Litfl Review 157
Welcome to the 157th LITFL Review. Your regular and reliable source for the highest highlights, sneakiest sneak peeks and loudest shout-outs from the webbed world of emergency medicine and critical care. Each week the LITFL team casts the spotlight on the blogosphere’s best and brightest and deliver a bite-sized chuck of FOAM.
The Most Fair Dinkum Ripper Beauts of the Week
Delayed Sequence Intubation (DSI) has been part of the FOAM critical care armamentarium for years. Now, the evidence is published in the traditional literature. Scott discusses the article (Open Access Article for a limited time) and how DSI can ...
Source: Life in the Fast Lane - November 24, 2014 Category: Emergency Medicine Authors: Marjorie Lazoff, MD Tags: Education LITFL review LITFL R/V Source Type: blogs
Is this acute STEMI? LV Aneurysm? Would you give Thrombolytics?
Recently I posted a case describing "Acuteness" on the ECG and how to assess whether it is too late for reperfusion, especially thrombolytics.This case was recently posted by Tyron Maartens on Facebook EKG club (he agreed to let me post it here), with the following clinical information:"42 year old male with two weeks of intermittent chest discomfort, awoke 4 hours prior to this ECG with a more severe, heavy chest pain (5/10). Self-medicated with 600 mg Ibuprofen and 750 mg Paracetamol (no change) prior to driving to the ED. BP 112/80, SpO2 100%. Patient appears only slightly anxious. No risk factors, leads a healthy ...
Source: Dr. Smith's ECG Blog - November 17, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Plavix and Aspirin After Stent: 8 Years Later – Is Longer Better?
No one thought it would take quite so long to get this information, but in just a couple hours results from the Dual Antiplatelet Therapy (DAPT) Study will be presented at the American Heart Association Scientific Sessions 2014. The question to be answered: Is there a benefit to extending dual antiplatelet therapy (aspirin plus a thienopyridine, such as clopidogrel/Plavix, prasugrel/Effient, etc.) beyond one year after stenting? (Source: Burts Stent Blog : The Voice in the Ear)
Source: Burts Stent Blog : The Voice in the Ear - November 16, 2014 Category: Medical Equipment Source Type: blogs
What happened after the PCI?
A middle-aged male with h/o CABG x 3, previous stents, and aortic valve and aortic root replacement presented primarily with headache, but also told the medics that he had chest pain (for 6 hours) because he "knew they would respond faster than if he said headaches." The chest pain was right sided rib and shoulder pain, worse with inspiration, sharp, and sometimes 7-8/10. But the headache was much worse. Chest pain was not relieved by sublingual NTG.He has noticed worsening exertional dyspnea, such that he feels he can only walk about a block before experiencing "chest tightness. Here is his ED ECG ...
Source: Dr. Smith's ECG Blog - October 30, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
18 hours of intermittent chest pressure
A male in his 60's with no previous cardiac history complained of substernal chest pain intermittently for 18 hours. It has more recently become constant. He was diaphoretic. He called 911 and had this prehospital ECG recorded:I saw this when he arrived, and was worried about the slight ST depression in V2 and the size of the T-waves in V5 and V6, as well as the minimal terminal T-wave inversion in aVL and a bit of ST depression there.We recorded this immediately:The same findings are here, without any evolution.BP was 140/80.His pain continued and would be relieved from 8/10 to 6/10 with sublingual nitro...
Source: Dr. Smith's ECG Blog - October 28, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
Research and Reviews in the Fastlane 054
Conclusions Wrong? (emlitofnote)
Critical Care, CardiologyGuyton AC. Regulation of cardiac output. Anesthesiology. 1968; 29(2): 314-26. PMID: 5635884
The modern emphasis on echo might make you think that the heart determines cardiac output. This classic paper by Guyton shows that unless the heart is failing, it has a permissive role in determining cardiac output. The real determinants are (1) the degree of vasodilation of the peripheral vasculature, especially veins, and (2) the filling of the circulatory system, indicated by the mean systemic filling pressure. Gotta love those Guyton curves!
