Conference Notes  3-6-2012

GOTTESMAN-WATTS ORAL BOARDS

Case 1:Brugada Syndrome.  More common in Asian males.  IRBBB with septal ST elevation.  Fever can elicit EKG changes.   Structurally normal heart.  It is an electrical problem.  Pt’s need an AICD

Case2: Aortic Dissection     Treated Pain well.  Thorough/Efficient  ROS and PMH.  Should give labetalol or some combination to decrease pulse pressure.  If you give a combo, give the betablocker first.  Ntg alone not best choice.  Nitroprusside is better choice with a beta-blocker .

Case3:  Flexor tenosynovitis.  Treated pain well.  Gave Rocephin.  Ring on adjacent finger should be removed.  Staph is most common etiology.  Kanavel’s sings, fusiform swelling, pain with passive

Gupta  Study Guide Trauma

Tension pneumothorax may have equal breath sounds.

CT abdomen is superior to ultrasound for diagnosing solid organ injury.

Indications for CT  for diagnosing renal injury is gross hematuria, hemodynamic instability, rapid decal injury.   Textbooks recommend In kids consider ct for microscopic hematuria.  U/S is the better test in kids in 2012 to reduce radiation.

ED thoracotomy is most likely to save a patient with cardiac tamponade due to a stab wound to the heart.

Myocardial contusion is a diagnosis that you don’t need to worry about unless the patient is hemodynamically unstable or has a significant arrhythmia.

Abdominal wall ecchymoses should raise suspicion of duodenal hematoma.  Initial CT may be neg.  Pt needs serial exams if they have continued pain.

Extraperitoneal bladder ruptures usually occur from lacerations due to pelvic fx.

LFT’s are not useful in trauma.  Pancreatic injuries may initially have normal amylase and lipase.

Most commonly injured organs in penetrating abdominal trauma:  small bowel>liver> colon.

Most commonly injured organ in blunt abdominal trauma: spleen

Treat rib fractures/contusions with pain medication and incentive spirometry. 

Left sided diaphragmatic injuries are 3X more common than right sided.   Delayed herniation is possible. These injuries do not heal spontaneously.   Best diagnostic test is laparoscopy.

Hemodynamically unstable patients due to pelvic fracture: tie pelvis with bed sheet,  next move is angiography with embolization.

EASTVOLD TOMASELLO  

ANTERIOR ISCHEMIA

Early repol: diffuse st elevation, nl r wave progression, short qt interval, nl t wave morphology, no reciprocal changes , J point notching

More likely a STEMI vs Bening Early Repol if greater ST elevation, longer QT (QTCmore than 392), lower R wave amplitude in V4 (less than 13mm).

If T Wave exceeds QRS amplitude, it suggests STEMI.

Pericarditis:  PR depression is most prominent in V5 and 6.   You will never have ST elevation with pericarditis in lead V1.   Check AVR for PR elevation.

Hyperkalemic T waves are pointed at their most superior aspect and there are flat ST segments.

Wellen’s Syndrome: Biphasic t waves leads V2-3.  Suggestive of proximal LAD occlusion.   EKG findings are seen when pt is pain free.

De Winter’s Sign:  Anterior ST depression followed by very prominent T waves.  Associated with proximal LAD occlusion.

ST SEGMENT CHANGES

  Flattened ST segment is fairly specific for ischemia

ST segment change sconcordant with the QRS  are indicative for ischemia

Subendocardial ischemia does not localize, it is diffuse.  So if you see focal st segment depression, look hard for ST segment elevation somewhere else.

Infero-lat ST depression with STE in AVR=severe left main dz or 3 vessel DZ.

If you see inferior st depression, look for ST elevation in the high lateral leads.

Millimeter criteria for STEMI will often fail you.  Look for patterns.

Localized depressions V1-3, think posterior ami.   If there is diffuse st segment depression it is subendocardial ischemia.

Isolated t wave inversion in AVL, think ensuing inferior MI.

Serial EKG’s are critical!

If ST elevation is greater in lead 3 than lead 2 in an inferior MI, that is suggestive of RV infarct as well.

Posterior MI has anterior ST depression with flat ST segments, upright t wave, and tall R waves.

Abnormal T wave balance: T wave in V1 is larger than V6 or 1.  Bundle branch blocks and LVH are the two times when this rule doesn’t work.

Pericarditis: AVR shows PR elevation and st depression,  V1 should have no pr or st changes.

RV strain=RBBB, tachycardia, T wave inversion in 3 and V3, terminal r wave in V1, S1Q3T3, 1 and AVL with upright T waves.

TCA overdose look for large terminal R wave in AVR.  Benadryl and cocaine can do the same thing.

PAILS: mnemonic for reciprocal changes  Post-Ant, Inf-Lat, Lat-Septal