I. Myocardial injury

• In inferior MI, if ST elevation in lead III is greater than ST elevation in II: probable RCA occlusion
  • higher risk of bradycardia, AV block, atrial fibrillation and RV infarct (always with RCA MI)
• In inferior MI, if ST elevation in lead II is greater than ST elevation in III: probable LCX occlusion
  • higher risk of papillary muscle dysfunction, acute mitral regurgitation, pulmonary edema
• Presence of wide and deep Q waves suggests large transmural MI and no viability
  • in acute MI: probable late presentation, no viability
  • in remote MI: consider LV aneurysm
  • In acute anterior STEMI, new right bundle branch block suggests large MI and high mortality
• Acute myocarditis can present with STEMI picture in the ECG
  • clinical presentation is different (severe acute heart failure, pulmonary edema)
  • ST elevation is frequently diffuse
  • conduction abnormalities (A-V block) are frequently present

 

II. Secondary ST-segment elevation

• With wide QRS complexes (left bundle branch block, ventricular pacing, WPW)
  • QRS and ST-Ts are usually discordant: discordant ST elevation is normal
  • ST elevation that is concordant with the QRS complexes strongly suggests STEMI
• In severe LVH with narrow QRS complexes
  • QRS/ST-Ts are usually discordant: ST elevation in the anterior chest leads may be normal
  • in questionable cases, compare with old ECGs; perform serial ECGs; stat bedside echo

 

III. Terminal notching of the QRS complexes followed by hammock-shaped ST elevation

• Pericarditis
  • tachycardia
  • ST elevation is diffuse but usually spares leads aVR and V1
  • depressed PR segment in lead I; elevated PR segment in lead aVR
• Hypothermia
  • bradycardia
  • large and diffuse terminal QRS notching (Osborn waves)
  • prolonged QT
  • shivering artifact
• Benign early repolarization
  • frequently present in young African-American males
  • terminal QRS notch and hammock-shaped ST elevation usually best seen in V4
  • heart rate and QT are usually normal
  • concern about risk of ventricular arrhythmia and sudden death in certain small subgroups

 

IV. Brugada syndrome, Brugada sign

• High take-off upward convex (“coved”) ST elevation followed by negative T waves in V1 and V2
• Increased risk of sudden cardiac death
• Endemic in South-East Asia (Laos, Vietnam, Cambodia, Thailand)
• Male predominance
• Highest risk of sudden death is in patients with resuscitated sudden death, h/o unexplained syncope, spontaneous and dynamic Brugada ECG pattern, nonsustained VT during monitoring
• Most asymptomatic patients without the listed risk factors, especially those who are older at the time of diagnosis, are at minimal risk of unexplained sudden death (“Brugada sign”)

Epistaxis

• Epistaxis is classified as either anterior or posterior.
  • Anterior epistaxis usually originates in the vascular watershed area of the nasal septum known as Kiesselbach's plexus involving the ethmoidal artery, sphenopalatine artery, and facial artery.
  • Posterior epistaxis usually originates from the sphenopalatine artery but may also arise from the internal carotid artery.
• Diagnostic studies of coagulation panel, hemoglobin, and platelet count are not necessary in the typical healthy patient with epistaxis.
• 65% of cases achieve hemostasis with use of topical vasoconstrictive agent and 10 minutes of continues pressure of the septum.
• Maintain the patient in “sniffing position” during examination to obtain the best possible views of the anatomy.
• If anterior source is identified, then attempt cauterization.
• If patient remains symptomatic, pack the anterior naris.  Be sure to provide anxiolytics as this is incredibly uncomfortable for the patient.  Anterior packing of bilateral nares may be required in order to provide a counterforce to the lesion.
• There are few studies concerning the use of antibiotics in patients with nasal packing for TSS prophylaxis, but most specialists recommend initiating Augmentin.
• If patient continues to bleed, it is most likely a posterior bleed and will require posterior packing.  A Foley catheter (10-14 French) can be used for posterior packing in a pinch.
• Patients with posterior packing could theoretically undergo lethal bradydysrithmias and should be admitted to a monitored bed.

