11.1.18 Conference Summary

—CLE RISING SERIES—

Dr. Enyo Ablordeppey, EM/Intensivist, WashU

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“Top 10 Ways I Use Ultrasound Every Day”

  • Volume Status

    • A-B-C-D(Drug)-E(echo)

    • Use POCUS to determine stroke volume

      • Qualitatively: look at squeeze, chamber size

      • Quantitatively: SV = LVOT area x LVOT VTI

      • Assess SV then give fluid bolus or passive leg raise test then reassess

  • Can I give more fluid?

    • High filling pressures = fluid is harmful

    • Diastology — look at pulse wave (PW) doppler of mitral valve inflow & tissue doppler (TDI)

    • IVC assessment

      • Differentiate from aorta (IVC is intrahepatic, not pulsatile; consider subcostal short axis view)

      • Look at diameter and % of inspiratory collapse

      • Less helpful in obstructive shock (IVC will be prominent, minimal resp variation)

  • Right heart failure

    • Associated with lung disease (increased pulm vascular resistance), MI (inferior), hypoperfusion states, etc

    • Optimize preload, cardiac output, perfusion pressure and decrease afterload

    • Apical 4 view is the best

    • Distinguish left from right on US (only need 1)

      • tricuspid annulus

      • LVOT

      • descending aorta near LV

      • moderator band

    • TAPSE (A4C view)

      • TAPSE <16mm, S’ <10cm/s suggests RV dysfunction

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  • Regional wall motion abnormalities

    • PSSA: Septal - Anterior - Lateral - Inferior (SALI) - moving clockwise from the left

  • Assess for pneumothorax

    • Lung sliding, sky-ocean-beach (mmode) —> no PTX

    • Absent sliding, barcode —> PTX

    • US more sensitive than CXR for PTX; similar specificity

  • Other lung pathology

    • Use low frequency probe (curvilinear, phased-array)

    • A lines: no fluid — normal, asthma, COPD, PE, ptx

    • B lines: pulmonary edema, bilateral pneumonia; if unilateral, consider focal pneumonia

    • Differentiate ‘opacity’ on x-ray — effusion vs consolidation

  • Why is the troponin increasing?

    • Hyper vs hypodynamic function

    • Right heart strain

    • RWMA

    • Thrombus: intra-cardiac, DVT, PE (RV strain, McConell’s sign)

  • Abdomen

    • Free fluid (traumatic & non-traumatic)

    • Hydronephrosis

    • Bowel dilation - bowel obstruction/ischemia

    • Aortic dissection/aneurysm/thrombus

  • Procedures

    • Ultrasound-guided lines/confirmation, post-CVC PTX

  • Tamponade

    • = pericardial effusion + RV collapse during diastole

    • Use location relative to descending aorta to differentiate pericardial (above) vs pleural (below)

    • Can use EPSS (assess proximity of MV and septum) — use M-mode w/ bar over tip of anterior leaflet of mitral valve, look for RV collapse during diastole



Point-of-Care Ultrasound: The Role of Implementation Research

  • Diffusion - Dissemination - Implementation continuum

    • Diffusion (passive) and Dissemination (active): spread of new practices to audience

    • Implementation: integrating something into practice; actually making it happen

  • Implementation research

    • Evaluates real world conditions/context in effecting change

    • Implementation often dependent on: relative advantage, compatibility, complexity, triability, observability

    • Need qualitative evidence to support

  • Diffusion of Innovation

  • Traditional Research

    • Clinical efficacy - clinical effectiveness -- hybrids (see below) -- implementation - improved process and outcomes

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  • Hybrid Type 1: test clinical intervention, observe/gather info on implementation

    —> LV assessment (filling pressures), starling curse

    • PWD: over mitral leaflet tip in A4C, looks at velocity

      • Normal: E>A

      • Impaired: A>E

      • Pseudo-normal: E>A (looks same as normal) -- need TD to differentiate normal from abnormal

      • Restrictive: E>>A

    • TD (tissue doppler): mitral annular velocities

      • measure e’ and compare to E — measure beneath baseline, average lateral and septal

        • E/e <8 give fluids

        • E/e <9-12

        • E/e >13 consider diuresis, hold fluids

  • Hybrid Type 2: test intervention, assess implementation strategy

    —> US-guided CVC confirmation

    • Historically, CXR obtained to confirm CVC placement & r/o PTX

    • POCUS has similar efficiency and is quicker but CXR still done

      • Why? —primarily institutional standards, lack of familiarity/experience with POCUS

    • POCUS reduced mean CVC confirmation by almost 1 hour, sens/spec nearly 100% for ptx

      • A4C view, give rapid flush of saline. If turbulence in 2 seconds, confirms venous placement

    • Important to understand scope of practice & limitations of POCUS

    • Strategies to promote adoption of POCUS over CXR vary based on target audience

  • Hybrid Type 3: test implementation strategies, gather info on clinical outcomes

    —>Cardiac imaging in cardiac arrest - is it a problem?

