I always say that it takes more skill to NOT intubate a patient. That is especially the case with severe CHF, where BiPAP, nitro and a couple of hours can turn them around completely. Intubation is a dangerous procedure, and I think we have come a long way in EM from the days when we had a low threshold to intubate intoxicated patients.

The TL;DR is that in patients suspected of “poisoning” (which to them means alcohol, drugs or medication), an expectant approach of “restricted intubation” led to improved outcomes of shorter ICU stay, shorter hospital stay, less pneumonia, and of course less adverse events from intubation.

Read this article and the commentary (both linked below). I thought this was too important to wait for Journal Club, but we could still cover it at JC in the near future. 20 different EDs, RCT, 225 total patients, excluded some poisonings that had easy reversal or needed antidotes. No patients died.

Here is the original research article. Here is the accompanying editorial.

HPI: 54 yo F with history of CAD s/p 4 previous stents (LAD and first diagonal branch) who presents with abdominal pain, nausea, and vomiting

EKG Interpretation: ST elevation (STE) in anterior, inferior with right ventricular extension, posterior, +/- lateral distributions (only elevation in V6). Reciprocal changes (ST depression) in leads I and aVL.

Cath Report: 100% occlusion of the RCA. 100% occlusion of the posterolateral subdivision. 50% in-stent restenosis of the mid LAD. 50% stenosis of the first diagonal branch

Procedure: Aspiration thrombectomy, PCI of distal and mid RCA x 2

Commentary:

-AHA/ACC for STEMI: Men < 40: 2.5 mm (2.5 small EKG boxes) ST-elevation in V2 or V3, 1 mm in any other lead, Men > 40: 2.0 mm ST-elevation in V2 or V3, 1 mm in any other lead, Women: >1.5 mm ST-elevation in V2 or V3, 1 mm in any other lead

-Leads and Vessel Correlation: V1-V4 are anterior/septal leads correlate with the Left Anterior Descending artery. II, III, and aVF are inferior leads correlate with the Right Coronary artery. I, aVL, V5-V6 are lateral leads correlate with Left Circumflex artery

-Posterior MI: Present if ST depression in the right precordial leads or presence of prominent R-waves and upright T-waves in these same leads. Accompanies 15-20% of STEMIs. Usually associated with inferior or lateral infarctions. Suggestive of a much larger area of myocardial damage. Can consider a posterior EKG to look for STE (V7-V9 in horizontal plane underneath the left scapula)

-Right Ventricular Infarction: Present if the magnitude of ST-segment elevation in lead V1 exceeds the magnitude of ST-segment elevation in lead V2, or if the ST-segment in lead V1 is isoelectric and the ST-segment in lead V2 is significantly depressed, or if the magnitude of ST-segment elevation in lead III exceeds the magnitude of ST-segment elevation in lead II. Associated with approximately 40% of inferior STEMIs. Patients tend to be very preload sensitive from poor RV contractility and nitrates are contraindicated. Consider EKG with right sided leads to look for STE (transfer V3-V6 to right side of chest)

Check out this recent lecture from Dr Stephen Smith of the famous ECG Blog. The link is to a google doc but it is still live after months. He describes some sophisticated ST segment and T wave changes that ER doctors must know to pick up subtle ischemia. You have to just love how Smith is so candid about his opinions. He does not mess around with anyone who argues with the Occlusion MI (OMI) paradigm or even individual tracings. He says that sadly some people just can’t see the subtle findings, but I maintain hope that every studious ER doc can master the image pattern recognition he teaches. And if they can’t, maybe AI can. Smith advises multiple companies that use AI to detect these subtle ECG findings, to determine when patients are having OMIs. His software appears to be quite effective.

Something to keep in mind while watching, he is going over (tons of) cases that all have a relatively high pretest probability of ischemia. He has selected them out. We are working on evaluating and treating more ‘cardiac patients’ at ULH, but his patient population (at Hennepin) would be more like Jewish or maybe even other centers in town with more active cath labs.

A few of the rules that came up repeatedly in the video:

Smith of course talks about the weakness of a STEMI/NSTEMI paradigm, arguing instead for the occlusion MI paradigm.

Proportionality, proportionality, proportionality – T wave size in proportion to the QRS. A medium sized broad T wave after a tiny QRS is concerning!

Similarly, the morphology of the Hyperacute T is usualy broad based, and not tall and peaked like hyperK+. Thus, thinking about the area under the curve of the T wave makes more sense.

Biphasic T waves (down up meaning recip change) – we usually talk about biphasic reperfusion T waves in the leads involved in ischemia, but here mostly shows biphasic T waves reciprocal to infarction pattern in other leads.

