tag:blogger.com,1999:blog-42662940485676633012024-03-13T23:18:03.551-07:00Mill Hill Ave CommandBrooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.comBlogger76125tag:blogger.com,1999:blog-4266294048567663301.post-27995441320865906102015-06-01T09:29:00.000-07:002015-06-01T18:42:40.318-07:00Guest Post - Perhaps Paramedics Should NOT Intubate!<style>
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<i>What if we're wrong? What if the "gold standard" for airway management is not approriate for EMS personnel? Even though many of us spent untold hours training to perform ET intubation, and have felt justifiable pride in performing this skill well, is it possible that our efforts have been (ahem) misplaced?<br /><br />This is a guest post by Ben Dowdy, <span style="font-family: inherit;"><span style="font-size: small;">NRP, exploring this unpopular position, reevaluating the opposite perspective. This is part of the inaugural "</span></span><span style="font-family: inherit;"><span style="font-size: small;"><a href="http://emsbasics.com/2015/06/01/the-first-ems-what-if-were-wrong-a-thon/"><b><span style="font-weight: normal;">What-if-We’re-Wrong-a-Thon</span></b></a>"</span></span> organized by Brandon Oto of <a href="http://emsbasics.com/"><b>EMS Basics</b></a> fame (and soon-to-be lead author in a Very Important Journal).</i><br />
<br /></div>
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The continued role of endotracheal intubation as a standard
prehospital skill continues to be debated, sometimes hotly.<span style="mso-spacerun: yes;"> </span>I’m going to present an argument against
prehospital endotracheal intubation.</div>
<div class="MsoNormal">
<span style="font-size: large;"><b><u>Aspiration
Prevention</u></b></span></div>
<div class="MsoNormal">
Proponents of endotracheal intubation often use the argument
that ET intubation protects the airway from aspiration.<span style="mso-spacerun: yes;"> </span>But how true is such a claim?<span style="mso-spacerun: yes;"> </span>Multiple studies of emergency airway
management list aspiration as an infrequent complication <sup>1,2</sup>, only
occurring 2.8-3.5% of the time.<span style="mso-spacerun: yes;"> </span>A study
of prehospital RSI<sup>3</sup> found that pre-intubation evidence of aspiration
was noticed in a significant number of patients, but only one incidence of
peri-intubation aspiration was recorded, and no instances of post-intubation
aspiration were reported.</div>
<div class="MsoNormal">
What to make of this?<span style="mso-spacerun: yes;">
</span>Aspiration pneumonia is a serious diagnosis, conferring an adjusted 2.3
odds ratio in favor of mortality<sup>4</sup>.<span style="mso-spacerun: yes;">
</span>But for the majority of patients having their airway managed in the
prehospital field, if aspiration is going to occur, it’s extremely likely that
it happens prior to EMS providers arriving and managing the airway.<span style="mso-spacerun: yes;"> </span>A prehospital ET tube prevents aspiration
very uncommonly.</div>
<div class="MsoNormal">
<span style="font-size: large;"><b><u>No Mortality
Benefit</u></b></span></div>
<div class="MsoNormal">
As EMS evolves, we’re constantly being challenged to ensure
that our treatments and procedures have meaningful, patient-oriented
outcomes.<span style="mso-spacerun: yes;"> </span>As I heard it referred to
early in my paramedic career, “we should be doing things <i style="mso-bidi-font-style: normal;">for</i> patients, not <i style="mso-bidi-font-style: normal;">to</i>
them.”<span style="mso-spacerun: yes;"> </span>For prehospital intubation,
unfortunately, that does not appear to be the case.<span style="mso-spacerun: yes;"> </span>The available literature investigating
prehospital intubation’s effects on mortality<sup>5-9</sup> overwhelmingly show
that if trauma patients are alive when they’re intubated in the field, their
chance of dying just increased.<span style="mso-spacerun: yes;"> </span>For
patients who are already in cardiac arrest, evidence is conflicting as to
whether ANY advanced airway management improves mortality, and even then the
champion between supraglottic airways and endotracheal intubation varies with
almost every new study that comes out.</div>
<div class="MsoNormal">
<span style="font-size: large;"><b><u>Can EMS Education
Programs Assess Competency in Intubation?</u></b></span></div>
<div class="MsoNormal">
Initial requirements for intubation training in EMS used to
be laughable under the National Standard Curriculum; 5 intubations was all you
needed, compared with 50+ in medical schools.<span style="mso-spacerun: yes;">
</span>The National EMS Education Standards thankfully replaced this with the
more blanket term of “demonstrating competency” during providers’ initial
training programs, allowing educational institutions to set the bar higher to
ensure that new paramedics could competently intubate patients.<span style="mso-spacerun: yes;"> </span>However, this higher standard has created difficulties.<span style="mso-spacerun: yes;"> </span>A series of surveys<sup>10</sup> distributed
by the Committee for Accreditation of EMS Programs (CoAEMSP) found that 53% of
programs have difficulty obtaining access to ORs for students to practice; 81%
use high-fidelity simulators to determine competency and 90.7% urged CoAEMSP to
allow these simulators as a means of demonstrating competency.<span style="mso-spacerun: yes;"> </span>In others words, most EMS education
institutions can’t ensure that their paramedic graduates will ever intubate an
actual person, even a stable one undergoing elective surgery, prior to getting
their certification or licensure.<span style="mso-spacerun: yes;"> </span>To add
even greater concern, the available airway mannequins commonly used in EMS airway
training (including the ones that most programs want to use to “prove”
competency) correlate extremely poorly with airway measurements of actual
people<sup>11</sup>.</div>
<div class="MsoNormal">
<span style="font-size: large;"><b><u>Summary</u></b></span></div>
<div class="MsoNormal">
Endotracheal intubation is a skill that’s difficult to
master; it takes a lot of realistic practice during initial education and at
frequent intervals afterwards to be able to succeed in prehospital
settings.<span style="mso-spacerun: yes;"> </span>Our education institutions
can’t guarantee that providers entering the field can competently intubate
patients.<span style="mso-spacerun: yes;"> </span>The common argument of
“aspiration protection” is a false one; aspiration doesn’t occur very often at
all during emergency airway management, it occurs before we ever show up.<span style="mso-spacerun: yes;"> </span>When we intubate people, their mortality rate
increases.<span style="mso-spacerun: yes;"> </span>It’s time to stop using
endotracheal intubation as a first-line airway management technique until we
can prove that we’re doing it <i style="mso-bidi-font-style: normal;">for</i> our
patients, instead of <i style="mso-bidi-font-style: normal;">to</i> them.</div>
<div align="center" class="MsoNormal" style="text-align: center;">
<b style="mso-bidi-font-weight: normal;"><u>References</u></b></div>
<div class="MsoListParagraphCxSpFirst" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Thibodeau LG, et al (1997).<span style="mso-spacerun: yes;"> </span>“Incidence of Aspiration after Urgent
Intubation.”<span style="mso-spacerun: yes;"> </span><span style="mso-bidi-font-family: "Segoe UI";">Am J Emerg Med. 1997 Oct;15(6):562-5.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Martin
LD, et al (2011).<span style="mso-spacerun: yes;"> </span>“<span style="mso-bidi-font-weight: bold;">3,423 emergency tracheal intubations at a
university hospital: airway outcomes and complications.”<span style="mso-spacerun: yes;"> </span></span>Anesthesiology. 2011 Jan;114(1):42-8.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Vadeboncoeur
TF, et al (2006).<span style="mso-spacerun: yes;"> </span>“<span style="mso-bidi-font-weight: bold;">The ability of paramedics to predict
aspiration in patients undergoing prehospital rapid sequence intubation.”<span style="mso-spacerun: yes;"> </span></span>J Emerg Med. 2006 Feb;30(2):131-6</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span>Lanspa MJ, et al (2015).<span style="mso-spacerun: yes;"> </span><span style="mso-bidi-font-family: "Segoe UI";">“Characteristics
associated with clinician diagnosis of aspiration pneumonia: a descriptive
study of afflicted patients and their outcomes.”<span style="mso-spacerun: yes;"> </span>J Hosp Med.<span style="mso-spacerun: yes;">
</span>2015 Feb; 10(2):90-6.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Evans
CC, et al (2013).<span style="mso-spacerun: yes;"> </span>“Prehospital non-drug
assisted intubation for adult trauma patients with Glasgow Coma Score less than
9.”<span style="mso-spacerun: yes;"> </span>Emerg Med J. 2013 Nov;30(11):935-41.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Karamanos
E, et al (2014).<span style="mso-spacerun: yes;"> </span>“Is prehospital
endotracheal intubation associated with improved outcomes in isolated severe
head injury?<span style="mso-spacerun: yes;"> </span>A matched cohort
analysis.”<span style="mso-spacerun: yes;"> </span>Prehosp Disaster Med. 2014
Feb;29(1):32-6.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Taghavi
S, et al (2014).<span style="mso-spacerun: yes;"> </span>“Prehospital intubation
does not decrease complications in the penetrating trauma patient.”<span style="mso-spacerun: yes;"> </span>Am Surg. 2014 Jan;80(1):9-14.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Kempema
J, et al (2015).<span style="mso-spacerun: yes;"> </span>Prehospital
endotracheal intubation vs. extraglottic airway device in blunt trauma.”<span style="mso-spacerun: yes;"> </span>Am J Emerg Med. 2015 Apr 29.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="mso-bidi-font-family: "Segoe UI";">Stockinger
ZT, McSwain NE Jr. (2004).<span style="mso-spacerun: yes;"> </span>“Prehospital
endotracheal intubation for trauma does not improve survival over
bag-valve-mask ventilation.”<span style="mso-spacerun: yes;"> </span>J Trauma.
2004 Mar;56(3):531-6.</span></div>
<div class="MsoListParagraphCxSpMiddle" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Kalish,
MA (2013).<span style="mso-spacerun: yes;"> </span>“Definition of Airway
Competency.”<span style="mso-spacerun: yes;"> </span><a href="http://coaemsp.org/Documents/Airway-Competency-Kalish-2013-09.pdf">http://coaemsp.org/Documents/Airway-Competency-Kalish-2013-09.pdf</a></div>
<div class="MsoListParagraphCxSpLast" style="mso-list: l0 level1 lfo1; text-indent: -.25in;">
<span style="mso-bidi-font-family: Calibri; mso-bidi-theme-font: minor-latin;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span>Schebesta
K, et al (2012).<span style="mso-spacerun: yes;"> </span>“Degrees of reality:
Airway Anatomy of High-fidelity Human Patient Simulators and Airway
Trainers.”<span style="mso-spacerun: yes;"> </span>Anesthesiology.<span style="mso-spacerun: yes;"> </span>2012 June;116(6):1204-9.</div>
<div class="MsoNormal">
<b style="mso-bidi-font-weight: normal;">Bio:</b> Ben Dowdy
B.S., NRP, is a paramedic and EMS educator currently working in northern
Idaho.<span style="mso-spacerun: yes;"> </span>His past experiences include
working as a paramedic, tactical paramedic, and SAR medic in urban, rural, and
wilderness areas, including Yellowstone National Park, and teaching EMS topics
for a university-based EMS education program, as well as across the US and
abroad for Wilderness Medical Associates.</div>
Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com144tag:blogger.com,1999:blog-4266294048567663301.post-68727481210015330252015-03-06T08:38:00.004-08:002015-03-06T08:38:53.183-08:00Update: Cyanokit for cardiac arrest in fire victims
<br />
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>I had <a href="http://millhillavecommand.blogspot.com/2014/04/part-2-different-edit.html" target="_blank">written about this topic</a> last year, but a recent EM:RAP segment and
ensuing Twitter discussion prompted me to revisit the issue. Sadly, there is
no new evidence to add to the discussion.<span> Nonetheless, let's</span> revisit the question: </span></span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span><b>If a pulseless patient is pulled from a
smoky, burning building, will giving Cyanokit during CPR help</b>?</span></span></span></div>
<div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span> <table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFm0EYef28cDTtoE5Imf-7hyphenhyphennAcnc5JXczo5_zwplC-jTMYFTMtcupyLuQyYDA7kW4_Ff4DEgPX1dXWr7gN6xGDDQjwVUlTGU8VCQDg8hl4HhpMq5kzQnIyvpC0g5E4lO3X18I5Z0BLXE/s1600/screenshot1052.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjFm0EYef28cDTtoE5Imf-7hyphenhyphennAcnc5JXczo5_zwplC-jTMYFTMtcupyLuQyYDA7kW4_Ff4DEgPX1dXWr7gN6xGDDQjwVUlTGU8VCQDg8hl4HhpMq5kzQnIyvpC0g5E4lO3X18I5Z0BLXE/s1600/screenshot1052.jpg" height="175" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Step 1</td></tr>
</tbody></table>
</span></span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3 class="MsoNormal">
<u><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>1. There is no known “50% ROSC rate”
because of Cyanokit. </span></span></span></u></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>The four studies looking at this
issue are, by design, unable to support any such conclusion. They were
case-series, with no controls whatsoever. They gave Cyanokit to a number of
people, and some of them lived. However, we have no idea if the “save rate” was
better or worse than usual care. These studies show that EMS can administer
Cyanokit, but they can’t speak to its effectiveness <i>at all</i>. <span> </span>As a result, even
toxicologists <a href="http://www.thepoisonreview.com/2010/05/22/cyanide-the-heart-and-hydroxocobalamin/">don’t
make much of these studies.</a></span></span></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>Furthermore, <a href="http://www.ncbi.nlm.nih.gov/pubmed/20185266">most of the “saves” in one
study</a> had ROSC <b>before</b> they
received the Cyanokit. It isn’t clear in the other studies when the patients
received the antidote, and the amount of missing data makes it hard to
interpret. </span></span></span></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-weight: normal;">Go
read the original studies; the links are at my post </span><span style="font-weight: normal;"><a href="http://millhillavecommand.blogspot.com/2014/04/part-2-different-edit.html">Does
Cyanokit save lives in cardiac arrest</a>? </span></span></span></h3>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAdG2o71oAEOXdH9DVvSd4vG2LEBZeJlsJEMCRMmoaZ-0QWb254-xtjrkQkTYnmWzBbxrU9wPzANf6n_XhYxDmJbcRMUOd1B2BoZwwntIw8BDPzg-D0knyx_7lcl0IqO6_q6JtC3XYedU/s1600/screenshot1053.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgAdG2o71oAEOXdH9DVvSd4vG2LEBZeJlsJEMCRMmoaZ-0QWb254-xtjrkQkTYnmWzBbxrU9wPzANf6n_XhYxDmJbcRMUOd1B2BoZwwntIw8BDPzg-D0knyx_7lcl0IqO6_q6JtC3XYedU/s1600/screenshot1053.jpg" height="175" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Step 2</td></tr>
</tbody></table>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3 class="MsoNormal">
<u><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>2. Meds, in general, don’t increase
save rates in cardiac arrest. </span></span></span></u></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>Although the AHA teaches a
“reversible cause” approach to arrest, this isn’t helpful most of the time. For
example, although heroin OD and severe hypoglycemia may cause cardiac arrest,
there is no AHA recommendation to give naloxone or dextrose in cardiac arrest. In
fact, naloxone use is discouraged.</span></span></span></div>
<div class="MsoNormal">
<br /></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal">
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span>Same with tPA. An AMI or a PE
commonly triggers cardiac arrest, and tPA could theoretically “treat the
cause.” But the evidence showed that, overall, <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa012885">it didn’t work during
cardiac arrest</a>. True, many of us have tried it once or twice, but <b>not routinely</b>. </span></span></span></div>
<div class="MsoNormal">
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS3WwFLVT9ePfL1LIPYLc5b15_vew4XUCmS2kgUDnfgHgdmnWLMfb0R2my_Xvo2AjADlDWL9w4XohAtPnX_bnbxDkNtCFStUOuVPMqjwmVpQHGtzTICmU0nq7Hz__Khum6kD2xxkkomCo/s1600/screenshot1054.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgS3WwFLVT9ePfL1LIPYLc5b15_vew4XUCmS2kgUDnfgHgdmnWLMfb0R2my_Xvo2AjADlDWL9w4XohAtPnX_bnbxDkNtCFStUOuVPMqjwmVpQHGtzTICmU0nq7Hz__Khum6kD2xxkkomCo/s1600/screenshot1054.jpg" height="175" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Step 3</td></tr>
</tbody></table>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3>
<u><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">3. I’m no EBM diehard, but we have to do better than this!</span></span></u></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">The evidence for Cyanokit is sort of like the evidence that supported
<b>Digibind</b> (for digoxin OD) or fomepizole/<b>Antizol</b> (for methanol/ethylene glycol
OD). Neither one of those drugs had a supporting RCT, or even a strong
case-control trial. Indeed, the important studies showing their benefit were
open-label, and uncontrolled. (E.g. Brent 1999 “<a href="http://www.nejm.org/doi/full/10.1056/NEJM199903183401102">Fomepizole for
the Treatment of Ethylene Glycol Poisoning,”</a> and Antman 1990 “<a href="http://circ.ahajournals.org/content/81/6/1744.full.pdf">Treatment of 150
cases of life-threatening digitalis intoxication with digoxin-specific Fab
antibody fragments</a>.”). </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">However, the low rate of adverse effects, and the
strong mechanistic and animal data, along with the difficulty of conducting a
true RCT, argued strongly in favor of using these drugs, despite active
discussion regarding the costs. So it’s appealing to use a similar argument to
support using Cyanokit.</span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">This argument, however, also suggests that recommendations for the routine administration
of Cyanokit are very premature. The studies of <b>Digibind</b> and <b>Antizol</b> were of far
higher quality than the 3 French and 1 Texas Cyanokit studies. </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">For example, both Brent 1999
and Antman 1990 used <b>prospective</b>
collection of data (rather than chart review), and both used <b>clear, quantitative criteria</b> for the
use of the antidotes. That approach generated high quality data, which could be
used to make <b>valid comparisons with</b> <b>historical cohorts</b>. By contrast, the Cyanokit
studies are of very low-quality, based on chart reviews with unclear methods,
and have plenty of missing data. </span></span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2D6RmA_4UH3ZfTNid8rvYTeiig64hpmlfGZYNZLet3jZtgtTqc1mI8zbYpgymqHb1WFQH2_aVi3YMZrO6MDX6RgjZ5Q1vhQxzDLXtMI23h8Ads1s1KQCPAntadN6KKbQTZXI9cFLrinY/s1600/screenshot1055.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg2D6RmA_4UH3ZfTNid8rvYTeiig64hpmlfGZYNZLet3jZtgtTqc1mI8zbYpgymqHb1WFQH2_aVi3YMZrO6MDX6RgjZ5Q1vhQxzDLXtMI23h8Ads1s1KQCPAntadN6KKbQTZXI9cFLrinY/s1600/screenshot1055.jpg" height="175" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Step 4</td></tr>
</tbody></table>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">4. <span> </span>Cardiac arrest at fire scene,
especially in a firefighter? </span></span></h3>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">It’s probably an MI, and the key issue isn’t getting a miracle drug started,
but getting access to the patient to start high-quality CPR, and defibrillating
as early as possible. Getting the gear off a “downed” firefighter requires a
coordinated team effort, with plenty of practice beforehand.</span></span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilPR_k1hUiHJCxAqyCVZEQFgarWbaW5f6pDHIRxi30a6JujitU8Ct9vwb9r7OSI87WiKeUFEnTNpZOANC7sBZlLvWUtY4wb8PvoPgWPf6CQBF3yvqyg7jghdJEEw2p_qeNqqYqnEuJIkY/s1600/screenshot1056.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilPR_k1hUiHJCxAqyCVZEQFgarWbaW5f6pDHIRxi30a6JujitU8Ct9vwb9r7OSI87WiKeUFEnTNpZOANC7sBZlLvWUtY4wb8PvoPgWPf6CQBF3yvqyg7jghdJEEw2p_qeNqqYqnEuJIkY/s1600/screenshot1056.jpg" height="176" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Step 5</td></tr>
</tbody></table>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">"Pit
crew" style CPR has been proven to save lives. Firefighters have been
shown to have high rates of cardiac disease, and high rates of on-duty
arrests. It's a fact that it's hard to do CPR on someone wearing bunker
gear and a SCBA. If your FD isn't drilling for this scenario, an
expensive drug isn't going to help. </span></span><br />
<br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">The good news about saving a firefighter's life is that it's free and proven - but you have to put in some effort. </span></span>Check out the <a href="http://fd-cpr.com/" target="_blank"><b>Firefighter Down- CPR </b></a>website for the specifics on how to improve your response. Here's the vid:</span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<iframe width="320" height="266" class="YOUTUBE-iframe-video" data-thumbnail-src="https://ytimg.googleusercontent.com/vi/45qDPFj4IpI/0.jpg" src="http://www.youtube.com/embed/45qDPFj4IpI?feature=player_embedded" frameborder="0" allowfullscreen></iframe></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span><div class="MsoNormal">
<br /></div>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">
</span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com113tag:blogger.com,1999:blog-4266294048567663301.post-52411923123943188312014-06-26T11:50:00.005-07:002014-06-26T11:50:43.069-07:00For better pain control, add a benzo? (Part 2 - Chest pain)<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">In my last post, I reviewed a recent study that demonstrated that adding a benzodiazapine (or "benzo") to morphine didn't seem to help in treating <b>traumatic</b> pain, and may increase the rate of side effects. But what about <b>atraumatic</b> pain? Specifically, what about chest pain?</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Well, at least chest pain from suspected cardiac ischemia...</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOmayJd3rsTR6vbWfyolOCCgUa7Qw7U_C488-i3PZ04BaVsxLQZuiUTnqghddBMm9vvun5Jck0P_KymRFShhOp4g5X6bXlzuE82DpU5LaW7kt0YWaNsacdcLQDU1-29EfZwbPWxXf1jQI/s1600/20090201-chest-2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOmayJd3rsTR6vbWfyolOCCgUa7Qw7U_C488-i3PZ04BaVsxLQZuiUTnqghddBMm9vvun5Jck0P_KymRFShhOp4g5X6bXlzuE82DpU5LaW7kt0YWaNsacdcLQDU1-29EfZwbPWxXf1jQI/s1600/20090201-chest-2.jpg" height="240" width="320" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Georgia,"Times New Roman",serif;">You can probably skip the ECG in this case.</span></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">So, could adding Ativan or Versed help when treating chest pain?</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: large;"><b>Background </b></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">There are some good reasons to think that controlling anxiety, and not just pain, would help in the treatment of patients with acute coronary syndrome, and especially STEMIs. For example, anxiety during an MI can cause an increased heart rate, and thus worsen oxygen demand, and so potentially worsen the cardiac ischemia. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">So, if we give beta-blockers to address this issue, why not treat the problem right at the root? </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">A <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/14654185">review from 2003</a> </b>looked over the basic science, a few small clinical trials, and also the side effect profile of using diazepam or similar agents in acute or subacute ACS. The conclusion was pretty enthusiastic about using benzos, describing the potential risk-benefit ratio as very favorable.</span></span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHtHwMh9mwNCL0EmyNCrue-Ou04Kvx0gIo0Vm3rwuP1Y6cTKACJ0qQRwfAYnij5kN85VDrXPZv0Nf5wb019wnelzH_XaS5sbJZKkTbxgWSeOBida-xNdzFXJ4IL-ivfkC7pmO2JzZU97o/s1600/screenshot646.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHtHwMh9mwNCL0EmyNCrue-Ou04Kvx0gIo0Vm3rwuP1Y6cTKACJ0qQRwfAYnij5kN85VDrXPZv0Nf5wb019wnelzH_XaS5sbJZKkTbxgWSeOBida-xNdzFXJ4IL-ivfkC7pmO2JzZU97o/s1600/screenshot646.jpg" height="242" width="320" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-size: x-small;"><span style="font-family: Georgia,"Times New Roman",serif;">"In conclusion, the authors disagree on whether the chief benefit of adding<br /> benzodiazepines is tasting great, or in being less filling."</span></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><style type="text/css">P { margin-bottom: 0.08in; }</style><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The studies they reviewed, however, were small, had conflicting
results, and didn't apply to EMS very well. Fortunately, our Swedish
friends stepped up to the plate, and conducted a randomized
prehospital trial to answer this question.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"> </span></span><br />
<span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">The Study</span></b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><i>Methods</i> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23727103"><b>Anxiolytics in patients suffering a suspected acutecoronary syndrome: multi-centre randomised controlled trial inEmergency Medical Service</b></a> studied if adding midazolam (Versed) to
standard analgesia (</span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">morphine</span></span>) could help patients with chest pain. The study included EMS systems from across the
Swedish region of <a href="http://en.wikipedia.org/wiki/V%C3%A4stra_G%C3%B6taland_County"><b>Västra</b></a>, including 500 prehospital personnel, 60 ambulances and <b>one</b> <b>EMS</b>
<b>boat. </b><span style="font-weight: normal;"><br /></span></span></span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpfVfHO5NzWAAPrPYmOCM5HVYqcrIo6K-KvyH7k5uwK-o-xK1Sk2nYYhpJ1XIkrkZ8ifVS0nyQqECoNgllN-97RmxROg1Q_Aw3DFA3_VOsG5HhiEL7OeYKnGL_8sjIckJlbWqAYriSGeU/s1600/VIKING_LONGSHIP_%22SEA_STALLION%22_ARRIVES_IN_DUBLIN.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpfVfHO5NzWAAPrPYmOCM5HVYqcrIo6K-KvyH7k5uwK-o-xK1Sk2nYYhpJ1XIkrkZ8ifVS0nyQqECoNgllN-97RmxROg1Q_Aw3DFA3_VOsG5HhiEL7OeYKnGL_8sjIckJlbWqAYriSGeU/s1600/VIKING_LONGSHIP_%22SEA_STALLION%22_ARRIVES_IN_DUBLIN.jpg" height="320" width="318" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">"Squad 51 responding 11:33. KMG365"
</td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-weight: normal;">The “usual” dose of
morphine was </span><b>5 mg</b><span style="font-weight: normal;">,
while midazolam was given in </span><b>0.5 mg</b><span style="font-weight: normal;">
boluses until a total of </span><b>1-2 mg</b><span style="font-weight: normal;">
had been given. The primary outcome was the </span><b>pain level at
15 minutes</b><span style="font-weight: normal;"> after the decision
to give analgesia. </span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-weight: normal;"><i>Results</i> </span></span></span>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"></span></span><span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><div style="font-weight: normal;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">After looking at the <b>1763</b> patients
enrolled in the trial, they found.... no difference. Even when they
looked at the subset of <b>599</b> patients who turned out to have
real ACS diagnosed in the hospital, there was no benefit to adding a
benzo for pain relief. </span></span></div>
<div style="font-weight: normal;">
<br /></div>
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<span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhv3fkhsYfOArwk2HHEhB917bSci_PlL1JTSX0jVFMc-nzd0k0GnK32eFOFD5b0RIlFeNpnuLsdtKXIvrAsN9mM5chxT0AAM3ucO3fqBSleqDe7XWSm9up_3SSM3SJrQ_k3h9bs5fPKST8/s1600/screenshot647.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhv3fkhsYfOArwk2HHEhB917bSci_PlL1JTSX0jVFMc-nzd0k0GnK32eFOFD5b0RIlFeNpnuLsdtKXIvrAsN9mM5chxT0AAM3ucO3fqBSleqDe7XWSm9up_3SSM3SJrQ_k3h9bs5fPKST8/s1600/screenshot647.jpg" height="88" width="320" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The addition of midazolam seemed to reduce the
heart rate and blood pressure to a <i>statistically</i> significant degree,
but the clinical effect was pretty minimal.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><div style="font-weight: normal;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Unfortunately, the benzo-getting
patients more often became drowsy (or “dozy,” per the authors'
language), much like in the trauma patients in my prior post.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><i>Limitations</i> </span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><div style="font-weight: normal;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Yes, the study could have been done
better. Many <b>potential patients were not enrolled</b>, and we don't know
if they were different from the enrolled folks. Many of the secondary
endpoints were vaguely defined, and <b>not based on the patients'
self-report</b>. For example, the degree of anxiety, unlike pain, was
judged by EMS personnel.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><div style="font-weight: normal;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Lastly, while the trial was
randomized, the EMS personal were<b> not blinded</b> to the study drug. In
other words, EMS knew who got midazolam, and who didn't. This could
have introduced some bias in the results (although I would expect it
only would have made the midazolam group report <i>better</i> pain
relief).</span></span></div>
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<span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">The Bottom Line</span></b></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">This trial may have had some shortcomings, but it did <i>not</i> suggest
a clinically significant role for benzos in treating chest pain of suspected
cardiac origin. So, we don't have to figure out a way to add a "B" into <a href="http://www.emlitofnote.com/2011/10/yes-let-mona-fade-away.html"><b>MONA</b></a>!</span></span><br />
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Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com398tag:blogger.com,1999:blog-4266294048567663301.post-22137304647107997532014-06-19T12:05:00.000-07:002014-06-19T12:11:50.178-07:00For better pain control, add a benzo? (Part 1 - Trauma)<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">If a patient is in pain, should we also be treating their <i>anxiety</i> more aggressively? Some medical practitioners feel strongly that we should be. <span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption">In <b>part 1</b>, I'll discuss the evidence for using "benzos" (e.g. midazolam, lorazepam) for traumatic pain. The (forthcoming) <b>part 2</b> will discuss using benzos to treat the pain of cardiac ischemia. </span></span><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"> </span></span></span></span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlQZrjrwR09oCsmzu-MO6P1JD4xfgc5shjhbNwtuL01Sx4t9S6QQNMfCVQEDDnqkwvjvVz7u7uO8sfSiYvIZR9lw7NAK0KKC-UpzKPAh63AXMDnjqtPjroiNYhfGG1WXPixwwJnZzmSJ0/s1600/screenshot402.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjlQZrjrwR09oCsmzu-MO6P1JD4xfgc5shjhbNwtuL01Sx4t9S6QQNMfCVQEDDnqkwvjvVz7u7uO8sfSiYvIZR9lw7NAK0KKC-UpzKPAh63AXMDnjqtPjroiNYhfGG1WXPixwwJnZzmSJ0/s1600/screenshot402.jpg" height="320" width="269" /></a></span></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: x-small;">Bourbon, for example, can treat the anxiety of MI.<br /><a href="http://www.theonion.com/articles/report-aspirin-taken-daily-with-bottle-of-bourbon,549/"><b>Source:<i> </i></b><i>Not</i> the NEJM</a></span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span style="font-size: large;"><u><b>Trauma, pain, and benzos </b></u></span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption">Many
paramedics believe that they could <b>control traumatic pain better</b>, and<b> reduce
morphine or fentanyl dosing</b>, if they were allowed to add a benzodiazepine, like midazolam or Ativan.
