7.5.18 Conference Summary

Pillars of Emergency Medicine with Dr. Noble

Three Pillars of EM:

  • Airway
  • Point of Care Ultrasound
  • Resuscitation

Emergency Medicine: Past, Present, Future with Dr. Miller

Past:

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  • EM is 50 years old!
    • 1968: ACEP was formed- need governing body, opening more EDs with people requiring trauma care/social services
    • 1970- First EM resident
    • 1973: Emergency Medical Services Systems Act- Dr. Eugene Nagel, Miam Dade
    • 1979: Approved as a specialty, 23rdspecialty

Future:

  • Challenges:
    • Capacity: we can handle it, so it’s not changed by hospital without a fight. So we’re moving up in management
    • Safety: EM physicians are targets, more open access
    • Resilience: At the top of burnout lists
    • Constantly asked to do more
    • Corporatization: less and less physician led group
  • How we differentiate ourselves
    • Resuscitation
    • Innovation
    • Technology
    • Leadership- formally and at the bedside
    • Each other- nuclear community

Simulation with Drs. Gaines, Li, and Stull

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  • Burn patients are trauma patient: think about all traumatic causes of hypotension.
    • Add escharotomy if necessary
  • Industrial Fire
    • Cyanide toxicity
      • Elevated PaO2 with poor saturation (not bound to hemoglobin, just free in their blood)
      • Disproportionally high lactate
      • Industrial fire
      • Cherry red skin
      • Almond bitter smell
  • Treatment: Cyanokit (hydroxocobalamin)
    • Board question: Alternate treatment includes Amyl nitrite/sodium nitrite (makes methemoglobinemia) -> sodium thiosulfate/methylene blue (not available in US)
  • Parkland Formula:
    • TBSA burned (%) x Wt (kg) x 4mL = Fluid Requirements
    • Give ½ of total requirements in 1st8 hours, 2ndhalf over next 16 hours

EKG Basics with Dr. Luk

EKG system: find one that works for you

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  • Documentation: rate, rhythm, axis, intervals, ischemia/infarction, how it compares to old EKGs
  • Rate: 
    • Regular: 300/large boxes between R-R
    • Irregular: # QRS complexes in 6 seconds (30 large boxes) x10
    • Shortcut: 300-150-100-75-60-50
  • Rhythm:
    • Regular vs irregular
    • Where does impulse originate from? AKA look at P waves, QRS
  • Interval:
    • PR/QRS/QTc
    • ST segment isoelectric with PR interval

Sinus rhythm: P-P equal, upright and uniform P waves, P before QRS, QRS after every P wave

  • Sinus dysrhythmia: Usually a physiologic reaction
  • Sinus arrest: SA node stops firing (ischemia, hypoxia, fibrotic disease, digoxin tox)
    • Treat symptomatic patients with atropine -> pacing

Supraventricular tachycardias

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  • Wandering atrial pacemaker (irregular, P waves change morphology, at least 3 shapes)
  • MAT (rate >100, irregular, different P waves)
    • Causes: advanced pulmonary disease, kypoK, ischemia, mitral valve regurg
  • PACs: P wave preceding QRS for a PAC has different morphology 
  • SVT: Atrial depolarization overrides SA node (Ps often buried, narrow QRS, 150-250)
    • Cases: Stress, caffeine, smoking, overexertion, frequently: CAD, rheumatic heart disease, WPW
    • Adenosine, vagal maneuvers, synchronized cardioversion
  • A flutter: atrial reentry rhythm (atrial rate 250-350, ventricular rate depends on conduction block, regular, saw-tooth pattern)
    • BB, CCB,  electricity
  • Atrial fibrillation (irregularly irregular, QRS normal)
    • Loss of atrial kick
    • Rate <60 = think dig toxicity
  • WPW (short PR, wide QRS, delta wave)
    • Frequently associated with afib
    • DO NOT USE CCB (blocks AV node, sends electricity to Kent bundle)

AV blocks:

  • First degree: prolonged PR interval
  • Second degree Mobitz Type 1: cyclical pattern of progressively longer PR
    • AV node ischemia most common cause
    • Frequently transient after inferior wall MI
  • Second degree Mobitz Type 2: PR interval constant, but no every P wave has a QRS
    • Causes: MI, septal necrosis
    • CAN PROGRESS TO THIRD DEGREE
    • Pace, can try atropine
  • Third degree block: Complete dissociation
    • MI, digoxin, degenerated conduction system
      • Pace

Bundle Branch Blocks

  • RBBB: QRS up in V1 + wide QRS = RBBB
  • LBBB: QRS down in V1 + wide QRS = LBBB

Ventricular Dysrhythmias (wide QRS)

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  • Ventricular escape beats/rhythm
    • All other pacemakers have failed
    • Usually seen first after defib (make sure not PEA)
  • Accelerated idioventricular rhythm
  • PVCs
    • Causes: MI, hypoxia, acid-base, electrolyte
    • Concern with multifocal, associated with chest pain, more than 6 a minute
  • VTach (150-250, wide QRS_
  • Torsade de Pointes: GIVE MAGNESIUM

QT interval:

  • Normally <440 sec
  • Varies with rate
  • Many causes- drug, electrolytes, etc

R wave progression: R sided precordial leads predominately negative, L sided positive, transition around V3-4

  • Poor progression: cardiomegaly, LBBB, leads, pulmonary disease, RVH
  • Early progression: LVH

Axis: 

  • I, aVF, II
  • Up in I, up in aVF = normal axis
  • Up in I, down in aVF -> look at II. Up in II = normal, down in II = LA