Abstract: Cardio vascular emergencies are life threatening disorders that must be recognized immediately to avoid delay in treatment and to minimize morbidity and mortality. Use of Homoeopathy as first aid is elaborated.
- An Approach to the very ill patient
The problem with very ill patients is that a life slipping through your fingers and you must find out what the matter is to save that life but the patient is too ill survive a detailed history and examination. Remember that in emergencies prompt action saves lives.
- Grading Emergencies
Even within emergencies there are gradations so that for most emergencies, there is time to assess your patient in some detail, these are Fatal Emergencies. Other emergencies demand the promptest action, such that when summoned from sleep, there is no time even to dress. These are Rapidly Fatal emergencies.
You need to know by instinct what to do when you arrive at the bedside of a patient in emergencies. My aim here is to allow the readers to prepare their minds so that they can make the most of such observations.
PLAN OF ACTION IN HANDLING EMERGENCIES
The trick is to buy time by supporting vital function. To achieve this you must proceed as follows:
FIRST QUESTION TO ASK YOURSELF IS AVPU? That is to say is the patient
V=Responsive to vocal stimuli
P=Responsive to pain
- If the patient is Alert or responding to vocal stimuli then patient is CONSCIOUS
- If the patient is unconscious look weather he is responding to painful stimuli then the patient is said to have ALTERED SENSORIUM
- If the patient is not responsive to verbal and pain stimuli then the patient is said to be in COMA.
Now once you have decided that the patient is conscious, in altered sensorium or in coma ask the following question to yourself and act accordingly
Q.1. is the patient PULSELESS with ABSENT RESPPIRATION?
- Remove any respiratory obstruction and start cardio-respiratory resuscitation.
Q.2. if there is a pulse and some respiratory effort, is the tongue blue?
- If so, put him on Ventilator.
Q.3. if there is a pulse and some respiration effort now ask; is the systolic BP recordable?
- if not (or <80mmhg) with NO Mycordial Infarction (MI) put up an IV line and infuse a plasma –like substance (eg Haemacel) fast, while you look for the cause.
- If MI is likely avoid fast IV fluids: the danger is precipitating pulmonary oedema.
Q.4. If there is a pulse and some respiration effort, is wheeze present?
- If so, treat as asthma, but rule out CHF/AVF, place the patient semi-prone (the coma position).
- To treat those things which are treatable and most likely to be rapidly fatal.
- Once ventilation and circulation are adequate start assessing your Patient in the traditional way.
If the patient is in COMA
Quick History from family or ambulance staff in case of COMA
- Onset of coma?
- How found?
- If injured suspect cervical spinal injury. Do not bend spine
- Is there head injury?
- Is he a know diabetic, asthmatic, opiate or alcohol abuser?
- Any travel?
- Any suicide note?
- Any known diseases?
AN APPROACH TO THE VERY ILL CARDIAC PATIENT
Cardiac emergencies are of two type: 1.Fatal 2.Rapidly Fatal
- FATAL CARDIAC EMERGENCIES
- ANGINA PECTORIS
- MYOCARDIAL INFARCTION (MI)
- RAPIDLY FATAL CARDIAC EMERGENCIES
- I + AF (Myocardial Infarction + Atrial Fibrillation)
- CARDIOGENIC SHOCK
- CARDIO RESPIRATORY ARREST
FATAL CARDIAC EMERGENCIES
ANGINA PECTORIS (ACS = Acute Coronary Syndrome)
A type of chest pain caused by reduced blood flow to the Heart. Homoeopathically speaking pain as a symptom should be complete under following heads as (CLAMES) i.e. Concomitants, Location, Aetiology, Modalities, Extension, Sensation. We must particularly see the accompanying symptoms with pain like –pain with fear, with terror, with weeping, with anger with or without nausea.
ECG shows T Wave inversion with ST segment inversion; Go in for TROP-T blood test to rule out myocardial ischemia
ANGINA PECTORIS (REPERTORY RUBRICS)
- CHEST-PAIN –tearing, Heart region of –extending to-arm-left
- CHEST-PAIN-Heart-extending to –hand-left
- CHEST-PALPITATION of heart-tumultuous, violent, vehement
- MIND-FEAR-death, of
- PERSPIRATION-PAINS- from
HOMOEOPATHIC FIRST AID FOR ANGINA PECTORIS
- ACONITE/ LACHESIS/ NAJA/ PHOSPHORUS/ LILIUM-TIG/ SPIGELIA/ KALMIA/
NEVER FORGET CACTUS/LATRODUCTUS MACTANUS
- Angina extending to left hand pain worse by sitting erect.
- Burning pain in heart region, oppression, at heart
- Extreme fear of death and predicts time of death
Angina grief from
- Angina worse lying on right & left side, menses before & after.
- Pain extending to left hand & left scapula.
- Aching, cramping, pressing, stitching, tearing pain in Heart shocks at the Heart during sleep.
