A 53 yo woman with cardiogenic shock. Believe me, this is not what you think.
This was sent by a reader.A previously healthy 53 yo woman was transferred to a receiving hospital in cardiogenic shock.pH was 6.9 and K was normal.Here was the ECG:There is sinus tachycardia.This is " Shark Fin " morphology.Shark Fin has also been called:"Giant R-wave""Triangular QRS-ST-T waveform"Usually shark fin is in one coronary distribution and represents massive ST elevation that is as high as the peak of the R-wave and thereforefuses the R-wave and ST segment.So Shark Fin really is just a dramatic representation of STEMI, and can be in any coronary distribution.It is often confused with a wide QRS due to condition...
Source: Dr. Smith's ECG Blog - February 15, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
Ventricular Fibrillation, ROSC after perfusion restored by ECMO, then ECG. Protocols can be overridden by Physician Judgment.
A middle-aged male had sudden chest pain and called 911. First responders arrived. Then the patient arrested. Chest compressions were started immediately. Paramedics arrived a few seconds later and found the patient in ventricular fibrillation. He could not be defibrillated after 3 attempts. He was intubated, given epinephrine and amiodarone, and transported.He arrived in the ED 35 minutes after arrest. He remained pulseless and in V Fib.Defibrillation was not successful.Cannulation for ECMO (Extracorporeal life support -- ECLS) was begun.He was debribrillated again and had brief (...
Source: Dr. Smith's ECG Blog - January 23, 2020 Category: Cardiology Authors: Steve Smith Source Type: blogs
Risk of cerebral hypoxia with ECMO
Venoarterial extracorporeal membrane oxygenator (ECMO) is a potential lifesaving intervention in those with refractory cardiogenic shock. But there is potential risk of cerebral hypoxia because of upper body hypoxemia. Upper body is perfused by the left ventricular output which can be hypoxemic if there is pulmonary edema. Lower body is perfused with oxygenated blood from the ECMO [1].
Reference
Rab T, Ratanapo S, Kern KB, Basir MB, McDaniel M, Meraj P, King SB 3rd, O’Neill W. Cardiac Shock Care Centers: JACC Review Topic of the Week. J Am Coll Cardiol. 2018 Oct 16;72(16):1972-1980. (Source: Cardiophile MD)
Source: Cardiophile MD - January 3, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Cardiac power output
Cardiac power output (CPO) = (Mean arterial pressure x Cardiac output)/451
Mean arterial pressure = [(Systolic blood pressure − Diastolic blood pressure)/3] + Diastolic blood pressure
Cardiac power output is measured in Watts and CPO less than 0.6 W is a poor prognostic indicator. It has been shown to be the strongest hemodynamic correlate of mortality in cardiogenic shock from SHOCK Trial registry [1].
Reference
Fincke R, Hochman JS, Lowe AM, Menon V, Slater JN, Webb JG, LeJemtel TH, Cotter G; SHOCK Investigators. Cardiac power is the strongest hemodynamic correlate of mortality in cardiogenic shock: a report from the...
Source: Cardiophile MD - January 2, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Pulmonary Artery Pulsatility Index
Pulmonary Artery Pulsatility Index (PAPI) is a recently described hemodynamic index, which has been used to predict right ventricular failure in those with inferior wall infarction and in those who have been implanted with left ventricular assist device (LVAD). It is also useful to assess the need for biventricular Impella (Bipella) support in those with cardiogenic shock on the mechanical circulatory support device Impella for the left ventricle [1].
Pulmonary artery pulsatility index (PAPI) = (systolic pulmonary arterial pressure − diastolic pulmonary pressure)/right atrial pressure.
This is the pulmonary arterial pul...
Source: Cardiophile MD - January 2, 2020 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
Christmas Eve Special Gift!! Prehospital Cath Lab Activation: What do you think?
A 60-something male was sent from Dialysis for several days of SOB. He did not know his medical history well.The patient was in no distress.The paramedics recorded an ECG:Here I magnify the limb leads and precordial leads:Now of course you see the convex ST elevation in V3 and V4, and the STE in V2 that is preceded by a spike. Is this STEMI?Here is the Computer Interpretation:The medics activated the cath lab. Do you agree? I was in the ED, and whenever I hear that there has been a prehospital cath lab activation, I like to go take a look because there are many false positive activations, es...
Source: Dr. Smith's ECG Blog - December 23, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Cardiology MCQ – Classic cardiogenic shock – Answer
Cardiology MCQ – Classic cardiogenic shock – Answer
My Cardiology MCQ books on Amazon
“Classic” cardiogenic shock having hypotension with features of hypoperfusion, needing inotropes and mechanical circulatory support comes under Stage — of the 2019 SCAI (Society for Cardiovascular Angiography and Intervention) classification:
Correct answer: 3. Stage C
The Society for Cardiovascular Angiography and Intervention (SCAI) has classified cardiogenic shock into stages from A through E.
Stage A: “At risk” for cardiogenic shock – large myocardial infarction or heart failure, but not yet in sho...
