Podcast # 460: Hunting for PE in Syncope

Author:  Michael Hunt, MD

Educational Pearls:

 

  • Most causes of syncope are benign
  • Pulmonary embolism can result in syncope and is life threatening
  • A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
  • PE should always be considered in cases of syncope but overall is a rare cause

 

Editor’s note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope – which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 452: CADASIL

Author: Sam Killian, MD

Educational Pearls:

  • Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals
  • The disease is caused by a defect in the NOTCH3 gene on chromosome 19
  • It is an important cause of stroke in young patients
  • Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy
  • Migraine with aura is often the first presenting symptom with onset by age 30
  • Strokes typically can occur by age 50
  • Diagnosis is with MRI for characteristic lesions
  • Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins

References:

Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast #441: Is Heparin Worthless for ACS?

Author: Don Stader, MD

Educational Pearls:

 

  • Recent study demonstrated patients with non-STEMI treated with heparin had no difference in survival, but had an increased risk of major bleeding
  • Heparin may be an outdated medication in the era of dual anti-platelet therapy and PCI
  • Heparin may fall to the wayside like other former treatments for ACS such as morphine, oxygen and nitroglycerin as far as mortality benefit

 

References:

Chen JY, He PC, Liu YH, Wei XB, Jiang L, Guo W, Duan CY, Guo YS, Yu XP, Li J, Li WS, Zhou YL, Lin CY, Luo JF, Yu DQ, Chen ZJ, Chen W, Chen YY, Guo ZQ, Geng QS, Tan N. Association of Parenteral Anticoagulation Therapy With Outcomes in Chinese Patients Undergoing Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome. JAMA Intern Med. 2019 Feb 1;179(2):186-194. doi: 10.1001/jamainternmed.2018.5953. PubMed PMID: 30592483

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 423: Blunt Cardiac Injuries

Author: Mike Hunt, MD

Educational Pearls:

 

  • Blunt cardiac injuries most commonly occur in motor vehicle collisions, auto-pedestrian collisions, and from sports injuries
  • The more anterior right ventricle is the most commonly injured structure
  • Look for new EKG changes such as bundle branch blocks, ST changes, or other arrhythmias
  • New EKG abnormalities should prompt consideration of further workup and admission for telemetry
  • Patients may have an elevated troponin – but it is unclear when exactly this should be drawn after the injury

 

References:

Bellister SA, Dennis BM, Guillamondegui OD. Blunt and Penetrating Cardiac Trauma. Surg Clin North Am. 2017 Oct;97(5):1065-1076. doi: 10.1016/j.suc.2017.06.012. Review. PubMed PMID: 28958358.

Marcolini EG, Keegan J. Blunt Cardiac Injury. Emerg Med Clin North Am. 2015 Aug;33(3):519-27. doi: 10.1016/j.emc.2015.04.003. Epub 2015 Jun 10. Review. PubMed PMID: 26226863.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 419: Etripamil

Author: Don Stader, MD

Educational Pearls:

 

  • Etripamil is an intranasal calcium channel blocker in development for use in SVT
  • A recent study showed that etripamil has an SVT conversion rate of around 80%
  • Etripamil does not have the same feeling of “impending doom” that can occur with adenosine

Editor’s note: Etripamil is still in development and these results are from a phase II clinical trial.

 

References:

Stambler BS, Dorian P, Sager PT, Wight D, Douville P, Potvin D, Shamszad P, Haberman RJ, Kuk RS, Lakkireddy DR, Teixeira JM, Bilchick KC, Damle RS, Bernstein RC, Lam WW, O’Neill G, Noseworthy PA, Venkatachalam KL, Coutu B, Mondésert B, Plat F. Etripamil Nasal Spray for Rapid Conversion of Supraventricular Tachycardia to Sinus Rhythm. J Am Coll Cardiol. 2018 Jul 31;72(5):489-497. doi: 10.1016/j.jacc.2018.04.082. PubMed PMID: 30049309.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 418: Vertebral Artery Dissection

Author: Don Stader, MD

Educational Pearls:

  • Vertebral artery dissection (VAD) contributes to just 2% of strokes overall but ~25% of strokes for patients < 30
  • VAD is associated with minor trauma (chiropractic manipulation, yoga), typically with neck extension and rotation.
  • VAD can cause posterior stroke symptoms (vertigo, diplopia, Horner’s Syndrome, Wallenberg Syndrome)
  • Overall a good prognosis with around 50% of patients recovering without lasting neurologic deficits.

References:

Debette S, Leys D. Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol. 2009 Jul;8(7):668-78. doi: 10.1016/S1474-4422(09)70084-5. Review. PubMed PMID: 19539238.

