We had a fantastic month of conference! Here are some learning points and follow-up resources from Sept EM Conference at Stony Brook.
EKGs 1 with Dr Pendell Meyers
If NSTE-ACS can't be medically managed, they need cath within 2 hours! If you want to cite cardiologists' own guidelines when getting pushback, they are below.
-These guidelines are meant to be applied to the patient who you truly believe has ongoing, refractory angina due to ACS, not just undifferentiated chest pain.
-Important terminology before reading the guidelines:
“NSTE-ACS” stands for “non-ST-elevation acute coronary syndromes”. This includes NSTEMI and unstable angina. It does not refer only to NSTEMI (non-ST-elevation myocardial infarction), which requires positive troponin.
The most important thing here is to notice what they say for “refractory angina.” Both the US and the European official cardiology recommend <2 hour catheterization for patients with NSTE-ACS who have ischemia refractory to medical management. Refractory ischemia in the eyes of the guidelines is identified by angina despite maximal medical therapy (which they define as ASA + clopidogrel/ticagrelor + heparin/LMWH). Refractory ischemic findings on ECG also satisfy this definition. The US guidelines have some exceptions and exclusions which could be broadly interpreted, so you should take a look at them (below) before you try to use these guidelines.
Everything below is directly quoted from the guidelines:
2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Circulation. 2014;130:2354-2394.
http://circ.ahajournals.org/content/130/25/2354
4.4.1. Early Invasive and Ischemia-Guided Strategies
1. An urgent/immediate invasive strategy (diagnostic angiography with intent to perform revascularization if appropriate based on coronary anatomy) is indicated in patients (men and women) with NSTE-ACS who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures).40,42,173,174 (Level of Evidence: A)
Class III: No Benefit
1. An early invasive strategy (ie, diagnostic angiography with intent to perform revascularization) is not recommended in patients with:
a. Extensive comorbidities (eg, hepatic, renal, pulmonary failure; cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C)
b. Acute chest pain and a low likelihood of ACS who are troponin-negative (Level of Evidence: C), especially women 178 (Level of Evidence: B)
ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)
European Heart Journal (2011) 32, 2999-3054
https://academic.oup.com/eurheartj/article-lookup/doi/10.1093/eurheartj/ehr236
5.4.2 Timing of angiography and intervention
The optimal timing of angiography and revascularization in NSTE-ACS has been studied extensively. However, patients at very high risk, i.e. those with refractory angina, severe heart failure, life-threatening ventricular arrhythmias, or haemodynamic instability, were generally not included in RCTs, in order not to withhold potentially life-saving treatment. Such patients may have evolving MI and should be taken to an immediate (<2 h) invasive evaluation, regardless of ECG or biomarker findings.
-This is also one of the first things Dr Smith talks about in his "Who goes to PCI" EMCrit Podcast 146:
https://emcrit.org/emcrit/who-needs-acute-pci/
-For more great content, go to http://hqmeded-ecg.blogspot.com/
EKGs 2 by Dr Pendell Meyers
-ST Depression (=STD) as a result of subendocardial ischemia does not localize
-STD from acute coronary occlusion does (reciprocal STD) = look in reciprocal leads, always!
-STD is normal or abnormal based on its preceding QRS complex
-Everything in the EKG is always proportional
-EKG Lead Placement: if the assistant can't do it, you should be able to - EMCrit Podcast 49 - https://emcrit.org/emcrit/mind-resus-doc-logistics/
-Roberts and Hedges, 5e, Chap 14: Basic ECG Techniques
-Standard precordial leads:
-V1: right sternal border, fourth intercostal space (landmark = sternal angle = 2nd intercostal space)
-V2: left sternal border, fourth intercostal space
-V3: midway between V2 and V4
-V4: left midclavicular line, fifth intercostal space
-V5: left anterior axillary line, same horizontal level as V4
-V6: left midaxillary line, same horizontal level as V4 and V5
-Note that V4 to V6 are placed at the same horizontal level, not all in the fifth intercostal space
-Posterior lead placement: Leads V7, V8, and V9 are placed on the same horizontal plane as V6
-V7 at the posterior axillary line
-V8 at the tip of the left scapula
-V9 near the border of the left paraspinal muscles
PGY3 Senior Grand Rounds: The P Value Fallacy by Dr Kartik Shah
-The p-value can’t tell you about the underlying truth of the hypothesis (e.g. red and blue pill are the same)
-p=0.05 means 5% chance of obtaining results assuming red pill and blue pill are same; so, if you started by assuming the red and blue pill are the same, you can't then say there's a 95% chance your assumption is wrong and that the red pill is better than the blue pill
-Convert p-value to a Bayes Factor
-Doing so creates a shift in mindset: everything must be viewed in its context, and you can use the Bayes Factor only if you have a prior probability (= your context)
-Bayesian viewpoint allows you to use new data, be it clinical or a new article, and add it to your prior framework
-The core of this talk was heavily based on these articles:
http://www.perfendo.org/docs/bayesprobability/5.3_goodmanannintmed99all.pdf (Toward EBM Statistics Part 1 and 2: P value fallacy and Bayes Factor – Goodman – Annals of IM 1999)
-For more, see Rory Speigel's talk: Science vs truth:
http://maryland.ccproject.com/2016/04/28/spiegel-science-vs-truth-an-approach-to-journal-analysis/
M&M
-"No acute distress" with pain 10/10 documented paints a conflicted picture
-O2, narcan, thiamine, glucose are the classic 4 initial interventions of AMS
-Definitely give octreotide on 2nd drop of glucose when on sulfonylureas
-Overdose as well as renal failure = extended half life of meds
-Get the rectal temp: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3236177/ (Oral and Tympanic Membrane Temperatures Are Inaccurate to Identify Fever - West Jrnl EM 2011)
-DOPES mnemonic for desaturating vent patient: https://emcrit.org/emcrit/finger-thoracostomy/
Grand Rounds: Shared Decision Making (SDM) with Dr Marc Probst
-What is SDM: SDM is a conversation
-When: options, capacity, time
-How: Acknowledge, exchange, agree
-Take home: be humble, embrace uncertainty, engage patients
https://www.aliem.com/2017/05/beyond-abstract-shared-decision-making-3-factors/
Pediatric Elbow Trauma by Dr Ismael Suleiman
-Think of abuse
-Elbow ossification: CRITOE
-Anteriorohumeral line
-Radiocapitellar line
-Fat pads – sail sign, posterior fat pad = bad
-Supracondylar – if any displacement, needs reduction, maybe surgery, and obs for compartment syndrome
Sim Day: Pregnant Trauma
-Aggressively resuscitate, since they can lose 25% volume and then plummet. Give the blood!
