THE MORNING REPORT

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  • Stony Brook Emergency Medicine

9/10/2020 Conference Summary

EKG : STEMI vs Non-STEMI – Dr. Johnson 

OMI Manifesto – Coronary occlusion often presents without classic ST elevations on ECG. Learn to recognize other ECG patterns consistent coronary occlusion MI (OMI) and advocate for PCI in these patients.  

Further Reading

General Tips for Interpreting ECGs

  • Ask for context 

  • Compare to prior 

  • Interpret ST segments and T-waves in context of QRS (ventricular hypertrophy) 

Posterior MI  

ST depressions maximal in V2-V3 -> GET POSTERIOR LEAD ECG 

Sgarbossa's Criteria – identifying STEMI hidden in LBBB or paced rhythm 



Dewinters – STEMI Equivalent 


Wellens Syndrome– Critical LAD Stenosis 



Brugada – Not a STEMI but can’t be missed



Right Heart Strain

  • Acute – RBBB with T-wave inversion 


  • Chronic - RVH 


SMALL GROUP CASES

Case 1 : TB 

Primary infection  

  • Focused in lower lobes of lungs spreads to regional LNs  

  • Usually disseminates to high O2 areas (apical and posterior segments of upper lung lobes, kidneys, bones, and brain) and then becomes dormant 

Latent TB 

  • Presence of inactive TB in the body 

  • Not infectious and cannot spread TB  

  • No symptoms and does not feel sick  

  • Positive skin test with normal CXR and negative sputum test  

  • Needs treatment to prevent active TB  

Reactivation TB  

  • Occurs in approximately 10% of patients who are infected  

  • Associated with weakened immunity  

Extrapulmonary TB (from primary or reactivation)  

  • Includes TB meningitis, pleural TB, genitourinary TB, miliary TB (disseminated), vertebral TB (Pott’s disease), ocular TB 


Treatment : RIPE 

  • rifampin, isoniazid, pyrazinamide, and ethambutol 

Empyema – Purulent effusion --> Need CT surgery consult

Case 2 : Hemoptysis 

Major Takeaways: 

  • The cause of death will be asphyxiation, not exsanguination so intubate early when massive hemoptysis is occuring to try to protect the good lung 

  • Call for help - anesthesiology (may help intubate/bronchial blocker if needed), pulmonology (bronchoscopy), IR (embolization), CT Surgery (ECMO) 

  • Reverse coagulopathies right away 


Further Reading

Case 3 : SCAPE 

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) aka Flash Pulmonary Edema 

Treatment Goal : Decrease LVEDV which improves SV and CO  

1. Decrease preload and afterload (Nitro +/- diuretics) 

  • Sublingual (0.4mg q3-5minutes) 

  • Transition to ggt when IV established (50-200 mcg/min : titrate by 20-40 mcg/min q3-5 min) 

  • Consider adjuncts if Nitro no sufficient (Captopril 12.5 mg SL or 0.635 mg enalapril IV)

2. Utilize BiPAP or CPAP 

3. Consider inotropes for cardiogenic shock (norepinephrine, dobutamine, milrinone) 


Further Reading

Case 4 : ARDS/Aspiration Pneumonia 

Major Takeaways: 

  • ARDS is a non-cariogenic pulmonary edema that leads to hypoxemia and further acute lung injury 

  • In general, ventilation strategies are “lung protective” in order to avoid VILI (ventilator-induced lung injury) 

  • If ARDSNet fails… consider APRV

Further Reading

RACCU – Dr. Weingart 


RSI MEDICATIONS 

Administration 

https://emcrit.org/pulmcrit/pulmcrit-rocketamine-vs-keturonium-rapid-sequence-intubation/


General approach – induction agent and paralytic 

  • Wrong – slow push induction followed by pause followed by slow push paralytic 

  • Less wrong – fast push induction followed quickly by fast push paralytic  

  • Ideal administration – push paralytic then immediately push induction 

Induction Agents 

When to choose Ketamine 

  • Always choose Ketamine unless hypertensive, neuroprotective (ICP), or concern for aortic dissection or AAA (need to minimize catecholamine surge). In which case, use etomidate.

When to choose Propofol  

  • Status epilepticus 

When to choose Midazolam 

  • If you anticipate that amnesia will be beneficial for the patient (Ex: Reduced dose RSI in hemodynamically unstable patients)


Paralytics

Default – Rocuronium  

Unless : 

  • Neuro exam needed : more theoretical, ideally let Neuro/Neurosurgery get an initial exam then use what you want - Keep in mind that there are reversal agents for Rocuronium

  • Status Epilepticus – Need to know if patient is still seizing immediately 

One argument for Succinylcholine reduced likelihood that patient is paralyzed without sedation 

  • DON’T FORGET POST INTUBATION SEDATION 

  • Train nursing staff that reaction to post intubation hypotension is to start pressor not to turn off sedation 


Delayed Sequence Intubation


Ketamine --> pause, assess --> paralytic 


Use for: 

  • Hemodynamic unstable patients – if patient remains too unstable after ketamine, proceed with awake intubation (do not give paralytic) 

  • Need to place NG prior to intubation (GI bleeds, SBO) 

  • Need sedation for pre-oxygenation (agitated) 

SALAD – Suction Assisted Laryngoscopy and Airway Decontamination 

Stony Brook
EMergency Medicine

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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