1/7/2015

Bradford L. Walters, MD, FACEP

William Beaumont Hospital
Oakland University William Beaumont School of
Medicine

Evaluation and initial treatment of

supraventricular tachycardia.
Mark S. Link, MD
N Engl J Med 2012;367:1438-48
This review started with a case presentation
and went through the types, diagnosis, EKG
patterns of SVTs.

Sinus tachycardia (ST) is the most common

SVT and is typically a physiologic response,
rarely > 220, P waves evident, regular.
Atrial fibrillation with rapid ventricular
response (AF-RVR) is the most common
pathologic SVT:

Risk factors = older age, male, HTN, CAD.

Can be acute onset in patient normally in NSR.
In chronic AF SVT can be more gradual in onset.
Ventricular rate 60-220/min.

This year there were 13 articles on 12 topics

(1 article was a commentary on another)
primarily on cardiac issues.
However, process improvement in the ED,
ketamine, pain management, and newer
anticoagulants were covered.
There was at least one must read article.

A 24 y/o female with only complaint of

racing heart, abrupt onset, prior H/O
palpitations that resolved spontaneously.
VS 84.60, 190
EKG = narrow complex tachycardia w/o clear
P waves.
How should this case be managed?

Atrial flutter (Afl) is the 2nd most common

SVT:
Due to reentry circuit around the tricuspid valve.
Atrial rate = 280-300, 2:1 block common giving a
ventricular rate = 150 (suspect Afl if rate is 150).

Pt. with a run of Afl

with variable block
that then went into
AF with a controlled
ventricular
response.

1/7/2015

Other common etiologies of SVT are:

Atrioventricular nodal reentrant tachycardia (ANRT)

Atrioventricular reciprocating tachycardia (ART)
Atrial tachycardia (AT)

Rates = 150-250.
Ventricular response is regular.
Occur in 1/500 persons in the U.S.

Share a lot of same characteristics:

Also known as reentry tachycardia due to a

bypass circuit of cardiac tissue that lacks the
usual normal insulation.
With antegrade conduction one can see a
delta wave in most cases (short PR interval).
Both the delta wave and tachycardia defines
Wolf-Parkinson-White syndrome.

Typically in patients > 20 y/o.

Caused by a reentry loop within the AV node
or atrial tissue.
Two conduits; one slow, one fast allows for a
reentry loop, P waves typically not seen on
EKG.

AT is a regular, focal tachycardia due to

micro-reentry circuit or automatic focus.
Unique characteristics of AT are:
They occur is repetitive short bursts.
Have a warm-up phenomenon of the rate
increasing over 5-10 seconds then stabilizing out.
EKG shows a P wave preceding each QRS unless
obscured by the T wave if the rate is high.

Less common SVTs:

Multifocal Atrial Tachycardia (MAT) requires at
least abnormal P waves, due to poisoning of the
atria by hypoxia, increase atrial pressure, or
theophylline, uncommon, irregular, rate modestly
faster than baseline.
Frequent PACs not technically an SVT but
morphologically appears similar, irregular, rate =
100-150/minute.

Junctional tachycardia very rare, unusual in

adults, can be seen in infants.
Paroxysmal junctional retrograde tachycardia
bypass tract near the AV node conducts
only retrograde, usually with dilated
cardiomyopathy.
Wide-complex reentrant tachycardia occurs
with conduction down abnormal atrial tissue
and back up the AV node.
All of these are so rare it is unlikely to be
seen by most practicing ED physicians.

1/7/2015

To begin the SVT differential the physician

should:
Look at the ventricular response (not atrial) on the
EKG.
QRS complex narrow vs. wide.
Regularity regular = <10% beat-to-beat variation.
Rapidity of onset.
Heart rate.

Once the QRS is noted to be narrow assess if a P

wave precedes it:

Sinus tachycardia.
Atrial tachycardia.
Multifocal atrial tachycardia.
Multiple atrial PACs.

P wave follow the QRS:

AV nodal reentrant tachycardia.

AV reciprocating tachycardia.

P waves not apparent:

Atrial flutter with rate > 150.

Atrial fibrillation with rapid ventricular response.

SVT with aberrancy

Wide-complex SVTs are more difficult to

diagnose can be ventricular or
supraventricular.
Ventricular VT, VF, torsades, polymorphic
VT.
SVT with aberrancy or by-pass tract results in
a widened QRS i.e. WPW
Ventricular sources tend to be irregular while
a regular wide-complex tachycardia can be
either ventricular or supraventricular.

Vagal maneuvers and adenosine can be

useful diagnostically and therapeutically.
Slowing of the rate can allow visualization of
P or flutter waves and can terminate AVNR
and AVT tachycardias.
Adenosine blocks AV nodal conduction
transiently and can terminate some 80% of
atrial tachycardias.
Rarely due to exciting atrial and ventricular
tissue adenosine can induce AF or nonsustained VT.

Torsades
VT

Verapamil, diltiazem are Ca-channel blockers

that block AV nodal conduction.
Hypotension can be an adverse side-effect so
they are not first line medications.
Electrical cardioversion is reserved for
unstable patients unresponsive to adenosine.

Presenters note: diltiazem is very effective in controlling the

ventricular rate with AF/RVR. Unstable = signs of
malperfusion including hypotension < 90mmHg, chest pain,
cardiac ischemia, cerebral malperfusion.

1/7/2015

Adenosine can be useful in wide-complex regular

SVTs not irregular where it can result in an
unstable rhythm.
Occasionally adenosine can open up a bypass
tract accelerating the ventricular rate.
Ca-channel blockers should not be used.
Procainamide, ibutilide, lidocaine, amiodorone,
and sotalol are all useful in treating widecomplex SVT of ventricular or atrial origin.
Cardioversion is often necessary and mandatory
in the unstable patient.

Regular SVTs = ST, AFl, AVNR, AVR, AT.

Irregular SVTs = AF, Afl with variable block,
MAT, multiple PACs.
Sudden onset = AF, AFl, AVNR, AVR, AT.
Gradual onset = ST, chronic AF/AFl, MAT,
frequent PACs.
Adenosine is useful diagnostically and
therapeutically but should not be used in
irregular wide-complex SVTs.

The current literature has mixed results in

regards to epinephrine finding it an
independent predictor of mortality, no
improvement in survival, and improves
likelihood of ROSC.
The statistics were pretty dense but one
unique variable was a propensity analysis to
see the effect of epinephrine used before
hospital arrival on immediate and1 month
survival.

Stable irregular wide-complex SVTs are

typically:
Atrial fibrillation with aberrancy.
Wolf-Parkinson-White syndrome.

This article suggests consultation with an

expert is generally required but I would defer
to ones clinical judgment.

Prehospital epinephrine use and survival

among patients with out-of-hospital cardiac
arrest.

Hagihara A, Hasegawa M, Abe T, et al.

JAMA 2012;307:1161-1168.
Prospective observational analysis of 417,188
OHCAs from 2005-8 in Japan in adult
patients.
The timeframe included introduction of
epinephrine as part of pre-hospital standard
resuscitation guidelines.

Using the Japanese National Database

information of OHCA patients was collected.
Glasgow-Pittsburg Cerebral Performance
Category (CPC) assessed cerebral function 1
to 5 scale of good cerebral performance to
death.
Overall Performance Category (OPC) assessed
neurologic outcome 1 to 5 scale of no/mild
disability to death.
Etiology of the cardiac arrest was determined

clinically by the attending physician.

1/7/2015

ROSC before hospital arrival.

Survival at 1 month.
CPC category 1 or 2 at one month post-arrest.
OPC category 1 or 2 at one month post-arrest.

417,188/431,968 OHCAs met inclusion

criteria, mean age = 72, no demographic
differences between epi/no-epi groups.
Rate of epi use increased from 190 cases in
2005 to 8,124 in 2008.

EPI

No Epi

18.2%

4.4%

Survival 1 month

3.8%

3.4%

CPC
category 1 or 2

0.6%

1.3%

OPC
category 1 or 2

0.7%

1.3%

ROSC
Pre-hospital

EPI

No Epi

ROSC
pre-hospital

21.1%

22.3%

Survival 1 month

15.4%

21.3%

CPC
category 1 or 2

6.1%

13.5%

OPC
category 1 or 2

6.2%

13.5%

There were 4 end-points:

13,401 patients who

receive epinephrine were
matched with 13,401
patients who did not.
Outcomes remained the
same increased rate of
ROSC that did not result
in greater survival or
function.

