EMRAP Live at ACEP 

 

ACEP CHF Fundamentals

Jess Mason and Jenny Farah

Take Home Points

1. The patient with acute pulmonary edema will be sitting upright, distressed, hypertensive, and tachycardic, with crackles in their lungs and peripheral
2. Bedside ultrasound is helpful to see overall diminished squeeze and rule out other causes of dyspnea
3. EKG (looking for ischemia) and chest x-ray should be obtained quickly
4. Chest x-ray may show cardiomegaly, pulmonary edema, Kerley B-lines at the periphery, and pleural effusions
5. Common labs ordered are CBC, chemistry, and troponin
6. When BNP is very low (<100) CHF is less likely, and when very high (>500) is more likely, but its interpretation is skewed in patients with chronic CHF, obesity, or renal dysfunction

References/Links

Fesmire FM, Brown MD, Espinosa JA, et al. Critical issues in the evaluation and management of adult patients presenting to the emergency department with suspected pulmonary embolism. Annals of emergency medicine. 2011 Jun 1;57(6):628-52. PMID:21621092

Kosowsky JM, Chan JL, Hermann LK, et al. Acutely Decompensated Heart Failure: Diagnostic and Therapeutic Strategies. Emergency Medicine Practice+ Em Practice Guidelines Update. 2006 Dec 1;8(12):1-35.

Martindale JL, Wakai A, Collins SP, et al. Diagnosing acute heart failure in the emergency department: a systematic review and meta-analysis. Academic emergency medicine. 2016 Mar;23(3):223-42. PMID: 26910112

Hunter BR et al. Approach to Acute Heart Failure in the Emergency Department. Prog Cardiovasc Dis. 2017 Sep - Oct;60(2):178-186. doi: 10.1016/j.pcad.2017.08.008. Epub 2017 Sep 1. PMID: 28865801

Scott MC, Winters ME.Congestive Heart Failure.Emerg Med Clin North Am. 2015 Aug;33(3):553-62. doi: 10.1016/j. emc.2015.04.006. Epub 2015 Jun 10. PMID: 26226866

 

Current Therapy of Acute Pulmonary Edema

Mel Herbert and Stuart Swadron

Take Home Points

1. Nitroglycerin, in its many forms of delivery and dosing regimens, remains the gold standard in the treatment of acute cardiogenic pulmonary edema
2. Non-Invasive Ventilation (NIV) is a very effective adjunct to nitroglycerin and should be applied immediately on arrival in appropriate patients with severe dyspnea, including those with CHF and COPD
3. The use of diuretics is appropriate in patients who are volume overloaded (abut half of those presentations with a CHF exacerbation).
4. The use of ACEIs is very regional. Example dosing is12.5mg sublingual for systolic BP 90-110 mmHg, 25 mg for BP > 110 mmHg. AHA guidelines advise caution with acute usage and suggest delayed oral dosing as inpatient
5. Nesiritide is also out of favor. There is no evidence that it is superior to nitrates and, it has a worse side effect profile with some evidence of increased renal failure and mortality.
6. Morphine, a traditional treatment for pulmonary edema, is now out of favor! It is associated with increased intubation, increased ICU admissions, and

References/Links

Peacock WF et al. Morphine and outcomes in acute decompensated heart failure: an ADHERE analysis. Emerg Med J 2008;25:205-9

Sacchetti A, et al. Effect of ED management on ICU use in acute pulmonary edema. Am J Emerg Med. 1999 Oct;17(6):571-4.

Sackner-Bernstein, J.D., et al, Short-term risk of death after treatment with nesiritide for decompensated heart failure JAMA 293(15):1900, April 20, 2005

Topol, E.J., Nesiritide: Not verified. N Engl J Med 353(2):113, July 14, 2005

 

How to Dose Nitrates in APE

Anand Swaminathan

Take Home Points

1. Proper administration of nitrates is critical in the management of APE to avoid intubation + worsening morbidity as they reduce both preload and afterload

2. Be Aggressive with Nitrates!
   • Start at 300-500 mcg/min for a short time (typically < 5 minutes)
   • Drop back to 150-200 mcg/min when patient status improves (RR drops, BP improves)
   • Stay at bedside + titrate

References/Links

Levy P et al. Treatment of Severe Decompensated Heart Failure With High-Dose Intravenous Nitroglycerin: A Feasability and Outcome Analysis. Ann Emerge Med 2007; 50: 144-52. PMID: 17509731

