EKG Challenge #1 – Unresponsive and Bradycardic – Case Conclusion

We'd like to start by thanking everyone who participated in the EKG challenge.  Without further ado, the case conclusion:

You are working in TCC when EMS arrives, bagging an unresponsive elderly-appearing female.   They report that they were called to a nursing home for unresponsiveness, and found the patient on the floor.  On their arrival, she was minimally responsive to noxious stimuli and had a heart rate of 36 on the monitor.  She received atropine 0.5 mg x 3 prehospital with minimal response.   Her blood pressure is 80/60.  To identify if there is heart block, you get an EKG demonstrating marked sinus bradycardia with a 1st degree AV block and possible ST elevation in the inferior and precordial leads (see below):

You intubate the patient, and as you are placing pacer pads on, your attending notes that she feels very cold to touch.  Her temperature by Foley catheter?  28.2 degrees! You take another look at the EKG and think – ah, not ST elevation after all, but J waves. 

After initating the patient on some aggressive rewarming with warmed IV fluids, a bear hugger and warmed ventilator circuit, you take a moment to ask two questions:

[1] Above and beyond the J waves of Osborn, what EKG findings are suggestive of/associated with hypothermia?

Luckily for you, emergency medicine EKG guru Amal Mattu wrote a paper on this very subject.   Entitled simply, “Electrocardiographic Manifestations of Hypothermia” it goes through a series of cases and highlights a few important take homes regarding EKGs in hypothermic patients:
a.  The J-wave is the most common EKG finding in hypothermia, and is found when core body temperatures are < 32 ˚C.  They can be seen in other situations as well, including subarachnoid hemorrhage, acute cardiac ischemia, and normal normothermic patients.
b. Atrial and ventricular arrythmmias become more predominant with the degree of hypothermia.  Marked sinus bradycardia with decreased AV conduction velocity (as seen in this patient) is a common finding.
            c. Intervals (as in all of them) can be prolonged.
d.  A pseudoinfarction, with ST elevation, pattern is sometimes seen.  The pattern should resolve with re-warming.
e. The EKG will not necessarily reflect the peaked T waves of hyperkalemia.  Be wary, this subset of “found down” patients can have hyperkalemia secondary to rhabdo or renal failure, but it won’t be as noticeable in the EKG.

Importantly, the intervention for the above arrythmmias is not anti-arrythmmics , pacing, or even pressors as these have limited utility in a cold myocardium.  The treatment is re-warming (see below), which will resolve most of the above.

[2]  What is the differential diagnosis for hypothermia – i.e., what tests should I send and what interventions should happen for this critically ill patient in the emergency department?
Remember, once you diagnose the patient with hypothermia, your workup and interventions do not stop there – hypothermia has a differential diagnosis: (see ref 2)
A.  Horses – environmental exposure, severe hypothyroidism, diabetic ketoacidosis,                   sepsis, multisystem trauma, and prolonged cardiac arrest
B. Zebras – Hypothalamic lesions, episodic hypothermia with hyperhydrosis

Therefore, there are two main components of the ED intervention:
 1. Diagnose and treat the underlying cause –  Check TSH, Initiate septic workup and broad spectrum antibiotics.
 2. Aggressive rewarming –There are four classifications for types of rewarming
         a Passive external – i.e. blankets – raises temp 0.5 – 4˚C/hr
         b. Active external – i.e BEAR hugger – raises temp 1-2˚C/hr
         c. Active internal – humidified vent, warm IV fluids, body cavity lavage  - raises temp 0.5 –    1.2˚C/hr
         d. Extracorporal – ICY lines and ECMO – raises temp 4-10˚C/hr.

a, b, and c are usually sufficient for mild to moderate hypothermia.
In the ER, the patient was intubated, aggressively warmed with a humidified vent, warm IV fluids and a bear hugger -  and had a concordant rise in her heart rate and blood pressure and resolution of her EKG findings: 

Clinical takehome – Be suspicious of hypothermia in patients with cardiogenic shock who are found down. Remember, a lot of your “go to” interventions will not work in these patients.  Treat hypothermia and related cardiac complications with aggressive rewarming, and don’t forget that hypothermia has a differential diagnosis.

[1] Mattu, A., Brady, W. J., & Perron, A. D. (2002). Electrocardiographic manifestations of hypothermia. The American journal of emergency medicine, 20(4), 314-326.
[2] Aslam, A. F., Aslam, A. K., Vasavada, B. C., & Khan, I. A. (2006). Hypothermia: evaluation, electrocardiographic manifestations, and management. The American journal of medicine, 119(4), 297-301.

Interested in some more learning about J waves?
and remember to look out for EKG challenge #2 next week.

Contributed by Maia Dorsett, PGY-3

Quick tips from The Alfred ICU ECMO Course

Largely due to the great work of one of the attendees, Jeram Hyde aka @CriticalHabits, Twitter has been abuzz with some great tips, tricks and take home learning points from this week’s ECMO course hosted by The Alfred ICU.

