Wednesday Lectures: 7/15/2015 – Cardiology/Chest Pain Day

TTHM a1.3 Cardiology/ Chest Pain Day  (7/15/15)  Tint. 52, 53, 55, 59, 60, 62, 122

 

10a ~ NSTEMI & STEMI (Johnson)
“We give back to you on Wednesdays” “for all the sh*t we give you to do the rest of the time”.  Know your STEMI/CVA/TraumaCode Policies!!!  Know your AHA & ACEP guidelines!

In presence of bundle branch block, Sgarbossa’s Criteria… 1mm concordant elevation or 5mm discordant elevation or depression (ST to T wave correlation).

Angina in the ED is ACS! ~ Leading cause of death, 1/5 of all malpractice $.

Chest Pain can be Abdominal Pain via diaphragm.

Visceral pain is nonspecific. Ischemic areas have penumbras.

Typical STEMI is ruptured atheroma causing acute vascular obstruction, ischemia, infarction.

3*HB often SA node problem supplied by RCA.

“If any symptoms sound like angina, it’s angina.”

Exertional? Ask if associated c fever or cough for DDx.

FamHx important for Chest Pain & Headaches.

Compare with old EKG whenever available!

National Standards state EKG must be obtained & interpreted within 10 min! ~ NYT Article…

Most MIs are NSTEMI > STEMI.  R sided EKG rarely done but may distinguish more dangerous kinds of MI…

ST segment elevation without MI? early repol, LVH, Pacer, Pericarditis/Myocarditis, Hypothermia, LV aneurysms…

23% of STEMI are “non actionable” but most should be acted on anyways.

1 to 4% of MI have completely normal EKG!!!

Twave inversions without ischemia… common in Peds, Intracranial Injury, Cor Pulmonale

BNP not very useful unless the hospitalist “needs” it for CHF admission baseline…

EchoCG, Stress Testing, other tools more specific once high risk is established…

Be wary of new “very high sensitivity Trops”.

Don’t send home new Pulm Edema… high cardiac risk, significant M&M!

 

11a ~ SG (Paolo & LaVoie)

STEMI transport tPa vs Dissection Case…

Intraventricular Conduction delays: RBBB, LBBB, Paced rhythms…

Sgarbossa (single lead changes in block):

https://en.m.wikipedia.org/wiki/Sgarbossa%27s_criteria

 

12 ~ Rapid Procedure Lab (Vatti)

Review of Pericardiocentesis http://emedicine.medscape.com/article/80602-overview

 

1230 ~ Jr/Sr sessions (Paolo/LaVoie)

Wellan’s, Brugada, Sgarbossa criteria… aVR in lateral or LM, aVL in inferior…

https://en.m.wikipedia.org/wiki/Wellens%27_syndrome

http://www.askdrwiki.com/mediawiki/index.php?title=Brugada_Criteria

https://en.m.wikipedia.org/wiki/Brugada_syndrome

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3615989/ (aVR)

 

130 ~ PE (Schenker/Patel)

Perc/Wellsx2…

http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/

NOT to be confused with the DVT Wells: http://www.mdcalc.com/wells-criteria-for-dvt/

http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/

http://boringem.org/2013/07/02/tiny-tips-perc-rule/

Lovenox, Heparin, DVT~US…

 

2p ~ Pericarditis (LaVoie)

https://en.m.wikipedia.org/wiki/Pericarditis

https://en.m.wikipedia.org/wiki/Electrical_alternans

 

230p ~ Ao Dissection (Prasad)

https://en.m.wikipedia.org/wiki/Aortic_dissection

Stanford Type A (DeBakey 1&2) ~ “Arch” ~ Surgery, generally.

Stanford Type B (Debakey 3) ~ “Below” ~ Medical Mgmt, generally.

https://en.m.wikipedia.org/wiki/Michael_E._DeBakey, https://en.m.wikipedia.org/wiki/John_Ritter

https://en.m.wikipedia.org/wiki/Lucille_Ball, https://en.m.wikipedia.org/wiki/Jonathan_Larson

Beta Blockers or CCB rather than Nitrates alone to reduce BP, prevent reflex tachycardia!

~Esmolol (500mcg/kg loading, & 50 to 200mcg/kg/min),

~Labetalol (20mg, then 0.5 to 2mg/min),

~Propranolol (1 to 10 mg load, then 3mg/hr)

~Nicardipine/Nifedipine or Nitrates used secondarily…

 

3p ~ Peds Chest Pain (Thabet)

Case: Dizzy & Near syncope, worse c exertion, 2 cousins died of HOCM, 1 unknown early death… EKG 3*HB.  Cath & Pacer.  Good outcome.  Think TSH & Lyme!  Fvr/recent illness?

Good Hx & Physical very important!!! Details!!! Associated Sxs…

Dizziness? Syncope? SoB? Palpitations? HR? hormonal? Feeding intolerance/Apnea?

Collagen Vascular disease? Marfanoid? Familial hypercholesterol? Early cardiac deaths?

Don’t miss: MI, HOCM, AoDissection, CardioMyopathy, Pericarditis, Myocarditis, PE, Arrhythmias…   Long QT? Medication side effects…

https://en.m.wikipedia.org/wiki/Long_QT_syndrome

https://en.m.wikipedia.org/wiki/Hypertrophic_cardiomyopathy

Troponin cutoff same regardless of age, however, can be artificially elevated

ALCAPA (anomalous L coronary Aa) most common actual cause of ischemia in infancy.

https://en.m.wikipedia.org/wiki/Anomalous_left_coronary_artery_from_the_pulmonary_artery

http://emedicine.medscape.com/article/893290-overview

Just get an EKG in kids.  Usually negative, but sometimes you’ll catch a zebra.  Trop less useful…  Peds Cardiology call & fax for EKG questions.

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