Journal Club – Diagnostic Accuracy of ECG for Acute Coronary Occlusion resulting in MI

Presenter: Dr. Nick Byers (iFMEM R2)

Host: Dr. Colin Rouse

Article:

Research question/PICOD

  • Question:
    • Does shifting from a STEMI/NSTEMI paradigm to a new approach (ACO-MI/ non-ACO-MI) result in better identification of the patients who need acute reperfusion therapy?
  • Population:
    • Adult ED patients with ACS Symptoms
  • Intervention/Comparison:
    • STEMI/NSTEMI vs ACOMI/NACOMI
  • Outcome:
    • Composite ACO defined as one of:
      • A) Total occlusion or presence of culprit lesion on angiography with a peak troponin I level equal to or greater than 1.0 ng/mL plus an at least 20% rise within 24 h
      • B) A highly elevated peak troponin (greater than 5.0 ng/mL), which was shown to be correlated with ACO
      • C) Cardiac arrest before any troponin rise has been documented with supporting clinical evidence of possible ACO
    • All cause in hospital mortality
    • All cause long term mortality
  • Secondary Outcomes: 
    • Time from ECG to coronary angioplasty or CABG
    • The sensitivity and specificity of current criteria in diagnosing ACO
    • The sensitivity and specificity of ECG without ST-segment elevation to diagnose ACO (accuracy of ECG interpretation of acute coronary occlusion without STEMI criteria)
    • The specificity of ECG with STEMI criteria (correct ECG interpretation of false positive STEMI criteria)
    • The sensitivity of ECG with STEMI criteria (correct ECG interpretation of false negative STEMI criteria)
    • The outcome according to ECG subclassifications (outcomes of the patients who are labeled as STEMI and the patients who are labeled as having NSTEMI but have acute coronary occlusion)
  • Design:
    • Single center, retrospective case-control study in Turkey

Results

Authors conclusions

“We believe that it is time for a new paradigm shift from the STEMI/non-STEMI to the ACOMI/non-ACOMI in the acute management of MI”

 

Discussion at Journal Club

Strengths

  • 3000 patients included, 1000 per arm
  • Reviewers were blinded, disagreements were resolved by a 3rd independent reviewer
  • EKGs were reviewed again 3 months later to decrease inter-observer variability
  • Consecutive patients with an initial diagnosis of MI (i.e. not a convenience sample)
  • All patients received guideline-recommended medical treatment
  • There were documented criteria of ECG findings to classify the ECGs

Weakness

  • This was a retrospective study and at a single centre.
  • When troponins were taken was not controlled for/accounted for in any way
  • Control group age, medical comorbidities, and cardiac risk factors were much less
  • Their results suggest 17% of patients in N-ACOMI (N-STEMI Subgroup B) with angiographic ACO were missed (slide 16 results)
  • Study wasn’t powered enough to indicate modest benefit of early intervention over late
  • Extrapolating results to the real world may be difficult because ecg interpretation

 

Bottom line/suggested change to practice/actions

  • This single center retrospective chart review suggests that considering coronary occlusion vs. just ST elevation on ekg decreases long-term mortality, and has a better sensitivity, specificity, PPV, and NPV.
  • This could be a great way of getting patients better access to PCI for occlusive lesions, though inter-operator variability and time constraints are likely to be difficult to implement

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External CPD Links

 

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EMSJ CPD Recommendations

 Dr Mackenzie Howatt MD FRCPC, Director of CPD

 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

External CPD Activities – Updated for January 2023


Clinical:

