Cardiovascular and Pulmonary Emergencies
Core concepts
You must be fluent in recognizing and managing acute coronary syndromes, lethal dysrhythmias, heart failure, cardiogenic and distributive shock, pulmonary embolism, pneumothorax (including tension), asthma and COPD exacerbation, and respiratory failure. Understand the difference between oxygenation and ventilation problems, and match the intervention to the defect: supplemental oxygen and positive pressure for oxygenation, ventilatory support for CO2 retention, needle decompression for tension pneumothorax, and reperfusion for STEMI.
Pattern recognition
Know classic presentations and their atypical variants: women, older adults, and people with diabetes may present with dyspnea, fatigue, or epigastric discomfort rather than crushing chest pain. Pulmonary embolism can mimic both cardiac and musculoskeletal pain. Asthma that is "silent" is worse, not better.
Traps to watch
- Withholding aspirin or nitrates when indicated, or giving nitrates in right ventricular infarction or with recent phosphodiesterase inhibitor use.
- Treating a tension pneumothorax with imaging before decompression.
- Missing that a patient with COPD may depend on hypoxic drive, yet still requiring oxygen for actual hypoxemia.
- Confusing sinus tachycardia with a primary dysrhythmia; find and treat the cause.
Rule of thumb
For any unstable patient with a wide-complex or fast rhythm, electricity (synchronized cardioversion or defibrillation) is preferred over pharmacology. For any patient in extremis from a reversible cause, fix the cause.
Worked example: A patient with sudden dyspnea, unilateral absent breath sounds, hypotension, and distended neck veins has a tension pneumothorax. The correct action is immediate needle decompression, not chest radiography.