Different reasons are offered for this approach, such as the role of
anxiety, the spasming of muscles in trauma, or the difficulty in
controlling pain quickly with just opioids. </span></span></span>An interesting new EMS study adds some evidence to this discussion.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The French authors of <span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">"<a href="http://www.ncbi.nlm.nih.gov/pubmed/24613655"><b>Does midazolam enhance pain control in prehospital management of traumatic severe pain</b></a>?" enrolled patients who had a traumatic injury, and who described their pain as at least a "6" on a 10-point scale. </span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><br /></span></span></span></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">All of the patients got <b>morphine</b>, and good doses too! The first dose was </span></span></span></span><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><b>0.1 mg/kg</b>, and then repeat doses of <b>3
mg</b> PRN every 3 minutes were administered, until the pain was down to a “3.” </span></span></span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><i>Half</i> of these patients also </span></span></span></span><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">received <b>0.04 mg/kg</b> IV of <b>midazolam</b> at the same time as the initial dose of morphine, while the <i>other half </i>received a <b>placebo</b> injection.</span></span></span></span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioDgJIhdeeBHpqtreeJDh0ZdFYj3FmzxJ4X6YYsb8fUcL46nkK9GuOkfyY8EnVSIf-somyVsF7kwYHmFPy7EbVnCCXAaHWUH35w-VGPk6QmQjyfF5ZAxh3fUIwtA7jNtkCVKype9swfRE/s1600/screenshot638.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEioDgJIhdeeBHpqtreeJDh0ZdFYj3FmzxJ4X6YYsb8fUcL46nkK9GuOkfyY8EnVSIf-somyVsF7kwYHmFPy7EbVnCCXAaHWUH35w-VGPk6QmQjyfF5ZAxh3fUIwtA7jNtkCVKype9swfRE/s1600/screenshot638.jpg" height="134" width="320" /></a></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">So, did adding the benzo help? It appears <b>not</b>.</span></span></span><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"> Surprisingly, the
patients who received midazolam had about the <b>same pain relief</b> as the placebo group. </span></span></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeMf2v3JB1y4jKrh8QnpFUaUuawrGmMqzqzdYaNdxiDenBci-gXxFGrcE1IXBdvXkeQFr5WXkXYlPnYIv9SD4VSLs3puUUhwj7IYmXDh9hBEgKYBlJ8p9ndG94AwtvKy6UbTi5JMwvN8w/s1600/screenshot621.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjeMf2v3JB1y4jKrh8QnpFUaUuawrGmMqzqzdYaNdxiDenBci-gXxFGrcE1IXBdvXkeQFr5WXkXYlPnYIv9SD4VSLs3puUUhwj7IYmXDh9hBEgKYBlJ8p9ndG94AwtvKy6UbTi5JMwvN8w/s1600/screenshot621.jpg" height="128" width="320" /></a></span></span></span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><i>Un</i>surprisingly, they also had much <b>higher rates of sedation</b>: <b>44</b>%, versus only <b>7</b>% for the placebo group. They also found a
strong trend for <b>more hypoxia</b> in the benzo group: <b>13</b>% versus <b>2</b>% for
placebo. Lastly, there was <b>no difference in the total dose</b>s of morphine given. </span></span></span><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"></span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"></span></span></span></span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWrinszDDxemItTKW1l94PqgGSAqkLkgO-wLnd-sREw1n8WZYUCx-FqhhfuYWLBgxTSTgk793N0C_ONXXHsnHlzaS4LaGuW0Khym8xDNiDpMBUu-AMleuZTWgjvbtqFaPF2iHyawppc1Q/s1600/screenshot637.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhWrinszDDxemItTKW1l94PqgGSAqkLkgO-wLnd-sREw1n8WZYUCx-FqhhfuYWLBgxTSTgk793N0C_ONXXHsnHlzaS4LaGuW0Khym8xDNiDpMBUu-AMleuZTWgjvbtqFaPF2iHyawppc1Q/s1600/screenshot637.jpg" height="135" width="320" /></a></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">So, unless you're looking to "snow" more patients, this isn't a good approach!</span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><br /> </span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><span style="font-size: large;"><u><b>How does this agree with other studies?</b></u></span><br /> </span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">Pretty well. For example, an <a href="http://www.ncbi.nlm.nih.gov/pubmed/21480984"><b>ED study done with kids with fractured arms</b></a> also looked at morphine <b>± </b>midazolam for pain control. Similar to the present study, they found no advantage in pain control, but more "drowsiness." (In the graph, "VAS" means pain level.)</span></span></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPHe1WErkVYJ8gIIWZlBUlSDAgmARVahd3TlVXMdhZdypyxenVVUN7BrWuR2AKBR5D-_Z9pjo97AoT0lNaADZi2CzJg7TZAbHuF8krojbfbtehkDU2K-aBJlkIrdMVQSq7Cj0Vlfbup1k/s1600/screenshot622.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiPHe1WErkVYJ8gIIWZlBUlSDAgmARVahd3TlVXMdhZdypyxenVVUN7BrWuR2AKBR5D-_Z9pjo97AoT0lNaADZi2CzJg7TZAbHuF8krojbfbtehkDU2K-aBJlkIrdMVQSq7Cj0Vlfbup1k/s1600/screenshot622.jpg" height="136" width="200" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show">The Bottom Line</span></span></span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption"><span class="text_exposed_show"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption">When I interviewed medics for <a href="http://www.amr.net/About-AMR/AMR-Medicine/Clinical-Quality-Initiatives/The-Things-that-Matter/pain-attitudes--2013.aspx"><b>a study I did a few years ago</b></a>,
I was surprised to hear that many medics, from both rural and
urban locations across New England, felt strongly about giving benzos for acute traumatic pain. Here's a sample quote from one of
the subjects:</span></span></span></span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJJUfQyFjlFA202xW22lY82YWdGR4n5Ln8gNDXk2JNezmszBQU_qviqOBaUZaXH0mRTqSJMk4SNj0qxYq1c-_SeLsPhddqsaOOOEjVjXUW2KaxCxbMjL-bqFoHMc99j6BONwr3HsjZCgc/s1600/screenshot620.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJJUfQyFjlFA202xW22lY82YWdGR4n5Ln8gNDXk2JNezmszBQU_qviqOBaUZaXH0mRTqSJMk4SNj0qxYq1c-_SeLsPhddqsaOOOEjVjXUW2KaxCxbMjL-bqFoHMc99j6BONwr3HsjZCgc/s1600/screenshot620.jpg" height="158" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22971168"><b>Ref</b></a>.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption">Despite having personally worked as a medic at a few of the places I visited, I was surprised to hear this perspective. Adding benzos for pain control is not common (or usually even permitted) in the emergency departments where these medics trained. </span></span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span class="fbPhotosPhotoCaption" data-ft="{"type":45,"tn":"*G"}" id="fbPhotoPageCaption" tabindex="0"><span class="hasCaption">Unless we are trying to sedate a patient, severe pain is probably best controlled with opioids <i>only</i>.</span></span></span></span><br />
<br />Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com54tag:blogger.com,1999:blog-4266294048567663301.post-68565347215356292802014-05-13T12:07:00.002-07:002014-05-13T12:07:24.524-07:00New thoughts on posterior MI for EMS<div style="margin-bottom: 0in;">
<span style="font-family: Georgia,"Times New Roman",serif;">Many savvy medics will check the "extra" ECG leads <b>V7 - V9</b> to look for a posterior MI. However, this isn't always necessary, since the appearance of leads<b> V1 - V3</b> will often show sufficient evidence of an acute MI. The only two problems here are</span><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Many medics don't know the classic criteria for posterior AMI.</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">The classic criteria may need to be changed somewhat!</span></li>
</ol>
<span style="font-family: Georgia,"Times New Roman",serif;">I wrote an article about this topic a few years ago in a post at <a href="http://www.ems12lead.com/2012/11/02/63-year-old-male-cc-substernal-chest-pain-discussion/"><b>EMS 12-Lead.</b></a> A newly published case report got me thinking about this again, though! </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">(Feel free to check out that link for a longer discussion.) </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The Case Report</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">In the article "<a href="http://informahealthcare.com/doi/abs/10.3109/10903127.2014.883000"><b>Acute Coronary Ischemia Identified by EMS Providers in a Standing Middle-aged Male with Atypical Symptoms</b></a>," the authors describe the case of apatient who had syncope, followed by cardiac arrest. After the patient had ROSC, they obtained an ECG:</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhHXFKvyGs1m2bsUxtUvJOrVPk90UusIQ3AQhWYYfeWh-KvLVNhqZLOqXu0uGGak8Zi8Nhu1BSLKP-lZ3ppcRfZM0ADRn_8CmZKrmECTLXzySsk5aoF5zF6n1THER8i02fm9yv3U7lqoQ/s3200/screenshot505.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhHXFKvyGs1m2bsUxtUvJOrVPk90UusIQ3AQhWYYfeWh-KvLVNhqZLOqXu0uGGak8Zi8Nhu1BSLKP-lZ3ppcRfZM0ADRn_8CmZKrmECTLXzySsk5aoF5zF6n1THER8i02fm9yv3U7lqoQ/s3200/screenshot505.jpg" height="172" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://informahealthcare.com/doi/full/10.3109/10903127.2014.883000">SOURCE</a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">They described this pattern of anterior ST depression only as "anterolateral ischemia," but could this really be a posterior STEMI?</span></div>
<div style="margin-bottom: 0in;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>ECG findings - The old thinking </b></u></span></span></div>
<div style="margin-bottom: 0in;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: black;">For years, the standard teaching on identifying a posterior MI has emphasized some common elements. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9672466"><b>Brady</b></a> summarized the most important of these:</span></span></div>
<blockquote>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Horizontal ST depression in V1-V4</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Tall, broad R waves (>30ms)</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Upright T waves</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Dominant R wave (R/S ratio > 1) in V2</span></li>
</ul>
</blockquote>
<div style="margin-bottom: 0in;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: black;">So, a classic posterior MI should look something like:</span></span></div>
<div style="margin-bottom: 0in;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></div>
<div style="margin-bottom: 0in;">
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;">
<tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY_SJkrEy3TfUPn-yCbysl5qkivjzAGHlYXXSKnYxrElRBWNwpSdPj1zYDBDJRBnq5gRohcM8dC9Tn2oNXUB_TuAlQX1C3AHqMTQ2CQZ62UXl7ydSE-ACWawXsS1r_CU2hlH7jUA9FabXx/s1600/Example+posterior+from+Rokos.png" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY_SJkrEy3TfUPn-yCbysl5qkivjzAGHlYXXSKnYxrElRBWNwpSdPj1zYDBDJRBnq5gRohcM8dC9Tn2oNXUB_TuAlQX1C3AHqMTQ2CQZ62UXl7ydSE-ACWawXsS1r_CU2hlH7jUA9FabXx/s400/Example+posterior+from+Rokos.png" height="173" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/21146650">Source</a></span></td></tr>
</tbody>
</table>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Problems with the old thinking?</b></u></span></span><br />
<div style="margin-bottom: 0in; orphans: 0; widows: 0;">
<span style="font-family: Georgia,"Times New Roman",serif;">The short-cut way to diagnose a posterior MI involves <a href="http://www.med.umich.edu/lrc/ecgoftheweek/cases/case03/answer04.html"><b>"flipping" the ECG</b></a>. The idea is that the ST <i>depression</i> in the anterior leads is a "mirror" view of ST <i>elevation</i> in the posterior wall, and that the tall R-waves are actually deep Q-waves.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">For example, when we take the ECG above, and "flip" leads <b>V1 - V3</b>, it now looks like a standard STEMI.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVsNSate79MwBGWZSIu_RkQsqMtvN6a8HKnGiB9LC4ZAxGdkw8D12Z0QxGswh9Hv7e2OpmSHhaRoYWRYR_G6r50yicoyZ9Wzgyw9-a6Jvnv4b8S869EA3f3eSrI9Kh3D2Pe2Hd-l3N_NU/s1600/Mirrored+ECG.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVsNSate79MwBGWZSIu_RkQsqMtvN6a8HKnGiB9LC4ZAxGdkw8D12Z0QxGswh9Hv7e2OpmSHhaRoYWRYR_G6r50yicoyZ9Wzgyw9-a6Jvnv4b8S869EA3f3eSrI9Kh3D2Pe2Hd-l3N_NU/s1600/Mirrored+ECG.jpg" height="233" width="320" /></a></span></td></tr>
<tr align="left"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><b>LEFT</b>: Unflipped - just boring ST depression<br /><b>RIGHT</b>: Flipping reveals an exciting STEMI. It's Magic!</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">So, our "classic" posterior, when it is flipped, looks like a STEMI. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">There is one problem though. The flipped ECG shows a big <b>Q-wave</b>, and the <b>T-wave</b> has started to invert. Usually, these findings aren't found in the early , acute stages of a STEMI. </span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBdSGYsXxw-lAdd6Bi14JIaG2o7HihetGbMRYiUObqOhr2oud6MyJcBYiCAYfFL0JgGh_gyPBu7qqqT1vQJ12lKsnWYcThsweenEZ_TgxvyHjyhQ73TDo1d1zbjXnkLhO_AAn_IfWpwRI/s1600/screenshot617.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBdSGYsXxw-lAdd6Bi14JIaG2o7HihetGbMRYiUObqOhr2oud6MyJcBYiCAYfFL0JgGh_gyPBu7qqqT1vQJ12lKsnWYcThsweenEZ_TgxvyHjyhQ73TDo1d1zbjXnkLhO_AAn_IfWpwRI/s1600/screenshot617.jpg" height="194" width="200" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.wikidoc.org/index.php/ST_elevation_myocardial_infarction_electrocardiogram"><b>Evolution of ECG in STEMI (source)</b></a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">Instead, this pattern of Q-waves and T-wave inversion suggests an AMI that has been progressing for a few hours.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>ECG findings - The <i>new</i> thinking</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"> This problem - that a classic posterior STEMI looks like a <b>subacute</b> or <b>old</b> <b>MI</b> - was described by the authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/22920785"><b>Common
pitfalls in the interpretation of electrocardiograms from patients with
acute coronary syndromes with narrow QRS: a consensus report</b></a>. These 13 cardiologists<span style="font-size: small;"> agreed that the old definition</span><span style="font-size: small;"> of posterior MI, that relies on<b> tall R-waves</b> and <b>upright T-waves</b>
in leads V1 - V4, describes </span></span><blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">"... the late
“mirror image” of <i>fully evolved</i> ST-segment MI (STEMI)
(Q waves with terminal T-wave inversion) and <i>not</i> the
acute phase of STEMI."
</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">They do not propose a better definition of a posterior STEMI ECG pattern. They do, however, offer this example of an ECG that better illustrates a truly <i>acute</i> posterior STEMI, resulting from a left circumflex occlusion. Note the ST depression in <b>V1 - V3</b>, and <i>no</i> significant <b>R-waves</b> or <b>T-waves</b>.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwZ8RS1vUR12NVBpSZDg7uGr97tWOH8ryNAS7rx5LhXvbckEcuz8RrT2QEx_BcscU1yH3OP-ZjJtyfr7nwrtW7PErhD1lx526oc5te5l3oqH-NI4uSGBhdX_E40ovdplnpxA4GzA7YQPA/s1600/Hyperacute+LCx.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwZ8RS1vUR12NVBpSZDg7uGr97tWOH8ryNAS7rx5LhXvbckEcuz8RrT2QEx_BcscU1yH3OP-ZjJtyfr7nwrtW7PErhD1lx526oc5te5l3oqH-NI4uSGBhdX_E40ovdplnpxA4GzA7YQPA/s320/Hyperacute+LCx.png" height="129" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Back to the case report!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The ECG from the case at the start of this post showed ST depression in <b>V1 - V4</b>, but only small <b>R-waves</b>, and only a hint of an upright <b>T-wave</b>:</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX-HANpEvKZBE5-l4NQUMmTQ3eGfFT1zqC2ymtNK-3tw-6n5cfqKsLkg_h2O-BaIa3SGUYUjvr6BBrm8-muGaetxclPkhhtxE9QcIuUyCSVkd2yrDj-kfNaVL4lcohONVvZg9D58UeTtk/s1600/case+report.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjX-HANpEvKZBE5-l4NQUMmTQ3eGfFT1zqC2ymtNK-3tw-6n5cfqKsLkg_h2O-BaIa3SGUYUjvr6BBrm8-muGaetxclPkhhtxE9QcIuUyCSVkd2yrDj-kfNaVL4lcohONVvZg9D58UeTtk/s1600/case+report.jpg" height="138" width="320" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">This ECG does not fulfill the "Brady" criteria listed above, but if we "flip" the ECG, we see that...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7x3VBA64UlILBDWkR9zxL9LOmcqgdZAcHLoXjHjCx6ITqgORRRFbEU1B5l04rAB1GbbQH-8i-WEXWpq5Jogu0aLdqfV3lut6ACKIcQSs8ZcrbXBK_NgbUPVTn1Ucl4MxMSk8I-0iqCDI/s1600/screenshot616.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh7x3VBA64UlILBDWkR9zxL9LOmcqgdZAcHLoXjHjCx6ITqgORRRFbEU1B5l04rAB1GbbQH-8i-WEXWpq5Jogu0aLdqfV3lut6ACKIcQSs8ZcrbXBK_NgbUPVTn1Ucl4MxMSk8I-0iqCDI/s1600/screenshot616.jpg" height="175" width="320" /></a></span></td></tr>
<tr align="left"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><b>LEFT</b>: Zoom on V1-V3<br /><b>RIGHT</b>: Flipped!</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">... we indeed have a classic, acute-looking STEMI! And in line with this interpretation, the patient was found to have a complete occlusion of the circumflex.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The Bottom Line</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">We don't have a good "new" definition of posterior STEMI that is based on interpretation of the anterior leads, but it appears that the "old" definition has shortcomings. Hopefully, future research will clarify the best ways to discern a posterior MI on the standard 12-lead ECG.</span><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><br />
<div style="margin-bottom: 0in; orphans: 0; widows: 0;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></div>
Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com31tag:blogger.com,1999:blog-4266294048567663301.post-14274734880664764312014-04-20T20:04:00.000-07:002014-04-20T20:05:06.285-07:00Part 2: Does Cyanokit save lives in cardiac arrest?<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">In the last post I reviewed some key facts about <b>hydroxocobalamin (HCB)</b>,
otherwise known by its brand name Cyanokit. However, paramedics and
firefighters aren't really concerned with the animal studies - they want
to know if it saves <i>human</i> lives! </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">And according to some flashy headlines, many people believe this stuff works when nothing else can.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJaWeaCOJinrDssjsdwVY5WVKrhSGJoOyZgQuSBgI2voAyh3E2zg3tBUQmUgL_O4mPDeSc8Rlrcqaa-bgSWGIzWvctOcYZtAWnnVeIlk-lwQ27XawWAZaGRIIK6F56yOhPf2Wm6RxFVzA/s1600/screenshot326.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJaWeaCOJinrDssjsdwVY5WVKrhSGJoOyZgQuSBgI2voAyh3E2zg3tBUQmUgL_O4mPDeSc8Rlrcqaa-bgSWGIzWvctOcYZtAWnnVeIlk-lwQ27XawWAZaGRIIK6F56yOhPf2Wm6RxFVzA/s320/screenshot326.jpg" height="47" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://myarlingtontx.com/2013/12/17/three-arlington-firefighters-to-be-recognized-for-saving-victim-using-a-cyanokit/">Source</a></span></td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLoBTTEDk4f0GQ0-Mrn1CtMKREMPqmP9dY20dpNOMWnxhCGFdYDCxQ7hhZi8rTGGcQtufWCQBixDrgnXjzbEvighN1EpqwiFoyDD_WryCBQkzAH3DHj7reH2584VUliYhfM9XwTKJ-tJ8/s1600/screenshot327.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhLoBTTEDk4f0GQ0-Mrn1CtMKREMPqmP9dY20dpNOMWnxhCGFdYDCxQ7hhZi8rTGGcQtufWCQBixDrgnXjzbEvighN1EpqwiFoyDD_WryCBQkzAH3DHj7reH2584VUliYhfM9XwTKJ-tJ8/s320/screenshot327.jpg" height="55" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.fireengineering.com/articles/2013/07/bolingbrook-il-fire-department-saves-life-with-cyanokit.html">Source</a></span></td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgh6CrcG1DL5DNP_Ra-WA_bd9TCg8W0Yg3X6_3NXiTAcWwkJf-jYnl8UmYtcn-s3LsKT3iE1SkMOq2gNvT_QpZjXC6ftAd8x0pudiGqGtExzaLUfCYZue4DX7fYlbkTf6z8nXy4MP6zKac/s1600/screenshot328.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgh6CrcG1DL5DNP_Ra-WA_bd9TCg8W0Yg3X6_3NXiTAcWwkJf-jYnl8UmYtcn-s3LsKT3iE1SkMOq2gNvT_QpZjXC6ftAd8x0pudiGqGtExzaLUfCYZue4DX7fYlbkTf6z8nXy4MP6zKac/s320/screenshot328.jpg" height="68" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://statter911.com/2011/01/14/a-big-thank-you-for-houston-fire-department-firefighters-cyanokit-credited-with-saving-man-found-unconscious-in-a-burning-assisted-living-facility/">Source</a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">But these are news reports and press releases - what does the <b>medical</b> evidence show? </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><span style="font-size: large;"><b>Does HCB help in cardiac arrest due to smoke?</b></span></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This
is the tough hurdle for studying any toxicologic antidote, and it's especially hard
to do research in <i>this</i> area. The events are rare, and it's usually an
emergency when these poisoning occur. For these reasons, and more, there
have only been a few studies of HCB in humans.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: red;"><b>Four studies</b></span> have looked at the use of HCB in
smoke-exposed patients. Interestingly, 3 of them were done in <b>France</b>, mostly in Paris. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipW9OWGLdCEh_kStQhCzn3KNso8ny3uy31WKU8XCr9MWSR20LVws1i4UK88lGt-QgXbtW9ZSIljwFVbTFfeLEj0Ml0hdDpR5lvqaXR4Y3HHJ-T4M0E5s7IMDUt1dDcak3iFKSV-Zo93EY/s1600/Paris+is+buring%21.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEipW9OWGLdCEh_kStQhCzn3KNso8ny3uy31WKU8XCr9MWSR20LVws1i4UK88lGt-QgXbtW9ZSIljwFVbTFfeLEj0Ml0hdDpR5lvqaXR4Y3HHJ-T4M0E5s7IMDUt1dDcak3iFKSV-Zo93EY/s320/Paris+is+buring%21.jpg" height="320" width="219" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Just for fun, Google "<b>Paris</b>" and "<b>burning</b>." </span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="color: red;">
<b><u>Study #1 - All smoke exposure patients who got HCB</u></b>
<span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"> </span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">The authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/16990192">the first study</a> looked</span> at <span style="font-size: small;">all the</span></span></span><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"> pa<span style="font-size: small;">t<span style="font-size: small;">i</span>ents treated with <span style="font-size: small;"><span style="font-size: small;">H</span>CB</span> over an 8-year<span style="font-size: small;"> peri<span style="font-size: small;">od</span></span></span></span></span></span></span><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"> for<span style="font-size: small;"> </span></span></span></span><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">"suspected cyanide poisoning<span style="font-size: small;">" after a smok<span style="font-size: small;">e inhalation, usually from a house fire.</span> It's important to understand that <span style="font-size: small;">there was <b>no comparison group</b> so it is <b>im</b><span style="font-size: small;"><b>possible to know</b> whether <span style="font-size: small;">the drug <i>helped</i>, <i>hurt</i><span style="font-size: small;">, or did <i>nothing</i>. </span></span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">With that in mind, all <b>101</b> patients got HCB, and all were from residential house fires<span style="font-size: small;">;</span> about <b>1/3</b><span style="font-size: small;"> of those were</span> in cardiac arrest.<span style="font-size: small;"> <b>Forty two</b> patients died<span style="font-size: small;">, <b>30</b> <span style="font-size: small;">survived</span>, and the sta<span style="font-size: small;">tus of </span><b>29</b> patients was "unknown.<span style="font-size: small;">" </span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ6KHpomx4uq1xtBeU_WmIBwzBEgQKFVmDQ6d7Zjk1fwJibQVyE-tqHI1603Eg6QE1ET5Yn7Mkzwwm1ga5uVYMZ6KZUl5-TcTgCDTASW9Caj_co-GSBzL0ZAuEkLaqpotmd3hX4-87WGM/s1600/survival+data.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ6KHpomx4uq1xtBeU_WmIBwzBEgQKFVmDQ6d7Zjk1fwJibQVyE-tqHI1603Eg6QE1ET5Yn7Mkzwwm1ga5uVYMZ6KZUl5-TcTgCDTASW9Caj_co-GSBzL0ZAuEkLaqpotmd3hX4-87WGM/s400/survival+data.png" height="163" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><b>How about patients found in cardiac arrest?</b> Of <span style="font-size: small;">the</span> <b>38</b> pati<span style="font-size: small;">ents who where found in arrest, </span></span></span><b>21</b> of <span style="font-size: small;">those</span> had prehospital ROSC<span style="font-size: small;"> - pretty encouraging. Unfortunately, </span> the majority of <i>those</i> (<b>19</b><span style="font-size: small;"><b>/21</b>) subsequently died in the ICU<span style="font-size: small;">.</span></span></span></span></span></span></span></span></span></span></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">This <i>might</i> be encouraging if we were givne some <span style="font-size: small;">data</span> about those <b>2</b><span style="font-size: small;"> out of <b>38</b> patients who survived. For instance, did they get the HCB <i>before</i>, </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><i>during</i></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;">, or </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><i>after</i></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"> their cardiac arrest? Unfortunately<span style="font-size: small;">, there<span style="font-size: small;"> are no further details<span style="font-size: small;">. </span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span></span> <br />
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<u><b>Study #2 - All cyanide exposures who got HCB</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Just like the study above, the authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/20185266"><b>study #2</b></a> included patients with <b>smoke inhalation
or cyanide ingestion</b> who were treated with HCB by EMS. Since this was written
by the same authors as study <b>#1</b> above, and covers mostly the same
period (<b>1995-2008</b>), it is likely that many of these patients overlap with those in
the prior study. <br />Out of the <b>161</b>
patients studied, <b>61</b> were found in cardiac arrest. Most of these died in the field, or ended up dying in the hospital, but <b>5 patients lived after getting HCB</b> from EMS!</span><br />
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<span style="font-size: small;"> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">That's an <b>8%</b> save rate, which <i>seems</i> very promising, but the authors note that most of these "saves" <b>didn't actually get HCB <i>before</i> they had ROSC</b>. As they point out (my emphasis):</span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="color: rgb(13.700000%, 12.200000%, 12.500000%);">"Among the 61 patients in [cardiac] arrest, <b>5</b>
survived without sequelae and, in<span style="color: rgb(13.700000%, 12.200000%, 12.500000%);"> </span>particular, without
neurological sequelae. <b>Four of the 5 patients</b> were <span style="color: rgb(13.700000%, 12.200000%, 12.500000%);">... </span></span>discovered in cardiac arrest by the fire brigade, and
spontaneous cardiac activity was obtained after cardiac
massage and oxygen therapy. ...</span></span> </blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><b>[H]ydroxocobalamin was <i>not responsible</i> for the recovery of spontaneous cardiac activity in these patients."</b></span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">I'll
point out that the <b>5th</b> cardiac arrest survivor had his age only listed
as "adult," suggesting that the EMS records were incomplete, at the
least... </span></span> <br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: red;"><b><u>
