Ten (10) Examples of Hyperacute T-waves in Lead V2 (a few in V3), due to acute LAD occlusion

Thursday's case, read by 60,000 people, provoked a bit of anguish among readers because they weren't all sure they would recognize this finding of LAD occlusion.  Others thought it was obvious.  Others thought they would detect it with troponins or serial EKGs (serial EKG was done and did not change; I don't know about serial trops, but one was "negative.")  Some persistently denied that the T-wave in V2 was a specific sign of ischemia.

These are 10 cases of LAD occlusion with subtle Hyperacute T-waves in lead V2 (or V3) only.

Steps to verify LAD occlusion, or exclude it:

1. Use of the LAD occlusion/early repolarization formula.  But beware the few false negatives, especially when there are hyperacute T-waves but no ST elevation (see Case 2 below):

Formula to differentiate Normal Variant ST Elevation (Early Repolarization) from Anterior STEMI.  


2. Use contrast echocardiography (This is the most reliable, short of angiography).  Bedside echo without contrast or speckle tracking can be misleading.  You must be an expert at this to rule out a wall motion abnormality.

3. A positive troponin is useful.  A negative one does not rule out MI.  2 or 3 do not rule out unstable angina, even in the era of high sensitivity troponin: this study by Thelin et al. showed 100% sensitivity for MI, but only 95% sensitivity for ACS using hs-TnT. 

4. Angiography.


Ten (10) Cases of Acute LAD occlusion manifesting as subtle hyperacute T-waves


Case 1
http://hqmeded-ecg.blogspot.com/2013/06/a-tough-ecg-but-learn-from-it.html


Case 2
http://hqmeded-ecg.blogspot.com/2010/08/35-yo-woman-with-lad-occlusion.html



Case 3 (April 20 case that provoked this post)
http://hqmeded-ecg.blogspot.com/2016/04/a-37-year-old-woman-with-chest-pain.html



Case 4
http://hqmeded-ecg.blogspot.com/2015/04/a-very-subtle-lad-occlusiont-wave-in-v1.html



Case 5
http://hqmeded-ecg.blogspot.com/2016/03/this-case-was-sent-by-one-of-our-great.html



Case 6
http://hqmeded-ecg.blogspot.com/2015/10/a-40-something-with-chest-pain.html



Case 7 (this one links to many other cases of hyperacute T-waves.
http://hqmeded-ecg.blogspot.com/2014/04/chest-pain.html



Case 8
http://hqmeded-ecg.blogspot.com/2011/07/missed-stemi-spontaneously-reperfused.html



Case 9
http://hqmeded-ecg.blogspot.com/2014/12/i-was-reading-stack-of-ecgs-yesterday.html



Case 10
This one is not posted, but was an LAD occlusion that went unrecognized.  The patient lived but lost the entire anterior wall.


The Alfred ICU Research Report 2015

At last, here is the Alfred ICU Research Report for 2015.

Led by Prof Jamie Cooper, the Alfred ICU Research team produced 132 research publications in 2015. This report details all of the research activities, active grants, publications and major presentations produced by the team last year. It also highlights that we ran 57 days of Alfred ICU courses open to external participants and that 11 of our excellent trainees successfully passed the FCICM Second Part exam in 2015.

Fantastic work by all – congratulations to the whole team!

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Blood cultures: when do they make a meaningful impact on clinical care?

Author: Desiree Brooks, MD (Senior EM Resident Physician, UTSW / Parkland Memorial Hospital) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF)

 

1) A 46-year-old male that reports he is otherwise healthy except for a childhood history of asthma presents to your emergency department with a 3-day history of fever, cough productive of green sputum, and shortness of breath. He has a temperature of 101.2 degrees Fahrenheit, he is tachycardic to 122 beats per minute, his respiratory rate is 22, he is hypoxic to 89% on room air, and he has a normal blood pressure. On physical exam, he appears mildly ill and you hear some scattered wheezes and has decreased breath sounds in his right middle and lower lobes. Your workup confirms your suspicion of pneumonia, and he has had mild improvement (wheezing, fever, and heart rate improve, but he remains tachypneic and hypoxic) with your treatments. You decide to admit for IV antibiotics. The inpatient team asks for blood cultures, and you wonder if this will benefit your patient.

