the single most important talk of your career begins in · numeroso f, mossini g, giovanelli m,...

The single most important talk of your career begins in...

5 Years

Cardiology Review

Wieters

From @srrezaie

No Disclosures

J. Scott Wieters MD @EMedCoach

[email protected]

5 Years

1. Avoid Pitfalls in DX Aortic Dissection 2. Diagnose the subtle STEMI 3. Manage Ventricular Dysrhythmias 4. Recognize and Treat Pericarditis 5. Admit less Syncope Patients

Diercks DB, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine 2015. PMID 25529153

Aortic Dissection

CDRD-dimer

USCTA

Diercks DB, et al. Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients With Suspected Acute Nontraumatic Thoracic Aortic Dissection. Annals of Emergency Medicine 2015. PMID 25529153

Aortic Dissection

CDRD-dimer

USCTA2017

LLSA

I’m Better At Diagnosing STEMI

5 Years

I’ve still got a LOT to learn…

STEMI Longer QTc

more STE V3 Smaller Rv4

BER Shorter QTc Less STE V3 Large Rv4

STEMI

BER

STEMI

BER

Longer QTc

Less STE v3

Smaller Rv4

Shorter QTc

More STE v3

Larger Rv4

STEMI

BER

QTc- 411

ST V3- 1.2

R v4- 7

QTc- 371

ST V3- 4

R v4- 19

STE 60 V3

QTc RAV4formula

value

2 460 13 25.294

>23.4 Sens. & Spec. for STEMI

http://hqmeded-ecg.blogspot.com/p/rules-equations.html

QTc- 411ST V3- 1.2

R v4- 6

QTc- 371ST V3- 4

R v4- 19

STEMI

BER

24

20.5

Value >23.4 predicts STEMI

Manage Ventricular

Dysrhythmias

5 Years

Electricity

Drugs

And

Ortiz M, Martín A, Arribas F, et al. Randomized comparison of intravenous procainamide vs. intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the PROCAMIO study. Eur Heart J. 2016;

Procainamide Amiodarone

PTS 33 29Adverse. Events 18% 31%MACE 9% 41%

CARDIOVERT 67% 38%

Procamio

Amiodarone Lidocaine Placebo Study

Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placeboe in Out-of-Hospital Cardiac Arrest. NEJM 2016.

PTS DC MR<3

Amio. 974 24.4% 18.8%

Lido. 993 23.7% 17.5%

Placebo 1059 21.0% 16.6%

Kudenchuk PJ et al. Amiodarone, Lidocaine, or Placeboe in Out-of-Hospital Cardiac Arrest. NEJM 2016.

Amiodarone Lidocaine Placebo Study

• pic of pads coming at patient.

Cabañas JG, Myers JB, Williams JG, De Maio VJ, Bachman MW. Double Sequential External Defibrillation in Out-of-Hospital Refractory Ventricular Fibrillation: A Report of Ten Cases. Prehosp Emerg Care. 2015 January-March;19(1):126-130. Epub 2014 Sep 22. PubMed PMID: 25243771.

10 Pts Failed 5 shocks

DSD 7/10 Converted

NONE Survived DC


M.A. Merlin, A. Tagore, R. Bauter, F.H. ArshadA case series of double sequence defibrillation Prehosp Emerg Care (2016), pp. 1–4

M.A. Merlin, A. Tagore, R. Bauter, F.H. Arched vA case series of double sequence defibrillation Prehosp Emerg Care (2016), pp. 1–4

Converted 5/7

Survived DC 3/7

CPC 1 2/7


Cortez E et al. Use of Double Sequential External Defibrillation for Refractory Ventricular Fibrillation During Out-of-Hospital Cardiac Arrest. Resuscitation 2016. S0300-9572(16): 30398 – 7. [Epub ahead of print] PMID: 27521470


