Grand Rounds - April 23, 2016

• Dyspnea in Pregnancy
• M&M
• LVADs
• AHA Guidelines Update

Dyspnea in Pregnancy – by Murteza Shahkolahi

• Presentation and Approach
  • There is no formalized risk stratification, validated PTP score for pregnant population (usually excluded from studies)
  • Diagnostic Algorithm
    • Standard of care: ATS/STR/ACOG
      • Do NOT Dimer
        
      • increases in normal preg
      • slowly declines postpartum
      • still can have false negatives

• *D-dimer cutoffs (D-dimer threshold increase with pretest probability unlikely for pulmonary embolism to decrease unnecessary computerized tomographic pulmonary angiography http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3319270/

• http://www.acog.org/~/media/Districts/District%20VIII/PulmonaryEmbolismPregnancy.pdf?dmc=1&ts=20140525T0200225053
  • Evolving perspective: Kline et al (not yet validated)
    • Revised D-dimer cutoffs*
      • First trimester <750
      • Second trimester <1000
      • Third  trimester <1250
    • Normal HR 100 -> 105                                                                              

• Alternative to V/Q scan -> just get a Q scan
  • normal perfusion scan = NPV approaching 100%
  • no reduction in diagnostic accuracy
  • Rosen’s has contradictory recommendations regarding D-dimer use
• Fetal Radiation Exposure:
  • CTPA: 25-50 cents
  • V/Q: 50-75 cents
  • 0.1 gray = $100
  • CXR: 1/10 of a penny
• CTPA > VQ by 150x

• Background radiation: $5 (during entire pregnancy)
• Shielding controversial (can bounce around off shield)

• Maternal Radiation Exposure:
  • Breast shields: 34-57% reduction (though some say machines calibrated to reduce exposure wo shield
• Treatment
  • Heparin or LMWH (Warfarin can be teratogenic in 1st trimester

 
 
 
Morbidity and Mortality – by Chrissy Woodward
Case 1

• 59M PMH aflutter s/p cardioversion 1m.a., presenting w DOE (planned ablation next week)
  • PMH CHF, HTN, Aflutter
  • PE: HR 125, 98% on 2L
  • Labs: Trop I 0.095, BNP 4,550
  • EKG: Aflutter 125 BPM w atrial conduction
  • CXR: cardiomegaly w early cardiac decompensation
  • Tx: Dilt 10mg IV
  • MDM: aflutter for several days, worsening DOE, admit to gold for ablation
  • Nursing note: Pt does not want to stay in hospital over 4-day weekend
  • Left AMA after multiple discussions, rpt Tn 0.089 (3h)
• Aflutter…not same as Afib
  • baseline is all p waves (sawtooth appearance) at rate >200 BPM
  • 2:1, 3:1, or 4:1 blocks most common
• Returned 3 days later, found down, intubated by EMS
  • CPR -> pronouncement of death
• Discussion:
  • Pt not angry, very aware of condition, educated, responsible, had f/u scheduled
  • Could have considered cardioversion before leaving
  • Could have considered asking him to return next day to ED for f/u
  • Important to document pt capacity

 
Case 2

• 23M no PMH presenting  with 3d acute R lower back pain
  • HPI
  • radiating to posterior R leg
  • worse sleeping/sitting, better w NSAIDs
  • 6mo chronic back pain
  • Mom at bedside worried about depression
  • PE: numbness in R toes, mild R lumbar TTP, occasional sadness, dec enervy, dec concentration, denies SI/HI/hallucinations
  • RX: valium, ibuprofen
  • Ed materials: sciatica, depression
  • DCI: Back pain possible from physical strain and poss psychological factors…pls f/u w PMD
  • F/u: 7 options listed (med and psych)
  • Attending MDM: depression, R sciatica, mom concerned wants psych eval, no SI/HI
• Returned as Trauma Yellow: jumped in front of metro train
  • BL BKAs, revisions, psych care
• Discussion:
  • Who warrants psych consult in absence of SI?
  • Psych SW is option for another opinion (depending on SW)
  • Can have pt get on phone w insurance while waiting in ED; if no appointment, can involve psych SW/psych residents
  • Suicide RFs: older, divorced/widowed, males, access to firearms, worthlessness, prior attempts, perfectionist -> psych overtones
  • Optional out-of-pocket appointments (can call James Griffith, GW Psych Chair)
    • GW $250/visit, cash only
  • Avg wait time for 1st apt:
    • uninsured homeless – 8 weeks
    • other - 3 weeks
  • ZocDoc – can sort by who takes Medicare/aid
  • Unity Care: Friendship Place (Homeless resources)
    • Thursdays 1-3pm, anonymous psych care, drop-in
  • Telepsychiatry: e-psychiatry.com(?) ($300 initial; $125 f/u consults)

