Category: Cardiovascular

Podcast # 367: Digital Necrosis after Epi Drip

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Author: Jared Scott, MD.

Educational Pearls:

  • 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!

References

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.

Podcast # 364: Other causes of ST elevation

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Author: Peter Bakes, MD

Educational Pearls:

  • 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.

 

References

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.

Podcast # 359: Normal EKG

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Author: Sam Killian, MD.

Educational Pearls:

  • Computer interpretation has a very good negative predictive value of a normal EKG (99%).
  • Of 222 interpreted as “normal,” 13 were deemed to have some abnormality by a cardiologist in a recent study.
  • Those 13 EKG’s were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.

References

Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones  Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.

Podcast #351: Indications for AICD

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Author:  Pete Bakes, MD

Educational Pearls:

  • 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.

References:

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.

Podcast # 350: Pressors and Ischemia

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Author: Nick Hatch, MD.

Educational Pearls:

  • 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.

 

References

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.

Podcast # 340: Drowning

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Author: Chris Holmes, MD

Educational Pearls:

  • 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.

References

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.

Podcast #332: Door To Furosemide Time

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Author: Nick Hatch, MD

Educational Pearls:

  • Recent study argues that CHF patients receiving furosemide within 60 minutes of arrival had a lower in-hospital mortality than those receiving it after (2.3% vs. 6.0%, p=0.002).
  • A flaw in the study is that there were significant baseline differences between groups.

References:

Matsue Y et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. JACC 2017. PMID: 28641794

Podcast #320: PE in Pregnancy

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Author: Don Stader, M.D.

Educational Pearls:

  • Pulmonary embolism is one of the leading causes of maternal mortality.
  • There is disagreement among different medical societies about the value of D-dimer as a screening modality. If you use it, consider the rational D-dimer approach whereby you add 250 to your cut-off for every trimester.
  • A useful screening modality is an ultrasound of bilateral lower extremities looking for DVT.
  • Keep in mind, both a V/Q scan and CT scan have a significant amount of radiation. CTA is probably the right diagnostic test (less radiation than CT w&w/o).
  • Always use the shared decision-making model and clinical acumen to choose your tests.

References:

Leung AN, et. al. (2011). An official American Thoracic Society/Society of Thoracic Radiology clinical practice guideline: evaluation of suspected pulmonary embolism in pregnancy. American Journal of Respiratory and Critical Care Medicine. 184(10):1200-8

 

Polak JF, Wilkinson DL. (1991). Ultrasonographic diagnosis of symptomatic deep venous thrombosis in pregnancy. American Journal of Obstetrics and Gynecology. 165(3):625-9.

Sachs BP, et. al. (1987). Maternal mortality in Massachusetts. Trends and prevention. New England Journal of Medicine. 316(11):667-72.

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Podcast #319: Cardiac Arrest Survival Factors

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Author: Aaron Lessen, MD

Educational Pearls:

  • Shockable rhythms like V-fib or V-tach have a better prognosis than patients with PEA or asystole.
  • Recent study has shown an initial electrical frequency in PEA between 10-24/min had worse outcomes than PEA with initial rhythm over 60/min.
  • Patients with an initial electrical frequency in PEA over 60/min did just as well as patients with shockable rhythms. Of them, there was a 22% survival rate with 15% having a good neurologic outcome.

References:

Weiser, C., et al. (2018). Initial electrical frequency predicts survival and neurological outcome in out of hospital cardiac arrest patients with pulseless electrical activity. Resuscitation. 125:34-38

Podcast #308: Ultrasound in Cardiac Arrest

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Author: Aaron Lessen, M.D.

Educational Pearls:

  • There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity.
  • Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged.
  • Cardiac activity is defined as “Any intrinsic motion of the myocardium.” However, even if this is present, it is important to ask if it clinically significant cardiac activity.
  • Despite disagreement, ultrasound can be useful for clinical decision making.

References:

Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital  and in-ED Cardiac Arrest. Resuscitation; 109: 33 ? 39.

Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.