 Foreign Bodies

• Button batteries and paired disc magnets are especially harmful.
• Most nasal foreign bodies are radiolucent.
• Patients often present with unilateral mucopurulent drainage.
• Initial attempts at removal should involve positive pressure techniques.
  • Have the patient blow his or her nose while occluding the nostril opposite of the FB.
  • “Mothers Kiss” involves having the parent provide oral positive pressure to a pediatric patient while occluding the unaffected nostril.
  • You can provide 15 L/min of O2 via a soft rubber Christmas tree to the unaffected naris, if a pediatric patient refuses to open their mouth.
• If positive pressure fails, helpful tools for manual extraction include otoscope, nasal speculum, curette, forceps, suction, and/or Katz catheter.  A pediatric foley catheter (5 french) can be substituted for a Katz catheter.
• Remember to use sedation and application of local analgesic and vasoconstrictive agents prior to manual extraction.

Henoch-Schönlein purpura

• Henoch-Schönlein purpura = IgA Vasculitis (IgAV)
• Disease process is mostly seen in pediatric populations
• Tetrad

1. 1. Palpable purpura WITHOUT thrombocytopenia or coagulopathy
2. 2. Arthritis / arthralgia
3. 3. Abdominal Pain
4. 4. Renal disease

 

• Usually self limited,  but total disease course can be long (except in adults)
• There are some instances where steroids may help, but not all cases.
• Follow up is key! Need repeat urine and renal studies!

-Overall relatively uncommon in the US, but the ED population is particularly high risk
-More common in the extremes of age, the medicated, and the chronic alcohol abusers
 
Wernicke Encephalopathy
-Thiamine deficiency
-Clinical diagnosis, but frequently missed
-2 of 4 criteria
                1. Nutritional deficiency
                2. Altered mental status
                3. Ocular findings
                4. Ataxia
-Altered mental state is the most common finding
-Nystagmus is more common than opthalmoplegia
-Tx: 500 mg IV q8hr x 2d, then daily until oral tolerated
-Insufficient evidence for prophylaxis, IV not necessary and expensive!
-It’s okay to give glucose if your patient needs it before thiamine
-Always walk your patients!
 
B12 Deficiency
-B12 requires intrinsic factor for absorption
-More common in elderly, autoimmune, and those on proton pump inhibitors
-Consider in megaloblastic anemia with neurological symptoms
-Tx: IM injections
 
Vitamin D
-Required for dietary calcium and phosphorus absorption
-Majority obtained from dermal synthesis
-Low levels leads to increased PTH, which results in mobilization of Ca from the bone
-Increased prevalence of Rickets in infants due to relatively low concentration in breast milk and sunscreens
-Classically lower extremity bowing, thin bone cortex, poor growth, delayed fontanelle closure
-May progress to tetany, seizures, prolonged QT due to hypocalcemia
-If seizing or tetany, give calcium. If thinned bones, give oral vitamin D
-In the elderly – common cause of osteopenia, fragility fractures, secondary hyperparathyroidism
 
Vitamin K
-Necessary for activation of coagulation factors
-Typically in leafy greens, synthesized from gut bacteria
-Increasing in prevalence due to families refusing vaccinations
-Infants have low stores at birth, sterile gut, low concentrations in breast milk
-Classic bleeding at 2 days- 4 weeks with bleeding from mucosal surfaces
-Late presentation 3 weeks-8 months- higher percentage of ICH, blown pupil may be a sign of SDH
-Look for decreased Hct, prolonged PT
Tx: preventable with 0.5-1 mg IM at birth
There is an oral option! 2 mg orally with 1st feed, repeated at 1, 4, and 8 weeks of age
Emergency: 1 mg Vit K, 10-20 mL/kg FFP if life threatening
 
Board Review buzzwords, less likely to present as emergencies
-Night blindiness, dry eyes, keratomalacia – Vitamin A deficiency
-Idiopathic intracranial HTN – hypervitaminosis A
-Diarrhea, dermatitis, dementia (Pellegra) – Niacin deficiency (B3)
-Petechiae, perifollicular hemorrhage, bruising, corkscrew hairs (Scurvy)- Vitamin C deficiency
-Angular chelosis – Riboflavin deficiency (B2)
-Isoniazid + seizure – pyridoxine (B6)
-Spina bifida – folate deficiency