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
Textbook: Rosen’s 9th ed, Chapter 21 - Hemoptysis or Tintinalli’s 9th ed, Chapter 63 - Hemoptysis
Corresponding CrackCast Podcast for Rosen's: Episode 212 - Hemoptysis (https://canadiem.org/crackcast-e212-hemoptysis/) - Note: The Q&A format of these episodes is fantastic for really learning emergency medicine, but it can be dry.
Internet Book of Critical Care chapter: Severe Hemoptysis (https://emcrit.org/ibcc/hemoptysis/)
Quick Summary at First10EM: https://first10em.com/massive-hemoptysis/
EmCrit Episode 199 - Management of Massive Hemoptysis (https://emcrit.org/emcrit/massive-hemoptysis/)
EmCrit Wee focuses on intubation technique (https://emcrit.org/emcrit/wee-massive-hemoptysis/)
EMRAP Critical Care Mailbag (https://www.emrap.org/episode/emrap2019march/criticalcare)
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
Textbooks: Rosen’s 9th ed, Chapter 2 - Mechanical Ventilation
Paper on initial ED vent settings by Weingart: https://emcrit.org/wp-content/uploads/2010/05/Managing-Initial-Vent-ED.pdf
Paper on vent and adjunctive therapies for ARDS by Dr. Wright: https://resusacademy.com/protect/core3/Bri-Wright-ARDS-Lecture.pdf
Most up to date ARDS definitions: http://jtd.amegroups.com/article/view/1057/1707
EM Docs blog: http://www.emdocs.net/acute-respiratory-distress-syndrome-ards-whos-risk-ed-relevant-management/
Logistics of Proning: https://emcrit.org/emcrit/logistics-proning/
RACCU – Dr. Weingart
RSI MEDICATIONS
Administration
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
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