Mohamud Daya MD, MS Jonathan Jui MD, MPH

Transcription

1 Mohamud Daya MD, MS Jonathan Jui MD, MPH

2 STEMI criteria > 2 mm STE in 2 contiguous precordial leads > 1 mm STE in 2 contiguous limb leads leads 2011 STEMI Mimics Pericarditis, Early Repolarization Hyperkalemia, Left Ventricle Hypertrophy 2012 More challenging ECGs with STE

3 36 year old male previously well presented to his PCP yesterday with fevers, chills and sore throat x 2 days. Exam showed tonsil redness with exudate. Started on antibiotics. This am awoke with a soreness across the chest as if someone was squeezing me. Went to PCP s office and was transferred rapidly to the ED. Given ASA 324 mg PMHx: nil Meds: Amoxicillin-Clavulanate

4 Alert, no distress, no diaphoresis BP = 103/71, HR = 72, RR = 15 No JVD Lungs clear Ext no edema

5 STE in V2, J point elevation in V3-v5. No reciprocal changes

6 ED STEMI activation Troponin 3.86 ECG repeated Persistent STE in V2 No reciprocal changes Echocardiogram Wall motion abnormality Cardiac catherization

7 Angiogram Clean coronary arteries Admitted CCU Pain control Troponin peak 15 STE persistent Discharged day 3 Studies Strep culture negative EBV viral panel negative for acute infection

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9 Inflammation of myocardium with cellular damage Clinical Flu-like illness Young age Male >>> Female Myocardial involvement can be focal or diffuse Focal mimic STEMI

10 Viruses Parvovirus B19 Enterovirus (Coxsackievirus) Adenoviruses Bacteria Campylobacter Immunizations (smallpox) Toxins

11 Male predilection Testosterone enhanced susceptibility Diagnosis ECG, Echo, Cardiac MRI, CT angiography Treatment NSAIDs Supportive (acute heart failure, dysrhythmia s) Prognosis Recurrence risks (immune)

12 No Q waves

13 Code 3 for Chest Pain 50 year old female who awoke this am with central CP going down both arms. Symptoms improved with NTG. Recurred after she smoked a cigarette, called 911 Now feeling better and denies any chest pain

14 Intermittent CP for one year Negative stress test last year Severe episodes of CP recently Cardiology clinic with the last week Protonix (PPI) for presumed GERD PMHx: HTN Meds: ASA, Atenolol, PPI

15 ASA 324 chewable Oxygen Monitor VS: BP = 171/110, HR = 80, SpO2 100%, RR = lead ECG

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17 STE in V2-V4, STD in II, III, avf

18 1982 ECG findings associated with high risk of anterior wall MI Proximal LAD coronary artery stenosis AMI with weeks in ¾ of case Seen while pain free Urgent catherization

19 Biphasic or deeply inverted T-waves in V2, V3 Often with QT prolongation Type A (inverted) Type B (biphasic) Little or no elevation of biomarkers STE < 1 mm No loss of precordial R wave No pathological Q wave History of angina

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21 Angiogram Left main - clean Proximal LAD 80% stenosis Circumflex very mild disease Right coronary clean Stent placed Clopidogrel, Aspirin Smoking cessation counseling

22 Dispatched on a TA-1 Car into a pole Witnesses state that the car was approaching a stoplight and they thought he blacked out They noted the patient to be initially unconscious but regained consciousness a short time later

23 Arrive to find an approximately 40 y.o. male restrained, conscious in his car. No obvious damage to his car or pole No airbag deployment

24 No previous history of similar events No diabetes No drugs / ETOH No previous cardiac history No trauma

25 BP 110/60, HR 60, RR 15, GCS =15 Asian male (speaks good English) HEENT nl Chest clear Chest wall non-tender Abdomen soft, non-tender Ext nl No fractures / deformities noted Neuro s intact with no deficits

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27 Genetic disease characterized by ST-segment elevation and T wave inversion in the right precordial leads, ± RBBB High risk of SCD in individuals with structurally normal hearts Asian adults, Male/Female = 4:1 Mean age ~ Autosomal dominant, heterogenous genetic defects Na, Ca and K channels mutations

28 Accentuated J wave in V1-V3 STE and T inversion Closely coupled extra systoles Rapid Polymorphic VT (Torsades) ECG features are dynamic and concealed Unmasked by fever (inactivates Na channel) and Na channel blocking agents Molecular mechanism repolarization diff between epi and endocardium re-entry

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30 Type 1 ECG plus Family Hx SCD < 45 Rhythm related Sx Syncope Seizures Arrhythmia PVT, VT

31 AICD Primary Secondary Pharmacology Isoproterenol Quinidine, Disopyramide Others Family screening of first-degree relatives

32 Subjective: Arrive to male c/c cardiac arrest. pt was walking up a hill with his wife. pt has been complaining of chest pain on and off for the past few weeks. wife on scene states pt with chest pain when he does physical activity like walking. pt has been advised by wife to see a dr. and pt did not see a dr. Pt went down on field next to road that pt was walking.. approx 1 minute elapsed before bystander cpr done by nurse. cpr of good quality.

33 (visualized by e-18 upon arrival.) cpr done by nurse for approx 5 minutes prior to arrival of e-18. cpr only and no mouth to mouth done. medical history pt does not see a dr. wife reported unstable angina. reported does not take meds. pt has notseen medical help for chest pain during exercise.

34 OBJECTIVE: arrive to male supine position with cpr being preformed. HEAD- with contusion and scratches on left face from fall. EYES- pinpoint in back of ambulance when checked. LUNGS : Clear ARMS/LEGS- unremarkable. SKIN- cool, dry, pink.

35 CPR VF documented Defib x 2 ALS Medications (vasopressin + EPI) PEA ETCO2 rises BP 191/ Lead Induced Hypothermia STEMI Alert

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38 Jon Jui MD, MPH

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43 The QRS duration > 120 ms There should be a RsR' wave in lead V6. There should be a QS or rs complex in lead V1

44 LBBB: QRS looks like M in V6 and W in V1 (WiLLiaM) RBBB: QRS looks like M in V1 and W in V6 (MoRRoW)

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50 ST-segment elevation 1 mm concordant with (in the same direction as) a predominantly positive QRS complex in at least one lead. (5 pt.) ST 5mm discordant (in the opposite direction from) a predominantly negative QRS complex. (1 pt.) ST 1mm in leads V1, V2 or V3 (3 pt)

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54 AVF V6

55 RBBB Criteria is the same, you just need to find the abnormalities Look first for ST Depression Look closely at V1 to V4 for the J point

56 LBBB Look first for concordance in V6, V5 Look second for ST depression in V1 (V2,V3) Look for concordance in inferior leads (II, III, AVF) Look for ST elevation > 5 mm

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