</u></b><b><u>Study #3 - All smoke exposures, who got HCB, and who made it alive to the ICU</u></b><span style="font-size: small;"> </span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The <a href="http://www.ncbi.nlm.nih.gov/pubmed/17481777"><b>last study </b></a>adopted a slightly different approach. The authors<span style="font-size: small;"> performed</span></span> a retrospective "observational case series" of all of the patients who who had <b>smoke exposure</b>, received <b>HCB in the field</b>, and were subsequently <b>admitted to the ICU</b>. </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">A total of <b>69</b> patients were enrolled. Of these, <b>15</b> patients had been in cardiac arrest when EMS found them. Of these <b>15</b> patients, only<b> 2</b> survived.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6e6eQzOKLzRSu72diMucvXKXICw3UAvGBvSSkxYoBAbG4yqhay0WsmSMS2hwq7_vslOsxH9NOfoFZ_00eoTdkYvW6qxj4Txlevkj07d64cx2wilYdl0a8Gh3VrJrK1uW57xFhj3VolPw/s1600/Prospective+table.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6e6eQzOKLzRSu72diMucvXKXICw3UAvGBvSSkxYoBAbG4yqhay0WsmSMS2hwq7_vslOsxH9NOfoFZ_00eoTdkYvW6qxj4Txlevkj07d64cx2wilYdl0a8Gh3VrJrK1uW57xFhj3VolPw/s400/Prospective+table.png" height="135" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;">Hey, <b>2/15</b> is a <b>13% save rate</b>, which <i>might</i> be really promising. Or <i>might not</i> be - we can't tell from the study design.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: red;"><b><u>Study #4 - </u></b></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: red;"><b><u>All smoke exposure patients who got HCB - in Texas!</u></b><span style="font-size: small;"><span style="font-size: small;"><span style="font-size: small;"></span></span></span></span> </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">You might not have thought that Paris and Houston would have a lot in common!</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWcrnLI7QY-aJEmhHHC3AvkfygN5Ej07hfRLdgJe1lfrbQcVafc1NqTexKUG351HxpPj3SqmoAg2k4nZFhZX7QJBWAlHsxK7f4uLTsMHDVQtmDcwBMOZVKPW1DeKaZEnq2pvtVdEoHsIg/s1600/screenshot590.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiWcrnLI7QY-aJEmhHHC3AvkfygN5Ej07hfRLdgJe1lfrbQcVafc1NqTexKUG351HxpPj3SqmoAg2k4nZFhZX7QJBWAlHsxK7f4uLTsMHDVQtmDcwBMOZVKPW1DeKaZEnq2pvtVdEoHsIg/s1600/screenshot590.jpg" height="127" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">You can skip <b><a href="https://www.google.com/search?q=paris+houston&client=firefox-a&rls=org.mozilla:en-US:official&channel=sb&tbm=isch&tbo=u&source=univ&sa=X&ei=NxlOU8_TJsKvyASezILYDQ&ved=0CDcQsAQ&biw=1440&bih=747#facrc=_&imgdii=_&imgrc=TnJ0qcCdK7zQ-M%253A%3B8sBu1Jlt6MTsvM%3Bhttp%253A%252F%252Fwww.sweatonceaday.com%252Fwp-content%252Fuploads%252F2012%252F06%252Fimage21.png%3Bhttp%253A%252F%252Fwww.sweatonceaday.com%252F2012%252F06%252Fhiatus-over-hasty-hastings-houston-comebacks-and-a-hilton.html%3B622%3B461">Googling</a></b> "<b>Paris</b>" and "<b>Houston</b>"</td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">As it turns out, both Parisians and Texans have been using <b>HCB</b> for years, and a just-published abstract describes the experience of the FD in Houston. Unfortunately, the study wasn't "<a href="http://www.urbandictionary.com/define.php?term=Texas-sized"><b>Texas-sized</b></a>," and was actually <i>smaller</i> than those done in Paris.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">Like the French studies, the <a href="http://naemsp.org/Documents/2014%20Annual%20Meeting%20Handouts/Abstracts%202014%20for%20PEC.pdf">Houston authors</a> looked retrospectively at all the patients who had received HCB for "possible cyanide poisoning." Over a period of 4 years, <b>22</b> patients got the drug. Half of those were found in cardiac arrest, and <b>8/11</b> had ROSC "after administration of HCB."</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">So, awesome, right? Unlike <span style="color: red;"><b>study #2</b></span> above, the patients in cardiac arrest actually got HCB <i>before</i> ROSC, not <i>after</i>. Is this proof that HCB, given in arrest, can produce ROSC rates in almost <b>75%</b> of cases? </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"> </span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Limitations of these "case series"studies</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Unfortunately, we still can't say. All of these studies were basically<a href="http://en.wikipedia.org/wiki/Case_series"><b> case series</b></a></span><span style="font-family: Georgia,"Times New Roman",serif;">. </span><span style="font-family: Georgia,"Times New Roman",serif;"> It is <a href="http://www.cebm.net/?o=1025">very low-quality evidence,</a> ranking just above expert opinion. You can think of such a study design as</span><span style="font-family: Georgia,"Times New Roman",serif;"> just a
fancy doctor phrase meaning "<i>a bunch of cool stories</i>."</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-family: Georgia,"Times New Roman",serif;">Why? Because there is <b>no comparison group</b> in any of them. Since the drug was never actually <i>tested</i> against another drug, let alone a placebo, we don't know if <b>HCB</b> <i>helped</i>, or did <i>nothing</i>. </span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-family: Georgia,"Times New Roman",serif;">Heck, for all we know, it may have even<b> <i>hurt</i></b><b> </b>patients. We just don't know.</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"> </span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>So, what can we do with this data?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><span style="font-size: small;">By itself, not much. HCB is a new therapy, with <b>potential</b>, but <b>no solid human evidence</b> to support when we should use it. Of course, we don't always wait for perfect evidence to come along before using drugs and therapies. </span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><span style="font-size: small;">With that in mind, what should you and your teammates do the next time FD drags a patient in cardiac arrest out of a fire? Or what if one of your firefighter teammates collapses next to you during a fire? <br /><br />The next post will offer some suggestions, based on better evidence, of techniques and therapies that <i>have </i>been shown to lives.</span></span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com35tag:blogger.com,1999:blog-4266294048567663301.post-1557317302610835742014-04-16T10:22:00.000-07:002014-04-16T10:22:55.660-07:00Cyanokit: What's the evidence? (Part 1)<span style="font-family: Georgia,"Times New Roman",serif;">Cyanide is a very, very potent toxin. I'm not sure this needs more emphasis, especially after two recent examples in the news (from <a href="http://www.wwnytv.com/news/local/Massey-Died-From-Cynaide-Poisoning-Report-Says-255181421.html">upstate NY</a>, and from a little <a href="http://connecticut.cbslocal.com/2014/04/14/fairfield-hazmat-team-called-out/">closer to home</a>). </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFzHVPGZSvML5zgf7NObtkHkklpcNUCABHArSfX1BsQ20f8daCPqCSoAffkV-gsRb5YFPQkZ1Bmj_mTXlNRm-z3t91iEmGMPwchj8bwSPrnsjRL3A_a7TBxkykxMVU2qoiJMJLH0MEccg/s1600/fairfield-hazmat-courtesy-fairfield-fire-dept.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhFzHVPGZSvML5zgf7NObtkHkklpcNUCABHArSfX1BsQ20f8daCPqCSoAffkV-gsRb5YFPQkZ1Bmj_mTXlNRm-z3t91iEmGMPwchj8bwSPrnsjRL3A_a7TBxkykxMVU2qoiJMJLH0MEccg/s1600/fairfield-hazmat-courtesy-fairfield-fire-dept.jpg" height="180" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Just a quiet suburb? (<a href="http://connecticut.cbslocal.com/2014/04/14/fairfield-hazmat-team-called-out/">source</a>)</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b>Hydroxocobalamin</b> (<b>HCB</b>) is an FDA-approved antidote for cyanide poisoning (brand name <b><a href="http://www.cyanokit.com/index.aspx">Cyanokit</a></b>). It isn't new, having been used for years in France, but there has been lots of talk about it in the U.S., especially for treating patients who have inhaled smoke; e.g. in a house fire.</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJ-cjwZKvtWf-vHNhI_WV6AWYeUGLZ5BU3IQNKzJGEJjziXZ7HXu-K5Q-JDPvBnZQXOOmByw5MqwJCgqsvkHwDUJ_Lok7S-YY9tQXlc-CHj4wM5Fki390Y0GmRys7261U7CSF3BkE_JPM/s1600/screenshot595.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjJ-cjwZKvtWf-vHNhI_WV6AWYeUGLZ5BU3IQNKzJGEJjziXZ7HXu-K5Q-JDPvBnZQXOOmByw5MqwJCgqsvkHwDUJ_Lok7S-YY9tQXlc-CHj4wM5Fki390Y0GmRys7261U7CSF3BkE_JPM/s1600/screenshot595.jpg" height="320" width="248" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>First step </b>in treating smoke inhalation: <br />Do not park ambulance <b>in</b> the fire! <a href="http://www.jonathanthewriter.com/healthcare/11cyanokit.html">(source)</a></span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">There are other antidotes for cyanide, such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/1569239"><b>sodium nitrite</b></a> or <a href="http://en.wikipedia.org/wiki/Sodium_thiosulfate#Medical"><b>sodium thiosulfate</b></a>, that have been available for years. The appeal of the "new" drug, <b>HCB</b>, is that the dosing is somewhat simpler, and there are perhaps fewer adverse effects (at least compared to <a href="http://www.ncbi.nlm.nih.gov/pubmed/1569239"><b>sodium nitrite</b></a>). </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b> </b></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7-s6oG1wodwSJ8o21Y5fBlHFF0Pj-VjYz3qcc6SoqSuLWu3wo_piy0CCeQNhKbLJ_w1W5JIaNqPMH8T3psd8bFFgcg3py-afje6L8fMOqMPK1uD-XqgCqZ6XyCX7WzVU43AQHDyVrFVo/s1600/screenshot29.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg7-s6oG1wodwSJ8o21Y5fBlHFF0Pj-VjYz3qcc6SoqSuLWu3wo_piy0CCeQNhKbLJ_w1W5JIaNqPMH8T3psd8bFFgcg3py-afje6L8fMOqMPK1uD-XqgCqZ6XyCX7WzVU43AQHDyVrFVo/s320/screenshot29.jpg" height="233" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><b>Second step</b> in treating smoke inhalation: <br />Remove patient from a burning ambulance! (<a href="http://www.cyanokit.com/">source</a>)</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br />But the interest in <b>HCB</b> doesn't just have to do with dosing or side effects, but also a number of well-publicized and exciting accounts of miraculously revived patients. However, there are still questions about <i>when</i> to use it, and <i>what the evidence</i> is.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">In this 3-part series, I'll review the basic and clinical evidence for <b>HCB</b>. In order to get a fuller picture, I also spoke with a number of paramedics, firefighters, and physicians. I also was able to discuss the evidence with <b>EMS physicians</b> around the country, as well as a number of <b>toxicologists</b>. This group included, of note, not one but <i><b>three</b></i><b><i> </i></b>dual-trained <b>firefighter/MDs</b>. </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">Okay, five things you should know about <b>HCB</b>... </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>1. It's pretty effective - if you're a dog<span style="font-size: large;">.</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The field of toxicology, in general, relies on a lot of basic science and animal studies. It's just too hard to conduct the controlled human trials that would be expected in other fields.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><b>HCB</b> has been studied in a number of animals - pigs, dogs, and even rabbits. I'll just give one example. In a study of <b><a href="http://www.ncbi.nlm.nih.gov/pubmed/16990189">beagles getting intravenous cyanide</a>,</b> researchers gave either <b>HCB</b> or <b>placebo</b>. They waited to give the drugs until the dogs had been apneic for <b>3 minutes</b>. Despite this "head-start" for cyanide, <b>none</b> of the dogs who got the high-dose <b>HCB</b> died, whereas <b>80</b>% of the untreated dogs died. </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEqSDnLt37uZ9SaAXe1hUr0t6LPc4jez2ZeL-s6mA2G8ySji3QuIbmZVKMv8Bs2LQWXH_45So2D5VkYGdneiJTfb_PxwYzLoQiyN9_qmr7aJ6Tq3xftkxX2MDbkhwZpQf2ymmXIGtrkIk/s1600/screenshot593.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEqSDnLt37uZ9SaAXe1hUr0t6LPc4jez2ZeL-s6mA2G8ySji3QuIbmZVKMv8Bs2LQWXH_45So2D5VkYGdneiJTfb_PxwYzLoQiyN9_qmr7aJ6Tq3xftkxX2MDbkhwZpQf2ymmXIGtrkIk/s1600/screenshot593.jpg" height="157" width="320" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;">This suggests suggests a <i>strong benefit</i> for <b>HCB</b>, (at least for dogs who are shooting up cyanide).</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>2. Then again, so is epinephrine (if you're a pig). </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/22424656"><b>Another group of researchers</b></a> took three groups of pigs, and gave them IV cyanide infusions, up until the point of cardiac arrest. Group <b>#1</b> of pigs got one dose of <b>HCB</b>, group <b>#2</b> got <b>epinephrine</b>, and group <b>#3 </b>got <b>nada</b>.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">The <b>nada</b> group (<b>#3</b>) didn't do well - <b><i>all</i></b> of those pigs died, despite CPR. On the other hand, almost <b>3/4 </b>of the pigs in <i>both</i> the <b>HCB</b> (<b>#2</b>)and the <b>epi</b> (<b>#2</b>) groups survived.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">The authors noted that other measures, like <i>lactate</i>, <i>troponin</i>, and <i>pH</i>, all showed benefit for <b>HCB</b>. Nonetheless, <b>HCB</b> and epi <b>looked just about the same for survival</b>, and both were <i>literally</i> better than nothing!</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">Okay - anybody want to read more animal data? </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR_gNwi0QfYY3cZo0rHvhcfLlGj0legzRgHenQLbroSK5QdadLEiir4FzIo_ddKD1sn533JQMPbqopX39JBDqUNuYxMDSqgHbDoSQ7e92vddtLgVlchSYogF-FPLYwr_X43TJ7n8egg-I/s1600/babe-2.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiR_gNwi0QfYY3cZo0rHvhcfLlGj0legzRgHenQLbroSK5QdadLEiir4FzIo_ddKD1sn533JQMPbqopX39JBDqUNuYxMDSqgHbDoSQ7e92vddtLgVlchSYogF-FPLYwr_X43TJ7n8egg-I/s320/babe-2.gif" height="261" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"We would prefer to see the human data, if it's all the same to you."</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Moving on then - How does this work in people?</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">3. It appears safe in human volunteers.</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">When <a href="http://www.ncbi.nlm.nih.gov/pubmed/16990190">HCB was given to human volunteers</a>, not much happened. There was a small bump in the systolic BP, about <b>20 mm Hg</b>, and a few minor allergic reactions. The most dramatic reaction was a "<b>skin redness</b>" seen in almost all the subjects who got HCB.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgomtz2SYZFoTvcNr2URjJPO8hFrK4SqcUAnHfHQFBL3Mw9S0rlyduHA66SyEBA0Cawm9_Sw4-WPacknnkkJlhyphenhyphenhsT9ip5LDIFKukzkf6cC93axhfYTcBoVKHyFYfvxdPavoAS49rMZMY8/s1600/red+face.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgomtz2SYZFoTvcNr2URjJPO8hFrK4SqcUAnHfHQFBL3Mw9S0rlyduHA66SyEBA0Cawm9_Sw4-WPacknnkkJlhyphenhyphenhsT9ip5LDIFKukzkf6cC93axhfYTcBoVKHyFYfvxdPavoAS49rMZMY8/s320/red+face.png" height="237" width="320" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;">This rash took up to 2 weeks to resolve in some cases! Not dangerous, but certainly something to be ready for. It also turned the urine and tears the same color.</span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>4. It's expensive!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This much is clear - it costs <b>$$$</b>. </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUfXrdm8TBn6UPnrdqkTAR1K0uYH1q5wAaFhLXk-jQFTRj1K1WbRSO19216BiEzV8J7mTVqprFcQqb0seEQfgRC2hMZeUN6TFH3AaGLQbZYM9hUmqlBKP8UzJtyNNPg0TtaH_Z_58F42s/s1600/screenshot27.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjUfXrdm8TBn6UPnrdqkTAR1K0uYH1q5wAaFhLXk-jQFTRj1K1WbRSO19216BiEzV8J7mTVqprFcQqb0seEQfgRC2hMZeUN6TFH3AaGLQbZYM9hUmqlBKP8UzJtyNNPg0TtaH_Z_58F42s/s400/screenshot27.jpg" height="62" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://www.boundtree.com/cyanokit--5-gm-hydroxocobalamin--contains-1-iv-admin-set-and-1-transfer-spike-pharm-1502-335.aspx"><b>Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Whew! <b>Over a thousand bucks. </b></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">By contrast, IV amiodarone costs about <b>$20</b> per code, while a <a href="https://www.boundtree.com/king-cardiac-lts-d-resq-kit-477-crq423ea-pharm-12931-48.aspx"><b>ResQPOD</b></a> will set you back about <b>$100</b>. On the other hand, <a href="http://en.wikipedia.org/wiki/Tenecteplase"><b>tenecteplase</b></a>, a fibrinolytic drug that is<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2672445/"> <b>proven to save lives in STEMI</b></a>, costs about <b>$1500</b> a shot.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">By contrast, the older drug, antidote <b>sodium thiosulfate</b> is relatively cheap. </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj89fcrp0JI9kpOcqlvBRNQierLO1SmpfSz6HU_dvG0Hf4oRlM_O9AKQ0y87DUVfhaqSuEEswIZHT_kRWDtJTcevAMbPsa60KJ80UdMRz7fR8Q2-XR8MAiSwOzt2xKwjgFQX64SUzha3RQ/s1600/screenshot592.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj89fcrp0JI9kpOcqlvBRNQierLO1SmpfSz6HU_dvG0Hf4oRlM_O9AKQ0y87DUVfhaqSuEEswIZHT_kRWDtJTcevAMbPsa60KJ80UdMRz7fR8Q2-XR8MAiSwOzt2xKwjgFQX64SUzha3RQ/s1600/screenshot592.jpg" height="76" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://www.boundtree.com/sodium-thiosulfate-25---12-5-gm--50-ml-vial-pharm-15897-335.aspx"><b>Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>5. HCB <i>might </i>save human lives...</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>$1000</b> might be worth it, or even cheap, <i>if</i> this drug can save lives. With that in mind, we'll take a look in the next post at the evidence "from the field."</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><i><span style="font-size: large;"><u><b>To be continued...</b></u></span></i></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com11tag:blogger.com,1999:blog-4266294048567663301.post-85051339456055037252014-04-08T19:42:00.002-07:002014-04-08T19:42:29.045-07:00Checking firefighters for carbon monoxide - recent studies, persistent concerns.<span style="font-family: Georgia,"Times New Roman",serif;">Carbon monoxide (CO), we can all agree, is bad. The symptoms are vague, the patients sometimes can't give a good history, and definitive diagnosis requires a needle stick. </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1ida9Hha8Y4n7a7VFkUEKyjRcPPVrSlRQOcxS3v23debJVytPq-a2ELZfr6VfTS7BaexH-yg6zfO8cGnUg_TqYVy9g1fFeTfK53VvmFZ2VOU2mJaowz8fhtLMskMZn1_sXbnLFQCam8I/s3200/facial+piercings.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj1ida9Hha8Y4n7a7VFkUEKyjRcPPVrSlRQOcxS3v23debJVytPq-a2ELZfr6VfTS7BaexH-yg6zfO8cGnUg_TqYVy9g1fFeTfK53VvmFZ2VOU2mJaowz8fhtLMskMZn1_sXbnLFQCam8I/s3200/facial+piercings.jpeg" height="200" width="150" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Do I have to? I can't <i>stand</i> having my blood drawn!"<a href="http://www.pinterest.com/pin/94575660895158804/"><b> (source)</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Of particular concern, <b>firefighters</b> can be exposed to high levels of CO in the course of their duties. For example, one small study suggested that FFs can <b>double their CO levels</b> during overhaul, a period when many personnel are not using SCBA (<a href="http://www.naemsp.org/documents/2008Abstracts_Journal.pdf"><b>see abstract #4</b></a>).</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">In response, many fire departments have started to screen for elevated carbon monoxide during the rehab phase of a fire. For the most part, EMS agencies and FDs use devices made by Masimo Corporation that monitor CO levels noninvasively, and are quite portable, whether as a stand-alone device (in the picture below), or available as an option in some monitor-defibrillators. </span><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-L7Co0tWb6HbiNUAgfheLfTWh_YPySpOCm9LNZHLHKbpLjcmBSaw2ylH_385GYzDSKp38Cu5KZKzxLxxvqFUVJp2EqU9ZvlUgyhTwZ6_IkZqHzKFMsXvcuHDMo7QxXocm2N0pj6B-BFU/s3200/screenshot574.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-L7Co0tWb6HbiNUAgfheLfTWh_YPySpOCm9LNZHLHKbpLjcmBSaw2ylH_385GYzDSKp38Cu5KZKzxLxxvqFUVJp2EqU9ZvlUgyhTwZ6_IkZqHzKFMsXvcuHDMo7QxXocm2N0pj6B-BFU/s3200/screenshot574.jpg" height="244" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Name <b>4 things done incorrectly</b> in this ad.<br />Answers below!</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Sounds great! What's the problem?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">They may not be accurate enough to screen FFs.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">A <a href="http://www.ncbi.nlm.nih.gov/pubmed/20605259"><b>large study done by Touger<i> et al. </i>in 2010</b></a>, conducted in an ED in the Bronx, looked at the ability of these devices to diagnose high CO levels. They compared the CO values obtained by the traditional blood draw method with the painless finger probe on the RAD-57.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">They checked out a bunch of patients who came to the ED with suspected CO poisoning, and found that the RAD-57 was usually correct if it predicted a <i>high</i> level, but ...</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzl9_E_sLr4FBwUo-pmCJCJLbY8GD9M4kwwmE7995VtRtXbJH4wG6F5UXFezkxNhh0ifP_BOL8tW_nk5dkUo5JgkHUzpEhsLPgutEBrd9SxWsBLM5dxzUkwQd5f4LkVk_vw_hGDz7YFRE/s3200/screenshot575.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgzl9_E_sLr4FBwUo-pmCJCJLbY8GD9M4kwwmE7995VtRtXbJH4wG6F5UXFezkxNhh0ifP_BOL8tW_nk5dkUo5JgkHUzpEhsLPgutEBrd9SxWsBLM5dxzUkwQd5f4LkVk_vw_hGDz7YFRE/s3200/screenshot575.jpg" height="139" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">... it <i>missed</i> a lot of cases too. <br /><br />In fact, it <b>missed about half of the cases </b>where the CO level was <b>≥ 15%.</b> In 3 cases where the patients had CO levels over 15%, the RAD-57 gave a value of "<b>zero</b>." The authors concluded that </span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"Our results do not support use of this<span style="font-size: small;"> device to replace standard laboratory measurement or as an out-of-</span><span style="font-size: small;">hospital triage tool."</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Why did they choose 15% CO as the cutoff?</b></u></span><br />Most toxicologists will tell you that they don't care as much about the specific CO <i>level</i>, as they do about the <i>symptoms</i>. A patient with a level of <b>17</b>%, but only feels some mild dizziness, is less concerning than a patient who passed out for 10 minutes, but has a "lower" level of <b>11</b>%. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Instead, the <b>15% threshold</b> comes from the National Fire Protection Association (<b>NFPA</b>) guidelines. Here's an example of what their training curriculum says about using CO levels. </span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqqRpqMtD-qOUf-bEVt1kiQsiGwDGhQHWw3WiqgZTp-yGIiiOjtteqOsE44Bd0NWzHmFDzGFtGNlZRHzMf6d2j079CXljdPucnaj-x2yXTfgwFJAwgwKvMYK-yOD3upwZIoODDKtR7aYw/s3200/screenshot576.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqqRpqMtD-qOUf-bEVt1kiQsiGwDGhQHWw3WiqgZTp-yGIiiOjtteqOsE44Bd0NWzHmFDzGFtGNlZRHzMf6d2j079CXljdPucnaj-x2yXTfgwFJAwgwKvMYK-yOD3upwZIoODDKtR7aYw/s3200/screenshot576.jpg" height="121" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.msfca.org/resources/assets/rehab/NFPA_1584_Objectives_Curriculum.pdf"><b>Rehabilitation and Medical Monitoring: A Guide for Best Practices : an Introduction to NFPA 1584</b></a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The implication of the Touger study is that <b>half of CO-poisoned firefighters</b> might not be identified during screening in the rehab sector. Not good.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: large;"><u><b>Can we use a different cut-off? </b></u></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Sure! A few studies have looked at this, but the results show that there is a trade-off.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b>How about a CO level of<span style="color: red;"> <span style="font-size: large;">1o</span></span>%?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;">A <a href="http://www.ncbi.nlm.nih.gov/pubmed/22609179"><b>2012 Candian study</b></a> (Zaouter) used human volunteers, instead of ED patients. This study was conducted in a lab setting, where the researchers were able to precisely deliver CO to the volunteers, and then test them using both the RAD-57 and the standard blood test.<b><br /></b></span></span></span><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><b>The Good Part</b>: They were able to look at the performance of the RAD-57 over a range of well-controlled CO levels. <b> </b></span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;"><b>The Bad Part</b>: You can't really give human volunteers more than 15% CO blood levels - too dangerous. </span></span></span></li>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;">The subjects breathed in CO until they reached levels of <b>10 - 15</b>%, and then the researchers measured the CO level, simultaneously using the finger probe and a blood draw. How did the RAD match up?</span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: small;">Not so hot. Using a cut-off of<b> ≥ 10</b>%, they found that (like <a href="http://www.ncbi.nlm.nih.gov/pubmed/20605259">Touger</a>), that <b>it</b> <b>missed about half of the cases</b>. Of the <b>24</b> patients who had CO levels of 10 - 14%, only <b>13</b> were identified by the RAD-57.</span></span> The authors note that:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"In light of this low sensitivity, it has been advocated that the RAD-57 <b>cannot be used to exclude CO poisoning</b> in any patient with an appreciable risk of being intoxicated."</span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b>How about a CO level of <span style="color: red; font-size: large;">6.6</span>%?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">However, an <a href="http://www.ncbi.nlm.nih.gov/pubmed/21459480"><b>Austrian study from 2011</b></a>, (Roth) seemed to show that the RAD-57 could pick up <i>almost all the cases</i> of CO poisoning. Like the studies done by <a href="http://www.ncbi.nlm.nih.gov/pubmed/20605259">Touger <i>et al</i></a>. and by <a href="http://www.ncbi.nlm.nih.gov/pubmed/23513247">Sabbane <i>et al.</i></a>, it was done in an ED, and involved simultaneous blood draws and use of the RAD-57. So why the difference?</span></span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-er9TJu9cOsUtHQ5WFZWkMNlrf6VwuX-gRvmcnEDkspLU97HUYJzuDhCkZHP30Ad2ehiVgchj037glEAVkmmHnlxN5r6cMF6EEKrhnYnNnsU6RItsA9nB7K7jjmSXLFCS8cyi22GpLBc/s3200/screenshot579.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-er9TJu9cOsUtHQ5WFZWkMNlrf6VwuX-gRvmcnEDkspLU97HUYJzuDhCkZHP30Ad2ehiVgchj037glEAVkmmHnlxN5r6cMF6EEKrhnYnNnsU6RItsA9nB7K7jjmSXLFCS8cyi22GpLBc/s3200/screenshot579.jpg" height="115" width="320" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Because they ended up using a <i>lower</i> CO level of <b>6.6</b>%, <i>not</i> <b>15</b>%. They calculated this level <i>after</i> running the tests, and then calculating receiver operating curves, statistics, etc. What this table <i>also</i> says, is that, if you ran <b>100</b> FFs with CO levels above <b>6.6</b>% through rehab, and checked them with the RAD, you would catch <b>94</b> of them. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">So, is the answer to use a cut-off of <b>7</b>% instead of <b>15</b>%? We don't really know. Problem was, almost no one in this study had CO poisoning - only <b>1.1</b>% of the patients. With so few "<i>positives</i>," the researchers couldn't say much about the rate of "<i>false-positives</i>." As the authors noted: </span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"The opportunity for false-negative results was limited. Because<b> a false-negative reading could have serious medical consequences</b>, this device should be tested in a much larger number of poisoned patients to confirm the generalizability of our stated cut-off values."</span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b>How about a CO level of <span style="color: red; font-size: large;">9</span>%?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">A <a href="http://www.ncbi.nlm.nih.gov/pubmed/23513247"><b>French team of researchers </b></a>(Sebbane) was also conducted in the ED, examining suspected CO-poisoned patients. The decided to try using different cut-offs for <b>smokers</b> and <b>non</b>-<b>smokers</b>, and defined CO toxicity as a blood level of <b>≥ 5</b>% in non-smokers, and <b>≥ 10</b>% in smokers. </span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXvRbb51PCivDZPFmPvMVHzxMe__fYGcbX8adgs8ZDwAAfEPEzjwOTUNtuWOE82LtV-XSg0aFqMmmi_5mv6d1L2H221WTZQs6ER-l-fRZpVKlr3D-gCYRyC4jZg5aU5FYyERIFGyao2Vs/s3200/screenshot580.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXvRbb51PCivDZPFmPvMVHzxMe__fYGcbX8adgs8ZDwAAfEPEzjwOTUNtuWOE82LtV-XSg0aFqMmmi_5mv6d1L2H221WTZQs6ER-l-fRZpVKlr3D-gCYRyC4jZg5aU5FYyERIFGyao2Vs/s3200/screenshot580.jpg" height="87" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">After studying a bunch of ED patients, and doing the same sort of statistical stuff as the Austrian team above, they found that using RAD-57 levels of <b>≥ 6</b>% and <b>≥ 9</b>%, respectively, they still missed a number of folks, all of them<i> non-</i>smokers. It was worse if they use a cut-off of <b>≥ 9</b>% for everyone.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The researchers concluded that: </span></span><br />
<blockquote class="tr_bq">
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">"Subjects with suspected CO poisoning and first-line, positive RAD-57 testing</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> (SpCO 9% in smokers, or 6% in non-smokers) <i>could</i> benefit from immediate care. However, <b>a negative RAD-57 test will not exclude standard blood COHb measurement </b>to confirm CO poisoning."</span></span></span></div>
</blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Large study using the RAD-57, with firefighters, in real-life!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Lastly I have to talk about the big study, the one that enrolled a pretty large number of active firefighters.<br /><br />In this "real-world" test of the RAD-57, the researchers enrolled all <b>firefighters</b> coming through the <b>rehab station</b> at major <b>structure fires</b>. They were able to simultaneously measure the blood levels of CO at the same time as using the RAD-57. Instead of being done in a lab setting, or even in an emergency department, they tested it in the challenging environment of a <b>true fire scene</b>. The firefighters were <b>dirty</b>, their fingers were <b>cold</b>, and the <b>real firefighters</b> (not research staff) checking the RAD-57 measurements didn't have time to obtain multiple measurements - they had to get it right the first time.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">So how did the RAD-57 measure up? How many CO-poisoned FFs did the device pick up? How many did it miss, and, as a result, let go back to their duties?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Well, <i>we don't know</i>. <b>Because no such study exists.</b> Despite the heavy marketing to fire departments around the country, telling them this device saves lives, <b>there are no studies showing that the RAD-57 can function accurately</b> in this environment. </span><br />