VERSUS

A positive association between epi use and

ROSC before hospital arrival was found O.R.
= 1.15.
A negative association between epi use and
survival at 1 month, CPC, and OPC was found
O.R. = 0.46.

More patients arrived with ROSC who received

epinephrine but this did not translate to
greater survival or better functional or
neurologic outcomes.

IV epinephrine administration was an

independent predictor of worse 1month
survival in OHCA even after controlling for
selection bias with a propensity analysis.
Epinephrine use was associated with an
increased rate of ROSC but that did not
translate into improved outcomes.

This might be due to epinephrine saving the

heart but not the brain.

A study with similar results recently was published Sanghavi

BS, et al. JAMA Intern Med
doi:10.1000/jamainternmed.2014.5420, published
11/24/2014

1/7/2015

Questioning the use of epinephrine to treat

cardiac arrest.
Clifton W. Callaway, MD, PhD
JAMA 2012;307:1198-1200.
A commentary on the previous epinephrine
article by a physician from the U. of Pittsburg
Department of Emergency Medicine and
Department of Pharmacy.

Epinephrine has a been a

mainstay drug in cardiac
resuscitation/ACLS since the
1960s.
It has been shown in animals and
humans to increase BP and
coronary perfusion pressure.
When CPR does not generate 1520 mmHg CPP cardiac
mechanical activity rarely occurs.
Dog studies from the 1960s
established the 1mg dose we
still use today.
However, experience shows us
that ROSC does not correlate
always with good outcome.

Raw data of the Hagihara study shows that

the administration of epinephrine is
associated with:

Increased ROSC (18% vs.. 5%)

Modest increase of survival at 1 month (5.4% vs..
4.7%)
But a lower rate of good functional status (1.4% vs..
2.2%)

Both Behringer and Holmberg in 2 observational

studies found that an increasing epinephrine
dose was associated with worse survival and
neurologic outcome (cause and effect?).
Gueugriaud and Callaham found additional epi
doses over 1mg did not correlate with greater
survival even with ROSC.
Behringer W, et al. Ann Intern Med 1998;129:450.
Holmberg M, et al. Resuscitation 2002;54:37.
Gueugriaud PY, et al. N Engl J Med 1998;339:1595.
Callaham M, et al. JAMA 1992;268:2267.

When looking at odds ratios particularly with

the propensity data better functional status
was lower in the epi-treated group (0.210.71).

One theory is that

epinephrine creates a
supply/demand mismatch
where the demand from
increased rate and blood
pressure on the heart is
not adequately met by a
compensatory increase in
CCP.

DEMAND
SUPPLY

Another untoward effect of

epinephrine is that it is
associated with a greater
incidence of arrhythmia that is
poorly tolerated post-ROSC

1/7/2015

So should physicians stop using epinephrine

the the setting of pre-hospital cardiac arrest
based on the findings by Hagihara?

The best available observational evidence

indicates that epinephrine may be harmful to
patients during cardiac arrest.
The author calls for a rigorously conducted
and adequately powered clinical trial
comparing epinephrine with placebo.

TH is a clinically-driven
treatment modality aimed
at reducing core body
temperature.
Various arguments over
precise temperatures for
mild, moderate, deep, and
profound hypothermia go
on.
Most authors agree that
TH currently targets a goal
temperature of 32-34oC
post-CPR.

Therapeutic hypothermia: a state-of-the-art

emergency medicine perspective.
Varon J, Marik PE, Einav S.
Am J Emerg Med 2012;30:800-810.
While hypothermia has been used in medicine
for centuries only recently has it been shown
to increase better neurologic outcomes postCPR.
The authors present the history of TH,
current applications, and its future.

Use of cold for local therapy dates back to

Egyptian times.
Hippocrates (460-370 BC) suggested cold water
for joint injuries.
Galen (130-200 AD) used cold cream for fevers.
Wm. Osler (1849-1919) lowered the mortality of
typhoid at Johns Hopkins from 24.4% to 7.1% by
cooling his patients.
Temple Fay (1895-1963) stuck cancer patients
outside to cool them to 90oF to control pain and
showed improved recovery from TBI.

(130AD 200AD)

Hippocrates (460BC 370BC)

Sir Wm. Osler

(1849-1919)

In the 1950s TH was being used in cardiac

surgery with better neurologic outcomes felt
to be due to decreased brain oxygen
consumption (pump head).
By 2003 the AHA and European Resuscitation
Council felt with 2 studies that there was
enough data to recommend TH for postarrest patients with ROSC.
Those studies from Australia and Europe
found better CNS outcomes with TH with the
NNT = 7.

Temple Fay
(1895-1963)

1/7/2015

CARDIAC ARREST
LOC in 10 seconds

EEG isoelectric in 20 seconds

Cerebral metabolism decreases 6-7% for every 1oC

reduction in core body temperature.
Cell wall integrity enhanced reducing apoptosis.
Inhibits NDMA receptors reducing intracellular Ca.
Improves oxygen supply to ischemic areas.
Decreases ICP secondary to hypothermia induced
cerebral vasoconstriction.
May act as anticonvulsant.

Anaerobic glycolysis, energy stores depleted,

intracellular calcium accumulation

ROSC

Moderate TH results in:

As core temperature
increases NDMA receptors
are activated and increases
cellular Ca.

Cerebral tissue injury continues with reperfusion due to free

radical generation worsened by any 0.5o increase in
temperature above 37oC

On the heart TH causes:

Decrease in heart rate, reduces metabolic demand.

Reduced CO ~7% for each 1oC fall in core temp.
Increased SVR so MAP is usually preserved despite
the fall in HR and CO.
Concerns for resistance to defibrillation are not
thought to be extent in moderate TH, swine data
suggests better response to defibrillation.
Ventilatory requirements are reduced, as expected,
optimal ABG strategy is not known at this time.
Renal blood flow increases resulting in a cold
diuresis and K+ loss.
Platelet function is decreased, bleeding rare.

Two modalities surface and invasive.

Surface cooling is simpler but achieving
target temperature takes longer, 2-8 hours.
Surface cooling may not decrease target
organ temperature very efficiently.
Shivering response is more pronounced with
surface cooling and needs to be controlled.
Ice packs, cold air or water blankets, or
hydrogel pads have all been used.

Invasive cooling have the advantages of

cooling the patient faster and more precisely.
Cools the core organs better.
Less shivering.
But is invasive and higher risk, more difficult
to institute.
Bypass and endovascular cooling catheters
are the most commonly used modalities.
Typically the catheter is placed in the femoral
vein up the inferior vena cava.

1/7/2015

Infusions of iced IV fluids (usually lactated

ringers) has been shown to be a means of
rapidly instituting TH.
Volumes of 2L to 30 cc/kg infused over 30
minutes has been shown to effectively lower
the core temperature to ~34oC.
Starting cold IV fluids can be done in the
prehospital setting though studies have not
shown improved outcomes.

A variety of devices and sites (rectal, bladder,

esophageal, endovascular) have been used to
monitor core body temperature.
Pulmonary artery probes are very accurate
but difficult to place.
Nasopharyngeal or esophageal monitors
correspond to brain temperature and the
most commonly recommended.

Current recommendation for TH is in an

unconscious adult with ROSC after OHCA.
Initial recommendations limited TH to postarrest VF patients but now any other rhythm
could benefit from TH.
Other modalities where TH has been used
include TBI, traumatic arrest, meningitis,
neonatal hypoxic encephalopathy, near
drowning, hepatic encephalopathy, ARDS, and
cardiac failure.

The use of TH in
traumatic brain injury is
gaining more acceptance
though the studies are
contradicting in terms of
outcome.
A Cochrane type review
suggested that best
evidence supports the
use of early TH.

1/7/2015

Animal models show better

neurologic outcomes of an
acute CVA with TH.
A few pilot studies have
shown induction with cold
IV fluids is safe.
Mild TH to 35oC is well
tolerated without shivering
in awake patients.
No randomized trials have
been performed to base a
recommendation of TH in
acute CVA.

