ECG of the Week – 24th November 2014 – Interpretation

This is one of the oldest ECG's I have in my collection and as such I don't have any clinical information on the case other then it's from a 90 yr old female. 
So why do we think she ended up in the Emergency Department based on the ECG ? 
Check out the comments on our original post here.





Click to enlarge
Rate:
  • ~48 bpm
Rhythm:
  • Irregular
  • No p waves visible
Axis:
  • Normal
Intervals:
  • QRS - Prolonged (~180ms)
  • QT - 720ms
Segments:

  • Inferior ST sagging
Additional:
  • RBBB Morphology
  • Osborn J waves
  • Prominent U waves best seen infero-laterally
  • T wave inversion leads aVR, aVL, V1-3



ECG with T, U and J waves labelled
Click to enlarge

Interpretation:


  • Slow Atrial Fibrillation
  • J-waves
  • Prominent U waves

Differentials for this ECG

Without more clinical information it's difficult to give a firm conclusion. I think this ECG is most consistent with hypothermia but some features could be explained by drug toxicity (digoxin, CCB's, beta-blockers), electrolyte abnormalities, ischemia, sinus node dysfunction. We should be mindful in the elderly that the clinical situation is often multi-factorial and could be a combination of the above causes. Also remember hypothermia in the elderly has a multitude of potential causes including environmental, sepsis and endocrine.

New Team Member

I'd like to welcome Dr Richard McClelland to our ECG blogging team - Richard is a EM registrar in Australia planning to continue his training back in the UK.

References / Further Reading

Life in the Fast Lane

Textbook
  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.

Anaphylaxis Q+A

Jason is a 2 year boy who presents to ED with a rash and cough. He had peanut butter for the first time about 20 minutes ago, and he suddenly started vomiting then coughing. His face is swelling and he sounds very wheezy. 

This is clearly anaphylaxis. Here’s a quick quiz to refresh your knowledge of treatment of anaphylaxis in children.

 

Adrenaline is the first line treatment - but what's the dose?

Adrenaline IM – use 1 in 1000 (or 0.1% – 1mg/ml)

The dose is 0.01ml/kg or 0.01mg/kg. Max dose is 0.5ml.

Give in as an IM injection into the anterolateral thigh. Don’t give IV boluses unless there is cardiac arrest due to the risk of cardiac ischaemia.

If it’s going to take a while to get the adrenaline drawn up and given, and the patient has an EpiPen, use the Epipen instead.

How does adrenaline help in anaphylaxis?

  • Bronchodilation
  • Vasoconstriction
  • Reduces airway oedema
  • Strengthens cardiac contractions
  • Reduces mediator release from mast cells
  • Reduces vascular fluid leakage into tissues

What are the adverse effects of adrenaline?

Potential adverse effects include:

  • Arrhythmias
  • Hypertension
  • Pulmonary haemorrhage
  • Intracranial haemorrhage

These are usually more of a problem with IV administration.

What position should the patient be in?

Ideally the patient should be lying flat (or at least sitting) to increase venous return.

Standing up suddenly can cause hypotension which can be fatal. (This is obviously tricky in this age group as the children can be very distressed.)

How long does adrenaline take to work?

You should see an improvement within 5 minutes.

The length of action is around 15 minutes.

How many dose of adrenaline can you give?

Give another dose of adrenaline if the patient doesn’t improve after 5 mins; if the symptoms are worsening; or if the symptoms recur.

The usual guidance for ED is that once you are giving your third dose of adrenaline, ICU should get involved.

What other things should you look out for?

Deliver oxygen to the patient with respiratory distress.

Measure the BP and watch for hypotension – give 20ml/kg N Saline bolus if hypotensive.

Get IV access if the child is hypotensive, otherwise it may not be necessary.

Remember that nausea, vomiting, shakiness, and tachycardia can all be side effects of the adrenaline, particularly if the BP is normal or high.

What other drugs should you consider?

Consider an adrenaline neb (5ml of 1 in 1000) for upper airway obstruction.

Consider salbutamol inhalers if wheeze is persisting.

Consider oral prednisolone (1mg/kg) or IV hydrocortisone 5mg/kg.

An IV adrenaline infusion can be considered if the patient isn’t responding to IM adrenaline.

