This week’s teaching is based on the new ACS guidelines. We will be concentrating on ECGs and STEMI Equivalents.

Here are the STEMI equivalents proposed in the guidelines.

In this weeks teaching we looked at the approach to the comatose Post ROSC patient.

Some key learning included:

Post ROSC patient care is a continuation of resuscitation. We must concentrate our efforts as intensely in the post ROSC period as we do, during the initial resuscitation to obtain ROSC.

During the initial resuscitation our goal is to DETECT OUTPUT. Post ROSC, our goal is to measure  and control everything as much as possible, to ensure the best survival rates.

Ischaemic injury occurs early in resuscitation, ie in the first few minutes of anoxia. In the emergency setting, as well as during reperfusion. In the post ROSC comatose patient, it is difficult to determine a prognosis for good neurological survival in the emergency department. This is done > 48 hours following ROSC.

In the post ROSC comatose patient, we should aim for the following:

Blood Pressure:

• SBP > 90 mm Hg as patients with SBP < 90 mm Hg are more likely to arrest.
• MAP > 65 mm Hg: No great evidence for this. Based on sepsis literature.
• There may be some patients that we need to aim for a higher blood pressure in.
• The BOX Trial found no benefit from targeting a higher BP, but there was also no harm.

Oxygenation and Ventilation

• sPO2 94-98%
• pCO2 35-45 mm Hg
• The BOX trial found no significant difference between restrictive and liberal oxygen therapy in terms of death or poor neurological outcome.

Temperature Control

• Aim to avoid fever ie > 37.5 Celcius.

Seizures

• Beware the patient with seizures as 30-50% of patients have them. They usually indicate anoxic brain injury, although some of these patients will have a good outcome…. We just don’t know which patients.
• We discussed post anoxic myoclonus and how to recognise it.

The Dizzy Patient

An Approach to the Dizzy Patient:

Here are 4 cases to consider. Come up with a diagnosis for each.

Case 1: A 68 yo woman presents with dizzyness, that was sudden in onset and she collapsed to the ground, but did not lose consciousness. She often has ringing in her ears and has reduced hearing loss on the right side. She has not been investigated for this. What is your working diagnosis and what would you do next?

Case 2: A 78 yo woman presents with dizzyness. She has had several episodes over the last 2 months, but more frequently over the last week. Symptoms have now resolved and her examination is normal. What is your differential diagnosis?

Case 3: A 68 yo male presents with a sudden onset of dizziness. The room is spinning. He tries to sit up in bed, for an examination, but cannot. What is your working diagnosis?

Case 4: A 48 yo woman presents with 9 months of constant dizziness. She has had an MRI scan 8 months ago which was normal. She is now complaining of left arm weakness. When you test the pronator drift sign, she raises both arms up to the level of her shoulders and the left arm lowers as in the image below. What is your diagnosis?

At our next teaching session we will be discussing ‘The Patient with Syncope’. Although the ECG only has a yield of about 5%, it is the most important investigation we will perform in patients with syncope.

Click this link to go to an ECG Quiz. Click on the ECG quiz at the top of the page. Here you will find 9 important ecgs to review. They are the ECGs of Syncope.

Please complete prior to the next teaching session.

Watch the Video if you missed the teaching, or watch and review.