<br />
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><b><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-size: large;"><u><b>The Bottom Line</b></u></span> </span></span></b></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Looking over all of these studies (plus a few more), a few results are found reasonably consistently:</span></span></span><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">On <b>average</b>, the RAD-57 is <i>fairly</i> accurate. </span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">However, the "average" can hide a <b>lot of variation</b>.</span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">You can <i>usually</i><b> trust a "high"</b> reading.</span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">A "negative" test, however, can<b> very often be false</b>.</span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Most importantly, <b>you cannot use the RAD-57 to "rule-out" CO toxicity</b>.</span></span></span></li>
</ul>
</div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span><ul>
</ul>
<ul>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;">Most toxicologists are very skeptical about using RAD-57-type devices to make clinical decisions. A<a href="http://www.uptodate.com/contents/carbon-monoxide-poisoning?source=search_result&search=carbon+monoxide+poisoning&selectedTitle=1~60"><b> very recent article</b></a>, written by 3 critical-care physicians, noted that </span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"Until well-performed trials demonstrate that these devices provide
consistently accurate measurements, we <b>cannot recommend their routine
clinical use</b>.</span>"</blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">With these results in mind, I'm not sure that fire departments can use this to safely return firefighters to duty. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"> </span><br />
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>Answer to picture question</b></span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></span></div>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeV4mDLX7AE1faScRbE139oNz6suqXarV7clOGviCCMC1K7uPvCNpICv9egSqUEaeoQxRO7fyCuFsB2pa3bbyvNSW3kfcBzx90UMWEP9FoFCaOZpYX2aBYYsa0hzFho-YsywuBbpeTIDk/s3200/screenshot583.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgeV4mDLX7AE1faScRbE139oNz6suqXarV7clOGviCCMC1K7uPvCNpICv9egSqUEaeoQxRO7fyCuFsB2pa3bbyvNSW3kfcBzx90UMWEP9FoFCaOZpYX2aBYYsa0hzFho-YsywuBbpeTIDk/s3200/screenshot583.jpg" height="244" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></td></tr>
</tbody></table>
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The rehab/medical monitoring station is set up right next to the fire and a diesel engine? This seems like a bad place to evaluate the</span></span><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> <b>asymptomatic</b> firefighter.</span></span> </span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Perhaps the FF is suspected to be <b>symptomatic</b> for suspected CO toxicity. In that case, where is the<b> high-flow oxygen</b>? </span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Since the FF is still fully dressed, and his face is covered in soot, we can assume that he hasn't had time to wash up. This could be a problem, since some researchers have found that <b>dirty fingers can lead to false CO measurements </b>(<a href="http://www.ncbi.nlm.nih.gov/pubmed/19852557">Piatkowski 2009</a>)</span></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Lastly, the CO level is being <b>checked in direct sunlight</b>. The <a href="http://www.masimo.com/pdf/rad-57/LAB5813D.pdf"><b>operators manual</b></a> states tha</span></span>t "direct sunlight, directed on the sensor, may not allow the Rad-57 to obtain readings."<span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></span></li>
</ol>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></span></div>
Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com11tag:blogger.com,1999:blog-4266294048567663301.post-10996671207430477222014-03-31T11:30:00.000-07:002014-03-31T11:30:05.842-07:00You gave adensoine for THAT? (part 3)<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">To recap - the paramedic had a patient who was throwing off<a href="http://millhillavecommand.blogspot.com/2014/03/you-gave-adenosine-for-that-part-2.html"> long segments of both narrow-complex tachycardias, and wide-complex tachycardias</a>. An initial dose of adenosine managed to transiently establish a sinus rhythm.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6qp1LQo1d9T7jy0uFJc6kT-jGEa1xX74QOfEat1n2aK7xqeWx7vLyVM-DLxR-ziob-T0pQWrCrrCF2xHTko7xnSv-HePQ-1qJUdACQdYvoMM9bXtoOzCPHK-7Z1YF77XPW3kgse-LXAo/s3200/post-aden.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh6qp1LQo1d9T7jy0uFJc6kT-jGEa1xX74QOfEat1n2aK7xqeWx7vLyVM-DLxR-ziob-T0pQWrCrrCF2xHTko7xnSv-HePQ-1qJUdACQdYvoMM9bXtoOzCPHK-7Z1YF77XPW3kgse-LXAo/s3200/post-aden.jpg" height="146" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Sinus rhythm for 3 <i>whole beats</i>! *Pumps fist in air*</span></td></tr>
</tbody></table>
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">So what was converted; SVT or VT?</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">It's tempting to think that, beacause it was converted by adenosine, it must have been a SVT with aberrant conduction. A few things suggest that this was, instead, true VT.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>Playing the odds...</b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">First, a wide-complex rhythm in an older patient is far more likely to be VT than SVT - if you're betting, that's where yo should put your money. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>Your instructor was right - axis is important!</b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Second, you could be tempted to call this a left bundle branch block, but the axis is unusual. A LBBB usually points off towards the <b>left</b>.</span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTZqCAYgKfbyVx2lJ5-zWc-4Ue4fbphlcfEvbYn1b-D18G6okSPl2bbEiMd4hrNVqnR1XMOXj4lWyEj7YtAz4m91l1PlohRjCS0QRVGxRkz7a0cfPE-03qeUvlkIiL9Q0t5cvbvMDkY5Q/s3200/LBBB@.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTZqCAYgKfbyVx2lJ5-zWc-4Ue4fbphlcfEvbYn1b-D18G6okSPl2bbEiMd4hrNVqnR1XMOXj4lWyEj7YtAz4m91l1PlohRjCS0QRVGxRkz7a0cfPE-03qeUvlkIiL9Q0t5cvbvMDkY5Q/s3200/LBBB@.jpg" height="133" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Note the large R waves in I and aVL (<a href="http://lifeinthefastlane.com/ecg-library/basics/left-bundle-branch-block/"><b>Source</b></a>)</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">Our patient, on the other hand, shows an axis oriented a bit to the <b>right</b>.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh26QCwfifetv7uJKbTM8nKa_FGXkJLGmLjLrmPUhcI6O36VrG49yyOgcvENb3H3dYMIFwmc_68TZLY_xFfgaUqjNGyVIMA45oMbbhqfG_LxxrhhSFPWsOA8zxgvKIOJmaosBWg7J0rF5s/s3200/Lightened+ECG.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh26QCwfifetv7uJKbTM8nKa_FGXkJLGmLjLrmPUhcI6O36VrG49yyOgcvENb3H3dYMIFwmc_68TZLY_xFfgaUqjNGyVIMA45oMbbhqfG_LxxrhhSFPWsOA8zxgvKIOJmaosBWg7J0rF5s/s3200/Lightened+ECG.jpg" height="90" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Note the large R waves in II, III, and aVF</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><b><u>Fusion beats </u></b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Third, the patient keeps kicking out fusion beats, or QRS complexes that show features of <i>both</i> a supraventricular beat, and a simultaneous ventricular beat. They usually look like an "average" of a PAC and a PVC. Here's an example from <a href="http://lifeinthefastlane.com/"><b>Life in the Fast Lane</b></a>: </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT4e-xS3v9cqsgLuiC0whxlxRGWh4o1pENERcyIGCBn-FU3IIspLJpOSWWeZGwzSAvXgv8_JxbMOX6Xl4XYmEobj8Kvci32mVqAo4d5MzXSrO3sr7kTeEnhQADRiwGWnm0-bRMJC1oF84/s3200/screenshot546.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiT4e-xS3v9cqsgLuiC0whxlxRGWh4o1pENERcyIGCBn-FU3IIspLJpOSWWeZGwzSAvXgv8_JxbMOX6Xl4XYmEobj8Kvci32mVqAo4d5MzXSrO3sr7kTeEnhQADRiwGWnm0-bRMJC1oF84/s3200/screenshot546.jpg" height="73" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Not wide, not narrow, just ... average. <br />(<a href="http://lifeinthefastlane.com/ecg-library/basics/fusion-beats/"><b>source</b></a>)</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"> When we look at the initial rhythm strip we see a bunch of sorta wide/sorta narrow beats.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH9oU59FHR156AZtQ1JMewGXDgBSR5m0f-1iRs32bcfpeTlAKaztTzkj3lOUFdOCc_hlSuJlHHo18wbg_lwu4ueDCD_tP16EWJnAiw7tMK8YlpVj_N0NHhXe-0FryaRhKlbGriSFaj7Io/s3200/screenshot548.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhH9oU59FHR156AZtQ1JMewGXDgBSR5m0f-1iRs32bcfpeTlAKaztTzkj3lOUFdOCc_hlSuJlHHo18wbg_lwu4ueDCD_tP16EWJnAiw7tMK8YlpVj_N0NHhXe-0FryaRhKlbGriSFaj7Io/s3200/screenshot548.jpg" height="130" width="320" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Another ECG, done in the ED, also shows multiple fusion beats, indicated by the arrows.</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQqaSKLOVWvCTkMcEIhZBRzWvFH-DNBf75YtgJmZfcDm5gv2NBR_92iLmZ3ZinTiUKPkqruQkZ8OkPq2y_zPKzT8rV9aFjzPeSvEJettZdgS-8HIrmrV72lexwRKhm67XclGJT9hXrbpA/s3200/thenthenthen.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQqaSKLOVWvCTkMcEIhZBRzWvFH-DNBf75YtgJmZfcDm5gv2NBR_92iLmZ3ZinTiUKPkqruQkZ8OkPq2y_zPKzT8rV9aFjzPeSvEJettZdgS-8HIrmrV72lexwRKhm67XclGJT9hXrbpA/s3200/thenthenthen.jpg" height="134" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Such a finding strongly suggests that this patient had ventricular tachycardia that was converted by adenosine. Crazy, right?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Well, it turns out that not everything that converts with adenosine is SVT! One infrequent kind of VT can convert with adenosine - <b>right ventricular outflow tachycardia</b>.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>RVOT</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">A fairly uncommon kind of VT is know as <b>RVOT</b>, named for the location of the problem. It basically looks like a LBBB, but with an <i>inferior</i>, rather than a <i>left-oriented</i> axis. A great example comes courtesy of Dr. Ken Grauer. Compare it with the initial 12-lead we have.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY32L4oN776sWZqeL-FgdUf8Kx0x-kMgSZCfShIcyfdfrXOxkYaJbdQ4bCk0ERPEYB2X9A70_dfU7Ym34883irN3fckoL9rwc7NvWmOZWst6nqkJIDvUv3so9M2z3BJvm7Jgzk9zEQBDw/s3200/Fig+1-+Blog+35-250-RVOT-VT-(1-10.1-2012)-USE.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhY32L4oN776sWZqeL-FgdUf8Kx0x-kMgSZCfShIcyfdfrXOxkYaJbdQ4bCk0ERPEYB2X9A70_dfU7Ym34883irN3fckoL9rwc7NvWmOZWst6nqkJIDvUv3so9M2z3BJvm7Jgzk9zEQBDw/s3200/Fig+1-+Blog+35-250-RVOT-VT-(1-10.1-2012)-USE.JPG" height="195" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://ecg-interpretation.blogspot.com/2012/01/ecg-interpretation-review-35-sct-vt.html">RVOT - from Dr Gauer's collection.</a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">I'm not going to go on further about this rhythm, since it's pretty uncommon, but if you want to know more go check out <span id="goog_657302297"></span><a href="https://www.blogger.com/goog_657302296"><b>Dr Grauer's blog</b></a><span id="goog_657302298"></span>. <br /><br />(I'll note again that my cardiology education started when I read the <a href="http://www.amazon.com/Acls-Certification-Preparation-Ken-Grauer/dp/0801670691">1993 edition of his ACLS textbook.</a> He has a <a href="http://www.amazon.com/dp/B00C81R08Y/ref=rdr_kindle_ext_tmb"><b>2014 update</b></a>, available on a variety of e-readers. Buy it!)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="font-size: large;"><u><b>
Uh, so there's this rare RVOT thing. Why should I care?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">As I mentioned in Part 2, there are two important things to know about giving adenosine for a WCT:</span><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Adenosine is <i>relatively</i> safe in <b><i>regular</i>, <i>monomorphic</i> WCT</b>.</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">However, it can convert <b>certain types of VT</b>.</span></li>
</ol>
<span style="font-family: Georgia,"Times New Roman",serif;">Since
the publication of the 2010 ACLS Guidelines, a large number of EMS
agencies have adopted adenosine as the first agent to administer in the
treatment of a stable, regular, and monomorphic wide-complex
tachycardia. I don't have any hard numbers on how common this protocol
is, but instead of a study, I can give you a collage! </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH5eKVracfQ1d5Lt3omTuyp2Jts2c2libZv8MtDkZ4EzlHzBPqePhQm9HwtUPq6CO_wDU40lQ__OUslAWE3CEa7l-PoJhXSwzaaLcNsJW1fZa_LW5yUHIteH2DHL3WNFIBfKigEBll0tY/s3200/screenshot535.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiH5eKVracfQ1d5Lt3omTuyp2Jts2c2libZv8MtDkZ4EzlHzBPqePhQm9HwtUPq6CO_wDU40lQ__OUslAWE3CEa7l-PoJhXSwzaaLcNsJW1fZa_LW5yUHIteH2DHL3WNFIBfKigEBll0tY/s3200/screenshot535.jpg" height="309" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">I makes it for u.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">Despite the popularity of this protocol, many clinicians have reservations about the wisdom </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">of this approach, since there are a number of potential pitfalls. One of the big ones would be to assume that adenosine is a reliable test for supraventricular rhythms. Keep in mind that he ACLS guidelines only state that <b>"<a href="http://circ.ahajournals.org/content/122/18_suppl_3/S729.full#sec-77">adenosine is relatively <i>safe</i> for both treatment and diagnosis</a></b>." <b> </b></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>Safe</b>, not <i>accurate</i>!</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The Bottom Line </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The <b>SHCGB</b> protocols allow for the use adenosine when the etiology of a WCT isn't clear. Keep in mind that, even if adenosine is successful, the etiology may <i>still</i> be unclear!</span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com9tag:blogger.com,1999:blog-4266294048567663301.post-85087175882603584612014-03-28T11:50:00.004-07:002014-03-28T11:50:35.221-07:00You gave adenosine for THAT?! (part 2)<span style="font-family: Georgia,"Times New Roman",serif;">In a prior post, I looked at whether you could give adenosine to a patient with a history of WPW (see "<a href="http://millhillavecommand.blogspot.com/2014/02/can-you-give-adenosine-to-patient-with.html"><b>Can you give adenosine to a patient with WPW</b></a>"<b>). </b>The answer was "Yes, but..."</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">I want to look at <i>another</i> adenosine issue today - can (or should) you give <b>adenosine</b> to a patient with a <b>wide-complex tachycardia (WCT)</b>? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Spoiler: The answer to this questions is...</span> <br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyU0qwEa-SzDKeT3HIpRT_r_mkJ0Kkp4limrrZ6-GXRJUjpy4rOvq5xXn5s_xuTDeHUHDWK6qqyX_60nPM3UX46DoLtTAiOURWK9Gw1H63OI95Uzp4OdCpPr2TRDTPpk0wxBCubT3m_p0/s1600/tumblr_inline_mtp7zcdJ2k1r2uoh1.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyU0qwEa-SzDKeT3HIpRT_r_mkJ0Kkp4limrrZ6-GXRJUjpy4rOvq5xXn5s_xuTDeHUHDWK6qqyX_60nPM3UX46DoLtTAiOURWK9Gw1H63OI95Uzp4OdCpPr2TRDTPpk0wxBCubT3m_p0/s1600/tumblr_inline_mtp7zcdJ2k1r2uoh1.jpg" height="203" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Or, more specifically:</span><br />
<ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Adenosine is <i>relatively</i> safe in <b><i>regular</i>, <i>monomorphic</i> WCT</b>.</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">However, it can convert <b>certain types of VT</b>.</span></li>
</ol>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>A case of WCT treated with adenosine by EMS </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Our paramedic was just "minding his own business"<span style="font-size: small;"> when he was called for a patient with palpitations. He was an older person, with no history of any cardiac problems, and was hemodynamically stable. His rhythm strip, however, looked like:</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEmhJezf7Wth7f3S0U-HUdbqxaKYKLukYWvWvSYogLxW6ny2cNSds31d6tcu2IwFfeniLABvBaUr-o3IXYo8OtIN4jhz7ENvUxfwcLBaSydnHGDw-3IhJI99PPP33f9RZYkNC3I_mliUg/s1600/post.jpg" style="clear: right; margin-bottom: 1em; margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEmhJezf7Wth7f3S0U-HUdbqxaKYKLukYWvWvSYogLxW6ny2cNSds31d6tcu2IwFfeniLABvBaUr-o3IXYo8OtIN4jhz7ENvUxfwcLBaSydnHGDw-3IhJI99PPP33f9RZYkNC3I_mliUg/s400/post.jpg" height="110" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Wut.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">Okay, that's a data-rich ECG! Taking a closer look at two different segments, we see evidence of both a regular monomorphic WCT...</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf4JzBkHWQxJktIyGKbdlUgMkFa8FCd9rDtGOh4hKSl8nx85gNzKSrT4IMVFWai72i8L_J1yN8C6-H7wFZ8kdmxYXcY26FWIe1PrV8t2c2k8OXZXWloW8rU9Y0L2MD8z00iPO-F0ABJ-c/s3200/screenshot507.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgf4JzBkHWQxJktIyGKbdlUgMkFa8FCd9rDtGOh4hKSl8nx85gNzKSrT4IMVFWai72i8L_J1yN8C6-H7wFZ8kdmxYXcY26FWIe1PrV8t2c2k8OXZXWloW8rU9Y0L2MD8z00iPO-F0ABJ-c/s3200/screenshot507.jpg" height="260" width="320" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>So it's VT, right? </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">... as well as a regular narrow-complex tachycardia.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgT8cQhQXsaJ1kFfSEbYB32jWrydUoUPiO106sq2z06UvVS8LCuyNfDOzOJ1ihaS5qiXklgXQtkpyCkQpgt-VUihrFaThOdgJIynz8_MsT3sDUmTATikj5R3r3ZGS1xWAYiAYqzYA3QLfs/s3200/screenshot508.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgT8cQhQXsaJ1kFfSEbYB32jWrydUoUPiO106sq2z06UvVS8LCuyNfDOzOJ1ihaS5qiXklgXQtkpyCkQpgt-VUihrFaThOdgJIynz8_MsT3sDUmTATikj5R3r3ZGS1xWAYiAYqzYA3QLfs/s3200/screenshot508.jpg" height="169" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Tell me if you see P waves. I didn't.</span></td></tr>
</tbody></table>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>VT with episodes of PSVT? </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The full 12-lead ECG looked wide and scarey:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJgex9ErcCeECEonjJRTRAp0JuP2LwDNbJBCaFiS5tZJHGam_pWAqLIfdNx-yTy9EPiXxQujAIpGfa5pwUDZKB_dQ0s1AQB48BWqL7SuCYtjdZmdlO3AfdsmFnSaZ2gFghh01XW0ZaejY/s1600/1.EMS+ECG.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiJgex9ErcCeECEonjJRTRAp0JuP2LwDNbJBCaFiS5tZJHGam_pWAqLIfdNx-yTy9EPiXxQujAIpGfa5pwUDZKB_dQ0s1AQB48BWqL7SuCYtjdZmdlO3AfdsmFnSaZ2gFghh01XW0ZaejY/s640/1.EMS+ECG.jpg" height="121" width="400" /></a></span></div>
<div style="text-align: center;">
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>So, what to do? </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Our intrepid medic decided that adenosine would be appropriate, and gave a slug, <i>right</i> as the patient was going through a spell of WCT.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">At first it seemed to work ....</span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKwWZs-HrDU_emLyNF-jx-4LhfS7RDDzu6HuxWwlRBb5hh9p7-Sco0TJ_WJVHE-tQ7G6aabhHqZOhyphenhyphenb6rhBp3STh14NOq6aRMQhbPHar88VkYlX4dPo3_0aloBuAJ_5w5SoXTscnZCAKU/s3200/screenshot523.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjKwWZs-HrDU_emLyNF-jx-4LhfS7RDDzu6HuxWwlRBb5hh9p7-Sco0TJ_WJVHE-tQ7G6aabhHqZOhyphenhyphenb6rhBp3STh14NOq6aRMQhbPHar88VkYlX4dPo3_0aloBuAJ_5w5SoXTscnZCAKU/s3200/screenshot523.jpg" height="118" width="320" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6YLPQyo6rZbF_9lNYxbslkLb1l1kUkpZhiDjdz19LP2lQBPcQ79mKoHFxOB67hPU2LRIqS2DOomc6-w0mFglcTrqN0HZGt93douaog_SvshUsHNvVpMFnecmJKcEXnnGnjTG-Lb9VvTg/s3200/screenshot522.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6YLPQyo6rZbF_9lNYxbslkLb1l1kUkpZhiDjdz19LP2lQBPcQ79mKoHFxOB67hPU2LRIqS2DOomc6-w0mFglcTrqN0HZGt93douaog_SvshUsHNvVpMFnecmJKcEXnnGnjTG-Lb9VvTg/s3200/screenshot522.jpg" height="146" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">... aaaand right back into the WCT, after a brief period of apparent sinus rhythm. </span><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Wait, what the heck - the adenosine converted a <b>VT</b>? Or was it aberrant <b>SVT</b>? What should the <b>next drug</b> be? How much does the <b>response to adenosine</b> change our impression? </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><i><b>To be continued...</b></i></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Tell me what you think, and I'll be back with the follow-up, as well as how lessons from this case should affect your assessment and treatment in the field.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com10tag:blogger.com,1999:blog-4266294048567663301.post-82196750135119574002014-03-03T09:22:00.001-08:002014-03-03T09:22:17.820-08:00"We had a LUCAS save!" - No, you didn't.<span style="font-family: Georgia,"Times New Roman",serif;">I don't get it.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">More and more, I'm seeing Facebook posts, newspaper articles, and personal testimony that excitedly describe a "<a href="https://www.google.com/search?q=lucas+cpr+save&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a&channel=sb#channel=sb&q=lucas+cpr+save&rls=org.mozilla:en-US:official&tbm=nws"><b>LUCAS save</b></a>." That is, a successful resuscitation is credited to the use of a <a href="http://www.lucas-cpr.com/en/lucas_cpr/lucas_cpr">mechanical compression device made by Physio-Control</a>. For example:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><b>"Saves man's life!"</b></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5JCfqyWYAjrswQdr7evS5G1bFCCadTbu7HakWOZW2dJWGsELqw1JqFaQi7RtyEHcu9oIMuwaxzq1IumF-tiv496_P2OwKvdkgWqLFPkOMyiE1Xwfw3JGQLNlHgaVOhSVjoPpOOp5VMCM/s1600/screenshot426.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg5JCfqyWYAjrswQdr7evS5G1bFCCadTbu7HakWOZW2dJWGsELqw1JqFaQi7RtyEHcu9oIMuwaxzq1IumF-tiv496_P2OwKvdkgWqLFPkOMyiE1Xwfw3JGQLNlHgaVOhSVjoPpOOp5VMCM/s1600/screenshot426.jpg" height="58" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.daytondailynews.com/news/news/donated-medical-device-saves-local-mans-life/ndBrL/"><b>Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b>"More residents survived thanks to LUCAS!"</b></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmge6Ct0ucIcnEFD0rssxDZw5P-TFCT2SBjVg6-DAHUSy_RK2EOkhLFWXYYhMg5c_I2f4j8OVKibu3Eyw0xAOHHH_ujgWoTaYOYK7R1PHH1QKAXmJILY3ShM723CYqUx_HtY3Fq7HMARs/s1600/screenshot427.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmge6Ct0ucIcnEFD0rssxDZw5P-TFCT2SBjVg6-DAHUSy_RK2EOkhLFWXYYhMg5c_I2f4j8OVKibu3Eyw0xAOHHH_ujgWoTaYOYK7R1PHH1QKAXmJILY3ShM723CYqUx_HtY3Fq7HMARs/s1600/screenshot427.jpg" height="180" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.iafflocal1563.org/index.cfm?zone=/unionactive/view_article.cfm&homeID=373383"><b>Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b>"Life-saving CPR technology!"</b></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoFYbNFT3q51c7CKLeMQXdNtrqObybtTx_X_65wWcnnEPlR7UI5E50r4G3XBbTja_Z4DByAUjGuf_qLSDc3cpSZubjmfhpEwdDwpOTQn4aW8E7hSc-OcTO4vJX5shgJt3CfZ02vo2oAGc/s1600/screenshot437.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjoFYbNFT3q51c7CKLeMQXdNtrqObybtTx_X_65wWcnnEPlR7UI5E50r4G3XBbTja_Z4DByAUjGuf_qLSDc3cpSZubjmfhpEwdDwpOTQn4aW8E7hSc-OcTO4vJX5shgJt3CfZ02vo2oAGc/s1600/screenshot437.jpg" height="72" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.mercyhealthsystem.org/body.cfm?id=152&action=detail&ref=860"><b>Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">"Life-saving technology!" "Saves local man!" "Thanks to LUCAS!" Why hasn't this news of <a href="http://en.wikipedia.org/wiki/Lazarus_of_Bethany">Lazarus-like</a> success swept the country? <i>Why are we still doing CPR with our hands</i>?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiO4XkCOkpR8BnTO1DjdxsXbmYfR-U8Ysb-EZBgn18y64zB7EmbhY_kNQVrQ9PFqY6j06nkNfGck6NxaJPfa-H4AYc49pcTKYTvd6CNru3GHFCQaKWkNvn4Js3OzdY0TYRn3p_64D0dtH8/s1600/tumblr_lgxz8f5LDQ1qfrrv2o1_500.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiO4XkCOkpR8BnTO1DjdxsXbmYfR-U8Ysb-EZBgn18y64zB7EmbhY_kNQVrQ9PFqY6j06nkNfGck6NxaJPfa-H4AYc49pcTKYTvd6CNru3GHFCQaKWkNvn4Js3OzdY0TYRn3p_64D0dtH8/s1600/tumblr_lgxz8f5LDQ1qfrrv2o1_500.jpg" height="400" width="305" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Doing CPR with our muscles... like a sucker!</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"> Well, there is <b>one teensy fact</b> that the press releases leave out...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The LUCAS <i>doesn't</i> save lives.</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">And <i><b>no</b></i>, I don't mean this in the clever "<i>guns don't kill people...</i>" sense. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">I mean this in the "<i>proven by science</i>" sense.</span><br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ5yTrPxU_g65U-fvPl-h1zeRPI5wekvqQBNykIfPPCMUyyqBJWzQo8abOWgkh87vm8f3SGblyaqpeUbmdyvWaQNW1OcT_XqmJMpUg8f9YMZ-x-3SzzWvcacPZC7DI85C3u7D1zuUCRB8/s1600/screenshot433.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQ5yTrPxU_g65U-fvPl-h1zeRPI5wekvqQBNykIfPPCMUyyqBJWzQo8abOWgkh87vm8f3SGblyaqpeUbmdyvWaQNW1OcT_XqmJMpUg8f9YMZ-x-3SzzWvcacPZC7DI85C3u7D1zuUCRB8/s1600/screenshot433.jpg" height="85" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/24240611">Source</a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/24240611">This study</a>, published in January, describes the use of the LUCAS in out-of-hospital cardiac arrest. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><b> - Methods</b><br />The study looked at patients who had a cardiac arrest treated by EMS. They enrolled adults, who had suffered a non-traumatic arrest, and were neither too small, nor too large, to fit in the LUCAS. They randomized patients to either get manual CPR according to <a href="http://www.ncbi.nlm.nih.gov/pubmed/16321716">2005 European ACLS guidelines</a>, or to get chest compressions delivered by a LUCAS device.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">The teams were well-trained - not only was there<b> initial preparation </b>for the teams with both usual and mechanical techniques, but team members had <b>twice-yearly re-training</b>, as well as random "<b>spot checks</b>" of individual participants using a manikin. Pretty rigorous! </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The primary outcome was maintaining <b>survival for 4 hours after ROSC</b>. You can quibble that this isn't as important as, say, neurologically-intact discharge from the hospital, but it's a reasonable goal, and likely easier to achieve.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b> - Results </b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This <i>should</i> <i>have</i> been a slam-dunk for the machine. Mechanical CPR is consistently high-quality, does not fatigue, and frees up EMS workers for other tasks. One more bonus for the machine - the protocol called for defibrillations to be given <b>during the mechanical compressions</b>, something that humans are <i>not</i> usually able to do! In theory, this <a href="http://www.jems.com/article/patient-care/how-peri-shock-pause-automated-external">elimination of the peri-shock pause </a><i>should have</i> increased survival in the LUCAS-treated patients.</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheC4UmsM87d-G15krzHOVvYAEQp9NShicIFECZ1Fex2vnevrJZbmF_7CisuwU3YNFGdAwz8HJklMHV7rlmnIm3V-3wyd2eQwRQo0DnJL70WuTM2BXnosfKaxcJf2-wtn8Ci0wcRBRKeuI/s1600/screenshot432.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheC4UmsM87d-G15krzHOVvYAEQp9NShicIFECZ1Fex2vnevrJZbmF_7CisuwU3YNFGdAwz8HJklMHV7rlmnIm3V-3wyd2eQwRQo0DnJL70WuTM2BXnosfKaxcJf2-wtn8Ci0wcRBRKeuI/s1600/screenshot432.jpg" height="197" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">LINC trial protocol</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">However, after <b>2500</b> patients were enrolled, they found squat for differences between manual CPR and the LUCAS. Nothing. No matter <i>what</i> outcome you picked, there was no advantage to using the LUCAS. <b>None</b>.</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4uuUmL9catrEc6C-3v0YC_GULTAuSQ6uu2q9Hd8Y2smJCbwm0rMEU9dHvMx0f2V_SfgShZkjfbNDIC56roCgOKxDoBGoxE8EZAh5QCBK0-U87mdd_DTGY0Lo6TSoTrwVHSjCP16SOmUo/s1600/screenshot430.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4uuUmL9catrEc6C-3v0YC_GULTAuSQ6uu2q9Hd8Y2smJCbwm0rMEU9dHvMx0f2V_SfgShZkjfbNDIC56roCgOKxDoBGoxE8EZAh5QCBK0-U87mdd_DTGY0Lo6TSoTrwVHSjCP16SOmUo/s1600/screenshot430.jpg" height="145" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">LINC trial results</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b> - Interpretation</b> </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So that's the end of the LUCAS for routine management of cardiac arrest by EMS, right? We did the research, it was negative, and we took the expensive machines off the rigs. The EMS services that haven't bought them have expressed relief that they didn't lay out the cheddar.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>"But the LUCAS..."</b></u></span></span><br />
<ul>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;">But
regardless of these completely negative results, people are protesting.
