10.11.18 Conference Summary

EM/IM Conference: Cardiac Chest Pain and Risk Stratification in the ED vs. In-Patient

Dr. Robert Hughes, Emergency Attending: “Have a HEART: Chest Pain Risk Stratification in the Emergency Department”

  • HEART Score was designed to add history into the risk stratification of chest pain to better evaluate for cardiac causes and need for further admission and testing, particularly in the Emergency Department setting

    • Components of HEART Score

      • History (duration, intensity, type, nitroglycerin response)

      • EKG (using the Minnesota Criteria)

      • Age

      • Risk Factors

      • Troponin

    • Score of <4 is less concerning with >6 highly concerning

  • Validation of score performed in Netherlands via a retrospective analysis

    • Found that scores >4 were associated with a significantly greater risk of major adverse cardiac event (MACE)

  • HEART Score was compared to TIMI/GRACE scores

    • Scores >4 were again associated with higher risks and were more sensitive and specific than both TIMI and GRACE at predicting MACE

  • HEART Scores >4 have intermediate risk and should be considered for observation and early stress testing, while scores >7 should be considered for admission and possible early coronary angiography

  • In the US, we have a very low threshold for missing MIs, as compared to Canada where a ~2% miss rate is considered acceptable

  • Limitations of Heart Score:

    • Generalizability (Netherlands has a homogenous population compared to US), different troponin assays at different hospitals in validation study

    • Be careful of discharging positive troponins regardless of story unless you can explain troponin elevation by another disease process

    • New EKG changes compared to previous EKG 10 years ago is difficult to


    • HEART Score of 3 can be considered a “gray zone” and shared medical

      decision making with the patient should be initiated

Dr. Ben Allencherry, Internal Medicine Chief Resident: “Cardiac Risk Stratification: A View from Above”

  • GRACE score often used by Internal Medicine for risk stratifying cardiac chest pain

    • Most helpful to determine in determining need for PCI in NSTEMI patients

    • Used only when diagnosis of ACS is made (not stable angina)

    • Used to predict in-hospital and 6 month risk of death or MI

    • Scores >140 is considered high risk with a mortality >3%

  • TIMACS and VERDICT trials attempted to answer when to perform coronary angiography, early or late

    • Studies found that there was no difference if performing angiography while in hospital vs delayed until after discharge

  • SCOT-HEART trial attempted to answer what role coronary CT angiography has on initial work up for stable angina

    • Significant difference in non-fatal MI, but no difference in mortality when CT angiography performed

  • Use of high-sensitivity troponin on reducing subsequent MI or cardiac death in those suspected with ACS in ED

    • Not associated with lower incidence of MI or death

    • Should we re-consider the definition or threshold for myocardial infarction?

EBM: Pain Dose Ketamine Protocol: Dr. Andrew Bloom (PGY-3)

  • Ketamine: non-competitive NMDA blocker primarily working in the CNS

  • Approved in 1970 by FDA

  • Gained traction in 1990s for procedural sedation in pediatric population

  • Who should we consider giving ketamine to in the ED for pain control

    • Reconsider or avoid in hemodynamically unstable patients

    • Avoid in patients with globe rupture or significant head trauma (evidence behind this is weak however)

    • More recent data shows ketamine does not significantly increase IOP or ICP so it may be safe

    • Consider other medication in patients with hx of schizophrenia as this may exacerbate these symptoms

  • Target population?

    • MSK and abdominal pain that is non-traumatic or traumatic

    • Brief painful procedures while awake (i.e. lac repair or abscess drainage)

    • Chronic pain with breakthrough (i.e. cancer, sickle cell crisis

    • Pain + emotional distress

  • Dosing?

    • Ketamine IV 0.1-0.3 mg/kg 15 min slow infusion in 100-250mL NS bag

    • Reassess 60-120 min later

    • Multiple studies show equal analgesia with ketamine compared to

      morphine 0.1 mg/kg push

    • Infusion vs. push: ACEP clinical policy favors infusion as less dissociation with infusion

  • K hole?

    • Doses >0.5 mg/kg increases risk of dissociative reaction and paradoxical


    • Do not re-dose in 1st 60 minutes

  • Why Ketamine?

