Episode 92 – Aortic Dissection Live from The EM Cases Course

Emergency Medicine Cases

Dr. Anton Helman

Education, Health & Fitness, Courses, Medicine, Science

4.7 • 602 Ratings

🗓️ 21 February 2017

⏱️ 49 minutes

🔗️ Recording | iTunes | RSS

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Summary

While missing aortic dissection was considered "the standard" in the late 20th century, our understanding of the clinical diagnoses has improved considerably since the landmark International Registry of Aortic Dissection (IRAD) study in 2000. Nonetheless, aortic dissection remains difficult to diagnosis with 1 in 6 being missed at the initial ED visit. With the help of Dr. David Carr we’ll discuss how to pick up atypical presentations of aortic dissection without over-imaging as well as manage them like pros by reviewing: 1. The 5 Pain Pearls, 2. The concepts of CP +1 and 1+ CP, 3. Physical exam pearls, 4. CXR pearls and blood test pitfalls, and 5. The importance of the correct order and aggressive use of IV medications. So with these objectives in mind…

Transcript

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0:00.0	Before we get into the live podcast on aortic dissection with David Carr recorded at the EMKases course in 2017,
0:06.3	I thought it might be cool just to take a few minutes to hear some of the comments from the participants and faculty at the course
0:12.9	and let them tell us why they came to the course and some of the things they learned.
0:17.8	Thank you so much to Michelle Yee, the EMKAS team member who played a central role in
0:22.5	producing the EMK's Digest eBooks, who interviewed these fine folks.
0:32.4	So I think the biggest take home from running a code where you're dealing with P.A. or acystoli
0:38.2	is that not all P.EA patients are the same. And just blindly giving epinephrine 1 milligram
0:45.0	IV and doing CPR may not be appropriate for all patients. So take a minute to actually look at the
0:51.3	ECG. Is it narrow and regular or is it wide and irregular? And that can
0:56.5	certainly give you a lot of clues about the differential diagnosis. And then don't be afraid to pull out
1:00.9	the ultrasound probe during your pulse check. Look at the heart. Is the heart beating or not?
1:05.0	And if you have a vigorously beating heart, giving a milligram of epinephrine is probably not
1:09.2	appropriate in those patients. So really start
1:11.3	aggressively looking for the reversible cause for that patient's shock. And keep in mind that a
1:17.3	milligram of epinephrine for a patient with a beating heart is potentially harmful. So start
1:22.3	revisiting the differential diagnosis and have a thoughtful approach to PEA. And if you divide patients into patients who have vigorous cardiac activity versus cardiac
1:31.3	standstill, you can have a more refined approach to dealing with their resuscitation.
1:37.1	You know, I was just had a great session with Emily Austin and Margaret Thompson on toxicology.
1:41.6	And I'm like the world's biggest lipidemulsion therapy fan. And I think one of the great points is when you got a lipophilic drug, firstly, you got to think about what the actual antidotes are for that drug, you know, whether it's calcium or beta blocker and you're giving insulin, whether it's a TCA and you're given bicarp. But one of the things is that intralipid doesn't work well in an acedotic milieu.
2:01.8	You have a patient with a lactate of 15.
2:05.0	Interlip is not going to work.
2:06.0	You want to optimize its use.
	...

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