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Case #1 47 year old female with Chest Pain
History ,[object Object],[object Object],[object Object],[object Object],[object Object]
History ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
History ,[object Object],[object Object],[object Object]
Physical ,[object Object],[object Object],[object Object],[object Object],[object Object]
Physical ,[object Object],[object Object],[object Object],[object Object]
EKG
CXR
Labs ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Labs ,[object Object],[object Object],[object Object],[object Object]
Assessment/Plan ,[object Object],[object Object],[object Object],[object Object]
Methemoglobinemia Troy W. Pennington DO Attending Physician- ARMC
Which of these Substances can cause Methemoglobinemia? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Nitroglycerin + Nitrates ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Some drugs associated with Methemoglobinemia
Enviromental Agents Aniline dyes Aromatic amines Arsine Butyl nitrite Chlorates Chlorobenzene Chromates Combustion Products Nitroaniline Dimethyltoluidine Foods containing  (nitrates / nitrites)   Well water Naphthalene Silver nitrate Trinitrotoluene Nitrophenol Nitrobenzene
Methemoglobinemia ,[object Object],[object Object],[object Object]
Methemoglobinemia ,[object Object],[object Object]
Methemoglobinemia What happens in metHb?  The iron within hemoglobin is oxidized from the ferrous (Fe 2+ ) state to the ferric (Fe 3+ ) state, resulting in the inability to transport oxygen and carbon dioxide.
*Most common*, enzyme deficiency in RBC ’s… Widespread deficiency of enzyme in multiple tissues, erythrocytes, liver, fibroblasts, and brain.  Associated with severe CNS symptoms, MR, cyanosis and premature death…  Hemopoietic system involved; platelets, RBC ’s, white cells only main consequence is cyanosis… Similar to type I, isolated erythrocyte involvement resulting in chronic cyanosis…
Causes of Methemoglobinemia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Met-Hb…Concentrations Normal methemoglobin concentrations are 1% (range, 0-3%) 3-15%- slight discoloration (eg, pale, gray blue)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Met-Hb…Concentrations
50-70% Altered mental status Delirium Death Met-Hb…Concentrations
Differential Diagnosis varies with age
Met-Hgb how do you make the diagnosis? -Diagnosis confirmed by direct measurement of methemoglobin by a multiple wavelength  co-oximeter ABG- Normal PaO 2  Concentrations are usually found on analysis ** Clinical cyanosis is the presence of normal arterial oxygen tensions is highly suggestive of methemoglobinemia** The arterial oxygen tension is related to the amount of oxygen dissolved in blood plasma, not the much larger pool that is bound to hemoglobin…
Met-Hb…    Traps ,[object Object],[object Object],[object Object],[object Object]
Pulse oximeter Pulse oximetry is a simple non-invasive method of monitoring the percentage of hemoglobin (Hb) which is saturated with oxygen.  An oximeter detects hypoxia before the patient becomes clinically cyanosed. How does an oximeter work?  A source of light originates from the probe at two wavelengths (660nm and 940nm). The light is partly absorbed by hemoglobin, by amounts which differ depending on whether it is saturated or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor can compute the proportion of hemoglobin which is oxygenated .  Pulse oximetry cannot distinguish between different forms of hemoglobin. Carboxy-hemoglobin (hemoglobin combined with carbon monoxide) is registered as 90% oxygenated hemoglobin and 10% desaturated hemoglobin - therefore the oximeter will overestimate the saturation. The presence of methemoglobin will prevent the oximeter working accurately and the readings will tend towards 85%, regardless of the true saturation.  A  CO-oximeter  measures absorption at additional wavelengths to distinguish CO from O 2  and determines the blood oxygen saturation more reliably.
Pulse oximeter Methemoglobin increases absorbtion of light at both wavelengths (more at 940nm)  Met-Hb offers optical interference to the pulse oximetery by falsely absorbing light This leads to the plateau in the oxygen saturation at 85%. Co-oximetry is KEY
Met-Hb making the case ,[object Object],[object Object],[object Object],[object Object],[object Object]
Met-Hb… making the case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
metHb-Blood Looks   Like Chocolate metHb  oxygentated blood…………..  blood
The Fugate Family
 
 
Jake & Ellwood
Blue People get… Blue Drugs :) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Case #2 71 Year old female with Chest Pain
71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative Aunt Bee EKG ………..  : 0-
71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative
That would be cheating, it didn ’t help anyway :)- Aunt Bee
Aunt Bee That would be cheating, it didn ’t help anyway :)-
Aunt Bee Mm-Mm-Good Your smarter than a computer ?  :)-
Aunt Bee That would be cheating, it didn ’t help anyway :)-
Aunt Bee
Aunt Bee Mm-Mm-Good That would be cheating, it didn ’t help anyway :)-
ACC/AHA  2007-2008 Guidelines ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
AHA / ACC Update 2008 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Characteristics of Angina Characteristic More likely to be angina Less likely to be angina Type of pain Dull, pressure Sharp, stabbing Duration 2 to 5 min, always <15–20 min Seconds or hours Onset Gradual Rapid Location Substernal Lateral chest wall, back Reproducible With exertion With inspiration Associated symptoms Present Absent Palpation of chest wall Not painful Painful, exactly reproduces pain complaint
Initial Evaluation and Management Immediate Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
AHA / ACC Quick Facts ,[object Object],[object Object],[object Object]
EKG- Rules To Live By ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
The Rodney Dangerfield Leads…..V7-V9 ,[object Object],[object Object],“ I just don’t get any Respect ”
The Posterior Leads V7-V9 ,[object Object],[object Object],[object Object],[object Object]
Posterior MI
Posterior MI with Posterior Leads
Posterior Wall MI ,[object Object],[object Object],[object Object],[object Object],[object Object]
Posterior Wall MI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ischemic ST Elevations Non-Ischemic ST Elevations
Outcome? ,[object Object],[object Object],[object Object],[object Object],[object Object]
THANK YOU   ,[object Object],[object Object],[object Object]

