Jacobi/Montefiore ED Resident of the Block – Calvin Sun

A little something to talk about during signout.

 

You may know that Calvin Sun is generally awesome, but do you know the specifics?

 

When he leaves the ED, he really leaves. The Monsoon Diaries is his travel blog-turned-accidental travel company! Started during medical school to inspire others to travel, Calvin showed us all you can never be too awesome, even on a tight budget and tight schedule. Now his awesomeness is catching on…4 years, 100 countries, hundreds of people later. Teaching others what can be done, he educates himself on the intersectionality and globalizations of all things. He’s working to understand how his travels, training, and background can influence his sense of cultural competency and activism for social justice causes. As longtime leader of ECAASU (The East Coast Asian American Student Union, the oldest and largest Asian American organization in the country), Calvin travels the country to speak on a variety of topics including intersectionality, coalition building, social justice, sex and sexuality, mental health, body image/beauty standards, and travel.  My favorite travel story? When he Monsooned in a blizzard to get to Jacobi. Ask him.

calvinsun

Just google him. He’s apparently been awesome for some time, check out some of the places he’s been featured, HuffPo, CNN, USAToday, MSNBC, and NatGeo – natch. Did we forget to mention his TED talk? Awesome.

 

Anyway, if you were wondering where all the need to keep moving started, keep reading. It probably related to his dance awesomeness. According to Calvin, “Dancing is like breathing for me, so I go to the dance studio in my neighborhood at least once a week to choreograph, or at least check off a week’s worth of cardio.” You could see him discussing music and dance for MTV where he used to be featured. He was also in the movie about demons and death – Cold Pupil – and of course like all actors, he really wanted to direct. Documentary awesomeness, check. Film Short. Check. What he should do is start a film festival…oh wait he did that too. Maybe he’ll play Ryu in the Street Fighter Origin storycalvinsun-ryu next.

 

There’s undoubtedly more to come from this past, present, and future rockstar.

 

Calvin Sun, MD PGY2 @csohosun is the Resident of the Block.

 

Who’s next?

 

send nominations with reasons to jacobi.em.chiefs@gmail.com

 

Resident of the Block – Gilberti

Jacobi/Montefiore ED Resident of the Block

 

A little something to talk about during signout.

 

You may know that Brian Gilberti is generally awesome, but do you know the specifics?

 

Here are a couple of things Brian’s been up to:

gilberti

He started EM Rounds with more awesome Jacobi/Montefiore residents to showcase the remarkable cases that have come through our doors and the insightful discussions we have about them. We all know how awesome the learning can be at Jacobi, and Brian is showing all the talent gathering in our conferences. EM Rounds helps broadcast what it’s like to be at Jacobi, so all your friends can know how awesome you from the awesome work of Brian.

 

As an intern, he created the website. AMiOFF.org which takes the schedules of all the residents from our eval taskmaster AmIOn.com to tell you who you can be awesome with outside of the hospital. Now you know who to ask to go out with.

He is not satisfied with only two awesome web resources though.  As an Assistant Editor at WikEM.org he enjoys dropping EM knowledge from this website to our brains. He helps its mission to provide quality FOAM (Free Open Access Meducation) content. He uses it as a digestible reference resource for post-shift review, and he’s awesome. Maybe you should take a look? You might get some of his awesomeness as a by-product.

If you get bleary-eyed by his awesome web presence, you can take a rest by using the new Sedation Guidelines on which he and JMC attending Vince Nguyen worked. They created a protocol for Acute Agitation in the ED is something we deal with quite a bit at JMC and through their awesomeness they are making our practices safer for both patient and staff.

If you are thinking “How else could his Awesomeness be Awesome?” Bam…Avid chess player, bushcraft enthusiast, urban exploration via razor scooter and … I think he enjoys long walks on the beach and puppies and kittens.

Brian Gilberti, MD PGY2 @User238345 is the Resident of the Block.

