Prolonged (63 minutes) Ventricular Fibrillation, Followed by Unusual Cardiogenic Shock
In this study, 5% of VF arrest was due to PE: V fib is initial rhythm in PE in 3 of 60 cases. On the other hand, if the presenting rhythm is PEA, then pulmonary embolism is likely. When there is VF in PE, it is not the initial rhythm, but occurs after prolonged PEA renders the myocardium ischemic.--Another study by Courtney and Kline found that, of cases of arrest that had autopsy and found that a presenting rhythm of VF/VT had an odds ratio of 0.02 for massive pulmonary embolism as the etiology, vs 41.9 for PEA. (Source: Dr. Smith's ECG Blog)
Source: Dr. Smith's ECG Blog - September 19, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything.
Then we heard, “STEMI. Activating prehospital.”
EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital signs were normal.
He...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Secrets Behind the Curtain
“Doc to the radio phone,” went the call over the PA. This is often just medics notifying about a diabetic refusing transport or stopping a futile code, though like most of emergency medicine, it can be anything.
Then we heard, “STEMI. Activating prehospital.”
EMS had been called to the house of a 54-year-old man. He had been experiencing chest pain on and off for several weeks. The most recent episode began about 30 minutes prior to ED arrival. He described 8/10 retrosternal pressure that radiated down his arms. He was tachypneic, but denied shortness of breath and was not hypoxic. Other vital signs were normal.
...
Source: Spontaneous Circulation - September 2, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
Poor Microvascular Reperfusion ("No Reflow"): Best Diagnosed by ECG
This study demonstrates the importance of frequent static ECG’s and the insensitivity of using only 2 static ECG’s to detect reperfusion. In 58% of patients, ST segments were unstable, rising and falling, before final resolution.Infrequent static ECG’sCaliff RM et al., Failure of simple clinical measurements to predict perfusion status after intravenous thrombolysis, 1988. Methods: Califf et al. (339) performed angiography on 386 TAMI patients at 60 and 90 minutes post-administration of tissue plasminogen activator (tPA). They recorded a baseline ECG and another at 90 minutes post-tPA, before ...
Source: Dr. Smith's ECG Blog - August 9, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Contraindications for insertion of IABP
(intra aortic balloon counter pulsation)
Aortic regurgitation and aortic disease are contraindications, both are likely to be worsened by the balloon counterpulsation. In aortic regurgitation, the main aim of improving coronary perfusion with IABP will not be achieved. It is interesting to note that diastolic pressure will be more than systolic pressure when IABP is used for cardiogenic shock. The balloon inflation is timed either by the pressure wave or by the ECG to correspond to the diastolic period. The balloon is positioned below the left subclavian origin and above the level of the renal arteries, in the descending ...
Source: Cardiophile MD - August 5, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Source Type: blogs
The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.
The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, with de...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The Pains of Separation
When a patient arrives to your ED fresh from karate class still in her uniform, you get a feeling about where the case is heading. This patient was 49, and reported that she always had some aches after karate. This evening, though, her pain was very different — and much more concerning. The pain had started about an hour into her class and worsened over the next 30 minutes. It was a severe achy pain over her left chest that radiated to her neck and was associated with pronounced diaphoresis. This prompted an expedited cardiac workup.
The ECG showed a sinus tachycardia with ST-elevation in V2-V3, I, aVR, aVL, with depr...
Source: Spontaneous Circulation - August 5, 2014 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs
The difference between Left Main occlusion and Left Main insufficiency
There are many publications stating that ST elevation in lead aVR, with diffuse ST depression elsewhere, is due to "left main occlusion." This is even stated in the lastest 2013 ACC/AHA STEMI guidelines, and they reference an article by Jong et al. (Int Ht J 2006; 47(1):13-20.) as evidence. If you go read that article, "occlusion" was defined as any stenosis greater than 50%. That is not occlusion, which is 100%. There are many other articles that confuse Left Main occlusion with Left Main insufficiency, and these are the sources of the mistaken belief that this ECG pattern reflects LM occlusio...
Source: Dr. Smith's ECG Blog - August 2, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Subacute AnteroSeptal STEMI, With Persistent ST elevation and Upright T-waves
DiscussionWhen there is full thickness infarction, there is epicardial inflammation (post-infarction regional pericarditis), and the myocardium is at risk of "rupture." The term "rupture" makes it sound like some sort of explosion or massive blowout, but it is usually a small, slow leak that, over time, can cause tamponade and death. Rupture can be either free wall rupture (causing tamonade) or septal rupture, causing ventricular septal defect with left to right flow and resulting pulmonary edema and shock. If detected early by ultrasound, the patient can be saved. Our own Dave Plummer of HCMC repor...