Source: Cardiophile MD - December 18, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
Cardiology MCQ – Classic cardiogenic shock
Cardiology MCQ – Classic cardiogenic shock
“Classic” cardiogenic shock having hypotension with features of hypoperfusion, needing inotropes and mechanical circulatory support comes under Stage — of the 2019 SCAI (Society for Cardiovascular Angiography and Intervention) classification:
Stage A
Stage B
Stage C
Stage D
Post your answer as a comment below (Source: Cardiophile MD)
Source: Cardiophile MD - December 17, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology MCQ DM / DNB Cardiology Entrance Source Type: blogs
SCAI Shock Stages A Through E
The Society for Cardiovascular Angiography and Intervention (SCAI) has classified cardiogenic shock into stages from A through E. This was developed by a multidisciplinary team from cardiology (interventional, advanced heart failure and noninvasive), emergency medicine, critical care and cardiac nursing.
Stage A: “At risk” for cardiogenic shock – large myocardial infarction or heart failure, but not yet in shock, with normal mentation and systolic blood pressure of 100 mm Hg or more.
Stage B: “Beginning” shock – hypotension or tachycardia without features of hypoperfusion (normal mentation). Systo...
Source: Cardiophile MD - December 16, 2019 Category: Cardiology Authors: Prof. Dr. Johnson Francis Tags: Cardiology Source Type: blogs
A young peripartum woman with Chest Pain
This is written by Brooks Walsh.https://twitter.com/BrooksWalshA 30 year-old woman was brought to the ED with chest pain.It had started just after nursing her newborn, about an hour prior, and she described it as a severe non-pleuritic “pressure” radiating to the back.She had given birth a week ago, and she had similar chest pain during her labor. She attributed the chest pain to anxiety and stress, saying " I ' m just an anxious person. "A CXR and a CTA for PE were normal.The ECGsAn initial ECG was obtained as the pain was rapidly resolving:Minimal upsloping ST Elevation in III, with a steeply biphasic T wave, and&nbs...
Source: Dr. Smith's ECG Blog - October 23, 2019 Category: Cardiology Authors: Brooks Walsh Source Type: blogs
A 40-Something male with a " Seizure, " Hypotension, and Bradycardia
This is by one of ouroutstanding 3rd year residents, Aaron Robinson, with some edits and comments by SmithEMS responded to a reported seizure in a 42 year old male. Per bystanders, he went down after some intense sporting activity, and had “shaking” type movement. He reports no personal or familial history of seizures.One of our EMS Fellows along with a Senior EM Resident were on duty that evening, and arrived on the scene with the Fire Department. When the physicians approached him, he was ashen, diaphoretic, and appeared in shock. Fire was able to obtain a BP of 60/palp and a pulse in the 40s. The physicians quickly ...
Source: Dr. Smith's ECG Blog - October 6, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Chest pain, pelvic and abdominal pain, hypotension, and severe ischemia on the ECG
An elderly male was lethargic at the nursing home and complained of some pelvic pain, but then also chest pain and abdominal pain. He was hypotensive. His medications include beta blockers.BP on arrival was 66/31, pulse 80, saturations 90% room air. The patient was lethargic and shocky.An ECG was recorded:There is severe diffuse ST depression of subendocardial ischemia, with the obligatory reciprocal ST Elevation in aVR.One might also think there are hyperacute T-waves in inferior leads, with reciprocal STD and T inversion in aVL. A bedside echo showed good LV function, no pericardial effusion,...
Source: Dr. Smith's ECG Blog - September 11, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Elderly with Paced Rhythm, Possible Ischemic symptoms, and an Equivocal Smith Modified Sgarbossa ECG
An 80 year old presented with a couple days of SOB, weakness, and diaphoresis. There was no chest pain.Here was her initial ECG:What do you think?-There is a paced rhythm. -There is some concordant ST Elevation (STE) in V5 and V6. -There is ST depression in V2. -There is minimal concordant ST depression in V3 (remember there should be, if anything, appropriately discordant STElevation).The treating physician did not think that there was sufficient concordant STE in V5 and V6. He saw the ST depression in V2, but did not see it as concordant or excessively discordant because the R-wave and S-wave w...
Source: Dr. Smith's ECG Blog - August 19, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
How does acute left main occlusion present on the ECG?
Post by Smith and MeyersSam Ghali (https://twitter.com/EM_RESUS) just asked me (Smith):" Steve, do left main coronary artery *occlusions* (actual ones with transmural ischemia) have ST Depression or ST Elevation in aVR? "Smith and Meyers answer:First, LM occlusion is uncommon in the ED because most of these die before they can get a 12-lead recorded.But if they do present:The very common presentation of diffuse STD with reciprocal STE in aVR is NOT left main occlusion, though it might be due to subtotal LM ACS, but is much more often due to non-ACS conditions, especially demand ischemia. In these ...
Source: Dr. Smith's ECG Blog - August 8, 2019 Category: Cardiology Authors: Steve Smith Source Type: blogs
Impella CP with SmartAssist: A Newly FDA Approved Heart Pump with Optical Positioning Sensor
Abiomed, the maker of popular left ventricular assist devices, is releasing its newly FDA approved Impella CP with SmartAssist device. The pump features an optical sensor that physicians can use to position and reposition the device without relying on a cath lab, X-ray, or ultrasound imaging. The sensor can be used either during initial implantation of the pump or while the patient is in the ICU, if necessary.
The pump can deliver up to 4.3 liters of blood per minute, which is about 85% of a normal full cardiac cycle, all while providing real-time information on an accompanying controller about important hemodynamic number...
Source: Medgadget - May 20, 2019 Category: Medical Devices Authors: Editors Tags: Cardiac Surgery Cardiology Critical Care Radiology Source Type: blogs
