Is RBBB More Indicative of Large Anteroseptal MI?

• Conventionally a new onset left bundle branch (LBBB) with acute myocardial infarction (MI) is associated with a massive MI
• Proximal left anterior descending artery (LAD) septal perforators perfuse the right bundle branch and the anterior fascicle of the left bundle branch ~90% of cases
• The right coronary artery (RCA) perfuses the posterior fascicle of the left bundle branch ~90% of cases
• Given the anatomy, a LAD occlusion should cause RBBB and/or LAFB; both a proximal LAD and RCA occlusion would be required for MI to cause LBBB
• A recent cohort study analyzed 233 patients to evaluate if RBBB or LBBB was associated with a large anteroseptal scar:
  • RBBB was associated with larger scar size (24% vs. 6.5%; p<0.0001)
  • RBBB was more indicative of ischemic heart disease (79% vs. 29%; p<0.0001)
• Based on this preliminary data RBBB may have a stronger association with ischemia and anteroseptal scarring than LBBB (*limitations - small cohort of cardiomyopathy patients with an EF<35%, further study is required)

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Treatment:

• Vitamin B6 has been shown in a number of randomized placebo-controlled trials to be very effective in treatment of the 1st trimester nausea and vomiting and is a supported recommendation by the American College of Obstetrics and Gynecology (ACOG).
  • For refractory symptoms, efficacy is increased with supplementation of the sleep aide Doxylamine (found in Unisom pills over the counter)
  • Dosing of Vitamin B6 is 10 to 25mg every 8 hours daily
  • Dosing for Doxylamine is 12.5mg as needed in the morning, 12.5mg as needed in the afternoon, and 25mg as needed at bedtime.

• Ginger (ginger ale and ginger supplements) taken at 250mg daily doses has been recommended as 1st line treatment by ACOG.

Consider these therapies the next time you see a pregnant with persistent nausea and vomiting in her 1st

--Yemi

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We have learned how to diagnose compartment syndrome in adults, but how do you determine the early warning signs in a nonverbal or even frightened child?  

Rising compartment pressures are related to increasing anxiety and agitation in children.  A Boston study in 2001 showed that increasing pain medication requirements were detected 7 hours earlier than a vascular exam change.  90% of the patients with compartment syndrome in this study reported pain, but only 70% had another ‘P” (pallor, parasthesia, paralysis or pulselessness).

This has led to the proposal of the 3 “A”s for early identification of compartment syndrome in children: increasing anxiety, agitation and analgesia requirement.

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General Information:

·      The coming of the Affordable Care Act (ACA) is designed to shift patient care from episodic encounters to continuous community based partnerships.

·      Elsewhere in the world, community health workers (CHWs) have been used effectively to improve health outcomes, reduce heath care costs and create jobs in infectious disease (TB, HIV), maternal child health and chronic disease management.

·      CHWs are paid, full time lay provider members of community health systems.

o   Sub-Saharan Africa is training, deploying and integrating one million CHWs into the health system via a targeted campaign.

o   Brazil’s CHWs are part of family health teams that care for 110 million people.

o   India employs 600,000 CHWs paid through a fee-for-service system for primary care functions.

·      CHWs cost less, reduce readmissions and help address root causes of preventable chronic disease while remaining embedded in the community helping to strengthen long-term community relationships.

Relevance to the EM Physician:

As frustration with non-compliant patients mounts and the impact of the ACA looms, CHWs integrated into American communities may be just the answer we haven’t yet considered to help reduce ED overcrowding and improve our patients’ outcomes.

University of Maryland Section of Global Emergency Health

Author: Emilie J.B. Calvello, MD, MPH

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Peri-Intubation Cardiac Arrest

• Emergency intubation is a common critical care procedure that carries the risk of life-threatening complications.
• Although cardiac arrest (CA) is an established complication, there is scant literature on the actual incidence ad factors associated with CA in the peri-intubation period.
• In a recent retrospective analysis from Carolinas Medical Center, investigators found:
  • Peri-intubation CA occurred in 4.2% of patients and was associated with a 14-fold increase in hospital mortality.
  • A pre-RSI shock index > 0.9 was indepedently associated with CA.
  • Obese patients had a higher incidence of CA; odds of CA increased 1.37 times for every 10 kg increase in weight.
• Take Home Point: Peri-intubation CA may be more common than previously thought and, not suprisingly, is associated with an increased risk of in-hospital death.

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Question

8 year-old girl presents with dysphagia and drooling, Xray is shown. What’s the diagnosis (and where is it located)?

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Colchicine is known to be effective in treatment of recurrent pericarditis, but until recently its efficacy during the first attack of acute pericarditis has been uncertain.