Who’s next?

send nominations with reasons to jacobi.em.chiefs@gmail.com

Jacobi Resident of the Block

Jacobi/Montefiore ED Resident of the Block

 

A little something to talk about during signout.

 

You may know that Italo Brown is generally awesome, but do you know the specifics?

 

When Italo is away from the ED, He works as a mentor with Tour For Diversity in Medicine. They are a group of young health professionals (MDs, DOs, DDSs) who work at the grassroots level to educate, inspire, and cultivate future professionals from underrepresented communities. This carries on his work from Meharry as a leader in this field. Just google him. He’s apparently been awesome for some time, check out awards from American Public Health Association (APHA), the Association of American Medical Colleges (AAMC), and the American Medical Student Association (AMSA). Oh, did you know he was featured author on KevinMD.com? Awesome.

italobrown

 

Anyway, back to Tour for Diversity, his most recent awesomeness. He and his colleagues travel to share experiences and offer strategies to help students navigate the various pathways from college to professional school.  In February, they embarked on our 9th Tour, a 5-day multi-stop road-trip visiting Historically Black Colleges and Universities and community college campuses in Oklahoma City (OK), Pine Bluff (AK), and New Orleans (LA).  Each day, hundreds of hopeful pre-professional undergraduate, non-traditional, and high school students turned out for  workshops/exercises that focused on strengthening applicants (i.e. resume/cv building, personal statement writing, test-taking strategies, interview skills, hands-on clinical skills).

 

No doubt, Italo successfully met his goal to increase the number of underrepresented minorities entering medical and dental programs. Italo has successfully climbed the ladder and he is pulling others up behind him to ultimately improve diversity within the healthcare workforce.

 

There’s undoubtedly more to come from this past, present, and future rockstar. He’s helping increase the awesome quotient of his community community of students from HBCU, the healthcare community, and the Jacobi/Montefiore community.

 

Italo Brown, MD PGY1 @gr8vision is the Resident of the Block.

 

Who’s next?

 

send nominations with reasons to jacobi.em.chiefs@gmail.com

 

Jacobi Resident of the Block

Jacobi/Montefiore ED Resident of the Block

 

A little something to talk about during signout.

 

You may know that Aly McEwan is generally awesome, but do you know the specifics?

AlyMcEwanWell, she just finished writing a chapter on Palliative Care in the ED for Clinics of EM with Dr. Silverberg. So when you need to know just how to start that sticky conversation, know that the ED is great place to have it and Aly is a great resource.

She also recently got back from a 9 day medical/surgical mission trip to Haiti. Her team stayed in a small town and consisted surgical attending, 2 other residents, 2 nurses and an OR tech. I saw a lot of patients in clinic and I assisted on a bunch of surgeries. But wait, there’s more, this was a follow up to a trip last year where she worked “A TON of level 1 trauma…and I pretty much ran all of it, considering that I was pretty much the only one with any trauma experience. Intubations, chest tubes, etc etc. It was crazy. It proved to me that our training at Jacobi is incredible and really does leave you ready for anything.”

You may have also seen her working with Dr. Birnbaum and her team on improving the patient experience recently. {sarcasm}What could be in need of improving?{/sarcasm}.

She’s doing even more, but it’s super hush hush secret spy stuff. So you’ll have to ask her about it and thank her for making our world a better place.

 

Alyssia McEwan, DO, PGY3 @AlyMc_EM is the Resident of the Block.

Who’s next?

send nominations with reasons to jacobi.em.chiefs@gmail.com

 

Cancel the Cath Lab Activation; Its only an NSTEMI

By Andrew Barbera, PGY3

Who Needs a Cath?