  • 1ml of 1 in 1000 adrenaline in 1000ml normal saline.
  • Start at 6ml/kg/hr (0.1mcg/kg/min)

What treatment can be given for the rash?

An antihistamine can help with the itching. It will have no effect on the non-cutaneous symptoms. Try to avoid a sedating anti-histamine as this can cause confusion between symptoms of anaphylaxis and sedation.

When can you send them home?

If a child has presented with anaphylaxis and only required one dose of IM adrenaline, they can go home after four hours, provided that their symptoms (excluding cutaneous symptoms) have resolved.

In other situations admission may be preferred, including where the family lives a long way from medical services.

Remember that biphasic reactions can occur in the first 72 hours.

Send them home with advice – ASCIA has lots of good information sheets.

Ideally they should go home with an EpiPen although this will be dependent on the resources available in your hospital. At least refer them to a paediatric allergist and emphasise the need for them to have an EpiPen as soon as possible.

GuidelinesForMe – Anaphylaxis treatment guidelines

References

ASCIA anaphylaxis resources

Anaphylaxis, Royal Children’s Hospital, Melbourne.

 

The post Anaphylaxis Q+A appeared first on Don't Forget the Bubbles.

Pulmonary Embolus pondering

A 52 y.o. bricklayer is transferred from another hospital with an acute episode of dizziness, palpitations and tachycardia. 2 days ago he had bilateral total knee replacements for osteoarthritis.

Observations on arrival: P 120, BP 130/75, RR 22, SpO2 88% room air, 98% 4 litres via nasal prongs.

ECG
ECG PE
CTPA
CTPA RA clot
Bedside echo in Emergency

  • Normal LV, dilated RV with moderate impairment, septal paradox (bowing RA septum towards left).
  • Troponin I (high sensitivity) 4410 ng/L

This man has acute Pulmonary Embolus (PE)

  • His ECG demonstrates a normal axis, tachycardia and SI QIII TIII (see also ECG changes in PE).
  • His CTPA demonstrates an extensive clot in the right PA (and subsegmental clots on the left).
  • There is evidence of right ventricular strain on echo and biochemical evidence of cardiac damage.

What are the treatment options? Does he need removal of the clot by some means?

Possible treatment options in acute PE:

  • Low molecular weight heparin and close observation
  • Unfractionated heparin infusion
  • IVC filter
  • Thrombolysis
  • Thrombectomy
  • Catheter directed therapy

Quality evidence to inform the treatment of PE causing cardiovascular instability has been sparse for many years. The initial study published in 1995 examining the role of thrombolysis for ‘massive’ PE was stopped prematurely after n=8 were recruited and all subjects in the control (heparin) group died. This was then the basis of our practice for many years. Whilst it is persuasive of the role of thrombolysis in ‘massive’ PE it does not represent good quality data, and certainly does not inform us of the role of thrombolysis in less severe PE.

How should we describe pulmonary embolus?.

More recently PE has been described as high, intermediate and low risk. Clinical characteristics and objective measurements now define risk groups, and they have nothing to do with the appearance, whereabouts or volume of the clot on the CTPA.

Classification of acute PE:

  • High risk (previously ‘massive’) PE patients have persistent shock or hypotension.
  • Intermediate risk (previously ‘sub-massive’) PE is defined as the presence of right ventricular (RV) dysfunction and/or myocardial injury in the absence of hypotension.
  • Low risk PE patients have none of these features and can probably be treated outside of hospital.

Until recently the role of thrombolysis in PE has been controversial with the short-term aim of early clot breakdown overshadowed by the very real risk of increased major bleeding episodes. We are not even sure if breaking down or removal of clot is necessary.

The pulmonary embolism thrombolysis (PEITHO) study was an international multicentre double blind RCT that investigated the efficacy and safety of tenecteplase in intermediate risk PE. 1006 normotensive subjects with confirmed PE, RV dysfunction and raised cardiac injury markers were enrolled and received either un-fractionated heparin and placebo, or un-fractionated heparin and tenecteplase (30-50mg).

The combined composite primary endpoint – death and/or haemodynamic decompensation within 7 days – was significantly reduced in the intervention arm (2.6% tenecteplase, 5.6% placebo; p=0.02).

So, does this make thrombolysis a good thing for intermediate-risk PE?