Wilson SS et al. Use of Nitroglycerin by Bolus Prevents ICU Admission in Patients with Acute Hypertensive Heart Failure. Am J Emerge Med 2016; 35(1): 126-31. PMID: 27825693

EMCrit Podcast 1 - Sympathetic Crashing Acute Pulmonary Edema (SCAPE)

 

Acute Pulmonary Edema Without The Toys

Vanessa Cardy @jamesbaydoc

Take Home Points

1. Hypertonic saline with furosemide
   • Option for APE patients with history of severe CHF, eGFR <2.5mg/dL and at least two weeks of high dose furosemide (>250mg/day)
   • Give 125cc hypertonic saline (try 3%) and 500mg furosemide
   • Large trials still pending but smaller trials in internal medicine world showed safety and efficacy in achieving diuresis and relieving APE symptoms
   • Not first line, but part of a back-up plan at this
2. Therapeutic phlebotomy
   • Remove 450-500cc blood volume in 5-10 minutes
   • Decrease symptoms quickly
   • Delay need for dialysis in HD patients
   • Does not help hyperK of course!

3. Rotating Congestion
   • Largely out of favor now as efficacy not clear
   • Have patient sitting up and place BP cuffs on three of four extremities and inflate cuffs to 40-60mmHg
   • After 10 minutes, deflate cuffs and rotate cuffs so one extremity is always cuff-free
   • Goal is to increase venous pooling and decrease strain on heart
   • Poor evidence but if you have nothing else, you can try it

References/Links

Eiser, A.I et al. Phlebotomy for pulmonary edema in dialysis patients. Clinical Nephrology, Vol 47. No 1-1997

Gandhi, Sumeet and Wassim Mosleh, Robert B.H. Myers Hypertonic saline with furosemide for the treatment of acute congestive heart failure: A systematic review and meta-analysis.

International Journal of Cardiology 173 (2014) 139–145

Habak PA, Mark AL, Kioschos JM, McRaven DR, Abboud FM. Effectiveness of congesting cuffs ("rotating tourniquets") in patients with left heart failure. Circulation. 1974 Aug;50(2):366- 71.

Liszkowski, M & Anju Nohria. Rubbing Salt into Wounds: Hypertonic Saline to Assist with Volume Removal in Heart Failure. Curr Heart Fail Rep (2010) 7:134–139

Paterna, Salvatore et al. Hypertonic Saline in Conjunction with High-Dose Furosemide Improves Dose–Response Curves in Worsening Refractory Congestive Heart Failure. Adv Ther. 2015; 32(10): 971–982

 

Fundamentals of RSI

Stuart Swadron and Jenny Farah

Take Home Points

1. Adequate pre-oxygenation is the single most important step in the RSI procedure. It makes for a calm, less-harried intubation and provides for a margin of error, should complications arise.
2. Optimal visualization of the cords during direct laryngoscopy is best achieved when the operator (not an assistant) provides external pressure on the
3. Preparations for adequate post-intubation sedation should be made prior to

References/Links

Algie CM et al. Effectiveness and risks of cricoid pressure during rapid sequence induction for endotracheal intubation. Cochrane Database Syst Rev. 2015 Nov 18;(11):CD011656. doi: 10.1002/14651858.CD011656.pub2.

Sørensen MK et al. Rapid sequence induction and intubation with rocuronium-sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth. 2012 Apr;108(4):682-9.doi: 10.1093/bja/aer503. Epub 2012 Feb 6. PMID: 22315329.

Weingart SD et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015 Apr;65(4):349-55. doi: 10.1016/j.annemergmed.2014.09.025. Epub 2014 Oct 23. PMID: 25447559.

 

Current Concepts in RSI

Anand Swaminathan

Take Home Points

1. Bed Up Head Elevated (BUHE) position is a simple intervention that can reduce the rate of intubation-related
2. The bougie should be considered standard practice in all intubations and has an NNT = 11 for 1st pass
3. Consider using Suction Assisted Laryngoscopy for Airway Decontamination (SALAD) for all intubations to avoid the failed airway due to

References/Links

Khandelwal N et al. Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesth Analg 2016; 122(4): 1101-7. PMID: 26866753

Core EM: Bed Up Head Elevated Positioning for Airway Management

Driver B et al. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017; 70(4): 473-8. PMID: 28601269

YouTube: SALAD Demonstration with the SSCOR DuCanto Catheter

 

Nasotracheal Intubation

Sanjay Arora and Mike Menchine

Take Home Points

1. Lidocaine till they cough
2. A flexible tube is a good tube
3. After you get the tube, put ‘em down
4. Sniffing position is good even if seated
5. The NP scope is your friend
6. Not all nostrils are created equal