Check them out for yourself below…

Visit The Alfred ICU Courses page to enrol in future ECMO courses, but get in quick – it sells out fast!

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The Alfred ICU Research Report 2013

The Alfred ICU Research Report 2013 is out.

The research team at The Alfred ICU, headed by Prof Jamie Cooper, produced 91 publications in 2013. This report details all of the research activities, active grants, publications and major presentations produced by the team last year.

A great effort by all – well done to everyone who contributed!

Alfred ICU Research Report 2013

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Support EM in Africa

Screenshot 2014-10-09 09.16.06Emergency Medicine is an emerging specialty the world over and we at St Emlyns and the EMJ are alwayts keen to promote innovation and learning wherever it takes place. In the past we have wholeheartedly supported the fantastic “Developing EM Conference” and its aims. Teaching and learning collaboratively across geographical borders is a challenge; teaching and learning across huge resource disparity is an even bigger one.

This month we have the opportunity to support another intervention for worldwide EM.
The African Federation of Emergency Medicine relies on financial support to assist delegates to attend its meetings. The second AFCEM conference is not far off but donations have been hit heavily in the wake of Ebola.

If you’ve ever been to a medical conference you know how amazing it feels to meet like-minded clinicians, to share knowledge and experience, build friendships and partnerships and to problem-solve together. African EM clinicians need your help in order to be able to attend the AFCEM 2014 AFCEM meeting in Addis Ababa next month.

Please support an African delegate – any financial contribution will help. You can AFCEM Support a Delegate Support a Delegate here.

You can read more about how this can make a difference in Help African EM Now! – LITFL this great piece by  Katrin Hruska on Twitter  over at Life in the Fast Lane.

Support an African delegate – together we can build EM the world over.

UPDATE – As of this today we have managed to assist 6 delegates to the conderence – let’s make it many many more




Natalie May

Consultant in Emergency Medicine

Royal Manchester Children’s Hospital


This post first appeared at St.Emlyn’s

Developing EM – Support an African Delegate

St Emlyns - Meducation in Virchester #FOAMed

Emergency Medicine is an emerging specialty the world over and we at St Emlyns wholeheartedly support the fantastic Developing EM conference and its aims. Teaching and learning collaboratively across geographical borders is a challenge; teaching and learning across huge resource disparity is an even bigger one. The African Federation of Emergency Medicine relies on financial […]

The post Developing EM – Support an African Delegate appeared first on St Emlyns.

Research and Reviews in the Fastlane 052

Research and Reviews in the Fastlane
Welcome to the 52nd edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.
This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Infectious Diseases, Epidemiology, Critical Care

R&R Hall of Famer - You simply MUST READ this!R&R Hot Stuff - Everyone’s going to be talking about thisWHO Ebola Response Team. Ebola Virus Disease in West Africa — The First 9 Months of the Epidemic and Forward Projections. NEJM 2014 PMID: 25244186

  • Since the onset of the Ebola Virus Disease epidemic 7 months ago a total of 4507 confirmed and probable cases, as well as 2296 deaths from the virus had been reported from five countries in West Africa — Guinea, Liberia, Nigeria, Senegal, and Sierra Leone. The disease is rapidly spreading with a case diagnosed in the United States this week. This is an excellent report on the clinical and epidemiologic characteristics of the epidemic and the analyses in this paper can be used to inform recommendations regarding control measures. Unfortunately the current epidemiologic outlook is bleak especially in Guinea, Liberia, and Sierra Leone. Control measures which include improvements in contact tracing, adequate case isolation, increased capacity for clinical management, safe burials, greater community engagement, and support from international partners need to improve quickly otherwise these countries will be reporting thousands of deaths each week. Experimental therapeutics and Vaccines are not available at present and certainly not in the quantities that are required. We must also face the prospect that Ebola Virus Disease may become Endemic to the human population in West Africa.
  • Recommended by: Nudrat Rashid

The Best of the Rest

Emergency Medicine

R&R Hot Stuff - Everyone’s going to be talking about this

Hwang V et al. Are pediatric concussion patients compliant with discharge instructions? J Trauma Acute Care Surg 2014. PMID: 24977765

  • The short and long term morbidity associated with pediatric concussions is becoming better recognized. This study looked at compliance with discharge instructions. Surprisingly (or maybe not so), 39% of pediatric patients returned to play (RTP) on the day of the injury. RTP is widely recognized as a risk for recurrent and more severe concussions as well as significant morbidity. It is the duty of the Emergency Physician to stress the importance of discharge instructions as well as the importance of appropriate follow up.
  • Recommended by: Anand Swaminathan

PediatricsR&R Mona Lisa -Brilliant writing or explanation” width=Singleton T et al. Emergency department care for patients with hemophilia and von Willebrand disease. J Emerg Med. 2010; 39(2): 158-65. PMID: 18757163

