Mortality And Morbidity Conference

1
Mortality And Morbidity Conference

• Dr. Meenakshi Aggarwal
• PGY2 Emory University
• Family Medicine

2
AGENDA

• Case Review
• Discussion
• Take Home Points

3
CASE HISTORY

• C/C Sudden loss of consciousness
• HPI 32 Y/o WM brought in by EMS due to sudden
  loss of consciousness and found to be having
  V-Fib cardiac arrest.
• PMH None
• PSH None
• SHx Smoker 1 PPD x 15yrs, occasional alcohol, no
  drugs. Works as a car mechanic.

4
History Contd

• Meds None
• Allergies Latex
• FHx H/o seizures in paternal grandfather and 2
  nephews.

5
Physical Examination

• VS T 98F, HR 89, BP 117/63, SPo2 99 on vent
• O/E Intubated
• HEENT Pupils sluggishly reactive B/L
• Chest Coarse breath sounds
• CVS RRR, No M/G/R
• Abd Soft, NT/ND
• Neuro Unresponsive. DTR 2
• Ext No C/C/E
• Skin No rash

6
LABS

• CBC HH 15.4/43.8, WBCs 6.8, Plat 298,000
• Chem Na 143, K 3.4, BUN 16, Cr 1.1, BG 134, Ca
  8.8
• LFTs AST 134, ALT 99, Alk PO4 113
• S.alcohol 0.105
• UDS Neg
• CE CK 231, CKMB 2, troponin 0.04
• U/A Normal

7
Sinus Tachycardia
8
Management in the ER

• Narcaine
• Lidocaine drip
• Bicarb
• Ativan
• Versed drip

9
BUT

• Pts urine looks GREEN.
• IS THE PATIENT HAVING ETHYLENE GLYCOL
  POISONING???
• Pt treated with Fomepizole and sent to the ICU.

10
Miscellaneous Labs

• TSH 3.08
• Ethyl Alcohol 0.105
• Isopropyl Alcohol Pending
• Methanol Pending
• Ethylene Glycol Pending

11
ST segment elevation in leads V1-V6 and
reciprocal depression in the inferior leads.
12
Is this patient having MI???
13
Management in the ICU

• Lidocaine drip d/ced and amiodarone drip started.
• Pt was given loading dose of lovenox and EKG
  repeated.
• ASA given through nasogastric tube and CEs sent
• Cardiologist was called
• Lopressor I/V x3 given

14

• Patient needs to be transported through air
  ambulance BUT crew not available.
• Wait..
• Wait.
• Finally, after 2 hrs, patient transported by road
  ambulance at 6 am in the morning.

15
(No Transcript)
16
ST segment elevation in V1-V3 with RBBB
17
Brugada Syndrome

• Disorder characterized by ST segment elevation in
  leads V1 through V3 on EKG
• RBBB
• EKG abnormalities may not be evident until
  unmasked by flecainide or procainamide infusion
  (antiarrythmic drugs) or augmented by beta
  blockers.

18
Brugada Syndrome

• Structurally normal heart
• Sudden death or syncope
• Presentation characteristic of ventricular
  fibrillation or ventricular tachycardia
• No prodromal symptoms

19

• Typical electrocardiogram of Brugada syndrome.
  Note the pattern resembling a right bundle
  branch block, the P-R prolongation and the ST
  elevation in leads V1-V3.

20
Etiology

• Autosomal Dominant
• Mutations in gene SCN5A that encodes for the
  sodium channels in the heart.
• Other genetic mutations also found

21
Schematic of SCN5A. Some mutations are associated
with combined phenotypes. a Subunit
22
(No Transcript)
23
Drugs that can induce BSlike EKG pattern

• Na channel blockers
• Class IC drugs (flecainide,encainide)
• Class IA drugs ( procainamide)
• Lithium
• Ca channel blockers
• Beta blockers
• TCA (amitriptyline, nortriptyline)
• SSRIs ( Fluoxetine)
• Cocaine Intoxication
• Alcohol intoxication

24
Types Of EKG Patterns in BS
Feature Type 1 Type 2 Type 3
J wave amplitude gt 2 mm gt 2mm gt 2mm
T wave Negative Positive or biphasic Positive
ST-T configuration Coved type Saddle back Saddle back
ST segment (terminal portion) Gradually descending Elevated gt 1mm Elevated lt 1 mm
25
Types of EKG patterns in BS
26
(No Transcript)
27
Treatment

• ICD ( Implantable cardioverter -defibrillator)
• Pharmacotherapy No proven drugs

28
Conclusion

• Never compare your own urine with the patients
  urine..

29
Take home points

• Syndrome of ST segment elevation in V1-V3, RBBB
  and sudden death
• Genetically determined
• Sudden death can only be prevented by ICDs

30
(No Transcript)
31
QUESTIONS?