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