Carolinas Emergency Medicine Residency

Sharpen YOur Calipers - Dr. Littmann

1/28/2016

0 Comments

What is STEMI without STE?

Patients presenting with acute chest pain may have clinical STEMI (acute total thrombotic occlusion of a large coronary artery) but no obvious ST-segment elevation in the ECG
This occurs with STEMI locations that are not well represented by conventional ECG leads
Such patients are at high for not receiving timely reperfusion therapy and for having poor outcomes
Easily memorizable ECG signs can help raise awareness of the possibility of STEMI without STE
If suspected, placing exploring electrodes to the area of interest can quickly uncover the STEMI

Posterolateral or High Posterior MI

The most common type of missed STEMI
Almost always due to acute occlusion of the LCX
May involve the posterior papillary muscle and can cause severe mitral regurgitation
Earliest ECG sign: ST depression in the anterior chest leads (mirror image of posterior ST elevation)
Frequent associated findings: subtle Q waves or subtle ST elevation in the inferior or lateral leads
Can be uncovered by placing exploring electrodes to the back (V7-V8-V9)

High Lateral MI

The second most commonly missed STEMI
Almost always due to acute occlusion of the first diagonal branch of the LAD (LAD-D1)
Fortunately usually small
Earliest ECG sign: ST elevation in leads I, aVL and V2, but not in V1 or V3, and ST depression in III and aVF
With the conventional 4x3 lead display format, the spacing of ST deviation resembles the shape of the South African flag (the “South African Flag Sign”)
Can be uncovered by placing the V4-V5-V6 ECG leads 1 and 2 interspaces higher

RV infarct

Almost always due to acute occlusion of the proximal RCA
Almost always associated with acute inferior STEMI
Recognition of RV infarct, therefore, is now less important because code STEM is usually called anyway for the inferior MI
Recognition can be important, however, if the ST elevation in the inferior leads is subtle or nondiagnostic
Clues to suspect RV MI:
1. Inferior STEMI with marked ST depression in I and aVL (left leads)
2. Inferior STEMI with ST elevation in V1 only but not in V2
Can be uncovered by placing right-sided chest leads
If inferior STEMI has been diagnosed, there is no need to waste time to record right-sided chest leads
Suspected RV MI:
1. Use caution with vasodilators (nitrates)
2. Consider IV fluids for hypotension with JVD

0 Comments

Carolinas Case CONFEREnce - Dr. Beverly

1/14/2016

0 Comments

Case 1:

Excess iodine exposure can lead to the Jod Basedow effect:
In presence of excess iodine, patient’s have autonomous production of thyroid hormone independent of normal regulatory functions

Average iodine intake for an average adult is 150ucg.
Iodine load in 1 CT scan averages 370mg/ml.
Each scan loads with 100-120ml.
Can affect patients will underlying thyroid disease

Treatment in the ED focuses on symptomatic care, adrenergic receptor blockade, blocking thyroid hormone synthesis, inhibiting hormone release and decreasing peripheral conversion

Case 2:

Postural orthostatic tachycardia syndrome is defined by excessive increase in heart rate (greater than 30bpm) when supine to standing in the absence of other overt orthostatic symptoms

Treatment focuses on preventing hypovolemia and treating excessive sympathetic tone.

Case 3:

Cerebellar strokes present with vague symptoms and are hard to diagnose.

Pitfalls in ED diagnosis include failure to recognize risk factors in young patients and failure to understand that there is a spectrum of disease.

Consider inpatient hospitalization for patients at higher risk.

Do not delay consultation if you are worried.

0 Comments

Esophageal Disasters (When it Really isn't the HEart) - Dr. Jannach

1/14/2016

0 Comments

1. Remember esophageal etiologies as a cause of life threatening chest pain.
2. Esophageal perforation is rare, deadly, and fast acting. Delay in diagnosis can cause doubling of mortality.
3. Know best imagning studies available at facility, and have low threshold for surgical consultation.
4. Quick recognization and initation of medical management is key:
NPO, PPI, and antibiotics (ie zosyn) in all cases.
5. Be familiar with the latest management of esophageal perforation: medical
management vs surgical management vs stent placement.

0 Comments

Sharpen YOur Calipers - Dr. Littmann

Carolinas Case CONFEREnce - Dr. Beverly

Esophageal Disasters (When it Really isn't the HEart) - Dr. Jannach

Archives

Categories