- Sensation as if Heart is suspended from left rib
- Sensation as if Heart is hanging or swinging by a thread & every Heart beat would tear it off.
- Sensation as if Heart is turning around, sensation of weakness about the Heart.
- Sensation as if Heart is has not enough room &is pressing against the chest.
- Paroxysmal anxiety in Heart.
- Weakness at the Heart accompanied by heat flushing of face & flushes of heat up the spine.
- Angina at night, while riding in a carriage.
- Angina extending to left hand, left scapula and as opposed to Lachesis, pain also extends to back, nape of neck & shoulder.
- Aching, cutting, stitching in heart
- Drawing pain in Heart with sensation as if Heart & ovary were drawn together.
- Can only lie on right side.
- Anxiety in Heart worse lying on left side, by tobacco smoking.
- Constriction in Heart better by drinking water.
- Angina worse from emotions & lying on left side.
- Pain extending to left hand.
- Shocks in Heart region after dinner.
- Aching, pressing, cutting, stitching pain in Heart
- Weakness in the Heart
- Anxiety in region of Heart
- Sensation as if Heart ceases to beat
- Coldness in the region of heart
- Constriction in heart at night better by bending chest forward &worse by walking erect. This constriction extends to the back
- Sensation of emptiness in the Heart
- Angina alternating with pain in uterus; worse by bending forward, eating after, exertion, lying on right side, motion, on stooping.
- Angina extending to right arm, axilla, back, left hand, left scapula
- Angina, gripping, sore bruised, pressing, eating after in heart
- Sensation as if heart were hanging or swinging by a thread.
- Sensation of weakness about the heart, Trembling in heart
- Tearing pain extending to left scapula & left upper arm.
- Anxiety in heart Region, worse lying on left side & by tobacco smoking.
- Sensation as if heart has ceased. Constriction & grasping sensation.
- Angina accompanied by difficult respiration, worse by inspiration, lying on left side, motion, walking & better by drinking hot water, lying on right side, drinking warm water.
- Angina extending to right arm, back, left hand, nape of neck & shoulder, right & left scapula, to shoulder & to sternum.
- Pulsation, cutting, drawing pain, pressing, sore-Bruised pain in heart
- Stitching in heart, periodical, synchronous with heart beat, worse by motion , during respiration, better by lying on right side with the head high
- Angina accompanied by difficult respiration, Angina extending to left hand, pain also extends right back, left scapula and to nape of neck and sternum. Pain accompanied by numbness.
- Angina alternating with Rheumatism.
- Sensation of warmth about the heart.
- Angina accompanied by difficult respiration, or angina accompanied by Unconsciousness.
- Angina extending to left hand, left axilla, back, lying on left side, aggravates. Pain worse menses before & during, motion, walking, pain is paroxysmal.
- Sensation as if heart is gripped by an iron hand vice
- Sensation as if heart is turning around, whirling about the heart.
- LATRODACTUS MACTANUS
- Violent, pericardial pain extending to the axilla and down the arm and forearm to fingers, with numbness of the extremity, cramping pain extending to abdomen. Pulse feeble and rapid with anxiety
- Patient screams with pain, sensation of weakness about the heart.
- Extreme apnoea, gasping respiration, patient fears losing breath.
MYOCARDIAL INFARCTION (M.I)
It is characterized by ANGINA, COLD SWEAT, TACHYCARDIA (Heart Beat>100/min).
It may be associated with cyanosis & fever. Death of Heart muscles occurs if blood supply is not established immediately. 25% die before reaching the hospital.
- Tests include ECG, It shows ST segment elevation,
- T-wave inversion, & q-waves are typical in the leads
- Positive TROP-T
M.I Repertory Rubrics
- GENERALS- COLLAPSE
- CHEST-PALIPITATION of heart-tumultuous, violent, vehement
- CHEST-PIAN- tearing- Heart, region of-extending to-arm-left
- CHEST-PIAN-Heart-extending to- hand-left
HOMOEOPATHIC FIRST AID FOR M.I
- ACONITE/ ARSENIC/ LACHESIS/ NAJA/ PHOSPHORUS/RHUS TOX
NEVER FORGET TABACUM
- Tabacum symptom picture is exceedingly well marked. The nausea, giddiness, death-like pallor, vomiting, icy coldness, and sweat, with the intermittent pulse, are all most characteristic.
RAPIDLY FATAL CARDIAC EMERGENCIES
MI + ARRHYTHMIAS AND CONDUTION DISTURBANCES
- I.is the commonest settings in which arrythmias are seen, usually occurring in the first hour and setting rapidly. They may also occur in the context of chronic ischemia (50% of those who die in the 1st month after MI die in the 1st hour due to arrhythmia).
- Conduction disturbances are also common after MI 25% with Inferior Wall MI have 1° or 2° AV blocks which tend to have a benign course. AV block in Anterior Wall MI is usually associated with RBBB (or hemi blocks).