 

63 year old male with history of HTN, OA s/p R hip replacement, PTSD was BIBEMS after syncopal event. Pt states that evening he felt acute general weakness when he was on the subway. The weakness worsened when he got off the subway and was walking in the street. He then developed acute severe SOB and he stopped and rested himself on the trunk of a car. Pt then lost consciousness and awoke in the ambulance. Pt stated upon awakening he was alert and oriented. Pt denied CP, palpitations, diaphoresis or dizziness before passing out or during initial ED evaluation. Pt also denied any recent exercise intolerance, recent chest pain, orthopnea or additional symptoms. Pt reported normal stress test done 6 months ago at VA for unknown reason. Initial EMS ekg showed sinus rhythm, slight left axis deviation, LBBB with 0.5 mm ST depression II, III, avF, I, aVL. Repeat EKG on ED presentation showed NSR, slight left axis deviation, with no ST-T depression/elevations or rhythm issues. Pt had received 162mg of asa by ems prior to ED arrival. During ED evaluation pt developed an episode of acute, moderate, left sided, pressure like CP. Pt was given sublingual nitro and morphine with full resolution within 45 min. Repeat EKG during this episode showed NSR, comparing the previous one, new TWI in III and aVF. Pt’s initial troponin was negative at 0.021, but repeat troponin was positive at 3.37. Cardiology was consulted. Pt diagnosed with NSTEMI. Cardiology at the time declined emergent transfer for coronary cath, and wanted to optimize the patient on medical management. Pt was loaded with 600mg of Plavix and heparin bolus and drip was started. Pt was transferred to CCU for additional medical management and cardiac monitoring.

 

CCU course pt remained chest pain free, serial EKG’s remained unchanged and pt had serial troponins that were down trending. Pt was additionally risk stratified with ECHO for wall motion abnormalities (hypokinesis) and LVEF and found to be normal. Pt was optimized on medical management with metoprolol, atorvastatin, Plavix and asa. Pt was discharged home with close cardiology follow up.

 

This made me think what are the indications for cardiac revascularization (aggressive) vs. medical management (conservative) in pts with NSTEMI. According to the 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction, Pt’s with NSTEMI who have signs of persistent angina or electrical and or hemodynamic instability should receive early cardiac revascularization.[1] Pt’s with acute decreased LVEF (40% or less) or signs of heart failure should also be considered for early cardiac revascularization. Additionally pts with any signs of continued or repeat ischemia, or new serious arrhythmia.[2]

Additionally there are several randomized trials including FRISC II, TACTICS-TIMI 18, both of which showed a significant lower rate of primary end point of death or repeat MI, especially in high risk individuals. [3]

 

In summary it seems that high-risk patients with NSTEMI/Unstable angina should undergo early cardiac revascularization. Patients with signs and symptoms of ongoing or repeat ischemia have better outcomes after reperfusion vs. conservative therapy, along with patients who have failed medical therapy. Pts that are lower risk for repeat or continued ischemia may have greater risk/benefit from the conservative medical management.

 

 

[1] Wright RS, Anderson JL, Adams CD, et al. 2011 ACCF/AHA Focused Update of the Guidelines for the Management of Patients With Unstable Angina/ Non-ST-Elevation Myocardial Infarction (Updating the 2007 Guideline): A Report of the American College of Cardiology Foundation/American Heart Association . Circulation 2011:2022–2060.

[2] Unstable Angina Treatment & Management. Unstable Angina Treatment & Management: Approach Considerations, Initial Medical Management, Further Medical Management. Available at: http://emedicine.medscape.com/article/159383-treatment. Accessed September 2016.

[3] Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009;84(10):917-38.

Found on floor

img331a

An elderly M is bib ems.  His wife called ems for an unclear reason.  He was found on the floor in filth in a disorderly apartment.  He has no complaints.  His exam is most notable for a laceration on his R neck and superficial slash wounds on his left wrist.  The neck injury looks like a puncture wound.  There is no hematoma, tenderness, or bleeding.  The patient is speaking normally.  He was discharged from inpatient psych two weeks ago for depression.  When asked about the laceration, he said he cut himself shaving.  Labs and an ekg are done.

– What do we do about the neck wound?

– What do we do think about the ekg?

– What is his dispo?

Why Not Dobutamine?

Why Not Dobutamine?

