Conerence Notes 5-14-2013

Conference Notes  5-14-2013  There are images in this document. If you don't see them, scroll to the bottom of the page and click "view in browser"

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Kessen/Collins          Oral Boards

Case 1.   28yo female with syncope due to ruptured ectopic pregnancy  Critical Actions:  Diagnose ectopic and identify intraperitoneal blood with FAST exam. Resuscitate with IV Crystalloid and give emergent PRBC transfusion when crystalloid fails to improve vitals.   Give Rhogam for rh neg mom.    Get OB-Gyne to take patient to OR emergently.

Case2.  27 day old male with  fever and “not acting right”   CSF shows signs of meningitis. Critical Actions: Septic work up including LP and stool culture (history of diarrhea), IV boluses, IV antibiotics (ampicillin and cefotaxime), check for signs of abuse. 

Case3.  38yo male with reported suicidal ideation.  Unknown ingestion later identified as APAP overdose.  Patient also had access to a firearm.  Critical Actions: Get important history from parents and girlfriend. Give NAC  for APAP overdose.   Search patient for any weapon.  Dave’s comment: there was a recent patient with suicidal ideation in the ED with a knife hidden in his sock.  Dosing with oral NAC is 140mg/kg PO first dose. Followed by 70mg/kg doses PO q4 hours for 17 doses.  No adjustment of dosing is needed if oral charcoal is given.  There are shortened oral courses of NAC in the literature for Certain clinical situations.  You should consult a toxicologist before stopping oral treatment before the 17th dose.

The approved 20 hour IV dosing regime is complicated and is performed as follows:

Administer an initial loading dose of 150 mg/kg IV over 15 to 60 minutes (we recommend 60 minutes).

Next, administer a 4 hour infusion at 12.5 mg/kg per hour IV (ie, total of 50 mg/kg over 4 hours).

Finally, administer a 16 hour infusion at 6.25 mg/kg per hour IV (ie, total of 100 mg/kg over 16 hours).   (Up to Date Heard, K et al)


Kettaneh/Herrmann                   STEMI Conference

Case 1. 78 you female.  PMH: seizure ,hypertension and high cholesterol.  Presents with syncopal episode/head injury with no chest pain but pt has nausea.     First EKG was not clear cut.  Dr. Silverman  noted somewhat diffuse st elevation with no reciprocal changes.  2nd EKG shows no evolution. 

 Dr. Mistry comment: Documentation is important in this type of case “PCI delayed due to additional diagnostic testing needed.”   Pt went to CT head. CT showed no acute bleed. Troponin was elevated.  Pt diagnosed as NSTEMI.  Dr. Silverman comment: A stat Echo in the ED would have been helpful to identify a focal wall motion abnormality.   At night the tech can take a clip of the image on their smart phone and transmit it to the cardiologist.  Pt was in ED overnight and was hypotensive.  3rd EKG in AM shows evolution and ischemic changes.

Patient was taken to cath lab.   Cath lab shows no coronary stenosis.  Diagnosis was Takotsubo’s myocarditis.   Silverman comment: Takotsubo’s is particularly difficult to diagnosis and is becoming more common.  Only way to diagnose is cath.

Common causes of false-positive STEMI alerts: early repol, myocarditis/pericarditis, takotsubo cardiomyopathy, coronary spasm.  Risks for false positive activations: no chest pain, no reciprocal change, less than 3 cardiovascular risk factors, symptom duration >6 hours.

Takotsubo’s CM: apical ballooning syndrome, presents with chest pain/syncope/dyspnea, ST elevation and elevated troponin but pt has no obstructive coronary lesions.  More common in post-menopausal females.

Case 2.   55yo male with chest pain.  First EKG with signs of posterior STEMI and subtle inferior ST elevation.  

Dr. Silverman comment: Judgment call on this first ekg but with good story, would call a STEMI activation.  2nd EKG 20 minutes later shows Inf-Post EKG.  

Dr. Silverman comment: 20 minutes is a long time to wait to get a second EKG when the first is concerning.  Posterior leads showed posterior STEMi.  Pt had a circumflex injury on cath.   Circumflex lesions are the most common cause of posterior MI.  Posterior MI’s are often associated with inferior MI’s.  Look for horizontal ST depression with a prominent R wave in the anterior leads.   WPW can also cause prominent anterior R waves.  When you do posterior leads, place the V4-6 leads on the left back with the middle lead placed on the inferior tip of the scapula and the other two leads placed symmetrically  around the middle lead.  These three leads become V7-V9.

