Educational Goals and Objectives
The educational objectives for the Emergency Medicine resident while on the Cardiac ICU rotation are as follows:
- Demonstrate the ability to perform an appropriate history and physical examination on the patient presenting with cardiac disease.
- Demonstrate the ability to perform the following procedures: endotracheal and nasotracheal intubations, cricothyrotomy, needle thoracostomy, central intravenous placement, Swan-Ganz placement, transvenous and transcutaneous cardiac pacing, arterial line placement, ABG, and foley catheterization.
- Demonstrate the ability to manage a patient on a ventilator.
- Demonstrate appropriate prioritization of diagnostic and therapeutic interventions in critically ill patients.
- Demonstrate knowledge of AHA recommendation for the treatment of acute ventricular fibrillation, ventricular tachycardia, asystole, pulseless electrical activity, atrial flutter and fibrillation, junctional ectopy, pre-excitation, supraventricular tachycardia, bradycardia, sick-sinus syndrome, and atrial-ventricular blocks.
- Describe the dosages, indications, and contraindications of pharmacologic interventions for shock, cardiac failure, dysrhythmias, sepsis, trauma, toxins, respiratory failure, hepatic failure, renal failure, and neurologic illnesses.
- Describe the etiologies, hemodynamic issues, and complications of septic, hypovolemic, neurogenic, cardiogenic, and immunologic shock.
- Discuss and interpret data from ECG monitors, cardiac outputs, hemodynamic monitoring, pulse oximetry, end tidal CO2 monitors and respirators.
- Demonstrate appropriate judgment in the management of critically ill patients.
- List items elicited from the history of patient with chest pain to suggest a risk for cardiac etiology.
- Discuss limitations in differentiation of cardiac chest pain from non-cardiac pain in patients with risk factors.
- Describe the pathophysiology of cardiac ischemia, acute angina chest pain, and acute myocardial infarction.
- Describe the typical electrocardiograph findings of patients with myocardial ischemia and subendocardial, myocardial, and transmural infarction.
- Discuss differential diagnosis of atypical chest pain.
- Discuss atypical presentations for acute cardiac ischemia and myocardial infarction.
- Discuss the sensitivity and specificity of ancillary studies for chest pain presentations including EKG, CXR, cardiac enzymes, and ABG.
- Describe the appropriate triage considerations for patients presenting to the ED with chest pain.
- Differentiate between stable and unstable angina and outline the initial treatment of patients with unstable angina including the use of nitrates, beta blockers, calcium channel blockers, etc.
- Discuss the concept of “silent” myocardial infarction and ischemia.
- Differentiate between transmural versus subendocardial infarction.
- Discuss the significance of acute complete AV block with inferior myocardial infarction versus anterior myocardial infarction.
- Describe the clinical findings of cardiogenic shock and outline therapy for cardiogenic shock.
- Differentiate cardiogenic shock from other etiologies for shock.
- Describe the clinical presentation for pericardial disease and outline the appropriate initial therapy and management for pericardial disease.
- Describe the presentations for myocardial infarction and their association with vessel involvement and outline initial treatment for myocardial infarction.
- List the indications, contraindications and complications of thrombolytic therapy for acute myocardial infarction.
- Describe the clinical presentation, etiologies for pathophysiology of, and current therapy for acute congestive heart failure.
- Describe the valvular anatomy of the heart and list etiologies for valvular heart disease.
- Describe the clinical findings of a mitral valve prolapse, valvular aortic stenosis, aortic regurgitation, tricuspid stenosis, tricuspid regurgitation, and pulmonary stenosis, and discuss management of these abnormalities.
- List complications of prosthetic cardiac valves and appropriate ED management.
- Differentiate between congestive cardiomyopathy, hypertrophic cardiomyopathy, and restrictive cardiomyopathy with the appropriate therapy for each.
- Define myocarditis and describe the EKG findings and acute management of myocarditis.
- Discuss the pathophysiology of acute pulmonary embolism and the predisposing factors for pulmonary embolism.
- Discuss the sensitivity and specificity of the various tests used to diagnose pulmonary embolism including ABG, EKG, CXR, etc.
- Discuss the sensitivity and specificity of ventilation-perfusion scan in acute pulmonary embolism.
- Outline treatment for acute pulmonary embolism.
- Differentiate between acute hypertensive emergencies, hypertensive urgency, and uncomplicated hypertension.
- Discuss the indications for treatment of hypertension in the ED.
- Describe the syndrome of hypertensive encephalopathy.
- Outline the treatment for acute hypertensive emergency and differentiate treatment in the setting of thoracic aortic dissection.
- Differentiate between primary agents for hypertensive emergency to include their advantages and disadvantages.
- Discuss the pathophysiology, etiology, and overall morbidity and mortality of patients presenting with acute aortic dissection.
- Explain the ED management of acute aortic dissection.
- Differentiate between expanding, ruptured, and dissecting aortic aneurysms.
Practice Based Learning and Improvement
- Demonstrate ability to obtain and appraise medical literature applicable to the management and treatment of cardiac patients.
Interpersonal and Communication Skills
- Demonstrate an understanding of the appropriate use of consultants in cardiac patients.
- Demonstrate an understanding of the ethical and legal principles applicable to the care of the critically ill patients.
The Emergency Medicine resident will accomplish these objectives in the following manner:
- Attend and participate in daily Cardiac ICU teaching rounds
- Attend all conferences given by the Department of Medicine while on rotation.
- Evaluate and manage patients under the supervision of Cardiac ICU faculty and fellows. Progressive patient care responsibilities are at the discretion of the Cardiac ICU faculty based on the resident’s clinical experiences, didactic knowledge, psychomotor skills, procedural abilities and credentialing.
- Discuss and interpret results of all ancillary testing with supervisory faculty.
- Perform procedures under faculty supervision commensurate with their post-graduate level of training and skill.
Where: 6th floor, CSCU
When: Monday – Friday: Come early on your first day (around 7am) so the fellow or other residents can show you how to review the telemetry events and round on your patients. Receive sign out from another resident. You may save yourself time on the first day if the previous EM rotator can sign out their patients to you. Rounds are variable, depending on the attending for the week. You can find out who the attending will be on the schedule (see below) and ask medicine residents when they typically round.
Schedule spreadsheet: Log on to mytbhc.org when you are in the hospital (no remote access). On the right side under the search bar click on button “on call schedule.” Then click “Resident Attending On-Call List,” scroll down to excel icon that says “Internal Medicine Resident.” Download this file. The first tab is a monthly view and the other tabs are for the weekly schedules.
Supervisor: Ramesh Gowda, MD (Chief of Cardiology)
- Ext: 8265
Attire: Scrubs with lab coat or professional attire with lab coat
Preparation: You should read the Cardiology chapters in Tintinalli, specifically on ACS and CHF. Also, review ECG basics, rate and rhythm abnormalities, etc. Dubin’s Rapid Interpretation of EKGs is a trusted and quick read. Online you can take a look at this list of free resources: http://lifeinthefastlane.com/ecg-library/best-ecg-resources/
Expectations: You’ll come in the morning prior to rounds and see all of your patients, document any overnight symptoms or telemetry events and prepare for rounds. The fellow or another resident will show you how to print the relevant telemetry events. You will first round with the fellow and then with the attending. After rounds you will finish up your tasks and duties for each patient and follow up results from tests you ordered that day. Discuss your patients with the fellow prior to leaving for the day. Make sure to update your patients and any new admissions on the official census (someone from the team will show you how).