They point out that, yeah, maybe <i>this</i> study didn't show a
difference. </span>"<b>But the LUCAS...,</b> " they point out... <br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;">"...delivers <b>better</b> CPR!" </span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">"...can <b>shock</b> during CPR!"</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">"...can do better CPR during <b>transport</b>!"</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">"...doesn't get <b>tired</b>!"</span></li>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;">Despite all that, which is likely true, <b>no difference</b> was found in a high-quality trial where the researchers has every opportunity to demonstrate these . This is how clinical research goes - the slaying of appealing theories by means of ugly facts.</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhg78c0wPBmGQMyf3sy0hq_9pRudC-AOQKMKATSFySjHqlGvlckbsaT_q1sBibIqS9EwrViRBnrH5IgVc8sGZAOWrNPnckgLPSStqyTVhU1Sl009pI-EkYKb1JDiEJWXAlBgz54bVglaLE/s1600/screenshot429.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhg78c0wPBmGQMyf3sy0hq_9pRudC-AOQKMKATSFySjHqlGvlckbsaT_q1sBibIqS9EwrViRBnrH5IgVc8sGZAOWrNPnckgLPSStqyTVhU1Sl009pI-EkYKb1JDiEJWXAlBgz54bVglaLE/s1600/screenshot429.jpg" height="238" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">The graph is explained <a href="http://forums.xkcd.com/viewtopic.php?f=7&t=13989"><b>HERE</b></a>, if you're into <i>that</i> sort of thing. </span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Don't give credit to a piece of plastic!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">A <a href="http://www.jems.com/article/case-month/mechanical-cpr-helps-save-day-and-patien">recent article over at <b>JEMS</b></a> describes a successful cardiac arrest resuscitation. The authors write about the myriad contributing factors:</span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">The <b>integrated training</b> between EMS responders and the CPR/<b>AED</b>-equipped
police officers; the multilayered, <b>coordinated</b> response and
resuscitation effort by police and EMS familiar with the <b>pit-crew</b>
approach to resuscitation and use of a mechanical CPR device; and the <b>
rapid response</b> and time-to-care by the rescuers—particularly at such a
large gathering—were all key factors in this successful resuscitation.</span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">But the authors <i>then</i> go on to emphasize in the last paragraph that the LUCAS "<u>was
clearly a part of this successful resuscitation</u>," and that "<i>they’d never seen this type of response in all of their years of managing cardiac arrest cases</i>." </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">In other words; "<b>We did okay, but we're pretty sure that this inanimate object should get the lion's share of the glory</b>." </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">You know, I think I've seen this before...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEio3SCbJV47aNR-x_Rt7wJVf0R2FclBgHGyo02GZwHl-3D3Muwu5USJ7UbMybc63F93xGaf31UECdEzmFFzTUl7brU4SH4fFEDyLa7eTDOweIYkxgjAUJW6tZ_sin1LmL_E6TgpakwK6pU/s1600/in+rod+we+trust.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEio3SCbJV47aNR-x_Rt7wJVf0R2FclBgHGyo02GZwHl-3D3Muwu5USJ7UbMybc63F93xGaf31UECdEzmFFzTUl7brU4SH4fFEDyLa7eTDOweIYkxgjAUJW6tZ_sin1LmL_E6TgpakwK6pU/s1600/in+rod+we+trust.jpg" height="320" width="303" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><b><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://en.wikipedia.org/wiki/Simpsons_Already_Did_It">"Simpsons already did it!"</a></span></b></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The Bottom Line:</b></u></span> </span> <br />
<span style="font-family: Georgia,"Times New Roman",serif;">You know what saves lives? </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="color: #0b5394;"><span style="font-size: large;"><b>You</b></span></span>. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">You, and your well-trained team, utilizing the <a href="http://www.sciencedirect.com/science/article/pii/S0735109708034074"><b>proven techniques that save lives</b></a>. Believe me, if the LUCAS was able to generate <i>these</i> sorts of results...</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilUsYWIx4SVP1_lOTPEPh4hwtbZAyxhK6PH4IArIAORSqHfQTXd32fv60MXuH9cvHtcFgRk1Nu4N12TTCGRhvMCv3tE6B9hcVSJCyO36o-rK0UYnv-Lk2Md7NZWwQx10Vd2ogzLf4fjAA/s1600/screenshot434.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilUsYWIx4SVP1_lOTPEPh4hwtbZAyxhK6PH4IArIAORSqHfQTXd32fv60MXuH9cvHtcFgRk1Nu4N12TTCGRhvMCv3tE6B9hcVSJCyO36o-rK0UYnv-Lk2Md7NZWwQx10Vd2ogzLf4fjAA/s1600/screenshot434.jpg" height="230" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.sciencedirect.com/science/article/pii/S0735109708034074"><b> Source</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">... you <i>would</i> have heard about it by now!</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-family: Georgia,"Times New Roman",serif;">(For another analysis of this trial, plus some interesting comments, read the post <a href="http://www.emlitofnote.com/2013/12/man-vs-machine-cpr-battle-to-the.html"><b>Man vs Machine: A CPR Battle to the...</b></a> over at <a href="http://www.emlitofnote.com/">Ryan Radecki's excellent blog</a>.)</span> </span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com30tag:blogger.com,1999:blog-4266294048567663301.post-24978768708791703632014-02-18T11:58:00.000-08:002014-02-18T12:21:49.441-08:00Sudden Cardiac Death Among Firefighters ≤45 Years of Age<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">I want to talk about a new study that looks at heart attacks in younger firefighters, so no jokes or funny picture today. It’s hard to come up with a humorous spin for a graph like this:</span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><img height="186" src="https://lh6.googleusercontent.com/6DrnQ_axvuRhl7eEMgenVLDgfq5QFJ7mGffHmwYwcMoDCRqiZcYZwHP2aIOKH-7Om0ewHXSwGOkjLVwdFCbUNwxntItGRnaCM7K4k_X8Lrqv1SETnG6YYg31Ig" style="border: 0px solid transparent; margin-left: auto; margin-right: auto;" width="400" /></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;">From a <a href="http://www.usfa.fema.gov/downloads/pdf/publications/ff_fat12.pdf"><b>2012 FEMA report</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The chart above comes from the 2012 <a href="http://www.usfa.fema.gov/"><b>USFA</b></a> report of firefighter fatalities, and it’s shocking.<i> Over half</i> the fatalities in that year had nothing to do with burns, entrapment, falls from ladders, or other traumatic dangers. Instead, <b>MI</b> and <b>stroke</b>, in general, were the biggest danger firefighters faced. </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Now, this is partly a function of age, but <b>15%</b> of the deaths from MI were in firefighters <b>younger than 45 years old</b>. A recent study focused on this group, and found some surprising results.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b><u>The Study</u></b></span><br /><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The authors of </span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;"><a href="http://www.sciencedirect.com/science/article/pii/S0002914913017116">Sudden Cardiac Death Among Firefighters ≤45 Years of Age in the United States</a> </span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">wanted to take a closer look at these younger firefighters who died of cardiac causes, and see if there were any risk factors that could explain those deaths.</span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">To do this, they used <span style="font-size: small;">the database maintained by NIOSH (</span></span><span style="font-size: small;"><a href="http://www.cdc.gov/niosh/fire/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">http://www.cdc.gov/niosh/fire/</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">) to find all cases of <b>firefighters < 45 years of age who had a sudden cardiac death</b>. They looked at the period from <b>1996</b> to <b>2012</b>, and examined autopsies and other reports.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">They then selected a bunch of age-matched, healthy, “</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">occupationally active” control firefighters</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> to compare them to. Additionally, they looked at </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">noncardiac traumatic fatalities </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(deaths due to blunt trauma, burns, or asphyxiation) to serve as a second comparison group.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><u><b>1. The FFs with sudden cardiac death</b></u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></span><br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">They found </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">87</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> FFs under the age of 45 who had a sudden cardiac death during that time. </span></span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6AiCu4Ps25yUqhlMaQ9OsxI3Xtz5EnyTaiuHQPcmX9ahlLz_LPWPDN5lPxGz21MXGpDt27KZhav2Mco4SUuPCpoSAQWZdW64ln3PID5gBPEEtaF1N8YhZ5UUYYfdGKkawpk9quhjW-X0/s1600/screenshot401.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi6AiCu4Ps25yUqhlMaQ9OsxI3Xtz5EnyTaiuHQPcmX9ahlLz_LPWPDN5lPxGz21MXGpDt27KZhav2Mco4SUuPCpoSAQWZdW64ln3PID5gBPEEtaF1N8YhZ5UUYYfdGKkawpk9quhjW-X0/s1600/screenshot401.jpg" height="140" width="320" /></a></div>
<span style="font-family: Georgia,"Times New Roman",serif;">A few results stand out:</span></div>
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<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Almost all were <b>men</b>.</span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Over<b> 1/4</b> of them <b>smoked</b> </span></span></li>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(Only <a href="http://www.cdc.gov/tobacco/data_statistics/fact_sheets/adult_data/cig_smoking/">18% of Americans </a>smoke). </span></span></li>
</ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Almost <b>2/3</b> (<b>63</b>%) of them had a <b>BMI ≥ 30</b>. </span></span></li>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(Versus about <a href="http://www.cdc.gov/nchs/data/databriefs/db82.pdf">36% of American males</a>)</span></span></li>
</ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Over <b>1/4</b> of them had a <b>BMI over 35</b>. </span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Over<b> 1/2</b> had evidence of <i>both</i> <b>cardiac disease</b> and <b>cardiomegaly</b>. </span></span></li>
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(Only <a href="https://www.nhlbi.nih.gov/about/factbook/chapter4data.htm#gr28">40% of men age 40-59</a> have CAD, HTN, CVA, or CHF)</span></span></li>
</ul>
</ul>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">At first glance, it looks like these firefighters had <i>much</i> worse health than the general public. But maybe this is due to the <b>unique stresses of the job</b>. For example, disruption of normal sleep patterns could encourage sleep apnea, leading to hypertension and obesity. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">So in order to clarify the issue, they compared the FFs who had sudden cardiac death with the people most like them - other firefighters!</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><b><u>2. Compared with occupationally active FFs</u></b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">When they compared these FFs to the </span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">“</span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">occupationally active"</span> FFs, however, they found concerning results, suggesting that the FFs who had cardiac arrests were indeed unhealthier than their own peers.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhza_4jbQkIr-1VjyfSB4nKdoL3OsNHz1ebJ7Pbi5nRAyUtc5De_LFGW6FpZynqCyvdioc9Qj6oIPYcxVp2U0tRPnEAYgL4nD7BaurLtkJa7_-81FU7NpZnRO2R6LQ7aKK9x_CUv1Ye9EQ/s1600/screenshot379.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhza_4jbQkIr-1VjyfSB4nKdoL3OsNHz1ebJ7Pbi5nRAyUtc5De_LFGW6FpZynqCyvdioc9Qj6oIPYcxVp2U0tRPnEAYgL4nD7BaurLtkJa7_-81FU7NpZnRO2R6LQ7aKK9x_CUv1Ye9EQ/s1600/screenshot379.jpg" height="206" width="400" /></a></b></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>Obesity</b>, <b>smoking</b>, and <b>hypertension</b> were significant predictors of cardiac death while at work. Not unexpectedly, a <b>history of cardiac problems</b> was a huge risk factor as well.</span></span></div>
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<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>3. Compared with FFs who had a traumatic death</b></span></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">When
they then compared the FFs who died from<b> sudden cardiac death</b> to those that had a <b>
traumatic death</b>, they found significant difference in both <b>age</b>, and in
the size of their hearts. FFs who suffered a cardiac death
had higher rates of cardiomegaly, or <b>enlarged hearts</b>, suggesting that they had had longstanding problems with hypertension
or obesity (or both).</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9Zz7Enum86gq4IgT4BW0bLIC7LxAD72n4za620eJ1nJjAgs2REMubxK9XuGjgAaU-qYfbAjpbk20PJABZphyphenhyphenXJ4OtP5CTPISUJLymLYMG4clGGBtqIzFxqa8W2baU_XTXr4_312UtC-4/s1600/screenshot380.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj9Zz7Enum86gq4IgT4BW0bLIC7LxAD72n4za620eJ1nJjAgs2REMubxK9XuGjgAaU-qYfbAjpbk20PJABZphyphenhyphenXJ4OtP5CTPISUJLymLYMG4clGGBtqIzFxqa8W2baU_XTXr4_312UtC-4/s1600/screenshot380.jpg" height="121" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><b><span style="font-size: large;"><u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">So what do we do with these results?</span></u></span></b><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br />First off, <b>prevention (i.e.</b> <b>lifestyle) trumps everything</b>. Quitting smoking, keeping a healthy weight, and maintaining a vigorous exercise routine, amongst other things, may have gone a long way towards preventing many of these deaths. Although firefighting presents many unique challenges to staying healthy (e.g. schedules that disrupt sleep patterns, exposure to heat stress), the comparisons to healthy FFs, as well as those who died from trauma, show that <b>smoking</b> and <b>hypertension</b> play a huge role in raising the risk of cardiac death.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></div>
<div dir="ltr" id="docs-internal-guid-649f2252-f98c-7a5a-a549-eb0fbee379c8" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Second, we need to<b> prepare for cardiac arrest in firefighters</b>. The unique nature of the fireground, as well as the obstacles that the clothing and equipment present, mean that departments need to practice their response to a "fallen" firefighter, aiming to start CPR and assess for a shockable rhythm as soon as possible. This requires special procedures, teamwork and practice. Watch these guys from <a href="http://www.hiltonheadislandsc.gov/departments/fire/"><b>Hilton Head FD</b></a> run through a drill.</span></span><br />
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<iframe allowfullscreen="" frameborder="0" height="315" src="//www.youtube.com/embed/dfTP6fDP_dI" width="420"></iframe>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Be safe, and take care of your heart! </span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com13tag:blogger.com,1999:blog-4266294048567663301.post-36472113489915474162014-02-09T19:08:00.001-08:002014-02-09T19:08:34.325-08:00Can you give adenosine to a patient with WPW?<div class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">Maybe you can answer the question in the title completely and confidently. If so, feel free to skip this post, and go on to some <a href="http://www.youtube.com/watch?v=CsWFLaHiQa8">more entertaining corner</a> of the web. However, it seems to me that many emergency providers are unsure about how to approach a confusing issue with adenosine:</span></div>
<ul>
</ul>
<blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">Can (or should) you give <b>adenosine</b> to a patient with <b>known or suspected WPW</b>?</span></blockquote>
<ul>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>Spoiler</b></u>: The answer to this questions is </span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyU0qwEa-SzDKeT3HIpRT_r_mkJ0Kkp4limrrZ6-GXRJUjpy4rOvq5xXn5s_xuTDeHUHDWK6qqyX_60nPM3UX46DoLtTAiOURWK9Gw1H63OI95Uzp4OdCpPr2TRDTPpk0wxBCubT3m_p0/s1600/tumblr_inline_mtp7zcdJ2k1r2uoh1.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyU0qwEa-SzDKeT3HIpRT_r_mkJ0Kkp4limrrZ6-GXRJUjpy4rOvq5xXn5s_xuTDeHUHDWK6qqyX_60nPM3UX46DoLtTAiOURWK9Gw1H63OI95Uzp4OdCpPr2TRDTPpk0wxBCubT3m_p0/s1600/tumblr_inline_mtp7zcdJ2k1r2uoh1.jpg" height="203" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">More specifically:</span><ol>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Adenosine is <b>safe and effective</b> for terminating SVT (narrow <i>or</i> wide) caused by WPW, but...</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Giving adenosine for WPW <b>with atrial fibrillation</b>, however, can be <span style="color: red;"><b>lethal</b></span>. </span></li>
</ol>
<span style="font-family: Georgia,"Times New Roman",serif;">One recent case that was treated in the field illustrates principle <b>#1</b>. Fortunately, no local medics have provided us with a demonstration of principle <b>#2</b>!</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>(As always - <span style="color: blue;">Follow your local protocols</span> for WPW and arrhythmias!) </b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><u><b><span style="font-size: large;">
<span style="font-family: Georgia,"Times New Roman",serif;">Can you give adenosine to a patient with WPW?</span></span></b></u><br />
<u><b><span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">Case report: </span></span></b></u><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This is best illustrated with a case! <b>Paramedic Harvey</b> had a patient with palpitations, tachycardia, and a good BP, and she obtained the following ECG.</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMELvJF7azqFd6y2L3vIQ5qT_Px1jVGwIwMYt0JOKTGIq3dKHYqwCYJpnvv9UxZbd_fuBqFtsPuGAIz54d9MIBFAqX7JxqV6KfsiKWkF8121pBC2kWgbN598twY4ddEWKNt_JIFfasyY8/s1600/screenshot178.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiMELvJF7azqFd6y2L3vIQ5qT_Px1jVGwIwMYt0JOKTGIq3dKHYqwCYJpnvv9UxZbd_fuBqFtsPuGAIz54d9MIBFAqX7JxqV6KfsiKWkF8121pBC2kWgbN598twY4ddEWKNt_JIFfasyY8/s320/screenshot178.jpg" height="116" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">A narrow-complex, regular tachycardia in a stable patient? Looks like an<b> <a href="http://lifeinthefastlane.com/ecg-library/svt/">SVT</a></b>! Medic Harvey decided, appropriately, to bust out the <b>adenosine</b>. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">A rapid bolus of <b>6 mg</b> broke the tachycardia, and restored NSR on the monitor, but the follow-up 12-lead looked a little odd:</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2kJokGwXcfoYmf7pPoQgU-XzsX4cmo3SF0HXIuOWDf7yib81kEvJp2GIrZ-greg0YK0m3PtdPRBsdr7I4wXN9EZRSLryvOtUJU0AbOGj88Fav9DWeB_lJTvWkoNcW2Sav08oQc7ZxXbE/s1600/screenshot179.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2kJokGwXcfoYmf7pPoQgU-XzsX4cmo3SF0HXIuOWDf7yib81kEvJp2GIrZ-greg0YK0m3PtdPRBsdr7I4wXN9EZRSLryvOtUJU0AbOGj88Fav9DWeB_lJTvWkoNcW2Sav08oQc7ZxXbE/s320/screenshot179.jpg" height="110" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">A few minutes later a second post-conversion ECG was obtained.</span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwkm1eaN_SrJ7AnYTVDKPirdbGd_gfNzKuzf_aR18RGeZAD2Kkol6YCvWiKNpCh0f7UxYa9HrybOCYgqfxi_G2BJpEGYAhx9P-90StIpdJIWjmv5kj0wvB62cCq5o83JlRT8utcWIFACY/s1600/screenshot180.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwkm1eaN_SrJ7AnYTVDKPirdbGd_gfNzKuzf_aR18RGeZAD2Kkol6YCvWiKNpCh0f7UxYa9HrybOCYgqfxi_G2BJpEGYAhx9P-90StIpdJIWjmv5kj0wvB62cCq5o83JlRT8utcWIFACY/s320/screenshot180.jpg" height="107" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Huh. You know, that sort of looks like...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">It was at this point that the patient told Heather </span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"<i>I probably should have told you that I have <b>WPW</b></i>."</span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Wait, what?!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Oooooo.... Isn't WPW supposed to be a dangerous rhythm, where you can send the the patient into VF just by <i>thinking </i>about adenosine? Holy cow, did the medic just get lucky, or what?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Brief Review of WPW</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Let me go over the pathophysiology briefly. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">(For a fuller description, check out a great new e-book by <a href="https://www.kg-ekgpress.com/about/"><b>Ken Grauer</b></a>,</span><span id="btAsinTitle"> entitled <a href="http://www.amazon.com/dp/B00C81R08Y/ref=rdr_kindle_ext_tmb"><b>ACLS - 2013 - ePub,</b></a></span><span style="font-family: Georgia,"Times New Roman",serif;"> for more education on WPW and other topics in ECG interpretation and ACLS.)</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1itLpNDpH-j-QhF5Dzt6LYSY24Kj9y-3BGqEaQkmjTpDa83eBBq3bhH7rGjemfrJ5Hc0ax8ENSD25UHmTMpOgLa3l8haGbqGhuKd89oSnDEyYDoCHpFrvfxN3NYFxLKcHZYSTqiJaq5E/s1600/b3d8224128a0c62d93e44010.L._SY300_.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1itLpNDpH-j-QhF5Dzt6LYSY24Kj9y-3BGqEaQkmjTpDa83eBBq3bhH7rGjemfrJ5Hc0ax8ENSD25UHmTMpOgLa3l8haGbqGhuKd89oSnDEyYDoCHpFrvfxN3NYFxLKcHZYSTqiJaq5E/s1600/b3d8224128a0c62d93e44010.L._SY300_.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">The <a href="http://www.amazon.com/Acls-Certification-Preparation-Ken-Grauer/dp/0801670691"><b>1993 edition</b></a> was pure gold when I was in paramedic school.<br />
It's only gotten better - seriously, <a href="http://www.amazon.com/dp/B00HX29ZAO/ref=rdr_kindle_ext_tmb"><b>download</b></a> this now!</td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">There are <b>2 common causes</b> of a regular narrow-complex tachycardia, or <b>SVT</b>. </span><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;">The most common is <a href="http://lifeinthefastlane.com/ecg-library/svt/"><b>AV nodal reentrant tachycardia</b></a> (<b>AVNRT</b>), which involves a "loop" of electrical current that is <i>confined within </i>the AV node. These are narrow unless aberrant conduction occurs.</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">By contrast, <a href="http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/"><b>AV reentrant tachycardia</b></a> (<b>AVRT</b>), involves a "short circuit," or accessory pathway, between the atria and the ventricles that <i>bypasses</i> the AV node. During normal sinus rhythm, the ECG will often demonstrate signs of "pre-excitation" of the ventricles; a short PR, a delta wave, and a wide QRS.</span></li>
</ul>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_0TbKp-KOE07MhN8iV7BME-hw3PovLfpEmzKvs_SgSKMiuRSv5zWLXKMzkujIm6FoIRWb-_szWUD_-wsGAozFxHGAuJHOLfIY1JD1_VnTzU_wjfI46WenjiBfmamDWOQrpG_RAU_AALA/s1600/screenshot385.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_0TbKp-KOE07MhN8iV7BME-hw3PovLfpEmzKvs_SgSKMiuRSv5zWLXKMzkujIm6FoIRWb-_szWUD_-wsGAozFxHGAuJHOLfIY1JD1_VnTzU_wjfI46WenjiBfmamDWOQrpG_RAU_AALA/s1600/screenshot385.jpg" height="287" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><b><a href="http://www.amazon.com/dp/B00C81R08Y/ref=rdr_kindle_ext_tmb">Grauer K: ACLS-2013-ePub, KG/EKG Press (<i>available in kindle/ibooks/nook/kobo</i>)</a></b></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">When an episode
of AVRT (aka SVT) is triggered, however, the QRS will <i>usually</i> be narrow, and the delta
wave will disappear (as seen in <u><b>Panel A</b></u> below). </span><span style="font-family: Georgia,"Times New Roman",serif;">As noted in <u><b>Panel B</b></u>, however, in a <i>rare minority</i> of patients the circuit of conduction will be "backwards," and produce a wide QRS.</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9pTfA0yudmFkSAjIYAcKVodBuuFP-LA6t8zmP5CiluUarGk9uxuOHyudgKBj-3JTTNtx1lff81Hxkp8n0nVMu8hGW_3CpXreWx1Q9cC5Zq7hyphenhyphenFgsnIIjluhEG0IWPs5SHPzQGB7uT5to/s1600/screenshot386.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9pTfA0yudmFkSAjIYAcKVodBuuFP-LA6t8zmP5CiluUarGk9uxuOHyudgKBj-3JTTNtx1lff81Hxkp8n0nVMu8hGW_3CpXreWx1Q9cC5Zq7hyphenhyphenFgsnIIjluhEG0IWPs5SHPzQGB7uT5to/s1600/screenshot386.jpg" height="348" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><b><a href="http://www.amazon.com/dp/B00C81R08Y/ref=rdr_kindle_ext_tmb">Grauer K: ACLS-2013-ePub, KG/EKG Press (<i>available in kindle/ibooks/nook/kobo</i>)</a></b></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">So, there are some <i>important differences</i> between the two main causes of SVT (AV<b>N</b>RT and AVRT). It's important to emphasize, though, that...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><b><u><span style="font-size: large;">
<span style="font-family: Georgia,"Times New Roman",serif;">AV</span></span></u></b><u><span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">N</span></span></u><b><u><span style="font-size: large;"><span style="font-family: Georgia,"Times New Roman",serif;">RT and AVRT have <i>3 important things in common</i>:</span></span></u></b><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;">Both <b>rely on the AV node to complete the "loop"</b> of electrical current that generates the tachycardia;</span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;">In both, the <b>sinus node is generating normal, controlled signals</b>; i.e., 60 - 100 beats per minute.; and </span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><b>Adenosine</b> will terminate the reentrant thythm <i>in</i> <i>both</i> by <b>shutting down the AV node</b>.</span></li>
</ul>
<span style="font-family: Georgia,"Times New Roman",serif;">In AV<b>N</b>RT, adenosine effectively "cuts" all electrical connections between the atria and ventricles (<i>temporarily</i>!). In <b>AVRT/WPW</b>, however, the bypass tract is unaffected by the drug, and is still capable of conducting electrical signals to the ventricles. This could <i>potentially</i> lead to sinus impulses being conducted anterograde down the AP, producing wide, "aberrant," QRS complexes, but at a controlled rate (i.e. 60-100 bpm).</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>WPW <i>with</i> AF can be <span style="color: red;">lethal</span> if treated with adenosine</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This is <i><b>entirely different</b></i> when the patient has <b>WPW</b> <i>and</i> <b>atrial fibrillation</b>. Remember that, in AF, the atria are firing off at <b>300</b> - <b>400</b> times a minute, not the controlled rate of 60-100 that the SA node generates. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">So, if these <i>all</i> of these electrical impulses are transmitted to the ventricles through the bypass tract, the myocardium will freak out. Like this.</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIskYF7p0j2la1k-eOIDaLzyO0O2qv7grAu7e9dNZlWxzzmBBe-kzREDToNBMNVo_u7tjud-lOXh5RyKMBuXs9Cg6g_DumGxUCR0dlUjV0JzYcA4XAmBRuLti8lWGUA_wHNeZck8C2IdY/s1600/screenshot370.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhIskYF7p0j2la1k-eOIDaLzyO0O2qv7grAu7e9dNZlWxzzmBBe-kzREDToNBMNVo_u7tjud-lOXh5RyKMBuXs9Cg6g_DumGxUCR0dlUjV0JzYcA4XAmBRuLti8lWGUA_wHNeZck8C2IdY/s1600/screenshot370.jpg" height="267" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/11428480"><b>Source: Shah 2001</b></a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;"><br /></span></b></u></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">WPW <i>without</i> AF is safe to treat with adenosine</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">We probably<b></b> don't need to worry</span><span style="font-family: Georgia,"Times New Roman",serif;"><b>*</b></span><span style="font-family: Georgia,"Times New Roman",serif;">, however, about giving adenosine in patients <i>with</i> <b>WPW</b>, but <i>without </i><b>AF</b>. There's a few reasons why. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>1) </b>First off all, about <b>a third of the SVTs</b> that you have given adenosine to in the past were actually caused by AVRT/WPW, just based on the epidemiology. Since practically none of these developed VF (<i>right</i>?), this is apparently a very safe practice.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>2) </b>Second, there was a concern in the past that a certain percentage of <b>wide-complex </b>tachycardia were actually <b>WPW with antidromic conduction</b>, and so the advice was to avoid adenosine. The rationale was that since the bypass tract was capable of retrograde conduction, shutting down the AV node could "expose" the ventricles to potentially unregulated pacing. However studies <a href="http://www.ncbi.nlm.nih.gov/pubmed/19623049"><b>such as this one</b></a> have convinced a number of people, including the <b>AHA</b>, that adenosine is pretty safe in anyone with a (<b>regular!</b>) wide-complex tachycardia. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>3) </b>Third, many cardiology experts believe that adenosine is safe in regular WCTs. The authors of a <a href="http://www.ncbi.nlm.nih.gov/pubmed/1934371"><b>1991 study</b></a> found it to be quite safe in this setting, and concluded that </span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">"Adenosine may cause acceleration of preexcited atrial arrhythmias, but
these effects are transient and should not discourage the use of
adenosine as a diagnostic agent in broad complex, regular tachycardias
of uncertain origin." </span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">Dr. Stephen Smith, of <a href="http://hqmeded-ecg.blogspot.com/"><b>Dr Smith's ECG Blog</b></a> fame, believes that we don't even need clinical evidence to prove that <a href="http://hqmeded-ecg.blogspot.com/2011/05/wide-complex-tachycardias-2-cases-what.html">adenosine is safe in <b>regular </b>tachycardias, wide or narrow, in a person with a history of WPW</a>. A fundamental understanding of cardiac physiology is enough to sh0w this:</span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"> </span><span style="font-family: Georgia,"Times New Roman",serif;">"Anyone who knows what AVRT</span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-family: Georgia,"Times New Roman",serif;"> </span> is, and what it is that electrical circuits do, knows
that it is safe to give adenosine. If you ask an electrophysiologist
for an article on this, they will say 'There are no articles, because
this is so obvious that it needs no proof.'</span> </blockquote>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">[A]denosine is safe in VT. One need not prove that it is safe in AVRT</span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-family: Georgia,"Times New Roman",serif;"> </span>."</span> </blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"> </span><br />
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">The Bottom Line</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So it turns out that adenosine was quite safe with Harvey's patient, as well as effective. This probably wasn't a fluke!</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Although many medics have been taught that Wolff-Parkinson-White (WPW)
and adenosine are a dangerous combination, this isn't often the case.
On the contrary - it seems likely that medics and physicians have <i>
frequently</i> given adenosine to patients with<b> <i>undiagnosed</i> WPW</b>, without apparent ill effects. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Furthermore, the recent emphasis on giving adenosine for<b> regular wide-complex tachycardias</b> <b>of</b> <b>uncertain etiology</b> makes it <i>even more</i> likely that <b>YOU</b> will give adenosine to someone with undiagnosed WPW.</span> <span style="font-family: Georgia,"Times New Roman",serif;">A small number of those WCTs represent WPW with antidromic conduction, but adenosine administration has not been documented to cause any problems to date.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">So, <span style="color: blue;"><b>follow your local protocols</b></span> for arrhythmias and WPW, but keep in mind the available evidence, as well as expert opinion, suggests that adenosine is safe in most cases.</span>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">__________________________________</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><b>* </b>Okay, there are a few, totally theoretic, reasons to worry about giving adenosine to patients with WPW. I mention these only out of a sense of completeness. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">First of all, adenosine is not <i>totally</i> benign, and it has <a href="http://emj.bmj.com/content/21/4/408.full">been shown to induce atrial fibrillation</a> in a number of case reports. Although the half-life is fairly short, it's conceivable that adenosine could <i>first</i> trigger AF in a patient with a history of WPW, and that the AF could <i>then</i> immediately degenerate into VF. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16573413">One case report</a> describes how a young woman with SVT developed AF after performing a Valsalva maneuver. Adenosine was then given, and the rhythm degenerated into a pulseless irregular WCT. Cardioversion restored a pulse and sinus conduction.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Second, although there are no case reports that I know of have shown an<b> antidromic WPW tachycardia</b> deteriorating after adenosine administration, this is a <i>rare</i> rhythm, and even a moderate <i>relative</i> risk of adverse effects from adenosine would produce a small <i>absolute</i> number of complications. For example, the <a href="http://www.ncbi.nlm.nih.gov/pubmed/19623049">study by Maril</a> (that demonstrated the safety of using adenosine in WCTs) only enrolled <b>2</b> patients with a history of WPW. One of those patients was determined to have been having a ventricular (non-accessory pathway dependent-) rhythm upon enrollment. It's hard to determine the absolute safety of a drug for such a rare rhythm. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Nonetheless, even a "worst-case scenario" suggests that an adverse event would be very rare.</span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com13tag:blogger.com,1999:blog-4266294048567663301.post-47696546380187044772014-01-13T11:58:00.000-08:002014-01-13T11:58:01.755-08:00Pediatric Anaphylaxis: Medication errors by EMS<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">You are called for a <b>5-year-old</b> child with trouble breathing. </span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The mother states the child has had 1 hour of <b>progressive respiratory distress</b> after being <b>stung by a bee</b>. The initial vitals are <b>BP 76/40, P 120, R 45, and SpO 91% </b>on room air. The patient is sitting upright, speaking in short sentences, and has audible wheezing. The physical exam reveals hives over the chest and arms. If you don't act in 2 minutes, your patient will decompensate. What do you do?</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(By the way, this is a HIPAA-compliant picture of your patient:)</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWaStjcB6AJIBe4n6IyYrkm9bFQ0hkq5V3Y8XycQeTvYs0kVg_NCmDVD2FvMVCXUVR2cRzaWD0MLmYXtBKlJi1zjT8UHYO-jIuKEZGkwWXhfp06g9v5cZwx3O_EKdIJhl0viY0lpWVMPM/s1600/screenshot348.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjWaStjcB6AJIBe4n6IyYrkm9bFQ0hkq5V3Y8XycQeTvYs0kVg_NCmDVD2FvMVCXUVR2cRzaWD0MLmYXtBKlJi1zjT8UHYO-jIuKEZGkwWXhfp06g9v5cZwx3O_EKdIJhl0viY0lpWVMPM/s320/screenshot348.jpg" width="241" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Yup, it’s a <a href="http://bladerunner.wikia.com/wiki/Replicant"><b>replicant</b></a>, and just like <a href="http://www.linkedin.com/in/roybatty"><b>Roy Batty</b></a>, he was programmed to die in this EMS simulation study performed in Michigan. </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Unlike Roy Batty, however, this replicant will live if he is given epinephrine in time!</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span><table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu2iEWfhNJzM4570CACxCUUgqE1Xx4yX8Djbj0GIX14G9C7snOr32-1_HQFVTRdBcNRGJ5Fs68UGjEUxPQFvjmzd9xna9W9DFnNhBcoiyoO4cy1lHgdN2Ub5gbjd7TbN7aN5BGh9B2s0U/s1600/20110823-064902.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgu2iEWfhNJzM4570CACxCUUgqE1Xx4yX8Djbj0GIX14G9C7snOr32-1_HQFVTRdBcNRGJ5Fs68UGjEUxPQFvjmzd9xna9W9DFnNhBcoiyoO4cy1lHgdN2Ub5gbjd7TbN7aN5BGh9B2s0U/s400/20110823-064902.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"I've seen things you people wouldn't believe... And I need some epi!"</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-size: large;"><u><b></b></u></span></span><br /></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/24401046"><b>Medication Errors in Prehospital Management of Simulated Pediatric Anaphylaxis.</b></a></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The authors used a <a href="http://www.gaumard.com/s3005-pediatric-hal/"><b>high-fidelity simulation manikin</b></a>, in a well-equipped simulation center, as well as the scenario described above. They allowed the EMS crews to use their <i>own</i> medication and equipment, but they all had to follow the state EMS protocol for pediatric anaphylaxis. </span></span></div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2zb7Th3KdKTEVk8OlLwHlHqDICxRB4PSQ-7JBp8D4R58t-kH1JddrkOyDEC_3CR2FaIfUUoPR9TG24iLQetG8HICMNWaYmCXcmufALSZgPJL5P0jfYPQzumlxtJ5VSPDQ8DloHgWGysE/s1600/screenshot350.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2zb7Th3KdKTEVk8OlLwHlHqDICxRB4PSQ-7JBp8D4R58t-kH1JddrkOyDEC_3CR2FaIfUUoPR9TG24iLQetG8HICMNWaYmCXcmufALSZgPJL5P0jfYPQzumlxtJ5VSPDQ8DloHgWGysE/s400/screenshot350.jpg" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://informahealthcare.com/doi/suppl/10.3109/10903127.2013.856501/suppl_file/anaphylaxis-scenario.pdf"><b>Michigan EMS protocols</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> If the crews gave the right medications and interventions, the kid got better. If not.... </span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="font-size: large;"><u><b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span>So what happened?</b></u></span> </span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">Before I answer that, let me point out that the EMTs and medics <i>volunteered</i> for this study. This suggests that these folks were <b>motivated</b> enough to participate in research, <b>aware</b> they were going to observed, and fairly <b>confidant</b> in their knowledge and skills. In other words, probably some good, smart people.</span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;">So, it's all the more distressing what the study found.</span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>1. Three out of 62 crews (5%) did not give epi</b></u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">For true anaphylaxis,<a href="http://www.ncbi.nlm.nih.gov/pubmed?term=18691308"><b> epinephrine is the required treatment</b></a>, with essentially no contraindications. </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>2. Epi was often given by the wrong route.</b></u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The protocol spelled out that epinephrine <b>should be given IM</b>, in line with several <a href="http://www.ncbi.nlm.nih.gov/pubmed/21823930"><b>national</b></a> and <a href="http://www.espai-eg.org/WAO%20anaphylaxis%20guidelines_JACI%202011.pdf"><b>international</b></a> guidelines. Despite this, only 37 out of 59 (<b>63%</b>) crews gave epinephrine IM. The authors were generous, and allowed SQ as an acceptable route, but this is an outdated practice.</span><u><b> </b></u></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>3. An epi dose of > 1 mg was given by 20% of crews.</b></u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">‘Nuff said about that...</span><u><b> </b></u></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>4. Epi was given intravenously by 15% of crews</b></u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Although IV epi is listed in the protocol, even <a href="http://www.ncbi.nlm.nih.gov/pubmed/17324313"><b>"low" doses of IV bolus epi</b></a> can cause badness. With that in mind, the protocol allowed for IV epinephrine only “<i>in cases of profound anaphylactic shock (near cardiac arrest).</i>” </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Because the patient was initially sitting upright, speaking, and perfusing, IV epi was considered a major error.</span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>5. Less than half of the crews gave epi by the right dose <i>and</i> route.</b></u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">As shown in this table:</span><u><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></u></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXnNLHQgD4hFvEjYo642EAk0gc8doUiT8rkThUOZutP4ottq0ZY3q_o-RhyphenhyphenC4hkdS9f71cBGo3B794HBUcPjC-Z-n6VOjrnnHKzqgky8a9E7tnudDUSy8MG8ZRuNn6SYA_V0jAK452-ME/s1600/screenshot352.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="91" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXnNLHQgD4hFvEjYo642EAk0gc8doUiT8rkThUOZutP4ottq0ZY3q_o-RhyphenhyphenC4hkdS9f71cBGo3B794HBUcPjC-Z-n6VOjrnnHKzqgky8a9E7tnudDUSy8MG8ZRuNn6SYA_V0jAK452-ME/s400/screenshot352.jpg" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>So why did this happen?</b></span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It's hard to manage a <b>rare</b> medical event, using a drug that is available in <b>multiple concentrations,</b> and can be given by <b>multiple routes</b>, but must be dosed accurately <b>by</b> <b>weight</b>. </span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span><div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">And as I said before, these were engaged and motivated EMS providers. Furthermore, the errors that they committed have been demonstrated to occur in a <a href="http://www.ncbi.nlm.nih.gov/pubmed/18166759"><b>number of prior studies</b></a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/20031267"><b>case reports</b></a>, involving a wide range of medical personnel. </span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">In other words, you can’t respond to this study by saying “<i>Well, <b>our</b> guys would never screw up like this!</i>” Or by saying “<i>We’ve been doing it this way <b>for years </b>without a problem.</i>” This study should force all of us to reevaluate how we teach, protocolize, and practice treatment of anaphylaxis. </span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">If you have the patience, download the author’s summary (the picture below) of the <b>types</b> of errors that were committed, and the <b>rationale</b> of the medics who committed them. Very informative!</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Lz-E_8k7npqJE_TCseUJzOc-6MmeYFCD3PFM7XMJIM9eJ8sSYSSRdtP99KcB4ZuiwKBLHS5fTIxZ2ERqAU1BswgWULk-x_ZXXo0o5vNZjzoFLn7_NOpgoNQWO3w5BQ3ndo0Rwse-DD4/s1600/screenshot351.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5Lz-E_8k7npqJE_TCseUJzOc-6MmeYFCD3PFM7XMJIM9eJ8sSYSSRdtP99KcB4ZuiwKBLHS5fTIxZ2ERqAU1BswgWULk-x_ZXXo0o5vNZjzoFLn7_NOpgoNQWO3w5BQ3ndo0Rwse-DD4/s400/screenshot351.jpg" width="288" /></a></span></div>