MI+ARRYTHMIA REPERTORY RUBRICS
- CHEST-PALIPITATION of heart-tumultuous, violent, vehement
- CHEST- PARALYSIS-Heart
HOMOEOPATHIC FIRST AID FOR M.I + ARRYTHMIA
- ACONITE/ ARSENIC/ LACHESIS/ PHOSPHORUS/ DIGITALIS
NEVER FORGET OXALIC ACID/ DIGITALIS
- Its greatest indication is in failure of compensation and especially when auricular fibrillation has set in.
- Where the pulse is weak, irregular, intermittent, abnormally slow.
- Auricular flutter and fibrillation.
- Heart block, very slow pulse.
- Other symptoms of organic heart disease.
- Cardiac muscular failure when asystole is present.
- Collapse, great weakness and sinking of strength, faintness, coldness of skin, and irregular respiration faint, as if dying.
- Bluish appearance of face.
- Respiratory- Nervous aphonia with cardiac derangement.
- Palpitation and dyspnoea in organic heart disease.
- Pulse feeble.
- Angina pectoris; sharp, lancinating pain in left lung coming on suddenly, depriving of breath.
- Precordial pains which dart to the left shoulder.
If the blood pressure is low so that vital organs are not perfused adequately, the patient is in shock. There are signs of end organ under-perfusion (pallor, cold peripheries, faints, restlessness, capillary refill > 2sec, oligourea), tachycardia hypotension (eg systolic BP < 90mmmhg). Quickly Examine BP; carotid pulse; pallor; cyanosis; jaundice; heart and chest sounds, aortic aneurysm and Melina.
CARDIOGENIC SHOCK REPERTORY RUBRICS
- GENERALS-DEATH APPARENT
HOMOEOPATHIC FIRST AID FOR CARDIOGENIC SHOCK
- ACONITE/ ANTIMONIM TART/ CARBO VEG / PHOSPHORUS/ CROTALUS HORIDUS/ OPIUM/ BELLADONA/ GLONINE
NEVER FORGET HYDROCYANIC ACID/ VEATRUM ALBUM/ CAMPHOR
C-SHOCK WITH CYANOSIS
- Feeling of suffocation, pain and tightness in chest, palpitation; pulse weak, irregular, cyanosis.
- Stage of collapse.
- Paralysis of lungs.
- Marked cyanosis.
- Violent palpitation. Pulse, weak irregular.
- Cold extremities.
- Torturing pain in chest. Angina pectoris.
Blood seems to stagnate the capillaries, causing blueness, The patient may be almost lifeless, but the Head is Hot with Cold Cyanosed Skin, coldness, breath cool. Pulse is imperceptible. Oppressed and quick respiration & must have air must be fanned hard.
- Face cold, blue pale; covered with sweat.
- Rapid, short, difficult breathing; seems as if would suffocate.
- Bronchial tubes overloaded with mucus.
- Oedema and impending paralysis of lungs.
- Much palpitation, with uncomfortable hot feeling.
- Pulse rapid, weak, trembling
- Tongue coated, pasty thick white, with red edges.
C-SHOCK WITHOUT CYANOSIS
- PERSPRATION PROFUSE, DROPLETS ON FACE
- SKIN COLD & CLAMMY LIKE MARBLE
CARDIORESPIRATORY ARREST REPERTORY RUBRICS
- GENERALS-DEATH APPARENT
HOMOEOPATHIC FIRST AID FOR CARDIORESPIRATORY ARREST
- CARBO-VEG/ OPIUM / HYDROCYNIC ACID/ PHOSPHORUS
NEVER FORGET BELLADONA/ OPIUM
PUPILS DILATED, PULSE ABSENT
PUPILS CONTRACTED, PULSE ABSENT
Q.1-IS HOMOEOPATHY MEDICINE OF CHOICE FOR FATAL EMERGENCIES?
HAHNEMANN’S ANSWER [The Organon, foot note aphorism 67,109] DO NOT USE HOMOEOPATHY IN FOLLOWING CONDITION:
- In most urgent cases where danger of life & imminent death allow no time for the action of homoeopathic remedy
- Surgical, diseases.
Q.2-IS HOMOEOPATHY REALY MEANT FOR USE IN EMERGENCY OR SHOULD IT BE USED AS FIRST AID
- WE DO NOT HAVE ICU’S NOR WE HAVE SUPPORT STAFF (minimum 5 people are needed)
- WHEN A LIFE IS AT RISK PLEASE GIVE HOMOEOPATHIC FIRST AID
- REFER THE PATIENT TO AN ICU
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- Schroyens Frederik, Repertorium , Homoeopahicum Syntheticum 9.1, Homoeopathic Book Publishers (4Jan 2013)
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- Dr.HARSH NIGAM MBBS; MD (Physiology); MF (Hom)
- Dr.SUJATA SINGH BHMS