1st Trimester Pelvic POCUS

• All patients who are suspected to be pregnant need a transabdominal US
• WHY? -> RULE IN UP 
• Trans Abd US POCUS
  • Full bladder
  • Sagittal view – scan through full anatomy (1st view – best idea of what the anatomy is going to look like)
  • Transverse view 
  • Measurements
    • M -Mode for FHR
    • CRL
  • Adnexa? Probably good practice
  • Linear probe for superficial uterus for better resolution
• TVUS
  • Hold probe with indicator on top (thumb on top)
  • When: Unable to confirm IUP on TAUS
  • Need EMPTY Bladder
  • Probe movements: Rock/Fan only
  • Start with placing probe into introitus, look at screen and then slowly advance probe with gentle pressure
• MUST HAVE at least a YOLK SAC to be confirmed as an IUP
• Do not use BhCG to determine if patient needs US
  • Ectopics can have BhCG level of 0 

Pleural Effusion and Opportunistic infections

• Evaluation
  • CXR, CT, US
    • Left lateral decubitus XR more sensitive than PA,  less fluid required
  • Pleural fluid tap
• Lights Criteria
  • Transudative vs Exudative 
• Treatment
  • Chest tube placement for drainage
  • Antibiotics
• Parapneumonic effusion/Empyema
  • Higher rates of morbidity and mortality
  • Higher risk in certain pops (IVDU, alcoholics, immunosuppressed, etc)
• Antibiotics
  • Pathogens MC – S pneumo > Anaerobes > S aureus > G- bacilli
  • Empiric Tx: Pip/Tazo + vanc (meropenem, cefepime, metronidazole if PCN allergy)
• Incomplete Drainage?
  • Fibrinolytics via thoracostomy tube
    • Alteplase + DNAse 
• PCP (P jiroveci) Pneumonia
  • HIV patients w. CD4 <200
  • SMX/TMP 15-20mg/kg divided into 3-4 doses daily
    • Dapsone, primaquine, atovaquone if need alternative
  • Steroids if PaO2<70 mmhg
• MAC (M avium)
  • HIV, CD4<50
  • Macrolide, ethambutol, rifampin 
• Histoplasmosis
  • Fungal infection endemic to central and south central USA
  • Amphotericin B preferred
  • Itraconazole alternative
• TB
  • RIPE therapy (rifampin, INH, pyrazinamide, pyridoxine, ethambutol) 
• Candidiasis
  • Very common in HIV w/ low CD4
  • Fluconazole best, can use itraconazole

The Analytical Evaluation of an Unwanted Outcome

• 50 yo M w/ CP/SOA while washing dog
• pmh HTN, HLD, hypothyroidism, TB use
• FH: brother died of MI in 40s
• Initial EKG w/ NSR, T wave inversion III, normal otherwise
• 2 prior ED admissions for similar symptoms w/ negative workup
• Trop 63, sent to Jewish via Lyft for Personal vehicle 
• Coded at Jewish in Vfib, Cath w/ 100% LAD and RCA, stented
• Things to think about
  • ALS vs BLS vs Lyft transfer
  • Should we have stricter rules to transfer to Jewish Cards Obs?
  • Should we call the fellow or attending on cards more often?

Pneumonia

• Severity classification for pna – differentiates what treatments to use
• No comorbidities = Monotherapy (Beta lactam, Doxycycline)
• Comorbidities= Beta lactam + Doxy or Azithro / or monotherapy w/ Levaquin
• Inpatient = IV ceftriaxone + Azithro or Doxy
• Prev hospitalization or IV abx in last 90d?  –> Vanc or Linezolid for MRSA coverage
• 5 days usually adequate if no comorbidities
• 7 days if Comorbid or MRSA/Pseudomonal coverage
• Procalcitonin essentially useless, Clinical criteria alone should be used
• Aspiration
  • Chemical pneumonitis – no abx required
    • Severe periodontal disease present – should be treated 
  • HAP / CAP = treat

Acute Bronchitis

• Rule out: Asthma, COPD, HF, pna
• Usually no fevers
• CXR indicated if tachycardic, tachypneic, rusty sputum, febrile
• Supportive care options
  • APAP, Ibuprofen, cetirizine/diphenhydramine, codeine, dextromethorphan (best results), benzonatate, guaifenesin (best data), albuterol (if wheezing or underlying asthma/copd)
• Educate patient on why Abx may not shorten illness, give supportive therapies, and expectations of illness/cough duration
• Bacterial
  • Sx> 10 d
  • Fever>102F w/ purulent nasal discharge/facial pain
  • Double worsening of symptoms
• Flu
  • Oseltamivir (Tamiflu) – within 48hrs of onset
    • Initial study – sx improvement only 16hrs earlier than placebo
    • 2023 meta analysis shows no benefit over placebo w/ primary outcome of hospitalization 
  • Who should get treated?
    • Hospitalized, immunocompromised, >2 yo or <65yo, pregnant

Research

• Think, Do, Write
• Research is fun, rewarding, and part of being a well rounded EM physician 
• Many conferences that you can go to (and Department will pay your way)

An interesting article worthy of a literature review was recently discussed at our Journal Club. Posted below is a description of the article and key takeaways from our discussion.

