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Hello everyone,

We had an enjoyable conference this week. Thank you to our resident speakers, Sheler and Shawn, and to our faculty presenters — Dr. Ginsburg, Dr. Strayer, Dr. Weingart and Dr. Andrus. Also thanks to the cardiology department for their participation in Sheler’s joint conference, and to Sohan, our graduating conference chief, who was on hand to lend his expertise with AV and other issues.

Below are some topics from conference that I wanted to touch upon — stuff that struck my fancy, really. Feel free to add your own in the comments section below.

Syncope Notes — ACEP, Wellens’ sign, and Orthostatics

• - Starting with Sheler’s lecture on syncope — she referenced many important papers in this topic, but for one stop-shopping on key management decisions and the literature to support these choices, check out the ACEP clinical policy that came out last spring.
• - Also, Sheler showed an EKG with inverted T waves in precordial leads, which triggered some discussion on Wellens’ syndrome between me, Raghu, and the cardiology fellows. Raghu correctly noted there are two morphologies associated with Wellens’ syndrome, which is a subtle but extremely important EKG finding. To quote Amal Mattu (PMID 12442245):

Two basic patterns of electrocardiographic change are encountered: (1) isoelectric or minimally elevated (ie, less than 1 mm) ST segment with a straight or
convex morphology that leads into a negative (inverted) T wave at an angle of 60° to 90°;2 (2) biphasic T waves in the right to midprecordial leads.

• - Pictures of Wellens’ signs are available here. Learn it, because it can signify significant LAD or left main occlusion, and patients with Wellens’ syndrome need intervention.
• - Sheler touched on orthostatic blood pressure readings, and their general inadequacy in aiding our decision making. I just wanted to reiterate, because sometimes consultants seize upon these measurements as the ultimate explanation. No. From ACEP’s clinical policy review on syncope:

Recurrence of symptoms such as light-headedness or even syncope on standing is more significant than any numeric change in blood pressure… Relying on the diagnosis of orthostatic hypotension as a cause of syncope should be symptom-related and a diagnosis of exclusion in otherwise low-risk patients, with the realization that many high-risk patients will have orthostasis.

• - Finally, Dr. Columbo noted that we’ll have care coordinators on hand in the EHC ED starting in July that can help arrange for Holter monitors for select syncope patients meriting discharge.

Stroke Notes — EMCREG recommendations, seizures, PO ASA and swallowing, NINDS

• - Dr. Strayer’s excellent TIA / Stroke lecture brought up numerous points of discussion, a few of which I’ll note here.
• - He cited new EMCREG recommendations for HTN emergencies (including hemorrhagic stroke, ischemic +/- lytics) that again say there’s no clear rationale for lowing BP in ischemic stroke outside the tPA window — but in cases of end-organ damage, favor labetalol or nicardipine (full disclosure: this organization has ties to industry).
• - Dr. Strayer touched on seizures. I did some digging and found that patients with seizure at stroke onset, while absolute contraindicated from receiving tPA in the NINDS trial, can still have ischemic lesions and benefit from tPA.
• - Dr. Nazarian pointed out that some regulatory agency is frowning upon PO aspirin administration in stroke patients before a swallow study can be performed. This was fascinating to me. Fortunately ASA can be administered through other orifices.
• - We were unfortunately short on time, and will have to revisit the controversy surrounding NINDS at a later date. The good news is this is a topic we’ve covered online before. Many others have attempted to summarize the critiques.

Cardioactive Steroid Toxicity -Dig levels, prognostic markers.

• - Shawn’s interesting case had it all — sex, drugs, and arrhythmias.
• - An important point in this rare overdose of a digoxin-like substance (which goes by Chan Su, Rock Hard, Love Stone, and simply, ‘la piedra’) is, you can’t go by serum digoxin levels! There’s some cross-reactivity with the lab assay for digoxin, but your hospital’s mileage may vary, and treating serum levels it with the traditional digifab dosing formula will undertreat. Go empirically based on symptoms, K, and EKG findings. Potassium is the best prognostic indicator.

Toxicologic Bradycardia - new HIE protocol

• - Dr. Ginsburg expanded upon Shawn’s dig-like overdose to also cover beta-blocker and calcium-channel blocker overdose.
• - She directed us to her excellent writeup of this topic in EMPractice.
• - In addition to reminding us of the traditional options, she expanded upon a new topic, High-Dose Insulin Euglycemia (HIE) for treatment of severe beta-blocker or CCB toxicity. However, her dosing regimen has evolved since she wrote her article, and she’s now recommending:

• –Pretreat with 1 amp D50 (hold if serum glucose >250 mg/dL)
• –Regular insulin 1 U/kg bolus, then infusion 0.5 U/kg/h, titrate up to 2 U/kg/h if no improvement after 30 min
• –Give with dextrose 0.5-1 g/kg/h (may use D5, D10), titrate to maintain serum glucose between 100-200 mg/dL)
• –Frequent serum glucose monitoring (q 15-30 min for 4 h until serum glucose consistently 100-200 mg/dL, then q h)
• –Monitor serum potassium q 4-6 h
• –Goals: EF 50%, SBP >90 mm Hg, improved mental status, UOP 1-2 ml/kg/h, decrease use of concomitant vasoactive drugs

Shock and Hypothermia - links to resources and protocols

• - We were lucky to catch a preview of two PV talks, by our esteemed critical care directors, Dr. Weingart and Dr. Andrus. They crammed a ton of useful material into their talks.
• - You can find the Dr. Weingart’s practical review of shock more fully expounded upon on his emcrit site and his recent review with Sinai grad Chad Myers in EMPractice.
• - Dr. Andrus outlined the Sinai experience with hypothermia for cardiac arrest, noting not just our cooling protocol but our shivering protocol (and check back often for updates at critical-care.info for Sinai patients, and EHCED.org for Elmhurst patients).
• - Unanswered questions going forward revolve around which arrhythmias are best treated by cooling, and the efficacy of lytics in a cooled patient.
• - Always remember to use the EDGT worksheet for all your sepsis patients, at either site.

Feel free to add your own comments below.

Posted on Wednesday, June 18th, 2008 at 10:31 pm by Nick. Filed under Post-Conference Letter, Monitoring, Arrhythmias, Blog.
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