Grand Rounds Recap 4.8.20

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R1 Clinical Diagnostics: Pacemakers WITH Dr. Broadstock

Pacemaker: electricity stimulates cardiac contraction; some indications include 3rd degree or advanced 2nd degree heart block, symptomatic breadycardia, sick sinus syndrome, atrial fib with SA dysfunction

Implantable Cardioverter-Defibrillator (ICD): delivers cardioversion or defibrillation for detected dysrhythmias; some indications include cardiac arrest from VT or VF not caused by reversible event, spontaneous sustained VT, syncope with VT/VF refractory to medications, NSVT with intrinsic myocardial dysfunction not suppressible by drugs, LVEF < 35% or NYHA Class II or III

  • These can be single chamber (lead goes to the right ventricle), dual chamber (leads go to right atrium and right ventricle) or biventricular (last lead goes to L ventricle)

  • Can look at the CXR to tell difference by counting leads. Also the coils on an ICD are much thicker than pacemaker

EKG Changes

  • Pacer spikes precede the QRS if ventricularly sensed and before p wave if atrially sensed

  • Would expect to see LBBB in ventricularly sensed pacemaker

  • Dual chamber pacemakers have spikes before p wave and QRS complex

Complications

Immediate

  • pneumothorax, hemothorax, cardiac perforation, tamponade

Subacute

  • Pocket infection: occurs in approximately 2%. Palpation of pocket elicits pain with associated erythema, induration, purulence or erosion. Differential include pocket hematoma, post-implantation inflammation. Important not to aspirate pocket. Antibiotics should cover MRSA.

  • Coronary sinus dissection: occurs during placement of biventricular device. Incidence is 0.3-7%. Dissection alone is often asymptomatic but can be associated with perforation and tamponade.

Chronic

  • Upper extremity venous thrombosis: prevalence is 30-50% and about 33% will have complete occlusion. Only 0.5-3.5% develop symptoms of acute thrombosis (edema, pain, SVC syndrome). Incidence of PE is 1.6%

  • Pacemaker syndrome: Atria and ventricles out of sync leading to atrial distension and CNS mediated vasodepression. Symptoms include syncope, orthostatic dizziness, fatigue, exercise intolerance, chest fullness or pain. Incidence up to 20%, but most are mild and patients can adapt, but 1/3 are severe. Treatment includes convert VVI to DDI or place dual chamber ICD or lower ventricular pacing rate.

  • Twiddler’s syndrome: pacemaker dysfunction due to patient inadvertantly disturbing or manipulating pacemaker

  • Pacemaker malfunction: less than 5% and rarely life threatening. Etiology often from dead battery, lead misplacement or fracture, myocardial scarring

    • Inappropriate sensing - most common and can be either undersensing (pacer spike seen after QRS complex so hitting the refractory period and myocardium not getting depolarized) or oversensing (thinks heart is beating more than it should so not delivering pacing)

    • Failure to capture - second most common and can be due to lead issue, exit block (due to ischemia, hyperkalemia, class III antiarrhythmics) or dead battery

    • Inappropriate rate - firing beyond upper limit. Etiology can be dead battery, ventriculoatrial conduciton in dual chamber device or 1:1 response to atrial dysrhythmias

Pacemaker FAQs

ACLS

  • You may defib/cardiovert at standard voltages

  • Place pads >10cm from pulse generator

  • Get a CXR after CPR to evaluate for lead migration

  • ICD discharge while doing CPR is safe

  • Transcutaneous pacing is ok, but transvenous pacing may be difficult due to wires/clots

MRI

  • Many are safe

  • Non thoracic MRI appears to be with safe with non-MRI compatible devices up to 1.5T

Tricuspid Regurgitation

  • New significant TR or worsening TR in 10-39% of patients after device placement

  • If valve is replaced, presence of pacemaker showed no difference in 5 year mortality, recurrent TR or need for repeat operation

Neuro Pitfalls in the time of covid WITH dr. kircher

With many outpatient clinics closed, we may be responsible for making longer term decisions about neurologic conditions. EM-Neuro-CC physician Charlie Kircher is here to troubleshoot:

Migraine

  • Migraine and other chronic headaches are leading causes of invisible disability; ED visits are a failure of outpatient management plans

