Podcast #220: A-Fib Cardioversion

Author: Aaron Lessen, M.D.

Educational Pearls

  • Atrial fibrillation is common.
  • One of the best treatments for a fib is cardioversion back into sinus rhythm.
  • Cardioversion may increase stroke risk if A-Fib duration is greater than 48 hours, but some new data suggests that this risk may happen as soon as 12 hours.
  • However, newer studies show that cardioversion is generally safe as a treatment for A-Fib.

References: Aatish Garg, Monica Khunger, Sinziana Seicean, Mina K. Chung, Patrick J.Tchou Incidence of Thromboembolic Complications Within 30 Days of Electrical Cardioversion Performed Within 48 Hours of Atrial Fibrillation Onset. JACC: Clinical Electrophysiology Aug 2016, 2 (4) 487-494; DOI: 10.1016/j.jacep.2016.01.018

Podcast #213: Oats and Potatoes

Author: Michael Hunt, M.D.

Educational Pearls:

  • Oats have been shown to lower LDL.
  • Oat bran is the most effective way to consume oats to lower LDL.
  • A Swedish study of 69,000 people who ate at least 3 servings of potatoes a week showed no increased risk of a MI or stroke associated with potato consumption.

References: Larsson SC, Wolk A. Potato consumption and risk of cardiovascular disease: 2 prospective cohort studies. Am J Clin Nutr. 2016

 

Podcast #205: Post Cardiac Arrest Temperature Control

Author: Michael Hunt, M.D.

Educational Pearls:

  • Research has shown that the higher temperatures post-cardiac arrests may lead to poorer outcomes.
  • Initially, 33 deg C was the target temp. However, more research is being done to find therapeutic temperature levels.
  • New studies have shown that the cooling protocol differs for inpatient cardiac arrests vs. outpatient cardiac arrests.   The results show that it may not be necessary to cool inpatient cardiac arrests.

References: http://www.hopkinsmedicine.org/healthlibrary/test_procedures/cardiovascular/therapeutic_hypothermia_after_cardiac_arrest_135,393/

 

Podcast #204: Thoracotomy

Author: Aaron Lessen M.D.

Educational Pearls:

 

  • Thoracotomy is a potentially life-saving procedure. However, outcomes are often poor and the procedure itself poses many risks to provider and patient.
  • Chance of surviving a thoracotomy when there is no cardiac activity on ultrasound is 0%.
  • Performing a thoracotomy is unlikely to benefit patients with no cardiac activity on ultrasound or patients that lost vital signs greater than 10 minutes before starting the procedure.
  • A thoracotomy is maximally beneficial in patients with a penetrating chest injury that occurred less than 10 minutes before the procedure.

 

References: K. Inaba et al, “FAST Ultrasound Examination as a Predictor of Outcomes After Resuscitative Thoracotomy: A Prospective Evaluation” Ann. of Surgery, 2015. https://www.ncbi.nlm.nih.gov/pubmed/26258320

 

Podcast #199: Prolonged QT with Zofran

Author: Aaron Lessen M.D.

Educational Pearls:

  • Zofran (ondansetron) is generally safe to use for the treatment of nausea and vomiting. However, it can prolong the QT interval and increase the chance for torsades.
  • Low doses of Zofran are not likely to be an issue. However, when multiple doses are given, especially in the setting of a preexisting LQTS, clinical concern should be raised.
  • When giving Zofran to a patient with an increased risk for torsades, consider continuous cardiac monitoring or an alternate anti-emetic.

 

References:  https://www.fda.gov/Drugs/DrugSafety/ucm310190.htm

 

 

Podcast #197: Ashman Phenomenon

Author: Dylan Luyten M.D.

Educational Pearls:

  • Ashman’s Phenomenon occurs in the setting atrial fibrillation and mimics ventricular tachycardia, but is harmless.
  • On ECG, the pattern of Ashman Phenomenon is a long cycle, followed a short cycle, followed by a complex wide complex beat.
  • The wide complex beats have  right BBB morphology. The long R-R followed by a short R-R leads to conduction down the left bundle branch while the right bundle branch is still in a refractory period.

