UMEM Educational Pearls

Category: Cardiology

Title: Rapid Atrial Fibrillation Treatment

Keywords: Afib, Atrial Fibrillation, Treatment (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Rapid Atrial Fibrillation Treatment 50% of patients with new AF spontaneously convert within 48 hours AF > 48 hours --> chances of spontaneous conversion decreases and chance of embolization increases significantly Most EM texts and lecturers still recommend diltiazem as first line medication for early rate control Patients in whom beta blockers are preferred: AMI, thyrotoxicosis, or if patient is already on BBs NEVER combine IV beta blockers and IV calcium channel blockers --> synergistic effect will cause hemodynamic compromise; start with one type of medication and stay with it

Category: Airway Management

Title: Venous Air Embolism

Keywords: Air, Embolism, Catheter (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Recognize the signs of venous air embolism when inserting a central venous catheter * Although rare, a feared complications of CVC insertion is venous air embolism (VAE) * Conditions that increase the risk of VAE are detachment of catheter connections, failure to occlude the needle hub during insertion, hypovolemia, and upright positioning of the patient * Clinically, VAE presents with acute dyspnea, cough, chest pain, altered mental status, tachypnea, tachycardia, and/or hypotension * Treatment includes placing the patient in a left lateral decubitus position, reverse Trendelenburg, and providing 100% oxygen via NRB * Also consider hyperbaric oxygen therapy * Aspiration of air, as recommended in some textbooks, is rarely successful Reference: Mirski MA. Lele AV. Fitzsimmons L. Toung TJ. Diagnosis and treatment of vascular air embolism. Anesthesiology 2007;106(1):164-77.

Category: Airway Management

Title: Plateau Pressure

Keywords: Plateau, Peak, Pressure, airway (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Use plateau pressure, rather than peak inspiratory pressure, as a means of assessing the risk of barotrauma * One mechanism (of many) by which mechanical ventilation can induce acute lung injury in patients with ARDS is overdistention of the alveoli * 2 common parameters used to assess airway pressures are plateau pressure (Pplat) and peak inspiratory pressure (PIP) * Pplat approximates small airway and alveolar pressures more closely than PIP * ARDSnet trial demonstrated a reduction in the number of ventilator days and mortality when Pplat was maintained < 30 cm H2O. References: 1. ARDS Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. NEJM 2000;342:1301-8. 2. Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:275-6.

Category: Cardiology

Title: Cyanide toxicity

Keywords: Cyanide, itroprusside, hypotension (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Be alert for cyanide toxicity when using sodium nitroprusside * Toxicity from sodium nitroprusside can be seen in as little as 2-4 hours with rates > 4.0 mcg/kg/min * Patients with hepatic and renal dysfunction are at greatest risk * Clinical signs of toxicity include altered mental status (agitation, restlessness), tachycardia, ventricular arrhythmias, and eventually hypotension * The classic anion-gap metabolic acidosis is a pre-terminal event - do not wait for this to develop to raise suspicion of toxicity! Reference: Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:148-9.

Category: Critical Care

Title: Critical Illness Neuromyopathy (CINM)

Keywords: Neuropathy, steroids, sepsis, neuromuscular (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Critical Illness Neuromyopathy (CINM) * CINM is the most common peripheral neuromuscular disorder encountered in the ICU * CINM may contribute to delayed weaning and prolonged ventilation * Risk factors for CINM include SIRS/MODS, sepsis, and hyperglycemia (corticosteroid use still controversial) * Current mainstay of management is directed at prevention * EM take home point -> Judicious use of medications associated with the development of CINM (aminoglycosides, neuromuscular blocking agents) Reference: De Jonghe B, Lacherade JC, Durand MC, et al. Critical illness neuromuscular syndromes. Crit Care Clin 2007;23:55-69. (compliments of Dr. Winters)

Category: Critical Care

Title: Fungal Infections

Keywords: Fungal, Infection, antifungal (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Fungal Infections * Fungal isolates are an increasingly common source of bloodstream infections in critically ill patients * Mortality ranges from 20% to 60% in some series * 50% are non-albicans species (C.glabrata, C.parapsilosis, C.tropicalis, and C. krusei) * Risk factors include ventilated patients, TPN, high APACHE scores, abdominal surgery, and prolonged ICU stays * Think of fungal infections in the septic patient with hypothermia and bradycardia * Newer antifungal agents such as voriconazole and caspofungin have improved efficacy against n

