ALMERO OOSTHUIZEN
UCT/US EMERGENCY MEDICINE
1 APRIL 2009

• Mrs. AS, 70y female
• PMH:
– Hypertension, 40py smoker (COPD)
– No previous ischemic events
• Medication:
– Ridaq 12,5mg od
– Currently using amoxil and paracodol for ‘flu’
• No allergies

• Presented to VHW ED at 16h10
• 15h00 - Generalised weakness; legs felt numb; vomited twice; appeared confused; could not understand speech or speak clearly
• 15h30 – Chest discomfort; sweating; tremulous. Lasted 30min, then came and went
• Also c/o leg discomfort ; 2 weeks of productive cough

• General:
– Frail, poor concentration, slightly slurred speech
– HR 75 ; BP 140/82 ; Temp 36,7 ; RR 24 ; Hb 11
• CVS:
– Regular pulse ; limb pulses not documented ; no failure ; no murmurs ; JVP not documented
• Chest:
– No abnormalities documented

• Abd:
– No abnormalities documented
• CNS
– GCS 14 (slightly confused); power both legs 4/5
– Nil more documented

• Casualty Officer (2’nd year intern) notes
– ?MI ; ?TIA ; ?LRTI
• Central question: In light of possible IC event, is it safe to strep patient?

• O
2
; Aspirin 300mg ; Morphine 4mg ; Isordil sl
• Trop T (neg)
• Casualty officer referred the patient to medical registrar (actually a cosmo)
– Recommended they phone GSH cardiology
– Said he’d be down as soon as possible
• GSH Cardiology
– “we don’t give advice re thrombolysis over the phone” AAARGHH! Intern! AAARGHH!

• Patient now comfortable and pain free
• Spoke to medics again
– Recommended ED hold off on strep until they have reviewed patient

• Patient became unresponsive (noticed immediately by attending nurse) and pulseless
• CPR commenced at once with chest compressions, and patient rushed to resuscitation area (cpr en route, transit time about 20 sec)

• BVM vent 2:30 high quality chest compressions ongoing
• Monitor attached within 40 seconds of initial arrest
• Arrest rhythm: Torsade du Pointes
• Immediate async. biphasic cardio version at
200J
• CPR commenced, adrenalin 1mg IV ordered, but not given yet

• During first cycle of chest compressions post shock, patient displayed signs of ROSC
– Moaning, moving
• Good pulse felt; rhythm = AF with incomplete
RBBB at 75bpm
• Patient woke up and was conversant within about two minutes, complaining of ‘sore ribs’
• By this time the medic arrived at last

• Post resuscitation care consisted of O
2 mask and ongoing cardiac monitoring via face
• 2g MgSO
4 infused IV over 5 minutes
• After discussion with the medical consultant, thrombolysis with streptokinase was started once the patient had been transferred to ICU.

• Stable post strep course in ICU
• Bilateral, severe PVD noted
• Critical ischemia of right leg
• Transferred to GSH ICU
• Right leg embolectomy and fasciotomy, with eventual right sided BKA (septic, non healing wound)
• Transferred back to VHW on 25-2-2009, and is doing well!

• Inferior STEMI with RV extension
– Possible intermittent complete AV block with bradycardia
– Complicated by Torsade arrest
– Post version/strep AF
• Acute limb ischemia (right leg)
– Initial embolectomy
– Eventual right BKA
• Probably never had a ‘TIA’

• ACS patients are not stable patients
– They should be intensively monitored
• Difficult management decisions on sick or complicated patients like this should be made by the most senior person available
• Torsade with arrest is still arrest: initial treatment remains good CPR and early cardio version. Other treatments may then be considered

• Drug induced: 1A and 1C antidysrhythmics, phenothiazines, cyclic antidepressants, organophosphates, antihistamines.
• Electrolyte abnormalities: hypokalemia, hypomagnesemia, hypocalcemia (rarely)
• Diet related: starvation, low protein
• Severe bradycardia or atrioventricular block
• Hypothyroidism
• Contrast injection
• Cerebrovascular accident (especially intraparenchymal)
• Myocardial ischemia

• Acquired Torsade is due to prolongation of the
QT interval and is usually precipitated by bradycardia
• The so-called short-long-short phenomenon
• Brady – early ectopic beat (‘escape’) – comp pause – recovery beat with long QT - R on T -
Torsade

• Speeding up the rate will shorten ventricular repolarisation
• This decreases the effective QT (and therefore vulnerable time) interval and decreases the chances of an early ectopic beat
• Voila!

• NB: Overdrive to prevent recurrent TdP vs.
Overdrive to convert resistant TdP
• Electrical overdrive to a ventricular rate of about 100 – 120
– Discussion of technique during lecture
• Chemical overdrive with Isoproterenol
– 2 to 10 mcg/kg/min
– Titrate to increase HR till VT suppressed




Congenital
Jervell and lange-Nielsen syndrome (deafness, autosomal recessive)
Romano-Ward syndrome (normal hearing, autosomal dominant)
Sporadic (normal hearing, no familial tendency)


Mitral valve prolapse.

Acquired
Cerebrovascular disease (especially subarachnoid hemorrhage)
Autonomic surgery: radical neck dissection, carotid endarterectomy, truncal vagotomy

• Unstable: Unsynchronized cardio version
– Sync not effective due to variable R wave amplitude, morphology and axis
• Other options
– Correct precipitant
– MgSO
4
1-2g IV in 10 ml D5W as a push for everyone
(may also consider K supplementation)
– Consider lidocaine or amiodarone (effectiveness not demonstrated)
• Class 1A and 1C contraindicated

• ACLS resource text (ACLS EP)
• 5 Minute emergency medicine consult, Rosen and Barkin
• Textbook of Emergency Medicine, Rosen and
Barkin
• Emedicine.com