Not an ED issue
ever!
Recommendation is
no faster than 0.5oC
per hour over 24
hours minimum.
Shivering often
needs to be
controlled.

Other complications include:

Dysrhythmias
Hyperglycemia
Coagulopathies
Infection, often pneumonia prophylactic
antibiotics are not currently recommended.
All TH patients should receive prophylaxis for DVTs
with at least calf compression devices.

Clearly the earlier the

better time is brain and
heart.
While no study has shown
improved outcomes with
invasive over surface
cooling the invasive
technique cools the
patient and core organs
faster and more precisely.

Shivering controlled with sedation

(midazolam) or anti-shivering agents
(meperidine).
The author recommends a combination of
propofol and remifentanil as they have such
short half-lives.
Paralysis may need to be initiated, typically
using rocuronium.

Ideal TH patient cardiac arrest with ROSC,

VF/VT, hemodynamically stable,
unresponsive.
How soon? ASAP, may still benefit 8 hours
out.
How to induce? ice packs, cold IV fluids,
surface cooling, invasive cooling.
Adjunctive meds sedation, paralysis.
Temperature monitoring continuous
bladder, esophageal, rectal, PA.

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1/7/2015

Accidental hypothermia.
Brown DJA, Brugger H, Boyd J, Paal P.
N Engl J Med 2012;367:1930-1938.
Unlike TH accidental hypothermia (AH) is an
involuntary lowering of core body
temperature (CBT).
This is a review article of the physiology and
treatment of accidental hypothermia often far
below that which is used therapeutically.

Priorities in the field include:

Careful handling to prevent VF.

Basic or advanced life support as the case warrants.
Passive and/or active external warming with warmed IV
fluids being effective (38-42oC).
Transport.

Large volumes of fluids can be necessary, but

one must be aware that a lot of NS can induce
hyperchloremic acidosis.
If not signs of life can be detected CPR should be
initiated.

The patient is not dead until they are warm and

dead.

As the body responses to maintain 37oC are

exceeded (movement, shivering) energy stores
are depleted and core body temperature drops.
Consciousness, breathing, circulation become
impaired.
Confusion at a CBT < 28oC is often seen.
AF is common at a CBT < 32oC with a greater risk
of cardiac arrest that increases substantially at a
CBT < 28oC.
Often AH is accidental but numerous diseases
can also cause low CBT.

An accurate CBT is necessary.

Esophageal probes work well in intubated
patients but can be falsely high is using
heated oxygen to ventilate the patient.
A bladder probe can also work well unless
one is doing warm peritoneal lavage.
A thermistor probe in contact with the TM is
one of the best means of temperature
measurement.
AH is considered if the CBT is < 35oC.

Patients with impaired consciousness should be

assessed for cardiac instability.
Stable patients may only require active external
warming with minimally invasive rewarming
(heating blanket + warm IV fluids).
Unstable patients (SBP < 90mmHg, CBT < 28 oC,
cardiac arrest) should, if possible, be transported
to a facility that can provide ECMO or cardiac
bypass warming.
Survival with good neurologic outcome has been
seen even with CPR that went on for hours
(longest CPR with good recovery = 190 minutes).

11

1/7/2015

For the stable patient treatment is relatively easy continue

active external warming, minimal invasive warming with
warmed IV fluids.
Should central line placement be necessary beware the
irritable heart and keep the wire and catheter out of the
heart to prevent the potential for arrhythmias.
ECMO or cardiac bypass may be necessary for the unstable
patient who does not respond to medical management.

Vasopressor use in animal

models have show mixed
results.
A modified approach to
ACLS with up to 3
defibrillations and holding
epinephrine until the CBT is
> 30oC.
The interval between epi
doses should be doubled
until CBT is > 35oC.
Terminate CPR if remains
asystolic with CBT > 32oC.

Rescue collapse refers to cardiac arrest

related to extrication and transport of a
patient in deep hypothermia.
Best evidence attributes to either
hypovolemia or cardiac arrhythmia.
After drop is defined as continue core cooling
after rescue seen more in artificial cooling
studies.
With active external and minimally invasive
rewarming this has not been reported.

With no signs of life or vital signs the

consensus opinion is to initiate ECMO or
cardiac bypass.
Survival rates of 47-63% have been reported
with initiating this form therapy without
such measures limited data gives a survival
rate of only 37%.
If such therapies are not available CPR with
rewarming should continue.
Should ROSC occur expect multi-organ
failure and the need for ventilatory support.

High K+ is seen primarily secondary to cell

death with an elevated level associated with
non-survival.
Highest recorded K+ levels in survivors:

11.8 in a 31-month old child

9.5 in 13 y/o child
7.9 in a 34 y/o adult
6.4 in an adult buried an avalanche

Authors recommend terminating

resuscitation if K+ > 12 mmol/L and if
between 10-12 initiating ECMO/bypass.

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1/7/2015

Trauma, shock,
cerebrospinal injuries can
all impair thermoregulation
making such patients prone
to hypothermia.
Clotting factor and platelet
activity is reduced,
particularly a CBT< 34oC.
Transfusions are commonly
necessary.

Lowest reported CBT with full neurologic

recovery has been:
14oC accidental
9oC induced

Most common cause of death = pulmonary

edema + organ failure.
For arrested patients with ECMO the mortality
is 50% with full recovery possible if hypoxia
did not precede the hypothermia and no
serious co-morbidities.

Cardiovascular disasters in pregnancy.

Sommerkamp SK, Gibson A.
Emerg Clin N Am 2012;30:949-959.
A review of pregnancy related heart/lung
disasters with the authors out of U. of
Maryland Department of Emergency Medicine.

Typically avalanche burial < 30

minutes is not associated with
hypothermia.
If the airway is obstructed with
snow, the victim has been
buried > 30 minutes, and is
asystolic CPR is unlikely to be
beneficial.
Cold water immersion without
submersion can have a better
prognosis even with deep
hypothermia and asystole.
The record submersion without
neurologic impairment to date
is 66 minutes in a 2.5 y/o child.

Advances in rewarming with more invasive

modalities has improved the outcome in
accidental hypothermia.
In the stable patient active external
rewarming + warmed IV fluids is associated
with a very good prognosis.
For unstable patients, those not responsive to
medical management, or who have arrested
ECMO/bypass offers the best outcome.
If asystolic once CBT reaches 32oC or the K+
is > 12 mmol/L CPR is considered futile.

Normal cardiovascular changes during pregnancy

include:

Cardiac output increase of 50%.

Increased blood volume.
Increased pulse rate.
Decreased systemic vascular resistance.

Such changes are particularly dangerous should

the patient have an underlying cardiac problem.
Overall pregnancy related mortality
is13.95/100,000 pregnancies with 8 cardiac
arrests or 1:20,000 maternities.

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1/7/2015

Venous thromboembolism (VTE)

is more common in the pregnant
state (1.94/100,000 pregnancies)
due to hypercoagulability.
D-dimer is less specific as it
elevates throughout the
pregnancy and its usefulness
decreases the later in pregnancy.
Adjusted trimester levels
proposed by Kline are:

CT less radiation exposure to the fetus, more to

mother (breast tissue).
V/Q more exposure to the fetus, less to mother.
Both imaging modalities have acceptable levels of
radiation exposure.
MRI no radiation, less available, have to lie supine
for a longer period of time.
US no radiation, misses pelvic VTE.
Echocardiogram excellent adjunctive test, looks
for RV strain to Dx submassive/massive PE.

750 ng/dl first trimester.

1,000 ng/dl second trimester.
1,250 ng/dl third trimester.

Treatment:
Traditionally heparin now
supplanted by LMWH.
Coumadin is a class X drug,
fetotoxic.
TPA on a case-by-case
basis, assume a PE is the
etiology of cardiac arrest in
a pregnant patient and has
been used successfully but
often fetotoxic.

Cardiac disease is not that

uncommon in pregnant women
and accounts 2.27
deaths/100,000 maternities
and complicates 1-4% of
pregnancies.
Obesity, HTN, DM,
hypercholesterolemia, and
older women having children
are felt to account for a rising
incidence of cardiac problems
during pregnancy.