  • Bleeding always catches our attention in the ED… especially when it won’t stop. Von Willebrand disease is often encountered in the Peds ED. Make sure that the patient and their family don’t know more about it than you do.
  • Recommended by: Sean Fox
  • Read More: Von Willebrand Disease (PED EM MORSELS)

Emergency MedicineR&R Game Changer? Might change your clinical practiceR&R Eureka - Revolutionary idea or conceptGorchynski J et al. The “Syringe” Technique: A Hands-Free Approach for the Reduction of Acute Nontraumatic Temporomandibular Dislocations in the Emergency Department. J Emer Med 2014. PMID: 25278137

  • Reduction of temporomandibular joint (TMJ) dislocations is difficult, time consuming and often requires procedural sedation. This article describes a novel method for reduction of atraumatic TMJ dislocations in the ED. The “syringe” technique successfully reduced 97% (30/31) of dislocations. 77% (24/31) reductions were completed in less than 1 min. While this is not proof of superiority to other techniques, the time to reduction here is stunning and it’s always nice to have another arrow in the quiver
  • Recommended by: Anand Swaminathan

R&R Game Changer? Might change your clinical practiceHalm BM. Reducing the time in making the diagnosis and improving workflow with point-of-care ultrasound. Pediatr Emerg Care. 2013; 29(2): 218-21. PMID: 23546429

  • Ok, so this isn’t hard core research, but I wanted to use it to highlight the fact that intussusception does not commonly present in the “classic” fashion and that by using point of care ultrasound, you can augment your physical exam to help diagnosis the condition in the child who presents with “altered mental status.”
  • Recommended by: Sean Fox
  • Read More: Intussusception & Altered Mental Status (PED EM MORSELS)

ResuscitationR&R Eureka - Revolutionary idea or conceptHeidlebaugh M et al. Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device. Ther Hypothermia Temp Manag. 2014. PMID: 25184627

  • Case report of a novel solution to a patient who sustained intra-cardiac catheterization cardiac arrest. An Impella device (an intraventricular LVAD) was placed into the left ventricle to provide adequate forward flow. Case report only but may offer an alternative to ECLS.
  • Recommended by: Cliff Reid
  • Read More: Left Ventricular Assist Device for Cardiac Arrest? (RESUS.ME)

Emergency Medicine, ObstetricsR&R Hot Stuff - Everyone’s going to be talking about thisKline JA et al. Systematic Review and Meta-analysis of Pregnant Patients Investigated for Suspected Pulmonary Embolism in the Emergency Department. Acad Emerg Med. 2014; 21(9): 949-959. PMID: 25269575

  • This systematic review and meta analysis looked at the literature (and gray lit) for pregnant patients undergoing work-up for pulmonary embolism, a cohort historically classified as high risk. The shocking take-home: we probably over-investigate PE in pregnant patients. The VTE rate in pregnant patients was 4.1%, compared with a rate of 12.4% in non-pregnant patients. The pooled RR of pregnancy VTE was 0.60 (95% CI 0.41-0.87) and patients of childbearing age (≤45 years) had RR 0.56 (95% CI 0.34-0.93). Of note, this study highlights the miniscule number of pregnant patients included in PE studies (n=506) and the tiny number of these who actually had VTE (n=29).
  • Recommended by: Lauren Westafer


Cheston CC et al. Social media use in medical education: a systematic review. Acad Med. 2013; 88(6): 893-901. PMID: 23619071

  • Systematic review of social media in medical education. They found 12 studies, mostly small, a lot of reflective work. Good to see a growing evidence base for integrating FOAM into formal curricula.
  • Recommended by: Seth Trueger

Resuscitation, Critical CareR&R Hot Stuff - Everyone’s going to be talking about this Gu WJ et al. Single-Dose Etomidate Does Not Increase Mortality in Patients with Sepsis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Chest 2014. PMID: 25255427

  • Etomidate, once the only available induction agent for RSI in US Emergency Departments, has long been maligned for its transient adrenal suppression in spite of the absence of any detrimental patient oriented outcomes. This systematic review and meta-analysis including 18 studies (only 2 RCTs) and > 5,500 patients demonstrated no difference in mortality in septic patients. For now, at least, etomidate is a viable option as an induction agent in patients with sepsis.
  • Recommended by: Anand Swaminathan

Emergency Medicine, OpthalmologyR&R WTF Weird, transcendent or funtabulous!” width=Moradi P et al. Sudden pseudoproptosis. Emerg Med J 2013; 31(8): 624. PMID: 24136120

  • Who knew there was such as thing as “Floppy eyelid syndrome”! Described in overweight middle-aged men. Interesting case with pictures described here. A disorder of unknown origin manifested by an easily everted, floppy upper eyelid and upper palpebral conjunctivitis. The upper eyelid everts during sleep, resulting in irritation, conjunctivitis and conjunctival keratinisation.
  • Recommended by: Jeremy Fried

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R

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