POTD: Brugada Syndrome

POTD: Brugada syndrome

Brugada syndrome is a cardiac disease cause by an inherited ion channelopathy (Na, K, and Ca channels affected) with a propensity to develop Vfib, Vtach, Afib, and rarely SVT leading to sudden death. Most events happen between midnight to 6am - in Thailand, Brugada Syndrome is known as "Lai Tai" or "death during sleep".

Demographics: asian, average age 41 yo, males are 9x more likely

EKG can be sinus then Brugada can triggered by fever, vagal tone, cocaine/alcohol use, ischemia, hypoK, hypothermia, medications (sodium channel blockers, calcium channel blockers, nitrates, a agonist, B blocker)

History: ask for family history of sudden death < 45yo, syncope and cardiac symptoms in the past

EKG look in V1/2

Type 1: elevated ST> 2mm that descends with upward convexity to TWI

Type 2: elevated ST> 1mm that descends toward baseline then rises again to upright T wave

Type 3: elevated ST> 1mm descends toward baseline then rises again to upright T wave

Treatment

If patient is asymptomatic and Brugada EKG was found incidentally, you can discharge with cardiology follow up.

If the patient has syncope, chest pain, sob or any concerning symptoms, admit for EPS study and ICD placement.

If the patient is in tachyarrhythmia (Vfib, Vtach, etc) and the patient is unstable, cardiovert

If the patient is stable, requiring recurrent cardioversion, or having recurrent shocks from pt's ICD (people known to have 50+ shocks etc.), you should treat medically. Ideally, consult cardiology for recommendations. If you are solo coverage in community without cardiology...oh God...

Given the channelopathies, many commonly used VTach medications for Brugada are contraindicated or ineffective.

www.brugadadrugs.org is a great site to tell you which medications should not be used: procainamide, flecanide, bupivacaine, propofol, ketamine, tramadol, lithium

Amiodarone is ineffective, case studies have found that it can unmask hidden Brugada but will not terminate the rhythm. BB and CCBs are also shown to be ineffective.

Quinidine is the best studied medication for tachyarrhythmias in Brugada, terminating 80% of arrhythmias. (Interestingly it is a Na channel blocker, but it's blockade effect on Ito an outflowing K channel is what helps it treat Brugada)

Immediate release form 200-400 mg PO q6h, then extended release 324 mg PO q12

Isoproterenol (B1/B2 agonist) is less studied but it can be given as a drip at 2-10 mcg/min tritrated to effect.

I spoke to pharmacy at Maimo and they were kinda enough to ask Dr. Adzic who said he would use Quinidine or Isoproterenol not amio.

Dental Trauma

Dental Trauma

Pulp – inner layer with neurovascular supply

Dentin – most of tooth under enamel

Enamel – thin outer layer

Cementum – outer layer of root surface

Crown – visible part of tooth

Root – part not visible covered by cementum

Primary/pediatric teeth – 20 teeth, 8 incisors, 4 canines, 8 molars, central incisors start at 7 months of age, 20 by 3 years of age (named A->T)

Permanent Teeth – 32 permanent teeth (8 incisors, 4 canines, 8 premolars, 12 molars), rerupt at 6-7 yo and all 32 by 13 yo

Fracture – evaluate for tooth mobility, sensitivity, fracture

Ellis class I: fracture of enamel, tooth is painless, superficial fracture, no intervention needed, refer to dentistry

Ellis Class II: dentin fracture, dentin which is has soft golden yellow appearance can be seen, this has higher risk of pulp necrosis/infection, needs f/u with dentistry within 24h, consider dental block for pain relief, CaOH sealant

CaOH paste comes in 2 tubes that need to be mixed then spread over the tooth after it has been dried off (have patient bite down on gauze or soak gauze with epinephrine)

Ellis III: pulp exposure which is a dental emergency, usually very painful unclear neurovascular damage, if pink or bloody discharge at fracture surface, need emergent dental evaluation in ED, high risk of abscess formation

              Cover with CaOH, likely will need root canal by dentistry

Subluxation – tooth is mobile but not displaced, conservative management w/ soft diet and dental f/u

Luxation – tooth is partially displaced from socket, need tooth splinting for 2-4 weeks, need emergent dental consult

Intrusion – tooth displaced apically, if deep > 3 mm, needs emergent dentistry for repositioning and stabilization, if < 3mm, needs urgent 24h dental f/u

              Consider CTH w/ face for boney fracture, consider CXR for aspiration, XR

Complete Avulsion – loss of entire tooth from socket, dental emergency

1. when did trauma occur – each minute tooth is out reduces viability by 1%, ideally reposition in 15-30 min

2. where is tooth? Aspirated (CXR), swallowed, embedded in oral mucosa, if you have the tooth, touch only the crown, rinse with water and ideally keep the tooth in the socket

              Store tooth in saliva (mouth), milk, saline (less ideal)

3. is tooth primary/permanent

primary tooth should not be re-implanted, needs dental f/u

permanent tooth needs emergent dentistry, periodontal ligament cells can die within 60 min the tooth is outside oral cavity, reimplant tooth to preserve periodontal ligament – splint until definitive management

Look for mandibular fracture – can pt open mouth normally, tongue blade test (can pt keep mouth closed to break a tongue blade when twisted), is there pre-auricular tenderness, hematoma at floor of mouth

EMS protocol of the week: Eye Injury

Let’s use this week as a cool down from all the talk of controlled substances over the last couple emails. This will be more of an FYI email, a reminder of what EMS does in the field. Attached are (BLS) Protocol 427 – Eye Injuries and (ALS) Protocol 527 – Chemical Eye Injuries.

427 lays out the initial BLS approach to a patient with an eye injury – they’ll be monitoring ABC’s, assessing for concomitant injuries, provide loose bandaging (WITHOUT putting pressure on the globe) and assisting with contact lens removal, if applicable. If there is concern for a foreign object, they will start irrigation with NS, and if there is an avulsion, they will stabilize, dress, and NOT attempt replacement (presumably after screaming internally, as we all would).

I include the BLS protocol because the ALS protocol starts by referring to BLS procedures (remember 1. that trauma is a BLS call type and 2. that good ALS care starts with good BLS care). The only thing 527 adds is topical analgesia in the form of either Proparacaine or Tetracaine. Did you know that ALS carries eye drops? Crazy!

All of this is Standing Order, so you likely won’t be receiving many OLMC calls with regards to these protocols, but hopefully this helps further your awareness of what sort of care patients may have received in the field.

Reach out with any questions/comments, check out www.nycremsco.org, and don’t forget about the binder!