Imaging becomes problematic:

2nd most common cause of

maternal death.
50% of dissections in women <
40 y/o occur during pregnancy.
Diagnosis is challenging and
shares the difficulties with
VTE/PE D-dimer non-specific,
imaging problematic.
TEE is ideal if available.
CT delivers a lot of radiation and
dye.
Treatment is the same an in
non-pregnant woman, betablockers felt to be safe.

Risk Factor

Pregnant, morbidly obese

at baseline , diabetic,
hypertensive and 38 years
old oh, perfect!

Points

NY Heart Association Class II-IV ht. failure or

cyanosis

Previous cardiac event (CVA, TIA, ACS) or

arrhythmia

Left heart obstruction (MV area < 2cm2, AV

area < 1.5cm2, LV outflow gradient >
30mmHg

Ejection fraction < 40%

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1/7/2015

Valvular disease, infectious or congenital, places

a pregnant patient at risk particularly with
mitral/aortic stenosis.
Cardiomyopathy is typically viral in etiology but
can be infectious, of particular risk if the ejection
fraction is < 40%.
Have a high level of suspicion for
cardiomyopathy in the pregnant patient
complaining of dyspnea, fatigue, pedal edema

(challenge being is all pregnant patients

complain of those symptoms).

BNP can be helpful with 100-300 pg/ml

indicating cardiac disease and >300 indicating
overt CHF.

Usually palpitations are benign but more

serious arrhythmias have to be ruled out.
SVTs are common and adenosine can be
used safely, rate control for AF/RVR, and
cardioversion as in a non-pregnant patient.
Cardioversion is safe in all trimesters,
sedation is more risky in the 3rd trimester
because of potential hypoxia or aspiration.
LMWH is the anticoagulant of choice.

Reversible causes:

Hypovolemia blood loss, DIC, placenta abruption

or previa.
Vasodilatation septic shock, thyroid storm.
Pump failure cardiomyopathy, AMI, arrhythmia.
Outlet obstruction pericardial tamponade, PE.
Should ROSC occur hypothermia is being
recommended more and more with one case report
of a favorable outcome for the mother and fetus.

If perimortem C-section is best if considered

within 4 minutes of onset of cardiac arrest.

Management of cardiomyopathy in pregnancy

is as usual save for no ACEI/ARBs.
AMI is 3-4x more common in pregnant than
in non-pregnant women.
Management is the same ASA, betablockers, nitrates, PCI.
Clopidogrel (Plavix) is considered safe but can
cause excess bleeding at delivery.
ACEI/ARBs, statins are contraindicated.

Cardiac arrest can have a number of different

etiologies with PE and primary cardiac being
the most common.
Compression on the aorta and IVC by the
gravid uterus has to be relieved with pushing
the uterus to either the right or left.
The usual ABCs should be changed to CAB,
medications and defibrillation as usual per
ACLS.
Consideration of TPA for a massive PE if the
patient remains unresponsive.

Reversible causes H&Ts

Hypovolemia
Hypoxia
Hydrogen ions (acidosis)
Hyper/hypokalemia
Hypothermia
Hyper/hypoglycemia
Tablets/toxins/OD
Tamponade cardiac
Tension pneumothorax
Thromboembolism (PE)
Trauma

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1/7/2015

Bleeding/DIC
Embolism
Anesthetic complications
Uterine atony
Cardiac disease
Hypertension/eclampsia
Other
Placental abruption/previa
Sepsis

Coronary CT angiography versus

standard evaluation in acute chest pain.
Hoffman U, Troung QA, Schoenfeld DA,
et al.
N Engl J Med 2012;367:299-308.
A mulitcenter trial where patients with
symptoms suggesting ACS without
ischemia on EKG or a positive troponin
were randomized to early CCTA or
standard evaluation during weekdays.

Between 4/2010 and 9/2012 patients

presenting at 9 different hospitals during the
week and in daytime hours with chest pain or
symptoms suggesting CAD between the ages
of 40-74 years old.
Patients were randomized to CCTA or the
standard CAD evaluation at that hospital.
Exclusion criteria were patients with known
CAD, evidence of ischemia by EKG or labs,
unstable, obese, or allergic to dye.

Cardiovascular emergencies in the pregnant

patient while not common are not
uncommon.
They tend to be devastating and can be
difficult to diagnose and treat.
The best chance for the fetus is to take care
of the mother.
Keep in mind PE, decompensated CHF, AMI,
arrhythmia.
Most often the therapeutic approach is
similar if not the same as it the non-pregnant
patient.

CCTA has been shown to have a high

sensitivity and specificity for the detection of
clinically significant coronary artery disease.
Normal findings have a very high negative
predictive value in low risk patients.
It is suggested that CCTA can rule out
significant CAD faster and with less radiation
than stress myocardial perfusion studies.
This study looked at a 64-slice CCTA
compared to a standard evaluation for CAD.

Primary endpoint hospital length of stay

(LOS).
Secondary endpoints time to diagnosis, rate
of direct discharge, resource utilization,
cumulative radiation exposure, 28-day
follow-up.
1,273 patients assessed, 1,000 randomized,
501 CCTA, 499 standard evaluation, 99-98%
were followed up at 28 days.

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1/7/2015

End Point

Of the 501 randomized to the CCTA group 28 did

not get the study for one reason or the other.
75 patients (8%) had a final diagnosis of CAD.
Agreement for discharge between the site and an
independent panel was high (kappa = 0.94).
Average LOS was 7.6 hours less for the CCTA
group with 50% discharged within 8.6 hours
compared to only 10% of the standard group in
that timeframe, mean time to diagnosis was
much less for the CCTA group.

No cases of undetected CAD were identified

in either group.
There were 8 major cardiac events at 28-day
follow up in the standard group, 2 in the
CCTA group.
Of those 2 patients in the CCTA group
significant CAD was identified but both had
negative stress tests and were treated
medically.

This study looked to see if early CCTA in the

work-up of low risk chest pain safely
improved the efficiency of clinical decision
making compared to standard evaluations.
The average LOS was significantly reduced
with a high proportion of CCTA patients
directly discharged from the ED without a
greater risk of undetected CAD.
There were no cases of missed CAD in either
group.

CCTA

Standard

LOS all patients

23.2 hours

30.8 hours

LOS patients w/o final Dx of CAD

17.2 hours

27.2 hours

LOS patients with final Dx of CAD

86.3 hours

83.8 hours

Time to Dx all patients

10.4 hours

18.7 hours

Time to Dx patients w/o final Dx of CAD

10.6 hours

18.8 hours

Time to Dx patients with final Dx of CAD

8.0 hours

17.1 hours

In the CCTA compared to

the standard group:

More diagnostic testing.

Non-significant higher rate
of eventual revascularization.
Higher radiation exposure as
only 33% patients in the
standard group received any
radiation exposure at all
compared to 100% of the
CCTA group.
Costs overall were similar
between the groups.

The CCTA group ended up with more invasive

coronary procedures as more CAD was
detected that had to be addressed and at a
cost of more radiation exposure to the group
overall.
There was no reduction in costs seen with the
use of CCTA despite its overall greater
efficiency.

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1/7/2015

Infective endocarditis.

Hoen B, Duval X.
N Engl J Med
2013;368:1425-1433.
A review of infective
endocarditis (IE) starting
with a case presentation.

Strep and Staph account for 80% of IE.

With increase in health-care
associated disease Staph IE is on the
rise.
Culture negative IE (~10% of cases) is
felt to be due to the patient getting
Abxs or fastidious organisms (PCR or
serologic testing can help) i.e.
bartonella, brucella, Q fever, HACEK
group of bacteria (haemophilis,
Aggregatibacter,
actinomycetemocomitans,
Cardiobacterium, Eikenella, Kingella).
Oral strep is less common now with
prophylaxis.

Strep pneumoniae

Annual incidence 3-9 cases/100,000

persons in industrialized countries with a 2:1
male to female ratio.
Risk factors prosthetic valves, intracardiac
devices, unrepaired congenital heart defects,
and a history of IE in the past.
Other factors valvular lesions, hemodialysis,
DM, immunodeficiency, HIV, IVDA.
~33% due to be due to health-care associated
bacteria.

