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Paucis Verbis: aVR Lead on ECG

ECG leads aVR lead

What lead is the most overlooked on the ECG?

 Answer: aVR Lead

This lead can provide some unique insight into 5 different conditions:

  1. Acute MI
  2. Pericarditis
  3. Tricyclic antidepressant (TCA) and TCA-like overdose
  4. AVRT in narrow complex tachycardias
  5. Differentiating VT from SVT with aberrancy in wide complex tachycardias by using the Vereckei criteria (possibly better than Brugada criteria)

PV Card: The aVR Lead on ECG


Adapted from [1-4]
Go to ALiEM (PV) Cards for more resources.

See also:

References

  1. Williamson K, Mattu A, Plautz C, Binder A, Brady W. Electrocardiographic applications of lead aVR. Am J Emerg Med. 2006;24(7):864-874. [PubMed]
  2. Vereckei A, Duray G, Szénási G, Altemose G, Miller J. New algorithm using only lead aVR for differential diagnosis of wide QRS complex tachycardia. Heart Rhythm. 2008;5(1):89-98. [PubMed]
  3. Kireyev D, Arkhipov M, Zador S, Paris J, Boden W. Clinical utility of aVR-The neglected electrocardiographic lead. Ann Noninvasive Electrocardiol. 2010;15(2):175-180. [PubMed]
  4. Riera A, Ferreira C, Ferreira F, et al. Clinical value of lead aVR. Ann Noninvasive Electrocardiol. 2011;16(3):295-302. [PubMed]
By |2021-10-11T15:47:33-07:00Nov 18, 2011|ALiEM Cards, Cardiovascular, ECG|
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Paucis Verbis: Methotrexate for ectopic pregnancy

Ectopic pregnancy methotrexate

Ectopic pregnancies account for as many as 18% of patients who present with first-trimester bleeding or abdominal pain in the Emergency Department. This Paucis Verbis card summarizes the 2008 American College of Obstetricians and Gynecologists (ACOG) guidelines on the use of methotrexate (MTX) for ectopic pregnancies. Not all ectopic pregnancies require operative management.

What are the indications and contraindications to MTX? When should they follow up with their obstetrician?

Answer: In 4 days for a repeat b-HCG and possible second dose of MTX

Note that one of the eligibility criteria is that the patient must have an “unruptured ectopic pregnancy”. Many would consider that any ultrasonographic evidence of free fluid may be a sign of an early rupture. It is left up to clinician judgment in how “unruptured” is interpreted.

PV Card: Methotrexate for Ectopic Pregnancy


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

Reference

  1. ACOG Practice Bulletin No. 94: Medical Management of Ectopic Pregnancy. Obstetrics & Gynecology. 2008;111(6):1479-1485. doi: 10.1097/aog.0b013e31817d201e
By |2021-10-11T15:53:39-07:00Nov 11, 2011|ALiEM Cards, Ob/Gyn|
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Trick of the Trade: Ultrasound-guided injection for shoulder dislocation

ShoulderDislocation

Who loves relocating shoulder dislocations as much as I do? I know you do.

Often patients undergo procedural sedation in order to achieve adequate pain control and muscle relaxation. Alternatively or adjunctively, you can inject the shoulder joint with an anesthetic. Personally, I have had variable effectiveness with this technique. In cases of inadequate pain control, I always wonder if I was actually in the joint.

How can you improve your success rate in injecting into glenohumeral joint injection?

(more…)

By |2019-01-28T22:35:26-08:00Nov 8, 2011|Orthopedic, Tricks of the Trade, Ultrasound|
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Paucis Verbis: Acetaminophen toxicity

acetaminophen toxicityDid you know that the American Association of Poison Control Centers reports that 10% of poison center calls are related to acetaminophen ingestions? That’s a lot. This Paucis Verbis card reviews the basics of acetaminophen toxicity. I included the Rumack Matthew nomogram to help you plot out the patient’s risk for hepatotoxicity.

In the Emergency Department, we often screen for acetaminophen toxicity for patients who may have ingested substances as a suicide attempt. We check the serum acetaminophen level 4 hours post-ingestion. Occasionally, we are surprised by a toxic level because in the first 24 hours, because symptoms are can be mild and nonspecific (abdominal pain, nausea, lethargy).

Rule of 150

  • The toxic ingestion dose of acetaminophen is 150 mg/kg.
  • The serum acetaminophen level when N-acetylcysteine treatment should be started is 150 mcg/mL (see Rumack Matthew nomogram)
  • The starting IV dose of N-acetylcysteine is 150 mg/kg over 15 minutes.

PV Card: Acetaminophen Toxicity


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

Reference

  1. Larson A. Acetaminophen hepatotoxicity. Clin Liver Dis. 2007;11(3):525-48, vi. [PubMed]
By |2021-10-11T15:53:18-07:00Nov 4, 2011|ALiEM Cards, Tox & Medications|
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Trick of the trade: Nebulized naloxone

NaloxoneOverdoses of long-acting opiates, such as oxycodone and methadone, are challenging to manage, especially if these patients are chronically on opiates.

On the one hand, you want to reverse some of the sedative effectives with naloxone so that they aren’t near-apneic and hypoxic. You also want to be able to take a history from them. On the other hand, you don’t want to abruptly withdraw them with naloxone such that they become violent and agitated. It is a fine balancing act.

Long-acting opiates present a separate challenging because naloxone wears off fairly quickly in 30-45 minutes. These patients may require repeat dosings and/or a naloxone IV drip.

(more…)

By |2026-02-02T20:32:13-08:00Nov 1, 2011|Tox & Medications, Tricks of the Trade|
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Paucis Verbis: Influenza – To treat or not to treat?

SwineFlu-1 influenza

Influenza season typically peaks in the United States during the Jan-Feb months and can start as early as October. You can read about the 2011-12 seasonal flu data on the CDC website.

Should you give a patient with influenza an antiviral agent or just provide supportive therapy?

This Paucis Verbis card summaries the CDC’s Advisory Committee on Immunization Practices (ACIP) recommendations for this upcoming 2011-12 flu season. I also let patients with uncomplicated influenza who are going to be managed as outpatients know that a 5-day course of osteltamivir or zanamivir will cost them about $50-80. Often that sways them towards declining a prescription and “toughing out” an extra day of the flu.

PV Card: Influenza


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

Reference

  1. Centers for. Infectious disease. Antiviral agents for the treatment and chemoprophylaxis of influenza. Ann Emerg Med. 2011;58(3):299-303; discussion 303-4. [PubMed]
By |2021-10-12T15:44:24-07:00Oct 28, 2011|ALiEM Cards, Infectious Disease|
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