  • Evidence based approaches that limit nursing load include alternate routes of administration (PO/IM) and limiting nonessential testing

  • First line: IM Toradol/PO Compazine, can escalate to IM Decadron, triptans, antipsychotics or valproic acid.  Nerve blocks (sphenopalantine, occipital) are also an option

  • Triptans are underutilized in the ED and at discharge in otherwise healthy patients without cardiovascular disease; both opiates and Fioricet can lead to rebound headaches and should be avoided

  • Discuss recurrent migraine patients with neurology to formulate a plan for outpatient followup and initiation of daily controller med

Acute Vertigo

  • Dr. Kircher relies less on the HINTS exam and more on degree of disability associated with symptoms; low threshold for thrombolytics in acute window with disabling symptoms

  • For mild nondisabling vertigo, or possible TIA with low risk factors, outpatient management can be appropriate even if a central cause is suspected

Teamwork

  • With outpatient clinics and diagnostics limited, consider how the ED can accelerate treatment and workup for subacute conditions – could include IV contrasted CTs, MRI in select cases, or LP if it will aid initiation of disease modifying treatment

  • Many outpatient clinics are moving to telemedicine and phone for followup; discuss what is needed with your consultant and develop a plan together to take care of your patient’s needs.

R3 small groups: High sensitivity Troponin WITH Drs. Gleimer, Gottula, hughes and Koehler

  • HS-cTn will inevitably replace the conventional troponin assay

  • HS-cTN is a continuous variable and will be “detectable” in a large number of healthy patients

  • Absolute concentration of HS-cTn is assay-intrinsic and does not correspond to conventional troponin concentration

  • Important values are level of quantification (the lowest level where an actual concentration can be be determined), level of 99 percentile for males and females, and a level which necessitates a cardiology admission

  • There is strong evidence that otherwise low-risk patients with a single HS-cTn below the level of quantification can be safely discharged

  • For intermediate HS-cTn levels, a one-hour delta is recommended to determine the chronicity of the level; those with a low delta may be observed or discharged, whereas those with a high delta should be admitted

  • A certain institution-dependent cutoff indicates acute myocardial injury and necessitates admission

R4 Capstone: Humility in Leadership WITH DR. Banning

This program prides itself in training leaders, and one of the qualities that is under recognized but is often considered a strength in leadership is humility. Dr. Banning shares the lessons she has learned from her own failures and mishaps throughout her 4 years of residency in order to help others who may be struggling.

  1. Learn to be comfortable being uncomfortable

  2. What we do is comical and it is ok to laugh at yourself

  3. Sometimes bad things happen and there is nothing we can do about it

  4. How we perceive ourselves is not always reality or how others perceive us

  5. It is ok to share your burdens with those who will lift you up in times of need

  6. Don’t play doctor to your own family… just try to be their family

  7. We can do better as healthcare providers when it comes to communicating with patients

If your experience in residency doesn’t feel perfect, that is ok and normal. It is the experiences that feel hard and trying that shape you into a better physician. Residency goes by fast, cherish these moments.

Taming the SRU WITH Dr. Skrobut

Elderly gentleman presenting with chest pain. Appeared ill, pale and diaphoretic. Sternotomy scar present on exam. EKG was notable for inferior MI with occasional paced beats which met Sgarbossa criteria. Patient then went on to lose pulses and underwent a heroic resuscitation.

Right Ventricular Failure

  • Results from multiple causes, however in this case was the result of infarction.

  • Causes decrease in RV preload, decrease in contractility or an AV block. All of which leads to decrease in LV preload, leading to decrease in cardiac output and in crease in LV afterload.

    • Treatments include

      • Fluids for the decrease in preload

      • Inotropes for decreased contractility

      • Pacing for AV block and overall cardiac cath as soon as possible

    • If cath not available, can administer thrombolytics

  • Rest of the “kitchen sink” includes balloon pump, impella, VA ECMO

Pacemakers and MI

  • Patient remained in PEA despite likely etiology of code from thrombosis. Concern there was an underlying ventricular arrhythmia that was being obscured by pacer.

  • There have been papers where (Academy of Emergency Medicine, 1996) showing evidence of ventricular fibrillation with background pacing masquerading as PEA.

  • Bedside US confirmed likely VF and shocks were delivered.

