Stony Brook
EMergency Medicine
Residency

(631) 444-3880

 

101 Nicolls Road,

Stony Brook, NY 11794

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Copyright 2019 Designed by Michael Beck MD

The Best in FOAM Education

September Conference Pearls

October 1, 2017

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/

 

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