Resuscitation Case Conference: AMS and STEMI

Presented by Dr. McDermott

Case Summary:

74 YO F presents to the ED for AMS and possible STEMI ultimately found to have ICH and with elevated cardiac biomarkers suspected to be 2/2 Takutsubo syndrome due to apical ballooning on bedside cardiac echo.

TAKUTSUBOS Syndrome Overview

• STEMI mimic causing chest pain, +/- biomarker elevation, characteristic apical ballooning seen on ECHO
• Must have normal coronaries- CANNOT DIAGNOSE IN THE ED
• Classically post menopausal woman with severe emotional distress (89% women, mean age 68)
• Can be common in older women s/p CVA- often asymptomatic

TAKE HOME POINT, if it meets STEMI criteria and you suspect Takutsubo, page the STEMI and leave it to cards to prove it isn’t ACS

Management

• After excluding ACS, myocarditis and pheochromocytoma- supportive care is key
• ACEIs, BBlockers, diuretics and usually ASA- INPT therapy with the exception of ASA
• Cardiac WMAs usually transient and resolve completely within two weeks.

Thought to be caused by a sudden surge in cathecholamines- the reason why this surge causes a characteristic wall motion abnormality remains debatable.  The most widely held view is that the catecholamines cause microvascular spasm, although left ventricular outflow obstruction is also likely to play a part.  The sympathetic nervous system is also implicated based on studies that show prevention of the syndrome s/p sympathecomy. 

Can you use Ketamine for Induction in a suspected elevated ICP patient?

A: It depends!

• If Hypo or Normotensive = YES
• If Hypertensive = NO
  *Should NOT use if ICP is due to spontaneous ICH however
• Goal to maintain MAP  and CPP and not increase ICP

“The best available evidence about this issue comes from a systematic review of 10 trials involving 953 critically ill patients, all managed with intubation and mechanical ventilation, which concluded that the use of intravenous ketamine did not adversely affect patient outcomes, including mortality and neurologic outcome. Although most trials included in the review had methodological limitations, two randomized, double-blinded trials comparing the effects of prolonged ketamine and sufentanil infusions found no difference in the mean daily intracranial pressure and cerebral perfusion pressure of patients, all of whom had sustained traumatic brain injury.”

References:

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847940
• http://lifeinthefastlane.com/ecg-library/tako-tsubo/
• http://lifeinthefastlane.com/subarachnoid-haemorrhage/
• http://lifeinthefastlane.com/ccc/pretreatment-drugs-for-rapid-sequence-intubation-rsi/
• http://emcrit.org/podcasts/neurocritical-care-intubation/
• http://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adults
• http://www.uptodate.com/contents/induction-agents-for-rapid-sequence-intubation-in-adults
• https://www.ncbi.nlm.nih.gov/pubmed/3403818
• http://onlinelibrary.wiley.com/doi/10.1002/ana.21459/full
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306060/
• https://www.uptodate.com/contents/cardiac-complications-of-stroke
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4306060/
• http://onlinelibrary.wiley.com/doi/10.1002/ana.21459/full