“Evaluating our progress with trauma transfer imaging: repeat CT scans, incomplete imaging, and delayed definitive care”

The research article was published in the journal Emergency Radiology. The study aimed to evaluate the progress made in trauma transfer imaging by investigating repeat CT scans, incomplete imaging, and delayed definitive care. The researchers conducted a retrospective review of all tier 1 trauma patients transferred to their trauma center between May 2018 and April 2019. They compared patients who underwent CT imaging at the initial hospital (IH) with those who did not. The study identified several imaging inadequacies, including repeat CT scans, C-spine inadequacies, incomplete chest-abdomen-pelvis (CAP) imaging, and CAP CT without IV contrast.

The results of the study showed that obtaining CT imaging at the IH led to significantly prolonged IH time. Among patients who had IH imaging, a considerable number required repeat CT scans, had C-spine inadequacies, incomplete CAP imaging, or one or more imaging inadequacies. Most patients with imaging at the IH returned to the CT scan at the trauma center. The study concluded that there are continuing issues with IH CT imaging, which result in delays in definitive care and increased radiation exposure for patients.

The most important takeaway from our discussion was the importance of following ATLS to manage your trauma patients. ATLS trained EM physicians know that a potentially critical trauma patient needs to be resuscitated, receive FAST examination, and receive chest/pelvic xrays where applicable. Once completed, these patients should be transferred to centers where definitive trauma management (ie surgery) is available. Spending time to obtain CT imaging usually leads to a delay in care for the patient.

Please use link below to access conference notes

https://docs.google.com/document/d/15_djB5-EtIzrueZ7b7sT1GAQjp80Mvj5-gyhTY2ADLU/edit?usp=sharing

Please access link below for full notes

https://docs.google.com/document/d/12mmZQoKA5VQpIw9IF8MXv9FB7tbrXiYgMEVcmH8ntkI/edit?usp=sharing

Oral Boards Review

• Always be reassessing the patient, especially after interventions are given
• Don’t be afraid to stand your ground when consults give pushback
• Think about what critical actions need to be taken for each patient
• Be thorough with your history taking, the examiner may not always be forthcoming with critical information

Cardiac Toxins

• When a pt presents with Bradycardia and hypotension, these medications should be on your differential
• Two different major categories: “Pump Killers” and “Electrical Disruptors”
  • Pump killers are your negative inotropes
  • In the setting of BB overdose, selective agents lose their selectivity and begin affecting both B1/B2 receptors
  • BBs in comparison to Ca channel blockers cause more profound AMS, classically cause hypoglycemia in contrast to Ca channel blockers which cause hyperglycemia
  • Early interventions include IVF, glucagon, atropine, and calcium. Consider placing a CVC early and gi decon
  • Bedside echo can be very valuable in helping guide management
    • If those interventions fail, move on to either Vasopressors or 1unit/kg insulin. End of the line is ECMO
    • In the setting of digoxin toxicity, potassium level is extremely valuable; One study found K+ >5.5 had a 100% mortality in those not given an antidote while <5.0 had 100% survival

EMS Radio Calls

• Main call-ins are for prearrival notification, requests for orders, requests to cease resuscitation or a patient refusing medical care
• There are strict guidelines for when we can vs cannot cease efforts in the field
• Often have to make critical decisions with very little information

Lightning Lectures

• -Average lifespan of the pulse generator is 6-10 years
  • -Leadless pacemakers are in the works. Can help reduce many of the risks associated with current pacemakers
• -Indications for pacemaker placement include Sinus Node dysfunction, high degree AV block or high risk to progress to high degree AV block
• -Magnet placement will revert any pacemaker back to the factory rate
• -Iphone 12s and newer models are known to be strong enough magnets to revert to factory settings
• -When a pacemaker is malfunctioning, interrogation is usually the first investigative step

• -AAAs that are symptomatic or > ~5cm require surgical repair
• -Most common complication of AAA: rupture
• -Risk Factors for AAA include Male gender, Smoking, HTN, age >50
• -Gold standard for diagnosis is CT, however, US can also be quite sensitive
• -Overall Tx goal is reducing shearing stress. Aggressively control pain, HR and BP

Using Self-Directed Learning Skills To Pass The Boards The First Time

• -Nationally across all specialties 20% of residents fail boards on the first attempt
• -Self directed learning has 4 main parts: Define a goal, identify the steps, choose the best strategy and asses
• -Important to try to identify gaps in knowledge; can help to ask yourself reflective questions
• -Try to create frameworks to organize your knowledge
• -How to read to gain knowledge: Ask yourself 1. What did I just read? 2. Why was it important? 3. How does it connect to something I already know?

PGY2 Clinical Pathway: Pulmonary Embolism

• -Helpful to divide acute vs subacute vs chronic. Stable vs unstable. Saddle vs segmental vs subsegmental
• -Wide variety of presentations ranging from asymptomatic to profound shock
• -ABG can sometimes be helpful (unexplained hypoxia should raise suspicion)
• -EKG abnormal in up to 70% of cases, however specific findings can vary widely
• -CTPE is 90% sensitive.
• -Treatment dependent on a number of factors including hemodynamic status and bleeding risk
• -Empirically anticoagulate those with low risk of bleed and high pre-test probability of PE