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<b></b><span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></b></u></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-size: 16px; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com16tag:blogger.com,1999:blog-4266294048567663301.post-89414242236204365242014-01-03T11:47:00.003-08:002014-01-03T11:47:36.847-08:00The Cardiac Save Pin<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">I’ll admit, I don’t understand why the <b>stork pin</b> is so popular. </span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The mother is doing all the pushing and tearing, while the medic or EMT isn’t really doing any work besides </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><i>not</i> dropping the newborn. That’s not really an advanced medical skill, you have to admit.</span></span></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijxfWPYY7Oz1rgGn-ngyiEAzf7ftiT3-M3gSU9-wZiRLIf7lJaYfuod5xUrlqdH96Yi8ZDpSk71yx8mBZDQ3PT1wYlj6x7LGioBMWmVRGSlBWL3yYxND8N-CO_jIjVOmRiyTHLwTJ3t7s/s1600/images.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEijxfWPYY7Oz1rgGn-ngyiEAzf7ftiT3-M3gSU9-wZiRLIf7lJaYfuod5xUrlqdH96Yi8ZDpSk71yx8mBZDQ3PT1wYlj6x7LGioBMWmVRGSlBWL3yYxND8N-CO_jIjVOmRiyTHLwTJ3t7s/s1600/images.jpg" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Good job holding a human off the floor!"</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Our new “<b>Cardiac Save</b>” lapel pin, on the other hand, recognizes the judgement that medics use in identifying a STEMI, and then communicating effectively with the ED and cardiology. These skills aren’t as dramatic as, say, sinking an ET tube or needle decompression, but they are arguably far more important.</span></span></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghLCuQqs9wobDjPgiKqOCHVJVuwG5NxRJBjsuTLJEcngaqWMUXBTNwWWMerxYzGgS2NlXecC02VWBhbqebWKK2-XiIJ8ly69bnIujzzPt18S5M7rNYEaq7c-Kxm3LTycNLrBre0M6xuAE/s1600/anatomic+heart.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghLCuQqs9wobDjPgiKqOCHVJVuwG5NxRJBjsuTLJEcngaqWMUXBTNwWWMerxYzGgS2NlXecC02VWBhbqebWKK2-XiIJ8ly69bnIujzzPt18S5M7rNYEaq7c-Kxm3LTycNLrBre0M6xuAE/s1600/anatomic+heart.jpg" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: x-small;">And they're made in New England! (<a href="http://www.lapelpinplanet.com/CC389-human-heart-lapel-pin.html?gdftrk=gdfV24966_a_7c1313_a_7c5689_a_7cCC389&gclid=CPbO0vuauroCFcGd4AodP2UADg"><b>site</b></a>)</span></span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">I wanted to illustrate this with a few recent STEMI cases. Basically, I just want to brag about EMS in Bridgeport!</span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">Case #1 - Not an obvious STEMI</span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">See what you think about the ECG. Older female, late at night, chest pain:</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZA0pepf-IzmNcAGyrk133CHZsFV_4-15_YhSWWADMPya-GvoKcd7z2ofSkTW-wi1Ue6G5KRzsdht7oBcmWeoNnxtaerem3CqQz7LvDbypNblVVJJYNsFSjCEBTB7T7ZlPu122BnHC4sM/s1600/MacCalla+ECG.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="142" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZA0pepf-IzmNcAGyrk133CHZsFV_4-15_YhSWWADMPya-GvoKcd7z2ofSkTW-wi1Ue6G5KRzsdht7oBcmWeoNnxtaerem3CqQz7LvDbypNblVVJJYNsFSjCEBTB7T7ZlPu122BnHC4sM/s400/MacCalla+ECG.jpg" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Kind of a tough one, since the <b>RBBB</b> mucks up the QRS. <i>Unlike</i> LBBB, however, the <b>ST segments</b> should be basically normal in RBBB. The paramedic, Gordon MacCalla, from <a href="http://www.valleyems.org/"><b>VEMS</b></a>, also thought this was a STEMI, despite the fact that the computer took a little longer coming to that conclusion than he had. </span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Once in the ED, this ECG had the cardiology fellow scratching their chin, but the interventional cardiologist only needed about 0.25 seconds to verify the STEMI before heading to the cath lab with the patient. Since this all happened late at night, the cath team needed to be called in from home, so Gordon's prehospital activation saved plenty of time and myocardium!</span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">Case #2 - Bypassing the ED</span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It’s not always possible for EMS to go directly to the cath lab, since the cardiac team may not have assembled by the time EMS gets to the hospital (as in case #1). Case #2 was the first time where the timing worked out, and paramedic Erin Smith, of <b><a href="http://www.townofstratford.com/content/39832/39846/39907/default.aspx">Stratford EMS</a>,</b> got to skip the ED.</span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">This middle-aged gentleman was actually hypotensive when EMS arrived. He complained of chest discomfort, and the first ECG showed:</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpTQXymI_-0jp_C6dUaTaLkv05WIuZKdKwHpGkfo5PAAElXShnyj55SPBU2lIwWNrHPAGNPcOxJNihC45LTkx54tZGTVpoiiQqtRjQSp33o2mUDOqdke5750NrfhHKPNogdF0DEXz6ego/s1600/Smith+ECG.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="185" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpTQXymI_-0jp_C6dUaTaLkv05WIuZKdKwHpGkfo5PAAElXShnyj55SPBU2lIwWNrHPAGNPcOxJNihC45LTkx54tZGTVpoiiQqtRjQSp33o2mUDOqdke5750NrfhHKPNogdF0DEXz6ego/s400/Smith+ECG.jpg" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Not subtle. Yeah, it was the <b>RCA</b>. By calling this in from the field and skipping the ED, medic Smith helped save this guy some heart muscle. The patient did well, spending less time admitted to the hospital than do most women after childbirth!</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">Case #3 - STEMI and cardiac arrest</span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Paramedic David Rodriguez of <b>AMR</b> had his hands full on this call! A not-old male had some chest discomfort, and called EMS instead of waiting it out. Good move.</span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Dave obtained the first ECG:</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjl-tiYrRLAC1izpAnWX7COKdWFVK9_0cPnkAt-N8xjEZqx5hyphenhyphen-07FveFNBVJxxYCsDLNObgAE0kQWEHqxTYBAVOWQd3pbKgxRgB5wSVwFZ_VJOqTiQtcfiw2de4KfOhXylfqYAiza0_E0/s1600/Rodrguez+ECG.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="147" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjl-tiYrRLAC1izpAnWX7COKdWFVK9_0cPnkAt-N8xjEZqx5hyphenhyphen-07FveFNBVJxxYCsDLNObgAE0kQWEHqxTYBAVOWQd3pbKgxRgB5wSVwFZ_VJOqTiQtcfiw2de4KfOhXylfqYAiza0_E0/s400/Rodrguez+ECG.jpg" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Nasty ST segment elevations in the anterior leads, eh?</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">That was bad enough, but then the patient went into <b>VF</b>! Fortunately, the time to first shock was minimal, since they were in the back of the ambulance at that point, with the defibrillator an arms-length away. After just one <b>200 joule shock</b>* the patient was back in NSR, with a pretty brisk return to consciousness. At the hospital, he went immediately to the cath lab, where a proximal LAD lesion was opened.</span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">This case is a good reminder - always think of STEMI with a cardiac arrest! Once you get a pulse and a blood pressure back, do an ECG if it hasn’t already been done.</span><br /></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">Case #4 - Fantastic Door-to-Balloon times</span></b></u></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Sorry, no ECG, but in a way that’s a good thing. Let me explain…</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Paramedic Dane Johansson from <b>Stratford EMS</b> responded to a call for a middle-aged male with chest pain. On-scene he quickly performed an ECG, found a large <b>anterior STEMI</b>, and immediately called for a cath lab activation.</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Despite a brief stop in the ED (again, EMS beat the cath lab team!), the door to balloon time was a stunning </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">36 minutes.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> That’s incredible - the national goal is </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">90</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> minutes, so Dane beat that by almost <b>2/3</b>s!</span></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>So why is the "missing" ECG a good thing?</b> Well, no hospital ECG exists because nobody needed one - all the cardiologist needed was the EMS ECG. The patient was discharged from the hospital before I could copy the EMS ECG, so we just have the “after” ECGs stored in our system!</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><u><b><span style="font-size: large;">The Bottom Line</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Earn a Cardiac Save pin yourself! All you have to do is follow the the SHCGB guidelines for a prehospital AMI alert.</span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOkga_CKtmAxEpijhz1DN3zhPt9jSfDM2aUitRHxkZ1NuDghjDt0gAw85eF95_RJoEgOM2mdxNGJ545BuTYTApBg2szyTwlhvGJlwRxwQSTtzL6tQlgEtt-4-updgJa6QLxbjzj-fWhBY/s1600/screenshot321.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="302" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOkga_CKtmAxEpijhz1DN3zhPt9jSfDM2aUitRHxkZ1NuDghjDt0gAw85eF95_RJoEgOM2mdxNGJ545BuTYTApBg2szyTwlhvGJlwRxwQSTtzL6tQlgEtt-4-updgJa6QLxbjzj-fWhBY/s400/screenshot321.jpg" width="400" /></a></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">* Sorry Barry! It's just that <b>shock</b> has fewer syllables!</span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com9tag:blogger.com,1999:blog-4266294048567663301.post-75048208119886840672013-12-17T11:25:00.001-08:002013-12-17T11:25:33.870-08:00¿Se puede... (parte 2): Èske ou ka pale ak pasyan ou a? <span style="font-family: Georgia,"Times New Roman",serif;">In case you can't read the title, it asks "Can you speak with your patients?" In Haitian Creole. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Prehospital medical providers pride ourselves on creative ways to deal with obstacles in the field. But when it comes to communicating with patients who can't speak English well, too many EMS providers only have one back-up solution:</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjECHPQXk3yov9z7khpkRZbbwCjAGsaxkszUBkbvI4iOfCuwctS8igmIxiMhgCle46NUsqaDqfiWziqdtwiffoLDAkGQukS2M08BJX3G1t5ZEkp0d6fRmYAuk2zs-J7Au8NIbqp0a3YDLY/s1600/screenshot268.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"> <img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjECHPQXk3yov9z7khpkRZbbwCjAGsaxkszUBkbvI4iOfCuwctS8igmIxiMhgCle46NUsqaDqfiWziqdtwiffoLDAkGQukS2M08BJX3G1t5ZEkp0d6fRmYAuk2zs-J7Au8NIbqp0a3YDLY/s320/screenshot268.jpg" width="251" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Dolor? Dolor?"<br /><span style="font-size: xx-small;">(<a href="http://reenarose.com/blog/?p=5333">image credit</a>)</span></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">And even that sure-fire method falls apart if the patient speaks Mandarin. Three recent articles highlight different aspects of the problem.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span><span style="font-size: large;"><u><b>1. Dispatching EMS takes longer for non-English speakers</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23952940"><b>The effect of language barriers on dispatching EMS response</b></a> looked at <b>272</b> calls to 911 that were felt to involve some sort of language barrier (not just Spanish). They showed that, either with or without the use of interpreters, 911 calls take longer to dispatch and are less accurate about the chief complaint and need for ALS. </span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaRFdb7MVq3BzlWzBeMKs4uKTRQHngD-J40UkzQr3nkCjCQ2CZCs29PCjesTM480Z62kbrkq3Lj1hPq5Nnq8vQG5YpW3h6sig1rQjb_2Z0qQzGLBl0rkZmwv9oXtJCkSNb5g16gy561uo/s1600/screenshot270.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="103" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaRFdb7MVq3BzlWzBeMKs4uKTRQHngD-J40UkzQr3nkCjCQ2CZCs29PCjesTM480Z62kbrkq3Lj1hPq5Nnq8vQG5YpW3h6sig1rQjb_2Z0qQzGLBl0rkZmwv9oXtJCkSNb5g16gy561uo/s400/screenshot270.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">ALS call took almost <b>3 minutes longer</b> to dispatch.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">In particular, <b>chest pain calls</b> often took much longer to dispatch than many other chief complaints. Since there is so much emphasis being placed on prehospital identification of STEMI, this represents a potentially significant source of delay to treatment.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The authors also found that calls involving a language barrier were far <b>more likely to be downgraded to BLS</b> after ALS was initially dispatched. Unfortunately, they are unable to comment on whether this downgrading was later proven to be appropriate.</span><br />
<br />
<span style="font-size: large;"><u><b>2. EMS care is slowed down by language issues</b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This study isn't quite as recent as the other two, but it points to the next step in prehospital care - how quickly EMS can get to the scene, evaluate and package the patient, and then transport to the hospital. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18189182">A 2008 study reported</a> on how often EMS providers reported various causes of delay. <b>Bad weather</b> was the most common reason, but the second-most common cited problem was <b>language</b>. Note that <b>Hazmat</b> and <b>safety</b> are both far less frequently cited than language as a source of delay.</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhW1F2WSpC0KTeYXW8wDq-e-_WaR5H9wRlVKNoL7igowBVF5Ne3cxHhx1YuSYymZUvhscE7txXKwlTBNwdRWVuHMXf-83YZvrj0ffEXrduZjo4EC69eNlRia3Bi-og7zPDGorNMUmzSxxE/s1600/screenshot277.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="249" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhW1F2WSpC0KTeYXW8wDq-e-_WaR5H9wRlVKNoL7igowBVF5Ne3cxHhx1YuSYymZUvhscE7txXKwlTBNwdRWVuHMXf-83YZvrj0ffEXrduZjo4EC69eNlRia3Bi-og7zPDGorNMUmzSxxE/s320/screenshot277.jpg" width="320" /></a></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Of course, this only applied to a small number of EMS calls - only about <b>3.3/1000</b> calls cited language as a problem. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">However, this study was done in Minnesota, a state where only about <b>8%</b> of the population speaks a language other than English at home, <a href="http://www.census.gov/prod/2003pubs/c2kbr-29.pdf">while in Connecticut, this figure is <b>> 18%</b></a>! Even more locally, <a href="http://en.wikipedia.org/wiki/Bridgeport,_Connecticut#Demographics"><b>> 38%</b> of the Bridgeport population</a> is of Hispanic origin, suggesting this issue might even be more prominent here.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>3. Language barriers affect EMS clinical decision-making</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">In-hospital data has shown that patients with limited English-proficiency are far more likely to get blood tests, imaging, and more invasive procedures. A recent case study shows that this can happen in EMS too, leading to absurd and wasteful decisions.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/24300472"><b>Triage in the Tower of Babel: Interpreter Services for Children in the Prehospital Setting</b></a> report on the case of a infant whose parents spoke only <a href="http://en.wikipedia.org/wiki/Amharic_language"><b>Amharic</b></a>. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br />
<b>ፖሊስጥራ ጥሪ።</b> (<a href="http://www.omniglot.com/language/phrases/amharic.php">Call 911!</a>)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br />Evidently, this child, while attempting to walk, fell onto his butt. Frustrated at this outcome, he started crying, but immediately had (in retrospect) a <a href="http://www.nlm.nih.gov/medlineplus/ency/article/000967.htm"><b>breath-holding spell</b></a>. A very unfunny <b><a href="http://en.wikipedia.org/wiki/Chinese_whispers">game of telephone</a></b> followed when a non-English/non-Amharic neighbor called 911: EMS was subsequently dispatched for "baby not breathing." </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Apparently at least 3 ambulances were dispatched (</span><span style="font-family: Georgia,"Times New Roman",serif;"><b><span class="fn entry-title"><a class="url" href="http://ems12lead.com/" rel="external nofollow">Tom Bouthillet</a></span> </b> would approve!), and found a fully recovered, well appearing child. Since they were unable to obtain a clear history, due to the language, they decided to err on the side of caution by treating him as a pediatric trauma. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">So what happened when they strapped this kid to the backboard? He cried and promptly had another breath-holding spell! Must have looked something like...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.youtube.com/embed/e0640GTjScQ?feature=player_embedded' frameborder='0'></iframe></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">... which must have scared the scat out of everyone. (Breath-holding spells are actually benign, common, and easy to recognize.)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Long story short, the infant received complete packaging, was declared a pediatric trauma <i><b>code</b></i>, and directly transported to a trauma center. He received an <b>IV</b>, a <b>femoral blood draw</b>, and 2 <b>CTs of the head</b>. Eventually, an RN of Ethiopian heritage was able to clarify the history, and the child was discharged with no (non-iatrogenic) injuries.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The authors go on to discuss the problem of language barriers in EMS, and draw a few conclusions. Apart from any legal or regulatory requirement, they consider it to be an <b>ethical obligation </b>to provide translation, even for EMS patients. This misdiagnosis and mistriage caused the patient and parents distress, as well as radiation and pain, and perhaps much of this could have been avoided had communication been clearer. Of course, there are <b>legal obligations</b> to provide translation in the hospital, and the authors highlight how the same laws also apply to EMS. Apart from laws and ethics, they also lay out the <b>economic rationale</b> to provide translation, since the over-triage and over-treatment of these patients ends up costing quite a lot of money!</span><br />
<br />
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">The bottom line</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">If you can't talk to your patients, your care will be incomplete, delayed, and possibly dangerous. If a foreign language is very common in your community, you should consider ways to tackle that challenge ahead of time.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com4tag:blogger.com,1999:blog-4266294048567663301.post-4478313352804672322013-12-09T11:50:00.000-08:002014-03-24T09:45:57.175-07:00¿Se puede aprender CPR en el internet?<span style="font-family: Georgia,"Times New Roman",serif;">(<b>UPDATE</b> 3/24/14: Dr Sasson's work has helped drive the production of a quality, up-to-date CPR video for <i>hispanohablantes</i>. Skip to the bottom for the video!) </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Say you want to learn CPR, but you only speak Spanish. What would you do? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">It looks like some organizations in the area offer CPR classes in Spanish (good outreach <a href="http://www.stamfordems.org/training/ctctraining.htm">Stamford</a>!), but not everyone can make it to these, and they may not be offered often. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">On the other hand, you can learn about anything on the internet these days, so why
should CPR be any different? After all, going to a class is <i>so</i> 1980's. These days, you should be able to Google a
few good websites for CPR, or even better, some videos on YouTube!</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqonX2Dc0i8cr8zuxQi9r7b71ACsNOtzzBiKRTjqSMMWyquoZr2xN__8mAxj7rGz2lL2qw0izlsHok_Mz06SfAAA2vPFSuLRA8PkfypCv8MPR29tkh_HehNHu3houfnTIS_5vw1G77U2Y/s1600/screenshot271.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqonX2Dc0i8cr8zuxQi9r7b71ACsNOtzzBiKRTjqSMMWyquoZr2xN__8mAxj7rGz2lL2qw0izlsHok_Mz06SfAAA2vPFSuLRA8PkfypCv8MPR29tkh_HehNHu3houfnTIS_5vw1G77U2Y/s320/screenshot271.jpg" height="234" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Or just watch some 80's videos on YouTube. Whichever.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">We have a lot of people in this country who speak mostly or only Spanish. Heck, we're the <a href="http://en.wikipedia.org/wiki/Spanish_language#United_States">second-largest Spanish-speaking country</a> in the world! We should be able to choose from a plethora of on-line resources to learn CPR. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Unfortunately,
it turns out that the information available to Spanish speakers is
usually out-dated, incomplete, or confusing. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">The study design</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The authors of <a href="http://www.ncbi.nlm.nih.gov/pubmed/24036407"><b>Availability and quality of cardiopulmonary resuscitation information for Spanish-speaking population on the Internet</b></a>
looked through Google, Yahoo, and YouTube for instruc<span style="font-size: small;">tion on "</span><span style="font-size: small;">
<i>
resucitacion cardiopulmonar</i>," and similar terms. They analyzed the websites and videos, and assigned quality ratings for 6 key elements.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">After sifting through > 300,000 websites, they came up with <b>116</b> results that fit with the study's focus.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The results</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">They foun</span>d that most websites, 86%, didn't teach <b>hands-only CPR</b>.
That's cool - it's only been in the AHA guidelines for laypersons for 5 years... Only half of the websites described <b>activating 911</b>. Other aspects, like <b>scene safety</b> or <b>depth of compressions</b>, were also
missing in many, if not most, internet resources. </span><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuFyjVGqlvwZodnm-s6IPV0nYNTxQGstLp2JTSFrSc-pk2dFpd1-BObn30NuX7VZquaSEmz0H8n7aRyZgmBIz97rWP0bjLrAEKZwEX7ThLnPlyHLtWYbZiALkcEb91RD1CmsPUYXtLthM/s1600/screenshot273.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuFyjVGqlvwZodnm-s6IPV0nYNTxQGstLp2JTSFrSc-pk2dFpd1-BObn30NuX7VZquaSEmz0H8n7aRyZgmBIz97rWP0bjLrAEKZwEX7ThLnPlyHLtWYbZiALkcEb91RD1CmsPUYXtLthM/s320/screenshot273.jpg" height="187" width="320" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The importance </b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Stop the presses - some health-related websites are wrong?! </span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVPwzua0Crk0S4_AYdukklOEw1EDmN38uSKuxE1MFb_h3U2jEku5DcUNDA5u2gAQJ2tHuL7fu1F8yqQNw_GYS-cahB1RfAoziGiUvM6qSq7m34_7N8fK30-vsmerpA5lM6GmkH6cChFfE/s1600/screenshot269.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiVPwzua0Crk0S4_AYdukklOEw1EDmN38uSKuxE1MFb_h3U2jEku5DcUNDA5u2gAQJ2tHuL7fu1F8yqQNw_GYS-cahB1RfAoziGiUvM6qSq7m34_7N8fK30-vsmerpA5lM6GmkH6cChFfE/s400/screenshot269.jpg" height="400" width="358" /></a></td></tr>
<tr align="right"><td class="tr-caption"><a href="http://xkcd.com/386/"><b>XKCD</b></a></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">Lots of internet information is iffy - Why is <i>this</i> a big deal?</span><br />
<br />
<i><span style="font-family: Georgia,"Times New Roman",serif;">* Chain of survival</span></i><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Well,
while researcher are busy wondering if we can eek out a higher survival
rate by using <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa012689">hypothermia</a>, or <a href="http://jama.jamanetwork.com/article.aspx?articleID=1713589">steroids</a>, or <a href="http://www.ncbi.nlm.nih.gov/pubmed/15642869">vasopressin</a>, or <a href="http://millhillavecommand.blogspot.com/2013/02/new-research-that-will-not-help-you.html">"leg-compression" CPR</a>, <b>none of this matters if bystanders don't do CPR in the first place</b>. While it's fun to hash out the evidence regarding the <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa1010821">ResQPOD</a>, the first link in the chain for survival will always be <b><a href="http://jama.jamanetwork.com/article.aspx?articleid=1745678">bystander CPR</a></b>.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><i>* Bystander CPR </i></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">This is why it so concerning that at least one study
has found that <a href="http://www.ncbi.nlm.nih.gov/pubmed/18606316">Hispanics are far less likely to get bystander CPR</a>, and the reasons why aren't clear. If <b>10%</b> fewer Hispanic patients are getting CPR, a <a href="http://www.ncbi.nlm.nih.gov/pubmed/23860985">bolus of prednisone </a>isn't going to save their brains! Part of the reason the AHA switched to "hands-only" CPR was to encourage bystander CPR, and this study suggests that website quality may affect this effort. (Strangely enough, 3 out of the 5 <i>bilingual</i> websites taught hands-only CPR.)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span><i>
</i><span style="font-family: Georgia,"Times New Roman",serif;"><i>* Barriers to accessing 911</i></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The Latino community does not need any further obstacles in dealing with medical emergencies. It's been shown that many people in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/21188532">Spanish-speaking community have doubts and fears when considering calling 911</a>. (And no, it doesn't just have to do with a fear of "<i>la migra,</i>" or the cost of the ambulance. Given that many peo<span style="font-size: small;">ple
had experience with EMS in countries with far different systems than
ours, they are confused about when it would be appropriate to call 911 versus drive to the hospital.)</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">The bottom line </span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">In the last month we've seen good evidence that the <a href="http://jama.jamanetwork.com/article.aspx?articleid=1774037"><b>LUCAS device doesn't save lives</b></a>, and that <a href="http://jama.jamanetwork.com/article.aspx?articleid=1778673">prehospital therapeutic hypothermia probably doesn't help</a> either. Early and effective CPR still remains our most important tool. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Keep in mind that successful prehospital resuscitation programs don't just involve "pit-crews" or regional cardiac-arrest centers. The best programs also put a lot of work into the <i>true</i> first responders, the bystanders. Bobrow et al. showed that <a href="http://jama.jamanetwork.com/article.aspx?articleid=186668">intensive public outreach in Arizona</a> was associated with a doubling in cardiac arrest survival.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">If your EMS catchment area includes many Spanish speakers, you have to figure out how to communicate with them, and enlist them in your efforts to improve cardiac arrest management. Sure, it's easy to do CPR classes in English, down at the high-school or community college like we've always done. But how are we going to reach the non-English speakers, and those that can't make it to a class? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">These days, this outreach is probably going to involve the internet - make sure it's a quality effort!</span><br />
<br />
<u><b><span style="font-family: Georgia,"Times New Roman",serif;">UPDATE:</span></b></u><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The AHA has a new, up-to-date, and complete video on performing CPR in Spanish. Check it out!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"> </span><u><b><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></b></u><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"> </span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com7tag:blogger.com,1999:blog-4266294048567663301.post-63521966267846780582013-10-15T13:03:00.000-07:002013-10-15T18:36:14.458-07:00Fever - does EMS need to treat it?<div dir="ltr" id="docs-internal-guid--36a3164-ba31-31b1-638c-f637598e422f" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Treating a kid with a fever seems like a <b>no-brainer</b>. It almost doesn’t seem to need any further justification - a fever is </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">bad</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, and medicine to treat the fever is </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">good</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">. It’s right up there with mom and apple pie!</span></span></span></div>
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpflIIEiERIjJ1qqIPJ-O6uPqsZo9zmLkR69GtorV5QVQ0V-eIH37BzJTh-hbhwAjuzbXPlOp9iJjabwauFHRlvABZqv00FDSHQ-OV0qdaEBD3Hrk9pMmSpU1SlNPvpxFrKgjNxNidJro/s1600/Zombie_Mom_by_VegasMike.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjpflIIEiERIjJ1qqIPJ-O6uPqsZo9zmLkR69GtorV5QVQ0V-eIH37BzJTh-hbhwAjuzbXPlOp9iJjabwauFHRlvABZqv00FDSHQ-OV0qdaEBD3Hrk9pMmSpU1SlNPvpxFrKgjNxNidJro/s320/Zombie_Mom_by_VegasMike.jpg" width="218" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Did I say "no-brainer?" My bad! (<a href="http://vegasmike.deviantart.com/art/Zombie-Mom-128912729">source</a>)</span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://vegasmike.deviantart.com/art/Zombie-Mom-128912729" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;"></span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It may appear like we're always taking drugs (e.g. </span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">atropine, furosemide) </span></span></span>and devices (MAST pants, pediatric intubation) <i>away</i> from EMS, So, it seems pretty nifty to actually <i>add</i> a drug to the EMS formulary. </span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">And why not? The medicines (Tylenol and ibuprofen) are relatively safe (even zombie moms are allowed to buy it for their babies), </span><a href="http://medicscribe.com/2010/02/tylenol/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">EMS can start the anti-fever therapy quickly</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, and we can prevent…. something. </span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Wait a minute, what are we <i>actually</i> treating? And why is treating a fever so darn important that EMS should do it?</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<span style="font-size: large;"><u><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">1. There is no agreement on when to "treat a fever."</span></span></u></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Tylenol and ibuprofen are used to <b>reduce fever</b>, and to <b>treat discomfort</b>, and are near-universal therapies for kids and adults.</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Treating mild discomfort is a great idea, since not all pain needs morphine. But protocols, in general, only mention <b>a number</b> (temperature) as a trigger for antipyretic use, and most protocols can’t even agree on <b>which</b> <b>number</b> that should be. You can find examples of fever "triggers" for antipyretic use at </span><b><a href="http://www.greenvillenc.gov/uploadedFiles/Departments/Fire_Department/Information/EMS/2006%20EMS%20PROTOCOL%20rev3%202007%20%282%29.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">100°</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, </span><a href="http://www.jointemsprotocols.com/tylenol" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">100.2°</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, </span><a href="http://www.scdhec.gov/health/ems/EMS-Protocols-Sections-1-4.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">100.4°</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, </span></b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">or even</span><b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><a href="http://www.northcentralctems.org/documents/June%202%202009%20NCCEMS%20EMS%20Guidelines%20g.pdf" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">101.5°</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">. </span></b></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">For example, check out the New Hampshire state protocols:</span></span></span></div>
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<span style="font-size: small; margin-left: 1em; margin-right: 1em;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span><img height="233" src="https://lh4.googleusercontent.com/DDFa9rhjLH_zYmq8VJxLnoN5dxOIgKVWfUrIGQBE02YCjbnjpdCpMUMzFJRn1w-n4su50_BVRdpzBXlG2vmj-jVS5mDv8E1SarSsN3uHLQ7fVWY3GnhbckTLfQ" width="400" /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It turns out there’s a <b>good reason</b> why there is no agreement on what temperature "needs" APAP - nobody knows! </span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">And not only is there no evidence saying <b>what</b> temperature elevation needs antipyretic therapy...</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<u><span style="font-size: large;"><b><span style="font-family: Georgia,"Times New Roman",serif;">2. <span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline;">Fever isn’t dangerous!</span></span></b></span></u></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">While having a fever is unpleasant, there is no evidence that it is harmful. In fact, most experts agree that damage can’t occur until the temperature has been <b>over 106°</b> for a while, which is almost unheard of for an infectious cause. </span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">(</span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Hyperthermia</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> - as in <a href="http://emedicine.medscape.com/article/166320-overview"><b>heat stroke </b></a>- is a entirely different matter, and brain damage can occur quickly, <b>even below 106°</b>. But no one talks about giving Tylenol to a kid that’s been locked up in a car during summer.)</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The <a href="http://pediatrics.aappublications.org/content/127/3/580.full"><b>American Academy of Pediatrics</b></a> makes it pretty clear </span></span></span></div>
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<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">There is <b>no</b> <b>evidence</b> that reducing fever reduces morbidity or mortality from a febrile illness. </span></span></span></div>
</blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Yeah, we <i>should</i> treat pneumonia or meningitis with antibiotics (or heatstroke with ice), but there is no benefit to Tylenol besides feeling a little better.<br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<u><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;">3. <span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">It won’t stop a febrile seizure, or keep it from happening again.</span></span></span></u></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Yes, febrile seizures are often unsettling to parents, but they are essentially harmless. <a href="http://pediatrics.aappublications.org/content/121/6/1281.full">Per the experts</a>:</span></span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">There is a <b>theoretical risk</b> of a child dying during a simple febrile seizure as a result of documented injury, aspiration,
or cardiac arrhythmia, but to the committee's knowledge, it has <b>never been reported</b>.