 

Airway Management 2000 Miles from Home

Vanessa Cardy @jamesbaydoc

Take Home Points 

1. Be familiar with more than one tool for intubating. Your favorite tool might not be available!
2. Know your vents and know how to intubate without the help of an
3. Prepare for how to move your intubated patient from the ambulance onto the
4. Prepare for the elements! Fluid in IV tubing can freeze and crack open the tube so keep the patient, the meds, the tubing and yourself
5. Prepare for patient trying to extubate themselves at worst possible moment
   • Have plenty of meds, of different types, for sedation
   • Restrain the patient with roll of kling under their back and tied to their own wrists
6. Use a transfer checklist
   • Reminds you to bring enough meds and enough oxygen
   • Reminds you to put water in any ET or Foley balloons
   • Reminds you to bring your wallet and food!
   • Reminds you to bring copies of notes and labs
   • It will save your hide when you are tired and stressed and makes you a little bit like Atul

References/Links

Chisasibi Hospital MDs

 

STEMI EKG Criteria

Jenny Farah

Take Home Points

1. Definition: ST elevation in 2 contiguous leads at the J point ≥ 1mv
2. J point: The “junction” between the QRS segment and T-wave
3. Conversion 0.1mv = 1mm (or 1 “little” box)
4. Exception: V2-V3; need greater elevation to call it a STEMI
   • ≥0.25 mV in men <40 yrs
   • ≥0.20 mV in men ≥40 yrs
   • ≥0.15 mV in women
5. Contiguous leads refers to the distribution of perfusion
   • LAD: V1-V4
   • LCx: V5-V6, I, aVL
   • RCA: II, III, aVF
6. Reciprocal ST depression is not required to call a STEMI, but makes for great corroborating evidence if present
7. STEMI Equivalents
   • LBBB (use Sgarbossa Criteria to identify STEMI)
     • Discordant STE ≥ 5mm or ≥25% of the depth of the preceding S-wave
     • Concordant ST Depression ≥ 1mm in V1-V3
     • Concordant ST Elevation ≥ 1mm (most concerning sign)
   • Posterior MI
     • May initially see only ST depression in V1-V2
     • Obtain posterior EKG to see if ST elevations are revealed

 

Preparing for Complications in STEMI

Jan Shoenberger

Take Home Points

• When you have sudden onset shock in MI, the differential diagnosis as to the etiology of that shock includes the following:
  • Infarct extension
  • RV infarction
  • Dysrhythmia (too fast or too slow)
  • Mechanical
    • LV free wall rupture
    • Acute ventricular septal rupture
    • Severe mitral regurgitation
  • Bedside ultrasound and ECG will be key in making a diagnosis
  • The various elements of the cardiac conduction system can be affected by the coronary artery territory of the MI. Ischemia to those areas may cause various types of
  • High degree or complete heart block occurs in inferior MI more than anterior MI
  • The AHA STEMI guidelines say that “temporary pacing is indicated for symptomatic bradyarrhythmias unresponsive to medical treatment”
  • Mechanical complications of MI include:
    • Papillary muscle rupture (mitral regurgitation)
    • LV free wall rupture (will see pericardial effusion)
    • Septal wall rupture (acute VSD) (loud systolic murmur)
  • Emergent cardiothoracic surgical consultation for these valvular emergencies may be necessary

References/Links:

Kosmidou I, et al. Incidence, predictors and outcomes of high-grade AV block in patients with STEMI undergoing primary PCI (from the HORIZONS-AMI trial). Am J Cardiol 2017;119(9):1295-1301.

O’Gara PT, et al. 2013 ACCF/AHA guidelines for the management of STEMI: a report of the ACCF/AHA task force on practice guidelines. Circulation 2013;127(4):e362-425.

Kutty RS, et al. Mechanical complications of acute myocardial infarction. Cardiol Clin 2013;31(4):519-31.

 

Cath After ROSC

Sanjay Arora and Mike Menchine

Take Home Points

1. Evidence for mandatory Cath following all OHCA is weak, ambiguous & contradictory both in terms of need and timing
2. Real STE still needs Cath
3. For NSTE, OHCA you should not feel obligated, but have a plan and follow your local hospital practice
4. 3 ongoing RCTs - more data to come!