Recommended by: Chris Nick...
Source: Life in the Fast Lane - October 20, 2014 Category: Emergency Medicine Authors: Nudrat Rashid Tags: Cardiology Clinical Research Education Emergency Medicine Infectious Disease Intensive Care Neurology Neurosurgery Obstetrics / Gynecology Orthopedics Pediatrics Trauma critical care literature R&R in the FASTLANE recommendat Source Type: blogs
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
Middle Aged Male with Burning Chest Pain -- Assess the Entire Clinical Scenario
A middle-aged male presented with “burning” mid chest pain, with radiation to bilateral shoulders (pain radiating to both shoulder is very specific for ischemia). It started about 5 hours prior to arrival. He obtained little relief from nitro x 3 by EMS. There was a history of previous MI, with a stent in the 1st Obtuse Marginal. He had taken his Plavix for 6 months, then discontinued and also stopped taking his antihypertensives and statin. He continued to smoke about 1.5 pks per day.Here is his ECG:Junctional Bradycardia (this is sinus arrest with junctional escape, and is highly su...
Source: Dr. Smith's ECG Blog - August 17, 2014 Category: Cardiology Authors: Steve Smith 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
Period of withdrawal of anti platelet agents prior to surgery
All patients with coronary stents will be on Aspirin and an additional agent which is a P2Y12 inhibitor (Clopidogrel, Prasugrel or Ticagrelor). The antiplatelet therapy is likely to be more aggressive in those on drug eluting stents (DES). More so in those who have been implanted with a DES in the past one year, because the risk of stent thrombosis on withdrawal on antiplatelet agents is higher in that period. Platelet function recovery takes place at the rate of about 10% per day. But full recovery of function may not be required for adequate hemostasis with platelet aggregation. There is also a chance of rebound prothr...
Source: Cardiophile MD - August 8, 2014 Category: Cardiology Authors: Prof. Dr. Johnson Francis MD, DM, FACC, FRCP Edin, FRCP London Tags: General Cardiology Clopidogrel P2Y12 inhibitor Prasugrel rebound prothrombotic state Thromboxane A2 ticagrelor trans urethral resection of prostate TURP and anti platelet therapy withdrawal of anti-platelet agents prior to surgery 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
Research and Reviews in the Fastlane 041
This study prospectively validated whether an age-adjusted D-dimer cutoff was associated with an increased diagnostic yield of D-dimer in elderly patients with suspected PE. Compared with a fixed D-dimer cutoff, the combination of pretest clinical probability assessment with age-adjusted D-dimer cutoff was associated with a larger number of patients in whom PE could be considered ruled out with a low likelihood of subsequent clinical venous thromboembolism. So if this is not your clinical practice already, maybe time to use age adjust d-dimer values?
Recommended by: Jerremy Fried
Read More: Age Adjusted D-Dimer Testing (RE...
Source: Life in the Fast Lane - July 29, 2014 Category: Emergency Medicine Authors: Soren Rudolph Tags: Clinical Research R&R in the FASTLANE critical care Emergency Medicine Intensive Care literature recommendations research and reviews Source Type: blogs
Syncope and Flash Pulmonary Edema with T-wave Inversions in V1-V3
A 60 yo with no cardiopulmonary history, felt dizzy, cold and clammy, and then had syncope. She denied SOB or Chest pain. Pulse oximetry was 95%. Lung and heart exams were normal.A bedside echo done by an ultrasound-fellowship-trained EP was recorded as normal.She had an ECG as part of her syncope workup:There is an abnormal Q-wave in lead III (greater than 40 ms in width is abnormal). There is nonspecific T-wave flattening in in inferior leads and in V2 and V3, and nonspecific T-wave inversion in V4-V6.With the abnormal, but nondiagnostic, ECG, a wider workup was initiated. A troponin I returned el...
Source: Dr. Smith's ECG Blog - May 31, 2014 Category: Cardiology Authors: Steve Smith Source Type: blogs
