Conference Notes 9-11-2012

Conference Notes 9-11-2012

Kettaneh   5 Causes of ST Elevation

  1. STEMI
  2. Benign Early Repolarization: People under 50yo, J point notching, concave up ST elevation, Prominent T waves concordant with QRS
  3. Pericarditis: Diffuse STE and/or PR Depression,  Reciprocal changes only in AVR (ST depression and PR Elevation) 

For deciding between  Early repol and pericarditis: ST segment elevation  compared to T wave height ratio in V6 is greater in pericarditis  (STE height/T wave height).   The T wave in early repol is taller than in pericarditis and the ratio is lower in early repol.

  1. Bundle Branch Block.   Sgarbossa criteria: 1mm Concordant st elevation, 1mm Concordant st depression, discordant st elevation >/= to 5mm.  Cabrera’s sign: notching in S wave in V3-4.  Chapman’s sign notching in the R wave V6.
  2. LV Aneurysm: can lead to sudden cardiac death,  arrhythmia, thrombus.  Consider after MI, absence of hyperacute T waves.


Other causes: brugada, lvh, hyperkalemia, hypercalcemia, myocarditis.


Girzadas question: Is benign early repol actually benign?  Answer: there is controversy but most references feel it is benign .   Silverman comment: BER has an emerging literature that shows a possible risk of sudden cardiac death.   However, no one knows what to do with this EKG finding.  There is no treatment protocol currently for this.

Harwood comment: Pericarditis vs. Early repol use tp segment as your baseline for identifying PR depression.  For figuring out the ST to T wave ratio use the PR segment as your baseline.  PR depression boosts the  ST elevation part of the equation increasing the ratio in pericarditis.



Herrmann  5 Causes of Wide QRS


Harwood comment: The best lead to measure the width of the QRS is the lead with the widest QRS.

  1. Bundle Branch Blocks: QRS>120ms.  RBBB can be associated with heart disease and PE but can also be present in normal hearts.   RBBB in an acute MI confers increases mortality.   If wide and up in V1 it is RBBB.  If wide and down in V1 it is a LBBB.
  2. Ventricular Rhythms: PVC’s are common in nl hearts.   Rules of malignant pvc’s : frequent pvc’s, couplets/triplets, multiform, pvc on t wave.  Ventricular escape rhythms are another cause of wide qrs. Accelerated idioventricular rhythm is associated with reperfusion with TPA.
  3. TCA  Overdose:Look for wide QRS generally and tall/wide R wave in AVR
  4. Hyperkalemia: Always consider this if the QRS is wide.   The ekg may also show a slow rhythm with loss of p wave.
  5. WPW: Slurred upstroke of the QRS complex (delta wave) due to accessory pathway.  Delta wave widens the QRS and shortens the PR interval.


Barounis STEMI Conference


Case 1: LR’s for historical items indicative of AMI is  highest for radiation to both arms, radiation to right arm, diaphoresis, and radiation to left arm.   Pressure has a relatively low LR of 1.3.   chest pain that is reproducible has a LR of 0.4 which lowers the risk but does not make the risk 0.    When you don’t have an old ekg to compare with, make an old ekg by getting another ekg to look for evolution.

Comments: The ekg had subtle st depression in 1/AVL. Some subtle st segment straightening inferiorly.

2nd EKG was diagnostic for inferior STEMI (STE greatest in 3)  

Harwood/Silverman  Comment:  Gotta get a repeat EKGwithin 10 minutes.  MD may have to stay at bedside for 10 minutes to get another EKG in high risk patients.

Other guest comment: Women will present with symptoms that can be atypical.


Case 2:  Evolving Inferior MI.    Cardiology comments an evolving ekg with chest pain should go to cath lab.  Recent normal stress test does not preclude AMI.   PT should go to cath lab even if ekg improves with ntg if other ER ekg’s were concerning.   

Dr. Silverman comment: Don’t delay more than 3 minutes waiting for return call from patient’s primary cardiologist.  After a 3 minute delay gotta contact intervential cardiologist on call.  He felt safest option is to call STEMI first and after that attempt contact with the primary cardiologist.   That way you get both cardiologists as rapidly as possible.


