ACLS come to life!

Another post from our senior residents in EM - Dr Koh Shao Hui.


It is a quiet Monday morning in the resus room. Suddenly the VHF radio crackles to life: “48, yr old, Indian male. Standby for AMI. ETA 10 mins”


A 12 lead ECG is faxed over by the paramedics


What does the pre-hospital ECG show? The team prepares for the arrival of the patient.


Patient arrives with rhythm strip on board ambulance. (Together with strip done at OPS)

2 3
Additional history: Chest pain radiating to left arm since last night. Worse this morning occurring even at rest. A/w diaphoresis. Went to OPS, conveyed here by SCDF. PO aspirin 300mg loaded en route.
O/e: Alert, Diaphoretic, cold and clammy peripheries. L: clear. H: dual heart sounds, no murmurs. Pulses equal. Calves supple. No pedal oedema
Vitals: BP 160/74 HR 70 spo2 98% on RA
Defib pads put on stat with continuous cardiac monitoring.


Standard and right-sided ECG leads

What do the above ECGs show?

Diagnosis: Inferior-right sided STEMI


Consent taken. Cath Lab activated. Patient loaded with PO ticagrelor. IV cannulation performed and bloods sent off.  Given IV morphine and maxolon.


Cath lab calls for patient. Ready to move out.


Change in cardiac rhythm noted on monitoring and patient becomes unresponsive.

1 x DC shock 150J delivered stat. Rhythm changes to NSR transiently and patient transiently regains consciousness. Goes back into VF shortly after. 2nd shock delivered. Goes back into NSR transiently but goes back into VF shortly after. Still spontaneously (agonally) breathing. Decision made to secure away via RSI. (Etomidate and Sux) Intubation performed. CPR commenced with manual bagging. Patient remains in VF. Further shock given. Given IV adrenaline 1mg. CPR continued. Further 4 shocks given. Further bolus doses of adrenaline given. IV boluses of amiodarone, lignocaine and MgSo4 given (As patient noted to have runs of polymorphic VT in between).


First semblance of a perfusing rhythm seen

Pulse present! BP 150/80. Total downtime (Time from collapse to first sustained ROSC) - 19 mins.
Patient connected to ventilator and started on IV fentanyl infusion 50mg/H. Maintained on amiodarone infusion.


Leaves ED for cath lab. Reaches cath lab. (Door to balloon time approx 1Hr)
Cardiac catheterisation performed with angioplasty done.

100% stenosis noted in p-mRCA (accounting for ST elevation in Right sided leads)

85% stenosis noted in dRCA extending into RPAV (accounting for ST elevation in inferior leads)
Thrombectomy performed and Drug eluting stents put into RCA and RPAV.

Patient is subsequently transferred to MICU (under cardiology) for further monitoring
He is extubated the next day with neurology fully intact.

2 days after:


Learning points:
1) Time is myocardium in STEMIs. The pre-hospital Emergency Medical System is an integral part of the chain of ensuring that the patient gets to the Cath lab ASAP (goal of 90mins door to balloon time). Do not disregard Pre-hospital ECGs and vitals as they provide important information.
2) Put on the defib pads onto the patient ASAP on STEMI cases. You may have to shock earlier than you think!
3) Take consent and active the CATH lab stat after (during office hours only).
4) Load the patient with PO ticagrelor 180mg and PO aspirin 300mg (if not given earlier) ASAP
5) Routine oxygen is out for normoxic patients.
6) Do Right sided +/- posterior leads in patients with ST elevation in inferior leads
7) Avoid nitrates in patients with Right sided infarcts.
8) If patient collapses, to resuscitate as per ACLS, with early intubation (RSI needed if patient is still spontaneously breathing) ensuring high quality chest compressions with minimal interruptions in between (Switch rescuers doing CPR frequently)
9) Consider therapeutic hypothermia.
10) If no ROSC, ECMO CPR may be beneficial if available.

Sensitive about the test?