A recent multicenter, double-blinded, RCT of patients with acute pericarditis found colchicine to be effective in reducing the rate of incessant or recurrent pericarditis (primary outcome), as well as the rate of hospitalization. Here are some highlights:

•  240 patients with acute pericarditis received conventional therapy (aspirin or ibuprofen), half of them were randomized to also get colchicine, the other half to placebo for 3 months
• Incessant or recurrent pericarditis: 16%  in the colchicine group versus 37% in the control group (relative risk reduction=0.56; CI 0.30-0.72; NNT =4; p < 0.001)
• Symptom persistence at 72 hours, recurrences per patient, and hospitalization rate were all significantly reduced in the colchicine group
• There were no significant differences in adverse effects or discontinuation of the study drugs

Bottom-line:

Colchicine is a safe and effective drug for the treatment of acute pericarditis. Consider adding colchicine to conventional therapies to reduce duration of symptoms, recurrences, and rate of hospitalization.

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Attachments

1309151219_NEJM-Colchicine_RCT.pdf (527 Kb)

The thumb MCP joint is subject to arthritric changes.

Sx's of arthritis will frequently present with pain in a similar region to deQuervain's disease.

The basal joint grind test

          Perform by stabilizing the triquetrum with your thumb and index finger and then dorsally subluxing the thumb metacarpal on the trapezium while providing compressive force with the opposite hand.

http://www.youtube.com/watch?v=oEJH7KFGx_Y

• occurs during neonatal period
• sterile pustules which then change to hyperpigmented macules, often with a rim of scale
• may persist up to 3 months
• histology is characterized by leukocytes
• benign condition with no sequelae
• requires no treatment

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With several new diabetes medications available, it is important to know which ones are likely to cause hypoglycemia after overdose. Based on mechanism of action and reported cases, the likelihood of hypoglycemia after overdose is listed below by drug class.

Keep in mind that other drugs can interact with antidiabetics resulting in hypoglycemia. This table applies only to single agent ingestion/administration.

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Background Information:

A recent review article in NEJM evaluated what effects globalization and climate change can be expected to have on human health.  If global population increases and temperatures continue to rise, diseases that were once limited by either remoteness or climatologic regions may have new geographical spread.

Pertinent Conclusions:

There are three primary ways which climate change may be expected to affect health:

- Primary: Direct biologic consequences (i.e. heat waves, extreme weather events, air pollution)

- Secondary: Risks caused by process changes (i.e. decreased crop yields, tropical vectors with increased spread)

-Tertiary: More diffuse effects (mental health issues in failed farmers, conflict due to scarce water)

Bottom Line:

No matter what your views are on the causes, the current trend is that the overall climate is getting warmer and human population is increasing. Anticipation of possible consequences is key to planning for the future.

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

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Necrotizing Pneumonia
 

Necrotizing pneumonia is a rare, but potentially deadly complication of bacterial pneumonia.

It is characterized by the finding of pneumonic consolidation with multiple areas of necrosis within the lung parenchyma. Necrotic foci may coalesce, resulting in a localized lung abscess, or pulmonary gangrene if involving an entire lobe.

Most common pathogens: S. aureus, S. pneumoniae, and Klebsiella pneumonia.  
Others include S. epidermidis, E. coli, Acinetobacter baumannii, H. influenzae and Pseudomonas.

Contrast-enhanced chest CT is the diagnostic test of choice and is also helpful in evaluating  for parenchymal complications. 

Empiric antibiotic therapy should include:

• Broad spectrum coverage for commonly implicated pathogens (vancomycin, pseudomonal-dose piperacillin/tazobactam)
• PLUS either clindamycin or metronidazole to cover possibly involved anaerobes

Consider an early surgical evaluation for the patient with necrotizing pneumonia complicated by septic shock, empyema, bronchopleural fistula, or hemoptysis. 

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Question

This week's case is challenging, but very interesting...

An elderly patient presents with a history of significant weight loss and chronic constipation; abdominal Xray is below. What's the diagnosis? (Hint: why is the right kidney and psoas muscle so well defined?)

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• In 1936 early repolarization (ER) was 1st described as ST-segment elevation in the absence of coronary artery disease, typically viewed as a benign ECG finding (BER) not association with increased cardiovascular mortality
• Classically the prevalence of BER tends to be associated with young athletes, male sex, and black race
• Recent data from Haissaguerre et al. and Tikkanen et al. suggest that certain subtypes of ER may be associated with a predisposition for malignant arrhythmias and sudden cardiac death (SCD)
• Although ER has various definitions contingent on the author, it consists of two components:
  • 1.) Prominent J wave
  • 2.) ST-segment elevation
• This article (9/13 JACC) focuses on the analysis and importance of the ST-segment contour and its possible relation to “malignant” repolarization
• Several studies (subgroup analysis) have found that a rapidly ascending ST-segment blending with the T-wave (Figures: A & C) confers BER, whereas a flat, horizontal, or even descending ST-segment (Figures: B & D) prior to the T-wave has potential to be malignant

*Please see the attachment below for Figures A-D

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Attachments

1309081121_gr1.jpg (74 Kb)

Although there is a paucity of data to guide dosing of antimicrobials in the critically ill obese patient, we can draw some conclusions from existing kinetic studies. Assuming normal renal and hepatic function, here's what to do:

Penicillins: Use the high end of dosing range. For example, if the plan is to use piperacillin/tazobactam 3.375 gm IV every 6 hours for a complicated intra-abdominal infection, use 4.5 gm instead.