PGY3 Neil McCormack

 

A patient rolls into the emergency room. You don’t need this. You’ve got a lot of other patients. This patient however is in shock. They are hypotensive and with a decreased mental status. You need to give them something and the attending asks what vasopressors you would like. “Why not dobutamine” the intern asks. With a sigh and a heavy eye roll you turn away. But… Why not dobutamine?

 

 

Dobutamine            Dobutamine is a synthetic catecholamine used primarily for cardiac stress testing outside of the hypotensive patient (8). This is due to the positive inotropic effects it plays on the heart. Dobutamine acts via a 3:1 selective agonist effect on β1 and β2 receptors respectively. This causes increased contractility of the heart (9). There is, however, a side effect of reflexive decrease in systemic vascular resistance (SVR) causing potential for worsening of hypotension. This is not seen in higher doses of dobutamine and the reason for this is because of dobutamine’s partial α1 agonist effect (9). Given this information, we can intuitively think that giving dobutamine would be a good option for use in a hypotensive patient. But what does the literature say?

There have been a few studies that look at the use and effectiveness of dobutamine in the setting of hypotension (1, 2, 9, 10, 12, 13). Partially due to the α1 partial agonist effect, dobutamine is not a first line recommended treatment option alone in patients with septic or hypovolemic shock (3, 4, 9). It has been proposed as a first line treatment for sepsis patients if used in conjunction with another vasopressor (example: norepinephrine) to prevent the reflexive SVR decrease and hypotension. In the absence of using multiple vasopressors, dopamine and norepinephrine have been listed as the first line drugs of choice for septic shock patients. According to the “Surviving Sepsis” guidelines (3, 4), norepinephrine is the first line vasopressor of choice for sepsis patients. However, dobutamine is the recommended inotropic agent to be used in combination to improve cardiac output (without going to supranormal levels of cardiac output) (3).

 

CHF

But what if this patient has a bad heart? The evidence for use of dobutamine in patients with cardiogenic shock is more favorable (7, 12, 14). Patients who need inotropic support primarily are recommended to undergo dobutamine therapy as their vasopressor of choice in the beginning. This is due to the positive effect that dobutamine has on the contractility of the heart muscle itself. It has been shown as well that dobutamine appears to have a more favorable effect on right ventricular (RV) contractility than on left ventricular (LV) though it is effective in both settings (14). The downside of dobutamine alone is, as mentioned, it is only a partial α1 agonist and thus, if the blood pressure does not respond to the increased inotropic effects, a second line agent will need to be added. In a trial looking at epinephrine vs dobutamine/norepinephrine, there was no difference in the overall outcomes of patients but the epinephrine patients had more side effects (including arrhythmias).

What does all this mean? Well what this means is that the intern may have, in fact, been correct to suggest that we use dobutamine for our now hypotensive patient. It all depends on the suspected cause (IE: cardiogenic vs septic vs other causes of hypotension). It is important to keep in mind, though, that unless this patient has a purely cardiogenic cause (such as severe heart failure), they may also require a second pressure support in order to maintain a healthy blood pressure.

 

references:

1) Bangash, Mansoor N, Ming-Li Kong, and Rupert M Pearse. “Use of Inotropes and Vasopressor Agents in Critically Ill Patients.” British Journal of Pharmacology 165, no. 7 (April 2012): 2015–33. doi:10.1111/j.1476-5381.2011.01588.x.

2) Beale, Richard J., Steven M. Hollenberg, Jean-Louis Vincent, and Joseph E. Parrillo. “Vasopressor and Inotropic Support in Septic Shock: An Evidence-Based Review.” Critical Care Medicine 32, no. 11 Suppl (November 2004): S455–65.

3) Campaign, Surviving Sepsis. “Leitlinienempfehlungen Zur Sepsistherapie.” Sepsis Und MODS, 2015, 377.

4) Dellinger, R. Phillip, Mitchell M. Levy, Jean M. Carlet, Julian Bion, Margaret M. Parker, Roman Jaeschke, Konrad Reinhart, et al. “Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2008.” Critical Care Medicine 36, no. 1 (January 2008): 296–327. doi:10.1097/01.CCM.0000298158.12101.41.

