Abnormal Presentations of ACS -Always think of this on your differential -Frequently re-evaluate patients -Interpret ECGs in a systematic fashion - and do this every time! RBBB and STEMI - No criteria for STEMI as there are in LBBB - Any ST elevation is abnormal - Read your EKG’s carefully and compare to old - It is never a bad idea to get serial EKG’s if the presentation is unclear ("One ECG Begets Another") De Winter’s Sign - This is an Anterior STEMI Equivalent! - Seen in 2% of acute LAD occlusions - Criteria -Tall prominent symmetric T waves in the precordial leads -Upsloping ST segment depression > 1mm at the J point -No ST elevation in the precordial leads -ST elevation in aVR aVR Sign -Widespread horizontal ST depression, most prominent in I, II, V4-V6 -ST elevation in aVR >1mm -ST elevation in aVR >V1 Hyphen
- Defined as blood in the anterior chamber - Complete a full visual examination - Must evaluate for ruptured globe - Ruptured Globe = Tetanus, antibiotics and emergency consultation Siedel’s Sign - Evaluates for aqueous humor leak secondary to violation of the anterior chamber - Apply topical anesthesia - Paint eye with fluorescein dye - Test is positive if there is a stream of dye emanating from the wound site
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Ovarian Torsion - Ovarian Torsion requires us to be vigilant. It is often misdiagnosed initially by both EM and GYN physicians. - Reconsider your DDx. "Appendicitis" and "Renal Colic" are common mimics of Ovarian Torsion. - Fight diagnostic momentum. - Don’t be fooled by “normal blood flow.” The ovary has two arterial supplies. Diminished venous flow should be alarming even if there is "normal" arterial flow. - See Ovarian Torsion. Perforated Gastric Ulcer - Review your own films! Radiologists are human too. You know what your concern is and may be able to actively see the important abnormality more easily! - Concerning abdominal exam? You don't need to wait for images to call a surgeon. - Think twice before sending to CT, especially with a concerning abdominal exam. - Resuscitate aggressively! Prepare for the patient to become dramatically more ill! - Don’t forget the broad spectrum antibiotics! Ruptured AAA- Resuscitate! (ABCs, Large Bore Access), but be comfortable with permissive hypotension.
- Target SBP ~80-90 mmHg - Do not be in a hurry to intubate the patient if they are breathing on their own. Many arrest after intubation. - IF you must intubate, VENTILATE SLOWLY. Increased intra-thoracic pressure will crush their already tenuous pre-load and cause an arrest. - Cross-matched PRBCs (consider massive transfusion protocol) - Contact your Vascular Surgeon emergently - At CMC, activate “Code Rupture” STEMI vs Pericarditis - Think STEMI if: Reciprical STD (except V1 or aVR), STE in III > II, horizontal or convex upwards STE, new Q waves, check mark sign (T wave takes off directly from S wave, no real ST segment). - Think pericarditis if: PR depression in multiple leads, PR elevation in aVR, Spodick’s sign (downsloping TP segment) Sgarbossa’s Criteria - Concordant ST elevation > 1mm or concordant ST depression >1mm V1-V3 - 90 % specific - Excessively discordant (>5mm discordant ST change or if ST change >25% S wave) – sensitive but not specific! - Only need one lead, do not need two contiguous leads Tick Paralysis - Commonly misdiagnosed as Guillain Barre Syndrome - Most common in females <8 yo with long hair in April-June - Presents with ascending flaccid paralysis, hyporeflexia, sensory sparing |
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