    • POC TTE associated with delays in chest compressions but provides useful information quickly & dynamically

    • Rescue TEE? - may improve image acquisition and helps minimize time off chest but expensive, requires more training, can be more helpful for advanced procedural guidance

ED Pharm 101: Review of Select Medications for Atrial Fibrillation

Christy McKenzie, PharmD, EM Clinical Pharmacist

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  • Physiology/Pharmacology review

    • Cardiac action potential phases

      • Rapid Na+ influx —> K+ efflux —> Ca2+ influx + K+ efflux —> Ca2+ channels close & delayed Ca2+/K+ channels remain open —> only delayed K+ channels remain open

    • Anti-arrhythmic classes & corresponding EKG changes

      • I: sodium channel blocker — widens QRS

        • 1a: +QT prolonged (some K blockade) — quinidine, procainamide

        • 1b: +/- QRS, +decreased QT — lidocaine

        • 1c: +/- QT — flecainide, propafenone

      • II: beta-blocker — decreases heart rate, prolongs PR

      • III: potassium channel blocker — prolongs QT +/- widens QRS — amiodarone, dofetilide, sotalol* (also II)

      • IV: calcium channel blocker (non-dihydropyridines) — decreases heart rate, prolongs PR

  • Atrial fibrillation pathophysiology review

    • Definition: SV tachyarrhythmia with uncoordinated atrial activation i.e. ineffective contraction

      • Usually due to underlying cause, increased risk for stroke & VTE (atrial thrombi & appendage)

      • EKG characteristics: Irregular R-R intervals, absent P waves, irregular atrial activity

    • Rate determined by conduction/refractory properties of AV node (in absence of accessory pathway)

    • L-type calcium channels & beta receptor stimulation most responsible for AV nodal conduction

    • Sympathetic activation/vagal withdrawal increase ventricular rate

  • Atrial fibrillation algorithm

    • If unstable, cardiovert!

    • Rate vs rhythm control

      • Rate control:

        • Beta blocker (caution in pts with COPD/asthma) — metoprolol 2.5-5 mg IVP up to 3x

        • Non-hydropyridine CCB (diltiazem, verapamil) — dilt 0.25mg/kg IVP then 5-15mg/hr

        • Consider Digoxin if LV dysfunction — 0.25mg/g IVP, daily max 1.5mg

        • Can consider amiodarone IV if critical or ablation/pacer if failing medical therapy

      • Rhythm control

        • Increased risk of VTE

        • Amiodarone: 150mg over 10 min —> 1mg/min x 6 hrs (numerous adverse effects)

        • Dofetilide: renally dosed (can cause QT prolongation, Torsades)

        • Flecainide: 200-300mg PO (avoid in structural heart disease)

        • **Procainamide: restricted to WPW (17mg/kg loading dose)

    • Cardioversion: electrical vs pharmacologic (rhythm control)

      • Unstable: immediately!

      • Stable: ok if onset <48 hrs + low thrombotic risk; otherwise anticoagulate at least 3 wks before and 4 wks after to avoid thromboembolism

  • Anticoagulation to prevent VTE

    • CHADSVASc vs HAS-BLED scores to determine risk benefit for AC

      • CHEST 2018 updated recs: no AC if score 0 in men or 1 in women

    • Warfarin if mech valve, adjust INR

    • Eval renal function if considering factor Xa inhibitors

    • Heparin high intensity

      • if HIT: use bivalirudin

Airway Grand Rounds - Dr. Matt Stull

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  • Indications for airway

    • Failure to oxygenate

    • Failure to ventilate

    • Failure to protect airway

    • Anticipated clinical course - shock, procedure, facilitate evaluation

  • Assessment — LEMON

    • Look (externally)

    • Evaluate — 3-3-2

    • Mallampati

    • Obstruction

    • Neck — mobility

  • 7 P’s of RSI

    • Preparation — SOAPME (Suction, Oxygen, Airway equipment, Positioning, Monitor, EtCO2

    • Pre-oxygenate — NRB if spontaneously breathing (BVM if not) + nasal cannula at least 3 minutes at 100%. If not at 100%, keep trying!

    • Pre-treatment (especially if concerned for increased ICP) — fentanyl 3mcg/kg vs lidocaine 1mg/kg

    • Paralysis with induction — paralysis associated with improved first-pass RSI success

      • Induction

        • Propofol 0.5-1mg/kg — least cardiac stable —> consider in hypertensive pts or those with high ICP

        • Etomidate 0.3mg/kg — 2nd least cardiac stable

        • Midazolam 0.3mg/kg & fentanyl 3mcg/kg — great for status epilepticus

        • Ketamine 1.5 mg/kg — avoid in pts with psychiatric disease & increased IOP, favorable in asthma/COPD; most cardiac stable

      • Paralysis

        • Succinylcholine 1.5mg/kg

        • Rocuronium 1mg/kg — not as good for neuro pts

        • Vecuronium 0.2mg/kg

    • Positioning — align airway axis (ear horizontal with sternal notch)

    • Placement with proof — video-assisted laryngoscopy (DL vs VL technique)

    • Post-intubation care — sedation, elevate HOB 30 degrees