Carolinas Emergency Medicine Residency

High Risk ACS without diagnostic ST-Segment Elevation - Dr. L. Littmann

1/25/2018

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Posterolateral MI

Acute thrombotic LCX occlusion – it is a STEMI
Diagnostic criteria
- presentation with acute chest pain
- ST depression in the anterior chest leads which may be due to anterior ischemia, posterior STEMI or RVH with strain
- posterior STEMI is frequently accompanied by subtle Q waves, subtle ST elevation or the “wishbone sign” in the inferior and/or lateral leads
It is a STEMI but ST elevation may not be seen in the 12-lead ECG (“STEMI without STE”)
Place ECG leads to the back (V7-V8-V9)
Any ST elevation in the posterior leads warrants immediate cath/reperfusion

Dressler - de Winter sign

Acute thrombotic proximal LAD occlusion – a STEMI equivalent
- in 98% of cases of acute LAD occlusion: there is frank electrocardiographic STEMI
- in 2% of cases of acute LAD occlusion: Dressler - de Winter sign
Diagnostic criteria
- presentation with acute chest pain
- very tall “hyperacute” T waves in the chest leads
- usually accompanied by upsloping ST depression (ST depressed at the J point)
- patients are frequently young males
- chest pain to the “de Winter” ECG presentation is usually within 30-120 minutes
Imminent risk of extensive anterior STEMI
The de Winter sign warrants immediate cath/reperfusion

aVR sign

80% specific for tight left main coronary artery stenosis – high risk of large STEMI
Diagnostic criteria
- presentation with acute chest pain
- diffuse ST-segment depression
- ST elevation ³1 mm in aVR
High but not necessarily imminent risk of STEMI, usually extensive, frequently lethal (“widow-maker artery”)
Urgent cath/reperfusion is indicated (but not necessarily immediate cath)

Wellens sign, Wellens syndrome

Suggestive of tight proximal LAD stenosis – high risk of subsequent anterior STEMI
Diagnostic criteria
- presentation with chest pain
- biphasic (positive-negative) T waves in the anterior chest leads (type A – 25%) and/or
- deep symmetrical negative T waves in the chest leads (type B – 75%)
- no abnormal Q waves; normal R-wave progression in the chest leads
- T-wave abnormalities can be present even in the pain-free state
- no or only subtle troponin elevation
If undetected/untreated, high risk of subsequent STEMI, usually days/weeks later
In typical Wellens syndrome: cardiac cath without prior stress testing is indicated

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Carolinas Case Conference - Dr. S. Pecevich

1/4/2018

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Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy: middle to older aged adults with a recent physical or emotional stressor, more common in women, usually patients do well but approximately 10% may experience shock
May need to differentiate between patients with left ventricular outflow tract obstruction and those without. Avoid inotropy in patients with murmur or other concerning signs for obstruction
Consider aortic balloon pump in complete LV failure
Avoid phenylephrine push dose boluses prior to RSI when you’re concerned about cardiogenic shock. Have other vasopressors ready and potentially the drip started
V fib arrest: think ischemia first! You need an EKG and if it’s concerning, need to stabilize the patient for the cath lab
Sedating a patient with recent ROSC can be tricky. Start low on the sedatives and increase as needed to as to not compromise hemodynamics
Bloody airway? Anticipate needing to use direct laryngoscopy. Have back up items ready for bagging including a supraglottic airway in case you are unable to find the cords on first view

REBOA Catheter in Penetrating Trauma

If systolic blood pressure around or below 90 in setting of trauma, arterial femoral access should be gained
Thoracotomy in isolated abdominal penetrating trauma has dismal outcomes and is generally not indicated
REBOA catheter can be used in penetrating trauma but with caution: it is contraindicated in thoracic penetrating trauma
Some studies suggest that REBOA may have better outcomes in penetrating abdominal trauma but numbers are still low to draw major conclusions
CPR is of little utility in pulseless trauma, particularly penetrating trauma. These patients need copious amounts of blood and potentially decompression of the chest. Additionally, performing procedures during chest compressions endangers staff and providers
Do not forgot the basics of trauma when performing procedures. Basic venous access and a good primary survey are paramount. A great deal of attention can go into procedures but the trauma captain needs to stay in control of the case
Order massive transfusion pack in advance; it does not have to be opened but should be available

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Transgendered Patients in the ED - Dr. A. Dozois

1/4/2018

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•For any marginalized population – up your communication game.
•Avoid misgendering – best practice is to ask for preferred pronouns
•Gender-affirming genital surgery is uncommon, but can have important complications, including (rectovaginal, urethrovaginal) fistulas and strictures.
•Impact of hormone therapy on CV risk is unclear
•Be an advocate for your patients - this is what Emergency Docs do!

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High Risk ACS without diagnostic ST-Segment Elevation - Dr. L. Littmann

Carolinas Case Conference - Dr. S. Pecevich

Transgendered Patients in the ED - Dr. A. Dozois

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