Medical Student Corner – “If your patient is sweating, so should you…”

Authors: Patrick Mescher, OSU MS4 // Michael Barrie, MD OSUEM

Standing in the physician’s office of a local Emergency Department I heard the familiar clunk of a chart being dropped into the metal bin. I walked over and picked up the chart and read “Chief Complaint: Chest Pain,” thinking to myself how this was the fifth “chest pain” I’ve seen this shift. After diagnosing GERD, costrocondritis, and pneumonia with previous patients, I felt comfortable evaluating this chief complaint so I went calmly to the patient’s room. But as I walked to the bedside I found a visibly uncomfortable patient, profusely perspiring. He told me he was having crushing chest pain. I was immediately concerned this may be the real deal STEMI.

I was then perplexed when the initial ECG returned without clear ischemia or STEMI. My attending insisted that a repeat ECG be done shortly there after. This time even computer got it right, reading **STEMI** across the top. The patient was given aspirin and rushed to the cath lab. When reflecting on this case,  I wondered why give the medications that we do to patients with an acute STEMI?”

There is a pneumonic to help remember STEMI medications –

  • M – morphine
  • O – oxygen
  • N – nitroglycerin
  • A – Aspirin, Antiplatelet

But, evidence has show that the only intervention with benefit is Aspirin, and the other agents in MONA can potentially cause harm.

Aspirin

Aspirin 324mg should be given to the patient as soon as possible. Aspirin is given as soon as possible as it is the only intervention outside of surgical intervention that is shown to reduce mortality in an acute MI, anywhere from 20-50% depending on the study. Of note, the original study was done with 162mg of Aspirin (2 ‘baby’ aspirin) chewed in mouth for best oral bioavailability. The number needed to treat is 42 to save 1 life in STEMI.

STEMI patients should also be considered for antiplatelet therapy in route to the cath lab. At many centers clopidogrel 600mg is the agent of choice, but many institutions are now using the preferred agents of ticagelor 180mg or prasugrel 60mg so long as patients are without contraindications (Absolute contraindications to prasugrel include a history of stroke or transient ischemic attack (T.I.A.) or active pathological bleeding. Weight <60 kg and age ≥75 years are relative contraindications). The antiplatelet is given prior to percutaneous coronary intervention (PCI) in anticipation of a stent being placed to help prevent early re-infarction or stent collapse. Heparin can be given prior to PCI to prevent and thrombosis during or immediately after the procedure because of the significant endothelial damage from the catheterization and stent placement, however this is unlikely to be used in STEMI patients and is reserved for NSTEMI patients that do not need emergent revascularization.

Morphine

It is reasonable to treat the patient’s pain, because it can in theory decrease strain on the heart. However, this has not been shown to be of benefit in acute STEMI beyond just treating pain.

Oxygen

Oxygen only if needed to maintain SATS above 90%. Oxygen should not be routinely used, as hyperoxia can worsen reperfusion injury. However, in patients with clinical signs of cardiogenic shock, pulmonary edema, and hypoxia supplemental oxygen (or bipap) is appropriate.

Nitroglycerin

Nitroglycerin can be used in patients without concurrent use of Viagra or suspected right sided infarct. This is because nitroglycerin reduces preload, and thus heart strain, and oxygen demand. However, if there is a right sided lesion the heart’s ability to perfuse the body is preload dependent. Giving nitroglycerine to a patient with an inferior STEMI could lead to catastrophic loss of blood pressure and end organ perfusion.

Conclusion

Treat every patient as if it’s your first patient of the day and never rely on one piece of information. Simply because the first EKG returned normal does not rule out an evolving STEMI or other serious pathologies. History, physical exam, and clinical gestalt are vital to providing appropriate patient care.

References:

  1. Protective Effects of Aspirin against Acute Myocardial Infarction and Death in Men with Unstable Angina — Results of a Veterans Administration Cooperative Study . http://www.nejm.org/doi/full/10.1056/NEJM198308183090703
  2.  A randomized controlled trial of oxygen therapy in acute myocardial infarction Air Verses Oxygen In myocarDial infarction study (AVOID Study). http://www.sciencedirect.com/science/article/pii/S0002870311008271
  3. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. http://www.sciencedirect.com/science/article/pii/S0140673601057014
  4. The NNT – http://www.thennt.com/nnt/aspirin-for-major-heart-attack/
  5. Up to Date Overview of the acute management of ST-elevation myocardial infarction, and Antiplatelet agents in acute ST elevation myocardial infarction.

When to send the patient home? Medical Student Notes

Author: Hiro Miyagi OSU MS4 // Editor: Michael Barrie OSU EM Attending

Medical Student Corner – When do kidney stone patients need immediate intervention?

A 51yo female presents with an acute episode of severe right sided back pain with nausea and vomiting. Patient has a past medical history of HTN and chronic back pain. The pain is intermittent, described as sharp and stabbing 10/10 pain. She has not been able to tolerate any liquids since the onset of pain. The patient denies fevers or chills, with no recent infections or illnesses. No dysuria, but with mild urinary frequency. She has a past surgical history of appendectomy 30 years ago.

Vital signs: Afebrile, HR: 96, RR: 16, bp: 140/98, SPO2: 100% on room air.

On exam, the patient appears restless, abdomen is soft but tender on the RLQ. Heart and lung exams are unremarkable. There is no CVA tenderness.

Labs: Creatinine: 0.98, wbc: 11, Hgb: 13.4, UA shows trace blood, positive nitrites, negative leukocytes, many squamous epithelial cells.

