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Mortality And Morbidity Conference

Mortality And Morbidity Conference. Dr. Meenakshi Aggarwal PGY2 Emory University Family Medicine. AGENDA. Case Review Discussion Take Home Points. CASE HISTORY. C/C: Sudden loss of consciousness

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Mortality And Morbidity Conference

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  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: H&H: 15.4/43.8, WBC’s: 6.8, Plat: 298,000 • Chem: Na 143, K 3.4, BUN 16, Cr 1.1, BG 134, Ca 8.8 • LFT’s: 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 CE’s 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. ST segment elevation in V1-V3 with RBBB

  16. 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.

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

  18. 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.

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

  20. Schematic of SCN5A. Some mutations are associated with combined phenotypes. α = Subunit

  21. 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) SSRI’s ( Fluoxetine) Cocaine Intoxication Alcohol intoxication

  22. Types Of EKG Patterns in BS

  23. Types of EKG patterns in BS:

  24. Treatment ICD ( Implantable cardioverter -defibrillator) Pharmacotherapy: No proven drugs

  25. Conclusion Never compare your own urine with the patient’s urine…..

  26. Take home points Syndrome of ST segment elevation in V1-V3, RBBB and sudden death Genetically determined Sudden death can only be prevented by ICD’s

  27. QUESTIONS?

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