April brought the third case of our Air Care Flight Physician Orientation Case Series with the goal of preparing our first year residents for their roles as Flight Physicians. This is a monthly series that will continue through the R1’s Flight Physician Orientation Day in June. First year residents discuss the case and its associated questions on our internal asynchronous learning forum, Slack. This month, a case of STEMI, seemingly simple, right… but what happens next?Read More
In this week's grand rounds, Dr. Stolz discussed all things DVT and the modified two-point compression study for lower extremity clots. In our recurring EM-neuro combined conference, Dr. Stettler discussed the recent DAWN trial results, and how to incorporate CT perfusion studies into our acute ischemic stroke decision trees. In our Quarterly Sim, we discussed the management of the crashing patient from a house fire, and practiced our escharotomy skills. In our mock oral boards, we went through cases on STEMI, carbon monoxide exposure and limb ischemia. Finally, Dr. Lane discussed the workup of acute diarrhea in the adult population, and Dr. Shah went through a particularly unique toxidrome presentation in his R4 Case Follow Up.Read More
Grand rounds this week started off with a review of the EMTALA law with Dr. Hinckley, as well as some case discussion. This was followed by a presentation from our clinical pharmacists, PharmD's Nicole Harger and Madeline Stephens, on anti-epileptic medications and their uses, as well as an update on our medication supplies in the ED. Drs. Murphy-Crews and Scanlon then presented their evidenced based algorithm for the management of STEMI, followed by our combined peds EM lecture with Dr. Kevin Overmann on the evaluation of the pale child and pediatric anemia. This was followed by Dr. Ludmer's R4 case follow up/best of residency cases. The day finished up with Dr. Sim Mand presenting her clinical diagnostics lecture on the assessment and management of the non-pregnant patient with abnormal uterine bleeding.Read More
In our first Grand Rounds of the academic year, we started with Dr. Pancioli teaching us about the history of Emergency Medicine. Dr. Palmer discussed team work and the case for building social capital and Dr. LaFollette worked through the disposition of patients with chest pain. Our clinical pharmacist Chris Droege, PharmD discussed the evolving landscape of agents we have to reverse oral anticoagulants.Read More
Real time, high sensitivity serum biomarkers have played an enormous part in the timely identification and intervention on of cardiac pathology in the Emergency Department. These biomarkers have sufficient sensitivity to identify cardiomyocyte injury even in the absence of physical exam, radiographic, or electrocardiographic findings. Unfortunately, the utility of these studies may be limited or obfuscated in certain clinical contexts. This article will discuss the possible pitfalls and obstacles physicians may encounter in interpreting cardiac biomarkersRead More
This week we spent some time with in-situ trauma simulations, followed up by lectures on medical causes of trauma with Dr. Thompson, STEMI and aspirin allergy with Dr. Axelson and a cardiology update with our specialist of the month from our cardiology intensivity and interventionalist Dr. Tim Smith.Read More
The UC Division of EMS has recorded a series of podcasts to celebrate EMS Week 2016. We are honored to be able to engage EMS Providers throughout the world with this forum. If you practice pre-hospital medicine, we would like to say thank you and that we appreciate everything you do to provide a high level of care to ill and injured patients in a wide variety of austere environments. For this podcast, we were joined by Dr. Tim Smith, an Interventional Cardiologist and Director of the Cardiovascular Intensive Care Unit at the University of Cincinnati Medical Center. Dr. Smith joined us to discuss our region’s partnership with the American Heart Association’s Mission Lifeline program to bring a regionalized system of care for STEMI patients to our area.Read More
