Topics in this EM Quick Hits podcast

Ian Chernoff on traumatic coronary artery dissection (1:05 )

Anand Swaminathan on proper use of insulin in DKA and in hyperkalemia (15:50 )

Brit Long & Hans Rosenberg on mesenteric ischemia pearls and pitfalls in diagnosis and management (21:47 )

Dave Jerome on managing exercise-associated hyponatremia and heat illness (33:47 )

Jesse McLaren on the Queen of Hearts AI model in helping identify occlusion MI on ECG (50:50 )



Podcast production, editing and sound design by Anton Helman

Podcast written summary & blog post by Brandon Ng, edited by Anton Helman, September, 2024

Cite this podcast as: Helman, A. Chernoff, I. Swaminathan, A. Long, B. Rosenberg, H. Jerome, D. McLaren, J. EM Quick Hits 59 Traumatic Coronary Artery Dissection, Proper Use of Insulin, Mesenteric Ischemia, Exercise Associated Hyponatremia, AI for OMI. Emergency Medicine Cases. September, 2024. https://emergencymedicinecases.com/em-quick-hits-september-2024/. Accessed November 19, 2024.

Traumatic Coronary Artery Dissection - Best of University of Toronto EM



Traumatic coronary artery dissection is a rare, but often fatal injury that is challenging to diagnose and requires specific knowledge of it's clinical features. Clinical clues for traumatic coronary artery dissection include:



* History of blunt force chest trauma ranging from low to high energy mechanisms (direct blow to the chest, high speed motor vehicle crash)

* Possible delayed presentation by many hours to days to weeks

* Typical angina symptoms in young patient with no cardiac risk factors

* Wall motion abnormalities on cardiac PoCUS

* Elevated troponin

* ECG ischemic changes



Why is traumatic coronary artery dissection difficult to diagnose?



* Cardiac injuries ranging from contusions to dissections occur in 5-15% of blunt chest trauma; traumatic coronary artery dissection comprises a small proportion of these patients

* Symptoms may not present for days to weeks after inciting event

* May occur even with low energy mechanisms

* Most often occur in young patients who are not at risk for cardiac ischemia – 82% under age 45 and have been reported in as young as age 14

* Often overlooked due to low index of suspicion in the context of other concurrent traumatic injuries







Traumatic coronary artery dissection vs SCAD (Sontaneous Coronary Artery Dissection)



* There are some corollaries with SCAD and traumatic CAD in that both have historically been under-recognized;h owever, whereas SCAD has now belatedly been recognized as the leading cause of MI in women under age 50, traumatic CAD continues to be under appreciated











Workup of traumatic coronary artery dissection



* Patients complaining of chest pain after sustaining blunt chest trauma should undergo prompt cardiovascular workup

* Current Eastern Association for the Surgery of Trauma (EAST) guidelines propose an ECG as well as cardiac markers should be performed on any patient in which one suspects blunt cardiac injury; doing so appears practitioner dependent







A key pitfall in chest trauma is assuming that a borderline ECG and positive troponin is due only to cardiac contusion, which does not warrant activation of the cath lab.