  1. CAEP -AIME – registration open for AIME (March 1 or March 2). Requires registration on CAEP website. https://caep.ca/cpd-courses/. AIME advanced Jan 28 and April 20 (both full but can be put on waitlist). AIME awake April 19. Different rates for CAEP and non CAEP members
  2. CAEP National conference – May 28-31. Toronto. Requires registration
  3. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  4. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023.https://icem2023.com/ Taking place in Amsterdam.
  5. Annual Update in EM – Feb 25-28th – Whistler, BC. Arranged by UofT DEM.https://www.cpd.utoronto.ca/whistler/.
  6. EM cases Summit – Feb 2-4, 2023. Virtual, based out of Toronto on the “EM cases” group.https://emcasessummit.com/
  7. SRPC Rural and Remote Conference. in Niagara , April 20-22 2023. https://srpc.ca/rr2023
  8. PEM Review Course – Banff, Alberta, Jan 26-Jan 28th. Can attend virtually or in person.https://emo.simplesignup.ca/en/11845/index.php?m=eventSummary
  9. https://imagesim.com/ – An online repository of pediatric images (xray, US, etc) and cases used for resident or faculty education. Different “packages” can be purchased and you have access for 2 years to the particular images/cases. Based out of SickKids in Toronto.
  10. CAEP – Geriatric EM – mix of video modules and then live virtual course on May 27th. Register https://caep.ca/cpd-courses-2/geri_em/.
  11. CAEP “National Grand Rounds” – Overcoming organizational Shame” by Dr’s Sara Gray, and Dr. Dawn Lim. Jan 25th at 1500 atlantic. https://caep.ca/cpd-courses-2/caep-national-grand-rounds/
  12. CAEP/BEEM Journal Club rounds – “Chest pain in the ED – High risk or not, what do I do?” Wednesday Jan 18 @ 1500 Atl. https://caep.ca/beem-caep-rural-journal-club/
  13. Dalhousie – 48th Annual Dalhousie Spring Refresher – Emergency Medicine – can be in person (Halifax) or virtual. 2 day event. April 21 and 22. Registration not yet open.https://medicine.dal.ca/departments/core-units/cpd/conferences.html

 


Administrative/Leadership/Faculty Development/Education:

  1. Dalhousie CPD – “What if I say the wrong thing? Integrating EDIA into teaching” Online session, need to register: https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html. Jan 24 5:30-7:00
  2. Physician Leadership Institute (PLI) – Through Joule (affiliated with CMA). Have a number of online leadership courses in the new year including: “Leadership starts with self-awareness”, “leadership for medical women”, “building and leading teams” “leading change” and “leading sustainable health systems”. There are also some “on demand” courses available as well. I think you need to be a CMA member to access the PLI courses. https://joulecma.ca/learning/physician-leadership-institute?_gl=1*ktqf2z*_ga*MTcxNjY1Njc0Mi4xNjcwOTQ1MDIz*_ga_91NZ7HZZ51*MTY3MDk0NTAyMy4xLjEuMTY3MDk0NTA0OC4zNS4wLjA
  3. CAEP – Better Together: moving towards Gender Equity in Emergency Medicine. https://caep.ca/cpd-courses-2/women-in-em-gender-equity/. April 5, 18th, and 25th at 8pm Atlantic.Online course designed to give physicians foundational knowledge in how female and non-binary trainees and physicians experience discrimination throughout medical training and in practice.

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Resuscitative Transesophageal Echo

Resuscitative TEE – the whats, the whys and the hows…. A brief review of the literature, examples of use and a proposed cardiac arrest protocol

Dr. David Lewis

Professor, Dalhousie Department of Emergency Medicine


Download SlidesPoCUS Rounds – TEE – Nov 2022



Further Reading

Introduction to Transesophageal Echo – Basic Technique

   http://pie.med.utoronto.ca/tee/

ACEP NOW – How to Perform Resuscitative Transesophageal Echocardiography in the Emergency Department

 

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Management of Supraventricular Tachycardia (SVT) in Pregnancy

 

Management of Supraventricular Tachycardia (SVT) in Pregnancy

Medical Student Clinical Pearl

 

Tyson Fitzherbert, DMNB Class of 2024

Reviewed by Dr. Luke Taylor and Dr. David Lewis

 


Case:

A 30-year-old pregnant (32 weeks) female presents to the emergency department with palpitations and chest discomfort. On ECG they are diagnosed with supraventricular tachycardia, a narrow complex arrythmia – how would you proceed?

 


Introduction:

Pregnant women have a higher incidence of cardiac arrhythmias. The exact mechanism of increased arrhythmia burden during pregnancy is unclear, but has been attributed to hemodynamic, hormonal, and autonomic changes related to pregnancy. A common arrhythmia in pregnancy is supraventricular tachycardia (SVT). SVT is a dysrhythmia originating at or above the atrioventricular (AV) node and is defined by a narrow complex (QRS < 120 milliseconds) at a rate > 100 beats per minute (bpm). The presentations of SVT in pregnancy are the same as the nonpregnant state and include symptoms of palpitations that may be associated with presyncope, syncope, dyspnea, and/or chest pain. Diagnosis is confirmed by electrocardiogram (ECG).

