Hart/Regan      STEMI Conference

Case 1.   Patient had environmental hyperthermia associated with lateral STEMI changes.  Decision between Emergency Physicians and Cardiology agreed that rapid cooling was indicated rather than emergent cardiac catheterization.   EKG changes resolved with rapid cooling.   Patient had markedly elevated CK due to Rhabdomyolysis.   Rhabdo was treated with IV fluids and eventually dialysis.  

There is a paper describing EKG changes in patients participating in the Haaj in Mecca who had hyperthermia.  Common EKG abnormalities seen were sinus tachycardia, QT prolongation, non-specific ST changes, and focal ST changes.  There are other case reports of STEMI appearing EKG changes in patients with hyperthermia.  Typically patients had resolution of EKG changes with rapid cooling.  Many had clean caths.   The EKG findings of hyperthermia are thought to be due to physiologic stress, dehydration, electrolyte abnormalities.

Harwood comment:  The treatment is to cool these patients not take them to the cath lab.  The Cardiology faculty present agreed.  They said treat the patient, not the EKG.  Cooling is the main therapy in this situation.

Case 2.  Elderly patient with prior CAD, stents, HTN presents with syncope.  Patient's initial EKG showed clear-cut STEMI changes.  Patient had history of placement of coronary stents for a prior STEMI about a week prior to this presentation. Cardiac Cath at this second presentation showed thrombosis at proximal portion of recently placed stent.

There is no clear-cut time frame for STEMI changes to resolve following MI.  If ST elevation is identified beyond 1 week post-STEMI that is probably an acute abnormality or an aneurysm or pericarditis.

Stent thrombosis is uncommon with about a1-2% frequency.  Stent thrombosis sually presents with STEMI or death.  Patients not taking anti-platelet therapy are at higher risk for stent thrombosis.  Bare metal stents most commonly occlude in the first 48 hours.  Drug eluting stents most commonly re-occlude within 30 days.  STEMI's secondary to stent thrombosis have worse outcomes than STEMI's caused by plaque rupture.  Cardiac Cath is very time-sensitive in these patients.

Cardiology comment: Most of the time stent thrombosis is due to either medication non-compliance or mechanical/placement issues related to the stent.

Cardiology comment: It is very important in patients with prior CAD and/or stents to compare their ED EKG with a prior EKG.  The patient may have aneurysmal changes or LVH changes that can look like acute STEMI.  If you have an old EKG showing similar changes it can help clarify the situation.

Case 3. Elderly patient presents with dyspnea. EKG showed a paced rhythm with anterior concordant ST depression.

Smith Modification of Sgarbossa criteria: If you identify concordant ST elevation or depression, that is significant.  If you have discordant ST change more than 25% of the main deflection of the QRS, that is also considered significant.   This last criteria replaces the 5mm discordant criteria from Sgarbossa.

Cardiology comment:  The decision to take patients to the cath lab with paced rhythms is difficult.  The decision has to be made on a case by case basis using Smith modified Sgarbossa criteria and looking at the overall clinical picture.

KennedyM&M

I only noted the take home points to avoid divulging the specific aspects of these cases.

When pacing, you have to set the asynchronous rate above the patient's native rate or you can get a pacer spike landing on a QRS complex.  This can cause V-tach, torsades, or V-fib.  If you are technically adept with the pacer device, placing the pacer in VVI mode also avoids this R on T phenomenon.

Harwood and Girzadas comment: There is a value to keeping things simple when placing a transvenous pacer.  The "Emergency" button on the pacer give you asynchronous pacing at the rate of 80 which does the job in the vast majority of patients who have a very low native rate.  Harwood made the point that once the patient is more stable you can then adjust the pacer box to the VVI mode. 

Carlson comment: Check the pacer battery while you are prepping to place the line.  It is not uncommon that the pacer battery may need replacement. You don't want to find out the battery is not working right when you need the device to pace.

Check vital signs prior to discharging patients. Document any re-assesments thatyou perform on patients.

Consider getting an EKG on patients that are persistently tachycardic with no good clear diagnosis.  Be on the lookoutfor myocarditis.

Tekwani comment: If you get a gut feeling about a patient in signout, go to the bedside and carefully re-evaluate the patient.  Don't ignore that gut feeling.

Lovell comment: Be cautious about chalking up symptoms and signs to anxiety.  Most of the time the diagnosis is actually anxiety but rarely it can be an occult pathology.

Sedation and positive pressure intubation can markedly decrease cardiac output and increase the chance of cardiac arrest.  Be sure to resuscitate the patient prior to intubation. Have pressors ready to go or even started prior to starting intubation.

Williamson comment: Take some time prior to every acute resuscitation to speak with the family and appraise them of the gravity of the situation.  It should be in your pre-resuscitation check list.

Menon/EinsteinOral Boards

Case 1.  Botulism secondary to IV drug use.  Treat botulism with anti-toxin.  You can obtain anti-toxin from CDC.  The Illinois poison control also has access to anti-toxin

*Botulism

Carlson comment: Heroin is the #1 cause of wound botulism.

Case 2.  Patient with recurring fever following trip to Africa.  Malaria was suspected based on CBC showing anemia and schistocytes.  Thick and thin smears confirmed malaria. 

Elise comment: You need to know this diagnosis for the boards.

*Thick and Thin smears for Malaria

Case 3.  Flexor tenosynovitis Treat pain, update tetanus, give IV antibiotics and consult hand surgery. Admit patient for further management and surgery.

*Knavel's 4 signs of Tenosynovitis

Destefani         Safety with Pediatric IV fluid Administration in DKA

IV fluid administration in pediatric patients with DKA needs to be done with caution to avoid cerebral edema. However, research illuminating how exactly to give fluids in Peds DKAis lacking.  Cerebral edema in DKA is rare and relatively unpredictable.

Do not bolus NS in DKA patients unless the patient there are signs of shock. 

PECARN group is currently doing a study looking at various IV fluid strategies in Pediatric DKA patients.

Any change in mental status in a pediatric DKA patient should raise your suspicion for cerebral edema.  Also be alert for headache, incontinence, and vomiting.

*Diagnostic, Major and Minor Criteria for Cerebral Edema

Small studies show that central lines in pediatric patients with DKA may be more at risk for DVT.  If you can't get peripheral IV access go to an IO line first.  Favored locations for pediatric IO lines are proximal tibia, distal tibia, and distal femur. Avoid placing IO lines above the femur in skeletally developing kids. 

Harwood comment:  Most DKA patients are not in shock and don't require rapid fluid boluses or large fluid resuscitation.  Give them fluid and insulin per protocol only and they will gradually improve.

Garrett-Hauser     Ethics     Reporting Medical Errors

We discussed a case scenario regarding end of life decisions.

The act of withdrawing care is not furthering a patient's death.  It is returning the patient to their original disease state.   However when you withdraw care, you do need to fill out a "Goldenrod Form" justifying the withdrawl of care.  Two attendings need to co-sign the Goldenrod Form.

A patient had unintended imaging.  Patient was informed of imaging and radiation exposure. A discussion with billing office was had to avoid the patient receiving a bill for an unintended test.

If a patient has an adverse outcome from a medical error, the appropriate approach is to discuss the error, the cause, and the expected outcome with the patient and family.   Families want to know how this problem will be prevented going forward.    It is good to have Chaplain support with these conversations.

All these cases highlighted the importance of error disclosure AND the challenges we all have with informing patients and families about errors.