Normal valve endothelium is resistant to

bacterial invasion unless the tissue is
damaged by jet lesion or inflammatory
disease.
Solid infective particles from IVDA can both
injury the valve and colonize it.
Old classification was based on rapidity of
onset.
Now the classification is based on underlying
cardiac conditions, location, presence of
intracardiac device, or mode of acquisition.

MRSA

Mortality:

Overall in-hospital mortality 15-22%.

5-year mortality 40%.
Right-sided lesions, oral strep, or left sided native valve
lesions in-hospital mortality 10%.
Prosthetic valve Staph aureus IE in-hospital mortality
40%+.
Risk factors for death:

Older age
S. aureus IE
Heart failure
Cerebrovascular and embolic events
Health-care associated IE

Diagnosis rests on clinical,

microbiological, and
echocardiographic findings
with the definitive diagnosis =

microorganisms identified by
culture or histologic
examination of vegetations,
intracardiac abscess, or
embolic specimen.

Duke criteria has

sensitivity/specificity of 80%.

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1/7/2015

Fever is present in 80%.

A new or worsening murmur in 48% and 20%.
Less common findings:

Janeway lesions
are small,
erythematous,
non-tender,
nodular lesions on
palms or soles due
to septic embolic
causing
microabscesses.

Hematuria in 25%.
Splenomegaly in 11%.
Splinter hemorrhages in 8%.
Janeway lesions in 5%.
Roths spots in 5%.
Conjunctival hemorrhages in 5%.

Splinter
hemorrhages are
tiny blood clots
seen in the nail
beds, usually plum
colored, seen in IE.

Labs show an elevated ESR/CRP, leukocytosis,

anemia in ~ 50% of cases.

Roths spots are

retinal
hemorrhages often
with a pale, white
center first
identified in 1872
felt to be
coagulated fibrin
and platelets seen
with IE.

Osler nodes are painful lesions on palms or soles seen in

IE made up of immune complexes.

Cerebral complications are the

most severe extracardiac
problems with IE.
They include ischemic or
hemorrhagic CVA, TIA, mycotic
aneurysm, brain abscess, or
meningitis.
60% of IE associated CVA/TIAs
precede the actual diagnosis.
Large, mobile, S. aureus mitral
valve lesions impart the
greatest risk of embolizing.
CT/MRI are the tests of choice.

Identifying the causative

organism is key with 3 blood
cultures finding the agent in
90%.
If cultures are negative
serologic testing for
bartonella, brucella, and C.
burnetii as in-patient.
TEE and transthoracic
echocardiograms reliably
demonstrate valvular lesions
showing vegetations in 90%,
regurgitation in 60%, and
paravalvular abscess in 20%.

Ruptured mycotic
aneurysm from IE.

Abscess just above the mitral

annulus with a dilated LV
secondary to S. aureus IE.

Criteria 2 major, 1 major + 3 minor, 5

minor = infective endocarditis.
Major Clinical Criteria BC positive x 2,
echocardiographic evidence of vegetation,
new valvular regurgitation.
Minor Clinical Criteria Risk factor for IE or
IVDA, fever, vascular complications i.e.
embolus/aneurysm/Janeway/, immunologic
phenomenon i.e. Osler nodes/Roth spots, or
blood culture positive without major criteria.

Antibiotics are key ranging from 2-6 weeks.

For native valves a beta-lactam Abx +
aminoglycoside is a good starting choice (Rocephin
plus gentamycin).
For prosthetic valves infected by staph the same
choice of antibiotics with the addition of rifampin if
the bacteria is susceptible.
Gentamycin is the most evaluated aminoglycoside
and should be used until sensitivities are back, how
often to give gentamycin is a matter of debate and
can be decided outside of the ED.
For MSSA gentamycin is not recommended as it does
not offer better clinical benefit but is advised with
MRSA for the first 2 weeks.
Daptomycin is gaining popularity as an alternative to
vancomycin in PCN allergic patients.

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1/7/2015

Early valve replacement

is becoming more
common, even during
the Abx course, ~50%.
Indications include heart
failure, uncontrolled
infection, and prevention
of emboli.
In the case of an
embolus that has already
occurred the risk of
surgery has to be
balanced with the risk
further emboli.

Duration of antibiotic treatment continues to

be debated particularly with the
aminoglycosides along with the role of oral
therapy.
Surgery timing also remains an area of
debate.
The treatment of unruptured mycotic
aneurysms is uncertain as Abx therapy can
resolve them though endovascular treatment
for large ones is advisable.

Surgery is indicated for heart failure,

uncontrolled infection, and to prevent emboli.
Treatment with antibiotics with a starting
choice of a cephalosporin plus gentamycin
until sensitivities come back, the addition of
rifampin initially with a prosthetic valve is
reasonable.
Prophylaxis is now confined to patients with
previous IE, prosthetic valve, or unrepaired
congenital heart lesion.

Oral anticoagulants are not recommended

even with prosthetic valves due to the risk of
cerebral hemorrhage.
Heparin for the first 2 weeks is used.
Antiplatelets are not recommended.
Current prophylaxis for IE is now restricted to
patients with a prosthetic valve, h/o IE, or
unrepaired congenital heart defect.
In Great Britain prophylaxis is not used under
any circumstances.

Staph and Strep account for 80% of IE with

staph currently the most common.
Cerebral complications are the most common
extracardiac complications and the most
severe.
Large, mobile lesions of mitral valve due to
Staph are at the greatest risk of embolus.
At least 3 blood cultures are necessary.
When IE is suspected echocardiography ASAP
with both TEE and transthoracic advised.

Lean thinking in emergency departments: a

critical review.
Richard J. Holden, PhD.
Ann Emerg Med 2011;57:265-278.
This was a not particularly useful review* of
the Lean process of improvement first
developed by the Toyota Production System.

*Authors note: it reminded me of why even as a sociology major I got out of the social sciences .

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1/7/2015

Lean thinking came out of the auto industry and

has spread to many different industries with
some 50% of EDs using this to improve
processes.
It looks to reduce waste, involve front-line
workers, and have continuous rapid improvement
sessions (kaizen).
This review looked to focus on the ED, how Lean
affects ED employees and patients, looks at
previous studies for desirable and undesirable
effects, analyze Leans variability in its success,
and analyzes previous studies with an analytical
framework as opposed to a narrative story.

The analytic framework yielded 6 questions:

How does Lean transform work structures and

processes?
How does Lean affect patient care?
How does Lean affect employee working conditions?
How does Lean affect employee outcomes directly?
How are employee and patient effects of Lean
linked?
How are patient care and employee effects of Lean
contingent on the organization implementing Lean
and features of the design and implementation of
Lean?

Table 2 and Figure 3 in the article ran down a

large laundry list of changes and results from
decreased LOC to improved patient
satisfaction to decrease time to doctor.
Various process changes established new
standards for performance, data collection,
and monitoring systems.
A number of salutary changes to patient care
were evident though changes in overall health
outcomes were not studied nor patient safety
measures were looked at in only one study.

The studies selected were analyzed according

how Lean affects the process of ED work.
Structure refers to work system elements
including tools, technology, worker factors
(education, training, responsibilities),
organizational factors (policy, staffing, incentives),
and physical environment.
Process the activities involving patient care and
flow of the patient through the ED.

Also looked at not just employee effects on

Lean but how Lean effected the employees
themselves.

18 articles involving 15 EDs included.

EDs tended to be large, teaching hospitals.
All involved frontline staff in some way, i.e.
suggesting/implementing/designing changes.
Most cases Lean was the only change process
used did not compare different approaches.
Analysis typically followed the change process
where bottlenecks, waste, or other problems
were identified and redesign suggested (changes

were evaluated and adjusted in an iterative way).

Indirect changes of Lean were not often

measured but some evidence of less staff
aggression, more courtesy, greater job
satisfaction, better retention were mentioned.
Direct effects of Lean were seen in employees
being more aware of their work, new values,
more eager to accept change, and more
control of their work.
No study looked at Lean related patient and
employee outcomes.

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1/7/2015

In the 5 years since Virginia Mason Medical

Center published their landmark experience
with Lean many EDs have used it to assess
and change their work environment to
address errors, delays, and crowding.
Patient care typically improved with these
efforts while direct links between Lean and
safety have yet to be shown they are implied
(i.e. less crowding is known to be associated
with fewer medication errors).