 


Figure 1: Rhythm strip demonstrating a regular, narrow-complex tachycardia, or supraventricular tachycardia (SVT).

In general, the approach to the treatment of arrhythmias in pregnancy is similar to that in the nonpregnant patient. However, due to the theoretical or known adverse effects of antiarrhythmic drugs on the fetus, antiarrhythmic drugs are often reserved for the treatment of arrhythmias associated with clinically significant symptoms or hemodynamic compromise. Below is a detailed description of the management of SVT in pregnancy.

 


Management:

Figure 2: Treatment algorithm for SVT in pregnancy.

 


General Considerations:

  • Non‐pharmacological treatment including vagal manoeuvres such as carotid massage and Valsalva manoeuvre are well tolerated and aid in management.
  • Intravenous adenosine can be used in all three trimesters, including labor.
  • Electrical cardioversion is an effective treatment method for hemodynamically unstable or drug-refractory patients, which has proven to be safe in all three trimesters, including labor. There are some examples of this leading to pre-term labor in the third trimester.
  • AV nodal blocking agents and anti-arrhythmic agents may be considered for cardioversion; see table below for effects in pregnancy and breast feeding.

 

 


Case Continued:

A modified Valsalva manoeuvre is performed with resolution to sinus rhythm after 2 attempts. The patient is discharged with OBGYN follow-up.

https://sjrhem.ca/modified-valsalva-maneuver-in-the-treatment-of-svt-revert-trial/

 


Further Reading


References:

  1. Patti L, Ashurst JV. Supraventricular Tachycardia. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK441972/
  2. UpToDate – https://www.uptodate.com/contents/supraventricular-arrhythmias-during-pregnancy#H11407709
  3. Ibetoh CN, Stratulat E, Liu F, Wuni GY, Bahuva R, Shafiq MA, Gattas BS, Gordon DK. Supraventricular Tachycardia in Pregnancy: Gestational and Labor Differences in Treatment. Cureus. 2021 Oct 4;13(10):e18479. doi: 10.7759/cureus.18479. PMID: 34659918; PMCID: PMC8494174. https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/pmc/articles/PMC8494174/
  4. Ramlakhan KP, Kauling RM, Schenkelaars N, et al, Supraventricular arrhythmia in pregnancy, Heart 2022;108:1674-1681. https://heart.bmj.com/content/early/2022/01/26/heartjnl-2021-320451#T2
  5. Goyal A, Hill J, Singhal M. Pharmacological Cardioversion. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www-ncbi-nlm-nih-gov.ezproxy.library.dal.ca/books/NBK470536/
  6. Vaibhav R. Vaidya, Nandini S. Mehra, Alan M. Sugrue, Samuel J. Asirvatham, Chapter 60 – Supraventricular tachycardia in pregnancy, Sex and Cardiac Electrophysiology. https://www-sciencedirect-com.ezproxy.library.dal.ca/science/article/pii/B9780128177280000607

 

 

 

 

 

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EMSJ CPD Recommendations – November 2022

Dr Mackenzie Howatt MD FRCPC, Director of CPD

External CPD Activities 

I’ve listed below a few external CPD activities for your perusal. I’m hoping to be able to update you monthly on upcoming activities both internal and external to our department to make sure everyone is aware of at least some of the myriad activities out there. I have no involvement/personal stake in any of the listed activities.

 

Clinical:

  1. CAEP -AIME – registration open for AIME Awake and Advanced in Jan 2023. AIME awake Jan 27th. AIME Advanced Jan 28th. Both in Halifax. Requires registration
  2. CAEP webinar – DOAC related bleeding management. Nov 30th 2 pm Atlantic. Requires online resgistration (free for CAEP members)
  3. CAEP National conference – May 28-31. Toronto. Requires registration
  4. EMU – Emergency Medicine Update – April 26-28 Toronto. https://emupdate.ca/. 3 day in person conference with updates to clinical medicine.
  5. ICEM (International Conference on Emergency Medicine) – June 13-16, 2023. https://icem2023.com/Taking place in Amsterdam.
  6. Annual Update in EM – Feb 25-28th – Whistler, BC. Arranged by UofT DEM.https://www.cpd.utoronto.ca/whistler/ .
  7. EM cases Summit – Feb 2-4, 2023. Virtual, based out of Toronto on the “EM cases” group. Tickets are available starting early November.https://emcasessummit.com/ . Not sure of the cost, and I suspect the videos are available after course for a fixed cost.

