2018 Bradycardia Clinical Guidelines

Colours correspond to Class of Recommendation.
*Atropine should not be given in patients after heart transplant.
†In patients with drug toxicity and severe symptoms, preparation for pacing should proceed simultaneously with pharmacologic treatment of drug toxicity.
AADs indicates antiarrhythmic drugs; AV, atrioventricular;BB, beta blocker; CCB, calcium channel blocker; COR, Class of Recommendation;ECG, electrocardiographic; H+P, history and physical examination; IMI, inferior myocardial infarction; IV, intravenous; PM, pacemaker; S/P, status post; and VS, vital signs.

Acute MI

  • Autonomic derangements during an acute MI are common, and small case series suggest that atropine can be used to increase heart rate. Atropine appears to be safe in those patients with atrioventricular  nodal block in the absence of infranodal  conduction system disease.
  • In contrast, it is important to recognize that the use of atropine in patients with infranodal  conduction disease or block can be associated with exacerbation of block and is potentially of harm. Aminophylline/theophylline has also been examined in this setting, and in the context of very limited data appears likely to be safe if atropine is ineffective. The methylxanthines theophylline and aminophylline (a theophylline derivative) exert positive chronotropic effects on the heart, likely mediated by inhibition of the suppressive effects of adenosine on the sinoatrial node.
  • Given that the natural course of a MI with conduction system abnormalities is frequently associated with recovery of conduction – early and unnecessary pacing should be avoided.

T-Waves

  • Hyperacute T-waves are often the first manifestation of complete vessel occlusion; they are wide, bulky and prominent.
  • Hyperacute T-waves are not necessarily tall, and small T-waves can still be hyperacute when paired with a low-amplitude QRS complex.
  • De Winter T-waves represent LAD occlusion (a STEMI equivalent) requiring immediate revascularization.
  • Previously inverted T-waves can appear normal and upright in the setting of acute vessel occlusion. This is known as pseudonormalization.
  • The tall T-waves associated with hyperkalemia are sharp, pointy, symmetric, and have a narrow base.
  • When in doubt, get serial ECGs (every 15 minutes) and use adjunctive information.

 

Heart Blocks: A Primer

  • Heart blocks can be a sign of underlying pathology such as MI, Lyme disease, myocarditis, structural heart disease, pulmonary embolism, autoimmune disease, electrolyte disturbances, medication side effects, Lenegre’s or Lev’s disease, increased vagal tone, or could be a normal variant.
  • Treatment with Atropine is indicated in bradycardic, symptomatic and/or unstable patients with a 1st or 2nd-degree Mobitz type 1 AV block. It is unlikely to be effective in high-grade blocks as the block is usually below the AV node. Atropine can still be used as a temporizing measure while setting up for transcutaneous pacing and/or transvenous pacemaker placement in high-grade blocks
  • Take the QUIZ

 

Top 10 Posts of 2017

Mistakes that Kill during Cardiopulmonary Resuscitation

  • Too Slow or Too Fast Chest Compressions
  • Too Shallow or Too Deep Chest Compressions
  • Too Many or Too Slow Breaths
  • Leaning on the Chest
  • Too Many Interruptions
  • Giving Up Too Soon
  • Too Slow Adaptation


 

Oxygen Bubble Bottles or Bacteria Swimming Pools?

Humidified oxygen is widely administered in hospitals and EMS vehicles and this is presumed to alleviate nasal and oral discomfort in the non-intubated patient. Humidification of supplemental oxygen is commonly delivered by bubbling oxygen through either cold or warm sterile water before it reaches the patient. However, the effect on patient comfort is negligible. Bubble humidifiers may, however, represent an infection hazard and should not be used.

 


 

Anaesthesia, Trauma & Critical Care

 

 


 

WHO Emergency and Trauma Care e-Learning Training Course

A modular e-learning course that can easily be accessed by medical providers in an effort to improve emergency trauma care. Give it a try.

 


 

Guillain Barré Syndrome (GBS)


 

Surviving Sepsis Guidelines 2016: Recommendations and Best Practice Statements

 

 

 

Treatment of Helicobacter pylori Infection

 

 


 

2017 American Diabetes Association Standards of Medical Care in Diabetes

 

 


 

I am an Emergency Department doctor…I make mistakes

 

 


 

The Health Act 2017 – Emergency Care

 


 

Thank you for all the support in 2017. We look forward to providing you with even greater emergency care content in 2018. From all of us at the Emergency Medicine Kenya Foundation, HAPPY NEW YEAR!

