PAINE #PANCE Pearl – Cardiovascular



Question

74yo woman, with a history of CAD and hyperlipidemia, presents to your office with a 6-month history of leg pain and swelling. She states that it seems to be worse when she is on her feet and improves when she can put her legs up. She denies worsening pain with activity or walking, but has recently developed a “rash” on her legs that is worrying her (see below). Physical examination reveals warmth to the feet and legs with scattered, thin hair. You appreciate 1+ DP and PT pulses bilaterally.

  1. What are some bedside maneuvers or tests you can perform to differentiate between arterial and venous insufficiency?
  2. What are the findings associated with each?

Ep-PAINE-nym



Bundle of His

Other Known Aliases atrioventricular bundle

Definitioncollection of electrical conduction cells of the heart that transmit impulses from the AV node to the ventricles

Clinical Significance this bundle of cells is responsible for communication contraction impulses from the atria to the ventricles. Any damage to this area can result in varying degrees of heart block and conduction abnormalities

HistoryNamed after Wilhelm His Jr. (1863-1934), a Swiss-born cardiologist and anatomist who received his medical doctorate from the University of Leipzig in 1889. The son of the equally famous Basel anatomist Wilhelm His Sr., he would become professor extraordinaire at his alma mater 6 year after graduating. He also went on to be physician-in-chief at the Friedrichstadt Hospital in Dresden, chair of internal medicine in Berlin, and advisory internist for several armies during World War I. He would describe his eponymous bundle as an assistant professor in 1893.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. His Jr, W. Die Tätigkeit des embryonalen Herzens und deren Bedeutung für die Lehre von der Hezbewegung beim Menschen. Arbeiten aus der medidizinischen Klinik zu Leipzig, 1893: 23.

#68 – Bundle Branch Blocks



***LISTEN TO THE PODCAST HERE***



Review of the Electrical Conduction System of the Heart

  • Cardiac cells specialized to initiate and distribute electrical impulses in an orderly and sequential manner
  • Sinoatrial Node
    • Located in superior region of the crista terminalis
      • SVC feeds into the right atrium
    • Pacemaker of the heart and initiates the heartbeat
      • Starts in the node, spreads down the walls of the atria, until it reaches the AV node, stimulating contraction of the myocardium
    • Arterial Supply – SA nodal artery via the RCA
  • Atrioventricular Node
    • Located in interatrial septum above the coronary sinus near the attachment of the septal cusp of the tricuspid valve (Triangle of Koch)
    • Passes SA node impulse to the AV bundle (Bundle of His)
    • Arterial Supply – AV nodal artery via the RCA (80-90%) or LCx (10-20%)
  • AV Bundle (Bundle of His)
    • Arises from the AV node and descends along the membranous portion of the interventricular septum, where it divides at the upper border of the muscular portion of the interventricular septum into the left and right bundles suppling their respective ventricles
    • Transmits AV nodal impulses through the interventricular septum to the left and right bundle branches, which gives rise to the Purkinje fibers that ultimately distribute the ventricular myocardium

Bundle Branch Blocks Pearls

  • R-wave = depolarization going TOWARDS the lead
  • S-wave = depolarization going AWAY from the lead
  • RBBB = delay in conduction is oriented to the RIGHT and ANTERIOR
    • QRS = Positive V1 and negative V6
  • LBBB = delay in conduction is oriented to the LEFT and either ANTERIOR or POSTERIOR
    • QRS = Negative V1 and positive V6
  • Wide QRS complex > 120 ms
    • Delay in conduction due to the block
  • Secondary Repolarization (ST-T) Abnormalities
    • T-wave discordance with last deflection of QRS

Causes

  • RBBB
    • More common in patients without structural heart disease
    • Congenital
      • ASD
    • Cardiac
      • Valvulopathies, ischemic heart disease
    • Pulmonary
      • Pulmonary HTN, PTE
  • LBBB
    • 4 main underlying conditions
      • Coronary disease
      • Hypertensive heart disease
      • Aortic valve disease
      • Cardiomyopathies