I don’t think so – and here is why. Combined primary endpoints make interpretation of clinical studies very hard – to be taken on face value they assume equal importance of the 2 (combined) outcomes. In this case we can argue that death is a pretty important, finite outcome. Haemodynamic decompensation, however, is not as serious nor permanent as death and, if recognised and managed appropriately, does not necessarily lead to death. In the PEITHO study, mortality at 7 days was no different between the groups (1.2% tenecteplase, 1.8% placebo; p=0.42) and therefore the signal for the primary endpoint being ‘met’ was due to haemodynamic instability (1.6% tenecteplase, 5% placebo; p=0.0002). There was no difference in those undergoing rescue thrombolysis between the groups.

The really important difference to note between the study arms is that of major bleeding with tenecteplase. Major extracranial bleeds (6.3% vs. 1.2%) and haemorrhagic stroke (2.0% vs. 0.2%) are more common. Tenecteplase conferred a 10-fold increased likelihood of stoke; this figure is even more sobering when you consider that the trial specifically excluded those thought to be at risk of bleeding. This risk of bleeding showed a non-significant increase in those above 75 years old. These findings are supported by a large recent meta-analysis that found increased risk of bleeding complications after thrombolysis in those over 65 years old.

So, what will thrombolysis do to our intermediate risk acute PE patient?

It may reduce ‘haemodynamic instability’ over the next 7 days but it won’t save life from death related to the PE, and it might cause major bleeding (1 in 17 patients) or stroke (1 in 50 patients). I don’t think that is an acceptable trade off.

PEITHO has not examined long-term outcomes such as RV failure or pulmonary hypertension. While recognised, these outcomes are unusual post-PE and in my opinion frequently represent recurrent VTE rather than persistent, chronic PE.

Treatments not investigated in the PEITHO study include surgical thrombectomy, IVC filters and catheter directed therapy. These have significantly less evidence to support, or inform, their use than thrombolysis did. More of that another time.

Peitho was the Goddess of persuasion, seduction and charming speech. The PEITHO study persuades us of 2 conclusions:

  • PE can (and should) be categorized into different risk groups (high, intermediate and low) based on objective clinical measurements;
  • The use of thrombolysis in intermediate risk PE cannot be routinely recommended due to an unacceptable risk-benefit profile.

By contrast, this study supports the use of anticoagulation in normotensive patients with PE even though there may be RV dysfunction, and/or evidence of cardiac strain. Monitor closely, be brave and patient, give a bit of fluid to support the RV if necessary, but above all don’t panic. Douglas Adams was correct.

LITFL Resources

References

  • Jerjes-Sanchez C, Ramirez-Rivera A, de Lourdes Garcia M, Arriaga-Nava R, Valencia S, Rosado-Buzzo A, et al. Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism: A Randomized Controlled Trial. Journal of thrombosis and thrombolysis 1995;2:227-9. [PMID 10608028]
  • Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galie N, Pruszczyk P, et al. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). European heart journal 2008;29:2276-315. [Reference and PDF]
  • Meyer G, Vicaut E, Danays T, Agnelli G, Becattini C, Beyer-Westendorf J, et al. Fibrinolysis for patients with intermediate-risk pulmonary embolism. The New England journal of medicine 2014;370:1402-11. [NEJM]
  • Chatterjee S, Chakraborty A, Weinberg I, Kadakia M, Wilensky RL, Sardar P, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014;311:2414-21. [PMID 24938564]

The post Pulmonary Embolus pondering appeared first on LITFL.

#FOAMed Review 22nd Edition

Welcome to the twenty-second edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.


Onto the FOAMed. 


NIPPV FOR OUT OF HOSPITAL SEVERE RESPIRATORY DISTRESS: [PODCAST]: As per usual the SGEM brings us a great discussion regarding the use of NIPPV in the prehospital setting that is a must listen.

ULTRASOUND GUIDED JOINT INJECTION FOR SHOULDER DISLOCATION [VIDEO]:

AORTIC ULTRASOUND [BLOG]: Bedside ultrasound really is your friend when it comes to evaluating the aorta. Learn the anatomy and technique with our most recent post from the ULA. 

MISINTERPRETED: EBM [BLOG]: We see EBM as our gold standard for proper patient care. But should we be regurgitating new studies without any of our own forethought? Lovely post from The Short Coat on this thoughtful topic


More FOAMed. 

