emx day 3 cases - cardiac (09/08/2015)
TRANSCRIPT
Cardiovascular Disease Emergency Medicine Experience (EMX)
Nick Montano, MS3 EMX Program Director E-mail: [email protected]
Reflections from our 1st Month…
“Frozen in Time”
Another appealing event that transpired during the visit was, what to me
seemed to be a trivial ethical dilemma that the physicians come across
frequently wherein the family refuses to give consent for “pulling the plug”
on the patient, but the physicians believed that that is the right thing to do
for the patient, considering the chronic illness, present health and living
conditions. The doctors knew that the patient would not be living, what is
said colloquially, a normal life, but the family was hopeful for improvement
of patient’s condition. In such cases, where the affected person is not in
the capacity to take any decisions for the self, does the patient autonomy
get renounced, if so then should the heart (the family) be followed or the
mind (the physician)? In any case, something that is primal to every human
being, autonomy, is being sacrificed. The patient in concern is merely a
mute spectator of other’s decisions that they have taken on his behalf and
only solace that he can hope for is the decision to be something that he
would have asked.
Written by,
Somebody awesome
Pulse Check A 42 y/o man collapses suddenly while running.
On arrival, EMS reports that he is pulseless and in
asystole per EKG monitoring. ACLS was initiated
en route, and the patient was intubated.1
CPR is in progress, his airway is intact, and there
is no pulse on initial assessment. You obtain this
monitor strip:
You also obtain and echocardiogram during the pulse check
http://www.ultrasoundoftheweek.com/uotw-37
Echocardiogram
http://www.ultrasoundoftheweek.com/uotw-37
The Emergency ECHO
Draw the Ultrasound Image…
Key Structures:
- R ventricle
- Aorta/LV outflow tract
- Bicuspid/mitral valve
- L atrium & ventricle
ECHO: Parasternal Long Axis
Draw the Ultrasound Image…
Key Structures:
- Inferior window
- Superior window
ECHO: Parasternal Short
Inferior Window Superior Window
Impression? http://www.ultrasoundoftheweek.com/uotw-37
Fine Ventricular Fibrillation Description2
Subtle, disorganized ventricular “twitching”
Requires defibrillation (electrical treatment)
Clinical Pearls3
Delayed diagnosis Decreased likelihood of successful defibrillation
Wrong diagnosis Unnecessary shocks; delayed treatment (CPR)
http://www.ultrasoundoftheweek.com/uotw-37-answer/
Fine V-Fib Asystole
Differences in Treatment
Case References
1. Smith, B. (2015, February 11). Ultrasound of the Week. Retrieved
February 15, 2015, from http://www.ultrasoundoftheweek.com/
2. Stewart JA. The prohibition on shocking apparent asystole: a history and
critique of the argument. Am J Emerg Med. 2008;26:(5)618-22.
[pubmed]
3. Herlitz J, Bång A, Holmberg M, Axelsson A, Lindkvist J, Holmberg S.
Rhythm changes during resuscitation from ventricular fibrillation in
relation to delay until defibrillation, number of shocks delivered and
survival. Resuscitation. 1997;34:(1)17-22. [pubmed]
“The value of a good exam, is invaluable.”
Someone smart once said this…
It wasn’t this guy…
Case: Arroz con Cardiac http://www.ultrasoundoftheweek.com/uotw-36
“Arroz con Cardiac” A 61 y/o Caucasian woman with no medical history
presents with nausea, vomiting, and epigastric
pain that began 4 hrs after eating at a Mexican
restaurant.
She is tachycardia with mild hypoxia (SaO2 92%
on RA). Abdominal US was unremarkable. Given
the patient’s age and abnormal VS, an ECHO was
performed…
http://www.ultrasoundoftheweek.com/uotw-36
The Emergency ECHO
Apical
Sub-Xiphoid
Parasternal Long
Parasternal Short
Draw the Ultrasound Image…
Key Structures:
- R ventricle
- Aorta/LV outflow tract
- Bicuspid/mitral valve
- L atrium & ventricle
ECHO: Parasternal Long Axis
Draw the Ultrasound Image…
Key Structures:
- Inferior window
- Superior window
ECHO: Parasternal Short
Inferior Window Superior Window
Case Study: Apical 4-Chamber ECHO
http://www.ultrasoundoftheweek.com/uotw-36
Learning ultrasound…
LV
LA
RA
RV
Diagnosis? http://www.ultrasoundoftheweek.com/uotw-36
Lange et al, 2005
Regional Wall Motion Abnormality (RWMA)
6-View ECHO (Lang et al, 2005)
- The other method uses 17 views!
Assessment
ECHO Interpretation
Global hypokinesis w/wall motion abnormality
Worst in septal and apical segments
http://www.ultrasoundoftheweek.com/uotw-36 http://www.ultrasoundoftheweek.com/uotw-36-answer/
No more uncertainty about RWMA!
LAD Ostial Lesion
Ostial Lesions
Arise < 3.0 mm of origin
Poor response to PCI
High complication rates
Adraktas D D et al. Stroke. 2010;41:1604-1609
Cardio PIMP’ing…
PIMP #1 PIMP #2
Cardio PIMP’ing…
What morphologic EKG changes
do we expect to see with
myocardial ischemia/infarction?
Why?
Consider the electrophysiology of
the cardiac action potential…
What geographic EKG changes do
we expect to see with a left ostial
lesion resulting in myocardial
infarction?
Why?
