Keywords: cardiac arrest, ventilation, oxygenation (PubMed Search)
Keywords: heart failure, congestive heart failure, CHF, diastolic dysfunction (PubMed Search)
Keywords: cardiac arrest, hypoglycemia, hypotension, hypothermia (PubMed Search)
An increasing amount of attention in the literature is now being paid to ways of optimizing care of patients that are post-cardiac arrest. Simple things to focus on for us in the ED are the following:
1. induction of therapeutic hypothermia
2. aggressively manage hypotension and cardiac ischemia
3. treat hyperglycemia aggressively
4. avoid hyperventilation, though maintain adequate oxygenation
Keywords: hyperkalemia, treatment, management, kayexalate (PubMed Search)
Keywords: hyperkalemia, treatment, management, beta agonists (PubMed Search)
Keywords: hyperkalemia, treatment, management (PubMed Search)
Keywords: myocardial infarction, delirium, confusion (PubMed Search)
Keywords: aortic dissection, aortic aneurysm, cardiac arrest, ultrasound (PubMed Search)
Death from ruptured aortic aneurysms and thoracic aortic dissection has a few key features that often help in distinguishing these entities from other causes of rapid decompensation and sudden death:
1. These aortic disasters have a tendency to present with hypotension but without necessarily any specific complaints of pain (in contrast to common teaching).
2. These aortic disasters tend usually to produce PEA as the initial arrest rhythm.
3. These aortic disasters are often diagnosable on bedside ultrasound (AAA seen when scanning the abdomen; dissections frequently produce pericardial tamponade as they dissect backwards into the pericardial sack).
ALWAYS take a look at a patient's aorta and pericardium with the ultrasound when that patient presents in extremis or in cardiac arrest. The results can help make some critical diagnostic and therapeutic decisions.
[recent article related to this topic: Pierce LC, Courtney DM. Clinical characteristics of aortic aneurysm and dissection as a cause of sudden death in outpatients. Am J Emerg Med 2008;26:1042-1046.]
Keywords: low voltage, electrocardiography (PubMed Search)
Keywords: coronary heart disease, cardiac disease, risk factors (PubMed Search)
The classic risk factors for coronary artery disease (e.g. hypertension, diabetes, smoking, etc.) are helpful at predicting the long-term risk of CAD, but they have limited utility at predicting whether a patient with acute symptoms is having an acute coronary syndrome or not. In one recent study of > 800 patients with suspected cardiac chest pain, 12% of patients with NO cardiac risk factors ruled-in for acute MI.
Never rule out ACS in a patient purely based on the absence of traditional cardiac risk factors!
[Body R, McDowell G, Carley S, et al. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation 2008;79:41-45.]
Keywords: syncope, seizure (PubMed Search)
Syncope patients are often misdiagnosed as having a seizure. Some factors favoring true syncope:
1. Preceding nausea or diaphoreses
2. Oriented (not confused) upon waking (no post-ictal period).
3. Age > 45
4. Prolonged sitting or standing before episode
5. History of CHF or CAD
Factors favoring seizures:
1. History of seizure disorder
2. Tongue biting
3. Confusion upon waking
4. Loss of consciousness > 5 min
5. Age < 45
6. Preceding aura
7. Observed unusual posturing, jerking, or head turning during episode
Amiodarone-induced hypothyroidism is well-reported and should be considered anytime a patient that chronically takes amiodarone presents with hypothyroid symptoms, including decompensated CHF, decreased mental status, or myxedema coma (e.g. bradycardia, hypotension, hypothermia).
Other drugs that have been implicated in producing hypothyroidism include lithium, iodine, iodinated contrast, and sulfonamides.
Keywords: coronary spasm,acute coronary syndrome (PubMed Search)
An estimated 20-30% of patients with ACS end up having no identifiable culprit lesion on angiography. Almost half of these patients have inducible coronary spasm. Although these patients have a good outcome, they also have a tendency to return to the hospital for frequent re-evaluations. Evaluation for and treatment of spasm can improve the quality of life for these patients and also to decrease re-visits.
When patients with reports of "clean" coronaries return to the ED with a concerning presentation for ACS, one of the considerations should be coronary spasm. Consider prompting the primary care physician or admitting team to look into this possibility, as it may result in a reduction in recurrent ED visits.
Keywords: cardiomyopathy, stress (PubMed Search)
Severe emotional stress is well-reported to produce an unusual transient cardiomyopathy that mimics cardiac ischemia or infarction on ECG as well as biomarker testing. On angiography, the coronaries are often clean. The ventriculogram takes on an apical or mid-ventricular ballooning appearance due to akinesis. In the ED, these patients will look just like a real thrombosis-related case of ACS and they often develop cardiogenic shock. Unlike true AMI-related cardiogenic shock, these patients have an excellent prognosis...if treated aggressively early-on with supportive therapy (e.g. pressors).
