Wellen’s Syndrome was first described in 1982 in which 75% of patients with t wave inversions in V2-V4 went on to have an acute myocardial infarction (MI). This was again repeated in 1989, and showed that all patients with this morphology had >50% LAD stenosis. The incidence in the United States is about 10-15%.
Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for the evaluation of critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states.
The RUSH Protocol was first introduced in 2006 by Weingart SD et al, and later published in 2009. It was designed to be a rapid and easy to perform US protocol (<2 minutes) by most emergency physicians.
Worldwide, death from cardiac arrest in the out-of-hospital setting remains the leading cause of mortality. Focuses have aimed at improving bystander CPR, public access to AEDs, minimizing chest compression interruptions, and decreasing the emphasis on advanced airway management. This latter concept has become so important that the AHA/ASA have now changed their “ABC” philosophy to “CAB.” Below is the review of the literature that has changed this philosophy.
The CaseA 56 y/o man presents to the ED via ambulance. He was sent from clinic for ‘new onset afib.’ His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to ‘rate control’ the patient with a goal heart rate < 100 bpm.
Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension.
What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?
You are handed an ECG for a 50 year old man with moderate chest pain for 2 hours now and no associated symptoms typical for ACS, PE, aortic dissection, or any other red flags of chest pain. He has no prior ECG’s on file.
Image courtesy of Dr. Steve Smith at HQMedEd-ecg.blogspot.com
Here are some great literature-based pearls compiled by Dr. Jason West (@JWestEM), an EM resident from Jacobi/Montefiore.
Adapted from [1–7]
Go to ALiEM (PV) Cards for more resources.
Furthermore, there is a formula to differentiate early repolarization vs STEMI, per Dr. Smith’s publication6:
(1.196 x STE60V3) + (0.059 x QTc) – (0.326 x RA V4)
A result of > 23.4 is predictive of a LAD occlusion causing a STEMI, rather than early repolarization.
P.S. The above ECG image shows early repolarization.
The goal of resuscitation in cardiac arrest is to respond in a timely, effective manner that leads to good patient outcomes. Resuscitation is not taking an ACLS and BLS course and going through the motions of a code. There have been several studies looking at the quality of intubation and CPR, and their association with good patient outcomes.
“Done Fell Out”, or DFO, is a common saying in the South to describe syncope. Although the saying is funny the diagnosis is not. Syncope accounts for about 3–5% of ED visits and 1–6% of hospital admissions. In patients >65, syncope is the 6th most common cause of hospitalization.
How do you approach the management of patients with syncope?