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Paucis Verbis: An approach to persistent tachycardia

Sinus Tachycardia ECG
Tachycardia is a common clinical occurrence in the ED. Most of the time the etiology can be discerned through the history and physical exam, but sometimes it cannot. This is problematic especially when we are about to discharge a patient home but his/her heart rate is still 115 beat/min. We can’t send this patient home yet. Do we then have to admit them for work-up of persistent tachycardia?

Attached is a list of common causes of tachycardia in the ED, as well as potential diagnostic and therapeutic considerations. Rather than a shot-gun approach, a limited and thoughtful method works best.

Can you think of other potential causes?

PV Card: Approach to Persistent Tachycardia


Go to ALiEM (PV) Cards for more resources.

This useful PV card was made by one of our new star faculty members at San Francisco General Hospital, Dr. David Thompson. Thanks, David!

By |2021-10-12T16:15:00-07:00Aug 19, 2011|ALiEM Cards, Cardiovascular|
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Paucis Verbis: Fibrinolytics for Acute Pulmonary Embolism

Pulmonary embolism fibrinolytics

When would you give fibrinolytics for a Pulmonary Embolism?

This Paucis Verbis card summarizes recommendations found in Circulation’s recently published Scientific Statement from the American Heart Association. Although it is rare to give fibrinolytics for a pulmonary embolism (PE) in the Emergency Department, it is important to remember when lytics are indicated.

PV Card: Fibrinolysis for Acute Pulmonary Embolism


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Jaff M, McMurtry M, Archer S, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation. 2011;123(16):1788-1830. [PubMed]
By |2021-10-12T16:21:19-07:00Jul 29, 2011|ALiEM Cards, Cardiovascular, Pulmonary|
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Paucis Verbis: Cardiac tamponade or just an effusion?

cardiac tamponade

What is a cardiac tamponade? It is a clinical state where pericardial fluid causes hemodynamic compromise. With bedside ultrasonography in most Emergency Departments now, it’s relatively easy to detect a pericardial effusion.

But what we more want to know in the immediate setting is: Is this cardiac tamponade?

You can look for RA systolic or RV diastolic collapse. What if it’s equivocal? How good is the clinical exam and EKG in ruling out a tamponade?

Answer

Poor to average, at best. The Beck’s triad of hypotension, distended neck veins, and muffled heart sounds are important to remember … only on tests.

Think about performing a pulsus paradoxus test to see if it’s >12 mmHg. This is a sign of physiologic compromise. Note that the typical cutoff has been 10 mmHg but 12 mmHg is a more specific test.

PV Card: Cardiac Tamponade


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Hemal Kanzaria for suggesting this JAMA article!

Refrence

  1. Roy CL, Minor MA, Brookhart MA, Choudhry NK. Does This Patient With a Pericardial Effusion Have Cardiac Tamponade? JAMA. 2007;297(16):1810. doi: 10.1001/jama.297.16.1810
By |2021-10-13T08:35:56-07:00Jul 8, 2011|ALiEM Cards, Cardiovascular, Ultrasound|
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Paucis Verbis: Blunt cerebrovascular injuries

Blunt Cerebrovascular Injury - AnatomyIn the setting of blunt trauma, it is easily to overlook a patient’s risk for blunt cerebrovascular injuries (BCVI). These are injuries to the carotid and vertebral arteries. Often they are asymptomatic with the initial injury, but the goal is to detect them before they develop a delayed stroke.

  • Who are at risk for these injuries?
  • What kind of imaging should I order to rule these injuries out?
  • Do I really treat these patients with antithrombotic agents even in the setting of trauma to reduce the incidence of CVA?

FYI: A simple seat-belt sign along the neck does not warrant a CT angiogram. Patients with higher risk findings such as significant pain, tenderness, swelling, and/or a bruit probably need imaging.