2) A 68-year-old Hispanic female presents to your emergency department with fatigue, fever, and rash. She reports that she does not take any medications. Her vital signs are normal. She looks well. You see the following rash:

Screen Shot 2016-04-22 at 4.32.42 AM

You diagnose her with bacterial endocarditis and admit her for IV antibiotics. You ordered two blood cultures in the emergency department to be drawn at separate venipuncture sites and wonder if you should have ordered a third.

 

Discussion

Blood cultures are commonly ordered in the emergency department for patients with suspected infection. They are generally considered to be the most sensitive method for detection of bacteremia or fungemia1 and are generally thought to be useful in certain diagnoses and critically ill patients; however, it appears as though rising trends in obtaining blood cultures over the past decade in low-risk patients have been tied to core measures and payments (introduced by the Joint Commission on Accreditation of healthcare Organizations and Centers for Medicaid and Medicare Services).2 As a result, their utility has been a focus of controversy prompting ample research in recent years all conveying the same information: blood cultures ordered from the emergency department rarely alter patient management and can at times cause harm to patients. Not only is the harm financial, false-positive results can lead to inappropriate antimicrobial use and longer hospital stays.3

 

Yield of Blood Cultures

The yield of blood cultures has been evaluated in multiple studies in several different patient populations. A study published in 2006 showed a useful culture rate of 2.8% (6/218) – meaning clinical management was influenced by culture result – and suggested that blood cultures should be eliminated in immunocompetent patients with common illnesses such as urinary tract infection, community acquire pneumonia, and cellulitis.4 Another study published in 2007 showed that of 2,210 blood cultures, only 132 (6%) yielded growth, and 4 (0.18%) resulted in altered patient management.5

 For patients with pneumonia, a NNT approaching 150 has been found in regards to blood cultures affecting patient care (such as cultures causing modification of the antibiotic regimen). This is based on 0.18% and 1.6% of blood cultures actually affecting patient management.6 Another study from 2007 found a true positive rate of 3.4% and false positive rate of 7.8%.7 Of these true positive cultures, 3 out of 23 patients had management changed based on cultures. These authors recommended eliminating use of blood cultures for community-acquired pneumonia.7 In 2005, another article was published also supporting decreased use of blood cultures and concluded “blood cultures rarely altered therapy for patients presenting to the ED with pneumonia. More discriminatory blood culture use may potentially reduce resource utilization.”8

Cellulitis is a common condition and is broken into simple and complicated, which is defined by an immunocompromised state such as HIV/AIDS, chemotherapy, organ transplantation, diabetes, and vascular insufficiency. Simple cellulitis is defined by absence of these conditions. Mills et al. examined five other studies, finding blood cultures did not alter treatment in immunocompetent patients with cellulitis.9 Paolo et al. examined the yield of blood cultures and found contaminated cultures in 4% of complicated and 3% of uncomplicated cellulitis cases. A change in management occurred in 6 of 314 cases in complicated cellulitis and in 4 of 325 uncomplicated cases. True positive cultures occurred more commonly in patients with fever and diabetes.10

 

Are there any factors associated with true positive cultures?

Coburn et al. in JAMA 2012 conducted a meta-analysis investigating true positive blood cultures in a population of immunocompetent adults.11 Predictors of true positive cultures included shaking chills, hypotension, vasopressor use, neutrophil to lymphocyte ratio > 10, and presence of SIRS. However, risk factors including subjective fever, tachycardia alone, elevated WBC, and documented fever were not found to be sensitive. Blood cultures were recommended in patients with pyelonephritis, severe sepsis, septic shock, and meningitis. Cultures in pneumonia and cellulitis were not recommended.11

A clinical predication rule has been created and validated for use in predicting true blood cultures.12 A prospective analysis in 2008 evaluated 3,370 patients. The study found several criteria increasing the predictive value of blood cultures. The major criteria includes suspected endocarditis, temperature > 103F, and indwelling vascular catheter. Minor criteria include temperature > 101F, age > 65 years, chills, vomiting, SBP < 90 mm Hg, WBC > 18,000, band count > 5%, platelets < 150,000, and creatinine > 2 mg/dL. The negative predictive value for true positive blood culture was 99.4% in the derivation group and 99.1% in the validation group.12

A second study in 2011 evaluated multiple predictors associated with bacteremia. This study conducted in an urban ED found a 90.9% probability of a negative blood culture if the following were negative: no chemotherapy within past 6 moths, heart rate < 100, and normal or elevated electrolytes to predict a negative blood culture.13 This rule has not been validated.

