Hart/Regan     STEMI   Conference

Case 1.   RV infarction.  Look for ST elevation in leads V1 and V2.   Also look at leads II and III.  If lead III has more elevation than lead II, that is consistent with RV infarct.

*RV Infarction EKG

Patients with drug eluting stents need ASA and Plavix for 6 months.  Bare metal stents should get ASA and Plavix for at least 1 month.  Drug eluting stents have been shown to have lower rates of requiring revascularization procedures but no difference in death and non-fatal MI.

Dr. Avula comment: Patients with history of cerebral aneurysm who present with chest pain have to be considered for thoracic aortic aneurysm or dissection.

Case 2.   Recent study (TRELAS) has shown that the incidence of troponin elevation in stroke is 14%.  It is thought that stroke causes autonomic instability and catecholamine surge inducing LV dysfunction.  Stroke patients with elevated troponins have lower incidence of identified culprit coronary lesions than patients with an isolated cardiac cause of troponin elevation.  There were no adverse neurologic or cerebral hemorrhagic effects of coronary cath in patients who had stroke and elevated troponin .  The authors concluded that stroke patients with elevated troponin don’t need coronary caths.

Another recent Korean study found a 0.42% incidence of Takotsubo-like cardiac dysfunction in acute stroke patients.   Patients with Takotsubo’s associated with stroke tended to be female, older age, and worse short term outcomes.

E. Kulstad/Bamman    Oral boards

Case 1. 2yo male ingested grandma’s verapamil.   Patient is hypotensive and bradycardic.    Patient treated with IV fluid bolus.  IV calcium gluconate and high- dose insulin and glucose were also given.   Atropine can be tried for bradycardia but frequently is not effective.   Glucagon can also be tried. Norepi is recommended as the first line pressor. Lipid emulsion therapy can be tried for severe overdoses.

*High-dose insulin therapy

Case 2.  72yo female with headache.   Vitals normal except for tachycardia and mild hypertension.   Patient notes some visual changes left eye.   Headache is gradual onset.   Patient notes nausea and vomiting.   Patient has temporal artery tenderness bilaterally.   Eye pressures bilat with tonopen were normal.  Ultrasound exam of left retina showed no detachment.   ESR=68.   Diagnosis is temporal arteritis.  Prednisone 60 mg was started.   Erik made the point that steroid therapy does not obscure the pathologic diagnosis of the biopsy.  So start steroids.    If the patient presents after visual loss has occurred give IV methylprednisolone. 

Harwood comment: Steroids don’t affect the biopsy results for at least a week.

Case 3.  23 yo female with abdominal pain.   HR 112 vitals otherwise normal.  Exam demonstrates left abdominal and left adnexal tenderness.  UCG is negative.   Pelvic ultrasound show enlarged left ovary with no vascular flow.   Diagnosis is ovarian torsion. 

·      U/S of ovarian torsion with no flow in the ovary.

Erik made to point to be alert for this diagnosis.  It is probably more common than realized.

Hart/Regan     Interesting Case

*Disulfiram Reaction

Disulfiram plus alcohol may produce serious adverse reactions (eg, respiratory depression, cardiovascular collapse, arrhythmias, myocardial infarction, acute congestive heart failure, unconsciousness, convulsions, death); intensity of reaction varies with each individual but is generally proportional to amount of disulfiram and alcohol ingested.

West        Oncologic Emergencies

Strategies to temporize malignant airway obstruction prior to intubation or cric/trach include: oxygen, heliox, and IV steroids.

When evaluating for spinal cord compression make sure you image at least 4 spinal levels above where you think the lesion is.  If you are worried about cauda equina syndrome or other lumbar/sacral pathology, image the thoracic spine in addition to the lumbar sacral spine.  The thoracic spine is a common site for metastases.

Osteoblastic lesions in bone are hyperdense.  Osteolytic lesions in bone are hypodense.

*Electrical alternans is a specific but not sensitive sign of malignant pericardial effusion.

*SVC syndrome.    Radiation therapy can be used to treat mechanical obstruction caused by tumor.  Thrombolytics can be used for SVC clot.   The SVC can be stented also.

*Pemberton sign.   Raising the arms will increase facial plethora in SVC patients.

Initial treatment for hypercalcemia is IV normal saline.   Diuretics don’t help lower the calcium level.

*Adrenal Crisis is commonly caused by abrupt stop to steroid therapy.   Treat with IV hydrocortisone 100mg Q6 hours for the first day.

*Tumor Lysis Syndrome

*Tumor Lysis Threapy

We had a discussion of taking a rectal temp or performing a rectal exam in pt’s who are or may be neurtopenic.   The consensus was don’t do a rectal exam or rectal temp.  Both can possibly cause bacteremia. 

Levato/Tumbush     HCAP in Non-ICU patients

There is an updated approach for these patients in an attempt to decrease “big-gun” antibiotic usage.

*HCAP Risk Factor Criteria

*Treatment guidelines

Holland         ED Admin Updates