2. Mortality And Morbidity Conference Dr. Meenakshi Aggarwal PGY2 Emory University Family Medicine

3. AGENDAAGENDA  Case Review  Discussion  Take Home Points

4. 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.

5. History Contd :  Meds: None  Allergies: Latex  FHx: H/o seizures in paternal grandfather and 2 nephews.

6. Physical Examination  VS: T: 98F, HR: 89, BP: 117/63, SPo2: 99% on vent  O/E: Intubated  HEENT: Pupils sluggishly reactive B/L  Chest: Coarse breath sounds  CVS: RRR, No M/G/R  Abd: Soft, NT/ND  Neuro: Unresponsive. DTR 2+  Ext: No C/C/E  Skin: No rash

7. LABSLABS  CBC: H&H: 15.4/43.8, WBC’s: 6.8, Plat: 298,000  Chem: Na 143, K 3.4, BUN 16, Cr 1.1, BG 134, Ca 8.8  LFT’s: AST 134, ALT 99, Alk PO4 113  S.alcohol: 0.105  UDS: Neg  CE: CK 231, CKMB 2, troponin 0.04  U/A: Normal

8. Sinus Tachycardia

9. Management in the ER  Narcaine  Lidocaine drip  Bicarb  Ativan  Versed drip

10. BUT……BUT……  Pts urine looks GREEN.  IS THE PATIENT HAVING ETHYLENE GLYCOL POISONING???  Pt treated with Fomepizole and sent to the ICU.

11. Miscellaneous Labs  TSH: 3.08  Ethyl Alcohol: 0.105  Isopropyl Alcohol: Pending  Methanol: Pending  Ethylene Glycol: Pending

12. ST segment elevation in leads V1-V6 and reciprocal depression in the inferior leads.

13. Is this patient having MI???

14. 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

15.  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.

17. ST segment elevation in V1-V3 with RBBB

18. 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.

19. Brugada Syndrome  Structurally normal heart  Sudden death or syncope  Presentation characteristic of ventricular fibrillation or ventricular tachycardia  No prodromal symptoms

20.  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.

21. Etiology  Autosomal Dominant  Mutations in gene SCN5A that encodes for the sodium channels in the heart.  Other genetic mutations also found

22. Schematic of SCN5A. Some mutations are associated with combined phenotypes. α = Subunit

24. 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

25. 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

26. Types of EKG patterns in BS:

28. Treatment  ICD ( Implantable cardioverter - defibrillator)  Pharmacotherapy: No proven drugs

29. Conclusion NN ever compare your own urine with the patient’s urine…..

30. Take home points  Syndrome of ST segment elevation in V1-V3, RBBB and sudden death  Genetically determined  Sudden death can only be prevented by ICD’s

32. QUESTIONS?