Colours correspond to Class of Recommendation.
*Atropine should not be given in patients after
†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.
- 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 nodalblock in the absence of system disease. infranodalconduction
- In contrast, it is important to recognize that the use of atropine in patients with
disease or block can be associated with exacerbation of block and is infranodalconduction potentiallyof 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 MIwith conduction system abnormalities is frequently associated with recovery of conduction – early and unnecessary pacing should be avoided.
- 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 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
- 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
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.
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.
Treatment of Helicobacter pylori Infection
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
|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|