Much Thanks to Erin Frazer for Providing Lunch today for the Residents!! If any attending or graduate would like to purchase a lunch for the residents on any conference Wednesday please contact Rose or the Chiefs.
Meyers/Htet STEMI Conference
Case 1. We discussed the management of out of patients who have V-Fib Arrest out of hospital. EKG on arrival to the hospital shows STEMI. CurrentLevel 1 Recommendations are to proceed with urgent Cath Lab activation and therapeutic hypothermia for these patients.
Now what do you do if the EKG is non-specific? It has been shown that 31% of patients who are post –arrest and have a non-specific EKG have a culprit coronary occlusion on coronary angiography. A non-randomized, retrospective analysis of post-arrest patients who go to the cath lab shows they have better survival with good neurologic outcome than patients who did not go to cath lab. Cardiology comment: This is retrospective data and likely represents selection bias.
*Algorithm for post-arrest patients. We focused on the risk stratification factors in the central portion of the algorithm. Most faculty present felt these were reasonable markers of poor prognosis. Harwood felt that patients with ESRD can sometimes be resuscitated by lowering the potassium level. He also felt that drug overdose victims could sometimes be saved with ECMO.
Paul Silverman comments: Even though 31% of patients have a culprit lesion there is no data to demonstrate that coronary angioplasty improves mortality in post-arrest patients. We are developing a cardiogenic shock protocol for patients who may benefit from a support device in clinical situations such as a drug overdose. A recent study showed that balloon pumps don’t improve mortality. We still use them but there is no proven mortality benefit.
The problem with cathingpost-arrest patients is that we can open the artery and stent the artery but these patients don’t recover their brain function and they still die.
If a patient has an arrest, wakes up and has chest pain and a nSTEMI on EKG they may not benefit from emergent cath. All cardiologists agreed that if a patient had recurrent V-Tach or V-Fib following arrest and they had neurologic function, they would take the patient to the cath lab. Please talk to the interventional cardiologist and discuss these cases prior to activating a CODE STEMI. Cooling is very important for all unconscious patients after arrest.
Erik Kulsad comment: I agree with Dr. Silverman. It is very ill-advised to base therapy on non-randomized retrospective data. It is quite common that when these topics are re-examined with a prospective randomized trial the exact opposite results are found.
Case 2. Patient with chest pain and evolving EKG with signs of posterior MI. Posterior EKG shows STEMI. Most commonly (85%) posterior MI is due to an RCA lesion. 15% of posterior MI’s are due to a left circumflex occlusion. Patient had V-Tach and needed to be cardioverted.
*Posterior MI
Be sure to repeat EKG’s in the ED when chest pain is continuing or worsening. ST changes are dynamic and STEMI can develop over time. If the patient is going to the cath lab be sure to pre-emptively place the Zoll pads on the patient to be prepared for V-Tach or V-Fib.
Paul Silverman Comment: In most cases, I would take the patient to the cath lab based solely on the anterior EKG showing posterior STEMI. If the posterior EKG shows ST elevation that is added confirmatory data but a suspicious anterior EKG is enough to cath the patient. The only caveat would be maybe to give some nitrates and see if the patient’s pain and ST changes improve. If they do, this could be anterior ischemia/angina rather than posterior MI.
Case 3. We discussed the difficult decision of taking patients with multiple co-morbidities to the cath lab. The Cardiology Faculty felt that poor renal function, anti-coagulation, DM, age, cancer all portend a poor outcome including possible renal failure due to contrast administration for the patient. Cardiology felt it would be totally fine to speak with the interventionalist on call and discuss these complicated cases prior to activating the CODE STEMI.
Girzadas M&M
Take home points:
• Respect Asthma (Common, Deadly, Deceiving). Patients can present with typical wheezing and dyspnea, altered mental status, or only cough.
• Be cautious with non-selective beta blockers (labetalol, propranolol, sotalol, carvedilol, and topical timolol) These drugs have B-2 blocking effects and can cause fatal bronchospasm in asthmatics. Topical ophthalmic beta blockers have caused fatal asthma attacks. Even selective beta-blockers can have an adverse effect on FEV1 in asthmatics.
*Effect of Beta Blocker in Asthma
• Optimize your communication with patients and their families. Be sure to discuss your plan for the patient’s care with their family.
• Think about your clinical thinking. Beware of “What You See Is All There Is” (WYSIATI). Our system 1 thinking works to make a coherent story out of limited and poor information. Use your critical thinking (System 2) to calibrate youSystem 1. To read more about this concept a great book is “Thinking Fast and Thinking Slow”
• LMA is a bridge device that should be used in a failed intubation scenario to obtain a temporary airway. You can then intubate thru the LMA or perform cricothyrotomy while you are bagging the patient through the LMA.
• If you are going to perform cricothyrotomy, don’t over-delay the start of the procedure. It is a common pitfall to start the procedure too late.
Navarrete Triage
Reasons for triage: Prioritize incoming patients, helps with appropriate bed assignment, and provides demographic data.
*ESI Triage system. The more severe the presentation, the lower the number.
*ESI Triage System Resources and non-Resources. The resources in this chart are used to differentiate levels 3-5.
Theresa used the ESI algorithm to work through multiple triage case studies.
Cirone HIV
HIV is a single stranded RNA that is enveloped. The virus has a spherical shape.
In 1982 the virus was named HIV.
Mangabies and Chimpanzee’s are the animal reservoirs of the virus.
HIV1 makes up 95% ofHIV cases world-wide. HIV2 is more prominent in West Africa. HIV2 accounts for 5% of HIV cases and is more indolent than HIV1.
AIDS= HIV infection plus CD4 count of 200 or less, CD4T <15%, or an AIDs defining illness.
*AIDS defining illnesses
*CD4 and Disease
The expected period of seroconversion after sexual assault is about 8 weeks. If a patient has a negative HIV test 8 weeks after sexual assault, they are negative.
The most common presenting symptom of acute HIV exposure is sore throat (mono-type clinical picture)
Michael then discussed his research that he will be presenting at the national CDC Academic Assembly. He found that ED patients are receptive to HIV testing. HIV testing does not interfere with ED flow. They were able to identify patients with HIV infections in the acute phase and also patients with AIDS.
Felder OB/Gyne
Treatment for chlamydia infection during pregnancy is Azithromycin.
Fetus at 2-8 weeks: Organogenesis, radiation is teratogenic
Fetus at 8-15 weeks: Radiation can affect neurologic development
*Radiation exposure from various tests during pregnancy.
*HELLP Syndrome. Consider this diagnosis in every pregnant patient with RUQ pain after 20 weeks gestation.
*Treatment of ecclampsia
Get a pelvic ultrasound in patients with abdominal pain or vaginal bleeding and a beta-hcg below 1500. The ultrasound may show an ovarian mass, free pelvic or intra-abdominal fluid. These ultrasound finding can help diagnose ectopic pregnancy. If the ultrasound is unremarkable with no IUP then you will need to do serial b-hcg’s and advise the patient about the possibility of ectopic pregnancy.
*Management of Amniotic Fluid Embolism
*Kleihauer Betke Test
* Kleihauer Betke Test Interpretation