A 20-year-old male presents with right posterior thigh pain and difficulty walking after he felt a “pop” while sprinting in a race. An ultrasound of the right posterior thigh is performed and the above image is seen on the transverse view without compression (Image 1. ST- semitendinosus; BF – bicep femoris; H – hematoma. Courtesy of Matthew Negaard, MD).
A 60-year-old African American female with a history of hypertension presents to the emergency department for an itchy, diffuse rash. She first noticed the lesions a few years prior, and they have progressively become larger and more inflamed. The lesions have become severely pruritic over the last couple of months. Steroid creams did not appear to improve symptoms. Currently, the lesions on her arm have become painful with yellow drainage. The patient denies nausea, vomiting, and fever.
The 2020 ACLS guidelines provide recommendations on the medication-specific management recommendations for toxicology [1]. Although the name of the guidelines emphasize they are ‘Advanced,’ these are still relatively basic toxicology recommendations and largely apply to patients in cardiac arrest or refractory shock. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used during cardiac arrest and arrhythmia management.
| Intervention | Beta-adrenergic blocker | Calcium channel blocker | Evidence (COR/LOE) |
|---|---|---|---|
| High-dose insulin | Reasonable | Reasonable | 2a/C-LD |
| Glucagon IV | Reasonable | May be considered | 2a/C-LD and 2b/C-LD |
| Calcium | May be considered | Reasonable | 2b/C-LD and 2a/C-LD |
| ECMO | Might be considered | Might be considered | 2b/C-LD |
Table: Medications and interventions in the management of beta-adrenergic and calcium channel blocker toxicity (COR: class of recommendation, LOE: level of evidence, ECMO: extracorporeal membrane oxygenation)
The 2020 ACLS guidelines provide recommendations on the medication-specific management for arrhythmias including wide-complex tachycardia, regular narrow-complex tachycardia, atrial fibrillation/flutter, and bradycardia [1]. There are also our 2020 ACLS guideline summaries on vasopressor and non-vasopressor medications used during cardiac arrest and toxicology-related conditions.
| Wide-complex tachycardia | Medication(s) | Evidence |
|---|---|---|
| Hemodynamically stable | Adenosine | COR 2b, LOE B-NR |
| Amiodarone, procainamide, or sotalol | COR 2b, LOE B-R | |
| NOTE: Verapamil is harmful | COR 3, LOE B-NR | |
| Polymorphic VT with long QT (torsades de points) | Magnesium | COR 2b, LOE C-LD |
| Polymorphic VT without long QT | Lidocaine or amiodarone | COR 2b, LOE C-LD |
The 2020 ACLS Guidelines were published in October 2020 [1]. This first of 3 blog posts will focus on vasopressor and non-vasopressor medications during cardiac arrest. Part 2 will focus on specific arrhythmia management and Part 3 will focus on toxicologic interventions.
There were no major updates for vasopressors and non-vasopressors used during cardiac arrest. The American Heart Association (AHA) published Highlights of the 2020 Guidelines [PDF] as a clear and concise summary. Now that the AHA is releasing focused updates in the 5-year period between guidelines (like this one on lidocaine), fewer major changes likely will be needed when the full guidelines are published.
| Vasopressor | Non-Vasopressor |
|---|---|
|
Epinephrine
|
Amiodarone or lidocaine
|
|
Vasopressin
|
Steroids
|
|
Calcium
|
|
|
Sodium bicarbonate
|
|
|
Magnesium
|
Table: Vasopressors and non-vasopressors used during cardiac arrest (VF: ventricular fibrillation, pVT: pulseless ventricular tachycardia)
Which component of the pictured plant is the cause of gastrointestinal symptoms when ingested? 
Figure 1: Case Courtesy of Dr. Peter M. Martin