Rounds May 2015

• This talk may be found at AndrewGeller.Weebly.com,

A recent NEJM study on the use of hypothermia in children after cardiac arrests showed that hypothermia resulted in a 30 % higher survival [38 % vs 20 % survival] and a 70 % higher likelihood of a good neurological outcome than normothermia. •Cooling slows metabolic demands , each degree Celsius reduces the metabolic rate by 7 % . It will also decrease intracranial pressure and decrease the heart rate.

Pregnancy and Cardiac Arrest • Cardioversion is safe

Turn the patient on the side, you must get the uterus off the IVC to improve blood flow ACLS recommendations for rx doses and defibrillation do not change If the pregnancy is advanced [uterus at the umbilicus] consider Csection if within 5 minutes of the arrest!

Oxygen• Once again…..• A recent article by Stub,D on STEMI patients

needs to be “aired”. The AVOID trial.• 683 pts with suspected STEMIs,441 confirmed.

They randomized the patients to NO o2 [O2 sat >94%] or 8 L/min by face mask. They found that those who received O2 had larger infarcts.

Cochrane Database• The Cochrane database review in 2010 and

updated in 2013 reported that there are 4 trials of AMI and O2 that looked at 430 patients and there are 17 excess deaths in the patients rx with O2. The RR is over 3. You are more than 3 times more likely to die if O2 is given when you are having an acute MI if the O2 saturation is > than 94 % [you don’t need it ] .

More on O2• Other studies reveal that at cath that coronary

blood flow will decrease by 30 % with 100% FIo2 compared to RA.

• Hyperoxia will decrease cerebral blood flow, shown in a 1988 study.

• These studies make it clear that O2 is a vasoactive drug and that it should be given only to patients who need it…. Per the AHA 2010 guidelines

Alcohol• The subject arises on how to determine

intoxication…..blood tests, breathalyzer etc. “The only reliable test for determining the level of intoxication is the physical examination” Can you carry on a normal conversation without slurring your words, can you walk without ataxia, is your judgment and insight reasonable ?

Tobacco • Smokers die on average more than a decade

before nonsmokers.• It is estimated to cause 480,000 deaths per

year [even more than cardiac arrests!] This is 1/5 of all the deaths in the US. More recently this number has been challenged …. It is thought that it probably causes 550,-600,000 deaths per year ! It has recently been thought to increase breast cancer and prostate cancer mortality.

End Of Life and EMS

• POLST ,physician orders for life sustaining treatment , the replacement for DNR , may allow us to think about how we can help this process along. Maybe think about discussing with nursing homes who does not need CPR , or DNH ,do not transport to the hospital. maybe we should have a list . Maybe …

Use of AVR to Diagnose Left main Occlusions

The value of ST segment elevation in lead aVR for predicting left main coronary artery lesion in patients suspected of acute coronary syndrome.

• 400 Pts with typical chest pain

• PCI performed within 48 hours of CCU admission

• 31% had aVR STE 1 mm

• Men/Women with STE in aVR: 40.7%/43.8%

• Sens/Spec: 62.7%/73.6%

Rom J Intern Med. 2012 Apr Jun;50(2):159 64.

• A second article was written about this entity by Hennings , J.R. et al. There was ST elevation in AVR with diffuse ST depression in many other leads. The patients had L main, Proximal LAD or multivessels CAD with acute coronary occlusions

STEMI with a LBBB

• Sgarbossa criteria: In a normal LBBB the ST segment is in the opposite direction of the QRS. When they are in the same direction a STEMI is likely [70 %] . The EKG that follows shows this.

From EP Monthly Stephen Smith, 4/30/15

From EP Monthly,Stephen Smith, April 30,2015

• In the EKG above the V1-V3 have a predominant S wave and the ST segments are positive. In V5-V6 the R waves are positive and the ST segments are negative. This is normal in a LBBB. However if you look at leads III and AVF there is a positive QRS and ST elevation ..they are in the same direction. This is not ok [concordant ] . It is likely due to a STEMI

From EP Monthly 4/30/15, stephen smith

STEMI and LBBB

• The above EKG is another example of this Now clearly in III and AVF there s ST elevation and a positive QRS. This is diagnostic of a STEMI with a LBBB. Lead V3 is also suggestive of concordance the ST segments and the QRS go in the same direction.

Shock• We have not discussed this in a while and a

brief review seems reasonable• Shock occurs when the body metabolic

demands exceed the supply. Mortality is high. The time to identification can decrease mortality . Early antibiotics for sepsis, earlier door to balloon times for cardiogenic shock, and early interventions with traumatic shock patients may decrease mortality

Shock continued • Classification:• Hypovolemic: either hemorrhage or fluid

losses,• Cardiogenic: the heart cannot maintain an

adequate cardiac output• Distributive : normal volume, but vasodilation

results in shock• Hypovolemia , usually hemorrhagic or volume

losses• Obstructive : Limited cardiac filling or

increased afterload

More shock

• Distributive: normal volume but vascular dilatation causes hypotension. The 3 best examples are sepsis, neurogenic and anaphylactic. All result from vasodilation. The neurogenic occur with a high cervical spinal cord injury and there is usually bradycardia

More on shock

• Obstructive : Tamponade resulting in minimal venous inflow, massive pulmonary embolism [limited RV cardiac output], and pneumothorax [again limited venous input]

Shock • Examination: start with the usual suspects –

primary survey. Assess that the airway is intact, and that the patient is ventilating the lungs.If there are absent BS then a pnemothorax or large effusion may be the cause.

• If there are signs of hemorrhage address these with pressure and potentially tourniquets . If pressure and tourniquets cannot be used , in areas like the axilla then Quickclot may be useful.

Shocking continued• Head to Toe exam is next.• Is the mental status diminished? It often is

with shock. Is there pallor from hemorrhage? Look for neck vein distention – a reflection of CVP and this may indicate tamponade, cardiogenic shock and may clearly show that hypovolemia is not the issue.

• Look at the belly. Is there any ecchymosis to indicate trauma? Is there a pulsatile mass from a AAA?

• Extremities:Pssive leg raise test transiently increases venous return .Hypovolemia present

Shock• Prehospital testing: • A FS glucose may reveal marked

hyperglycemia • EKG A STEMI is often the cause of cardiogenic

shock. Ischemia may also be the result of the hypotension. Electrical alternans suggests tamponade

Electrical Alternans

Electrical alternans is recognized by alternating amplitudes of the QRS complexes. The most frequent cause is a pericardial effusion . It is thought to result from the swinging motion of the heart from the weight of the effusion in the perciardial sac.

From UP TO DATE

STEMI Diagnosis

• Use of reciprocal changes

Is There STE?

Is There STE?