Grand Rounds Recap 10/21

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Grand Rounds Recap 10/21

Morbidity and Mortality Conference with Dr. Curry

Acute Coronary Syndrome in Pregnancy

Epidemiology

  • Incidence reported at about 6/100,000 deliveries
  • Maternal mortality is between 5-9%
  • 75% are STEMI
  • 2/3rds are anterior wall MI (LAD or LM as the culprit vessel)

Risk Factors

Many of these are typical ACS risk factors but are less prevalent in the pregnant population

  • Older age (>35 years old for pregnancy is considered older age....yikes)
  • Hypertension
  • Diabetes
  • Obesity
  • Smoking
  • Dyslipidemia
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Grand Rounds Recap 10/14

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Grand Rounds Recap 10/14

Simulation with Dr. Hill

Case 1: 45 yo male comes to the ED after being found down at the mall s/p defib x2 for a V fib arrest per EMS with a King Airway in place and undergoing active CPR. In the ED you achieve ROSC after defib x1 for Vfib and then PEA with multiple arounds of epinephrine. EKG shows inferior STEMI.  

Case 2: EMS calls with advanced noticed for GI bleed presents tachycardic and hypotensive, actively bleeding with melanotic stool and hematemesis. 

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Grand Rounds Recap 10/7

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Grand Rounds Recap 10/7

Evidence Based Medicine on Tachydysrhythmias with Drs. Ludmer and Miller

  • SVT is an umbrella term that includes AVNRT, atrial fibrillation and flutter, and polymorphic multifocal atrial tachycardia (MAT)
  • AVNRT (AV Node Re-entrant Tachycardia) is the correct term for what is commonly diagnosed as SVT, 
  • MAT usually occurs in critically ill elderly patients with respiratory failure and is a poor prognostic sign, associated with 60% in hospital mortality. Treatment is to treat the causative pathology.
  • REVERT Trial: Modified valsalva vs standard valsalva performed in 10 EDs with 428 patients in England. Findings included a 17% conversion with standard methods and 43% with the modified valsalva. 
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Grand Rounds Recap 8/26

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Grand Rounds Recap 8/26

M&M with Dr. LaFollette

Case 1: Troponin Use in ESRD

  • Evaluating cardiac ischemia in ESRD patients can be difficult due to baseline troponin elevations. However, all is not lost...
  • Troponins can be used as a reliable marker of ischemia, even despite its collection in proximity to dialysis, if you take some things into account:
  • Studies vary widely on troponin levels during dialysis, consensus being that troponin levels do not vary significantly vary with dialysis.
  • Although the baseline may be abnormally elevated, ESRD patients nonetheless have a new baseline. Changes above this baseline and especially up trending troponins should trigger alarms that the patient may be having active ischemia.  
  • Troponin elevation in ESRD patients, even if at their baseline, is an independent risk factor for short term mortality
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Ground Rounds Summary 8/19/15

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Ground Rounds Summary 8/19/15

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.
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Grand Rounds Summary 8/5

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Grand Rounds Summary 8/5

Taming the SRU Case Follow-Up: GSW to the Head with Dr. Grosso

  • In one census: 66% of violent deaths are suicide, with 30k suicide deaths annually in the US
  • ~50% of suicide attempts include firearms
  • GSW to head mortality is 80%, and 71% die on scene
  • ~40% of those who survive to hospital have favorable outcomes
  • Favorable prognosis: GCS>8, normal pupillary reaction, absence of coagulopathy of trauma/hemodynamic instability
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