5) Huang, Xuan, Shu Lei, Mei-fei Zhu, Rong-lin Jiang, Li-quan Huang, Guo-lian Xia, and Yi-hui Zhi. “Levosimendan versus Dobutamine in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials.” Journal of Zhejiang University. Science. B 14, no. 5 (May 2013): 400–415. doi:10.1631/jzus.B1200290.

6) Levy, Bruno, Pierre Perez, Jessica Perny, Carine Thivilier, and Alain Gerard. “Comparison of Norepinephrine-Dobutamine to Epinephrine for Hemodynamics, Lactate Metabolism, and Organ Function Variables in Cardiogenic Shock. A Prospective, Randomized Pilot Study.” Critical Care Medicine 39, no. 3 (March 2011): 450–55. doi:10.1097/CCM.0b013e3181ffe0eb.

7) Lewis, Tyler, Caitlin Aberle, Diana Esaian, and John Papadopoulos. “EFFICACY AND SAFETY OF MILRINONE VERSUS DOBUTAMINE IN CARDIOGENIC SHOCK.” Critical Care Medicine 43, no. 12 Suppl 1 (December 2015): 34. doi:10.1097/01.ccm.0000473960.43621.41.

8) Miller, Todd D., J. Wells Askew, and Nandan S. Anavekar. “Noninvasive Stress Testing for Coronary Artery Disease.” Heart Failure Clinics 12, no. 1 (January 2016): 65–82. doi:10.1016/j.hfc.2015.08.006.

9) Müllner, M., B. Urbanek, C. Havel, H. Losert, F. Waechter, and G. Gamper. “Vasopressors for Shock.” The Cochrane Database of Systematic Reviews, no. 3 (2004): CD003709. doi:10.1002/14651858.CD003709.pub2.

10) Rudis, M. I., M. A. Basha, and B. J. Zarowitz. “Is It Time to Reposition Vasopressors and Inotropes in Sepsis?” Critical Care Medicine 24, no. 3 (March 1996): 525–37.

11) Smith, Maria A. “Use of Vasopressors in the Treatment of Cardiac Arrest.” Critical Care Nursing Clinics of North America 17, no. 1 (March 2005): 71–75, xi. doi:10.1016/j.ccell.2004.09.010.

12) Steltzer, H., P. Simon, A. N. Owen, M. Thalmann, and A. F. Hammerle. “The Effects of Dobutamine Therapy in Critically Ill Patients Measured by Transoesophageal Echocardiography and Intracardiac Monitoring.” Anaesthesia 49, no. 5 (May 1994): 432–37.

13) “Vasopressors and Inotropes in Shock.pdf,” n.d.

14) Vincent, J. L., C. Reuse, and R. J. Kahn. “Effects on Right Ventricular Function of a Change from Dopamine to Dobutamine in Critically Ill Patients.” Critical Care Medicine 16, no. 7 (July 1988): 659–62.

 

Dilt v. Metoprolol in Afib/RVR

by Najm Haque, PGY2

 

Atrial fibrillation with rapid ventricular response is a common emergency room problem. Patient with stable blood pressure who present in Afib with RVR need medications to control their heart rate (unstable patients require more cardioversion). Traditionally, these patients receive beta blockers or calcium channel blockers in IV form for rate control. The most common medications used in the US are metoprolol and diltiazem, but it is unclear which is superior.

afib-RVR-PVC

Fromm et al Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department

This study was published in the Journal of Emergency Medicine in April 2015 and compared how fast rate control was achieved in diltiazem vs metoprolol. This was a prospective, double-blind study which compared the effects of both medications at 30 minutes, as well as looking at mean decrease in heart rate, and adverse effects. Patients were randomized and either received Diltiazem 0.25 mg/kg IVP (maximum dose of 30mg) or Metoprolol 0.15mg/kg IVP (maximum dose of 10mg). A second escalation dose of 0.35mg/kg of diltiazem (max of 30mg) or 0.15mg/kg of metoprolol (max of 10mg) was given at 15 minutes if target HR was not achieved. The results of the study showed that diltiazem reached the target HR of <100 much more frequently at 5 minutes (50% vs 10.7%) and at 30 minutes (95.8% vs 46.4%) when compared to metoprolol. There was no difference in adverse effects.