Cortez E et al. Use of Double Sequential External Defibrillation for Refractory Ventricular Fibrillation During Out-of-Hospital Cardiac Arrest. Resuscitation 2016. S0300-9572(16): 30398 – 7. [Epub ahead of print] PMID: 27521470

Converted 9/12

ROSC 3/12

Survived DC

3/12

CPC 1 2/12

Elliot M. Ross, Theodore T. Redman, Stephen A. Harper, Julian G. Mapp, David A. Wampler, David A. Miramontes, Dual defibrillation in out-of-hospital cardiac arrest: A retrospective cohort analysis, Resuscitation, Volume 106, September 2016, Pages 14-17,

279 Recurrant VF

50 DSD 229 SD

28%ROSC 38%ROSC

6%CPC1 11% CPC1

Summary?

Refractory Vfib May respond to

DSD?

• pic of pads coming at patient.

Esmolol?

41 Pts with Ref. Vfib

ESMOLOL NADA p

PTS 16 25 0.007

ROSC/ICU 56% 16% 0.38

CPC1-2 18% 8% 0.38

Lee YH et al. Refractory Ventricular Fibrillation Treated with Esmolol. Resuscitation 2016. [Epub Ahead of Print]. PMID: 27523955

Electricity

Drugs

AndDSD

Esmolol

Refractory Vfib?

Pericarditis?

5 Years

CASEBP 150/92

P 105

RR 35

Sat 87%

T 98.7F

In Your ED

Pericarditis

Clinical?

Rub?

EKG?

Markers?

ECHO?

STEMI?Is there ST depression in a lead other than AVR or V1?

Is there convex up or horizontal ST elevation?

Is there ST elevation greater in III than II?

No PR depression in multiple leads…

Mattu Pericarditis 2012

Reciprocal changes

PR Depression

Diffuse ST elevation <5mm

ST to T wave >0.25

PR Elevation

ST II>III

Pericarditis

Repol. v. Pericarditis

ST = 3 mm

T = 6 mm

ST / T ratio = 50%

The ST / T ratio > 25%= pericarditis.

www.lifeinthefastlane.com

63 / = 50%

ST = 1 mm T = 6 mm ST / T ratio = 16% The ST / T ratio < 25%= BER


61 / = 16%

Repol. v. Pericarditis

Fish Hook = BER


Reciprocal changes

PR Depression

Diffuse ST elevation <5mm

ST to T wave >0.25

PR Elevation

ST II>III

Pericarditis

Which Meds?

“When I get a headache, I take two aspirin and I keep away from the children. Just like the Bottle says”

NSAIDS?

Steroids?

Imazio M, Adler Y. Treatment with aspirin, NSAID, corticosteroids, and colchicine in acute and recurrent pericarditis.

Heart Fail Rev 2013;18:355–60.

Colchicine?

-240 participants -PC DB RCT

-Colchicine vs Placebo

ICAP

Imazio M, et al. “A Randomized Trial of Colchicine for Acute Pericarditis”. The New England Journal of Medicine. 2013. 369(16):1522-1528. PMID:23992557

2016 LLSA

ICAP

Imazio M, et al. “A Randomized Trial of Colchicine for Acute Pericarditis”. The New England Journal of Medicine. 2013. 369(16):1522-1528. PMID:23992557

72 hrs 18 moColchicine

ASA and NSAID 19% 9%

placebo ASA and NSAID 40% 21%

-564 participants -four RCTs

Alabed, Samer, Cabello, Juan B, Irving, Greg J, Qintar, Mohammed, Burls, Amanda. Colchicine for pericarditis. (Protocol) Cochrane Database of

Systematic Reviews 2014, Issue 8.

Cochrane 2014

“Colchicine, reduces pericarditis recurrences”

Alabed, Samer, Cabello, Juan B, Irving, Greg J, Qintar, Mohammed, Burls, Amanda. Colchicine for pericarditis. (Protocol) Cochrane Database of

Systematic Reviews 2014, Issue 8.

