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2/21/2019 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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EMGuideWire

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

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YOUR CART

Hyperkalemia EKG Changes

PEA: A Better Approach

Wide Complex Tachycardia Part 3: The Unstable Patient

Interpreting Rhythm Strips with Wide Complexes

Wide Complex Tachycardia- Part 2 - Irregular Wide Complex Tachycardia

Wide COmplex Tachycardia - Part 1

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

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