Intracranial catastrophes, such as hemorrhage, ischemic stroke, and head trauma; and severe medical illnesses, such as sepsis, pheochromocytoma, and catecholamine-excess states, are also reported to produce a similar syndrome of LV dysfunction.
The takeaway points: (1) severe emotional stress can be deadly...be wary of diagnosing "anxiety" or "panic attack" without checking an ECG; (2) check an ECG early in the course of any patients with the above conditions that look sick; (3) if the ECG shows signs of severe ischemia, aggressive treatment can be life-saving.
[ref: Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118;397-409.]
Keywords: EKG, ECG, electrocardiography, acute myocardial infarction, prognosis (PubMed Search)
A normal ECG should not be a huge source of relief when evaluating patients with possible or confirmed myocardial infarction. 8% of acute myocardial infarctions have a completely normal ECG at the time of presentation, and these patients have a 5.7% in-hospital mortality. Serial electrocardiography can certainly improve the yield of electrocardiography but does not rule out AMI with 100% accuracy.
Like most tests in medicine, the ECG is very useful at ruling in disease, but it is limited at ruling out disease.
[The Prognostic Value of a Normal or Non-specific Initial ECG in AMI. JAMA 2001.]
Keywords: syncope, arrhythmia, dysrhythmia (PubMed Search)
17-18% of cases of syncope are attributable to dysrhythmias.
The best predictors of dysrhythmias in these patients are:
1. abnormal ECG (odds ratio 8.1)
2. history of CHF (odds ratio 5.3)
3. age > 65 (odds ratio 5.4)
[reference: Sarasin FP, et al. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003.]
Keywords: HIV, human immunodeficiency virus, coronary heart disease (PubMed Search)
HIV positive patients are at increased risk of premature atherosclerosis for at least a few reasons:
1. HIV disease causes increased activation of platelets.
2. HIV produces arterial endothelial dysfunction [which promotes thrombosis formation].
3. Protease inhibitors produce dyslipidemias and insulin resistance.
HIV-associated CAD is also unusual in that the vessel involvement is frequently diffuse and circumferential along the whole artery.
HIV positive patients are known to have their first MI at an earlier age than non-HIV controls, and the effect is not related to CD4 count (not related to severity of disease).
The takeaway point here is to always strongly consider ACS in the differential diagnosis of patients with HIV that are presenting with cardiopulmonary complaints, even in relatively younger patients.
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular Manifestations in Human Immunodeficiency Virus-Infected Patients. Am J Cardiol 2008;102:635-642.]
Keywords: troponin, sepsis (PubMed Search)
Troponin levels are often elevated in patients with sepsis. This doesn't necessarily mean that the patient has suffered an acute Mi or ACS, but rather it seems to correlate with myocardial dysfunction that is caused by sepsis. Much like with true MI, troponin elevations predict a greater risk of in-hospital mortality in these patients.
Keywords: HIV, human immunodeficiency virus, pericardial effusion (PubMed Search)
Patients with HIV are at increased risk for several cardiovascular complications of the disease. The most common cardiac manifestation in HIV disease is reported to be pericardial effusion.
The presence of a pericardial effusion in HIV is a poor prognostic sign, an independent predictor of mortality (62% mortality at 6 mos is reported, compared to 7% in those without effusion).
The pericardial effusion is often associated with TB in endemic areas, but can also be associated with other organisms including Staph, Strep, Chlamydia, and some viruses. HIV itself can cause an effusion as part of a generalized serous effusive process.
Takeaway: In late-stage HIV patients with any cardiopulmonary complaints, it would be prudent to make bedside ED ECHO part of your usual initial evaluation.
[reference: Khunnawat C, Mukerji S, Havlichek D, et al. Cardiovascular manifestations in human immunodeficiency virus-infected patients. Am J Cardiol 2008;102:635-642. Authors are from Michigan State Univ.]
Keywords: bedside ultrasound, bedside echocardiography, fluid status (PubMed Search)
The longitudinal subcostal view on bedside ultrasound can be very helpful at addressing a patient's fluid status.
Take a look at the diameter of the IVC 2 cm proximal to the hepatic vein on this view and ask the patient to quickly sniff. If the patient has normal fluid status, the diameter of the IVC will collapse approximately 50%.
If you notice that the IVC completely collapses during the sniff, the finding is highly accurate at predicting hypovolemia and a low CVP.
If, on the other hand, the IVC doesn't appear to collapse much at all, the finding is highly accurate at predicting a high CVP and elevated right atrial pressure. This may occur in the presence of fluid overload from decompensated CHF, cardiac tamponade, and conditions associated with RV failure (e.g. massive pulmonary embolism).