Conference Notes 2-14-2012

IN TRAINING ZEBRAS    GIRZADAS

 

STEMI CONFERENCE

Out of hospital arrests are contributing to high post- PCI mortality rate.  If patient has prolonged resuscitation, decision to go to cath lab needs to be discussed with cardiologist.

Posterior-Lateral ST segment elevation suggests circumflex artery lesion.

Cardiogenic shock after cardiac arrest is a strong marker for eventual death.

Concordant st elevation with a bundle branch block is very suspicious for AMI.   Similarly, “ironing out” or straightening of the st segment is also very suspicious for an impending stemi. 

You shouldn’t see a Q wave in lead 1 in a LBBB.

DOCUMENTATION   McGURK

Document that you visualized and interpreted  the imaging study you ordered.  

TRAUMA GSW TO TORSO NON-OPERATIVE MANAGEMENT  PATEL

Pt has to have hemodynamic stability and no peritonitis to be considered for non operative management.   Also cannot have signs of hollow viscous injury on CT.

Serial abdominal exams are required.  This has the best sensitivity and negative predictive value for intra-abdominal injury.   Serial lab testing is also required.

Laparascopy is used for penetrating LUQ injuries to look for diaphragmatic injuries.

Some Trauma research has shown success with non-operative management of penetrating torso trauma.

FAST exam has little utility for penetrating abdominal trauma.  It is too nonspecific.  Blood could be coming from solid organ injury.  It is useful in penetrating trauma to the chest to rule out pericardial tamponade.  

Negative lap carries a lifetime risk of 15% for SBO.

CASE F/U  AFIB WITH RVR  COLLANDER

Afib with RVR: 60% convert with 100J biphasic.   80% with 200J biphasic. 200 J is a reasonable starting dose of electricity.   Use synchronized cardioversion.

Predisposiing factors for Afib: rheumatic heart, htn, etoh binge drinking, ischemic heart disease, obesity.  Fish oil may decrease risk.

Who should be cardioverted?  Unstable, first episode, infrequent episodes, worsening symptoms.

Who should not be converted?  Asymptomatic, elderly with multiple comorbidities, bleeding risk, symptoms more than 48 hours.

If you get them back into sinus, they can go home without meds.

Ottawa Protocol:  1 gram of Procainamide over 1 hour first,  if not successful cardioversion with 200J.

No need for anticoagulation following successful cardioversion.

If you fail with cardioversion, you can re-try with pt in exhalation, or use disconnected paddle to press zoll pad down more firmly.