RBBB EKG Diagnostic Criteria

  • QRS > 120 ms
    • If all other criteria met but QRS < 120 ms, it is termed incomplete RBBB
  • rSR’ pattern in V1 and V2
  • Slurred S-wave in lateral leads (I, aVL, V5, V6)
  • ST depression and T-wave inversion in V1-V3

LBBB EKG Diagnostic Criteria

  • QRS > 120 ms
  • Dominant S-wave in V1-V3
    • Moving away from the leads
  • Broad, monophasic (M-shaped or notched) R-wave in lateral leads (I, aVL, V5, V6)
    • Moving towards the leads
  • Appropriate discordance
    • ST-segment and T-wave are in OPPOSITE direction to the main vector of the QRS complex
  • Left axis deviation
  • Poor R-wave progression

SPECIAL CONSIDERATIONS


Fascicular Blocks

  • Anterior
    • Pathology
      • When blocked, the conduction to the high lateral portion of the ventricle is delayed
        • Spreads to the intact posterior fascicle and RBB
          • Causes left axis deviation
    • Criteria for left anterior fascicular block
      • QRS normal to slightly prolonged
      • Left axis deviation WITHOUT other reasons
      • Small R-wave and large S-wave in inferior leads (II, III, aVF)
      • Small Q-wave with large R-wave in lateral leads (I, aVL)
  • Posterior
    • Pathology
      • When blocked, the conduction to the inferior portion of the ventricle is delayed
        • Spreads to the intact anterior fascicle and RBB
          • Causes right axis deviation
    • Criteria for left posterior fascicular block
      • QRS normal to slightly prolonged
      • Right axis deviation WITHOUT other reasons
      • Small R-wave and large S-wave in lateral leads (I, aVL)
      • Small Q-wave and large R-wave in inferior leads (II, III, aVF)

Sgarbossa’s Criteria

  • Used in the presence of LBBB or paced rhythm to uncover potential ischemia
  • Original (1996)
    • Concordant ST elevation > 1mm in leads with a positive QRS complex (5 points)
    • Concordant ST depression > 1mm in V1-V3 (3 points)
    • Excessively discordant ST elevation > 5mm in leads with a negative QRS complex (2 points)
    • Score ≥ 3 has a specificity of 90% for detecting concomitant ischemia
  • Smith-Modified Sgarbossa Criteria (2012)
    • ≥ 1 lead with ≥ 1mm of concordant ST elevation
    • ≥ 1 lead of V1-V3 with ≥ 1mm of concordant ST depression
    • ≥ 1 lead ANYWHERE with ≥ 1mm ST elevation AND proportionally excessive discordant ST elevation
      • Defined as ≥ 25% of the depth of the preceding S-wave

1893 Cottage Physician

References

  1. Heart. In: Morton DA, Foreman K, Albertine KH. eds. The Big Picture: Gross Anatomy, 2e. McGraw-Hill; Accessed January 17, 2021.
  2. Jaffar A. Anatomical Structure of the Heart. In: Elmoselhi A. eds. Cardiology: An Integrated Approach. McGraw-Hill; Accessed January 17, 2021.
  3. Goldberger AL. Electrocardiography. In: Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 20e. McGraw-Hill; Accessed January 17, 2021.
  4. LITFL. Right bundle branch blocks. https://litfl.com/right-bundle-branch-block-rbbb-ecg-library/
  5. LITFL. Left bundle branch blocks. https://litfl.com/left-bundle-branch-block-lbbb-ecg-library/
  6. REBELEM. Bundle Branch Blocks. https://rebelem.com/bundle-branch-blocks101/
  7. Sgarbossa EB, Pinski SL, Barbagelata A, et al. Electrocardiographic diagnosis of evolving acute myocardial infarction in the presence of left bundle-branch block. GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) Investigators. N Engl J Med. 1996; 334(8):481-7. [pubmed]
  8. Smith SW, Dodd KW, Henry TD, Dvorak DM, Pearce LA. Diagnosis of ST-elevation myocardial infarction in the presence of left bundle branch block with the ST-elevation to S-wave ratio in a modified Sgarbossa rule. Ann Emerg Med. 2012; 60(6):766-76. [pubmed]
  9. Meyers HP, Limkakeng AT Jr, Jaffa EJ, et al. Validation of the modified Sgarbossa criteria for acute coronary occlusion in the setting of left bundle branch block: A retrospective case-control study. Am Heart J. 2015; 170(6):1255-64. [pubmed]
  10. CORE EM. Validation of Modified Sgarbossa Criteria. https://coreem.net/journal-reviews/modified-sgarbossa-criteria/

PAINE #PANCE Pearl – Cardiovascular



Question

62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.