PV Card: Imaging for Blunt Cerebrovascular Injuries


Adapted from [1-3]
Go to ALiEM (PV) Cards for more resources.

References

  1. Burlew C, Biffl W. Imaging for blunt carotid and vertebral artery injuries. Surg Clin North Am. 2011;91(1):217-231. [PubMed]
  2. Paulus E, Fabian T, Savage S, et al. Blunt cerebrovascular injury screening with 64-channel multidetector computed tomography: more slices finally cut it. J Trauma Acute Care Surg. 2014;76(2):279-83; discussion 284-5. [PubMed]
  3. Bruns B, Tesoriero R, Kufera J, et al. Blunt cerebrovascular injury screening guidelines: what are we willing to miss? J Trauma Acute Care Surg. 2014;76(3):691-695. [PubMed]
By |2021-10-13T08:38:34-07:00Jul 1, 2011|ALiEM Cards, Cardiovascular, Radiology, Trauma|
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Paucis Verbis: International Registry on Aortic Dissection (IRAD)

What do these 3 people have in common?

  • Lucille Ball (comedienne)
  • Jonathan Larson (wrote the musical “Rent”)
  • John Ritter (comedian)

They all died from an aortic dissection. We commonly consider this diagnosis for Emergency Department patients presenting with severe chest pain. There is an International Registry on Aortic Dissection which published a retrospective, descriptive study of 464 patients with dissections.

I find this list helpful, because it illustrates the fact that the classic signs and symptoms aren’t actually very common. Here are some scary examples:

  • A pulse deficit in the carotid, brachial, and femoral arteries is only present 15% of the time.
  • A tearing or ripping quality of pain is present in only 50% of patients.
  • Not all patients have a widened mediastinum or abnormal aortic contour (only 78.7%).

PV Card: Aortic Dissection


Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA. 2000;283(7):897. doi: 10.1001/jama.283.7.897
By |2021-10-13T08:51:53-07:00May 20, 2011|ALiEM Cards, Cardiovascular|
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Paucis Verbis: Brugada syndrome

Brugada Syndrome

You always hear about it when working up syncope and sudden cardiac arrest in young patients, but it’s so easy to forget what it looks like on ECG. We so rarely see it… or DO we?!

This Paucis Verbis card on Brugada Syndrome is to help emblazon these ECG tracings in our mind, so that we don’t miss the subtle findings which place a patient at risk for sudden cardiac death. Pay special attention to Type 1, which is most specific for Brugada Syndrome.

PV Card: Brugada Syndrome

* Update 8/2/18: Only Type 1 and Type 2 are recognized for Brugada syndrome. The type 3 pattern is likely a normal variant.

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Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

  1. Antzelevitch C. Brugada Syndrome: Report of the Second Consensus Conference: Endorsed by the Heart Rhythm Society and the European Heart Rhythm Association. Circulation. 2005;111(5):659-670. doi:10.1161/01.cir.0000152479.54298.51
By |2021-10-15T11:04:55-07:00May 6, 2011|ALiEM Cards, Cardiovascular, ECG|
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Paucis Verbis: AMI and ECG Geography

Sometimes a picture is worth MORE than a 1000 words. Such is the case of the above illustration that I saw on the Life In The Fast Lane blog. When I first saw it, I knew that I immediately had to find out who made the graphic. It turns out it is the multitalented Dr. Tor Ercleve, who is an emergency physician at Sir Charles Gairdner Hospital and an established medical illustrator.

ECG anatomy illustration AMI

This graphic demonstrates the EKG findings for the various types of acute MI’s as broken down by coronary vascular anatomy (right coronary artery, left circumflex artery, left anterior descending artery). This detailed illustration won’t be readable in print form but is great in digital format on your mobile device.

Thanks, Tor!

[PDF]

Go to ALiEM (PV) Cards for more resources.
By |2021-10-15T11:17:43-07:00Apr 8, 2011|ALiEM Cards, Cardiovascular, ECG|
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