It’s true that sometimes critical care transport missions to transport STEMI patients to PCI are fairly uneventful. But if we allow ourselves to get lulled into a “Milk Run” mindset, it will most definitely come back to bite us. The jovial, normotensive, fairly comfortable-appearing STEMI patient may be only a couple of minutes away from V Fib arrest or florid cardiogenic shock. When that occurs, if we have expected and prepared for such a complication, it’s likely that we’ll be able to manage it successfully.Read More
M&M with Dr. LaFollette
Modified Sgarbossa Criteria to aid in diagnosing STEMI in the setting of LBBB
- Can be used in the setting of induced (paced) LBBB
- Unweighted scoring (any of the following indicates STEMI equivilance)
- Concordant ST elevation
- Concordant ST depression in V1,V2,V3
- Inappropriate discordance of >25% ST elevation / S wave amplitudes
- Improves your test metrics from the original criteria from sens/spec of 36%/96% to 80%/99% respectively in a new validation study
It is early October and you are the flight doc in C-pod on a brisk but clear Saturday morning. The day starts out with several challenging patients with vague complaints and has just begun to ramp up in volume when a patient rolls into your pod by EMS, restrained face-down to the cot, covered in feces and urine, screaming about hearing voices. You begin to take report from EMS when, as if by divine intervention, the tones drop and you are dispatched for an inter-facility transfer. You gleefully (almost too gleefully…) give a brief patient sign-out to your staff, grab the blood cooler, and head to the roof...Read More
1. The ACC/AHA Criteria (1) (2)
ST-elevation in 2 contiguous leads that is:
Men < 40: 2.5 mm 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
STEMI's have a 90-minute door-to-balloon time mandate from the Center for Medicare Services (CMS). To be good stewards of our resources we need to be familiar the false positive STEMI patterns. Ultimately, however, some degree of over triage and activation for false positives is expected and (potentially even) desirable.Read More
Simulation - Clonidine Overdose
- 30 yo FM presents after having taking a handful of pills with the following VS: HR 45, BP 83/60, RR 8, 100% RA, T 98. FS101. It gets better—there's a baby behind that baby bump.
- Ddx for AMS, hypotension and bradycardia? Tox, hemoperitoneum, spinal shock, myxedema coma, and a quite atypical sepsis.
- By EMS report this lady reportedly took a handful of unknown pills in an effort to harm herself. Remember to consider clonidine overdose in addition to beta blockers and calcium channel blockers. This lady found herself a bottle of clonidine and a near successful suicide attempt.
Thanks to everybody who chimed in on our last "Flight"! We had a great discussion on the management of the STEMI transfer patient. These aren't just "milk runs" as pointed out by Dr. Hinckley. The highlights of the discussion are below with additional commentary on the case by Dr. Bill Hinckley and Air Care Resident Assistant Medical Director Dr. Matt Chinn. Out final flight will be lifting off June 1 and it's a doozy - looking forward to the discussion!Read More
Oral Boards Practice Cases
Case 1 - 22 yo F in a "coma" with normal vital signs. Not responding to Narcan and Dextrose. Found in a garage. On exam, she has sluggish and dilated pupils. pH 6.98, pCO2 29, bicarb 2
High concern for toxic alcohol ingestion: consult DPIC and nephrology for dialysis
- Fomepizole is the antidote for ethylene glycol only
- Can use ethanol drip to treat both ethylene glycol and methanol
- Replace folate aggressively and early
- Methanol is metabolized to formic acid, if you give folate you can prevent methanol from going down the formic acid pathway
Morbidity and Mortality Learning Points with Dr. Stull
1. Should Post-ROSC patients get cardiac cath?
- Cardiac arrest patients who have STEMI on EKG after ROSC tend to have good outcomes (overall survival and intact neurologic survival) if they get cath'ed.
- According to latest Australian study (all patients with ROSC from OHCA, not STEMI) OR for overall survival is 2.77 and OR 2.2 for good neurologic outcome
- VT/VF cardiac arrest patients who do not have a STEMI on EKG: improved survival and likelihood of good neurologic outcomes if cath'ed within 24 hours.
- Our cardiology department wants all post-ROSC VF/VT patients to have cath lab activation. All other post-ROSC cases, call cardiology to discuss need for cath lab
- All post-ROSC STEMI should go to cath lab no matter what their neuro status is