Author: Nick Tsipis, MD
- Persistent fever or positive blood cultures should raise suspicion for endocarditis
- Patients with recent dental procedures, recent cardiac surgeries are at risk, or who inject drugs are at higher risk
- Physical exam findings may include fever with a new murmur, Janeway lesions, Osler nodes, and/or splinter hemorrhages
Long B, Koyfman A. Infectious endocarditis: An update for emergency clinicians. Am J Emerg Med. 2018 Sep;36(9):1686-1692. doi: 10.1016/j.ajem.2018.06.074. Epub 2018 Jul 2. Review. PubMed PMID: 30001813.
Murdoch DR, Corey GR, Hoen B et. al. International Collaboration on Endocarditis-Prospective Cohort Study (ICE-PCS) Investigators. Clinical presentation, etiology, and outcome of infective endocarditis in the 21st century: the International Collaboration on Endocarditis-Prospective Cohort Study. Arch Intern Med. 2009 Mar 9;169(5):463-73. doi: 10.1001/archinternmed.2008.603
Author: Sue Chilton, MD
- An unusual cause of leg pain that can mimic sciatica/claudication
- Predominantly occurring in high endurance athletes, particularly cyclists and runners
- Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive
Mansour A, Murney S, Jordan K, Laperna L. Endofibrosis: an unusual cause of leg pain in an athlete. J Sports Med Phys Fitness. 2016 Jan-Feb;56(1-2):157-61. Epub 2015 Jul 3. PubMed PMID: 26140352.
Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: a systematic review. Eur J Vasc Endovasc Surg. 2012;43(2):208–17.
Author: Don Stader, MD
- 8014 patients with out-of-hospital cardiac arrest randomized to epinephrine vs placebo
- 30-day survival was not dramatically better between groups (3.2%in the epinephrine group and 2.4% in the placebo group)
- Functional neurological outcome was nearly identical at 2.2% and 1.9% of patients
- Adds to literature that epinephrine provides little important benefit in cardiac arrest – focus on chest compressions and early defibrillation
Editor’s note: NNT for epinephrine to prevent one death in this study was 115 – compared to bystander CPR (NNT 15) and defibrillation (NNT 5) from prior studies.
Perkins GD et. al. . A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018 Aug 23;379(8):711-721. doi: 10.1056/NEJMoa1806842. Epub 2018 Jul 18.
Kitamura T, Kiyohara K, Sakai T, et al. Public-access defibrillation and out-of-hospital cardiac arrest in Japan. N Engl J Med 2016;375:1649-1659.
Hasselqvist-Ax I, Riva G, Herlitz J, et al. Early cardiopulmonary resuscitation in out-of-hospital cardiac arrest. N Engl J Med 2015;372:2307-2315.
Hagihara A, Hasegawa M, Abe T, Nagata T, Wakata Y, Miyazaki S. Prehospital epinephrine use and survival among patients with out-of-hospital cardiac arrest. JAMA. 2012 Mar 21;307(11):1161-8. doi: 10.1001/jama.2012.294. PubMed PMID: 22436956.
Sanghavi P, Jena AB, Newhouse JP, Zaslavsky AM. Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. JAMA Intern Med. 2015 Feb;175(2):196-204. doi: 10.1001/jamainternmed.2014.5420.
Author: Jared Scott, MD
- EKG changes do not necessarily correlate to degree of hyperkalemia
- Traditional progression through peaked T-waves, flattened p-waves, QRS widening, and then sine-waves before asystole
Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.
Author: Aaron Lessen, MD
- Non-blinded randomized study assessing 30-day mortality benefit from plasma-first resuscitation in patients at risk hemorrhagic shock
- Study involved aeromedical transport of trauma patients
- 30-day mortality 23.2 % in intervention group vs. 33.0% in standard care group
Editor’s note: a similar study published in Lancet at the same time showed no mortality benefit from prehospital administration of plasma in a slightly different population which had much shorter ground transport times a major trauma center
Sperry JL, Guyette FX, Brown JB, Yazer MH, Triulzi DJ, Early-Young BJ, Adams PW, Daley BJ, Miller RS, Harbrecht BG, Claridge JA, Phelan HA, Witham WR, Putnam AT, Duane TM, Alarcon LH, Callaway CW, Zuckerbraun BS, Neal MD, Rosengart MR, Forsythe RM, Billiar TR, Yealy DM, Peitzman AB, Zenati MS; PAMPer Study Group.. Prehospital Plasma during Air Medical Transport in Trauma Patients at Risk for Hemorrhagic Shock. N Engl J Med. 2018 Jul 26;379(4):315-326. doi: 10.1056/NEJMoa1802345.
Author: Jared Scott, MD.
- Make sure to monitor for limb ischemia in all patients on vasopressors
- Good reminder that vasopressors are not risk free – use them only on patients that need them!
Daroca-Pérez, R., & Carrascosa, M. F. . Digital necrosis: a potential risk of high-dose norepinephrine. Therapeutic Advances in Drug Safety. 2017. 8(8), 259–261. http://doi.org/10.1177/2042098617712669.
Author: Peter Bakes, MD
- Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation.
- Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads.
- Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.
Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138?. ISBN 978-1-4160-0311-3.
Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.
Author: Pete Bakes, MD
- AICD: Automated Implantable Cardioverter-Defibrillator.
- Can be placed for secondary prevention of cardiac arrest (i.e. history of cardiac arrest not from reversible cause).
- Also indications for primary prevention: EF 35% or less; ventricular tachycardia with underlying structural heart disease; Brugada; genetic-induced prolonged QT-syndromes.
Al-Khatib SM et. al. 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2017 Oct 30. pii: S1547-5271(17)31249-3. doi: 10.1016/j.hrthm.2017.10.035.
Author: Nick Hatch, MD.
- A common concern using vasopressors is the risk of digital and mesenteric ischemia.
- The absolute risk of digital ischemia and/or mesenteric ischemia is pretty low. Norepinephrine at its highest doses carries a 5% digital ischemia rate and a 2% mesenteric ischemia rate.
- The studies demonstrating this complication were predominately patients with pre-existing liver disease.
- Providers commonly mistake purpura fulminans, a common complication of sepsis, for digital ischemia.
Brown, SM. et al. Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest. 2013. 143(3), 664?671. http://doi.org/10.1378/chest.12-1106.
Malay MB et al. Heterogeneity of the vasoconstrictor effect of vasopressin in septic shock. Critical Care Medicine. 2004. 32(6), 1327-31.
Author: Chris Holmes, MD
- Epidemiology: 80% male, ages 1-4 at greatest risk, African-American > Caucasian.
- Freshwater and ocean water may have more bacteria than pool water.
- Salt water is hyperosmolar, which theoretically increases risk of pulmonary edema.
- Greatest physiologic insult is from hypoxia secondary to fluid aspiration or laryngeal spasm. Patient survival is related to presentation on arrival.
- Workup includes CXR and ABG; consider C-spine immobilization/imaging when cervical injury is strongly suspected (i.e. diving injury).
- Treatment consists of supplemental oxygen therapy. Consider CPAP or intubation.
Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012. 366(22):2102-10. doi: 10.1056/NEJMra1013317.
Schmidt A, Sempsrott J. Drowning In The Adult Population: Emergency Department Resuscitation And Treatment. Emerg Med Pract. 2015. 17(5):1-18.