Consider the 12-Lead EKG
electrode placement…
PIMP #1: STEMI
http://myheart.net/articles/stemi/ http://www.cvphysiology.com/Arrhythmias/A006.htm
ST Elevation = Infarction
Of course, exceptions exist…
12-Lead ECG: Ventral Leads
http://www.publicsafety.net/12lead_dx.htm
12-Lead EKG: “Geography”
http://clinicaljunior.com/cardiologyecg.html
Left Anterior Descending (LAD) Circumflex (CFX)
PIMP #2: LAD/CFX STEMI
Myocardial Supply
Ventricular septum
Lateral wall of LV
EKG Correlation
Septal V1-V4
Lateral V5-V6; Lead I, aVL
Myocardial Supply
LA and Inferior LV
Lateral wall of LV
EKG Correlation
Inferior Lead II, III, and aVF
Lateral V5-V6; Lead I, aVL
Evaluate the EKG…
Being called on to diagnose the EKG in front of everyone…
When I didn’t even know the EKG existed in the first place!!!
What is your diagnosis?
http://www.ultrasoundoftheweek.com/uotw-36-answer/
References
Avita, J. (2015, February 5). Ultrasound of the Week. Retrieved February
15, 2015, from http://www.ultrasoundoftheweek.com/uotw-36
Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber
quantification: a report from the American Society of Echocardiography’s
Guidelines and Standards Committee and the Chamber Quantification
Writing Group, developed in conjunction with the European Association of
Echocardiography, a branch of the European Society of Cardiology. J Am
Soc Echocardiogr. 2005;18:(12)1440-63. [pubmed]
Adraktas D D et al. Stroke. 2010;41:1604-1609
Stupid Transition Slide…
Which one has narcolepsy?
Done Fell Out
DFO at School: 7 y/o Female
ID: Previously healthy 7 y/o girl collapsed at school
HPI: Witnessed fall at school by classmate/child. Previously healthy,
playful, and energetic. No fevers, URI Sx, N/V/D/C, or rash. No FHx
of congenital heart disease or sudden death.
Approach to Syncope
Is it truly syncope?
What is the underlying cause?
Is it serious or life-threatening?
Red Flags for PEDS Syncope
Family History (e.g., CHD, SIDS)
Triggers (e.g., Loud startle)
Consider non-accidental trauma
http://emergencymedicinecases.com/episode-25-pediatric-adult-syncope/
DFO at School: 7 y/o Female
ID: Previously healthy 7 y/o girl collapsed at school
HPI: Witnessed fall at school by classmate/child. Previously healthy,
playful, and energetic. No fevers, URI Sx, N/V/D/C, or rash. No FHx of congenital heart disease or sudden death.
Per EMS, was in Vfib on scene , defibrillated twice, and given one dose of
epinephrine without ROSC. BIBA to St. Emyln’s ED, was intubated and CPR
continued for another ~15 min, over which time she received two
additional doses of epinephrine; total CPR time 25 minutes, pH 6.95 at time
of ROSC.
Transferred to Janus General - PICU without incident.
PMHx None
PSHx None
FHx No CHD or SIDS
SHx Unremarkable
BHx Unremarkable
DFO at School: 7 y/o Female
Allergies NKDA
Medications None
Immunizations UTD
When EMS rolls in with a pediatric DFO-to-CPR…
And trying to recall the 13 differentials.
DFO at School: 7 y/o Female
VS (on arrival)
T 37.1 oC (98.8 oF)
BP 63/84 mmHg
HR 153 bpm
RR 26 bpm (vent)
O2 97%
PE
GEN Sedated, intubated on vent
ENT Bilateral conjunctivitis, oral ETT, C-collar in place
PULM Labored respirations, good exchange, no adventitious sounds
CVS Sinus tachycardia, PMI at L midaxillary/4th ICS, CRT < 2 sec
GI/GU ABD ND and w/o bruising, no incontinence
NEURO Pupils 2 2 mm, midline bilaterally; initiating breaths, strong
cough; LE flexion posturing w/painful stimuli
DFO at School: 7 y/o Female
Acid/Base Analysis???
pH Low (Acidosis) PCO2 High (Respiratory) HCO3 Low (Metabolic)
Mixed acidosis
Learning acid/base in med school…
DFO at School: 7 y/o Female
DFO at School: 7 y/o Female
DFO at School: 7 y/o Female
DFO at School: 7 y/o Female
DFO at School: 7 y/o Female
Sinus tachycardia with Fusion complexes
Left axis deviation
Nonspecific ST and T wave abnormality
No previous ECGs available
DFO at School: 7 y/o Female
7 y/o girl who collapsed at school today. EMS reporting V-Fib upon arrival.
Neuro
Therapeutic hypothermia to 32-34 oC
Keppra prophylaxis while cooling
F/U head CT read from OHS
Pulm
Hyper-expansion on CXR – wean PEEP as tolerated
Consider post-obstructive edema – hold PEEP as indicated
Goal is SaO2 > 94% while elevated lactic acidosis
Goal is eucapnea to limit cerebral volume load
CVS
Cardiology consult for V-fib arrest
Send viral myocarditis screening labs
Goal is MAP > 50; currently not requiring vasoactive Rx
Interpreting PICU Plans…
DFO at School: 7 y/o Female
Discharge Summary
Neuro EEG negative for evidence of Sz activity. MRI was concerning for
ischemic injury to frontal lobes. Agitated post-extubation, improved
with time
Pulm Intubated at OHS, remained intubated during active cooling x 48
hrs. extubated to room air on HD#4
CVS ECHO negative for structural abnormality. Viral myocarditis panel
negative. Genetic testing for long QTc sent (pending). AICD placed
in OR on HD#12, started on nadalol
Renal Started on furosemide for volume overload after admission.
Tolerated diuresis, currently euvolemic and not requiring meds.
ID Myocarditis panel (-), rhinovirus (+). Post-AICD prophylaxis
Moral of the Story
Now, an ULTRAcase!!!
Thanks for coming!!!