Case3: EKG initially was non diagnostic in a young patient with chest pain.  Dr. Silverman  advised stat echo in this situation.   If echo is nl, ekg is likely not stemi but more likely BER.  If echo is abnormal, then pt should go to cath lab.


CT angio for CAD:  Cardiologists generally not for it due to radiation exposure and low sensitivity.  Dr. Trevedi did say it has a good negative predictive value.  Dr. Trevedi felt hypertensive patients with chest pain may be a good pt group to use this test.  It give info about aortic dissection in addition to showing the coronary arteries.

Mila Felder’s summary points:

  1. Repeat EKG in 10-15 min if questionable EKG and/ or persistant pain. EKG department and ED techs are accountable for giving it to physician to review. There is follow-up pending to making sure copies of EKGs are placed on the chart.
  2. In case of dynamic EKG and consistent story, activate code STEMI. During the day, the patient's cardiologist may be able to take them to lab if ready to go and able to get to the hospital immediately. Do not delay care/ cath for convenience, and ok to use interventionalist on call to avoid delay in door to cath.
  3. Pay attention to early repolarization (no longer considered benign). In case of consistent story, evaluating heart rate, other lead changes, potassium level, and other historical facts, be suspicious of early MI. Additionally, easy to miss the blocks in conduction when only looking for ST changes.



McKean  Syncope


Brugada:  Has been diagnosed in patients age 2-82. EKG findings can be transient. Pt’s have RBBB pattern with STE in septal leads.   Fever can bring out the findings.  Treatment is an AICD.


WPW: Treat with electricity for unstable patients and procainamide for stable patients.

Long QT syndrome: risk of polymorphic V-Tach.   Measure from start of Q to end of T. Quick and dirty is QT should be less than 0.5 the RR interval.   Treat with AICD.


HOCM: LVH without inciting stimulus.  Thickening of intraventricular septum.  You can get exertional syncope due to dynamic  LV outflow changes.   On EKG pt’s will have LVH and deep narrow q waves V4-V6.  Treatment is myomectomy and pacer/aicd


PE: Sinus tach is most common EKG abnormality.  Also look for RV strain pattern (t wave inversions inferior and anterior-most specific finding).   Pt’s may have RBBB.   S1Q3T3 is nonspecific.


A number of ekg examples were discussed along with some embarrassing old pictures of residents especially Barounis.


Harwood pimp question: What is LGL?  Brian Febbo knew it is WPW with no delta wave.  Lown-Ganong-Levine Syndrome is diagnosed by the presence of a short PR interval and normal QRS complex on the surface electrocardiogram (ECG).


Kessen  Heart Blocks


Sorry I missed part of this lecture.

Lenegre’s DZ:  fibrotic sclerodegenerative change of conduction system progresses to complete heart block

Lev’s DZ: sclerosis of left side of heart in older patients causing heart block


1st degree av block: PR interval >0.2msec=5 small boxes.


2nd degree AV block Type 1=Wenckebach.  Progressively longer pr intervals.  RR interval shortens until the qrs gets dropped.   Not treatment indicated.


2nd degree AV block Type 2: PR interval remains constant before and after non-conducted atrial beat.   Atrial rhythm is regular and ventricular rhythm is irregular.


Look for AV block with inferior MI’s.


Harwood comment:  SA block is uncommon but it happens.  You can only see type 2 Sinus block on an ekg.  You can’t see Type 1 or 3 SA block.   SA block is different than AV block. 

Second degree SA nodal exit block has two types.

  • § 
  • §  In type II exit block, the P-P output is an integer multiple of the presumed sinus pacemaker input

Sayger/Felder/Katiyar /McGurk   Billing and Coding


All pneumonia patients going to ICU require blood cultures before antibiotics.

You need 10 ROS systems for level 5.

Document that you visualized and  interpreted the xray and give your interpretation.

Document the number of and type and drug that you used for nebulizer treatment.

You need either a social or family hx to get a level 5.

Keep track of your time you spend with critically ill patients.   Any time the attending spends on the care/ordering/discussion/documentation/decision making with the critically ill patient should be counted toward critical care time.

You need 8 organ systems on physical exam to bill a level 5.

Mnemonic: FORTUNATE    4-2-10-8.  4 HPI items, 2 history items, 10 ROS items and 8 physical exam items to bill level 5.


Ryan  Medical Student Review     Confidential Meeting