 
Case 3

• 21M PMH whiplash, slipped and fell from standing while intoxicated
  • HPI: initially unable tomove extramitiyes, sleep overnight, woke w HA, + pina and needles, difficulty using phone
  • PE: mild distress, TTP head globally, neuroexam intact
  • Imaging: CT head normal, CT spine: congenital spinal canal narrowing at C1-C2
  • Meds: 2L IVF, Compazine, tylenol, ketorolac
  • MDM: conscussion, w subjective weakness + paresthesias, ambulatory, HR in 80s
  • F/u: GWU-NSGY (given copy of imaging results), concussion clinic, family doc, internist
• Returned to Georgtown: unstable CS injury (cord contusion from congenital PLUS trauma), fusion occiput to C4
• Discussion:
  • In pt with narrowed spinal canal, should we be more aggressive in investigating minor clinical findings?
  • CT was fine, would have needed MRI for further eval

 

 
Case 4

• 25F with epigstric pain, pleuritic
  • Meds: Carafate, Pepcid
  • MDML substernal pain rad to back, d-dimer pos, but CTA neg for PE
  • Returned w epigastric + RUQ pain rads to back x 3 days, N/V
  • PE: mild distress, TTP upper back and epigastrium
  • Labs: AG 16, TB 4.5 Alk Pho 244, transaminases 500s, lipase…(not in presentation)
  • Dx: gallstone pancreatitis
• Course: admitted, endoscopy, failed stone extraction, lap cholesy, TPN for persistent N/V/pain
• Discussion:
  • Should have gotten lipase on initial visit

 
Case 5

• 58F PMh lymphedema, obesity, hypothyroid presenting w worsening DOE x 1 wk
  • HPI: previously exercising w no SOB, substernal CP 1 w.a.
  • PE: normal VS, normal exam
  • EKG: low voltage, NSR, non-specific lateral TW changes
  • Labs: BNP 641, Dimer 2.59 (sent at end of shift, per request of Gold team)
  • MDM: Pt PMH CP wks ago, not recurred, increasing DOW x wks, resovled w rest. Concern for angina pain despite EKG, planned admit to Gold.
• Course: admitted to Gold, normal cath, got CT showing large saddle PE, xfer to Blue team, R pop vein VTE, lovenox > xarelto, additional hx long plane flight, formal echo showed no R heart strain
• Discussion:
  • Right heart strain -> shock = 2x mortality
  • EKG
    • Sinus tachycardia is MC EKG finding in PE
    • S1Q3T3 – not common
    • right axis deviation
    • RBBB
    • RV strain

 
Case 6

• 84M PMh CAD w pacemaker, HTN, DM, p/w CP x 1h
  • HPI: midsternal, heavy , no rads, has cardiologist
  • PE: exam normal
  • EKG:
  • Labs: WNL (including CEs and CXR)
  • Meds: ASA, NTG -> Bp dropped to 70/40, the improved w IVF
  • MDM: Suddden onset SSCP rads to BL arms, mild SOB, admit to Gold
• Course: 2nd Trop just before moved upstairs slipped through cracks, morning Tn 29, “paced EKG hard to tell STEMI vs NSTEMI”, got urgent cath: 80% LAD stenosis, OM2 90%, DES x 3, doing well
• Discussion:
  • systems errors, orders placed in transit get lost in cracks
  • Sgarbossa Criteria:
  • http://www.aliem.com/2013/modified-sgarbossa-criteria-ready-primetime/
  • http://lifeinthefastlane.com/ecg-library/basics/sgarbossa/
    • ORIGINAL SGARBOSSA CRITERIA
      • Concordant ST-segment elevation ≥ 1 mm in any lead (5 points)
      • Concordant ST-segment depression ≥ 1 mm in lead V1 – V3 (3 points)
      • Discordant ST-segment elevation ≥ 5 mm in any lead (2 points)
    • WHAT ARE THE NEW MODIFIED SGARBOSSA CRITERIA?
      • Concordant ST-segment elevation ≥ 1 mm in any lead
      • Concordant ST-segment depression ≥ 1 mm in lead V1 – V3
      • Discordant ST/S Ratio ≤ -0.25

 

 
 
 
 
 
 
 
LVADS – by John Greenwood (UMD Pulm Crit Care Fellowship recent grad)
johncgreenwoodEgmail.com
@JohnGreenwoodMD