TOXICOLOGIC DISORDERS 

NALOXONE DILUTION FOR OPIOID OVERDOSE [BLOG]: Be nice to your opioid overdose patients and don't go slamming 0.4 mg directly into their veins if they don't need the whole dose! Brian Hayes at ALiEM with a trick of the trade on diluting down your naloxone

INFECTIOUS DISORDERS  

STOP PACKING ABSCESSES [BLOG]: The Mayo EM Blog with a convincing plea to stop packing abscesses. There isn't much evidence that it improves outcomes but it sure is painful. Read more here

OBSTETRICS & GYNECOLOGY

FIRST TRIMESTER BLEEDING [PODCAST]: A nice post to help guide our thought process and decision making in the pregnant patient with first trimester vaginal bleeding from Bits & Bumps. 

THORACIC & RESPIRATORY

BRONCHIOLITIS UPDATE [BLOG]: Help sort out all the confusion on management of bronchiolitis with this excellent 8 part (concise) update by Brad Sobolewski from the PEM Blog. 

CARDIOVASCULAR DISORDERS

A CASE OF IDENTITY PART II [BLOG]: Is there really a benefit to dual anti-platelet therapy in the ED prior to catheterization? An outstanding piece by EMNerd on the paucity of evidence behind this standard practice


See you next week. 

 

#FOAMed review is brought to you by Michael Macias. If you want to recommend content you think should be added to our curriculum, send me an email, I would love to hear from you. 

 
   

Research and Reviews in the Fastlane 059

Research and Reviews in the Fastlane

Welcome to the 59th 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

Emergency Medicine, CardiologyR&R Hall of Famer - You simply MUST READ this!
Makam AN, et al. Use of Cardiac Biomarker Testing in the Emergency Department. JAMA Intern Med 2014. PMID: 25401720

  • This study looked at national survey data from 2009-2010 of patients >18 y/o presenting to the ED (n=44,448 visits) and found that cardiac enzyme testing was performed in 16.9% of visits, including in 8.2% of visits lacking ACS-related symptoms (which includes things like nausea, vomiting, abdominal pain, dyspnea, etc). This begs the question, why then, was a troponin (or ck-mb) ordered? It’s probably not changing management. In an era in which we’re discovering that there are harms to downstream testing, this study calls out just how trigger happy we may be. As more sensitive cardiac assays are used, this may mean even more for our patients.
  • Recommended by: Lauren Westafer

The Best of the Rest

Critical CareR&R Game Changer? Might change your clinical practice

Curtis JR, et al. The importance of word choice in the care of critically ill patients and their families. Intensive Care Med. 2014; 40(4): 606-8. PMID: 24441669.

  • Word choice in critical care is critically important. This article shows why, and gives you alternatives to these shockers: “Withholding or withdrawing care”, “there is nothing more that we can do”, “Withholding and withdrawing life-sustaining measures are morally equivalent”, “consider an end-of-life decision” and “no escalation of treatment”.
  • Recommended by: Chris Nickson

Resuscitation, NeurosurgeryR&R Game Changer? Might change your clinical practice
Scotter J et al. Prognosis of patients with bilateral fixed dilated pupils secondary to traumatic extradural or subdural haematoma who undergo surgery: a systematic review and meta-analysis. Emerg Med J 2014. PMID: 25385844

  • Don’t give up on patients with epidural hematomas and fixed and dilated pupils. In this systematic review, patients with bilateral fixed and dilated pupils with an epidural hematoma, the mortality was 29.7%. More importantly, 54.3% of them had favorable outcomes. Unfortunately, the presence of bilateral fixed and dilated pupils with subdural hematomas did not fare as well (6.6% favorable outcomes).
  • Recommended by: Cliff Reid
  • Read More: Bilateral Fixed Dilated Pupils? Operate if Extradural! (Resus.me)

Emergency MedicineR&R Landmark paper that will make a difference

Waxman DA, et al. The effect of malpractice reform on emergency department care. NEJM 2014; 371(16): 1518-25. PMID: 25317871

