, Max

thank youhope that was helpful!

Got questions?

Thoracotomy + sub-total pericardectomyPost-op care with chest tube x 2-3 days>70% survival rate for >18 months (1218 vs 538 days)

Surgery

• Recurrence rate: 9% in 1 yr+
• Tumor spread
• Pleural effusion - concern for mesothelioma for at least 6 months?
• Thorascopic procedure?

(Case et al., 2013; (Mayhew et al., 2018, Johsnon et al, 2004) .

Oxygen (flow-by)

Therapeutics

LRS

Invasive ventilation

NS

Fluids

Dextrose

Colloids

Amoxiclav

Metronidazole

Antibiotics

Enrofloxacin

Doxycyline

Opioids

Meloxicam

Analgesia

Ketamine

Gabapentin

Diuretics

Pimobendan

Cardiac meds

ACEi

Anti-arrhythmics

Whole blood

pRBC/Plasma

Transfusion

Dexmedetomidine

Midazolam

Other

Steroids

Tranexamic acid

Effect on right heart: - increased RA pressuresEffect on left heart: - reduced preload, increased afterload = reduced CO

Obstructive and hypovolemic shock

Systemic circulation: - concurrent hypovolemia- RAAS activation- shock

Sinus tachycardia

Not better than echoScreening for metastasis or extracarsiac lesionsGuide biopsy or surgical procedures

CT

Not better than echoMass description

Cardiac MR

VS

(Reetz et al., 2019, K.F.Scollan et.al., 2015) .

(K.N.Boddy et al., 2011; 8 cases

Please can you place an IV catheter?

IV cath

Can you take bloods through the catheter?

Bloods

Please can you bring the ultrasound and gel?

Ultrasound

Not better than echoScreening for metastasis or extracardiac lesionsGuide biopsy or surgical procedures

CT

Not better than echoMass description

Cardiac MR

VS

(Reetz et al., 2019, K.F.Scollan et.al., 2015) .

(K.N.Boddy et al., 2011; 8 cases)

Angiocath or long Jelco catheter18G - 20GUS-guided entry if needed

Catheter

3-way catheter + extension lineClosed sterile collection unitSave sample for clot test and fluid analysis

Suction

Collect into a bag or mugMeasure volumePericardial decompression syndrome

Collect

Evidence of hemorrhage.No infectious agents or atypical cells visualized.

Oxygen (flow-by)

Therapeutics

LRS

Invasive ventilation

NS

Fluids

Dextrose

Colloids

Amoxiclav

Metronidazole

Antibiotics

Enrofloxacin

Doxycyline

Opioids

Meloxicam

Analgesia

Ketamine

Gabapentin

Diuretics

Pimobendan

Cardiac meds

ACEi

Anti-arrhythmics

Whole blood

pRBC/Plasma

Transfusion

Dexmedetomidine

Midazolam

Other

Steroids

Tranexamic acid

CBC

Lab tests available

Chemistry

Electrolytes

PCV/TS

Blood smear

Blood gas

Baseline cortisol

GI panel (TLI, Folate, B12)

Urinalysis + culture

Fluid cytology + culture

FNA cytology

Microbiology

NT-ProBNP

Cardiac troponin-I

Thyroid panel

Coagulation panel

Oxygen (flow-by)

Therapeutics

LRS

Invasive ventilation

NS

Fluids

Dextrose

Colloids

Amoxiclav

Metronidazole

Antibiotics

Enrofloxacin

Doxycyline

Opioids

Meloxicam

Analgesia

Ketamine

Gabapentin

Diuretics

Pimobendan

Cardiac meds

ACEi

Anti-arrhythmics

Whole blood

pRBC/Plasma

Transfusion

Dexmedetomidine

Midazolam

Other

Steroids

Tranexamic acid

VHS: > 11.9 for lateral and > 12.3 for ventrodorsalSphericity Index (SI): ≤ 1.17 for globalVery poor accuracy in tamponade

X-rays

Finding a mass: Mass Types: Metastasis: 50%-60% in both types

Echocardiogram

VS

(Guglielmini et al., 2012; Cote et al., 2013) .

(MacDonald et al., 2009; 107 cases

Specificity

Right atrial

Heart-based

Sensitivity

98% - 100%

74% - 82%

Neuroendocrine tumors or ectopic thyroid gland tissue. Others: (hemangiosarcoma, mesothelioma)

Hemangiosarcomas predominantly. Other (neuroendocrine tumors, ectopic thyroid gland tissue, mesotheliomas, lymphosarcomas, and sarcomas)

35 months at least if echo-negative Poor if masses Mesothelioma?If all is good - surival expected > 3 yrs

Prognosis

ActivityDietMonitoringMedications

Discharge care

Look at Max now!

Follow-up

16 days without treatment 46 days with pericardiectomy and tumor resection 164 days with pericardiectomy, tumor resection and chemotherapy Chemodectoma: better, but recurrent effusions (730days)

Could still have mestholioma - Max's biopsies were negative! Watch for 6 monts- could develop malingant pleural effusion from mesothelioma If happens - MST around 13 months?

- sinus tachycardia- mild regenerative anemia- acute vomiting

- Tricavitary effusion - pericardial effusion with cardiac tamponade - hypotension - incr urea, ALT - clinical signs of pulsus paradoxus and jugular venous distension

Problems

• No cardiac lesions or heart-based masses noted
• Large volume pleural and peritoneal effusion remains, mild pericardial effusion remains
• Sternal and mediastinal lymphadenomegaly noted.

CT Scan report for Max

- Abdominal Distension: Indicates potential abdominal effusion (Baisan et al., 2013)- Muffled Heart Sounds: Dimmed cardiac sounds during examination (Baisan et al., 2013).- Tachycardia: High cardiac frequency on ECG noted in affected dogs (Baisan et al., 2013).- Vomiting: Present in 51% of cases (Fahey et al., 2017).

- Dyspnea: Severe difficulty breathing noted (Haritha, 2019). - Exercise Intolerance/Lethargy: Common symptoms associated with pericardial effusion (Fahey et al., 2017). - Weakness/Collapse: Observed in dogs with pericardial effusion (Fahey et al., 2017). - Coughing: Frequently reported in cases of left atrial rupture (Reineke et al., 2008). - Syncope: Possible sign of pericardial effusion (Haritha, 2019).

Spectrum of clinical signs in pericardial effusion

No growth on aerobic and anerobic culture

Cardiac-Associated Tumors1. Hemangiosarcoma2. Heart-Base Tumors- Chemodectoma3. Ectopic thyroid carcinoma4. Other tumor typesInfiltrative Neoplasia1. Mesothelioma2. Carcinoma3. Metastatic Neoplasia4. Lymphosarcoma

Canine pericardial effusion

Differentials

Idiopathic conditions:

1. Idiopathic pericardial effusion (or benign pericardial effusion)
2. Congenital Conditions
3. Peritoneopericardial diaphragmatic hernia (PPDH)

Infectious Causes

1. Infectious pericarditis (e.g., Coccidioidomycosis)

Coagulopathy 1. Coagulopathy (e.g., rodenticide or warfarin toxicity)Miscellaneous

1. Uremia-related (rare)
2. Pancreatitis-related (rare)
3. Congestive heart failure (CHF)–related (atypical for dogs)