  1. What does it show?
  2. What are the diagnostic criteria present?

Answer

  • The EKG reveals a right bundle branch block most likely due to his underlying COPD and pulmonary hypertension.
  • Diagnostic criteria for RBBB are:
    • Wide QRS > 120 ms
    • RSR’ pattern in V1-2 (“rabbit ears”) with R’ > R
    • Wide, slurred S wave in I, aVL, or V5-6
  • Other common findings, though not always associated, is ST depression and T wave inversion in the right precordial leads (V1-3)

Ep-PAINE-nym



Beck’s Triad

Other Known Aliases none

Definitionclassic physical examination findings associated with critical cardiac tamponade

Clinical Significance although not seen in every patient with cardiac tamponade, it is a common question on boards and certification examinations. These include: 1) hypotension, 2) JVD, and 3) muffled/distant heart sounds.

HistoryNamed after Claude Schaeffer Beck (1894-1971), an American cardiac surgeon who recieved his medical doctorate from Harvard University in 1921. He would attend surgical residency at Case Western University, where he would spend his entire career. He developed a novel re-circulation technique for cardiac ischemia called the Beck Procedure, where pectoral muscle was implanted in the pericardium, and later placing a vein graft between the aorta to the coronary sinus. He also pioneered the first successful use of a defibrillator in 1947 to restore ROSC in a 14yo patient he was operating on for a congenital heart defect. His eponymous triad was first described in 1935 in an article entitled “Two cardiac compression triads” in the Journal of the American Medical Association.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Beck CS. Two Cardiac Compression Triads. JAMA. 1935;104(9):714-716. [link]
  7. Theruvath P, Ikonomidis JS. Historical perspectives of The American Association for Thoracic Surgery: Claude S. Beck (1894-1971). JTCVS. 2015;149(3):655-660. [link]

PAINE #PANCE Pearl – Cardiovascular



Question

62yo man, with a history of COPD and 52-pack-year history of smoking, presents to your office to establish care. His shortness of breath has been manageable using tiotropium daily with albuterol 2-3x per month for exacerbation. He denies angina, chest pain, or unreasonable dyspnea with exertion. An EKG was performed and is below.

  1. What does it show?
  2. What are the diagnostic criteria present?

Ep-PAINE-nym



Austin Flint Murmur

Other Known Aliases none

Definitionlow-pitched, rumbling, mid-to-late diastolic murmur heard best at the apex

Clinical Significance this murmur is associated with severe aortic regurgitation and is due to two distinct mechanisms. First, the aortic jet flow impinging on the mitral valve causing vibrations from premature closing and second, turbulence of two columns of blood from the left atrium to left ventricle and aorta to left ventricle.

HistoryNamed after Austin Flint I (1812-1886), an American physician who received his medical doctorate from Harvard University in 1833. He would practice in Boston, Buffalo (where he would help found the Buffalo Medical College, and New York City, where he was professor of medicine at the famed Bellevue Hospital. A proponent of European diagnostic methods (as he was mentored by James Jackson at Harvard, who was a follower of Laënnec), he advocated and popularized the use of the binaural stethoscope in physical diagnosis. He was a prolific writer and researcher with his Treatise on the Principles and Practice of Medicine considered as a classic medical text. He is also recognized as having coined the term “broncho-vesicular breathing” in lung auscultation. He would publish the first detailed description his eponymous murmur in 1862 in the American Journal of Medicine Sciences in an article entitled “On cardiac murmurs”.