Cochrane 2014

Colchicine for

pericarditis.

Meta-Anaylsis 2016

Papageorgiou N, Briasoulis A, Lazaros G, Imazio M, Tousoulis D. Colchicine for prevention and treatment of cardiac diseases: a meta-analysis. Cardiovasc Ther. 2016 Aug 31. doi: 10.1111/1755-5922.12226. [Epub ahead of print] PubMed PMID:27580061.

17 Studies 2,000 Pts

Colchicine

Imazio M, Gaita F, LeWinter M. Evaluation and Treatment of Pericarditis: A Systematic Review. JAMA. 2015 Oct 13;314(14):1498-506. doi:10.1001/jama.2015.12763. Review. Erratum in: JAMA. 2015 Nov 10;314(18):1978.JAMA. 2016 Jan 5;315(1):90.

Reduced A. Fib In Pericarditis

-1-2mg day one -Then 0.5-1 mg/day 3mo

Avoid Colchicine in:

- Renal Failure - Hepatic dysfunction - Pregnant or Lactating - Immunosuppression

Gastric Protection?

-Master the EKG -ASA -NSAIDS -Colchicine -Avoid Steroids

Summary Pericarditis

1(800) RIO-DROPPrehospital Services

Prehospital Services1(800) RIO-DROP

Syncope

5 Years

15%

Mattu

SAH

PEEctopic

ADAAA

ACS

Syncope

Sens. Spec. NPV PPV

San Fran.

87% 52% 97% 19%

Boston 100% 57% 100% 44%

OESIL 98% 28% 98% 28%

EGSYS 95% 61% 99% 33%https://www.aliem.com/2013/management-of-syncope-aka-done-fell-out/

Rules, Rules, Rules…

Level A:

H&P to Risk Stratify ECG

ACEP on Syncope

High risk of AE: Older Structural HD CAD

ACEP on Syncope

Low risk of AE: Young Nonexertional NO CVD NO Comorbidities NO Fam Hx SCD

ACEP on Syncope

Admit CHF, Ischemia or structural heart disease Older age (>70) and associated co-morbidities Abnormal ECG HCT < 30

ACEP on SyncopeLevel C:

Lab ECHO

CT

better chart

Numeroso F, Mossini G, Giovanelli M, Lippi G, Cervellin G. Short-term Prognosis and Current Management of Syncopal Patients at Intermediate Risk:

Results from the IRiS (Intermediate-Risk Syncope) Study. Acad Emerg Med. 2016 Aug;23(8):941-8. doi: 10.1111/acem.13013. Epub 2016 Aug 1. PubMed PMID: 27178670.



IRiS



Decomp. HD Fam. Hx SCD Bad Story Valvular HD Bad EKG

HIGH Risk



Decompensated HD Fam. Hx SCD Exertion/Supine Palpitations/CP Valvular HD Bad EKG

Hx CHF?Age?

Hx CAD?



347

243 95

28.4%0.8%

Int. High

IRiS

MACE MACE



IRiS

Discharge?

Costantino G, Syncope clinical management in the emergency department: a consensus from the first international workshop on syncope risk stratification in theemergency department. Eur Heart J. 2016 May 14;37(19):1493-8. doi:10.1093/eurheartj/

ehv378. Epub 2015 Aug 4. PubMed PMID: 26242712; PubMed Central PMCID: PMC4872282.

International Workshop Syncope In ED Consensus



“Difficult to gain Consensus”



“Admit Intermediate and High risk patients.”

Summary1. Avoid Pitfalls in DX Aortic Dissection 2. Diagnose the subtle STEMI 3. Manage Ventricular Dysrhythmias 4. Recognize and Treat Pericarditis 5. Admit less Syncope Patients

@EMedCoach

[email protected]

5 Years?

the single most important talk of your career begins in · numeroso f, mossini g, giovanelli m,...

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