• LVADs give pts a second chance
• Myth #1: The Manual Pump
  • LVADs used to have a backup manual pump, but no longer exist
• Pt 1 – Joe, wanted to see grandkids graduate
  • given HeartMate II
  • alarm went off one day and he passed out
  • at hosp, alarm went off again, Joe went into VT
• Measuring BP w LVAD
  • inflate cut on axillary artery and deflate until you register on Doppler = MAP
• VADs are preload dependent, but afterload sensitive
  • give IVF early
• LVAD Initial Assessment
  • A – auscultate: should hear nice consistent hum of motor
  • B – battery: usually 2 external batteries, can push battery button on controller to show charge; need to be charged
  • C – controller: iPhone sized; ask family, they’re usually well-trained
  • D –driveline: check surrounding skin for infection
  • E – EKG/echo bedside: EKG - nothing specific to VADs (often low voltage, evidence of end-stage HF, prone to tachydysrhythmias but you’ve got more time since they have VAD as backup)
• Controls:
  • Don’t be afraid to press buttons – you won’t turn it off
  • Press home button + silence button to review alarms
• Mechanical problems:
  • Suck Down: when LV is empty (low preload), can suck wall of LV into inlet
    • give fluids
• What the Cardiologist wants to know:
  • Speed
  • Flow
  • Power/PI
  • Other:
    • recent changes to settings
    • pulsatility – measure of how much native heart function is contributing to flow
• Echo:
  • LV underfilled: if inflow valve is 1:1 size of LV -> high risk of suck down
    • hypovolemia
    • tamponade
    • excessive pump speed
    • RV failure
  • LV overdistended
    • pump malfunction (rare)
    • pump thrombus
    • AR
    • severe HTN
  • RV underfilled
    • hypovolemia
    • tamponade
  • RV overdistended
    • RV failure
    • hypervolemia
    • PE
    • severe TR
• Pump thrombosis
  • mortality 48%
  • particular problem in HeartMate II machines (quadrupled rate from 2011-2013 for unknown reason)
  • machine gets hot, strianing
  • consider LDH – thrombus could be spinning and hemolyzing
  • if suspected, call CT team right away, poss start hep drip
• Myth #2 – If you perform CPR on pt w LVAD, they will explode
  • unkown if pumps are dislodged – but better than dead!
  • options: (e.g. if MAP <40)
    • start inotrope – epinephrine (low dose, 5mcg/min or wt-based)
    • start a pressor – levophed
    • call for ECMO, get lines started
• Pt 2 – Frank
  • HeartWare (axial flow device – thought to cause less trauma)
  • had GI bleed – VAD pts more prone to AVM in GI tract, also possible shearing forces on platelets
  • intubated
  • endoscopy found AVM
• Myth #3 – Never reverse AC in a VAD pt
  • get a TEG/ROTEM
  • fix platelets (give DDAVP, or dose of plts)
  • reverse INR (PCC or FFP)
• Intubation
  • remember, they are preload dependent
  • Rocketamine! (preload sparing)
    • ketamine
    • rocuronium
• Bottom Line:
  • ABCDE (of VAD)
  • Focus on the tank
  • Fix the coagulopathy

 
 
 
 
AHA Guideline Update – by Stas Haciski
2015 ACLS UPDATES- https://circ.ahajournals.org/content/132/18_suppl_2/S315.full.pdf+html

• FOAM Resources:
• http://first10em.com/2015/10/21/acls-2015/
• http://emergencymedicinecases.com/acls-guidelines-2015-cardiac-arrest/
• http://emergencymedicinecases.com/acls-guidelines-2015-cardiac-arrest/
• CPR
  • Hard and fast – but not more than 120
  • …and allow rebound
  • minimize compression interruptions
    • chest compression fraction: how much of total time during resus is spent with compressions ongoing (80-85% is good; Seattle has 90+%)

 

• Machines
  • ResQPod – regulates pressure in airway to maximize efficiency of compressions
    • conflicting studies, not formally recommended in guidelines
  • LUCAS – automate compression device
    • no difference in outcomes between manual CPR
      • many confounders
      • delayed time to defib in mechanical arms
    • guidelines state “it may be reasonable” in certain circumstances
• Pressors
  • Epinephrine
    • Alpha 1 increased contractility
    • Downsides: increased cardiac demand
    • Studies show no benefit to neurologic function w/wo epi
      • recent study showed increased interval bw epi administrations lead to better outcomes
    • Guidelines: standard dose (1mg) Epi “may” be reasonable
    • High-dose Epi (5mg) a/w myocardial necrosis
    • Epi drip studies in pigs were promising
  • Vasopressin
    • No advantage vs standard dose Epi
    • Removed from guidelines in 2015
    • RTC in 2013 of vasopressin, Epi, and steroids showed improved neurologic outcomes
      • guidelines say “can consider”
• When to call the code?
  • 88-92% don’t make it
  • If EtCO2 <10mmHG (intubated) after 20 mins, is ONE component to consider
  • EtCO2 jumps with ROSC, but finish round of CPR!
  • Consider whole picture:
    • ROSC on scene by EMS
    • age
    • co-morbid conditions
    • POCUS – though cardiac standstill can be survived
    • reversible cause
    • time