Category: Cardiology

Title: Helpful clues to distinguishing pericarditis vs. STEMI

Keywords: Pericarditis, STEMI, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Helpful clues to distinguishing pericarditis vs. STEMI Pericarditis: PR depression in multiple leads, PR elevation > 2 mm in aVR; friction rub (specific though not sensitive) Remember that PR depression mainly only shows up in viral pericarditis, not other types STEMI: horizontal or convex upwards (like a tombstone) STE, ST depression in any lead aside from aVR and V1, STE in III > II

Category: Cardiology

Title: Infective endocarditis (IE)

Keywords: Endocarditis, treatment, vancomycin (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Infective endocarditis (IE) The most common overall cause of IE is Streptococcus viridans. The most common cause of IE in injection drug users is Staphylococcus aureus. The most common cause of IE in patients with prosthetic valves is also Staphylococcus species; in the first two months postop coag-negative Staphylococcus predominates, and after that the most common causes are Staphylococcus aureus, Streptococcus viridans, and enterococcus. In treating IE of prosthetic valves and/or in injection drug users, the addition of rifampin to the standard regimen of nafcillin/vancomycin + gentamycin is often recommended in order to add additional gram positive coverage.

Category: Cardiology

Title: Calcium Affect on ECG

Keywords: ECG, Calcium, hypercalcemia, hypocalcemia (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Calcium's main effect on the ECG appears to be on the duration of the ST segment, such that: 1. Hypercalcemia shortens the ST segment, producing also a short QTc. 2. Hypocalcemia prolongs the ST segment, producing also a long QTc. As an aside, there are only three conditions in which a short QTc is typically noted: hypercalcemia, digitalis toxicity, and a recently described syndrome that causes sudden death--"the short QT syndrome" (in which the QTc may be < 300ms...that's REALLY short!). As another aside, there are only two conditions that prolong the QTc via prolongation of the ST segment--hypocalcemia and hypothermia.

Category: Cardiology

Title: Blunt Chest Trauma

Keywords: Chest, Trauma, Aortic, murmur (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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The most common valvulopathy after blunt chest trauma is acute aortic insufficiency. These patients will present with a new diastolic murmur. Stability depends on the degree of AI. On the other hand, if a chest trauma patient presents with a new systolic murmur, think about acute septal rupture. These patients are much more often unstable, or may die before arrival. These diagnoses may be missed in the unstable patient because physicians focus on the abdomen in the unstable patient. Pay attention to the heart sounds also!

Category: Toxicology

Title: Urine Drug Screens

Keywords: drug abuse, urine drug screen, cocaine (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Urine Drug Screens Though we order them often, be sure you know what your results mean: Cannabinoids: an accurate test though clinically not important information, positive for 5 days to a full month with chronic users. Cocaine: the most accurate and precise test, positive for 3-5 days. Amphetamine: the most imprecise with many false positives and false negatives. Cough/cold preparations that contain pseudephedrine, phenylephrine or other decongestants can turn it falsely positive. BDZ: only benzodiazepines that are metabolized to oxazepam will turn positive. You can see false negatives with alprazolam and even lorazepam. Opioids: Semisynthetics like oxycodone and hydrocodone may give false negatives at low levels. This screen will NOT catch methadone, meperidine, fentanyl, propoxyphene, tramadol. PCP: False positives from dextromethorphan and ketamine

Category: Cardiology

Title: Cardiovascular trauma

Keywords: Cardiovascular, CXR, ECG, rupture (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Cardiovascular trauma Up to 40% of traumatic aortic ruptures/disruptions in patients surviving to the ED will be associated with normal-looking mediastinums on CXR. Therefore, a CTA or angiogram should be ordered purely based on a good mechanism of sudden deceleration.

