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Conference 4/9/2020

As we proceed into the fourth week of virtual conference I think it is fair to say that we have hit our stride with video conferencing. Again kudos to all of our presenters last week, including Dr Jain, Dr Phillips, Dr Buchak, Dr K. Smith and Dr Kirby. This week will be more toxicology, and we look forward to Journal club with the highly philosophical Dr MacDonald at the helm. We need some more Greco-Roman philosophy in our lives during these times, and we appreciate your humor and candor!

The Aristotle of Ft Worth himself – Dr MacDonald (PGY3)

There are several landmark studies over the past 15 years for cardiology that have run the gamut of pro-PCI vs more conservative ‘medical’ management, all with excellent supporting populations and samples. So why the variance? Dr MacDonald will attempt to answer some of these questions during the next journal club. Keep an eye on your email for the articles.

Speaking of landmark trials, the following are some of the most important cardiology trials ever performed. They changed the face of invasive PCI approaches significantly, and are ones I recommend having a working knowledge of.

The ISCHEMIA trial – JACC 2019. https://www.acc.org/latest-in-cardiology/clinical-trials/2019/11/15/17/27/ischemia. Briefly – the ISCHEMIA trial failed to show that routine invasive therapy was associated with a reduction in major adverse ischemic events compared with optimal medical therapy among stable patients with moderate ischemia.

This builds upon the original landmark paper – the COURAGE trial -NEJM 2007. https://www.nejm.org/doi/full/10.1056/NEJMoa070829. which initially showed as an initial management strategy in patients with stable coronary artery disease, PCI did not reduce the risk of death, myocardial infarction, or other major cardiovascular events when added to optimal medical therapy.

This brings us to the next trial called the COMPLETE trial – NJEM 2019 – https://www.nejm.org/doi/10.1056/NEJMoa1907775. Which showed among patients with STEMI and multivessel coronary artery disease, complete revascularization was superior to culprit-lesion-only PCI in reducing the risk of cardiovascular death or myocardial infarction, as well as the risk of cardiovascular death, myocardial infarction, or ischemia-driven revascularization.

Stenting the (Non-STEMI inducing) culprit lesion hasn’t shown to be superior to medical management however widespread multivessel revascularization has shown to be superior to culprit lesion management? hmm… Evaluate these papers and also do some reading about TIMI flow https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847159/ after stenting in PCI, and build your own conclusions.

In other news..

Dr Patel discovers his long lost glasses, and can now read things that are >10 feet in front of him. For months he’s been telling me that it is hard for him to see without them. I think it is rather convenient that his recent discovering of the long lost vision aids just so happen to coincide with his upcoming birthday….

In any event, it is a landmark milestone birthday for Dr Patel on tuesday the 7th, so make sure to wish him happy birthday! We Love you Dr Patel!

Now, onto toxicology..

EMDOCS has a good article that highlights a generalized and step-wise approach to the poisoned patient. it includes general considerations, as well as classic antidotes and typical management of tox cases. It’s a good starting point and/or review if you have forgotten a few points here or there. 

There is also a great series that has come from Canada called CritCases, which is a subcategory of Emergency Medicine cases by creator Anton Helman MD from the University of Toronto. 

You can take a look at some of the cases and subcategories below, but since this is Toxicology month I would like to highlight a few articles which deserve some of your attention below. 

This case of TCA overdose highlights a patient who has taken a massive TCA overdose with corresponding physiologic and EKG changes – Wide complex tachycardia with prolonged Qtc >440ms, and Tall R wave in aVR, which is consistent with sodium channel blockade. A cornerstone of TCA poisoning. Take a look at the EKG below..

https://emergencymedicinecases.com/wp-content/uploads/2015/12/TCA-overdose-ecg.jpg

The next article is titled “low and slow” and in reference to CCB, BB, Digoxin, opiates, clonidine and other types of toxicities that can cause bradyarrhythmias and other complications. 

Here is a great flowchart they have created which I will include for your reference here in the approach to BB or CCB overdose. 

All image and content from EMCASES credit goes to Anton Helman|EM CasesEmergency MedicineEpisodesToxicology

See you this week – Stay tuned for virtual conference 4/9/2020

Stefan Meyering DO, FAAEM

Dad, Academic EM Attending Physician, Fish Nerd & Backyard Mechanic | APD @ Ft Worth EM | Interests: Graduate Medical Education, Risk Management and Legal Medicine, POCUS, Free Open Access Medical Education (FOAMed), Physician Wellness

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