emDocs.net Podcast – Episode 7: Diagnosing Cardiogenic Shock, Prostatitis, Stent Thrombosis, CVC Lines

Today on the emDocs cast with Brit Long, MD (@long_brit) and Manpreet Singh, MD (@MprizzleER) we cover four posts: diagnosing cardiogenic shock in the ED, prostatitis, stent thrombosis and the ECG, and CVC lines.


Part 1: Diagnosing Cardiogenic Shock

Key Points from the Podcast and Post:

  1. CS is primarily caused by an acute MI (~70%) and is the focus of most studies but other causes should also be considered (see full list in Figure 1).
  2. Mortality secondary to CS remains high (~60%), although early identification and intervention improves survival.
  3. Perform a careful physical exam looking for hypoperfusion and congestion. JVP is an important physical exam component for the diagnosis of CS and is associated with increased mortality (RR = 1.52).
  4. The RUSH exam is both sensitive and specific (0.89 and 0.97, respectively) in the diagnosis of CS. Bedside ultrasound should be repeated frequently as most patients do not initially present in CS.
  5. Using LVOT VTI is a simple and noninvasive method for evaluating CO with low measurements associated with adverse outcomes.
  6. A suggested approach for evaluating patients with suspected CS with focus on its heterogeneous pathology and presentation is summarized in the figure below:


Part 2: Prostatitis

Key Points from the Podcast and Post:

  1. Prostatitis can be tricky to diagnose, but complete a focused but thorough history and exam. The key to diagnosis is considering the disease. Tenderness on DRE helps to make the diagnosis of prostatitis.
  2. Patients with recent instrumentation, immunocompromise, and diabetes or anatomic abnormalities are at higher risk for prostatitis.
  3. Patients with sepsis, poor follow-up, acute urinary retention, or concern for other infections such as endocarditis should be admitted.
  4. Treatment includes antibiotics for 2-6 weeks. Patients should start feeling better with remission of fever and dysuria within the first week of antibiotic treatment
  5. Imaging is recommended for those with suspicion of prostatic abscess, which should be considered in patients who do not symptomatically improve with antibiotic treatment.
  6. E. Coli is the most common cause. Consider covering for G+ organisms in patients with a concern for endocarditis, valvular abnormality or other concurrent infection.

Part 3: ECG Pointers – Cardiac Stent Thrombosis

Key Points from the Podcast and Post:

  1. Stent thrombosis is an uncommon complication that can happen at any point after the placement of a stent. Presentation resembles acute MI.
  2. Posterior STEMIs can accompany 15-20% of Inferior and Lateral STEMIs. Consider getting a posterior EKG in these patients.
  3. Dual antiplatelet therapy and modern, drug eluting stents have significantly reduced the rate of stent thrombosis.

Part 4: Unlocking Common ED Procedures – CVC Lines

Pearls and Pitfalls:

  • If time allows, consider and evaluate the anatomy of multiple insertion sites. The right internal jugular may be the go-to site for many, but the anatomy of the left internal jugular may be more appropriate when visualized under ultrasound.
  • If there is concern for coagulopathy or bleeding, the femoral vein may be the more appropriate choice, given the compressibility of the site.
  • Always keep the tip of the needle in view under ultrasound when advancing in order to avoid injury to underlying anatomic structures.
  • Once the needle is within the vein and flow is obtained into the syringe, decrease the angle and recheck flow to assure the needle is still within the vessel.
  • Brisk, even near pulsatile blood flow, can be seen when placing an internal jugular vein central line in the setting of certain pathologies such as heart failure or cardiogenic shock due to a severely elevated central venous pressure. In this situation, careful confirmation of the wire within the jugular vein should be performed with ultrasound.
  • If resistance is felt while advancing the wire, cease advancement, decrease the needle angle and reattempt. If there is still resistance, remove the wire and reassess flow with the syringe.
  • Never let go of the wire, but if it is lost, attempt to clamp the line and remove the wire and line as discussed above. If the wire is unable to be removed, obtain emergent imaging and consultation for removal.
  • The emergency department can be a difficult place to maintain sterility. If there is any concern regarding the sterility of the central line, it is prudent to inform the admitting team for follow up care.

 

Rapid Procedure Review:

  • Position the patient in trendelenburg.
  • Assess the anatomy under ultrasound bilaterally to assure the safest site is utilized.
  • Sterile preparation of the procedure site and the proceduralist.
  • Drape patient.
  • Prepare sterile ultrasound probe cover.
  • Prepare central line by flushing all lines and applying caps to 2 of the 3 ports.
  • Anesthetize insertion site by first making a wheel of lidocaine at the site and then injecting lidocaine throughout the subcutaneous and deep tissues under ultrasound guidance.
  • Under ultrasound guidance, insert introducer needle through the skin and advance towards the internal jugular vein via the tract of lidocaine previously made.
  • Always keep the needle tip in view under ultrasound.
  • Once flow is obtained within the syringe, drop the angle of the needle and reconfirm blood flow. See above for methods of managing loss of flow.
  • Remove syringe from needle and advance wire. See above for methods of managing difficulty in wire advancement.
  • Once the wire is at least 20cm within the vessel, remove the needle over the wire and confirm placement of the wire under ultrasound.
  • Make a small nick of a #11 scalpel with the blade facing away from the midline.
  • Advance dilator over the wire with the intention of dilating the soft tissue but not the vessel. This depth of dilation will be dependent on body habitus and anatomy which should be taken into account when assessing the anatomy under ultrasound.
  • Advance the catheter over the wire and carefully feed the wire back through the catheter once at the skin to assure control of the wire before catheter advancement into the vessel.
  • Once the catheter is within the vessel, remove the wire completely.
  • Cap the third port from which the wire was removed.
  • Flush all 3 ports.
  • Secure line with suture.
  • Apply antibiotic patch and sterile dressing.
  • Sit patient up and order post-procedure chest x-ray.

 

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