Case 3.  59yo male with chest pain.  Pt staes he had 7 previous MI’s.  First EKG with inferior ST depression and mild high lateral ST elevation.  Anterior t waves are inverted as well. Dr. Patel comment: first EKG does not meet strict STEMI criteria but is concerning.  Pt developed more chest pain in ED and 2nd EKG showed Acute High lateral AMI. STEMI was called. 

Cath showed occlusion of ramus intermedius artery.   The Ramus intermedius is a coronary anomaly present in 35% of patients.  It is a trifurcation of left main coronary artery. Can supply anterior, lateral or high lateral heart regions.   Again documentation should read:  Delay in PCI due to additional diagnostic testing needed.   Other exclusionary statements include:   PCI delayed due to st elevation in only one lead.  Or PCI delayed due to initial ekg with less than 1mm of ST elevation.   Don’t use the words “mild ST elevation” that does not kick out the case from the CMS bundle.   Mila comment: We have templated phrases in FirstNet.   Dr. Patel comment:  If ST elevation is decreasing from V1-V6 think PE.  Most AMI’s with antero-lat st elevation have increasing elevation from V1-6.

Possible example of decreasing amplitude ST elevation anteriorly c/w pe

Chastain     M and M

49yo male with refractory V-Fib due to respiratory arrest from Influenza Pneumonia

Airway:  LMA can be an effective bridge device for the difficult airway

Anchoring bias: Tendancy to rely on initial information when making decisions.  A Way to reduce this bias is to be aware of it.   Briefly consider alternate/opposite possibility.   Chintan comment: good team work helps to mitigate this bias.

Mistry and Girzadas comments: the Paradigm of leadership is not always the authoritarian dogmatic approach.  A better model is a leader with a global view of the resuscitation who is open to team members suggestions and concerns.

EZIO can be life-saving for  vascular access in the crashing patient.

Setting up zoll pads can be time consuming.   Erik comment: don’t forget the paddles.  They are the fastest option for defibrillating the crashing patient.

Case2.  2yo with severe angioedema.  Pt got SubQ epi prehospital.  Airway with mild stridor and tongue is markedly swollen.  O2 sat is 96% on nasal cannula O2.  IM Epi given, IV steroids given in the ED.  CXR shows pneumomediastinum with diffuse subQ air and bilateral apical pneumos.  Pt has repeated emesis.  

Awake intubation with Ketamine and atropine.  Glidescope was used and anesthesia back up was present.   Things learned: Pediatric bougie does not fit down a 4.0 ET tube.   Pediatric Glidescope does not come with a rigid stylet.

Discussion among faculty: What would be best airway approach between fiberoptic nasotracheal intubation by anesthesia or glidescope intubation by EM in this patient.  

Pt decompensated during airway management attempts.  Airway had to be obtained with surgical tracheotomy in ED.  Bilateral needle thoracostomies and chest tubes were placed for pneumothoraces.

The “angioedema” patient was experiencing was really severe subcutaneous air from chest trauma.  Patient was discovered to have been physically abused.

Pneumomediastinum:  3 main sources esophageal, alveolar, or trauma.  Air can extend into the submandibular space, the retropharyngeal space.   Spinacher sign with pediatric pneumomediastinum is due to displacement of thymus to right side of chest due to air pressure.


spinnaker sign

Peds Airway Pearls: Due to a decreased functional residual capacity, kids desaturate quite quickly compared to healthy adults.    You don’t need to put blade in the oropharynx deeply initially.  Just initially go to the base of the tongue and assess your position. Remember  passive oxygenation at 5L per minute.

Difficult cases can affect physicians emotionally and phsycially.  Group discussion of the emotional toll of difficult cases on physicians.  Girzadas comment: ER docs are the people with the guts to "be there" for patients, even the super difficult cases.  Sometimes you are just "that guy" who is there caring for a patient whom no one can save but you still feel like you should have.   Mistry comment: All you can do is your very best.  We can't always control the outcome.  Willison comment: We are compared to pilots with regard to safety, but our job is tougher.  We can't decide not to take a case because it is too hi risk.  Pilots only fly one plane while we manage multiple patients at a time.  If one of our patients "crashes" we can't go off line and stop working.