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2/21/2019 0 Comments

Hyperkalemia EKG Changes

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5/27/2018 0 Comments

PEA: A Better Approach

  • The H's and T's are of taught for Ddx of PEA... but...
    • ​​They are difficult to remember
    • They only apply if you work in an area that speaks English
    • They are not perfect
      • HYPOkalemia rarely causes PEA
      • HYPOthermia is usually not a medical mystery

  • A Clinically Useful Approach by Dr. Laszlo Littmann et al.
    • Littmann L, Bustin DJ, Haley MW. A Simplified and Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Medical Principles and Practice. 2013;23(1):1-6. doi:10.1159/000354195.
    • ​​PEA? Wide or Narrow Complexes?
      • ​Narrow
        • ​Electrical activity in cardiac muscle is normal, but there is a mechanical obstruction of flow (Pseudo-PEA)​
          • Pulmonary Embolism
          • Tension pneumothorax
          • Cardiac Tamponade
          • Mechanical Hyperinflation
        • "Need Needles" to resolve (ex, Needle to give thrombolytics, Needles to decompress)
      • Wide
        • Cardiac muscle electrical activity has been "poisoned". True PEA.
          • Hyperkalemia 
          • Sodium channel blocker
          • Agonal rhythm 
        • Treat with Calcium and/or Sodium Bicarbonate.
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5/18/2018 0 Comments

Wide Complex Tachycardia Part 3: The Unstable Patient

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4/26/2018 0 Comments

Interpreting Rhythm Strips with Wide Complexes

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4/19/2018 1 Comment

Wide Complex Tachycardia- Part 2 - Irregular Wide Complex Tachycardia

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3/16/2018 0 Comments

Wide COmplex Tachycardia - Part 1

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3/10/2018 0 Comments

Atrial Fibrillation (AFib) Management for the Acutely Ill in the ED

  • In the acutely ill patient with rapid Afib, management should focus on quick rate control
  • IV diltiazem should be the treatment of choice
  • Bolus is crucial; re-bolus is crucial – they brake the vicious cycle of fast ventricular rate, reduced LV filling, reduced stroke volume, all resulting in further adrenergic activation
  • Diltiazem drip does not reduce the heart rate; it maintains whatever you achieved with the bolus
  • Never order “diltiazem drip, titrate to heart rate”
  • Ideal dose of initial diltiazem bolus is 0.25 mg/kg over 2 minutes
  • Ideal dose of re-bolus is 0.35 mg/kg over 2 minutes

  • Marked hypotension may limit giving the optimum doses of diltiazem boluses
  • Under these circumstances, there are several options for pre-treatment before the IV diltiazem bolus
    • IV fluid boluses
    • IV digoxin, 0.5 mg
    • Phenylephrine, 100-300 mcg IV push over 10-30 sec
  • With the help of one or more of the above, IV diltiazem can almost always be given safely

  • Consider IV beta blocker (esmolol) instead of diltiazem for patients with rapid Afib and acute MI, ongoing ischemia, thyrotoxicosis and HOCM crisis
  • IV amiodarone is almost never needed for rate control
  • If rate control is still inadequate despite maximum tolerated doses of diltiazem, adding 0.5 mg of IV digoxin will frequently “finish the job”
​​
  • For critically ill patients with rapid Afib, consider emergent cardioversion
  • Do not shock the patient with MAT or with repetitive Afib characterized by the presence of occasional sinus complexes
  • These patients are frequently good candidates for rhythm management with amiodarone or beta blocker
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    Author

    EM GuideWire Team , J. Lee Garvey Innovation Studio
    Department of Emergency Medicine
    Carolinas Medical Center

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From the J. Lee Garvey Innovation Studio in the 
Department of Emergency Medicine
Carolinas Medical Center
Charlotte, NC
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