4. • A 31 year old male smoker with DM came into
the ER with 4 days of intermittent chest pain.
His EKG is consistent with Wellens Syndrome,
which is associated with stenosis of the LAD. .
His troponin was positive and his
catheterization revealed a 95 % occlusion of
the LAD, which was successfully traeted with a
stent.
5. WELLENS SYNDROME: A LIFE SAVING
DIAGNOSIS
• Critical stenosis of the proximal LAD
• Classic ECG presentation
•
• Biphasic or deeply inverted T waves in leads V2 and V3
• Sometimes V1, V4, V5 and V6
• Despite zero or minimal ST elevation, loss of precordial R wave
• progression or pathologic precordial Q waves
Parikh, K.S., et al, Am J Emerg Med 30(1):225.e3, January 2012
6. WELLENS SYNDROME: A LIFE SAVING DIAGNOSIS
• Type 1 (A) (76%)
– Deep symmetrically inverted T waves in precordial
leads V2 V3
• Type 2(B) (24%)
- Biphasic T waves in V2 V3 identified as a
distinctive upsloping followed by a sharp
downslope that differs from T wave inversion
due to other etiologies
9. Articles
• 1. ER volume matters. Patients have a lower
likelihood of inhospital death if admitted
through high volume EDs. The study looked at
the largest database in the US with 8 million
admissions per year and over 1,000 hospitals
per year.
• The higher volume EDs had lower mortality .
10. CVA and Thombectomy
• For the first time a study of acute CVA patients
suggested that intraarterial thrombectomy within
6 hours could lead to a better outcome [32 % vs
19 % rate of functional independence] . This may
prove to be a game changer.
• Almost all of these patients were first given TPA ,
and all of these patients had proximal, anterior
large vessel occlusions on angiograms.
• Also 9 % of the patients had distal embolization
into new territories… read new CVAs.
11. Intranasal fentanyl
• A recent study looked at kids and the use of
intranasal fentanyl. 5 Minutes after its use the
pain was rated as only half as severe. It works
quickly, and it should be kept in mind both for
adults and children, especially if an IV is
problematic.
12. Falls
• A recent study of falls at 30 assisted living facilities was provocative.
It suggests that perhaps we could use a protocol to decrease the
number of transports after the elderly have falls .
• The patients who did not require transport were either without
complaint [Duh] , with simple contusions or skin tears, had no
obvious injury, no change in their ambulatory status, had no acute
medical emergency condition , no alteration in mental status from
baseline their VS revealed a BP > 90, pulse of <120 and > 50 , no
acute neck pain, hip pain or uncontrolled hemorrhage. Also no fall
on Coumadin or other blood thinner [Plavix, Xarelto, etc] . No need
for new analgesia.
• In spite of this long list over half of the calls did not require
transport !. The study was retrospective but the results are
provocative.
13. Metronomes and Dispatch
• A study in Wisconsin used a metronome to
provide guidance to bystanders for CPR rate .
We should try to do this .
14. Double Sequential Defibrillation
• When a patient has refractory ventricular
fibrillation a recent study utilized double
sequential defibrillation. It does not increase
survival . It did break the Vfib in 70 % of cases.
• The definition of refractory Vfib was 5
unsuccessful single shocks, epinephrine and
amiodarone with persistent Vfib.
• The technique used 2 defibrillators charged to
maximum, with shocks delivered simultaneously.
15. Chest Compression Injuries After CPR
• A recent study in Minnesota looked at 235 arrests
and the risk of injury after CPR. The LUCAS was
used in 44 % .
• There were injuries identified in 13 % , the most
common injury being rib fracture [often more
than 1] This was seen in only 9 %. The use of the
Lucas was not more likely to cause injury. The
major risk factor for injury was a compression
time > than 10 minutes. Injuries did not prolong
hospital stays.
16. Vagal Maneuvers and SVT
• Valsalva maneuvers will convert
approximately 20 % of patients with SVT. If the
patient’s face is placed in ice water and at the
same time a carotid sinus massage is
performed the rate increases to over 50% in
two studies .
• The carotid sinus massage should always be
on one side at a time and not both at once.
17. TXA
• Tranexamic acid has recently been reported to be
possibly useful to stop hemorrhage. There is an
ongoing study with hypotensive , bleeding
tachycardic patients in air medical transport . Up
to 80 % of deaths in the first hour and 50 % of the
prehospital deaths from trauma are from
hemorrhage. TXA binds to plasminogen to
prevent its conversion to plasmin which degrades
fibrin and results in the cascade of bleeding. In a
recent study, CRASH 2, a 1 gm bolus of TXA
inhibited fibrinolysis and reduced hemorrhage
and death. It needs to be given within 1 hour.
18. Side Air Bags
• NHTSA just published its collected data on
side air bags and Curtain plus torso bags are
the most effective reducing mortality by 31 % .
The reductions are less for curtain only and
torso only air bags. Additionally with rollovers
there is a 41 % reduction in mortality!
• The data comes from an analysis of 73,000
crashes. Make sure your cars have side air
bags.
19. Intranasal Narcan
• Remember it is faster to administer [no IV
required], but it less potent . Frequently we
need 6-8 mg of narcan for complete reversal
of obtundation.
20. Spinal Immobilization
• There is an accumulation of data that suggests
that self extrication gets less neck movement
than our best efforts. I am not suggesting any
changes in practice …yet. But be aware.
21. Preshock Pauses
• Remember that a preshock pause of <20
seconds is associated with improved survival
in cardiac arrests. The less interruption of
compressions the better the patient will do.
All defibrillators should always be on manual
mode . The automatic mode should not be
used.
22. Anaphylaxis
• Definition: remember skin plus either upper
or lower respiratory involvement with
shortness of breath , hypoxemia, wheezes , or
stridor .
• OR
• Skin or mucosa, plus decreased BP, or
respiratory symptoms, or syncope, or GI
symptoms.
23. Anaphylaxis contd
• The Rx of choice is epinephrine.It should be
given in the thigh IM. Do not give it in the
arm, do not give it sub Q.
• Benadryl is slow in onset and has no effect on
BP, upper airways and lower airways.
• If the BP does not rise with the epinephrine a
fluid bolus of 1-2 liters is indicated.
24. Cases
• 1.patient taken out to ambulance before
stabilization. 22 minutes before IV placed in a
patient with an MI, 25 minutes to ASA, 29
minutes to NTG
• TOXICOLOGY of the month :
Cannabinoid Hyperemesis Syndrome
More on Cannabis: ? Increase in COPD,
psychosis
25. More Cases
• Successful CCR
• Rapid AFIB needs RX
• Chest pain and no EKG
• Patient with “difficulty breathing “, very
interesting case
• Bradycardia case