    • Everyone is in pain

    • Avoidance and reduction of opiate use

    • Reset pain receptor

    • Extra tool in toolbox

    • Extensive literature supporting it

    • Less hypotension, less respiratory depression

Ketamine Protocol.png

Clinicopathological Conference #2: Drs. Nicholas Parmar (PGY-2) and Dr. Jen Li(Emergency Medicine Attending)

Patient presentation and initial work-up by Dr. Nick Parmar:

  • 71 yo M presented with AMS; found down unresponsive; last known well night before; ?nausea/vomting/diarrhea over last few days

    • VS on arrival: afebrile, BP 80/50, HR 160, RR 24, 99% on 2L

    • Patient unresponsive but breathing; rightward gaze and sluggish pupils

    • EKG showing Afib with RVR

    • IVF initiated, 10 mg diltiazem  pushed with temporary conversion but resumed Afib quickly thereafter

    • Diltiazem drip started @ 5 mg/hr  increased to 15 mg/hr

    • CXR read as normal by radiology

    • CBC showed WBC 21k with lactate 2.8 and troponin 0.32; normal electrolytes

    • Patient electrically converted with 50 J but returned back to Afib with RVR

    • Asymmetrical radial pulses: R arm 96/60, L arm 170/90

    • Cardiology consulted and recommended amiodarone which successfully converted to NSR

    • RUE now cool to touch



Rebuttal by Dr. Jen Li:

  • Recap: 71 yo M with PMH of HTN, DM, traumatic brain injury, HLD, cataracts

    • Unknown meds, PSH, family hx or social hx

    • Triage note reads “difficulty obtaining vital signs”

    • PE: rightward gaze deviation with rhythmic eye movements; decreased R radial pulse; moves toes on command

    • Arterial full panel with pH 7.44

    • Labs: leukocytosis with left shift, normal BMP, troponin 0.32, UDS negative, serum drug screen positive for benzos

    • Multiple attempts at radial and femoral arterial line without success

    • Given 2 L NS, 2x 10 mg IV Cardizem  push


Differential dx: stroke, seizure, Todd’s paralysis, ICH/SDH/SAH, intracranial mass, dissection, DVT, subclavian steal syndrome, thyroid dysfunction, toxidrome, metabolic encephalopathy

 Single test of choice: Ct angio head/neck/chest for presumed diagnosis of:

 Aortic dissection with resultant stroke and possible seizure


Continued resuscitation by Dr. Parmar

  • CTA of head/neck/chest showed R M1 occlusion and possible aspiration pneumonia

  • MRA of R upper extremity while inpatient showed filling defect at origin of R brachial artery with diminished flow distally

  • PMH obtained later: legally blind; family hx of blood clots but patient never worked up

    • Further history given by sister later reports LKN was 10a that morning

  • Patient determined not to be stable for M1 thrombectomy and no TPA was given

  • Admitted to NSU

  • Vascular surgery consulted and RUE thrombectomy without heparin performed; reclotted

  • Developed large R hemorrhagic stroke with SAH and IVH later during NSU stay; patient ultimately died in NSU

Updates in Acute Stroke Management and CT reading: Dr. Cathy Sila

  • First step, CT head

    • Determines whether old stroke or blood in the brain

    • Edema on CT = concern for older stroke, so no tPA because higher risk for bleeding complications

  • Neuro-Imaging in Stroke: Uses in determining treatment course

    • Contraindications for tPA based on imaging: CT presence of early infarct signs (ECASS 1), CT hypodensity involving >1/3 MCA territory (ECASS II), DWI lesion volume >90 cc (DEFUSE)

      • HOWEVER: only 75% intra-operator agreement on size of infarct

    • Always consider imaging findings when determining tPA eligibility: Some people complete their stroke almost immediately and aren’t a candidate for intervention (DAWN trial)

    • Cerebral Perfusion: CT equivalent for DWI imaging- looks for core infarct on cerebral blood flow (CBF) maps

      • Look for <30% CBF for core infarct and mismatch with areas of decreased perfusion- if large area of decreased perfusion with small infarct, candidate for intervention

  • Tips and Tricks for Reading CT Scans:

    • Use the brain window (narrower window) can help find hypodensities that are otherwise difficult to see

    • Get a CT with contrast if there is concern for abscess or mass as a stroke mimic

      • For example, tonic posturing very rare in strokes- can see leg clonus with ACA strokes but very rare in arms

  • Always Remember:

    • You can have seizures at CVA onset, so always be concerned for stroke with neuro deficits even if the patient seized

    • Fluctuating symptoms: Embolus is still there but flow dependent because not completely occlusive = can give tPA if symptoms recur

    • Always re-evaluate your patient: The NIHSS is a good tool but can miss subtle presentations and other stroke mimics