Thanks to Elise for writing last weeks Conference Notes.
Shorter, summer version of the Notes today
Case 1. Middle age male with some chest pain during the night. Pain resolved but wife made him come to the hospital. Further history revealed that patient has been having chest pain with exertion over the last few weeks.
EKG showed anterior ST elevation with Q waves and no reciprocal changes. Patient went to the cath lab and had a 99% LAD occlusion.
This case was interesting because the patient had a STEMI without pain in the ED.
About 5-10% of STEMI’s are painless. Painless STEMI’s are more common in female patients, diabetic patients, and patients with EKG’s that have ST elevation with Q waves. There is no difference between painless and painful STEMI’s regarding culprit lesions and maximal troponins. Painless STEMI’s in general have worse outcomes compared to painful STEMI’s.
There was some discussion among the cardiologists about whether they would take a patient with history of intermittent pain but no pain in the ED to the Cath Lab acutely. In the end they agreed that the ST elevation pretty much pushes you to do a cath.
Harwood comments: Patient may say they don’t have pain but if you ask them if they have pressure or tightness or discomfort they will say yes. Also, reciprocal ST depression is only present in about 80% of STEMI’s.
Case 2. Middle age male with sudden onset central chest pain. Initial EKG shows subtle anterior STEMI. ST elevation was at most a box but inferior leads show down-sloping ST depression. Emergent cath showed total occlusion of the LAD and 80% occlusion of obtuse marginal.
Interestingly, patient had a normal stress test a few weeks prior to this episode.
As part of the nuclear stress test, a little known aspect of the report (at least to me) is a TID score (Transient Ischemic Dilation score). It is usually listed in the body of the nuclear stress test report. If elevated the TID is a reliable marker of multi-vessel disease.
TID is an abnormal finding in stress myocardial perfusion imaging that suggests severe and extensive CAD and signifies a worse prognosis. TID has been reported with exercise and pharmacologic stress testing, planar and SPECT imaging, and Tl-201, Tc-99m, and dual-isotope protocols. Underlying mechanisms include a combination of stress-induced subendocardial hypoperfusion, ischemic systolic dysfunction, and less likely physical LV dilation with severe ischemia. TID appears to represent a significant ischemic burden and, compared with increased pulmonary Tl-201 uptake, suggests less permanent LV dysfunction and more myocardium at risk. Stress-to-rest LV volume ratios of 1.12 (epicardial) and 1.22 (endocardial) have been consistently shown to be highly specific for severe and extensive CAD. Reference: McLaughlin, M.G. & Danias, P.G. J Nucl Cardiol (2002) 9: 663. doi:10.1067/mnc.2002.124979
Last teaching point on this case: Subtle ST elevation does NOT have a better prognosis compared to marked ST elevation.
Lovell/Cirone Oral Boards
Case 1. Middle age patient presents with seizure. Patient travelled from Mexico. Diagnosis was neuro-cysticercosis. Manage the airway. Treat seizure. Order a CT scan to identify ring lesions. Get an ID consult to discuss management. Albendazole and steroids are the first line treatment.
*Neurocysticercosis on CT
If a person eats infected pork they get intestinal worms. If a person eats food contaminated by feces with tenia eggs they get cysts in the brain. This disease is a common cause of epilepsy world-wide. Be alert to this illness in patients travelling from endemic areas.
Case 2. Female patient with vaginal bleeding and abdominal cramping. Patient has a positive pregnancy test. History reveals patient had recent in-vitro fertilization. U/S shows an IUP and a right ovarian mass. Diagnosis is heterotopic pregnancy. Patient had severe bleeding. Treatment is blood product replacement and emergent surgery. Patient was RH negative so Rhogam was administered. 1/3 of intrauterine pregnancies will be lost when patient goes to the OR for ruptured heterotopic pregnancies. Fertility therapy markedly increases the risk of heterotopic pregnancy.
When a patient has a history of recent in-vitro fertilization/fertility therapy, think of 2 diagnoses: heterotopic pregnancy and ovarian hyper-stimulation.
Case 3. Pediatric patient with itchy red rash of right foot after waking on the beach in Puerto Rico.
*Diagnosis is cutaneous larva migrans. Hookworm larva get into the skin. Treatment is ivermectin or albendazole. Manage itching with Benadryl and topical steroids.
Einstein/Ohl Patient Communication & Satisfaction
Noah and Sean discussed a new printed form that protocolizes how we keep patients informed about their ED course and discharge plans.
*EMCrit Pressor decision-making
*EMCrit Push dose Epi
Ohl Bullous Skin Disorders
*Porphyria cutanea tarda
*Porphyria cutanea tarda
*Orf disease Shock and awe among the conference attendees when Elise knew this one immediately.
(Wikipedia Reference) Orf is a zoonotic disease, meaning humans can contract this disorder through direct contact with infected sheep and goats or with fomites carrying the orf virus. It causes a purulent-appearing papule locally and generally no systemic symptoms. Infected locations can include the finger, hand, arm, face and even the penis (either caused by infection from the hand during urination and/or bestiality). Consequently, it is important to observe good personal hygiene and to wear gloves when treating infected animals. The papule may persist for 7 to 10 weeks and spontaneously resolves. It is an uncommon condition and may be difficult to diagnose. There have been no reported cases of human to human infection.
While orf is usually a benign self-limiting illness, it can be very progressive and even life-threatening in the immune-compromised host. One percent topical cidofovir has been successfully used in a few patients with progressive disease. Serious damage may be inflicted on the eye if it is infected by orf, even among healthy individuals. The virus can survive in the soil for at least six months.
Hart/Regan Visual Diagnoses
There were so many great images in this lecture. I only can show a few.
*Gingival hyperplasia50% caused by phenytoin, 20% caused by cyclosporine
*Vitreous hemorrhage on ultrasound
*Retinal detachment on ultrasound
Stanek Safety Lecture
Rebuilding a better suture cart.
Holland Administrative Update
Patrick updated the residents and faculty on ongoing administrative and process improvement initiatives.