The authors offer 9 suggestions regarding

Lean:

Be ready for change.

Take a human-centered approach.
Secure expertise.
Obtain top management support and resource
allocation.
Secure leadership.
Aim for culture change.
Adapt Lean to the local context.
Improve continuously.
Learn from previous experience.

Relief of pain and anxiety in

pediatric patients in emergency
medical systems.
Fein JA, Zempsky WT, Cravero JP,

The Committee on Pediatric

Emergency Medicine and Section on
Anesthesiology and Pain Medicine.
Pediatrics 2012;130:e1391-e1406.
An extensively researched
summary to create a systematic
approach to pediatric pain
management in the emergency
setting.

Typically the use of Lean was not directed to

improving the employee work environment
and only one study measured job satisfaction
related to Lean change initiatives.
The authors note Lean can increase workload,
threaten autonomy, and create anxiety.
Some of the research effects of Lean suffers
from a Hawthorne Effect, i.e. employees were
more satisfied because Lean forces more
attention on them and their work
environment.

Lean is a process to implement change that has

been widely adopted in many EDs.
Typically it has favorable effects.
The link between Lean and effects on patient
safety, quality outcomes, and on employees is
not well known.
Factors that contribute to Leans success are also
not well defined.
Employee engagement was typically improved
and often EDs find they cannot go back to old
ways of doing things following Lean
implementation.

Pain management varies with the age of the

patient with numerous barriers in the ED:
Difficulty in assessing pain in young children.
Unfamiliarity with new techniques and drugs.
Fear of adverse effects.
Time and staffing limitations in busy EDs.
Misconceptions about masking symptoms that
prevent accurate diagnoses.
Physician and parent biases.
Ethnic and socioeconomic variations in analgesic
administration.

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1/7/2015

There is evidence that minor

procedures (needle sticks, IV starts,
heel sticks) can affect a childs long
term emotional well-being.
Best evidence in neonates is with
more effective procedural pain
management there are better
outcomes.
Pediatric oncology patients report
higher pain scores when their pain is
invalidated by health-care personnel.
Do not forget the Joint Commission
that mandates the right of all
patients to have their pain assessed
and managed.

Authors emphasize a pediatric

environment with colorful walls,
toys, games, video/TV devices to
distract patients are important to
minimize fear a major
contributor to the pain
experience.
They also tout the child life
specialist who is trained to assess
and manage anxiety and pain with
distraction techniques, imagery,
education, and coping plans.
Family presence during
procedures can also be helpful in
reducing pain.

Presenters total unscientific, non-controlled,

non-randomized convenience sample of pain
scores (3 weeks ago):

Effective and safe pain

management can begin with
EMS providers.
Adult and 1 pediatric trial
showed that opiates and
tramadol can decrease pain
scores without causing
respiratory depression.
Transmucosal delivery
systems can be particularly
easy and effective to use in
the prehospital setting.

Topical anesthetics can be used to control the

pain of IV catheters:
More rapidly acting agents; EMLA, liposomal
lidocaine cream, heat activated systems, sprays.
Intradermal injection; benzyl alcohol, buffered
lidocaine.

Children < 3 y/o, in ED for medical problem,

parents responding, N = 8 pain score average =

10.
Prompt care, mix of adults and adolescents, mix of
primarily limb injures, N = 12, average pain score =
13.66 (two were > 10).
Adult side, illness, non-trauma, N = 10, average
pain score = 8.5.

The Joint Commission has mandatory rules for

pain assessments in the hospital.
Usually some form of age appropriate pain scale
is used.
There is question as to the utility of such scores
let alone basing the quality of care on them
most patients rate their pain in the ED at 10 and
the issue of a statistically significant change in
pain scale rating being clinically relevant.

Topical anesthetics for laceration repair

placed at triage; LET/XAP, EMLA.
Use of tissue adhesives and absorbable
sutures to avoid having to remove sutures.
Buffered lidocaine reduces the pain of
injection.

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1/7/2015

Sucrose has been found to

decrease to discomfort of
heel sticks, injections,
vaccinations with the best
evidence in neonates.
Skin-to-skin contact and
breast feeding also has
been shown to decrease
discomfort.
Elimination of heel sticks
and IM injections as IV
starts has been shown to
be less painful.
Pain scores for venipuncture in neonates

There has been in the past great

theoretical concern that analgesic
administration has the potential
to alter that ability to clinically
assess a patient particularly
abdominal pain.

Just tell me
what the CAT
scan showed

There is no evidence that altering

the level of pain impairs that
clinical assessment.

To a large extent imaging (CT

scan) has replaced that icky task
of actually getting a history, doing
a physical exam, and talking to a
patient for general surgeons.

In children with developmental issues pain

management can be particularly difficult in
the prehospital setting.
Pain modulation vary widely related to
neurotransmitter alterations in the brain or
spinal cord alters but does not preclude pain
perception.
Ascertaining the degree of discomfort in
children who cannot communicate is difficult.

Optimal pain management requires

expeditious assessment and rapid
administration of an opiate IV or
transmucosal can be useful in the
prehospital and ED setting.
Pain versus anxiety is particularly
difficult to separate in younger
children if a procedure is expected
to painful analgesics should be used,
anxiety provoking sedatives might be
more appropriate.
Nitrous oxide is very effective but
contraindicated in pneumothorax,
bowel obstruction, intracranial injury,
and cardiovascular compromise.
ED Nitrous Oxide
analgesic delivery
system

Personnel who administer sedation and analgesic

for procedures must be able to manage the
pediatric airway.
A study of 131,751 elective pediatric sedations
found no difference in adverse events between
anesthesiologists and pediatric medical
subspecialists.
A separate person monitoring the patient is felt
to be essential.
NPO guidelines are controversial with insufficient
data to determine safe NPO times.
The urgency of the procedure is paramount.

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1/7/2015

Training and education in pediatric pain

assessment and management should be
provided to all EMS personnel.
Child life specialists can be valuable adjuncts
in non-pharmacologic techniques to reduce
pain along with family involvement.
Pain assessment begins in the prehospital
setting and follows through to the ED and
instructions to family on discharge.

Clinical practice guideline for emergency

department ketamine dissociative
sedation:2011 update.
Green SM, Roback MG, Kennedy RM, Krauss B.
Ann Emerg Med 2011;57:449-461.
This is a comprehensively researched
summary of the literature on ketamine by two
of the leading lights in ketamine and sedation
in emergency medicine (Green, Krause).

Ketamine disconnects the thalmocortical and

limbic systems isolating the CNS from outside
stimuli.
The dissociative effect is seen at doses:

IV 1-1.5 mg/kg
IM 3-4 mg/kg
In smaller doses it is analgesic and disorienting
Once the dissociation threshold is reached additional
doses of ketamine does not deepen that effect and are
unnecessary.
At these doses there is no clinically important effect on
airway integrity, respirations, or blood pressure.

The dissociative state created by ketamine is not

a general anesthetic state by all definitions.

The administration of analgesics should be an

painless as possible.
Neonates and young infants should receive
adequate pain prophylaxis for procedures.
Analgesia does not preclude the clinical
assessment of pediatric patients.
Sedation and dissociative agents should be
provided by appropriate trained personnel
and full monitoring should be instituted.

Ketamine is the most popular agent for

pediatric procedural sedation with clinical
practice guidelines in 1999, updated in 2004,
and was felt to be due for another update.
Ketamine is sufficiently different from other
sedatives in its dissociative effect that it
warrants a separate guideline and
consideration.

MEDLINE search of the literature 2003-2010.

Strength of scientific evidence adapted from the
American Society of Anesthesiology:
Supportive compelling association of clinical
intervention and clinical outcome.
Suggestive enough information from a single study or
report to support the intervention and clinical outcome.
Inconclusive studies exist but cannot provide a clear
causal interpretation.
Insufficient to few studies to support a conclusion.
Silent no studies to address the relationship in
question.

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1/7/2015

The literature is strongly

supportive of the safety and
efficacy of ED dissociative
sedation for a variety of brief
painful or emotionally disturbing
procedures in both children and
adults.