-Pregnant airway is tough – lot of fat and edema, and then we paralyze so that mass comes down
-Call Ob at community so they can come; will need at least 6 hr toco for abruption
-DIC panel for abruption
-May eventually need RhoGAM
Recommended from the ALiEM AIR series:
http://www.emdocs.net/resuscitation-of-the-pregnant-trauma-patient-pearls-pitfalls/
http://www.emdocs.net/trauma-management-of-the-3rd-trimester-pregnant-patient-pearls-pitfalls/
Sim Day: Central Lines
Cordis: dilator goes inside the cordis, so dilation and cordis insertion is one step
Tons at EMCrit on Central Line Mastery:
http://emcrit.org/central-lines/
http://emcrit.org/podcasts/central-line-show/
http://emcrit.org/podcasts/central-lines-placement-tips/
http://emcrit.org/wee/central-line-micro-skills-deliberate-practice/
https://emcrit.org/emcrit/microskills-dilation/
Critical Care Talks by Dr Scott Weingart
Pulmonary Hypertension
-Podcast 181 on RV Failure and Pulm HTN: https://emcrit.org/emcrit/pulmonary-hypertension-right-ventricular-failure/
-Fantastic review article in Annals of EM by Susan Wilcox: https://emcrit.org/wp-content/uploads/2016/03/Pulm-HTN-Wilcox.pdf
-Pressors (norepi/vasopressin) over IVF to raise MAP to perfuse RV
-Echo to assess pump function - if poor, ionotropic agent
-Decrease RV afterload with inhaled agents
-Goal is eucarbia and euoxia; get the ABG for precision
-If you must intubate, ideally do it awake
-Vent: minimize PEEP, keep them doing their own TV work for neg pressure breaths
-CVP monitoring useful in these patients
Pregnant Endocarditis Case
-1 blood culture = 1 set = 2 bottles; fill them up until blood stops flowing
-Sick endocarditis patient - get lots of cultures immediately and then give abx (vs waiting for cultures over time)
-If platelet clumping causing low lab value, send blood in heparinized vial ("citrated platelet")
-Low grade fever associated with PE more than high grade fever - PIOPED data - http://journal.chestnet.org/article/S0012-3692(15)30926-0/pdf (Fever in Acute PE – Stein – Chest 2000)
-Endocarditis causes inflammatory arthritis (part of JONES criteria)
LAMW Series: 10 things Weingart's learned and changed
-No such thing as a crash airway: use the LMA with ETCO2 to optimize your first pass
-Position: 3 parts: external auditory meatus to sternal notch, face plane parallel to ceiling, base of neck flexion
-Checklist
-https://emcrit.org/emcrit/intubation-checklist-2-0/
-Physiologically difficult airway (HOp killers, pulmonary HTN)
-https://emcrit.org/emcrit/tube-severe-acidosis/
-https://emcrit.org/emcrit/intubation-patient-shock/
-https://emcrit.org/emcrit/lamw-oxygenation-kills/
-https://emcrit.org/emcrit/lamw-oxygenation-kills-ii/
-https://emcrit.org/emcrit/pulmonary-hypertension-right-ventricular-failure/
-Pre-Ox: get to 100%, then new recommendation: stick on NC with one of following 4: ventilator, oxylator, bipap, or BVM/PEEP
-Use video: standard geometry and test yourself, but attending now is at peace
-SGA: use ETCO2; IGel is idiotproof
-Awake intubation: for physiologically or anatomically difficult intubation
-https://emcrit.org/emcrit/definitive-emergent-awake-intubation/
-Ketamine: versatile agent
-Surgical airway: finger-scalpel-bougie
-https://emcrit.org/emcrit/surgical-airway/
Miscellaneous:
-Call Poison Control Center, esp for overdose admissions - they follow-up to ensure proper care upstairs
-After gastric bypass, internal hernias more common due to potential spaces created
-Oral contrast esp useful in bypass pt; don't need full 2 hour, just 20 min, since we want to assess upper GI anatomy
-Give clinical history in CT order to help radiologists
-If delay in CT, get upright abdominal film to eval for free air
-Not all aortic dissections are hypertensive! See EMCrit Podcast 91 for 5 causes of hypotensive aortic dissections: https://emcrit.org/emcrit/aortic-dissection/