  • This large study looking at Medicare claims looks at the effect of tort reform on emergency physician practice. By examining advanced imaging (CT and MRI) rates as well as ED charges and admission rates, they determined whether there was a correlation of these factors and states which enacted stricter malpractice language. No such relationship of significance was found. This study does a great job of demonstrating that resource intensive practice of the ED is due to more than simple fear of legal repercussions, but likely to other behavioral and cultural motives.
  • Recommended by:  Jeremy Fried

Social Media
R&R WTF Weird, transcendent or funtabulous!” width=
Hall N. The Kardashian index: a measure of discrepant social media profile for scientists. Genome Biol. 2014; 15(7):424. PMID: 25315513

  • How do you know if a scientist is a social media loudmouth or just a quiet achiever? Calculate his or her ‘Kardashian Index’. The K-index is a a measure of discrepancy between a scientist’s social media profile and publication record based on the direct comparison of numbers of citations and Twitter followers. Surely a scientist doesn’t want to score too high, nor too low, but what is the ideal number? Most FOAM creators will score on the high side, should we just shut up?
  • Recommended by: Chris Nickson

ResearchR&R Game Changer? Might change your clinical practice

Mounsey A, et al. 7 questions to ask when evaluating a noninferiority trial. J Fam Pract. 2014; 63(3): E4-8. PMID: 24701606

  • As this article says, “review of 116 noninferiority trials and 46 equivalence trials found that only 20% fulfilled generally accepted quality criteria”. Read this, if your understanding of non-inferiority trials is, well, inferior. (Hat tip to EMU’s Yosef Liebman).
  • Recommended by: Chris Nickson

Emergency Medicine, NeurologyR&R Hot Stuff - Everyone’s going to be talking about this
Kelly AM et al. Sensitivity of proposed clinical decision rules for subarachnoid haemorrhage: An external validation study. Emerg Med Austral 2014. PMID 25381840

  • This is a retrospective validation study of the Ottawa SAH decision instrument published by Perry et al in JAMA last year (link – http://www.ncbi.nlm.nih.gov/pubmed/24065011). This group found that the instrument performed well in a small population and that while it probably wouldn’t reduce the rate of CT scanning, it may be helpful in further risk stratification. Unfortunately, the study was retrospective and rather small (n = 59).
  • Recommended by: Anand Swaminathan

Emergency Medicine, ResuscitationR&R Game Changer? Might change your clinical practiceBennett C, et al. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database of Systematic Reviews 2014, Issue 11. PMID 25414987

  • This is systematic review appraising the evidence around the use of TXA for gastrointestinal bleeding. Unfortunately the quality of the available evidence is moderate to poor. TXA vs. no standard interventions (ie, no PPI or EGD) appears to be beneficial, however compared to standard interventions, the effect is lost, suggesting minimal or no effect in real clinical practice where patients tend to go under emergent endoscopy for evaluation and treatment. Current evidence does not support use of TXA for GI bleeding when other interventions are available. Evidence may change once ongoing studies (ie, HALT-IT) are publish.
  • Recommended by: Daniel Cabrera

CardiologyR&R Hot Stuff - Everyone’s going to be talking about this
R&R Game Changer? Might change your clinical practice
Ownbey M et al. Prevalence and interventional outcomes of patients with resolution of ST-segment elevation between prehospital and in-hospital ECG. Prehosp Emerg Care 2014;18(2):174-9. PMID 24400994

  • What to do with the patient with prehospital ST elevations that resolve after treatment in the field? This article has a number of mehodologic issues due to difficulties in obtaining full records but suggests that dynamic ST elevations should still have cardiology consultation with strong consideration for emergent catheterization.
  • Recommended by: Anand Swaminathan
  • Further information: STEMI with resolved STE…What do you do? (Amal Mattu’s Emergency ECG of the Week)

Emergency Medicine, Resuscitation, PediatricR&R Game Changer? Might change your clinical practice
Hughes NT, et al. Damage control resuscitation: permissive hypotension and massive transfusion protocols. Pediatr Emerg Care. 2014 Sep;30(9):651-6. PMID 25186511

  • Damage Control Resuscitation is the talk of the town (or the ED at least)… but does it really apply to children? Remember that children have different physiologic tolerances and responses… so perhaps not. The hypotensive child is at a different place compared to the hypotensive adult.
  • Recommended by: Sean Fox

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&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 059 appeared first on LITFL.