When assesing patients with collapse with unidentified cause, its possible underlying arrhytmia is present. The following ECG changes can suggest this
This list is ongoing and not complete yet
For every cardiology patient visualise the status of the following stuff:
1. Electrical Rhythm and conduction
Tachyarrhytmias, bradyarrhytmias, heart blocks, pacemakers
2. Coronary arteries
Coronary artery disease, risk factors, Stress-test/angiograms/scan?, PCI or CABG history?
3. Heart muscle function
Cardiomyopathies,
4. Valve function
Regurgitation, stenosis
5. Accesories
pericard, vasculator (aorta), systemic diseases affecting the heart (DM2), elektrolytes, pulmonary function
Case: A 50 year old male with alcohol abuse present in the Emergency department with mild chest pain. He has been nautious and vomiting the past couple of days. Also there is diffuse abdominal tenderness. He gets admitted to control pain and CT-scan next days but detiorates suddenly. He dies. Obduction shows a ruptured oesophagus.
Boerhaave syndrome is rupture of esophagus and rapidly fatal.
History: a dutch grand admiral was retching and tore his oesophagus apart. He died after eating a duck.
Pathofysiolygy: rupture of esophagus due to increase intraluminal pressure usual due to vomiting or retching. Alcohol intake is related. Higher risk if gastro-intestinal disease is present.
Other causes: straining, childbirth, heavy lifting, seizures, fits of coughing or hiccup
Clinical symptoms: chest pain, nautious, vomiting (bloody), dysphagia, dyspnea,
Anderson Triad: Subcutaneous emphysema, rapid respirations, and abdominal rigidity
Macler triad: vomiting, pain, subcutaneous emphysema
Physical examination: Crepitus in the neck, abdominal rigidity, abdominial pain. tachycardia, tachypnoe
Chest X-ray signs:
If still suspected make CT-thorax/abdomen (contrast in esophagus?).
Treatment:
* Surgery as soon as possible
Aggresive resuscitation and broadspectrum antibiotics.
The cause of death is usually polymicrobial septic shock and mediastinitis.
Serious: STE-ACS, dissection, thoracal aneurysm, massive pulmonary embolism, pericardtamponade, tension pneumothorax, esophagel rupture
Moderate: NSTE-ACS, pulmonary embolism, pericarditis, pleuritis, pneuomnia, unstable angina pectoris, aortic stenosis, pneumothorax,
Mild: tendomyogenous, ribfracture, reflux, panic, stable angina pectoris, hyperventilation, costochondritis,
Gastro-intestinal: Pancreatitis, stomach ulcus, gallstones
Diagnostic consideration: D-dimer, abdominal enzymes, X-thorax
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