Troponins have been with us from the 90's and the more refined they are, the more wide your "catch" will be from the high sensitivity "net" we cast. But you may wonder what the outcome is from all the high sensitivity. Here's a short viewpoint from an Aus study.

Original article from Medscape:

High-Sensitivity Troponin Test Yields Only Modest Benefit in Assessing Chest Pain in ER

Larry Hand
August 12, 2016

BEDFORD PARK, AUSTRALIA — Use of high-sensitivity troponin T (hs-TnT) assays, compared with standard TnT assays, may result in only modest improvement in evaluating emergency-department patients with chest pain, according to a new study[1].
For the high-sensitivity assays to be clinically effective, it may require closely joining them with protocols that can help guide interpretation and care, researchers conclude.
"The adoption of new technologies such as high-sensitivity TnT assays requires commensurate adaptions in the health service. Just releasing the assays provides very modest improvements in care and outcome since practice, appropriately, needs to remain conservative," Dr Derek P Chew (Flinders Medical Center, South Australia), told heartwire from Medscape by email.
Chew and colleagues conducted a prospective trial involving 1937 emergency-department patients without ST-segment elevation presenting at five hospitals in Adelaide, Australia, between July 2011 and March 2013.
The results were published online August 9, 2016 in Circulation: Cardiovascular Quality and Outcomes.
The patients were randomized to troponin testing reported to standard TnT levels (>30 ng/L n=964) or high-sensitivity TnT levels (>3 ng/L, n=973) to assess for the cumulative composite end point of all-cause mortality and new or recurrent acute coronary syndrome (ACS) within 12 months. Median patient age was 61, and just over half were men.
The researchers found no significant between-group differences for the primary end point. At 12 months, deaths or new or recurrent ACS occurred in 57 (9.7%) of patients in the high-sensitivity group and in 69 (7.2%) of patients in the standard group (hazard ratio 0.83, P=0.362).
Although the researchers found no between-group differences overall in discharge to home directly from the emergency department, they did observe a higher rate of discharge from the emergency department among low- or no-risk patients in the high-sensitivity group compared with the standard group (168 vs 148, P=0.010).
Researchers observed a significant interaction between use of hs-TnT and the prescription of aspirin among patients with peak troponin of 14 to 29 mg/L within 24 hours (55.4% vs 34.0%, P=0.006).
During the index hospitalization, 1466 patients (75.7%) reached maximal troponin of <30 ng/L within 24 hours.
The researchers found no between-group difference in performance of angiography, and high-sensitivity reporting did not lead to a reduction in 12-month death or new or recurrent ACS overall. But they did observe a modest reduction in death or new or recurrent ACS among patients with troponin levels <30 ng/L (2.6% vs 4.4%, HR 0.58, P=0.050).
The authors say that this study is the first to evaluate unguided troponin T reporting at levels that are possible with a high-sensitivity troponin T assay "on clinical care and outcome within a randomized clinical trial embedded within routine emergency-department care.
"Reporting of the troponin T level without integration with clinical protocols had relatively little impact on admission and cardiac investigations, with modest differences in discharge rates among patients at low and intermediate risk based on other clinical criteria," they conclude.
"To that end, I am a little surprised that the difference is very small, given the numerous voices demanding access to new tests," Chew said. "Clearly, better access will require validated protocols. The further research that is needed is validation of some of the emerging protocols that have been promoted without randomized evidence of safety and efficacy. We have commenced a randomized study with a 1-hour protocol."
The National Health & Medical Research Council of Australia and the South Australian Department of Health supported this research. The authors reported no relevant financial relationships.

Webucation 24/7/16

This edition of webucation was slightly delayed due to holidays but we're back with pearls from surgical trauma, cardiology updates and even a funny xray of sorts... As always visit and support the content creators.

That last list is a solid reminder that although sedation is COMMON in EDs, it is far from safe. Buyer beware and make sure you got one of these before you start!