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Flint A. On cardiac murmurs. American Journal of Medical Science. 1862;7;29-54 [link]
  7. The Mitral Valve. Austin Flint. http://www.themitralvalve.org/mitralvalve/austin-flint

PAINE #PANCE Pearl – HEENT



Question

62yo man, with a history of pseudotumor cerebri, presents to your clinic with progressive headache and vision changes. You would like to confirm an increased intracranial pressure before sending him to the neurologist.

  1. What are two (2) ways at the bedside you can confirm and what are the thresholds for positive findings?


Answer

  1. The old and busted bedside way to determine if a patient has increased intracranial pressure is the fundoscopic examination. What you are looking for specifically is the cup:disc ratio of the optic nerve. Normal is around 0.3, or 1/3rd. If it is increased, it suggests increased intracranial pressure.

2. The new, hotness is using bedside POCUS to measure the optic nerve directly. Using the high frequency linear probe with a tegaderm placed over the patient eye, place a generous amount of gel over the globe and measure the optic nerve 3mm from the retina. A normal optic nerve should be < 5mm in diameter and anything over than suggests increased intracranial pressure

Ep-PAINE-nym



Rinne Test

Other Known Aliases – none

Definitionbedside test to evaluate hearing loss using a 512hz tuning fork

Clinical Significance this maneuver is performed by vibrating a 512hz tuning fork and placing it on the mastoid process. The patient then informs the provider when they no longer can hear the ringing, at which point the tuning fork is moved in front of the canal. In normal hearing, the patient should still be able to hear the ringing (although it can also occur in sensorineural hearing loss). If conductive hearing loss is present, bone conduction is greater than air conduction.

HistoryNamed after Heinrich Adolf Rinne (1819-1868), a German otologist who received his medical doctorate from the University of Göttingen. He would practice here for the majority of his career exploring the diseases of the ears, nose, and throat. He first described his eponymous test in 1855, but did not get widespread recognition for it until 1881 when it was further publicized by otologists Bezold and Lucae


References

  1. Firkin BG and Whitwirth JA.  Dictionary of Medical Eponyms. 2nd ed.  New York, NY; Parthenon Publishing Group. 1996.
  2. Bartolucci S, Forbis P.  Stedman’s Medical Eponyms.  2nd ed.  Baltimore, MD; LWW.  2005.
  3. Yee AJ, Pfiffner P. (2012).  Medical Eponyms (Version 1.4.2) [Mobile Application Software].  Retrieved http://itunes.apple.com.
  4. Whonamedit – dictionary of medical eponyms. http://www.whonamedit.com
  5. Up To Date. www.uptodate.com
  6. Heck WE. Dr. A. Rinne. Laryngoscope. 1962;72(5):647-652. [link]

#67 – Epistaxis



***LISTEN TO THE PODCAST HERE***



Anatomy

Anterior

  • Kiesselbach’s Plexus (Little’s area)
    • Confluence of three main vessels
      • Septal branch of the anterior ethmoidal artery
      • Lateral nasal branch of the sphenopalatine artery
      • Septal branch of the superior labial branch of the facial artery

Posterior

  • Woodruff’s Plexus
    • Posteriorlateral branches of the sphenopalatine artery
      • Posterior inferior turbinate

Epidemiology

  • Up to 60% of population will experience a significant nosebleed each year
    • Only 10% need to seek attention
  • Common ENT admission condition, but rarely needs surgical intervention
  • Bimodal age distribution
    • Before 10 years or between 45-65 years
  • Male predominance before the age of 49, then equalizes
    • Estrogen has been shown to protective for mucosa
  • Anterior bleeds are significantly more common (>90%) and resolve with minor interventions
  • Posterior bleeds can result in significant hemorrhage

Etiologies

  • Nose picking
  • Low environmental moisture
  • Mucosal hyperemia of viral or allergic rhinitis
  • Trauma
  • Foreign body
  • Anticoagulation
  • Coagulopathies
    • Osler-Weber-Rendu, von Willebrand, hemophilias
  • Connective tissue disease
    • Aneurysm development
  • Neoplasm
    • Squamous cell, inverted papilloma
  • Hypertension
    • Debated as a cause, but has shown to prolong bleeding
  • Nasal medications
    • Steroids, oxymetazoline
  • Heart failure