Very useful in mentally impaired

children.
Can be safely used for longer
procedures but for something
that requires the patient to be
motionless (CT, MRI) the random
movements with ketamine can be
a disadvantage.

Risks may outweigh benefits:

Age previous guidelines suggested ketamine

should be avoided in children 3-12 months, large
meta-analysis does not support this and global
evidence suggests minimal to no enhanced risk.
Laryngeal Stimulation ketamine preserves and can
exaggerate airway reflexes increasing the risk of
laryngospasm with stimulation of the oropharynx,
large meta-analysis failed to corroborate an
increased risk in typical ED procedures (intraoral
laceration, dental procedures, foreign body) though
efforts to keep secretions/blood out of the
oropharynx is prudent.

Risks essentially always

outweigh benefits:

Age - < 3 months there a

anecdotal reports of airway
complications with ketamine (no
different than any sedative) likely
due to age specific airway
anatomy and laryngeal
excitability.
Mental State ketamine can
exacerbate schizophrenia and
should not be used on such
patients, the literature is silent on
other forms of psychosis.

Risks may outweigh benefits:

Anatomy Inconclusive data on the use of ketamine
in patients with tracheal surgery, stenosis,
tracheomalacia but such conditions may confer
higher risk.
Upper airway infection some indirect evidence
that with an active URI there could be a higher risk
of laryngospasm in children not adults, there were
some anecdotal cases in the 1970s and that
admonition was listed in all guidelines on ketamine
ever since though there is insufficient evidence of
this.

Risks may outweigh benefits:

Asthma while ketamine has
been used for therapy for
asthma its safety in sedation is
not known and active asthma is
a known risk for laryngospasm,
in quiescent asthma there is no
contraindication.
Laryngospasm ketamine
associated laryngospasm is rare
(0.3% risk is a large metaanalysis), transient, and
responds to assisted ventilation
and oxygen.

The infants airway is:

- smaller so secretions easily
obstruct the opening.
- the tongue is larger in
proportion to the mouth.
- Pharynx is smaller and
cone shaped.
- Epiglottis is larger and
floppier.
- narrowest at cricoid.
- trachea is narrower and
less rigid.

Risks may outweigh benefits:

Cardiac disease widely recommended that ketamine be

avoided in CAD in both children and adults, its
sympathomimetic effect increases BP and pulse mildly
but evidence is inconclusive regarding if this increases
oxygen demand.
The literature is silent on the maximum age for ketamine
though millions of older adults have received ketamine
safely worldwide over the past 40 years.
In addition, the literature is silent on ketamines use in
patients on OTC sympathomimetic (pseudoephedrine) so
these meds do not represent a contraindication.

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1/7/2015

Risks may outweigh benefits:

Increased ICP probably no other
unverified caution to the use of
ketamine has persisted in the
literature more than not using it
in head trauma or suspected
increased ICP, newer data
indicates what increase there
might be is minimal assuming
normal ventilation and
ketamines vasodilatory effect
might actually improve cerebral
perfusion.

Irrespective of age the more comorbidities a

patient has the greater the risk of adverse
events with benzodiazepines, opiates,
inhalational anesthetics, and propofol.
However, no such association has been
shown with ketamine in children and given its
supportive cardiopulmonary effects is likely
the preferable agent for sedation.

IV route:
Minimum dissociative IV dose is 1.5mg/kg with
recommended loading dose of 2mg/kg.
Repeat doses of 0.5-1mg/kg as needed.
IM route:
Minimum IM dose to reliably induce dissociation is 45mg/kg.
Repeat half or full dose as needed is typically effective
if needed in a longer procedure.

Risks may outweigh benefits:

Sz disorder though the literature is silent on this

ketamine does have anticonvulsant properties.
Increased IOP inconclusive and conflicting
evidence regarding ketamine increasing
intraoccular pressure and should be used with
caution.
Thyroid ds., Porphyria inconclusive data regarding
ketamines sympathomimetic effect in thyroid and
porphyria patients, use caution.
NPO status there is no data to correlate NPO
status with adverse events with ketamine, in 40
years of use and a large ED study showed no
association between fasting and adverse events.

Unlike almost any other drug ketamine does not

show dose-related increase in adverse events
save once IV doses exceed 2.5 mg/kg or 5
mg/kg total dose showing more vomiting and
recovery agitation.
There is no apparent benefit to using IV 1mg/kg
vs.. 2mg/kg or IM 3mg/kg over 4mg/kg.
Even data from the 1970s with doses of 715mg/kg by anesthesiologists showed no
increase in adverse events over standard doses.

Anticholinergics in the past it was

recommended to coadminister atropine or
glycopyrolate but a meta-analysis showed this is
typically unnecessary, can increase airway events
but decrease vomiting.
Benzos 2 meta-analyses showed prophylactic
administration to prevent recovery agitation
failed to show a benefit, such reactions are
readily ameliorated with titrated
benzodiazepines.
Antiemetics prophylactic ondansetron does
reduce recovery emesis, NNT = 13.

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1/7/2015

Laryngospasm occurs in 0.3%, occurs more

with higher doses IV, typically transient with
need for BVM/intubation very rare, could be
increased with active asthma but not with oral
procedure/age/route/coadministered meds.
Respiratory depression very unusual with
ketamine save if given rapidly.
Emesis early adolescence is peak age, more
with IM route, typically late recovery stage,
decreased by Zofran.

Adult use existing evidence supports the

safety and efficacy of ketamine in adults and
it is used worldwide (save in the US); more
rigorous studies would be helpful.
Ketofol several ED studies show this
combination to safe and effective.
Neurotoxicity in animals accelerated nerve
cell apoptosis with high doses has been seen
but is in complete odds with the human data.
Subdissociative doses used for analgesic,
may reduce opiate use.

The prophylactic use of anticholinergics or

benzodiazepines is unnecessary.
Recovery agitation is unusual and treatable with
titrated benzodiazepines.
Ondansetron (Zofran) can reduce ketamine
emesis that is typically seen in the recovery
stage.
Safe and effective use in adults has been
demonstrated.
Like any sedative/analgesic used for procedures
careful patient selection and monitoring ensures
safe use

Recovery agitation hallucinations but

unpleasant and pleasant are legendary with
ketamine, rarely disturbing in children,
occurs in 1.4% in kids and 0-30% in adults,
the ED experience is that is uncommon and
mild for adults, easily treated with benzos.
In a large meta-analysis in children this was
not related to age, dose, adolescents were
not at greater risk, higher incidence with
subdissociative doses (<3mg/kg IM).

Ketamine has been shown to be a safe and

effective sedative for painful procedures in a
wide-variety of ED settings in children and
adults.
Dissociative doses are IV 2mg/kg, IM
4mg/kg.
Most of the concerns with ketamine have not
born out in studies and closer scrutiny
including recovery agitation is older patients,
increased ICP, cardiac risk, and laryngospasm
with oral procedures.

Electrocardiogram findings in emergency

department patients with syncope.
Quinn J, McDermott D.
Acad Emerg Med 2011;18:714-718.
A study of consecutive ED patients with
syncope to determine the sensitivity and
specificity of the San Francisco Syncope Rule
(SFSR) to predict at risk patients of a cardiac
problem.

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Syncope is a transient LOC and

postural tone followed by
spontaneous recovery
accounting for 1.2% of ED visits.
By far the usual causes are
benign, typically vasovagal
however, 5-10% have more
serious etiologies with
significant mortality.
Because of that a large number
of patients are admitted (5085% in the U.S. compared to 1530% in Canada and Australia)
with a cost of $2 billion/year.

Some dated cost data on

some common tests done to
ascertain the etiology of
syncope.
Gives a sense on how this
could cost $2 billion
particularly when some 85%
of patients who present to
the ED with syncope are
admitted in the U.S.

Numerous studies looking to derive

predictors of serious etiologies with the EKG
consistently one of the major determinants.
However, studies vary on what is an
abnormal EKG, in the derivation of the SFSR
it was any non-sinus rhythm on EKG or

monitoring.

In that study cardiac and non-cardiac serious

outcomes were lumped together and did not
specify which EKG findings were abnormal.