Cephalosporins: Use the high end of the dosing range.

Carbapenems: Use the high end of the dosing range.

Quinolones: Use the high end of the dosing range.

Aminoglycosides: Dose using adjusted body weight. ABW (kg) = IBW + 0.4 X (actual body weight - IBW)

Vancomycin: 15-20 mg/kg actual body weight every 8 to 12 hours. Adjust based on trough level.

When dosing most antibiotics in critically ill obese patients, use the high end of the dosing range (if not more).

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NMS is most often seen with the typical high potency neuroleptic agents (e.g haldol, fluphenazine)

All classes of antipsychotics can cause NMS, including low potency and newer atypical agents; antiemetics can cause this as well.

Symptoms usually occur after the first 2 weeks of therapy, but may occur after years of use

Signs and symptoms include:

mental status changes

muscular rigidity (“lead pipe”)

hyperthermia (>38 - 40 degrees).

Autonomic instability (tachycardia, tachycardia and diaphoresis)

Treatment includes discontinuation of the offending agent and providing supportive care.

While no clinical trials have ever been undertaken, dantrolene (muscle relaxant) is commonly used.

Bromocriptine (dopamine agonist) may also be used, and amantadine (dopaminergic and anticholinergic agent) is used as an alternative to bromocriptone

Recently, several case reports have documented the successful use of diazepam as a sole pharmacologic agent. This may be an alternative or a supplement to the above agents

UEDVT comprise 10% of all DVTs (majority are lower extremity), but incidence of UEDVT is rising; UEDVTs are categorized into distal (veins distal to axillary vein) or proximal (from superior vena cava to axillary vein)

Compared to lower extremity DVT, UEDVTs have lower:

• mortality
• risk of pulmonary embolism
• rates of recurrence

75% of UEDVT are secondary (indwelling catheters, pacemakers, malignancy, etc.) and 25% are primary in nature; #1 primary cause of UEDVT is Paget – Schroetter disease

Up to 25% of patients with primary UEDVTs are eventually found to have an underlying malignancy; patients with idiopathic UEDVT should be referred for cancer workup

Treatment includes removal of the catheter (if no longer needed) and:

• anticoagulation (minimum of 3 months)
• consideration of thrombolytics, including catheter-directed administration
• mechanical thrombolysis (clot aspiration, fragmentation, etc.)
• surgical thrombectomy / venous bypass

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Question

Elderly male presents with headache, confusion, and trouble with gait. What's in your differential diagnosis?

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A recently revised ACEP clinical policy aims to guide emergency physicians in the evaluation and management of such patients.

They make the following recommendations (Level C):

• Routine screening tests (ie, CXR, ECG, UA, BMP) do not reduce adverse outcomes and are not required from the ED.
• Initiation of medical treatment does not reduce adverse outcomes and is not required in the ED.
• Patients with persistently elevated blood pressure should be referred for primary care follow-up.
• In select patient populations (eg. poor access to care), a screening creatinine level may identify renal injury that may alter disposition.
• If medication is started in the ED, the goal should be to facilitate gradual long-term control. Rapidly lowering blood pressure may be harmful.

Bottom-line:

There's little evidence to guide the decision of which patients with markedly elevated blood pressures to test or treat in the ED. This new clinical policy suggests that routine screening and treatment is not required. Asymptomatic patients should be referred for close follow-up, but consider a BMP in patients with poor follow up. 

Want more emergency cardiology pearls? Follow me @alifarzadmd

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Attachments

1309011328_Ann_Emerg_Med_2013_Wolf.pdf (186 Kb)

There are Type 1C Anti-Dysrhythmics, like propafenone and flecainide, that are utilized to suppress atrial fibrillation. They are called Type 1C due to their sodium channel blocking effects. Flecainide has a potent effect on the ECG and has caused significant and resistant widening of the QRS complex. 

Typically, a sodium channel blocker like a TCA can be treated with hypertonic sodium bicarbonate but flecainide has been resistant to this at times and there is a reported overdose utilizing magnesium sulfate. (1) Keep that in mind if you were to see a widened QRS complex in the face of a flecainide ingestion.

There has been a Brugada ECG pattern also reported (I know Amal is smiling)  (2) ontop of the widened QRS, PR intervals though minimal effect on the QT.

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  1: Cabrera Ortega M, Gell Aboy J, Díaz Berto E, Monagas Docasal V. [Acute  flecainide overdose]. An Pediatr (Barc). 2011 Jan;74(1):56-8.       2: Martínez-Mateo V, Arias MA, Rodríguez-Padial L. [Brugada electrocardiographic  pattern elicited by flecainide overdose]. Med Clin (Barc). 2011 Mar  19;136(7):320.