Calcium before Diltiazem may reduce hypotension in rapid atrial dysrhythmias

The Case

A 56 y/o man presents to the ED via ambulance. He was sent from clinic for ‘new onset afib.’ His pulse ranges between 130 and 175 bpm, while his blood pressure is holding steady at 106/58 mm Hg. He has a past medical history significant for hypertension and hypercholesterolemia. His only medications are hydrochlorothiazide and atorvastatin. The decision is made to administer an IV medication to ‘rate control’ the patient with a goal heart rate < 100 bpm.

Calcium channel blockers, such as diltiazem and verapamil, can both cause hypotension. In the case above, the patient has borderline hypotension.

The Clinical Question

What is the evidence behind giving IV calcium as a pre-treatment to prevent hypotension from calcium channel blockers?

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By Bryan D. Hayes, PharmD, DABAT, FAACT, FASHP|2016-11-11T19:47:24-08:00May 22, 2013|Cardiovascular, Tox & Medications|

PV card: Early repolarization vs STEMI on ECG

You are handed an ECG for a 50 year old man with moderate chest pain for 2 hours now and no associated symptoms typical for ACS, PE, aortic dissection, or any other red flags of chest pain. He has no prior ECG’s on file.

Is this early repolarization or ST elevation MI?
Should I activate the cardiac catheterization lab?

Image courtesy of Dr. Steve Smith at HQMedEd-ecg.blogspot.com

Here are some great literature-based pearls compiled by Dr. Jason West (@JWestEM), an EM resident from Jacobi/Montefiore.

PV Card: ECG – Early Repolarization vs ST Elevation MI

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Adapted from [1–7]
Go to ALiEM (PV) Cards for more resources.

Furthermore, there is a formula to differentiate early repolarization vs STEMI, per Dr. Smith’s publication6:

(1.196 x STE60V3) + (0.059 x QTc) – (0.326 x RA V4)

STE60V3 = STE elevation height at 60 msec (1.5 small boxes) after the J-point in lead V3 (mm)
QTc = The computer-read QTc interval
RA V4 = R wave amplitude in lead V4 (mm)

A result of > 23.4 is predictive of a LAD occlusion causing a STEMI, rather than early repolarization.

P.S. The above ECG image shows early repolarization.

References

Brady W, Syverud S, Beagle C, et al. Electrocardiographic ST-segment elevation: the diagnosis of acute myocardial infarction by morphologic analysis of the ST segment. Acad Emerg Med. 2001;8(10):961-967. [PubMed]
Brady W, Perron A, Syverud S, et al. Reciprocal ST segment depression: impact on the electrocardiographic diagnosis of ST segment elevation acute myocardial infarction. Am J Emerg Med. 2002;20(1):35-38. [PubMed]
Smith S. Upwardly concave ST segment morphology is common in acute left anterior descending coronary occlusion. J Emerg Med. 2006;31(1):69-77. [PubMed]
Larson D, Menssen K, Sharkey S, et al. “False-positive” cardiac catheterization laboratory activation among patients with suspected ST-segment elevation myocardial infarction. JAMA. 2007;298(23):2754-2760. [PubMed]
Nfor T, Kostopoulos L, Hashim H, et al. Identifying false-positive ST-elevation myocardial infarction in emergency department patients. J Emerg Med. 2012;43(4):561-567. [PubMed]
Smith S, Khalil A, Henry T, et al. Electrocardiographic differentiation of early repolarization from subtle anterior ST-segment elevation myocardial infarction. Ann Emerg Med. 2012;60(1):45-56.e2. [PubMed]
Chung S, Lei M, Chen C, Hsu Y, Yang C. Characteristics and prognosis in patients with false-positive ST-elevation myocardial infarction in the ED. Am J Emerg Med. 2013;31(5):825-829. [PubMed]

By Michelle Lin, MD|2021-10-08T09:16:44-07:00May 16, 2013|ALiEM Cards, Cardiovascular, ECG|

Three predictors for success in cardiac arrest resuscitations

The goal of resuscitation in cardiac arrest is to respond in a timely, effective manner that leads to good patient outcomes. Resuscitation is not taking an ACLS and BLS course and going through the motions of a code. There have been several studies looking at the quality of intubation and CPR, and their association with good patient outcomes.

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By Salim Rezaie, MD|2019-09-10T13:38:38-07:00May 14, 2013|Cardiovascular|

Patwari Academy videos: Salter Harris fractures

Dr. Rahul Patwari discusses Salter Harris fractures in pediatric patients with a helpful mnemonic to help you remember the categories. He also poses several questions in the first video, which are answered in the second video.

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By Michelle Lin, MD|2019-01-28T21:59:38-08:00May 12, 2013|Orthopedic, Patwari Videos, Pediatrics|

PV card: Ectopic pregnancy

Ectopic pregnancy is the leading cause of maternal death in the first trimester of pregnancy. A recent JAMA systematic review,¹ from The Rational Clinical Examination series, looked to risk-stratify women in early pregnancy presenting with abdominal pain or vaginal bleeding for ectopic pregnancy. The authors set out to identify the accuracy and precision of elements in the history, physical examination, beta hCG, and ultrasound in ectopic pregnancy.

The systematic review consisted of 14 studies (n=12,101). The search consisted only of English language studies from 1965 to 2012 in which ectopic pregnancy was the final diagnosis with 100 or more patients per article. The summary prevalence of ectopic pregnancy was 15% (95% CI, 10-22%) in women presenting with abdominal pain or vaginal bleeding.

History and Physical

Patients symptoms had limited clinical value. Most symptoms had an unhelpful positive LR of less than 1.5.
The absence of cervical motion tenderness, peritoneal signs, adnexal mass, or adnexal tenderness did not significantly decrease likelihood of ectopic pregnancy.
In descending order, the most significant physical exam findings were:
- Cervical motion tenderness (Positive LR = 4.9)
- Peritoneal findings (Positive LR = 4.2-4.5)
- Adnexal mass (Positive LR = 2.4)

Ultrasound showing normal IUP as shown by the double decidual rings and presence of a yolk sac in a gestational sac

Ultrasound

Findings of an intrauterine pregnancy (IUP) such as gestational sac or fetal pole ruled out ectopic pregnancy, except in rare cases of heterotropic prengnacy.
Bedside ultrasound is the single most useful diagnostic test. Positive LR = 111.

Beta-hCG

The “discriminatory zone” continues to be debated – no consensus on the number.
A one-time hCG level does not rule out ectopic pregnancy.

PV Card: JAMA Review on Ectopic Pregnancy

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

Reference

Crochet J, Bastian L, Chireau M. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. [PubMed]

By Javier Benitez, MD|2021-10-08T09:20:50-07:00May 9, 2013|ALiEM Cards, Ob/Gyn|

Pediatric Appendicitis: CT or Ultrasound?

Appendicitis is the most common pediatric surgical emergency accounting for 5% of urgent pediatric outpatient visits for abdominal pain. Computed tomography (CT) and ultrasonography (US) are two imaging modalities used in the diagnostic evaluation of acute pediatric appendicitis. Both have decreased the incidence of negative appendectomy results. It is well known that CT has greater diagnostic accuracy than US for diagnosing acute appendicitis, but there is concern over long-term cancer risk, with routine use of CT in children.