References: https://lifeinthefastlane.com/ecg-library/atrial-fibrillation/

Podcast #196: DVT and May-Thurner Syndrome

Author: Samuel Killian M.D.

Educational Pearls:

  • Lower extremity DVTs are extremely common. There are more left lower extremity DVT due to anatomical variation.
  • May-Thurner Syndrome is a form of anatomical variation in which the left iliac artery compresses the left iliac vein.
  • Anticoagulation may not be sufficient to treat those with May-Thurner syndrome – endovascular stenting may be needed
  • Patients with with recurrent LLE DVT, especially those in whom anticoagulation fails, should be referred to a specialist.

References: Peters M, Syed RK, Katz M, et al. May-Thurner syndrome: a not so uncommon cause of a common condition. Proceedings (Baylor University Medical Center). 2012;25(3):231-233. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3377287/

Podcast #184: Frostbite

c0f1bd63-7a23-4a10-83b7-9e4491410320Run Time: 3 minutes

Author: Michael Hunt M.D.

Educational Pearls:

  • Frostbite injuries are graded by the severity of tissue depth.
  • A Grade 1 injury has no cyanosis of the tissue, and usually just redness is present.
  • A Grade 2 injury has acral cyanosis.
  • A Grade 3 injury has cyanosis past the mid phalanx of the digits, resulting in a high chance of amputation.
  • A Grade 4 injury has cyanosis beyond metacarpal/metatarsal phalangeal joints, and almost certain amputation.
  • Treatment for frostbite is gradual rewarming in water of 100-104 degrees fahrenheit. If a patient has injuries to all 4 extremities the entire patient can be placed into a warm bath.
  • It is suggested that IV or intra arterial tPA can also be used to improve salvage of the digits because ice crystals form in the tissues when frostbite occurs, and when the patient is rewarmed they can be subjected to clotting.
  • The tPA must be started within 24hrs of rewarming – the time that the patient suffered the frostbite injury is not as important.

Link to Podcast: http://medicalminute.madewithopinion.com/frostbite/

References: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3440898/

Podcast #182: Syncope and PE

Run Time: 3:44 minutes

Author: Aaron Lessen, MD

Educational Pearls:

  • A new Italian study has been released, which looks at the prevalence of Pulmonary Embolism (PE) in patients admitted for syncope.
  • This study examined all patients admitted with syncope, regardless of their clinical picture, and worked them up for PE, which included wells score, D-dimer, and CT
  • Study demonstrated 1 out of 6 pts admitted for syncope had a PE.
  • Despite the headlines this study is making in the news, it is difficult to make conclusions. The study was not perfect, and mainly looked at a sick population of patients (only those who warranted admission) who had many comorbidities.  Until further studies are conduction, current practice should be to only work up syncope patients for a PE if they are exhibiting related signs and symptoms.

Link to Podcast: http://medicalminute.madewithopinion.com/syncope-and-pe/

References: http://www.heart.org/HEARTORG/Conditions/Arrhythmia/SymptomsDiagnosisMonitoringofArrhythmia/Syncope-Fainting_UCM_430006_Article.jsp

Podcast #180: Aortic Dissection

a_dissectionRun Time:  4 minutes

Author: Jared Scott, MD

Educational Pearls:

  • Aortic dissection = separation between 2 layers of vessel wall (usually intima and media)
  • Aortic Aneurysm = cystic dilation of the aorta
  • Aortic dissection associated with severe HTN or connective tissue disorders (Marfan’s, Ehlers-Danlos, etc.)
  • AAA associated with HTN, DM, HLD, smoking (same risks for MI)
  • Aortic dissection starts proximal in chest and peels down
  • AAA confined to abdomen and can rupture. 90% mortality.

Link to Podcast: http://medicalminute.madewithopinion.com/aortic-dissection/

References: http://www.mayoclinic.org/diseases-conditions/aortic-dissection/basics/definition/con-20032930