</span></span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">But OK, they aren't, like, <i>medically</i> bad, sure. But why not quickly treat the fever in a kid who <b>just seized</b>, or who has a <b>history of febrile seizures</b> and just spiked a temp? Well, a number of studies have been done on the subject, and they all say the same thing - aggressive use of Tylenol or Advil does <b>nothing to prevent the next febrile seizure</b>. Phenobarbital or valium <i>do</i> prevent them, but they have significant side effects.</span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">As the <a href="http://pediatrics.aappublications.org/content/121/6/1281.full"><b>AAP</b> guideline on febrile seizures</a> notes that (my emphasis):</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span><br />
<blockquote class="tr_bq">
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">In situations in which </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">parental anxiety</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> associated with febrile seizures is severe, intermittent oral diazepam at the onset of febrile illness may be effective in preventing recurrence.</span></span></span></div>
</blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The paramedic’s job should be to reassure (when appropriate) the parents, and treat any mild discomfort associate with a fever. Wrestling a kid to give them Tylenol “to get their fever down” isn’t worth it, and likely doesn’t do much to help their mild discomfort. </span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">I'm also not sure how much the wrestling helps treat the "<b>severe parental anxiety</b>!"</span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<span style="font-size: large;"><u><span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">4. In adults with septic shock and fever, antipyretics could increase mortality</span></span></u></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">A recent issue of <a href="http://journal.publications.chestnet.org/"><b>Chest</b></a> (a journal for pulmonary/critical-care physicians) featured a <a href="http://www.ncbi.nlm.nih.gov/pubmed/24081339">spirited debate on whether septic patients with a fever </a>should be cooled. </span></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The only point on which everyone agreed was that antipyretics like Tylenol or ibuprofen weren’t useful, and could in fact make the situation worse. As the "pro-cooling" team in the debate conceded, </span></span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">“<b>Little evidence-based support exists</b> for use of antipyretic medications to improve fever-associated morbidity and/or mortality.”</span></span></span></blockquote>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>
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<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<u><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">5. It may promote “fever phobia” in parents <i>and</i> medical providers.</span></span></span></u></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">By carrying the drug, and promoting its early use, EMS may play a role in driving "<a href="http://www.nbcnews.com/id/48617869/ns/health-childrens_health/#.Ul2TASSE5oA"><b>fever phobia</b></a>." This is the name for the belief that many parents (and <i>far</i> too many doctors and nurses!) have, that <i>fevers are very dangerous</i>. </span></span></span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">As the expert pediatricians at the AAP put it,</span></span></span></span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> <a href="http://pediatrics.aappublications.org/content/early/2011/02/28/peds.2010-3852">too many doctors and nurses worry</a> about fever causing <b>seizures, brain damage, or death</b>. They then pass on these irrational concerns to the public. As they put it:</span></span></span></span></span></span></span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">It
is argued that by creating undue concern over these presumed risks of
fever, for which there is no clearly established relationship, <b>
physicians are promoting an exaggerated desire in parents to achieve
normothermia</b> by aggressively treating fever in their children.</span></span></span></span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">As a consequence, our medical offices, emergency departments, and EMS systems get many calls for a "kid with a fever," who doesn't otherwise look sick, wasting time and money, sometimes prompting unnecessary tests, and in general causing a whole bunch of bother. </span></span></span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><span style="font-size: large;"><u><b>The Bottom line </b></u></span></span></span></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Giving Tylenol or Motrin, in accordance with your protocols, is fine. These are very safe drugs, and they do well at treating small aches and discomforts. But keep a realistic view of what you are using them for. </span></span>And try to avoid spreading any medical myths!</span><br /><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"></span></span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com19tag:blogger.com,1999:blog-4266294048567663301.post-62081571397216232812013-09-05T12:04:00.001-07:002013-09-05T12:04:43.839-07:00One more word on needling the chest.<span style="font-family: Georgia,"Times New Roman",serif;">Of course, no sooner had I posted <a href="http://millhillavecommand.blogspot.com/2013/08/4-things-to-know-before-you-needle-chest.html"><b>4 things to know before you needle the chest</b></a>, when I found a new article from Australia, just published, describing how new EMS guidelines and education improved their approach to tension pneumothorax. It describes a "new" approach to tension PTX, but also has some of the limitations of the older studies. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/23859653"><span style="font-size: large;"><u><b>"Improvement in the prehospital recognition of tension pneumothorax: The effect of a change to paramedic guidelines and education."</b></u></span></a></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">The authors of this study out of Melbourne had been concerned by the number of patients with a unrecognized tension PTX being brought into their hospital by EMS. Their guidelines for needle decompression evidently placed a certain amount of emphasis on certain physical signs for the diagnosis of progression to tension; e.g. tracheal tugging, subcutaneous emphysema, and JVD, amongst others. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoxL_EdWzLJOCVBuys_LO7_SNF-y15OfIajtgjc8encLYVnm9IxybBSbuhEbjBhmzP7t6kYMc_QtPiCqFP4JF9Uhb5kE1uxI4PqxACGTfwC1vgjweDuFmy1Z7Tgxajz7E3BRNv3uLXrho/s1600/screenshot214.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="117" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhoxL_EdWzLJOCVBuys_LO7_SNF-y15OfIajtgjc8encLYVnm9IxybBSbuhEbjBhmzP7t6kYMc_QtPiCqFP4JF9Uhb5kE1uxI4PqxACGTfwC1vgjweDuFmy1Z7Tgxajz7E3BRNv3uLXrho/s400/screenshot214.jpg" width="400" /></a> </div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Realizing that these indications for decompression were vague and difficult to use in the field, they re-wrote the guidelines with an emphasis on the clinical situation most likely to present with a tension - an intubated patient with chest trauma.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">On top of this, they made <b>7.5 cm</b> IV needles available, as well as a <a href="http://www.youtube.com/watch?v=4aAXDbOUCeg"><b>10 cm-long</b></a> commercial device:</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdREXTdr8RSBD0d7T8BOFbZRNNnGlvb2PJqfXsGaHQ5NLFY9F8GvJC3UiuJuy7WU3xnDee58yubIFbLKVfcTM6nzhh0aypyfZSWJmx3XLrB0gVgvdFY40pAfkEUVHkT2_LAX9OpFwUp78/s1600/screenshot216.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="153" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhdREXTdr8RSBD0d7T8BOFbZRNNnGlvb2PJqfXsGaHQ5NLFY9F8GvJC3UiuJuy7WU3xnDee58yubIFbLKVfcTM6nzhh0aypyfZSWJmx3XLrB0gVgvdFY40pAfkEUVHkT2_LAX9OpFwUp78/s400/screenshot216.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">This Cook device comes with a <a href="http://en.wikipedia.org/wiki/Crossguard">crossguard</a>, for effective parrying.</td></tr>
</tbody></table>
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">Fewer unrecognized tension PTXs</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So the new guidelines and education worked. The rate of tension PTX that was treated by EMS went from about <b>66%</b> to <b>90%</b>. Put another way, the number of unrecognized tension pneumos went from <b>10</b> in one year, to <b>4</b>. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Since the EMS service had also started doing RSI intubations for trauma, the <i>absolute</i> number of tension PTXs also went up - this one EMS agency needled <b>81</b> patients in one year! (BTW, what the heck is going on in Melbourne?! That's a lot of serious trauma.)</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheQqxj194GBpcfhIYOeos088evIWTHuln4Z9i7A_a87STKl-LSV5v5-kqMYtV2hyajoWFwOz-Db9RjAkKeFqSQGMwvEPX2-iFK5ZSx_jnCKzXv5qEu7rKu78TWrEMROaJokBxw4c1a18k/s1600/screenshot221.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEheQqxj194GBpcfhIYOeos088evIWTHuln4Z9i7A_a87STKl-LSV5v5-kqMYtV2hyajoWFwOz-Db9RjAkKeFqSQGMwvEPX2-iFK5ZSx_jnCKzXv5qEu7rKu78TWrEMROaJokBxw4c1a18k/s400/screenshot221.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Imagine what they could do if they had guns!</td></tr>
</tbody></table>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">The limitations</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So, how do we know that the paramedics were sticking needles into <i>true</i> tension pneumothoraces? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Short answer: we don't, not for sure.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Longer answer: This has been the problem with older studies that merely reported, for example, a rate of needle decompression by medics, with no attempt at verification. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11754880"><b>One prior study</b></a>, however, used the subsequent presence of an air leak from a chest tube as a surrogate for tension PTX, and found a very low rate of "true" tension PTX - just <b>14%</b> of the patients that were "needled" by EMS. An<a href="http://www.ncbi.nlm.nih.gov/pubmed/20733183"> ultrasound-based study</a> also casts doubt on the prehospital diagnosis of tension PTX.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br />
The authors of the current paper used a "case definition" to identify tension PTX. That is, they went over all the clinical records and imaging studies, and made a best guess about what the patient had in the field. As you might imagine, this is an imperfect method, and we can only guess at the accuracy of the paramedics' diagnoses.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-size: large;"><u><b><span style="font-family: Georgia,"Times New Roman",serif;">The bottom line</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Despite these concerns about accuracy, there were <b>fewer</b> patients brought into the ED with a tension PTX, even as the rate of RSI, and thus positive-pressure ventilation, <b>increased</b> over the study period. That's a good thing, and it seems as though there was no large increase in complications. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">In the meantime, if anyone is planning a large prehospital study to look at PTXs, it sounds like Melbourne is the place for you! </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br />
</span><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com3tag:blogger.com,1999:blog-4266294048567663301.post-4773515340426395632013-08-31T10:56:00.001-07:002013-08-31T10:57:23.568-07:004 things to know before you needle the chest. <span style="font-family: Georgia,"Times New Roman",serif;">Looking for a tension pneumothorax (PTX), and especially deciding to perform a needle decompression, can trip up even the most smartest EMS provider. There's a balance between the need for aggressiveness, and the wisdom of careful monitoring.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2WOmQqgwnDK2c1hyphenhyphen0bSWozsyM2cMytAzV8Kxapk7azgBVzDS7bxPShTTC6N1N9DGJ9JDVef9D2kugI2dBHcluN1NlQiB83MrompU8xzd88Z3H1Xku0JXJquoh-pfZQ-coerDRMW7B-Z8/s1600/tumblr_m5uy3o1Ywk1rvdh8no1_400.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2WOmQqgwnDK2c1hyphenhyphen0bSWozsyM2cMytAzV8Kxapk7azgBVzDS7bxPShTTC6N1N9DGJ9JDVef9D2kugI2dBHcluN1NlQiB83MrompU8xzd88Z3H1Xku0JXJquoh-pfZQ-coerDRMW7B-Z8/s1600/tumblr_m5uy3o1Ywk1rvdh8no1_400.gif" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Ok, that was too aggressive - dial it back next time.</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">A few recent cases brought into
Bridgeport Hospital, as well as some recent research, help us refine
the approach to evaluation and treatment. 4 fun facts about tension PTX!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>1. It's rare!</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">While
<a href="http://www.ncbi.nlm.nih.gov/pubmed/8550162"><b>some authors have described</b></a> a <b>6%</b> rate of tension PTX in<b> </b>prehospital<b> </b>trauma
patients, the rate is probably far lower in most U.S. EMS systems, with some estimating it
happens in <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658372/"><b>fewer than 0.3% of blunt trauma</b></a> patients.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Another study, <a href="http://www.ncbi.nlm.nih.gov/pubmed/23414956"><b>published in 2013</b>,</a>
found that about <b>1%</b> of the trauma patients coming into a Level 1 center had received a needle by EMS for a suspected PTX, and that most of them ended up getting a chest tube in the ED or OR. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Problem is, they weren't able to tell if the patients had had a <b><i>tension</i></b> PTX when EMS needled them, or just a plain ol' pneumo<span style="font-size: small;">. So, at worst, 1% of severe trauma patients have a tension PTX.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>2. Paramedics have trouble identifying it.</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">That last study showed that paramedics are pretty good at diagnosing a pneumothorax. How good are they at diagnosing the <b>tension</b> part? <b><br /></b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><b>A</b><a href="http://www.ncbi.nlm.nih.gov/pubmed/11754880"><b> study done in Nashiville</b></a> looked at 19 patients who got a needle decompression by EMS for suspected tension. About <b>1/4 of those patients </b>were proven to have <i>any</i> sort PTX (tension or not), and only <b>2/14</b> of the living patients were considered to have had a tension PTX (based on finding an air leak after placing a chest tube). </span><br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvL8wnA8jA0minYoAK5YFObyxAHAA_wb5aUiT48CKFK9G_dOaDJFHVGOFYEt_v5HcfUjOh4avQs5_y0J4Af_y3AKY8155XNVL9ss6tFXCaG-IME2FhHd67rJqq3Mntr5cYXgQDxxnUVgw/s1600/screenshot201.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvL8wnA8jA0minYoAK5YFObyxAHAA_wb5aUiT48CKFK9G_dOaDJFHVGOFYEt_v5HcfUjOh4avQs5_y0J4Af_y3AKY8155XNVL9ss6tFXCaG-IME2FhHd67rJqq3Mntr5cYXgQDxxnUVgw/s320/screenshot201.jpg" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">So, only <b>14</b>% of patients who got a needle actually had a tension PTX</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>3. Diminished lung sounds & crepitus ≠ tension</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">A patient can have complete collapse of a lung, and still not need a needle! </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">A few months ago one of the medics was concerned that they hadn't treated a trauma patient as aggressively as he should have. The patient had fallen a few days prior, and was complaing of shortness of breath. The medic noted bruising over the chest, paradoxical chest wall motion, and absent lung sounds. Nevertheless, the patient was breathing better on 2 lpm of oxygen, and the vitals were fine.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">In the ED, the patient was promptly sent to the CT scan... </span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr8IKT1BaTF-WsxtTfzABrV1cCXWCHTDAc9ryNLVyj45IlZGmhe6An6nkXQMcimQDJ9l9Vg4xMJEdA3KPzCcDEDy6LJktNft6p6XqjT2GSNMIVzM3PHpsPiy4EsPgi4ziUuAHpJco9Is8/s1600/screenshot200.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr8IKT1BaTF-WsxtTfzABrV1cCXWCHTDAc9ryNLVyj45IlZGmhe6An6nkXQMcimQDJ9l9Vg4xMJEdA3KPzCcDEDy6LJktNft6p6XqjT2GSNMIVzM3PHpsPiy4EsPgi4ziUuAHpJco9Is8/s320/screenshot200.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Pneumthorax, as well as subcutaneous air</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">... and got a chest tube right away! So the medic was concerned - should they have placed a needle in the field?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">It doesn't sound like it. It's important to remember why a <b>tension</b> pneumo is bad. Progressive collapse of the lung leads to hypoxia, and the rise in intrapleural pressures compress the IVC, leading to hypotension. In other words, patients don't die from a pneumothorax - they die from hypoxia and shock. <a href="http://roguemedic.com/2011/11/when-should-ems-use-needle-decompression/"><b>Rogue Medic</b></a> wrote about this at some length, and you might enjoy his take on the subject.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">So if subcutaneous emphysema and absent lung sounds don't require you to decompress, what signs should? A very <a href="http://www.ncbi.nlm.nih.gov/pubmed/15611534"><b>thorough (and free!) review article</b></a> from 2005 provided a list of the signs that trauma experts agree could warrant EMS attempting to decompress.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Just remember - hypoxia and hypotension!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6Exfxr5OQSbZOxc7s_Oa-Y32KuQS9vY9_Cs3BNGcKYZ5-e0Y53qU3jUNhh-S8uVcU3HQixEaFU9WpU56b1d_CDSnKvTSB5-EntlK8tlXNBv0kc5Vvg6Z7XLqMUpO1MSHMZJnXAkxUBoM/s1600/screenshot202.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" height="230" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj6Exfxr5OQSbZOxc7s_Oa-Y32KuQS9vY9_Cs3BNGcKYZ5-e0Y53qU3jUNhh-S8uVcU3HQixEaFU9WpU56b1d_CDSnKvTSB5-EntlK8tlXNBv0kc5Vvg6Z7XLqMUpO1MSHMZJnXAkxUBoM/s320/screenshot202.jpg" width="320" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/15611534"><b>Source</b></a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">(Keep in mind that you should be <i>suspecting</i> tension
pneumothorax - <b>don't</b> needle the patient with bradypnea, pinpoint pupils,
and track marks just because she's hypoxic with a decrease LOC.)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjarvO1_ARM6bXGbDD4yc_UR66Rrp7lXL0Vo8UkUQ3eNZTE0YP95LKbEBM62wBllSoYImMtccd_n2UNjtTfVAOTj38SBk-pm9s-6Q0gvQP3YcKk3GI-4rkv8GrFtmEVYN6oqsdtNWMuwLk/s1600/pulpfictionmianeedle.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" height="206" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjarvO1_ARM6bXGbDD4yc_UR66Rrp7lXL0Vo8UkUQ3eNZTE0YP95LKbEBM62wBllSoYImMtccd_n2UNjtTfVAOTj38SBk-pm9s-6Q0gvQP3YcKk3GI-4rkv8GrFtmEVYN6oqsdtNWMuwLk/s320/pulpfictionmianeedle.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">It's only helped in one case report.</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>4. Your needle may be too short (or your patient too big...)</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So, another medic brought in a trauma patient, thrown from a motorcycle, with pain over the left chest, and absent lung sounds as well. The medic had already needled the chest with the standard 14g IV catheter, but reported that lung sounds were still absent.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Sounded like a no-brainer to me; if the patient <a href="http://www.ncbi.nlm.nih.gov/pubmed/23414956">hadn't already needed a chest tube before</a>, now they most likely did (since a needle decompression can also <i>cause </i>a pneumothorax). But when the patient was rolled into the trauma bay, we found no pneumo on chest x-ray, ultrasound, or even CT. Heck, looking at the CT, we realized there was no way the stubby 14 g ever made it near the lung!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">This is a very common experience - unless
you have a special long catheter, you may not
be able to reach the pleural space, especially in the standard
"midclavicular, 2nd intercostal space" that we've been taught. Why? Because <a href="http://thisiswhyyourefat.com/">we're all getting bigger</a>, and the catheters are not!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9fsOydxFTkgvx47cgpYgW4E4wQIF5sl9J2IlDh6pXm21qaqQx0C6AK93axbsX415b0F2FqaKuebit1meuHM0pPKwjuEURG4qRmCYas0gD_PurnlmI9bYLqCc86ReDcYaW_PbeJHJCaUw/s1600/screenshot212.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="65" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9fsOydxFTkgvx47cgpYgW4E4wQIF5sl9J2IlDh6pXm21qaqQx0C6AK93axbsX415b0F2FqaKuebit1meuHM0pPKwjuEURG4qRmCYas0gD_PurnlmI9bYLqCc86ReDcYaW_PbeJHJCaUw/s320/screenshot212.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">A standard 14g iv catheter; <b>2"</b> or <b>5 cm</b>,</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Seems big at first, but take a look at where we're trying to put this needle:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhF3kcWRJrViv4upZbncP3qSJxMY0eGfJNARQF8QYUw7Gs5n6zztisFEi7Wn8TyMDs6ItLUg7EIXRgm9mzlhPFIyhxlbB3YPw4QUbn7zfLFw_ug3LzDFX8l26IiNb4h1CovEQ18736f6ek/s1600/screenshot205.jpg" style="margin-left: auto; margin-right: auto;"><img border="0" height="172" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhF3kcWRJrViv4upZbncP3qSJxMY0eGfJNARQF8QYUw7Gs5n6zztisFEi7Wn8TyMDs6ItLUg7EIXRgm9mzlhPFIyhxlbB3YPw4QUbn7zfLFw_ug3LzDFX8l26IiNb4h1CovEQ18736f6ek/s320/screenshot205.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">People can be thick, both in the 2nd ICS anteriorly (left),</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">as well as the 5th ICS laterally (right)</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">(Adapted from <a href="http://www.ncbi.nlm.nih.gov/pubmed/23618786"><b>Schroeder et al</b></a>)</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;">That can be a lot of skin, fat and muscle to get through! A standard 5 cm catheter <i>may</i> reach the pleura in <a href="http://www.ncbi.nlm.nih.gov/pubmed/21185558"><b>most</b> Japanese patients</a>, and <b>some</b> <a href="http://www.ncbi.nlm.nih.gov/pubmed/23116647">Turkish patients</a>, but only in a <a href="http://www.ncbi.nlm.nih.gov/pubmed/22987168"><b>minority</b> of Americans</a>. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">One option is to place the needle at the <b>5th ICS</b>, along the anterior axillary line, since there is generally less muscle and fat there than at the traditional <b>2nd ICS</b>. <a href="http://www.ncbi.nlm.nih.gov/pubmed/22987168">One study, done in Los Angeles</a>, found that a standard 5 cm (2 inch) needle placed at the <b>2nd ICS</b> would be too short in <b>42</b>% of patients, but only in <b>15</b>% at the <b>5th ICS</b>.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">So, a lateral placement might help, but so might more needle. They make a longer 14 g iv catheter <a href="http://www.emsworld.com/product/10237843/tytek-medical-inc-tpak-chest-decompression-needle">just for decompressing,</a> <i>extra</i> long at <b>3.25 inches</b>, or <b>8 cm</b>. Of course, what's the <i>downside</i> of having an extra-long needle shoved into the left side of the chest?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlTnCnyFDpkrcXGEl7VmltnIUtj6us6-XyrOiHQIJKIRx1MaGDZb0GoRM_x2zyix92IBIYwTnG5Scb7k3kXa-g1vjaT7gPXC7Efe5VJN-Mtc2LWrV_Ox_ggXspi2cdgy_yetnylrzd8UI/s1600/screenshot213.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="212" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlTnCnyFDpkrcXGEl7VmltnIUtj6us6-XyrOiHQIJKIRx1MaGDZb0GoRM_x2zyix92IBIYwTnG5Scb7k3kXa-g1vjaT7gPXC7Efe5VJN-Mtc2LWrV_Ox_ggXspi2cdgy_yetnylrzd8UI/s320/screenshot213.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"With a PTX, is the blood <i>supposed</i> to shoot out?"</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b>The Bottom Line</b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">A pneumothorax happens relatively often in severe trauma, but these do not require any specific prehospital treatment. A tension PTX, on the other hand, is <b>rare</b>, <b>difficult to diagnose</b> in the field, and there are some <b>obstacles to treating</b> it appropriately.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">You're looking for a patient with not just absent lung sounds, but persistent <b>hypoxia</b>, and worsening <b>hypotension</b>. And when you place the catheter, you have to make sure it's actually reaching the pleura - but not too far in!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com9tag:blogger.com,1999:blog-4266294048567663301.post-22583223320561587202013-07-10T12:00:00.001-07:002013-07-10T12:14:41.320-07:00Medics for cath lab activation of STEMI? Non merci!<span style="font-family: Georgia,"Times New Roman",serif;">Although we often talk about "prehospital activation" of the cath lab for STEMI, it isn't always clear what we're talking about. For example, in some EMS systems, the medics give a "heads-up" to the ED, so that a physician can meet them on arrival to confirm a STEMI. Other systems rely on the paramedics to interpret the ECGs themselves, and make a judgement about activation on their own initiative.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">A group of <span dir="auto">Québécois cardiologists, however, decided that they wanted to try a new system, where neither the paramedic, nor the ED physician, would make the decision. Heck, it wouldn't even be a cardiologist. Instead, the turned the decision over to...</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkgo7mPSzzOX2elTRY7jE1MDwgFdHrniBbk57BlUWfmXDB3hLxEHkHkZnUcNev1Jv5r03l1X34MPP9dKXKZ-NzBz20yyuKqRV1wPAbewH1R82gMUto11L3_M2UyGrtwaHADbusW9Xbd_U/s1600/R2-D2-star-wars-3966785-800-600.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgkgo7mPSzzOX2elTRY7jE1MDwgFdHrniBbk57BlUWfmXDB3hLxEHkHkZnUcNev1Jv5r03l1X34MPP9dKXKZ-NzBz20yyuKqRV1wPAbewH1R82gMUto11L3_M2UyGrtwaHADbusW9Xbd_U/s320/R2-D2-star-wars-3966785-800-600.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Beep boop click tweet" (Translate: "I could go for some <a href="http://en.wikipedia.org/wiki/Poutine"><b>poutine</b></a>.")</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b><span dir="auto">The Study</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">The prehospital providers in <a href="http://en.wikipedia.org/wiki/Laval,_Quebec"><b>Laval, Quebec</b></a>, were trained to obtain a 12-lead ECG on patients with <b>chest pain</b> or <b>dyspnea</b>, but did not receive any instruction on interpretation. If the machine (a Zoll, not actually an R2 unit!) gave an interpretation of *** AMI ***, the EMTs put in a call to the hospital paging system to activate the cath team. The ECG was <i>not</i> immediately analyzed or transmitted, although it was saved.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">Over the course of 2 years the EMTs activated the cath lab <b>157</b> times, and most of those went to angiography and were found to have coronary occlusion (a "<b>true</b> STEMI"). A few patients (<b>5%</b>) had a very suggestive ECG, but had nothing on cath ("<b>false positive activation</b>"). It happens.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHSnVxMQt6zLuRAt_CS3n46Dg8DJz0iv5MQAbthyphenhyphenNifUFyN4VnQ3NSSn3NG1yly229tS_QbxMJVdOw74Fyq0UfzUYGoIvYckQGX72WC8-dRjBbJ3sWjLe2AgPjYDNmc-XT1GFV_VkOr8A/s1600/screenshot162.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHSnVxMQt6zLuRAt_CS3n46Dg8DJz0iv5MQAbthyphenhyphenNifUFyN4VnQ3NSSn3NG1yly229tS_QbxMJVdOw74Fyq0UfzUYGoIvYckQGX72WC8-dRjBbJ3sWjLe2AgPjYDNmc-XT1GFV_VkOr8A/s320/screenshot162.jpg" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">Unfortunately, <b>12%</b> of the group were found to be "<b>inappropriate activations</b>," meaning that the ECG shouldn't have led to activation. The authors divide these up into human factors (poor quality tracings, lots of artifact), and machine factors (the machine tried to interpret STEMI during a SVT).</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b><span dir="auto">What's helpful about this study</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">It's good that they have distinguished between "false-positive" and "inappropriate" activations, since these concepts often are mixed up in these kinds of studies. They also highlight the importance of obtaining a quality ECG, free of artifact, as well as the perils of diagnosing a STEMI during tachycardia.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><span style="font-size: large;"><u><b>What's <i>not</i> so helpful</b></u></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The authors focus quite a bit on decreasing the rate of non-STEMI cath lab activations, which is of course a worthy goal. But there is little discussion of the STEMIs that EMS did <b>not</b> catch with the automated system. I.e., this study demonstrated the <b>specificity</b> of the system, but said nothing about the <b>sensitivity</b>.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Look at it this way. Laval is a big town, with about <a href="http://en.wikipedia.org/wiki/Laval,_Quebec">400,000 residents</a> in the city. Based on estimates of the incidence rate of STEMIs (about <span dir="auto"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3011975/">100 STEMIs/year per 100,000</a> people)</span>, there should have been about 800 STEMI patients in Laval during the study period. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">In other words, where were the other 800 - 128 = <b>672</b> STEMIs? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">How many of those 672 patients were transported by EMS? How many were "missed," either because of a bad-quality tracing, a misinterpretation by the algorithm, or because they presented with atypical symptoms, and so never even received an ECG by EMS? We have no idea.</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">So, while decreasing false or inappropriate cath lab activations is a worthy goal, so is making sure that we're not missing anyone who <b>should</b> be sent there! </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>On the other hand, in Denmark...</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">A <a href="http://www.ncbi.nlm.nih.gov/pubmed/23768460">recent article out of Denmark</a> described the experience with a "modern" approach to cath lab activation (e.g., activation based on smaller degrees of ST segment elevation, inclusion of old LBBB patients, use of EMS activation). The Danish cardiologists found a whooping <b>20%</b> rate of negative coronary caths - and were <i>totally fine</i> with it. In their discussion, they express more con<span style="font-size: small;">cern with missing the opportunity for an early intervention, than with the "false negative"rate. They conclude that</span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">a triage program with acute angiogram for
all suspected STEMI patients should anticipate that<b> 1 of
5 patients</b> will not need primary PCI.