Source: Dr. Smith's ECG Blog - July 18, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
The LITFL Review 143
The LITFL Review is your regular and reliable source for the highest highlights, sneakiest sneak peaks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the best and brightest from the blogosphere, the podcast video/audiosphere and the rest of the Web 2.0 social media jungle to find the most fantastic EM/CC FOAM (Free Open Access Meducation) around.
Welcome to the 143rd edition, brought to you by:
Kane Guthrie [KG] from LITFL
Tessa Davis [TRD] from LITFL and Don’t Forget The Bubbles
Brent Thoma [BT] from BoringEM, and ALiEM
Chris Ni...
Source: Life in the Fast Lane - July 9, 2014 Category: Emergency Medicine Authors: Kane Guthrie Tags: Education eLearning Emergency Medicine Featured Health Intensive Care LITFL review LITFL R/V Source Type: blogs
Respiratory Failure and ST Depression: Is there Posterior STEMI?
The ultrasound in this case was recorded by Dr. Robert F. (Rob) Reardon, one of my partners here at Hennepin County Medical Center (HCMC) in Minneapolis, and one of the world leaders in emergency ultrasound. He is also an editor of this great new textbook of emergency ultrasound (Ma, Mateer, Reardon, Joing, eds.), and one of the authors of the Cardiac Ultrasound chapter (other authors of this chapter are Dr. Andrew Laudenbach (also of HCMC) and Dr. Scott Joing (also of HCMC, and the creator of the outstanding FOAMed site, www.hqmeded.com).CaseA middle-age woman with a history of emphysema presented in severe res...
Source: Dr. Smith's ECG Blog - June 24, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Acute Cardiogenic Shock: What is the Diagnosis?
Click on this link of a recently posted a similar case with great ultrasound images. Let's see how much you learned and remember.Acute Cardiogenic ShockA 69 yo previously healthy woman had very sudden severe dyspnea. Her husband reported that they had been physically active that day, and that the patient had complained of some chest pain one week prior for which she did not take his advice to go to the ER. She presented in pulmonary edema, hypoxic on high flow O2, and sats at 90% on Noninvasive Ventilation. BP was 130/70 but she was clinically shocky. Cardiac physical exam was unremarkable exc...
Source: Dr. Smith's ECG Blog - May 26, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Sudden Cardiogenic Shock
An elderly woman presented with rather sudden altered mental status, hypoxia, and hypotension. She had no significant past medical history except for cognitive decline. She was cool and mottled with thready pulses. BP was 54/32. No murmurs were heard. Tissue perfusion monitor recorded 33% (very low) [see this explanation of StO2 by our new chief and prolific researcher, Jim Miner]She was immediately intubated by blind nasotracheal technique (very fast, no complications).Immediate ultrasound showed good sliding signs and B-lines (a sign of pulmonary edema) only on the right.Here was her initial...
Source: Dr. Smith's ECG Blog - April 20, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Should we measure LV EF in the early hours of STEMI ?
LV ejection fraction (EF) is the most commonly used LV systolic functional index.Since , it is an easily acquired parameter, it’s popularity has zoomed among both learned and novice cardiology professionals .(Not withstanding the serious shortcomings!)
In one of the evening rounds in my CCU , a young cardiology fellow told me about a patient with acute anterior MI with ST elevation V1 to V5.
The patient was lying supine with trunk up . HR was 110 . BP was 100 /70 There were few basal crackles .The patient was undergoing lysis with streptokinase.
It was suggested to me by the fellow that ...
Source: Dr.S.Venkatesan MD - April 8, 2014 Category: Cardiology Authors: dr s venkatesan Tags: Cardiology -unresolved questions Echocardiography - LV dysfunction Echocardiography-Limitations of LV EF % Infrequently asked questions in cardiology (iFAQs) asessing LV function following stemi echocardiography in stemi LV ejection fraction Source Type: blogs
The ECG told the whole story, but no one listened: ECG interpretation skills are critical to patient outcomes.
Preface This was sent by a medical student somewhere in the world who will remain anonymous. But it happened at a prestigious cardiac center. Details are scant so that it cannot be recognized.The minute this medical student saw the first ECG, he knew the diagnosis without any further information. Reading ECGs is hard, but can be done with commitment to learning, which comes from an awareness of its importance. My most talented blog readers are paramedics because they have to put themselves on the line every time they activate the cath lab. And they teach me a lot. One of my most talented reade...
Source: Dr. Smith's ECG Blog - March 30, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
