TEAM Challenge CoRE Concepts

Myocardial infarction with papillary muscle rupture

• Rare complication, cited in 1-2% of acute MI. Most often secondary to papillary muscle necrosis following RCA infarction. 
  
• Present with new onset severe mitral valve regurgitation with complicating heart failure.
  
• Ultimately, patient requires surgical intervention for valve repair/replacement, though intra-aortic ballon pump can be used as bridge. 
  
• Avoid fluids given heart failure; nitroglycerine also problematic given preload dependence. Need vasopressors, with dobutamine being mainstay of treatment. 
  
• Literature cites usage of afterload reducing agents such as nicardipine, though difficult in practice. Emergent interventional cardiology and CV surgery consultation is paramount.
  
• Intubation should be approached with great caution, given high risk of arrest in setting of preload reduction,  increased intra-thoracic pressure and catecholamine suppression.
  

Thyroid storm

• Most commonly due to severe exacerbation of underlying hyperthyroidism (i.e. Graves’ Disease) caused by trigger (pregnancy, substance abuse, infection, surgery, trauma, iodine load).
  
• Consider in young patients with new onset atrial fibrillation with RVR with concomitant altered mental status/agitation, GI disturbance, heart failure. 
  
• Treatment must occur in stepwise manner to prevent worsening of disease process: 

1. Block synthesis (methimazole, PTU)
   
2. Block hormone release (iodine solutions given >1hr after methimazole)
   
3. Block peripheral conversion (steroids)
   
4. Block peripheral effects (propranolol)
   
5. Give supportive measures/treat trigger.
   

• May rapidly progress to high output heart failure! Endocrinology consultation and ICU admission a must!
  

Aspirated foreign body

• 70% of aspirated FB occurs in pediatrics, with food items accounting for 49% of aspirations.
  
• Important to assess level of obstruction: Larynx, trachea, bronchus.
  
• Right primary bronchus most common level of deep aspiration.
  
• Often objects not radio-opaque; consider expiratory/decubitus films.
  
• All objects need to be removed, given potential for delayed complications (i.e. post-obstructive pneumonia).