Administrative/Leadership/Faculty Development

  1. Dalhousie CPD – “Language Matters: Navigating Stigma and Respect Clinical Education and Patient Care”https://medicine.dal.ca/departments/core-units/cpd/faculty-development.html. Online webinar from 8-9 AM over Zoom. Free.

Education

  1. Dalhousie- Fundamentals of Teaching: Fundamentals of Clinical Teaching and Supervision – Nov 1 – Dec 13.  A hybrid course of offline readings, videos, quizzes, etc that ends with a 1hr live webinar on Dec 13. https://medicine.dal.ca/departments/core-units/cpd/faculty-development/programs/Fundamentals_Teaching.html. 100$ registration fee.
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Pediatric Hip Dislocation & Reduction

Pediatric Hip Dislocation & Reduction

Resident Clinical Pearl (RCP) – November 2022

Dr. Nick Byers , R2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. Brian Ramrattan


Case:
A 10 year old presents to the local emergency department after playing with their sibling. The child was “tackled” from behind. A history and physical exam inform you that the child has been healthy until now with a completely uneventful childhood. They are normal, healthy body habitus and laying on their right side, a pillow between their flexed left knee & hip, and straight right leg. This is the only position of comfort for the child. Neurovascular exam is normal and the child refuses to let you move the leg at all. Foot and ankle move normally. Xrays were obtained promptly. A dislocated hip was readily identified (note the arrow sign below).


Greater than 85% of traumatic pediatric hip dislocations are posterior. Male children are at a greater risk by a 4:1 ratio, and in younger patients, they often occur with minimal force, whereas older children tend to require much greater forces due to the strength of structures surrounding the joint. Fractures can be an associated injury, though it was not in this case. A general triad to consider when evaluating for posterior dislocation is an adducted, shortened, and internally rotated leg as seen below:


Treatment:

A simple dislocation should be treated with closed reduction under sedation, ideally within six hours of injury to reduce the risk of osteonecrosis of the femoral head.


Reduction techniques:

There are many reduction techniques discussed in the literature. Most involve in-line traction of the femur with abduction and external rotation as the leg lengthens, with counter-traction (or downward pressure) placed on the pelvis. This allows for the femoral head to enter the acetabulum gently.

A quick review of technique with attending staff present on shift included the following three options:

  1. The Allis maneuver (https://www.youtube.com/watch?v=zmk3vafjAd4): The physician stands on the stretcher with arms hooked under the flexed knee & hip (both at 90o) on the injured side and an assistant provides downward pressure on the pelvis. Hip extension and external rotation can be applied as the hip reduces.

2.  The Captain Morgan technique (https://www.youtube.com/watch?v=lQMWaFX-MeQ&t=6s): The physician flexes the injured hip and knee to 90o and places their foot on the stretcher at the injured hip of the patient, their knee under the patients. They then grasp the patient’s leg with one hand under the popliteal fossa and one at the ankle. With counter-traction/downward pressure on the pelvis by an assistant, the physician plantar-flexes their foot to put traction on the patient’s femur. External rotation and abduction can be applied with the lower leg as the hip is reduced.

3. The cannon technique: The stretcher is raised and the patient’s knee and hip are flexed to 90o with the popliteal fossa sitting directly over the physician’s shoulder, hands on the patient’s ankle (while facing the patients feet). An assistant stabilizes and provides downward pressure on the pelvis. The physician slowly stands up straight providing in-line traction on the femur until the hip is reduced.


Case Conclusion:

Once x-rays confirmed a posterior hip dislocation, closed reduction under sedation in the emergency department was performed by a resident and staff physician using the cannon technique. Post-reduction films and repeat neurovascular exams were normal and follow-up with orthopedics was in place before discharge home.

Post reduction film:


References:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations

https://www.emnote.org/emnotes/captain-morgan-hip-reduction-technique

CASTED course manual, Arun Sayal

Traumatic hip dislocation during childhood. A case report and review of the literature. American Journal of Orthopedics (Belle Mead, N.J.), 01 Sep 1996, 25(9):645-649

https://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip

https://posna.org/Physician-Education/Study-Guide/Hip-Dislocations-Traumatic

https://www.ochsnerjournal.org/content/18/3/242/tab-figures-data

https://coreem.net/core/hip-dislocation/

https://westjem.com/case-report/emergency-physician-reduction-of-pediatric-hip-dislocation.html

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