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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Podcast #377: Endocarditis

Author:  Nick Tsipis, MD

Educational Pearls:

  • 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

 

References:

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

Podcast #374: Iliac Artery Endofibrosis

Author:  Sue Chilton, MD

Educational Pearls:

  • An unusual cause of leg pain that can mimic sciatica/claudication
  • Predominantly occurring in high endurance athletes, particularly cyclists and runners
  • More common in men
  • Check supine ABIs 1 minute after activity in the ED: a value < 0.5 is 80% sensitive

 

References:

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.

Podcast # 372: The Latest on Epinephrine in Cardiac Arrest

Author:  Don Stader, MD

Educational Pearls:

  • 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.

 

References

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.

Podcast # 371: EKG changes of Hyperkalemia

Author:  Jared Scott, MD

Educational Pearls:

  • 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

References

Mattu A, Brady WJ, Robinson DA. Electrocardiographic manifestations of hyperkalemia. Am J Emerg Med. 2000;18:721–729.

Podcast # 368: Prehospital Plasma

Author: Aaron Lessen, MD

Educational Pearls:

  • 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

References

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.

Podcast # 367: Digital Necrosis after Epi Drip

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

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

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

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.