 

When (and how) to order blood cultures in the ER

UpToDate suggests that diagnoses in which blood cultures are considered important include sepsis, meningitis, osteomyelitis, septic arthritis, endocarditis, peritonitis, pneumonia, and fever of unknown origin. 1 In general, patients who are acutely ill or have high likelihood of continuous bacteremia should have blood cultures drawn in the emergency department.11

At least two sets of blood cultures should be drawn prior to initiation of antimicrobial therapy. A single blood culture lacks sensitivity as well as precludes the ability to distinguish contaminants from true bacteremia.17 It is reasonable to obtain four blood cultures when the probability of bacteremia is high and the anticipated pathogen is likely to be a common contaminant (ex: infected internal hardware is suspected).1

An article published in 2008 demonstrated that fever at the time of blood culture collection is neither sensitive nor specific for the presence of bacteremia.18 Blood cultures therefore do not need to be rapidly drawn when a patient is noted to be febrile.

Antiseptic technique is essential. The skin should be cleaned first with an alcohol swab followed by chlorhexidine from two separate venipuncture sites.14 An IV catheter line at the time of IV insertion should not be used.15 Volume does matter when obtaining a culture, as there is a 3% increase in positive culture per milliliter blood obtained. At least 7 ml per bottle are recommended.16

 

Cases

1) Blood cultures are still recommended in this patient because he has evidence of sepsis on arrival to the emergency department.

2) The Duke diagnostic criteria are widely used to diagnose endocarditis and require at least 2 positive blood cultures either persistently positive for the same organism from cultures drawn more than 12 hours apart OR 3 or more separate blood cultures drawn at least 1 hour apart.11, 19

 

Summary

  • In general, patients who are acutely ill or have high likelihood of continuous bacteremia should have blood cultures drawn in the emergency department.
  • Blood cultures should not be taken from routinely stable, immunocompetent patients with common or typical infections such as cellulitis, orchitis, and community acquired pneumonia.12
  • Blood cultures should be obtained prior to initiation of antibiotic therapy to maximize possibility of being useful clinically
  • When you have high suspicion for endocarditis, you may order 3 blood cultures from different venipuncture sites in the ED, each drawn 1 hour apart, OR 2 blood cultures from different venipuncture sites with a third to be ordered >12 hours later by your inpatient team.11,19
  • Fever at the time of blood culture collection is neither sensitive nor specific for the presence of bacteremia.10
  • An IV catheter line at the time of IV insertion should not be used.8

 