Gottesman RF, Sharma P, Robinson KA, et al. Clinical characteristics of symptomatic vertebral artery dissection: a systematic review. Neurologist. 2012;18(5):245-54.

Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001 Mar 22;344(12):898-906. Review. PubMed PMID: 11259724.

 

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

 

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Podcast # 416: Wide Complex Tachycardia

Author: Aaron Lessen, MD

Educational Pearls:

  • Defined as QRS over 120 ms and rate over 120
  • Two major rhythms = Vetricular tachycardia (VT) or SVT with aberrancy
  • Safest approach is to assume it is VT
  • Synchronized Cardioversion is preferred even for stable VT for multiple reasons including safety and efficacy
  • Procainamide is preferred pharmacologic option
  • Amiodarone is less preferred third option
  • Calcium channel blockers (i.e. diltiazem) can worsen certain rhythms and should be avoided

References:

Long B, Koyfman A. Best Clinical Practice: Emergency Medicine Management of Stable Monomorphic Ventricular Tachycardia. J Emerg Med. 2017 Apr;52(4):484-492. doi: 10.1016/j.jemermed.2016.09.010. Epub 2016 Oct 15. Review. PubMed PMID: 27751700.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 414: Acute Limb Ischemia

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Symptoms of acute limb ischemia are the 5 P’s: Pulselessness, pain, pallor, paresthesias, and poikilothermia
  • Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis
  • Obtaining an ankle brachial index (ABI) can help confirm the diagnosis
  • Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging

 

References:

Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast #409:  Acute CHF Second Liners

Author: Nick Hatch, MD

Educational Pearls:

 

  • Quick review on typical treatments for acute CHF:
    • Nitrates are a mainstay to reduce preload
    • Furosemide has fallen out of favor in regards to urgency but still essential; it can also be utilized in those with poor renal function
  • Before going into the weeds:
    • Phlebotomy can be used to remove volume and may be helpful in certain clinical scenarios
    • Trapping venous blood by using blood pressure cuffs on three of four extremities was a very early treatment of CHF

 

References:

Alzahri MS, Rohra A, Peacock WF. Nitrates as a Treatment of Acute Heart Failure. Card Fail Rev. 2016 May;2(1):51-55. doi: 10.15420/cfr.2016:3:3. PubMed PMID: 28785453; PubMed Central PMCID: PMC5490950.

Paterna S, Di Gaudio F, La Rocca V, Balistreri F, Greco M, Torres D, Lupo U, Rizzo G, di Pasquale P, Indelicato S, Cuttitta F, Butler J, Parrinello G. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose-Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015 Oct;32(10):971-82. doi: 10.1007/s12325-015-0254-9. Epub 2015 Oct 31. PubMed PMID: 26521190; PubMed Central PMCID: PMC4635178.

Huijskes RV, Hoogenberg K, Wiesfeld AC, Pijl ME, van Gelder IC. Phlebotomies as a treatment of serious heart failure due to haemochromatosis: a case report. Neth Heart J. 2009;17(11):438-41.

Burch, George E., and Nicholas P. DePasquale. “Congestive Heart Failure—Acute Pulmonary Edema.” JAMA 208.10 (1969): 1895-1897.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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Podcast #400: ECMO

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Extracorporeal membrane oxygenation (ECMO) is similar to bypass
  • ECMO is being utilized routinely at some centers and even prehospital in cardiac arrest
  • There are two general types of ECMO:
    • Venovenous (VV-ECMO) is useful when the patient cannot oxygenate but has adequate heart function.
    • Venoarterial (VA-ECMO) is more like typical bypass and can be used in a pulseless patient

 

References:

Ouweneel DM, Schotborgh JV, Limpens J, Sjauw KD, Engström AE, Lagrand WK, Cherpanath TGV, Driessen AHG, de Mol BAJM, Henriques JPS. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med. 2016 Dec;42(12):1922-1934. doi: 10.1007/s00134-016-4536-8. Epub 2016 Sep 19. Review. PubMed PMID: 27647331; PubMed Central PMCID: PMC5106498.

Tonna JE, Johnson NJ, Greenwood J, Gaieski DF, Shinar Z, Bellezo JM, Becker L, Shah AP, Youngquist ST, Mallin MP, Fair JF 3rd, Gunnerson KJ, Weng C, McKellar S; Extracorporeal REsuscitation ConsorTium (ERECT) Research Group.. Practice characteristics of Emergency Department extracorporeal cardiopulmonary resuscitation (eCPR) programs in the United States: The current state of the art of Emergency Department extracorporeal membrane oxygenation (ED ECMO). Resuscitation. 2016 Oct;107:38-46. doi: 10.1016/j.resuscitation.2016.07.237. Epub 2016 Aug 11. PubMed PMID: 27523953; PubMed Central PMCID: PMC5475402.

 

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

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