emx day 3 cases - cardiac (09/08/2015)

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


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


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]

http://www.ncbi.nlm.nih.gov/pubmed/18534295


“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…


The Emergency ECHO

Apical

Sub-Xiphoid

Parasternal Long

Parasternal Short


Key Structures:

- R ventricle

- Aorta/LV outflow tract

- Bicuspid/mitral valve

- L atrium & ventricle

ECHO: Parasternal Long Axis


Key Structures:

- Inferior window

- Superior window

ECHO: Parasternal Short

Inferior Window Superior Window

Case Study: Apical 4-Chamber ECHO


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/


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


Allergies NKDA

Medications None

Immunizations UTD

When EMS rolls in with a pediatric DFO-to-CPR…

And trying to recall the 13 differentials.


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


Acid/Base Analysis???

pH Low (Acidosis) PCO2 High (Respiratory) HCO3 Low (Metabolic)

Mixed acidosis

Learning acid/base in med school…


Sinus tachycardia with Fusion complexes

Left axis deviation

Nonspecific ST and T wave abnormality

No previous ECGs available


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…


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!!!

emx day 3 cases - cardiac (09/08/2015)

Health & Medicine