Patient Assessment

  • Primary
    • Airway assessment
      • RR, O2
    • Cardiovascular stability
      • HR, BP
  • Secondary
    • History
      • Medications
        • Anticoagulation, aspirin, nasal medications
      • PMH
        • Bleeding disorders, HTN, liver disease
        • Recent trauma
        • History of nosebleeds
          • How often, how long do they last, ever been admitted for one
  • Diagnostic Studies
    • Coagulation studies should NOT be routinely ordered
      • Should be in patients on anticoagulation
    • In patients with prolonged bleeds:
      • CBC
      • Type and cross
  • Examination
    • Have patient blow nose to remove clots and blood
    • Examine nasal cavity to see if you can see the bleeding site
      • Otoscope, nasal speculum
      • Don’t have patient tilt head back
        • Nasopharynx lies in anteroposterior plane and this will obscure the majority of the cavity from view

Interventions

  • Initial (Woodpecker/Walrus technique)
    • Have patient blow nose to remove clots
    • In a small basin mix any or all of the following:
      • Oxymetazoline
      • Lidocaine with epinephrine
      • Tranexamic acid
      • If available, soak GelFoam/Surgicel in this fluid and place BEFORE the sponge sticks
    • Trim two oral sponge swabs to better fit in the nasal cavity and soak in the fluid
    • Make a nasal bridge clamp by taping two tongue depressors together on one end
    • Place swabs in nasal cavities and apply nasal clamp for 10-15 minutes
    • Ice pack can also be used
  • Cautery
    • If the bleeding site can be visualized on direct examination
    • Apply topical anesthetic
    • Silver nitrate sticks
      • Start from periphery and roll to center of bleeding
      • No more than 10 seconds
      • A white eschar should form
  • Nasal packing
    • Use if cautery fails
    • Ensure topical anesthesia
    • Soak in sterile water
    • Insert by sliding along the floor of the nasal cavity PARALLEL to floor
    • Insufflate the balloon with air
  • Nasal Balloon Catheters
    • For posterior bleeds
    • Follow same steps for nasal packing
    • Insufflate posterior balloon FIRST and apply gently traction
    • Then insufflate the anterior balloon
  • Foley Catheters
    • If you don’t have a prefabricated nasal balloons, a foley catheter can work
    • Insert the catheter until you can see it in the posterior oropharynx
    • Insufflate with 5-10cc of water
    • Apply traction to seat balloon in posterior choana
    • Add additional water to tamponade
    • Clamp catheter with umbilical clamp or c-clamp from NG tube

Disposition and Follow-up

  • For simple nasal packing, patients should be evaluated by ENT within 24-48 hours
    • Discuss with consultant need for antibiotic prophylaxis
      • No good evidence supports routine use, but ENT often prefers
        • Amoxicillin-Clavulanate is most commonly used
        • Clindamycin or trimethoprim/sulfamethoxazole should be used if concern for nasal carrier of MRSA
  • Posterior bleeds should be immediately assessed by ENT for potential surgical intervention
    • Endoscopic sphenopalatine artery ligation
    • Anterior ethmoid artery ligation
      • Open or endoscopic

1893 Cottage Physician

References

  1. Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician. 2005; 71(2):305-11. [pubmed]
  2. Villwock JA, Jones K. Recent Trends in Epistaxis Management in the United States JAMA Otolaryngol Head Neck Surg. 2013; 139(12):1279-84. [pubmed]
  3. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996; 78(5):444-6. [PDF]
  4. Fishpool SJ, Tomkinson A. Patterns of hospital admission with epistaxis for 26,725 patients over an 18-year period in Wales, UK. Ann R Coll Surg Engl. 2012; 94(8):559-62. [PDF]
  5. Min HJ, Kang H, Choi GJ, Kim KS. Association between Hypertension and Epistaxis: Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2017; 157(6):921-927. [pubmed]
  6. Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010; 267(10):1641-4. [pubmed]
  7. Lin G, Bleier B. Surgical Management of Severe Epistaxis. Otolaryngol Clin North Am. 2016; 49(3):627-37. [pubmed]