Tony’s Take Home Memo 8/13

(Notes from Wednesday Lectures, 8/13/2014)

10a Syncope (GJ)

  • “people who wake up & now feel normal”
  • HOCM, longQTc, Brugada, WPW(preexcitation), AVnRT/SVT
  • Life threats in stable asymptomatic pt c transient LoC…
  • QTC >500 concerning: Hypomagnesemia, Hypocalcemia, Hypokalemia, Hypothermia, Congenital, Drugs…
  • Brugada Syndrome is Na Channel Abnormality… unmasked by CCB or NaChBlk…
  • (ST elevation c T wave inversion, nonspecific otherwise?)
  • “S in V1 plus R in V5” total >35? HOCM also may have septal Q waves & nonspecific Twave changes…

1030a Electrolytes (Prasad) Hyper/HypoKalemia

  • Case 1: Dialysis Dependent pt… weak, nausea, malaise, mild BPelevation… crackles on exam… anticipate hyperkalemia! EKG progression from Twave peaking to QRS widening to sine wave/VTach… odd variants include “dumping” & “z wave” patterns.

    Treat c: Calcium gluconate (except c Digoxin tox!), insulin & glucose (K down 0.4 to 0.6), careful c IVF load in dialysis pts!, consider bibcarb & albuterol… lasix or dialysis to remove K.

    Bicarb is still class 1A in hyperkalemic cardiac arrest.

  • Case 2: 20yo college student syncope, hx bulemia… HypoK (<3), flattened Twave & Uwave present, sinus bradycardia (also found in hypoCalcemia)
  • Case 3: ST depression & Twave inversion mimicking ischemia in 30F with negative troponin.

11a Small Groups (Lavoie, Prasad)

  • hyperkalemia (dialysis pts c peaked T…)
  • hypokalemia (bradycardic, longQTc, Uwave, flattened overall)
  • hypercalcemia (short QTc, also found in digoxin toxicity)
  • LVH (axis change & 35mm sV1 plus rV5) plus Twave peaking & nonspecific ST changes common in dialysis dependence.
  • torsades de pointes requires Magnesium (>2g) plus ACLS (prn)… Prasad says usually takes ~6g before conversion.
  • STEMI v nonspecific ST changes: distribution & shape of ST segments (III > II STE or convex up/horizontal shape is MI until proven otherwise!)
  • Pericarditis: diffuse changes, concave up ST (no reciprocal change/ST depression), PR depression common c reciprocal PR elevation, downsloping of the TP segment & PR segment (Spodick sign), can be associated c myocarditis (beware resting teachycardia after treatment, IVF, etc.) & troponin elevation, most often viral illness.

12p Holy Cow Cases (Joslin)

  • (Maley) SCIWORA EtOH pt… beware for revised radiology read!
  • (Ku) RPA with Leukemia! (Eikanella, Strep)

1230p JrSr Sessions (Paolo, Lavoie)

  • EKG Lab!
  • PAILS (Posterior > Anterior > Inferior > Lateral > Septal)
  • Idioventricular Rhythm (reperfusion) is good after thrombolytics
  • RBBB look at slurred Swave in I & V6
  • PE S1 Q3 T3 (also could be L posterior fascicle block)
  • VTach~ish… go to ACLS pathway!
  • PseudoRBBB with downsloping STE! ~ Brugada Syndrome (rare but happens…)
  • Careful c Calcium in dialysis pts? CaCl faster but sclerosing.
  • MAT v PAT (different pwave morphologies)
  • Osborne Waves in hypothermia
  • Sooo many QTc prolonging drugs! Torsades get Magnesium.
    (fluoroquinolones, azith, zofran, reglan, TCAs, antipsychotics, methadone…)
  • LGL short PR preexcitation syndrome
  • Wellan’s Sign associated c ischemia! c CP, goes to cath lab… (biphasic Twave, commonly V2, V3 in multiple vessel disease.)
  • Posterior MI! Tall R wave in V1 with ST depressions in V1, V2… (most common miss!)
  • aVR STEMI!
  • Sgarbossa Criteria for LBBB
  • Spodick sign in Pericarditis c PR depression (aVR PR elevation) & diffuse ST elevations s reciprocal changes.
  • Takotsubo “Octopus Pot” stress induced cardiomyopathy
  • Symmetric Twave inversions can be caused by SAH! (but call ischemia until shown otherwise)