References / Further Reading

  1. Doern, Gary. Blood cultures for the detection of bacteremia. UpToDate. Accessed April 1, 2016. http://www.uptodate.com/contents/blood-cultures-for-the-detection-of-bacteremia/.
  2. Makam AN, Auerbach AD, Steinman MA. Blood Culture Use in the Emergency Department in Patients Hospitalized for Community-Acquired Pneumonia. JAMA Intern Med. 2014;174(5):803-806. doi:10.1001/jamainternmed.2013.13808.
  3. Mandell  LA, Wunderink  RG, Anzueto  A,  et al; Infectious Diseases Society of America; American Thoracic Society.  Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.
  4. Mountain D, Bailey PM, O’Brien D, Jelinek GA. Blood cultures ordered in the adult emergency department are rarely useful. Eur J Emerg Med. 2006;13(2):76–9. doi:10.1097/01.mej.0000188231.45109.ec.
  5. Howie N, Gerstenmaier JF, Munro PT. Do peripheral blood cultures taken in the emergency department influence clinical management? Emerg Med J. 2007;24(3):213–4. doi: 10.1136/emj.2006.039875.
  6. Kelly AM. Clinical impact of blood cultures taken in the emergency department. J Accid Emerg Med. 1998 Jul;15(4):254-6.
  7. Benenson RS, Kepner AM, Pyle DN 2nd, Cavanaugh S. Selective use of blood cultures in emergency department pneumonia patients. J Emerg Med. 2007 Jul;33(1):1-8.
  8. Kennedy, Maura et al. Do Emergency Department Blood Cultures Change Practice in Patients With Pneumonia? Annals of Emergency Medicine. 2005. Volume 46, Issue 5, 393 – 400.
  9. Mills AM, Chen EH. Are blood cultures necessary in adults with cellulitis? Ann Emerg Med. 2005 May;45(5):548-9.
  10. Paolo WF, Poreda AR, Grant W, Scordino D, Wojcik S. J Emerg Med. 2013 Aug;45(2):163-7.
  11. Coburn B, Morris AM, Tomlinson G, Detsky AS. Does this adult patient with suspected bacteremia require blood cultures? JAMA 2012; 308:502.
  12. Shapiro NI, Wolfe RE, Wright SB, Moore R, Bates DW. Who needs a blood culture? A prospectively derived and validated prediction rule. J Emerg Med. 2008;35(3):255–64. doi: 10.1016/j.jemermed.2008.04.001
  13. Roque PJ, Oliver B, Anderson L, et al. Blood culture prediction rule in an urban emergency department. Ann Emerg Med. 2011;58(4):S290.
  14. Little JR, Murray PR, Traynor PS, Spitznagel E. A randomized trial of povidone-iodine compared with iodine tincture for venipuncture site disinfection: effects on rates of blood culture contamination. Am J Med 1999; 107:119.
  15. Norberg A, Christopher NC, Ramundo ML, et al. Contamination rates of blood cultures obtained by dedicated phlebotomy vs intravenous catheter. JAMA 2003; 289:726.
  16. Mermel LA, Maki DG. Detection of bacteremia in adults: consequences of culturing an inadequate volume of blood. Ann Intern Med. 1993 Aug 15;119(4):270-2.
  17. Mirrett S, Weinstein MP, Reimer LG, et al. Relevance of the number of positive bottles in determining clinical significance of coagulase-negative staphylococci in blood cultures. J Clin Microbiol 2001; 39:3279.
  18. Riedel S, Bourbeau P, Swartz B, et al. Timing of specimen collection for blood cultures from febrile patients with bacteremia. J Clin Microbiol 2008; 46:1381.
  19. Durack DT, Lukes AS, Bright DK. New criteria for diagnosis of infective endocarditis: utilization of specific echocardiographic findings. Duke Endocarditis Service. Am J Med. 1994 Mar. 96(3):200-9.

 

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I am Dr. Masashi Rotte, Emergency Physician and Assistant Professor: How I Stay Healthy in EM

How I Stay Healthy logoDr. Rotte is an emergency physician currently practicing in New York. His passion for traveling, love of hiking, and commitment to eating right are some of his secrets on how he maintains wellness. Dr. Rotte shares how he is able to get away, travel, and stay well, while keeping up with his work demands. We could all use a little of Dr. Rotte’s passion for life long learning! Here is how he stays healthy in EM!

 

  • RotteName: Masashi Rotte, MD, MP
  • Location: New York, NY
  • Current job(s): Assistant Professor, NYU/Bellevue
  • One word that describes how you stay healthy: Division
  • Primary behavior/activity for destressing: Travel

What are the top 3 ways you keep healthy?

  1. Activity. I commute by bicycle so I get at least an hour of exercise every day I work.
  1. Travel. I travel as often as I can. One of my favorite activities is hiking so whenever I can get out of the city or (even better) out of the country, I try to find a destination where I can get some hiking in. In order to get time off, I stack my shifts as much as my schedule allows. Sometimes that means I end up trading into less favorable shifts so I can stack together days off. But when I’m standing at the peak of a trail in Zion National Park or Torres del Paine looking out on snow-capped mountains, a few extra night or weekend shifts seem pretty insignificant.
  1. Mininizing . Being healthy of mind and spirit is as important as having a titanium body. FACT: YOU ARE HUMAN! You need to be able to vent, share your hopes, dreams, fears, failures and inadequacies. Learn about emotional intelligence and mindfulness. Have an outlet … talk! (I also journal).I think mental health is as important in our job (and intertwined) as physical health. I’m single with no kids (I do have a remarkably handsome cat though), so the main sources of stresses in my life are focused around my work life. To minimize work stress, I try to get everything that’s expected of me done as well as I can and as quickly as possible. For example, if my chair sends out a survey to the faculty or my medical director forwards me a patient complaint, I address them as soon as possible.

What’s your ideal workout?

I go to a gym that has branches near both of the hospitals I work at. Because I get at least an hour of cardio in during my commute, I primarily lift weights at the gym. My gym has a pool at a few branches, so I swim instead of lifting some days. I’m not a “gym rat” by any means, but learned most about what I know about weight lifting from reading, The Weider System of Bodybuilding, and from taking advice from coaches in high school and college.