Category: Cardiology

Title: GI Bleed and Myocardial Ischemia

Keywords: GI Bleed, Myocardial Ischemia, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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GI Bleed and Myocardial Ischemia Myocardial ischemia or infarction occurs in up to 20% of patients with significant UGI bleeds. For reasons that are uncertain, the majority of these patients have "silent" MIs (i.e. no pain). It's also unclear whether these patients develop MI purely because of hypoperfusion or because the stress causes a plaque to rupture and thrombose. Whenever you have a patient with a massive UGIB, get an ECG early, regardless of whether or not the patient is having chest pain, and if it's concerning, get cardiology involved early as well. anecdote--I've seen 2 patients with STEMI in the presence of an UGIB, one at Mercy and one at UMMS; neither had chest pain; both got transfused, seen by GI, and went cath within several hours; the takeaway--get both consultants involved EARLY!

Category: Cardiology

Title: Ventricular dysrhythmias in pregnanc

Keywords: Dysrhythmia, Pregnancy, Treatment, Procainamide (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Ventricular dysrhythmias in pregnancy Amiodarone should be considered a last choice in pregnancy. It is the only class D antiarrhythmic, and even short infusions can be associated with fetal hypothyroidism, IUGR, fetal bradycardia, and prematurity. Lidocaine or procainamide are preferred. Also, cardioversion/defibrillation/pacing is considered safe in any stage of pregnancy.

Category: Cardiology

Title: Non-ACS causes of elevation troponins

Keywords: Troponin, cause, Non-ACS (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Non-ACS causes of elevation troponins: 1. acute PE 2. Stanford A aortic dissections 3. acute heart failure 4. strenuous exercise (e.g ultra-endurance activities) 5. cardiac toxins 6. ablation therapy/cardiversion 7. cardiac infiltrative diseases 8. post-heart transplant (may persist up to 3 mos) 9. cardiac contusion 10. sepsis 11. rhabdomyolysis

Category: Cardiology

Title: AMI versus Aneurysm

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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AMI versus Aneurysm For ECG distinction between AMI versus ventricular aneurysm, look for reciprocal changes and height of T-waves: 1. Reciprocal ST depression strongly favors AMI. 2. Large T-waves in leads with Q waves and STE is likely AMI. Ventricular aneurysm usually gives you "blunted" or flat T-waves in those leads.

Category: Cardiology

Title: Dyspnea

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Elderly are more likely to present with dyspnea (49% [the most common anginal equivalent]), diaphoresis (26%), nausea and vomiting (24%), and syncope (19%) as a primary complaint. The takeaway point: always get that ECG early in elderly patients with these complaints, even when CP is absent!

Category: Cardiology

Title: Syncope

Keywords: Syncope, CHESS, San Francisco (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Syncope Patients with syncope that are considered to be relatively low risk for complications clinically (i.e. those patients that are not clear-cut admissions) should be evaluated for the 5 CHESS criteria (from the San Francisco Syncope Rules). If they meet none of those criteria, then they are considered to be at very low risk for short-term adverse outcomes and they can be discharged for outpatient follow-up. If they do have any CHESS criteria, they are considered to be at higher risk and admission should be strongly considered. CHESS criteria: history of CHF, hematocrit < 30, ECG abnormalities, shortness of breath, presenting systolic pressure < 90.

Category: Cardiology

Title: Cardiac Output After Age 35

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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After the age 35, cardiac output decreases by approximately 1% per year. That means that elderly patients are at much higher risk for CHF, especially when they are stressed in some way. CHF can develop in the elderly as a result of any stype of infection or other non-cardiac insult. If decompensated CHF is diagnosed in an elderly patient, don't forget to evaluate the patient carefully for potential non-cardiac causes.

Category: Cardiology

Title: Acute Pericarditis

Keywords: Pericariditis, TB, Viral (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 4/13/2024)
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Acute Pericarditis Viral and idiopathic causes account for 80-90% of cases of acute pericarditis (AP) in immunocompetent patients from developed countries. Therefore empiric treatment and extensive search for an underlying cause is unnecessary in the majority of cases we see. However, the etiology of AP in developing countries is very different, with TB-related AP predominating. 70-80% of cases from Sub-Saharan Africa and more than 90% of HIV-related cases of AP are tuberculous. Therefore, in the U.S. tuberculous pericarditis should be strongly considered among immigrants/visitors from developing countries and among patients with HIV.