Why did you get an EKG on that 26 year old? CAPA 2015 Annual Conference. Why do I do this?

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Horace Alexander
8 years ago
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1 By: Jennifer Carlquist, PA-C Central Coast Cardiology, Salinas Valley Emergency Room ER, CAQ ER Medicine Why do I do this? Why did you get an EKG on that 26 year old? 1

2 Because of him. 20 y/o nausea, malaise BIB Mom N/V/Malaise x 4 d Rapid heart rate this morning Dry, non productive cough Mild dyspnea, dizziness 2

3 What is the rhythm? WPW VT AFIB SVT Atrial Flutter SVT! Given adenosine.no effect. Beta blockers nothing. Unstable, so..cardioversion! But first, ketamine! Vitals/Labs HR 220, RR 20, 93/67 98 %RA Trop 0.1, T4 13.9, TSh 3.72, WBC 12.5 Mag 2.1, K 4.5 3

4 Then Cardiac arrest. Epinephrine, bicarbonate, levophed. Bedside quick look to pronounce. shows EF 10%. Why would a 20 y/o have low EF? Viral cardiomyopathy? HOCM? CHF? Drug induced? What else do you want to know? CXR- no effusion no overload Heart border slightly elevated UTOX: + marijuana and cocaine 4

Why would a 20 y/o have low EF? Viral cardiomyopathy? HOCM? CHF?

5 What happened? He was doing a lot of cocaine Had a pacemaker and ICD placed Transferred for cardiogenic shock DX: Drugs kill. Palpitationsfor 4 hours: 47 y/0 female 30 year old palpitations 5

6 38 y/o femaleschool teacher weak ER note Sent to ER by urgent care for abnormal cxr Pt. states sent for increasing cough and DOE x 1 week. C/O swelling to legs for 1 week. Denies hx of renal or heart disease. Denies fever, chest pain, abd pain or N/V/D. Diagnostics Labs: TSh 2.2, BNP 6131, Trop <0.015, Glucose 310 CXR: Left pleural effusion CTA: no PE Lexiscan: Mod severe LAD, RCA lesions, EF 20% 6

Denies hx of renal or heart disease. Denies fever, chest pain, abd pain or N/V/D.

7 What happened? H bypass! EF of 20% She lived. 36 y/o I feel weak Post cardioversion 7

8 24 y/o female - altered History BIB ems unresponsive BG 30 dextrose IV On dialysis, diabetic, htn, anemia Says: I have been telling my doctor for months I have chest pain. They didn t listen to me. Cath report: Prox LAD: 95% - stent Circ: 95% - stent 18 year old dizzy wrestler Screening EKG was normal Labs normal Had a syncopal was seen at ER work up normal Is he just over training? 8

9 1 month later 2 nd syncopal Referred to cardiologist Holter reveals nothing Now what? What do you look for on a dizzy wrestler? WPW? Long QT? Drug use? Cardiomyopathy? Sick sinus And the winner is. 9

10 36 year old male palpitations 26 y/o male cardiacarrest That s odd 10

11 Brugadas 11

12 CardiologyOver-read 22% of ERMD s disagreed with each other VT v. SVT aberrancy -Courtesy Mike Taigman, Advanced Field Cardiology 12

13 Has an ICD: Palpitations for4 hours 50 y/o male chest pain Pain resolved 1 st trop normal Normal Lexiscan 10 days ago PMH: Smoker, previous stent, hyperlipidemia 13

14 74 y/o male: chest pain P unprovoked Q- pressure R Left arm, jaw, neck, head S 8/10. Dyspnea, diaphoresis at home T Intermittent for four days History PMH: None Meds: None SH: Lives with girlfriend, wife lives in Mexico. Drives a tractor Hasn t seen a doctor in 20 years + Former smoker, drinks 12 beers a day 75% stenosis onlad 14

Meds: None SH: Lives with girlfriend, wife lives in Mexico.

15 I need a wheelchair to the ramp And I think he s drunk He walked in here but he doesn t look so good Hook him up while we get a 12 lead He s 42.CC: not feelingwell 15

16 Drinks 6-12 cans a day Hx of VT gave me a shot of something 5 yrs ago Given 1 mg Ativan, ketamine and Cardioversion 100 which led to this Post cardioversionekg When he soberedup from the Ketamine. He was at a friends drinking Had acute onset chest pain, left sided I was going to pass out Felt like my heart was going to jump out of my chest so he called a taxi. 16

17 Labs Troponin 3.2 TSH 1.99 ETOH 229 Glucose 130 Creatinine 2.2 DX: Sustained VT ETOH? ARF from dehydration Alcohol abuse, acute no DTS EF: 40% Normal coronaries Rash x 2 weeks 12 y/0 female who has been tired x 1 week Dyspnea Buttock pain when sitting for an hour VS: 112/90, HR 168, RR 28, o2 sat 99% 17

ARF from dehydration Alcohol abuse, acute no DTS EF: 40% Normal coronaries

18 History No PMH Vaccinations up to date Recent travel (got home from Philippines 5 weeks prior) Symptoms started two weeks after getting home No family history Seen yesterday at clinic ordered labs Diagnostics EKG: ST 146, no ST elevation, no S1, q3, T3, No ectopy, No LVH LABS: WBC 13, Hgb 10, TSH: 3.3, Urinalysis 3+ protein RF neg, Flu Given fluids bolus, still tachycardic VS: 100.0, HR 158, RR 28, o2 sat 98% My side hurts 18

EKG: ST 146, no ST elevation, no S1, q3, T3, No ectopy, No LVH LABS: WBC 13, Hgb 10, TSH: 3.

19 Give her rocephin Reassessed. Radiologist called. Can you please take a better look at the XR? CXR read by radiologist CXR 19

20 What lab was missing? ESR was 104 ANA pending D-Dimer Over 4000 Pull the triggeron thatct His EKG 20

21 51 year old generalweakness Felt unwell like the water ran out of me Under stress HX: HTN, psyche, chronic neck pain Drank alcohol, did cocaine Called 911 EMS says had an episode of urinary incontinence, pt felt weak Dizzy, dyspnea, chest discomfort Field EKG: Sinus tachycardia with borderline st elevation in V1, V2 with one PVC Then goes into torsades. Is shocked at 200 j once, brief CPR Post shock in ER 21

22 What were her risks? K was 2.7 Qt prolonging meds Did cocaine Hx of prev long qt. Female At clinic visit I think I need something stronger for pain I didn t take my blood pressure medication as it was too expensive I did take my nieces medication, it starts with an L I did take two methadone that day for pain Clinic EKG 22

23 Her med list Prozac Methadone Trazadone Pepcid Rispiridal Xanax, Neurontin Take home points Don t write off young patients Look for high risk findings on every EKG Short PR, Long QT, Star in the PR interval Money leads of Brugadas DON T TRUST the READ! Jennifercarlquist@yahoo.com 23

Is it really so? : Varying Presentations for ACS among Elderly, Women and Diabetics. Yen Tibayan, M.D. Division of Cardiovascular Medicine

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