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2 cases of chest pain

  • 1. Case #1 47 year old female with Chest Pain
  • 2.
  • 3.
  • 4.
  • 5.
  • 6.
  • 7. EKG
  • 8. CXR
  • 9.
  • 10.
  • 11.
  • 12. Methemoglobinemia Troy W. Pennington DO Attending Physician- ARMC
  • 13.
  • 14.
  • 15. Some drugs associated with Methemoglobinemia
  • 16. Enviromental Agents Aniline dyes Aromatic amines Arsine Butyl nitrite Chlorates Chlorobenzene Chromates Combustion Products Nitroaniline Dimethyltoluidine Foods containing (nitrates / nitrites) Well water Naphthalene Silver nitrate Trinitrotoluene Nitrophenol Nitrobenzene
  • 17.
  • 18.
  • 19. Methemoglobinemia What happens in metHb? The iron within hemoglobin is oxidized from the ferrous (Fe 2+ ) state to the ferric (Fe 3+ ) state, resulting in the inability to transport oxygen and carbon dioxide.
  • 20. *Most common*, enzyme deficiency in RBC ’s… Widespread deficiency of enzyme in multiple tissues, erythrocytes, liver, fibroblasts, and brain. Associated with severe CNS symptoms, MR, cyanosis and premature death… Hemopoietic system involved; platelets, RBC ’s, white cells only main consequence is cyanosis… Similar to type I, isolated erythrocyte involvement resulting in chronic cyanosis…
  • 21.
  • 22. Met-Hb…Concentrations Normal methemoglobin concentrations are 1% (range, 0-3%) 3-15%- slight discoloration (eg, pale, gray blue)
  • 23.
  • 24. 50-70% Altered mental status Delirium Death Met-Hb…Concentrations
  • 26. Met-Hgb how do you make the diagnosis? -Diagnosis confirmed by direct measurement of methemoglobin by a multiple wavelength co-oximeter ABG- Normal PaO 2 Concentrations are usually found on analysis ** Clinical cyanosis is the presence of normal arterial oxygen tensions is highly suggestive of methemoglobinemia** The arterial oxygen tension is related to the amount of oxygen dissolved in blood plasma, not the much larger pool that is bound to hemoglobin…
  • 27.
  • 28. Pulse oximeter Pulse oximetry is a simple non-invasive method of monitoring the percentage of hemoglobin (Hb) which is saturated with oxygen. An oximeter detects hypoxia before the patient becomes clinically cyanosed. How does an oximeter work? A source of light originates from the probe at two wavelengths (660nm and 940nm). The light is partly absorbed by hemoglobin, by amounts which differ depending on whether it is saturated or desaturated with oxygen. By calculating the absorption at the two wavelengths the processor can compute the proportion of hemoglobin which is oxygenated . Pulse oximetry cannot distinguish between different forms of hemoglobin. Carboxy-hemoglobin (hemoglobin combined with carbon monoxide) is registered as 90% oxygenated hemoglobin and 10% desaturated hemoglobin - therefore the oximeter will overestimate the saturation. The presence of methemoglobin will prevent the oximeter working accurately and the readings will tend towards 85%, regardless of the true saturation. A CO-oximeter measures absorption at additional wavelengths to distinguish CO from O 2 and determines the blood oxygen saturation more reliably.
  • 29. Pulse oximeter Methemoglobin increases absorbtion of light at both wavelengths (more at 940nm) Met-Hb offers optical interference to the pulse oximetery by falsely absorbing light This leads to the plateau in the oxygen saturation at 85%. Co-oximetry is KEY
  • 30.
  • 31.
  • 32. metHb-Blood Looks Like Chocolate metHb oxygentated blood………….. blood
  • 34.  
  • 35.  
  • 37.
  • 38. Case #2 71 Year old female with Chest Pain
  • 39. 71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative Aunt Bee EKG ……….. : 0-
  • 40. 71 year old female -chest pain Intermittent yest. Constant now Today substernal chest pressure 9/10 since 9am today… PMH: none Meds: none Alg: none SH: negative
  • 41. That would be cheating, it didn ’t help anyway :)- Aunt Bee
  • 42. Aunt Bee That would be cheating, it didn ’t help anyway :)-
  • 43. Aunt Bee Mm-Mm-Good Your smarter than a computer ? :)-
  • 44. Aunt Bee That would be cheating, it didn ’t help anyway :)-
  • 46. Aunt Bee Mm-Mm-Good That would be cheating, it didn ’t help anyway :)-
  • 47.
  • 48.
  • 49. Clinical Characteristics of Angina Characteristic More likely to be angina Less likely to be angina Type of pain Dull, pressure Sharp, stabbing Duration 2 to 5 min, always <15–20 min Seconds or hours Onset Gradual Rapid Location Substernal Lateral chest wall, back Reproducible With exertion With inspiration Associated symptoms Present Absent Palpation of chest wall Not painful Painful, exactly reproduces pain complaint
  • 50.
  • 51.
  • 52.
  • 53.
  • 54.
  • 56. Posterior MI with Posterior Leads
  • 57.
  • 58.
  • 59. Ischemic ST Elevations Non-Ischemic ST Elevations
  • 60.
  • 61.