CT scan: 3.5mm x 4mm obstructing R ureteral stone with mild right hydronephrosis

Patients with kidney stones are no strangers to emergency physicians. While the differential for flank pain can include renal or ureteral stones, pyelonephritis, lobar pneumonia, AAA, hydronephrosis, and gynecologic causes among many others, I wanted to specifically discuss flank pain secondary to kidney stones and what the indications are for prompt intervention.

During my emergency medicine rotation, I was taught that disposition is one of the most important questions to answer while in the ED. Can the patient go home? Do they need further studies? Do they need prompt intervention? Below I have reviewed the indications for prompt intervention in kidney stone patients.

Indications for prompt intervention

  1. Prolonged complete or high grade unilateral urinary obstruction.
  2. Any degree of bilateral urinary obstruction.
  3. Any degree of urinary obstruction in a solitary kidney.
  4. Any degree of urinary obstruction with urinary infection or sepsis.
  5. Any degree of urinary obstruction with a rising creatinine.
  6. Symptoms refractory to medical management – Inability to tolerate oral intake because of severe nausea or vomiting, or severe pain not controlled by oral analgesics.

Can this patient go home? This patient has positive nitrites suggesting that she has a UTI which is a definite indication for a stone intervention. But wait– upon closer inspection, we can see that her UA is contaminated with many squamous epithelial cells. A repeat UA was ordered (consider straight catheterization if repeat UA is contaminated). On repeat testing nitrites were negative. In an otherwise healthy female with a 4mm ureteral stone, she has a greater than 60% chance of passing the stone with time. Patients should be prescribed pain medications – NSAIDs, Tylenol, and consider opiates. Consider alpha-antagonists such as tamulosin especially when kidney stones are larger than 6mm. And like nearly all ED patients we send home, recommend aggressive fluid hydration.

The next time you see a kidney stone patient, I hope that review of these indications can help you determine the disposition of the patient.

Case Conclusion

After Toradol 15mg IV and oral Tylenol, the patient’s pain is controlled and she is now able to drink some water. The patient felt comfortable to manage her symptoms at home, and was discharged with a urine strainer and urology follow up as needed.

 

References:

American Urological Association-Surgical Management of Stones: AUA/Endourology Society Guideline, http://www.auanet.org/guidelines/surgical-management-of-stones-(aua/endourological-society-guideline-2016).

American Urological Association-Medical Student Curriculum: Kidney Stones, https://www.auanet.org/education/auauniversity/medical-student-education/medical-student-curriculum/kidney-stones.

Airway Corner with Dr. Kaide

Dr. Kaide’s Airway “tip of the month”

There was this hypothetical patient…who was being intubated.  As soon as the patient was paralyzed dark blood came pouring out into the mouth from an upper GI bleed. The resident immediately suctioned a continuous flow of blood from the airway. She could not see any airway structures because of the bleeding.  Now what?

The reason for this post is to add some thoughts to how to trouble shoot a very bad situation in advance so as to avoid trying to be creative in the moment. Under pressure people rarely rise to the occasion but rather regress to the mean…unless the trouble shooting process is thoroughly engrained.

The solution that we used was to introduce an 7-0 ETT without a stylette aimed with the tip down and to slide it along the back of the tongue into the esophagus and blow up the balloon. As soon as it went in, blood spewed out of the ETT. We stuck the yankaur into the ETT. This diverted the blood out of the airway and with a few seconds of suctioning of the mouth, she was able to see cords and successfully pass the ETT into the airway.

LEARNING Points. These are my thoughts, love to hear other thoughts!!

  1. Divert the blood immediately!
  2. Don’t use the stylette as it can be traumatic to the esophagus.
  3. Aim the ETT tip downward to increase the likelihood of an esophageal intubation.
  4. Have dual suction set up.
  5. Preoxygenate like you are in 2017 with NC at 15 LPM and NRB to flush (50 LPM). This means the knob is turned until it can’t be turned any farther. Keep NC on during intubation.
  6. This patient should have started in the ramped position to help use gravity to your advantage and keep passive blood from coming up from the stomach.
  7. Probably should put down an NG before intubation to decompress the stomach…depends on your “pre-test” probability of stomach volume trouble.  NG is NOT contraindicated in suspected variceal bleeding.
  8. Still can’t see? There are 2 holes and you plugged one up. Aim up and blindly put the tube in the only other hole there is. A bougie would be useful in this situation.
  9. Here ind something totally not on the radar…consider digital intubation.
  10. Still can’t get it in? Try blind nasotracheal intubation. You may be able to simulate a breath in the paralyzed patient by having someone compress the chest when you are listening to the ETT.
  11. Still can’t get it in but sats are still OK, consider retrograde intubation. No kit? Use a triple lumen kit because the guide wire is long enough to allow an ETT to be placed. I have done 3 of these on living humans but not recently since the age of video laryngoscopes. I have done a ton on cadavers when teaching in the procedure lab. Easy procedure. If they are desaturating, don’t try retrograde (especially for the first time). It takes a minute or so to do if all goes well.
  12. Digital intubation?
  13. If they are desaturating, you can try bagging even with the ETT still in the esophagus. It takes one person to hold the mask very tightly around the tube to keep the seal. Place one or 2 nasal trumpets to help. Alternatively, you could take the ETT out and bag.
  14. One other trick that has worked for me in the past in this exact situation is to place an ETT into the mouth and have someone squeeze the mouth closed like a purse string around both ETTs and bag the ETT that is in the mouth. Make sure to pinch the nostrils shut too. It actually works! I call this the Gorgas Method, named after Diane Gorgas, one of my now colleagues who taught it to me when I was a resident and she was the associate residency director (1993-96)!
  15. Can’t intubate, can’t oxygenate? This is now a failed airway and proceed to open cric.​