 

Diltiazemmetoprolol

Demircan C, Cikriklar HI, Engindeniz Z, et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation.

This study was published in the Journal of Emergency Medicine in 2005. Similar to the study by Fromm et al, this study compared diltiazem (0.25mg/kg, max of 25mg) and metoprolol (0.15mg/kg, max of 10mg), was prospective and randomized, and used a target heart rate < 100. They compared the two medications at intervals of 2, 5, 10, 15, and 20 minutes. In each interval, the success rate of diltiazem was higher than metoprolol, and at 30 minutes 90% of patients receiving diltiazem reached the target heart rate while 80% of patients receiving metoprolol reached the target heart rate. In addition, the decrease in heart rate was higher in the group receiving diltiazem than the group receiving metoprolol.

 

Scheuermyer FX, Grafstein E, Stenstrom R, et al. Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute underlying medical illness.

This study was published in 2013 and compared the effect of calcium channel blockers and beta blockers in ER patients with known Afib who present with Afib with RVR. The primary outcome of this retrospective cohort study was hospital admissions and patients with underlying medical conditions requiring hospitalization were excluded (which means this study looked for patients who were admitted to the hospital for Afib with RVR and no other medical problem). The study enrolled 259 patients over a 4 year period and noted patients receiving CCBs were more likely to be admitted (31% vs 27%) although this was statistically insignificant. Secondary outcomes were ED length of stay, adverse effects, return visits in 7 or 30 days, and the incidence of stroke or death in 30 days. In all categories, both CCBs and beta blockers were essentially equal.

 

What do these studies tell us?

The studies by Fromm et al and by Demircan et all are essentially the only two studies published which compare diltiazem and metoprolol directly in an emergency room population. The first of these studies (Demircan) noted that diltiazem was slightly better than metoprolol in achieving a target heart rate while the most recent study by Fromm noted that diltiazem was significantly better than metoprolol. Of note, Fromm did use a higher maximum dose of diltiazem (30mg vs 25mg). Both studies did an adequate job of excluding patients with other conditions which caused the afib with RVR. The third study compared the broad group of CCBs vs beta blockers and concluded there was no difference, but it does not specify which medications were used and it’s primary end point was not heart rate but whether or not a patient was admitted to the hospital. So what should you do in the emergency room? In patients who present with Afib with RVR with no other underlying condition like infection, ingestion, STEMI, it appears diltiazem is more effective than metoprolol in achieving rate control. However, if there is an underlying condition like sepsis, there is currently no published data about what agent should be given.

DiltiazemAFib-ratecontrolled

 

What about using both?

If a patient is given 2 doses of metoprolol without resolution of rapid ventricular response, the instinct is to give diltiazem to try and achieve better rate control. However, there is a theoretical risk of causing the patient to go into complete heart block if this is done. There are no published case reports of this happening, so the risk is purely theoretical, but the administration of both medications should be avoided.

Demircan C, Cikriklar HI, Engindeniz Z, et al. Comparison of the effectiveness of intravenous diltiazem and metoprolol in the management of rapid ventricular rate in atrial fibrillation. Emerg Med J 2005;22(6):411-4. Erratum in: Emerg Med J 2005;22(10):758.  PubMed PMID: 15911947.

 

Scheuermeyer FX, Grafstein E, Stenstrom R, et al. Safety and efficiency of calcium channel blockers versus beta-blockers for rate control in patients with atrial fibrillation and no acute  underlying medical illness. Acad Emerg Med 2013;20(3):222-30. PubMed PMID: 23517253.

 

Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. [Epub ahead of print]