Take-home Points

  1. Know the kitchen sink

  2. Don’t follow the algorithm if something doesn’t make sense

  3. Don’t be afraid to ask for help

  4. Find your own way to cope with difficult losses

PEM Lecture: Pediatric ophthalmology emergencies WITH Dr. zamor

The 5 Essentials Under 5

  1. Visual Acuity: a vital sign for the eye, but will they be cooperative?

    • 3 mo - focus on objects

    • 6 mo - fix and follow

    • >3 yr - chart with pictures

    • >6 yr - acuity approaches 20/20

  2. External Exam

  3. Motility

  4. Pupil

  5. Fundus Exam

Pediatric Ocular Trauma

  • Projectiles (20%), blunt objects (10%), MVAs (4%)

  • Most common cause of monocular blindness

  • More likely to suffer complications (infection, amblyopia)

  • Examine the eye with the child in position of comfort (minimize agitation)

  • Management of most traumatic ocular cases similar to adults

CASE 1

10 day old full term male with R eye drainage for 3 days. Started clear but now copious and mucopurulent

Opthalmia Neonatorum

  • DDx: chemical, chlamydia, gonococcal, trauma, nasolacrimal duct obstruction

  • Etiology: Timing is important as gonnorrhea appears 2-5 days from birth and chlamydia appears 5-12 days

  • Key points in HPI: prenatal care, mode of delivery, topical ointment prophylaxis, fever history

  • Treatment: gonococcal conjunctivitis = IV ceftriaxone x1, chlamydial conjunctivitis = PO and topical erythromycin x 14 days; also should receive frequent eye irrigation with saline

  • Complications: corneal ulceration and perforation

Case 2

9 mo previously healthy female with R eye pain for several weeks, but worsening over the last several days. Eyes have been watery and sensitive to sun, but no discharge or redness. No trauma. Photophobia on exam, but rest of exam normal

Primary Pediatric Glaucoma

  • DDx: nasolacrimal duct obstruction, corneal abrasion, uveitis, conjunctivitis

  • 1 in every 10,000 births; 25% occur at birth, 80% develop before 1 year of age

  • Classic symptom triad: epiphora (excessive watering), blepharospasm (uncontrolled closure of eyelid) and photophobia

  • Gradual increase in IOP leads to gradual stretching of tissues which leads to enlarged cornea, enlarged eye size and corneal cloudiness.

  • Consider genetic disorders such as Sturge-Weber, Neurofibromatosis Type I

  • Treatment: surgical repair; 80% recover if surgery completed before 1 year of age

  • Requires urgent referral to pediatric ophthalmologist as they may start eyedrops or oral glaucoma medications as temporizing measures prior to surgery

Case 3

2 year old female presenting with eyelid and lower extremity swelling for 1 month. Bruising also noted around eyes, but family denies trauma. Exam significant for well appearing child with slight non-pitting edema to lower extremities and HEENT with ecchymoses around bilateral eyes.

Metastatic Neuroblastoma

  • DDx: NAT, bleeding disorders

  • 3rd most common pediatric cancer; most common to cause orbital meds. Survival <50% if distant mets. Other ocular findings include Horner syndrome, proptosis, difficulty with extraocular movements

  • Workup: evaluate for an abdominal mass, CBC, CMP, urine catecholamines. Needs imaging of head, chest, abdominal, but not emergently

  • Refer to ophthalmology when following is found on exam: raccoon eyes, new onset nystagmus, evidence of Horner syndrome

Case 4

11 yo female with blurry vision and headache x4 days. Seen by PCP 2 days previously and noted to have “dilated pupils”. Brought to the ED today because noted to have blurry vision from R eye and walking into walls. Exam notable for pupils 8mm, consensual light reflex present. 20/400 in R eye.

Optic Neuritis

  • DDx: acute disseminating encephalomyelitis (ADEM), MS, neuromyelitis optica, transverse myelitis, retinal detachment (traumatic, tumor)

  • Sudden and unilateral vision loss. Can be bilateral and often associated with a viral infection.

  • Can be an isolated condition or associated with a variety of autoimmune disorders

  • Incidence of 1-5 per 100,000. Prognosis better with younger patients, but often have worse visual acuity compared to adults. Up to 30% will develop MS in adulthood.