 

Code STEMI or No Code STEMI

Stuart Swadron

Take Home Points

1. Most patients with chest pain and ST segment elevation do not have an acute coronary occlusion.
2. The clinical presentation is more important than the ECG. Persistent symptoms or signs with ECG changes or clinical instability all may indicate a need for emergent
3. In some cases, an initial period of observation and serial ECGs may help to identify candidates for emergent

References/Links

de Winter RW et al. Precordial junctional ST-segment depression with tall symmetric T-waves signifying proximal LAD occlusion, case reports of STEMI equivalence. J Electrocardiol. 2016 Jan-Feb;49(1):76-80. doi: 10.1016/j.jelectrocard.2015.10.005.

Ibanez B et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018 Jan 7;39(2):119-177. doi: 10.1093/eurheartj/ehx393.

Lawner BJ et al. Novel patterns of ischemia and STEMI equivalents. Cardiol Clin. 2012 Nov;30(4):591-9. doi: 10.1016/j.ccl.2012.07.002.

 

The ECG in Syncope

Stuart Swadron

Take Home Points

1. Arrhythmias and ischemia are the first considerations when looking at the ECG in syncope.
2. There are at least 7 “exotic” causes of syncope (and sudden cardiac death) the may be unmasked on a 12 lead ECG - these include:
   • ARVD (arrhythmogenic right ventricular dysplasia)
   • Brugada syndrome
   • LVH (seen in both AS and HOCM)
   • Pulmonary embolism (acute right heart strain)
   • Long QT
   • Short QT
   • WPW
3. Some of these ECG patterns occur in many patients and are rather non-specific (e.g. the famous S1,Q3,T3). A clinically concerning history (or family history) is an essential ingredient to warrant a cardiology

References/Links 

Dovgalyuk J et al. The electrocardiogram in the patient with syncope.Am J Emerg Med. 2007 Jul;25(6):688-701.

 

Trauma Visuals

Kenji Inaba MD

Take Home Points

1. Bleeding control
   • Priority one
   • Focused, manual pressure to start
   • Tourniquets for extremities
   • Balloons or x-stat if cavitary, especially junctional
2. Seatbelt Mark
   • Almost a quarter of patients will have an intra-abdominal injury
   • 8 fold injury rate compared to MVC occupants without a mark
   • Not enough to mandate OR but…
   • High degree of suspicion, CT and observation, 24h
3. Hematuria
   • Microscopic - no further workup
   • Gross, need to rule out bladder or kidney injury, CT+Cystogram
   • Unlikely to be ureter
   • Blood at meatus, hematoma, pelvic fracture, male…RUG
4. Retained Items
   • Low, but real possibility that there is tamponade by object
   • Often difficult to image because of artifact
   • Safest to remove under direct visualization in OR
5. Cardiac US
   • Near perfect sensitive for clinically significant injury
   • Specificity also excellent
   • If heart at risk, do FAST first
   • Positive: go to OR
   • Negative: send home
   • Equivocal: repeat, TTE or window
6. Hemothorax
   • Chest Tube effective for majority of traumatic hemothorax
   • Goal is to evacuate all blood
   • Open small is as good as large
   • Hypotension, or >1L initial output or >2-300 mL/h for a few hours, consider operation
7. Pelvic Binders
   • Effective at reducing anatomic volume of pelvis
   • Unclear impact on bleeding
   • But will reduce pain, splint fracture, facilitate movement
   • Definitive treatment is packing, angiography, # stabilization
8. REBOA
   • Resuscitation adjunct, bridge to definitive treatment
   • Facilitates volume loading, perfusing brain and coronaries
   • Hypotensive, blunt trauma below diaphragm, pelvic #
   • Other indications?
9. Tension Pneumothorax

• • ND works, but need to get into the chest
  • Controlled studies, <50% success, especially females and obese
  • If no clinical response, repeat
  • Or, adjust entry location

 

Transvenous Pacemaker Placement

Jess Mason and Anand Swaminathan

Take Home Points

1. Transcutaneous pacemakers are fraught with issues. Become master of the transvenous pacemaker by reviewing the basics and familiarizing yourself with the equipment
2. Don’t forget to place the plastic accordion sheath prior to floating the wire which allows you to adjust the pacing wire depth after placement
3. Go simple on the initial settings: Rate = 80, Output = 20 mAmp, Sensitivity = off
4. Confirm electrical capture by watching the cardiac monitor rate and mechanical capture by watching the oxygen saturation tracing

References/Links

EMRAP HD: Transvenous Pacer

EMRAP April 2016: Transvenous Pacemakers

Ultrasound Podcast: Transvenous Pacer Placement with @edecmo