Mortality And Morbidity Conference Dr. Meenakshi Aggarwal PGY2 Emory University Family Medicine
AGENDAAGENDA Case Review Discussion Take Home Points
CASE HISTORY C/C: Sudden loss of consciousness HPI: 32 Y/o WM brought in by EMS due to sudden loss of consciousness and found to be having V-Fib cardiac arrest. PMH: None PSH: None SHx: Smoker 1 PPD x 15yrs, occasional alcohol, no drugs. Works as a car mechanic.
History Contd : Meds: None Allergies: Latex FHx: H/o seizures in paternal grandfather and 2 nephews.
Management in the ICU Lidocaine drip d/ced and amiodarone drip started. Pt was given loading dose of lovenox and EKG repeated. ASA given through nasogastric tube and CE’s sent Cardiologist was called Lopressor I/V x3 given
Patient needs to be transported through air ambulance BUT crew not available. Wait….. Wait…. Finally, after 2 hrs, patient transported by road ambulance at 6 am in the morning.
Brugada Syndrome Disorder characterized by ST segment elevation in leads V1 through V3 on EKG RBBB EKG abnormalities may not be evident until unmasked by flecainide or procainamide infusion (antiarrythmic drugs) or augmented by beta blockers.
Brugada Syndrome Structurally normal heart Sudden death or syncope Presentation characteristic of ventricular fibrillation or ventricular tachycardia No prodromal symptoms
Typical electrocardiogram of Brugada syndrome. Note the pattern resembling a right bundle branch block, the P-R prolongation and the ST elevation in leads V1-V3.
Etiology Autosomal Dominant Mutations in gene SCN5A that encodes for the sodium channels in the heart. Other genetic mutations also found
Schematic of SCN5A. Some mutations are associated with combined phenotypes. α = Subunit
Drugs that can induce BS like EKG pattern Na channel blockers: Class IC drugs (flecainide,encainide) Class IA drugs ( procainamide) Lithium Ca channel blockers Beta blockers TCA (amitriptyline, nortriptyline) SSRI’s ( Fluoxetine) Cocaine Intoxication Alcohol intoxication
FeatureType 1Type 2Type 3 J wave amplitude > 2 mm T waveNegativePositive or biphasic Positive ST-T configuration Coved typeSaddle back ST segment (terminal portion) Gradually descending Elevated > 1mm Elevated < 1 mm Types Of EKG Patterns in BS