And don’t’ forget…

 

The Health Act 2017 – Emergency Care

 

Did you know Adrenaline doesn’t work for Cardiac Arrest?

Adrenaline may improve return of spontaneous circulation, but it does not improve survival to discharge or neurologic outcome. The timing of epinephrine may affect patient outcome, but Basic Life Support measures are the most important aspect of resuscitation and patient survival.

 

Chest Pain in Atrial Fibrillation

This is a great example of how the dichotomy between STEMI and Non-STEMI is false.  They are both due to thrombus in the coronary artery and both are very dangerous.  STEMI and NonSTEMI exist on a spectrum.  Thrombus can lyse and propagate, and NonSTEMI can convert to STEMI.

 

Post ROSC

System Action
Airway Intubate → Ventilation tidal volume @ 6-8 mL/kg
Place OG or NG tube
Confirm endotracheal and OG/NG tube placement with chest x-ray
Breathing SpO2 goal >94% → adjust PEEP & FiO2 to achieve goal
EtCO2 goal 30-40 mmHg → adjust respiratory rate to achieve
Circulation 12-lead ECG → Activate cardiac catheterization lab for STEMI; consult cardiology for all other patients
SBP goal >90 mmHg (MAP > 65 mmHg) → Use fluids, norepinephrine infusion, then epinephrine infusion to achieve goal
Place central line
Place arterial line
Perform point of care ultrasound with the cardiac, lung, and IVC views
Send labs, which includes an arterial blood gas and serum lactate
Place Foley catheter → Goal urine output 0.5-1 mL/kg/hr
Consider CT chest angiography to rule-out a pulmonary embolism
Disability Begin cooling → Goal temperature 32–36°C
Consider head CT

 

 

 

Top 10 Posts of 2016

 

10. All Shock Explained

critcare03_lg


9. Priapism

Priapism

Non-ischemic (high-flow) Ischemic (low-flow)
Physical Exam Typically painless, not fully tumescent Painful, fully tumescent with corpus cavernosa rigidity without involvement of corpus spongiosum and glans penis
Aetiology High-flow priapism is extremely rare and most commonly associated with antecedent trauma including blunt trauma, or resulting from needle injury of the cavernosal artery. Low-flow priapism is caused by impaired relaxation and/or paralysis of cavernosal smooth muscle and in sickle-cell disease
Management NOT Emergency Emergency

read-more


8. 2016 Guidelines

 

 

 


7. Sepsis Six in 60 Minutes: World Sepsis Day – September 13th

Sepsis

NEW SEPSIS PATHWAY

FLUIDS

ANTIBIOTICS

…for every hour you delay, the patient has a 33% increased risk of death!

Capture

 

 

 

LACTATE


6. Did you know about the RULE OF TENS for Fluid Resuscitation in Burns?

Burns Rule of TENS:

1. Estimate burn size (TBSA) to the nearest 10%.
2. Multiply %TBSA x 10 = Initial fluid rate in mL/hr (for adult patients weighing 40 kg to 80 kg).
3. For every 10 kg above 80 kg add 100 mL/hr to the rate.

 

 


5. New 2015 Resuscitation Guidelines Compedium

BLS

 

 

 

 


4. LFTs explained

LFTs Explained

  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
    • Hepatocellular pattern = transaminases >  ALK
  • ALT is generally considered to be more specific to liver damage
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
    • Mild = NAFLD, Drug Induced Liver Injury, Alcohol-Induced Liver Injury
    • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
    • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity

 

read-more

 

 


3. The GCS is out-of-stock

GCS

Contrary to common belief, The Glasgow Coma Scale (GCS) is NEVER out-of-stock and the lowest score possible is 3.

  • An intubated patient still gets 1 point for verbal meaning they score 3T…there is nothing like a 2T score (at least not in human beings)
  • The phrase ‘GCS of 11’ is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
  • The Scale was described in 1974 by Graham Teasdale and Bryan Jennett (Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81-4.) and is the most reference paper in medical literature

 

 


2. Nairobi Accident Hotspots

Accident Hotspots

The most dangerous time to walk on Nairobi’s streets is on a Friday, around 7am, particularly along  Mombasa Road.

read-more


1. Salter-Harris Fracture (remember the mnemonic SALTR)

  1. Slipped (i.e., through growth plate and not involving bone) / Type I
  2. Above growth plate (i.e., through metaphysis) / Type II (most common)
  3. Lower growth plate (i.e., through epiphysis) / Type III
  4. Through (i.e., through metaphysis growth plate and epiphysis) / Type IV
  5. Rammed (i.e., Crush injury) / Type V (worst prognosis)