This study was an analysis of a previous

database to determine the sensitivity for the
EKG criteria of the SFSR for cardiac outcomes.
The initial prospective study was from 20002002 and this reanalysis was blinded to the
initial assessment, looked only at cardiac
outcomes (sudden death, AMI, arrhythmia).
Abnormal EKGs included rhythm
abnormalities (SVT, VT, blocks, paced), RBBB,
LBBB, ST changes, non-specific ST changes,
PR/QT interval changes, ectopy, Q-waves.

684 consecutive patients considered

634 had EKG and rhythm analysis completed
42 (6%) suffered cardiac outcome

EKG criteria predicted 36 of 42 patients with cardiac outcomes

Sensitivity = 86%

Specificity = 70%

Negative predictive
value = 99%

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Specific EKG findings:

Isolated LBBB, any LBBB (partial or complete) were

associated with serious cardiac outcomes.
Q-waves, RBBB, ST segment changes, NSR were not
associated with serious cardiac outcomes.
On a separate rhythm analysis a significantly
greater number of patients had non-sinus rhythms
that what was just seen on EKG (72% vs.. 34%).

Any non-sinus rhythm, any LBBB, any left

bundle conduction problem (LAHB, LPHB, QRS
widening) were 2.8-3.2 times more likely to
have a significant cardiac outcome.

New oral anticoagulants in the ED setting: a

review.
Charles V. Pollack, MD
Am J Emerg Med 2012;30:2046-2054.
A general review of the new OACs coming
into use for treatment of VTE and stroke
prophylaxis in AF and their adjunctive use
with antiplatelet agents for ACS patients.

Warfarin, LMWH, fondaparinux all have a lot of

interpatient variability due to genetics, a very
large number of drug-drug and drug-food
interactions, need frequent monitoring, and
bleeding with coumadin the most frequent cause
of drug-related admission in older patients.
The NOACs have 2 classes; direct thrombin
inhibitors, selective factor Xa inhibitors.
They are more bioavailable, have little drug-drug
and drug-food interactions, have less associated
bleeding, do not need monitoring.

In the SFSR (and any other syncope rule) the

EKG plays a key role to determine risk.
That risk was very low in patients with a
normal EKG.
Any non-sinus rhythm confers a 2.8 times
greater risk of a serious cardiac outcome, the
EKG may miss a significant number of nonsinus episodes picked on rhythm analysis.
Any LBBB or left bundle conduction
abnormality confers a 3.2 times greater risk
of a serious cardiac outcome.

Novel oral anticoagulants (NOACs) have

indications for:
Prevention and treatment of VTE.
Stroke prophylaxis in non-valvular AF.
Acute coronary syndrome.

They replace the traditional LMWH or UFH

followed by long-term vitamin K antagonists
(VKA) for VTE and long-term VKA for stroke
prophylaxis in AF.
The newest paradigm is the addition of the
NOACs to antiplatelet agents long-term after
ACS.

Factor Xa Inhibitors
-Rivaroxiban (Xarelto)
- Apixaban (Eliquis)

Thrombin Inhibitor
- Dabigatran
(Pradaxa)

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Acute VTE Treatment:

Patients with proximal DVTs or PEs who required 6

months of anticoagulation had similar recurrence
rates compared to coumadin (2.4% and 2.1%) with
significantly less bleeding.

Acute VTE Treatment:

Patients with either proximal DVT or extensive calf
DVT apixaban compared to coumadin showed
similar recurrence (4.2% vs.. 4.7%) and bleeding
rates (7.3% vs.. 7.9%).

For secondary VTE prevention a trial is

currently in progress but has yet to be
indicated for prophylaxis.

In the RE-LY study dabigatran 150mg BID (75mg

BID if CrCl is 15-30 ml/min) reduced the risk of
stroke and embolism in non-valvular AF by
1.53%/year compared to coumadin at
1.69%/year.
Rates of ICB were lower in the dabigatran group
as was the incidence of intracranial bleeding.
A greater rate of stomach upset was seen with
dabigatran.
The rate of AMI was also higher with dabigatran.

Acute VTE Treatment:

Compared to coumadin the DVT recurrence rates
were 2.1% vs.. 3.0% with similar major/non-major
bleeding.
For PE compared with coumadin recurrent VTE was
similar with less bleeding with rivaroxaban.

Secondary VTE Prevention:

Patients who had 6-18 months of anticoagulation

who needed continue therapy for another 6 months
had a minimal recurrence rate (0.4%) compared to
placebo and in another trial had a similar
recurrence rate to coumadin (1.8% vs. 1.3%) again
with much less bleeding (0.9% vs. 1.8%).

Secondary VTE Prophylaxis:

For DVT or PE after 6-12 months with either
placebo or rivaroxaban showed a lower recurrence
rate (1.3% vs.. 7.1%) for rivaroxaban and a bleeding
rate of 6%.

AF affects 1-2% of the general population

expected to increase 2.5x as the population
continues to age.
Paroxysmal AF confers a 5x increased risk of
stroke.
With coumadin there is a 68% relative risk
reduction, 21% for ASA.
The NOACs are also being used in AF not
associated with prosthetic valves,
hemodynamically significant valve disease,
renal failure, or advanced liver disease.

A dose of 20mg a day of rivaroxaban (15mg

if CrCl is 15-30 mg/min) reduces the risk of
stroke and embolism in non-valvular AF.
In the ROCKET trial the rate of
stroke/embolism was 2.4%/year for coumadin
and 2.1%/year for rivaroxaban.
Major bleeding was similar at 3.4% vs.. 3.6%
with rates of ICB or fatal bleeding lower but a
higher rate of GI bleed with rivaroxaban.

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Apixaban is the only NOAC compared to ASA

in AF patients not suitable for coumadin.
The study was ended early given apixabans
superiority.
The ARISTOTLE compared coumadin with
apixaban in AF with stroke/embolus rate of
1.6% for coumadin and 1.27% for apixaban.
The rate of bleeding was similar (3.09%/year
vs.. 2.13%/year) but a significantly lower
mortality rate and ICB rate with apixaban.

Dabigatran showed greater bleeding than

placebo and a numerically lower rate of CAD
death, nonfatal AMI, and ischemic stroke it was
not statistically significant.
With rivaroxaban in TIMI 51 there was a modest
reduction in cardiovascular deaths (8.9% vs..
10.7%) with a reduction in stent thrombosis and
significant differences in bleeding.
Apixaban in the APPRAISE trial was terminated
early for higher rate of major bleeding.

Lab monitoring none of the NOACs require

routine lab testing nor is there an available
test to quantify the degree of anticoagulation.
PT can show a patient is anticoagulated with
apixaban or rivaroxaban but there is no
standardization.
Anti-factor Xa assays may be the best means of
assessing the anti-FXa NOACs but still are not
readily available at this time.

Once ACS patients are stabilized on

antiplatelets (ASA, clopidogrel) they are
considered for anticoagulation depending on
the type of stent (DES or BMS).
Coumadin plus antiplatelets is not widely
accepted but is used.
While the NOACs are being evaluated for this
indication none as of this articles publication
are approved.

Drug interactions few clinically significant

interactions compared to coumadin:

All 3 NOACs are substrates for drug transporter Pglycoprotein and can interact with such agents as
rifampin.
Rivaroxaban and apixaban are partially metabolized
by cytochrome P450 and can interact with strong
inducers of that isoenzyme.
The most important clinical issue of renal function
as there can be serious bleeding if a patients renal
function falls or they are used in patients with renal
insufficiency/failure.

Dose adjustments all current NOACs are to

some degree excreted via the kidney so renal
insufficiency does require a reduction in
dose.
Bleeding events to date there is no specific
reversal agent for the NOACs, activated
prothrombin complex concentrates have been
used with some success but data is limited.
For the most part bleeding is handled with stopping
the drug, potential dialysis with dabigatran, and
consideration of aPCCs.

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NOACs are becoming more common for use

in VTE, AF prophylaxis long-term, VTE
prophylaxis in joint replacement surgery.
They offer the advantages over coumadin of
less drug-drug or drug-food interactions.
They are more bioavailable and consistently
achieve therapeutic anticoagulation without
the genetic variability seen with coumadin.
Bleeding events are less common but exactly
how to reverse the NOACs is as yet not
completely worked out.

Yeah! We are done!

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