Lightning Lecture – Advance Directives
– Living Wills – May contain DNR but typically do not
– Health Care Proxy – legal document that establishes who makes decision on behalf of the patients
– DNR orders can vary by state
– There are different types of DNRs
– POLST/MOLST – Physician/Medical Orders for Life-Sustaining Treatments – Kentucky’s newest forms
– Be open, honest, and compassionate when it comes to discussing end-of-life care
– At ULH, we have 24/7 palliative care services which are available in the ED

Lightning Lecture – Steven-Johnson Syndrome
– Extreme immune reaction causing keratinocyte necrosis diffusely
– Causes – medications, infections (Mycoplasma pneumonia), malignancy, immunosupression (HIV)
– Onset 1-3 weeks
– Prodromal viral symptoms – headache, fevers, msk pain
– Macular rash with bull -> skin sloughing (+/- Nikosky sign)
– Genital lesions, GI necrosis, pneumonia, interstitial pneumonitis
– Workup – basic labs, inflammatory markers, CXR
– ScorTEN – scoring algorithm to assess overall mortality
– SJS <10% TBSA involvement
– SJS/TEN Between 10-30% TBSA involvement
– TEN > 30% TBSA involvement
– Treat it like a burn – stop suspected offending agent, give a significant amount of IVF, local wound care, pain management

Interesting/Important EKG Findings
– P waves best seen in V1 and lead II
– In lead II, SA node P waves should be upright
– In lead VI, SA node P waves should be biphasic
– P pulmonale – right atrial enlargement
– P mitrale – left atrial enlargement
– Q waves usually occurs in the setting of post-MI
– Not all Q waves are indicative of MI
– One small box wide and one small box deep inside the Q wave is more indicative of pathologic Q waves
– T Waves – predominately upright
– Usually when inverted they represent ischemia vs strain
– U waves are rare upright waves following T waves typically only seen in significant dysfunction and illness
– Normal QRS: 60-100msec
– Incomplete BBB: 100-120msec
– Complete BBB: >120msec
– Short QT (500) Syndromes exist
– R wave progression – R waves should slowly appear through the precordial leads
– Should at lest be present by lead V2
– R should be isoelectric around V2-V3
– R wave should peak by V4-V5
– Early RWP can be lead placement, RVH, PHTN, or RBBB
– Late RWP can be old infarct, lead placement, LBBB
– Bundle Branch Blocks
– Is the terminal QRS deflection (last deflection) positive in V1? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V6? then in is a RBBB
– Is the terminal QRS deflection (last deflection) negative in V1? then in is a LBBB
– Is the terminal QRS deflection (last deflection) positive in V6? then in is a LBBB
– Most of the time, a true new LBBB does not pass the “eye test” – i.e. they look terrible in person
– If higher STEMI in Lead II vs Lead III -> likely LCx lesion instead of RCA lesion
– aVR – care about it because it can represent a left main lesion
– Reciprocal changes help identify a posterior MI
– Sgarbossa Criteria
– Concordant ST elevation > 1mm in leads with a positive QRS complex (positive terminal deflection of QRS complex with elevation in the T wave)
– Concordant ST depression > 1mm in V1-V3 (negative terminal deflection of QRS complex with depression in the T wave)
– When to obtain a posterior EKG:
– If posterior heart is infracting, should have reciprocal changes in the anterior waves (V1-V3)
– Lead II, Lead III, Lead aVF all negative deflections – this makes it a LAFB – NOT a LBBB equivalent
– A flutter – rate around 300bpm, vent rate usually 2:1
– AVNRT is the most common form of SVT
– Brugada Algorithm exists
– 200j is a good idea for most everything
– Run a 12 lead rhythm strip if possible while defibrillating unstable arrhythmia
– Causes of cardiogenic syncope
– ARVC, QT Syndromes, Conduction Delays, Etc
– Short PR interval in the right setting is a sign of WPW
– Brugada has types?
– Brugada pattern is when EKG changes present without symptoms
– Brugada Syndrome – EKG changes with syncope, chest pain, heart failure symptoms
– Metoprolol has more significant breakthrough events with long QT syndrome so Propranolol and/or Nadolol are preferred
– T wave inversions present in V1-V3 with syncope is concerning ARVD – look for epsilon waves – notching immediately after QRS
– Arrhythmogenic Right Ventricular Dysplasia
– Fatty infiltrative disease of the right ventricular free wall

Brief Review of Statistics
– Normal Distribution – 68%, 95%, 99.7%
– P value is the probability that the observed effect within the study would have occurred by chance if, in reality, there was no true effect
– Confidence interval provides a range of values within a given confidence including the accurate value of the statistical constraint within a targeted population
– Type I Error – the result of the study is said to be statistically significant but in-reality it was not
– Type II Error – the result o the study is said to not be statistically significant but in-reality is was
– Closely associated with the power of the study
– Power – ability to correctly reject a null hypothesis that is indeed false
– Higher powered studies are better when evaluating high risk and/or life-threatening stuff?
– SPin and SNout
– PPV and NPV
– Higher prevalence, higher PPV and Lower NPV
– memorize the chart
– Prevalence – total existing cases/total population
– Incidence – new (over a certain time period) cases / total population
– Precision vs Accuracy
– Probability – event of interest / total events measured
– Odds – event of interest / not event of interest
– Risk Ratio – probability of one group / probability of another group
– Odds Ratio – odds/odds
Confidence intervals -> crosses 1 -> no difference
– Meta-analyses and Systemic Reviews are the best type of evidence based medicine
– High bias = low validity