130p STEMI (Joslin)

  • full thickness, sudden occlusion, troponin positive, needs cath, bad hemodynamics…
  • ST elevations, Qwaves…
  • PAILS mnemonic to look for reciprocal changes
  • Progression: hyperactute T (asymmetric), ST elevation, Qwave, ST elevation c Twave inversion…
  • Posterior STEMI needs only 0.5mm depression?!
  • check aVL for Lateral STEMI
  • Know R sided v Posterior EKG…
  • “Old MI”? “Age Indeterminate”? Read it yourself.
  • Acute LAD occlusion ~deWinter morphology, v. Chronic LAD occlusion ~Wellens morphology
  • Pt c shocked resuscitation should go to cath lab.
  • Paced EKG should be compared to prior, & ?consider Sgarbossa criteria.

2p NSTEMI & Ischemia (ERod)

  • Ischemia is dt interruption of optimal blood flow.
  • STEMI has EKG evidence of infarction & biomarker elevation.
  • NSTEMI missing EKG evidence but may have biomarker elevation or Echo evidence.
  • Unstable Angina is without biomarker elevation.
  • Treat ACS c ASA, O2, NTG(prn)
  • NSTEMI can become STEMI!… recheck for progression! ACS is dynamic process.
  • Compare against old EKGs.
  • EKG 1small box amplitude is 0.1mV;  1 small box across is 0.04s (large box is 0.2s)
  • New ST depression threshold is >0.05mV!!!  V2,V3 can be slightly >0.1mV (0.15, 0.2, 0.25 depending on age & gender by 2012 AHA guidelines) & potentially wnl!
  • Most STE cutoffs are 0.1mV though.
  • Twave inversions not always ischemia… can happen in LVH or SAH.
  • Hyperactute Twaves in ischemia have slightly different morphology than hyperkalemia (less symmetric).
  • Be careful c aVL elevations because low amplitude dt isoelectric vector may hide changes.
  • Deep symmetric Twave inversions in anterior leads ~ Wellens, indicates chronic multivessel CAD… Cath only if active Sx.
  • aVR should always be checked, may have apparently isolated mild elevations…
  • New Tall Twave in V1 is marker of ischemia! (“NTTV1” ~Mattu)
  • Inverted Uwaves predictive of L occlusion(s)? (>75%?)
  • Remember ACS is dynamic continuum. Know Wellens.  Careful c aVR &aVL

230p EKG Review (Deepali)

  • HyperK, HypoK…
  • Hypercalcemia potentially short QT (& can also cause Osborn wave, like hypothermia)
  • PE has anterior lead Twave inversion in 85%! (rare pathognomonic S1Q3T3)
  • Consider Thyroid causes of arrhythmia
  • Myxedema Triad ~ Bradycardia, low QRS voltage, Twave flattening & inversion

3p Pediatric Syncope (Thabet)

  • Syncope is loss of consciousness & postural tone with rapid return to baseline.
  • Very common in kids.  Always get EKG, though most is noncardiac.
  • QTc, WPW, Brugada, HOCM…
  • Most common cause of syncope vasovagal or idiopathic.
  • Primary differential vs Seizures! (tongue biting, postictal period, headache, incontinence?)
  • FamHx heart Dsx? Murmur? Orthostatics? (change >20 in HR or SBP?)  Drugs/Meds?
  • Consider Tox!
  • Case 1: QTc prolongation & syncope dt Zofran, Risperdal, Azith… orthostatic? vasovagal? HCG? GLUCOSE? Check for hypertrophic murmur (louder when standing, lower c valsalva).
  • Case 2: Actual longQTc case… check Ca, Mg, TSH… other Tox screen? give Mag…
  • Plus WPW?! ~ given Digoxin dt relative contraindication for Adenosine (in Asthmatic) c syncope & SVT episode during transfer for Appendicitis?!

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