Do you track your fitness? How?

I don’t track any objective data such as my weight, heart rate, or steps per day. If my credit card bill is particularly high or my scrubs are a bit more snug, I know I’ve been eating out too much lately.

How do you prepare for a night shift? How do you recover from one?

I find the most important part of preparing for a night shift is to take a nap before I head into work. Even if it’s only 30 minutes, it refreshes me and prepares me for the night.

I stack my night shifts to get them out of the way. After a string of nights, I usually feel pretty run down, but I find that it’s important to get back into a regular sleep schedule as soon as possible. To do this, I try not to sleep all day after my last night shift, but rather take a short nap and then try to get up and do something productive so that I can get back into a normal sleep schedule.

How do you avoid getting “hangry” (angry due to hunger) on shift?

When I was an intern, I noticed that I had a lot of nervous energy during shifts and one side effect was that I would constantly snack. So if I brought a bag of chips or cookies to work they would be gone halfway through the shift and I quickly got chubbier than I care to remember.

I worked with one attending who would bring in a huge tupperware container of fresh vegetables. I realized that if I emulated him and brought in healthier snacks I could keep up my habit of nervous eating, but I’d be chowing down on carrots and apples rather than salty carbs.

New York City has a lot of produce stands on the street where you can pick up a huge bag of fresh fruit or vegetables for $5-10. I usually stop by one of these stands on my way to work and load up with fruits and vegetables to snack on. I always try to bring in enough to share with the residents, nurses, and other staff.

How do you ensure you are mentally in check?

In our field, I think it is vital to be on time and mentally prepare for the duration of a shift. I really do love my job and I work with great co-workers and residents, so I’m usually happy and motivated during my shifts.

However, if you’ve got significant family or personal issues going on, it might be impossible to be completely focused during your shift. For residents who deal with long hours and myriad expectations, I think it’s imperative to reach out to your program directors for support or guidance early on, if you have any outside issues that are interfering with work.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

I think “burnout” is a huge challenge in our field. The stress of treating difficult patients, dealing with unprofessional or unresponsive consultants, or managing boarding patients, while new patients keep checking in wears all of us down over time. Additionally, the field of EM is rapidly changing and we now have observation medicine, doctors in triage, patient satisfaction scores, and ever expanding metrics applied to us. Whether or not you are for or against these changes, they are all here to stay.

When I was a resident (and constantly stressed out), I tried to consciously identify what about EM was causing me stress and think about ways to manage those factors. One factor was the feeling that I didn’t have enough knowledge to perform well at work. To manage this area of stress, I identified limitations in my knowledge base and addressed them head on. For example, I didn’t feel like I knew enough about interpreting EKG’s, so I bought several books on the topic and studied them until I felt comfortable reading EKG’s on my own. As an attending I read journals, periodicals, and blogs to keep expanding my knowledge base and reinforce diagnosis or management for diseases I may not have recently treated.

Another factor for me is job satisfaction; I didn’t want to feel like I went to medical school and residency just to earn a better paycheck. I choose to work in an academic environment rather than in a community setting because I truly believe in the adage “see one, do one, teach one.” By teaching medical students and residents, I am challenged to understand the pathology or procedure being discussed inside out. I also take personal satisfaction in being able to clarify the reasoning behind my medical decision making when a medical student or resident asks me questions about patient care.

Finally, I’ve found that working constructively with colleagues is imperative to minimizing stress at work. I’ve seen residents and other attendings (and unfortunately myself at times) behave in a condescending or unprofessional manner towards other doctors, nurses, technicians, clerks, and cleaning staff. There is nothing to be gained by making yourself feel better than a colleague, no matter their role in the hospital, but much to be lost. If a cleaning staff is sweeping the floors in your area, take the 30 seconds to pick up your bag, move your chair, smile, and thank them for keeping the ED clean, rather than just sitting there and making them sweep around you. If a nurse or tech questions your orders for a patient don’t respond with snark comments, but listen to their concerns and consider if you might have missed something. If you are pleasant and professional it’s likely that colleagues will respond to you in kind and your shifts will be that much more pleasant (and less stressful).

Best advice you have received for maintaining health?

Stop eating when you are full (I do not follow this advice very often).

Who would you love for us to track down to answer these questions?

Pranav Shetty

 

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

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