February Rounds

Andrew Geller MD, FACEP, MPH

A variant BVM mask

WELLENS SYNDROME:

A LIFE SAVING DIAGNOSIS

• A 31 year old male smoker with DM came into the ER with 4 days of intermittent chest pain. His EKG is consistent with Wellens Syndrome, which is associated with stenosis of the LAD. . His troponin was positive and his catheterization revealed a 95 % occlusion of the LAD, which was successfully traeted with a stent.

WELLENS SYNDROME: A LIFE SAVING DIAGNOSIS

• Critical stenosis of the proximal LAD • Classic ECG presentation• • Biphasic or deeply inverted T waves in leads V2 and V3

• Sometimes V1, V4, V5 and V6

• Despite zero or minimal ST elevation, loss of precordial R wave

• progression or pathologic precordial Q waves

Parikh, K.S., et al, Am J Emerg Med 30(1):225.e3, January 2012

WELLENS SYNDROME: A LIFE SAVING DIAGNOSIS

• Type 1 (A) (76%) – Deep symmetrically inverted T waves in precordial leads V2 V3

• Type 2(B) (24%) - Biphasic T waves in V2 V3 identified as a

distinctive upsloping followed by a sharp downslope that differs from T wave inversion due to other etiologies

WELLENS SYNDROME: A LIFE SAVING DIAGNOSIS

Articles

• 1. ER volume matters. Patients have a lower likelihood of inhospital death if admitted through high volume EDs. The study looked at the largest database in the US with 8 million admissions per year and over 1,000 hospitals per year.

• The higher volume EDs had lower mortality .

CVA and Thombectomy

• For the first time a study of acute CVA patients suggested that intraarterial thrombectomy within 6 hours could lead to a better outcome [32 % vs 19 % rate of functional independence] . This may prove to be a game changer.

• Almost all of these patients were first given TPA , and all of these patients had proximal, anterior large vessel occlusions on angiograms.

• Also 9 % of the patients had distal embolization into new territories… read new CVAs.

Intranasal fentanyl

• A recent study looked at kids and the use of intranasal fentanyl. 5 Minutes after its use the pain was rated as only half as severe. It works quickly, and it should be kept in mind both for adults and children, especially if an IV is problematic.

Falls• A recent study of falls at 30 assisted living facilities was provocative. It

suggests that perhaps we could use a protocol to decrease the number of transports after the elderly have falls .

• The patients who did not require transport were either without complaint [Duh] , with simple contusions or skin tears, had no obvious injury, no change in their ambulatory status, had no acute medical emergency condition , no alteration in mental status from baseline their VS revealed a BP > 90, pulse of <120 and > 50 , no acute neck pain, hip pain or uncontrolled hemorrhage. Also no fall on Coumadin or other blood thinner [Plavix, Xarelto, etc] . No need for new analgesia.

• In spite of this long list over half of the calls did not require transport !. The study was retrospective but the results are provocative.

Metronomes and Dispatch

• A study in Wisconsin used a metronome to provide guidance to bystanders for CPR rate . We should try to do this .

Double Sequential Defibrillation

• When a patient has refractory ventricular fibrillation a recent study utilized double sequential defibrillation. It does not increase survival . It did break the Vfib in 70 % of cases.

• The definition of refractory Vfib was 5 unsuccessful single shocks, epinephrine and amiodarone with persistent Vfib.

• The technique used 2 defibrillators charged to maximum, with shocks delivered simultaneously.

Chest Compression Injuries After CPR

• A recent study in Minnesota looked at 235 arrests and the risk of injury after CPR. The LUCAS was used in 44 % .

• There were injuries identified in 13 % , the most common injury being rib fracture [often more than 1] This was seen in only 9 %. The use of the Lucas was not more likely to cause injury. The major risk factor for injury was a compression time > than 10 minutes. Injuries did not prolong hospital stays.

Vagal Maneuvers and SVT

• Valsalva maneuvers will convert approximately 20 % of patients with SVT. If the patient’s face is placed in ice water and at the same time a carotid sinus massage is performed the rate increases to over 50% in two studies .

• The carotid sinus massage should always be on one side at a time and not both at once.

TXA

• Tranexamic acid has recently been reported to be possibly useful to stop hemorrhage. There is an ongoing study with hypotensive , bleeding tachycardic patients in air medical transport . Up to 80 % of deaths in the first hour and 50 % of the prehospital deaths from trauma are from hemorrhage. TXA binds to plasminogen to prevent its conversion to plasmin which degrades fibrin and results in the cascade of bleeding. In a recent study, CRASH 2, a 1 gm bolus of TXA inhibited fibrinolysis and reduced hemorrhage and death. It needs to be given within 1 hour.

Side Air Bags

• NHTSA just published its collected data on side air bags and Curtain plus torso bags are the most effective reducing mortality by 31 % . The reductions are less for curtain only and torso only air bags. Additionally with rollovers there is a 41 % reduction in mortality!

• The data comes from an analysis of 73,000 crashes. Make sure your cars have side air bags.

Intranasal Narcan

• Remember it is faster to administer [no IV required], but it less potent . Frequently we need 6-8 mg of narcan for complete reversal of obtundation.

Spinal Immobilization

• There is an accumulation of data that suggests that self extrication gets less neck movement than our best efforts. I am not suggesting any changes in practice …yet. But be aware.

Preshock Pauses

• Remember that a preshock pause of <20 seconds is associated with improved survival in cardiac arrests. The less interruption of compressions the better the patient will do. All defibrillators should always be on manual mode . The automatic mode should not be used.

Anaphylaxis

• Definition: remember skin plus either upper or lower respiratory involvement with shortness of breath , hypoxemia, wheezes , or stridor .

• OR • Skin or mucosa, plus decreased BP, or

respiratory symptoms, or syncope, or GI symptoms.

Anaphylaxis contd

• The Rx of choice is epinephrine.It should be given in the thigh IM. Do not give it in the arm, do not give it sub Q.

• Benadryl is slow in onset and has no effect on BP, upper airways and lower airways.

• If the BP does not rise with the epinephrine a fluid bolus of 1-2 liters is indicated.

Cases

• 1.patient taken out to ambulance before stabilization. 22 minutes before IV placed in a patient with an MI, 25 minutes to ASA, 29 minutes to NTG

• TOXICOLOGY of the month :Cannabinoid Hyperemesis SyndromeMore on Cannabis: ? Increase in COPD, psychosis

More Cases

• Successful CCR• Rapid AFIB needs RX• Chest pain and no EKG• Patient with “difficulty breathing “, very

interesting case• Bradycardia case