</span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Now, I'm not endorsing this rate of negative caths as a goal, and some of their comments suggest that they may have swung the pendulum a bit too vigorously (E.g. "liberal access to acute coronary angiography means some of the patients had a “rule-out”
angiogram, for example younger patients with chest pain
and an ECG compatible with pericarditis.").</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"> Nonetheless, it's clear that the authors are concerned with catching everyone they can in their cardiology "net."</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><span style="font-size: large;"><u><b>So, should we take medics out of the loop on STEMI? </b></u></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">Well, as usual, "it depends." There are so many local factors that go into the design of every EMS system, and this may be the most appropriate response, say, in an area that will likely never be able to support the training and QA/QI that ALS systems require. And, frankly, if all you want your EMS system to do is identify the obvious STEMI cases, this is probably the way to go.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">Except, you probably want your EMS system to do more. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">You want to identify and treat the <b>N</b>STEMI patients who need early intervention, as well as STEMI patients. You want medics to identify the potential, "hyperacute," STEMIs. You want them to find and treat CHF, distinguishing "cardiac asthma" from plain ol' asthma, and even discriminate between primary and compensatory tachycardias. </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto">But the "automated" STEMI activation doesn't provide any benefit beyond getting one small slice of the EMS patient population earlier care. That's fine, great even, but it's still a limited benefit. Why not aim just a bit higher?</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span dir="auto"><br /></span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com5tag:blogger.com,1999:blog-4266294048567663301.post-52222394706195028112013-07-05T12:55:00.001-07:002013-07-05T12:55:30.126-07:00"Cardiac anaphylaxis" after IM epinephrine?<span style="font-family: Georgia,"Times New Roman",serif;">Can IM epinephrine, at the proper dose, cause an MI? A lot of paramedics worry about this, and, as a result, under-treat anaphylaxis. This is a problem, since this is one of the small group of problems where paramedics can truly save a life.</span><br />
<br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifNYIwbDcYhvJnen7WxV09FcdAnPc-PGXKlcfNu10aIoK1dmmoDI1yrwaGFVOKGg1Ve65PuxoMB2vY1yCMHkiKSOWipnTtPcosV8OGjTTxbVw3SZ7D5BESwvzNHbB58BBN8tiTqkp4mxo/s1600/life-saving-murphy-elliott.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="256" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifNYIwbDcYhvJnen7WxV09FcdAnPc-PGXKlcfNu10aIoK1dmmoDI1yrwaGFVOKGg1Ve65PuxoMB2vY1yCMHkiKSOWipnTtPcosV8OGjTTxbVw3SZ7D5BESwvzNHbB58BBN8tiTqkp4mxo/s320/life-saving-murphy-elliott.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Another example: whatever this guy is doing (<a href="http://fineartamerica.com/featured/life-saving-murphy-elliott.html"><b>source</b></a>)</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Of course, some of the previous descriptions of complications after epinephrine therapy involve mistakes in dosing or route. For example, this case report states that a <a href="http://www.cjem-online.ca/v8/n4/p289">young woman developed an AMI after getting "low-dose" epinephrine</a>. Well, she actually received <b>100 µg</b> IV, or 0.1 mg, which is about <b>ten times</b> what these <a href="http://www.ncbi.nlm.nih.gov/pubmed/14988337">allergy experts used in their study</a>. </span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2L0PCZgy2gk2iqLEbRNmhwGNqz88I13CeVA7GBccgfbSMclUkMNC_FX-1hIQO9ZdTqnGSmjfyeFec2DO7hIIRSnfluWyFwBvLB53GEYCuNAdJC4BzPjniNzaNmW25nOUh_ji5eBpD5uA/s1600/Anaph_Tx_Protocol.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2L0PCZgy2gk2iqLEbRNmhwGNqz88I13CeVA7GBccgfbSMclUkMNC_FX-1hIQO9ZdTqnGSmjfyeFec2DO7hIIRSnfluWyFwBvLB53GEYCuNAdJC4BzPjniNzaNmW25nOUh_ji5eBpD5uA/s320/Anaph_Tx_Protocol.jpg" width="185" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Start at <b>5-15</b> µg/min"<br /><b>NOT</b> 100µg/min.</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Or even worse - how about<a href="http://www.ncbi.nlm.nih.gov/pubmed/2757714"> giving 2mg epi IV instead of Narcan!</a> Can you imagine the paperwork you would have to fill out after doing that?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhboCfITS42WWUAnHanG7nx2BPyvJ92GwxTQUM1sxA_tNXlCZOKxPzKPLRw7BHbNbotod_aie_xTeGJWRsL_yvPgDEXATWx-GGNVBcVCgIqLn4PxWTo9lB67GTflR1znAm-cJ-65zGNezs/s1600/h95B766A5.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="247" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhboCfITS42WWUAnHanG7nx2BPyvJ92GwxTQUM1sxA_tNXlCZOKxPzKPLRw7BHbNbotod_aie_xTeGJWRsL_yvPgDEXATWx-GGNVBcVCgIqLn4PxWTo9lB67GTflR1znAm-cJ-65zGNezs/s320/h95B766A5.jpg" width="320" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">A recent case report might cause some EMS providers to worry about administering the appropriate IM dose of 0.3 mg. I don't think that it should - let me explain more.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/23706578"><span style="font-size: large;"><u><b>"Cardiac anaphylaxis: A case of acute ST-segment elevation myocardial infarction after IM epinephrine for anaphylactic shock."</b></u></span></a></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">This case report describes the clinical course of a middle-aged gentleman:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;">A 62-year-old male smoker with no other comorbidities presented to emergency department at 6 <span class="smallcaps">am</span>
with complaints of generalized pruritus and shortness of breath after
taking diclofenac for toothache 1 hour back. On examination, pulse was
97/min; blood pressure, 84/60 mm Hg; jvp, normal; cardiovascular system,
unremarkable; respiratory system, rhonchi bilaterally. </span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;">Sounds like anaphylaxis! The ECG, before epinephrine, showed:</span><br />
<br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicxBTDHRwlsTXAIBys1Z7sIRT6dq6zW5Jxo2I04VBWLKPatydyzmVvRJ_bzEdX3T_0A6G7REuyuhsi6aAYmBzgZHoH5tA_OrmW_poS9VuR0W6ASJRGZiPNQ-clocacjf0PpsYy-fj7EGo/s1600/screenshot157.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="186" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEicxBTDHRwlsTXAIBys1Z7sIRT6dq6zW5Jxo2I04VBWLKPatydyzmVvRJ_bzEdX3T_0A6G7REuyuhsi6aAYmBzgZHoH5tA_OrmW_poS9VuR0W6ASJRGZiPNQ-clocacjf0PpsYy-fj7EGo/s400/screenshot157.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">"Nonspecific [ECG] changes on arrival"</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">He then received <b>1 mg</b> epinephrine IM, which is <b>3 times</b> the recommended dose. Interestingly, they describe the IM administration as having been given over 5 minutes.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">A second ECG was obtained after the patient developed chest pain:</span><br />
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<br />
<span style="font-family: Georgia,"Times New Roman",serif;">He underwent PCI, and a thrombus was sucked out of his LAD. He ended up doing well.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Was the STEMI really due to the epinephrine?</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">I'm not so sure - take a closer look at the initial, "non-specific," ECG:</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxq9zcmIsytxfUS_BjAwdLQ7mOqPYeACu6BNY0p1-tj-YcSashudA37fp_twHx6052Dkr13Og1bzGDj_C6VqTsMa7ae9u6Yfu-0dSsEhc4bihYQixYpMAi_Q3JYFacdIVVsFiVV3Sv42s/s1600/screenshot158.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxq9zcmIsytxfUS_BjAwdLQ7mOqPYeACu6BNY0p1-tj-YcSashudA37fp_twHx6052Dkr13Og1bzGDj_C6VqTsMa7ae9u6Yfu-0dSsEhc4bihYQixYpMAi_Q3JYFacdIVVsFiVV3Sv42s/s320/screenshot158.jpg" width="189" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Close up of V1-V3</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">That looks like quite a bit of ST elevation, especially relative to the QRS, in V2 and V3. But why would someone have a STEMI before getting epinephrine?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Well, sometimes anaphylaxis itself can cause an MI. It's called <a href="http://www.ncbi.nlm.nih.gov/pubmed/20461972"><b>Kounis Syndrome</b></a>, and there a number of case reports out there:</span></span><br />
<h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/19773510"><span>Acute coronary syndrome triggered by honeybee sting: a case report.</span></a><span> </span></span></span></h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18649957"><span>ST-segment elevation myocardial infarction following a hymenoptera (bee) sting.</span></a></span></span></h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">
</span></span><h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18554734"><span>Acute anterior myocardial infarction after multiple bee stings.</span></a></span></span></h1>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: large;"><u><b>The Bottom Line</b></u></span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The authors acknowledge this possibility, and also acknowledge that epinephrine-related MI is not typical.</span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Acute myocardial infarction (MI) following anaphylaxis ("cardiac
anaphylaxis") is rare. Epinephrine causing ST</span> elevation in these
anaphylactic patients is even more rare.</span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"> In this case, I wonder about the initial "nonspecific" ECG, and the role of epinephrine in causing his STEMI. Despite the authors' certainty that "high-dose epinephrine 1 mg (1:1000) IM has triggered the formation of a thrombus in the left anterior descending artery," I wonder if the STEMI was underway before they gave the epinephrine. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">What do you think?</span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com2tag:blogger.com,1999:blog-4266294048567663301.post-36889142088767260742013-06-17T11:15:00.004-07:002013-06-17T11:15:21.486-07:00Atrial Fibrillation: Sure, you can cardiovert it! But should you? (Part 2)<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"> In the <a href="http://millhillavecommand.blogspot.com/2013/05/atrial-fibrillation-sure-you-can.html">first half of this post</a> I emphasized a few points about AF. It can be triggered by a variety of non-cardiac sources - <b>hypovolemia</b>, <b>alcohol</b>, and especially <b>sepsis</b> can all exacerbate chronic AF, or provoke a new episode. You <i>can</i> cardiovert a hypotensive AF patient with any of those problems, and it might (might) fix the rhythm, but it would be unlikely to correct the underlying issue.</span></span><br />
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><br /></span></span>
<span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;">Need another example? Alright, how about AF and an ECG that suggests <b>STEMI</b>? </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"> <u><b><span style="font-size: large;"> </span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">AF and <i>proven</i> STEMIs - first case</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">The
examples above weren't actually hypotensive, but this last patient was. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">An elderly patient with a history of paroxysmal AF was transported by
EMS for acute onset dyspnea, chest and abdominal pain. Things got more complicated when she arrested right upon arrival in the ED. </span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpM6yIMHbXtuBFQHAUuNztQEFyi6-5hlvCT9JmKJVNDPv1V-wGSBJIZ2B4BX5vpS6Y6qW_Ce7nYXrFIsrW8YweYPNmpTbe2UNzp9dLmkr7SUUdcHdXpsvMMqy1rj7zmDl8HZQGNtHDuXI/s1600/Homers_Triple_Bypass.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="248" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhpM6yIMHbXtuBFQHAUuNztQEFyi6-5hlvCT9JmKJVNDPv1V-wGSBJIZ2B4BX5vpS6Y6qW_Ce7nYXrFIsrW8YweYPNmpTbe2UNzp9dLmkr7SUUdcHdXpsvMMqy1rj7zmDl8HZQGNtHDuXI/s320/Homers_Triple_Bypass.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Not the patient - this is <b>me</b> when the patient arrests 10 seconds after arrival.</td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"> Fortunately, this meant that the patient got full, immediate, and successful resuscitation. The post-ROSC
ECG, however, was concerning:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwbBdQTGOV1f6u0Cy0PpVv_GCDLDlAQGyMWpafc2LgfksNz6JpKVAbxX-k_-eDBaYWYeAmY_G_8DwXEZehz2iZfMS6QGASrWSQBi62h2KDklttjfOa9BVsEXMlMfgvTMSrphBe_cqDFUU/s1600/AF_LAD_STEMI.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="148" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwbBdQTGOV1f6u0Cy0PpVv_GCDLDlAQGyMWpafc2LgfksNz6JpKVAbxX-k_-eDBaYWYeAmY_G_8DwXEZehz2iZfMS6QGASrWSQBi62h2KDklttjfOa9BVsEXMlMfgvTMSrphBe_cqDFUU/s400/AF_LAD_STEMI.png" width="400" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">The
patient had a pressure of 80/50 - what should the team have done next? If you say cardioversion, what would you have done if the first attempt didn't work?
(or the second?)</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">(Also, does it help if you know that the prehospital ECG looked like this?)</span></span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9DpM7ND5aMXYgmwiyS9J91pmRaudF550oAhcBj7w2hUMU04daUD7R9i3cgpT5kEM0elpcigQLJW1ffAbbHnkNqkS2ZSC13nMxdaILXzaohAhE_RF1o01MZgq_EWSeglS6jqpYG4qQ_Co/s1600/screenshot150.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="147" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi9DpM7ND5aMXYgmwiyS9J91pmRaudF550oAhcBj7w2hUMU04daUD7R9i3cgpT5kEM0elpcigQLJW1ffAbbHnkNqkS2ZSC13nMxdaILXzaohAhE_RF1o01MZgq_EWSeglS6jqpYG4qQ_Co/s400/screenshot150.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Anything jumping out at you?</span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Well,
you need a <b>plan B</b> in atrial fibrillation! In this case, the team
decided not to re-shock a patient who had <i>just</i> regained their pulse, and
who was apparently<a href="http://eurheartj.oxfordjournals.org/content/30/9/1038.abstract"><b> undergoing a STEMI</b></a>. During emergent cardiac cath, a complete occlusion of their <b>left anterior descending artery</b> was found, and successfully stented.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"> </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><u><b><span style="font-size: large;">AF and <i>proven</i> STEMIs - second case</span></b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">I've <a href="http://millhillavecommand.blogspot.com/2012/01/just-little-burning-and-ton-of-bricks.html">talked about this case before</a>, so I'll be brief.</span> Midlle-aged woman, acute onset chest symptoms:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhk0cn1yYtopqD1em41tqvMCopHDUohjrT8891V3uzSO9ZZYKtVuFZnQv1086jVK68QRy0eKKRUcBlDPTWT5BgglXsYmbufgEBRQLl5b-AQp2ZQh0dovhNx-5pPqTK5z-Ujsgrku46coHQ/s1600/screenshot151.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="138" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhk0cn1yYtopqD1em41tqvMCopHDUohjrT8891V3uzSO9ZZYKtVuFZnQv1086jVK68QRy0eKKRUcBlDPTWT5BgglXsYmbufgEBRQLl5b-AQp2ZQh0dovhNx-5pPqTK5z-Ujsgrku46coHQ/s400/screenshot151.jpg" width="400" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">However, once the medic brought the rapid ventricular response (RVR) down a bit, and the symptoms improved a little, the <b>computer message</b> disappeared when the repeat ECG was obtained...</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz4yu3gcBph5fvCktRi1FhOPPVfmAAtJzkZs5ClQEsBmeSnMbfcNEYtQ_aL-CjWIIDvXUp_yQDvqTmTNw7QfnqmhF4rBHlmr6uOP3M_SBM9ovSFzQrs5XZaG-l1TO1Brx2Iwg0acvcPfE/s1600/screenshot152.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="138" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjz4yu3gcBph5fvCktRi1FhOPPVfmAAtJzkZs5ClQEsBmeSnMbfcNEYtQ_aL-CjWIIDvXUp_yQDvqTmTNw7QfnqmhF4rBHlmr6uOP3M_SBM9ovSFzQrs5XZaG-l1TO1Brx2Iwg0acvcPfE/s400/screenshot152.jpg" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">... but <i>not</i> the <b>ST elevations</b>, <i>nor</i> their apparent reciprocal changes. Her old ECG showed very normal inferior ST segments, supporting the diagnosis of an acute STEMI. During the emergent PCI, they found that an old stent in her <b>RCA</b> was 100% occluded.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>On the other hand...</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Some physicians are fairly skeptical about ST changes that are found in AF with RVR.</span><span style="font-size: small;"> As with other arrhythmias, you can end up with a variety of ST changes that resolve with the tachycardia. <a href="http://lifeinthefastlane.com/ecg-library/pre-excitation-syndromes/">PSVT very commonly produces ST depressions</a>, even in young folks with no heart disease. </span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">For example, despite the dramatic ST depressions (and aVR elevation!), this patient... </span></span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggzBi3mIGWmze_ECAu9aTmr1r6WqYzHzWXibzmGQHI0Vk-2pXPfdurAlk1GkxHdJ_gq1POiILCro_7NzZpkf1i7YqduFCPlT1YJ5p4jRLHRrjf3wt7SxqP65Li-arwjwxoaBNvPNoj_2U/s1600/68yo-M-CP-1-12L.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="171" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEggzBi3mIGWmze_ECAu9aTmr1r6WqYzHzWXibzmGQHI0Vk-2pXPfdurAlk1GkxHdJ_gq1POiILCro_7NzZpkf1i7YqduFCPlT1YJ5p4jRLHRrjf3wt7SxqP65Li-arwjwxoaBNvPNoj_2U/s400/68yo-M-CP-1-12L.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">ECG from a great case at <a href="http://ems12lead.com/2011/09/68-year-old-male-cc-chest-pain-conclusion/"><b>EMS 12-Lead</b></a></span></td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"> ... never had a troponin increase - <b>no MI</b> - and the ST segments normalized after cardioversion.</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Stephen Smith, of <a href="http://hqmeded-ecg.blogspot.com/"><b>Dr. Smith's ECG blog</b></a>, also voices wariness about calling a STEMI in AF with RVR. He has a <a href="http://hqmeded-ecg.blogspot.com/2009/06/atrial-fibrillation-with-rapid.html">great case at his site </a>that illustrates the lesson that, if the patient is <b>losing units of blood</b> from their GI tract, the cath lab is probably not the best first stop, even if the ECG computer is trying to tell you otherwise!</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqe1mD1pCdsE-IMJynEvs8sfEkNSfvmyoqkpN2FRKZwBMHvaAcsQyp_D3zK7_7dGISQ1jlyRuRVZRlS5h-tq4-dPbkKy_TSOqJcrdHLlB18ux4Uy7hkga0XRqey6fj3D8DBrnKiJPfXPU/s1600/killbill_3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="193" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiqe1mD1pCdsE-IMJynEvs8sfEkNSfvmyoqkpN2FRKZwBMHvaAcsQyp_D3zK7_7dGISQ1jlyRuRVZRlS5h-tq4-dPbkKy_TSOqJcrdHLlB18ux4Uy7hkga0XRqey6fj3D8DBrnKiJPfXPU/s400/killbill_3.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Pictured: <b>Not</b> a cath lab candidate.</td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;">So, when <i>do</i> you activate the cath lab? Do you wait to make the call until you've loaded the patient with diltiazem, or do you do it first thing? How long do you look for other causes, versus get everyone moving to the lab?</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Ah, good question, and I wish I had some hard and fast answers. I don't know of any research that looks at this issue, and the experts can disagree. It's often going to depend on the clinical context, as well as evolutions in the ECG findings, echocardiograms, and comparisons with old ECGs - all of which are hard to do in the back of a rig!</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>The Bottom Line</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">This
is a cornerstone of emergency medicine - if the rhythm is fast, and the
patient is not doing well, and you think they are not doing well <i>because of that rhythm</i>, then the patient should be cardioverted. </span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">(Repeat - "</span></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">they are not doing well <i>because of that rhythm</i></span></span>..." Important!)</span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">This is clearly supported in our <a href="http://www.woofmedic.com/SHCGB/protocols.htm"><b>SHCGB protocols</b></a>:</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9xVk0L9UwQtYQ0el1CHJqWAMoa651f-j1iGPdZWUUMBNZWMA9huJC2fmpAtZyyYim-nbLBhyphenhyphenpykISM9xUJqHhjkzJJSW6Njz1QS8iaHCDkPwGYuCvsXjvqAN3FTO4_7O0e9hicO4i0LM/s1600/screenshot89.jpg" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="248" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9xVk0L9UwQtYQ0el1CHJqWAMoa651f-j1iGPdZWUUMBNZWMA9huJC2fmpAtZyyYim-nbLBhyphenhyphenpykISM9xUJqHhjkzJJSW6Njz1QS8iaHCDkPwGYuCvsXjvqAN3FTO4_7O0e9hicO4i0LM/s400/screenshot89.jpg" width="400" /></a></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span><span style="font-size: small;">But
we have seen in these posts a number of examples where cardioversion
probably wouldn't have been effective, since the underlying medical
issues needed treatment. Cardioversion isn't going to treat low
magnesium, hypovolemia, and especially not sepsis!</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"></span><br /><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Cardioversion
for hemodynamically unstable AF is reasonable, but this isn't as
"simple" as ventricular fibrillation. You need to consider the causes
and aggressively treat them, and be ready with a "<b>plan B</b>."</span></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com5tag:blogger.com,1999:blog-4266294048567663301.post-50565689103067169342013-05-30T13:53:00.001-07:002013-05-30T13:53:46.748-07:00Atrial Fibrillation: Sure, you can cardiovert it! But should you? (Part 1)<div dir="ltr" id="docs-internal-guid-4213a751-e3bd-2838-1c1f-16abdc6def27" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Some cardiac arrhythmias are exciting and fun for the prehospital provider. </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">Ventricular fibrillation</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> has, essentially, only one proven therapy, but needs a well-choreographed team to deliver it. </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">Paroxysmal supraventricular tachycardia</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">,
on the other hand, has a far less dire prognosis, but the treatment is
generally safe and dramatic - very satisfying for both the patient and
provider!</span></span></span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV-qdGXpgJ_gcFUrl3ULJk9XoBJSL0BfTqva6_UKIZp6K4aNlVzEdMNtOwbPYVUwO3j5vThc7tG1domSkMHm6yufuDCRjbEhWIa2Yx8P7F0g4LBbrF-6hReIs4cbr5iVeg2WJc0_AUhgI/s1600/Screenshot-baseketball_1998_clip.mp4-1.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="168" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiV-qdGXpgJ_gcFUrl3ULJk9XoBJSL0BfTqva6_UKIZp6K4aNlVzEdMNtOwbPYVUwO3j5vThc7tG1domSkMHm6yufuDCRjbEhWIa2Yx8P7F0g4LBbrF-6hReIs4cbr5iVeg2WJc0_AUhgI/s320/Screenshot-baseketball_1998_clip.mp4-1.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">
<dl>
<dt><span style="font-size: x-small;">Milwaukee Beers ≠ "<span style="font-family: Georgia,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">well-choreographed team"</span></span></span></dt>
</dl>
</td></tr>
</tbody></table>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Unlike
VF or PSVT, however, atrial fibrillation <i>isn’t</i> a fun rhythm to deal
with, either in-hospital or prehospital, and there are many ways to screw up. Even
the new edition of</span><a href="http://www.amazon.com/Nancy-Carolines-Emergency-Care-Streets/dp/1449645860/ref=rec_dp_2" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">Nancy Caroline's Emergency Care in the Streets</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> has little to say about management of atrial fibrillation, only mentioning that </span></span></span><br />
<blockquote class="tr_bq">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">"</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">Prehospital treatment of atrial fibrillation is rare because of the risks involved</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">."</span></span></span></blockquote>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">However, they don't describe those risks, or how to avoid them!</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">They are likely correct about the "rare" part - one </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/11146008" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: underline; vertical-align: baseline;">study of atrial fibrillation treated by EMS</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">
backs this up - you just aren't likely to have a patient with atrial
fibrillation that needs cardioversion or emergent diltiazem. On the
other hand, atrial fibrillation is </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">really</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">
common in EMS, and we should know a bit more about this. There are lots
of recent articles and old insights about AF - how about we start with</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;"> 4</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> things?</span></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">1. AF is often a </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">symptom</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">, not the disease</span></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Some
rhythms require treatment, regardless of the history or exam. In other
words, sometimes we "treat the monitor." AF is not like this.</span></span></span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">Example:
A medic recently brought us an older female with <b>
palpitations</b>. Evidently this had started about <b>3 hours</b> prior, and was
just getting worse. She had been taking all her "heart pills," but had
had some <b>vomiting and diarrhea</b> for the past day and a half. Her HR was <b>
180</b>, and she was somewhat hypotensive at <b>95/60</b>. Her sat and RR were
basically normal. </span></span></span></div>
<div dir="ltr" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">A 12-lead was obtained:</span></span></span><br />
</div>
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTiEc9eJKIjqwsCcUCJmJlb2049-cID9D-K-Ktmd_L7DODyKaHNHiEaA4IOa2XHPhp-eVfnn_prmmCsTCeXEn016G01l6PI5VEOTm1caWnW266hh-Viv2SCAc8_DtJOZ_QfLciPQr8ilU/s1600/screenshot64.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="151" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgTiEc9eJKIjqwsCcUCJmJlb2049-cID9D-K-Ktmd_L7DODyKaHNHiEaA4IOa2XHPhp-eVfnn_prmmCsTCeXEn016G01l6PI5VEOTm1caWnW266hh-Viv2SCAc8_DtJOZ_QfLciPQr8ilU/s400/screenshot64.jpg" width="400" /></a></span></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">ST-segment
changes, rapid AF and hypotension - should the patient receive <b>diliazem</b>, <b>metoprolol</b>, or even<b> cardiovert</b>? These can the
right answers for many rhythms with & without hypotension (e.g. VT, PSVT), but AF
can be different.</span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The
medic decided, based on the recent history of volume losses, that a
fluid bolus should be tried. After 300 ml of NS he saw a change in heart
rate, and recorded ECG #2:</span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBNgB4oitQH5enxbGu_JRSMpvA44DXysHpbb1zfFnuQK_m6rmQ4WMhw_W3YHLnOyHaUW1ZXLV_qFfRskGCoBUfdl2xoseAqVR_u-OX2mATst1LBKGEjzmZrWGLCncGQ6HcAD6mvakuO_Y/s1600/screenshot65.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="151" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBNgB4oitQH5enxbGu_JRSMpvA44DXysHpbb1zfFnuQK_m6rmQ4WMhw_W3YHLnOyHaUW1ZXLV_qFfRskGCoBUfdl2xoseAqVR_u-OX2mATst1LBKGEjzmZrWGLCncGQ6HcAD6mvakuO_Y/s400/screenshot65.jpg" width="400" /></a></span></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"></span><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">The
blood pressure settled out at 120s/70s, and the rest of transport was
uneventful. She ended up getting some diltiazem in the ED, but it looked
more like <b>dehydration</b> that caused her tachycardia, as well as
impaired absorption of her medications.</span></span></span><br />
<div dir="ltr" id="docs-internal-guid-4213a751-e3bf-c144-2641-1e81f9f48995" style="line-height: 1.15; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">This is very common - AF is often provoked or worsened by non-cardiac problems. A</span><a href="http://www.medscape.com/viewarticle/587135" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">drinking binge</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> can do it, and so can</span><a href="http://www.bmj.com/content/345/bmj.e7895" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">hyperthyroidism</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">. A</span><a href="http://www.ncbi.nlm.nih.gov/pubmed?term=23172839" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;"> low magnesium</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, in some cases, may be responsible.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> Both a large</span><a href="http://www.ncbi.nlm.nih.gov/pubmed/22212132" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">pulmonary embolus</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> (because of the right atrial strain), and an</span><a href="http://eurheartj.oxfordjournals.org/content/30/9/1038.abstract" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: underline; vertical-align: baseline;">MI</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">, may kick off AF. And as for alcohol...</span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><b><span style="font-size: large;"><u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><b>2. Alcohol (too much <i>or</i> too little) and AF.</b></span></u></span></b></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;">He was weak, had <b>vomited</b> at least 10 times that day, and couldn't stop <b>shaking</b>. This 40 y.o. man had <b>stopped drinking 2 days ago</b>, and had not done well since. The <b>palpitations</b> were the final straw, pushing him to come to the ED.</span></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><br /></span></span></span>
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"Excuse me, did something crawl down your throat and die" <br />
<a href="http://www.imdb.com/name/nm0144657/?ref_=tt_trv_qu"><span class="character"></span></a>"It didn't die!" </td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">His heart rate was bumping up <b>over 200</b>, but the ECG caught him at a relatively slow point:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhotbErDaOXaKvoGbUnpwqwHwLG6L8laC4cc17D_CYOVH95EqR_kTOg1FgeyUgYDLTQIRDuj3NR3a2dytq7LRp96HWG9PcxCIqQXcrcFqdOIlRiwP8uWFvJnIo9gijpspNBFQxuxY_Lw4o/s1600/AF_ECG_Detox_&_vomiting.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="146" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhotbErDaOXaKvoGbUnpwqwHwLG6L8laC4cc17D_CYOVH95EqR_kTOg1FgeyUgYDLTQIRDuj3NR3a2dytq7LRp96HWG9PcxCIqQXcrcFqdOIlRiwP8uWFvJnIo9gijpspNBFQxuxY_Lw4o/s400/AF_ECG_Detox_&_vomiting.png" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">His labs confirmed that he has dehydrated, with <a href="http://www.ncbi.nlm.nih.gov/pubmed?term=23172839"><b>low levels of magnesium</b></a> and <b>potassium</b>. His alcohol history, <a href="http://www.medscape.com/viewarticle/587135"><b>both the excess, and the abrupt cessation</b></a>, also likely contributed to provoking a new-onset atrial fibrillation. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">He clearly didn't need cardioversion, but it also seemed premature to use diltiazem or metoprolol first. He received a liter of <b>saline</b>, some <b>magnesium</b> and <b>potassium</b>, as well as <b>Valium</b> for the withdrawal. This went a long way towards improving his heart rate, and he only needed a small dose of <b>metoprolol</b> after all that.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">So, while he had atrial fibrillation, he had other medical issues (like the withdrawal) that were more important. This is actually pretty common - <span style="font-size: small;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/23406079"><b>about 75% of patients</b></a> who come to the emergency department who have AF on their ECG actually have a </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: bold; text-decoration: none; vertical-align: baseline;">different primary diagnosis</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: normal; text-decoration: none; vertical-align: baseline;"> - the top three diagnoses are <b>CHF</b>, <b>pneumonia</b>, and <b>chest pain</b>. </span></span></span></div>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5sXditPVlV8CC3WFlnjzam8pDxWm5ciGnsAw8O3JPmrsn5bAKOkTvvmHBLM5RKoVEczwBBaXWKrVD5YW1izEOgjM-nzXJTQT8vjYT5MuRfgPk04g6vHChWpUb-LgMVJ21H_H9W3xZOJg/s1600/Table_Prim_AF_vs_Second_AF.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj5sXditPVlV8CC3WFlnjzam8pDxWm5ciGnsAw8O3JPmrsn5bAKOkTvvmHBLM5RKoVEczwBBaXWKrVD5YW1izEOgjM-nzXJTQT8vjYT5MuRfgPk04g6vHChWpUb-LgMVJ21H_H9W3xZOJg/s400/Table_Prim_AF_vs_Second_AF.png" width="236" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/23406079"><b>Patients with AF and an Alternative Primary Diagnosis in the ED </b></a></span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><b><u>3. This is <i>especially</i> true for sepsis and AF. </u></b></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">I
recently saw a patient brought in from a nursing home with AF at <b>170</b>-<b>180</b>
bpm, as well as <b>hypotension</b>. Sorta looked like this:</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2gtHB4EJrWVEdXTv_QcjBHnSv5S_q7ZiBPuInyv_CM_Qm2tkJxCABtguc49PIvuwFDdvhhgRJhTC1ko4hYYsvIfILNX3roJZrvx2CyfmrDfyNx0JV54uWwEK6k6Df6vTBUXhAbvI5BQA/s1600/af2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="101" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi2gtHB4EJrWVEdXTv_QcjBHnSv5S_q7ZiBPuInyv_CM_Qm2tkJxCABtguc49PIvuwFDdvhhgRJhTC1ko4hYYsvIfILNX3roJZrvx2CyfmrDfyNx0JV54uWwEK6k6Df6vTBUXhAbvI5BQA/s400/af2.jpg" width="400" /></a></span></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="http://lifeinthefastlane.com/ecg-library/atrial-fibrillation/"><b>LITFL</b></a></span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">However, she also had a new history of a <b>
cough</b> and <b>altered mental status</b>, although no documented fever. I decided to try a <b>liter
of saline</b> first, rather than a bolus of diltiazem, thinking that the rapid ventricular response was due to pneumonia and metabolic stress. Fortunately, the bolus dropped the heart rate down
to 110-120, and raised her BP. She was admitted to the ICU with a bad case of <b>sepsis</b> and <b>pneumonia</b>, no diltiazem or metoprolol needed.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">This case was not unusual - it turns out there is a HUGE relationship between sepsis and AF. Some surprising facts:</span></span><br />
<ul>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">New-onset AF happens in > <a href="http://www.sciencedirect.com/science/article/pii/S0002870313002263"><b>6</b>% of severe sepsis</a> cases (<a href="http://ccforum.com/content/14/3/R108">or even <b>46</b>%!</a>) </span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><b>14</b>% of new-onset AF cases in the hospital <a href="http://jama.jamanetwork.com/article.aspx?articleid=1104649#ref-jce15005-31">occur during severe sepsis</a></span></span></li>
<li><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">Mortality of patients w/ <a href="http://jama.jamanetwork.com/article.aspx?articleid=1104649#ref-jce15005-31">severe sepsis and new-onset AF</a> is > <b>50</b>%</span></span></li>
</ul>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrCOFHdePZKR7kDRSB3uZ_lDL3cNQDbObKqYCpWtSG45F3lwvJ7iGsojQYe84nV3amGMC3W2Q6443pQWsYSuYMOzCJecrJgU0Z06RT5sYbcAEWH7ZyZtfiA35L2GfSgUDXmmec-5muBuM/s1600/cc9057-3.bmp" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="264" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgrCOFHdePZKR7kDRSB3uZ_lDL3cNQDbObKqYCpWtSG45F3lwvJ7iGsojQYe84nV3amGMC3W2Q6443pQWsYSuYMOzCJecrJgU0Z06RT5sYbcAEWH7ZyZtfiA35L2GfSgUDXmmec-5muBuM/s320/cc9057-3.bmp" width="320" /></a></span></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><span style="font-size: x-small;">AF & sepsis = bad news bears.</span></span></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">It isn't clear how AF should be treated in severe sepsis, besides treating the source of infection and supportive care. The use of rate-controlling medications (diltiazem and metoprolol) may "<b>mask</b>" the signs of sepsis, complicating the use of fluid boluses or pressors. Cardioversion with drugs or electricity pose their own hazards.</span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;"><br /></span></span>
<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: small;">So, if your nursing home patient has new AF, think: <b>Could this be sepsis?</b></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<br /><u><span style="font-size: large;"><b>To be continued!</b></span></u><br />
<span style="font-family: Georgia,"Times New Roman",serif;">So far these patients I've discussed haven't been terribly unstable. In my last example (to be posted soon!) I'll discuss a truly critical patient with paroxysmal AF, where cardioversion was <i>not</i> performed. I've already shown the ECG on the <a href="https://www.facebook.com/photo.php?fbid=360472280721669&set=a.281990401903191.48279.145223525579880&type=1"><b>Mill Hill Ave Command Facebook</b></a> page, but I'll share more elements, and how they relate to management. </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com12tag:blogger.com,1999:blog-4266294048567663301.post-89746916302615548152013-05-09T13:13:00.000-07:002013-05-09T13:13:57.120-07:00Two ECGs - which goes to the cath lab?<span style="font-family: Georgia,"Times New Roman",serif;">A recent study suggests that a computer interpretation of the ECG can be extremely specific for diagnosing a STEMI; i.e. if the computer reads </span><br />
<br />
<div style="text-align: center;">
<span style="font-family: Georgia,"Times New Roman",serif;"><b>*** ACUTE MI ***</b></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">you can take that to the bank.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">This hasn't fit with my experience, and so I was very interested in <b><a href="http://medicscribe.com/2013/05/computer-stemi-interpretation-revisisted/">Peter Canning's latest post</a></b>, since it validated my suspicions. He found that the ECGs his system are acquiring show surprisingly poor sensitivity and specificity for STEMI, <b>if</b> you simply rely on the computer to diagnose. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">As an illustration of this point, I submit ECGs from 2 patients. </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">(For more pairs of ECGs that show the problem with relying on the computer diagnosis of STEMI, click on the label "<a href="http://millhillavecommand.blogspot.com/search/label/Paramedics%20need%20to%20read%20EKGs"><b>Paramedics need to read ECGs...</b></a>" on the right.)</span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">Case 1</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Let's say that this was a middle-aged female, who started having substernal chest pain about 15 minutes ago. The EMS 12-lead shows:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivRiLCBHeHspRN5msGxuCaxKoRCx2QwZMgGv_mIACHVc0cqIkyemKxOvNvZbruK44T6L6Yx4DnqVDwdbzd2uXmBNI4e5uVG1_L-Ecbn-HXVgfdvbZutU3K3sQCUGCrNRqnmkN2PR8BPrs/s1600/screenshot106.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="161" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEivRiLCBHeHspRN5msGxuCaxKoRCx2QwZMgGv_mIACHVc0cqIkyemKxOvNvZbruK44T6L6Yx4DnqVDwdbzd2uXmBNI4e5uVG1_L-Ecbn-HXVgfdvbZutU3K3sQCUGCrNRqnmkN2PR8BPrs/s400/screenshot106.jpg" width="400" /></a></span></div>
<br />
<span style="font-family: Georgia,"Times New Roman",serif;">Aside from diagnosing the patient as "<a href="http://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml"><b>borderline</b></a>," anything else look suspicious? </span><br />
<br />
<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">Case 2</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">Again, a middle-aged female, this time with pleuritic chest pain and wheezing. An ECG obtained 5 minutes after arrival in the ED shows:</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmfyVVwPHk8nfk4MuoqtT-gXRDOWj8ny-jC7_3UOfa2cdRICkYB9HCzvvs1ipLnUsshArMPuSFykBfA6QJWNUvR0mU2ZLaFMtuGlXKT2i1MVtf3SEtO0hvPQpietobMIDsRijcqMEqdKc/s1600/screenshot108.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="273" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgmfyVVwPHk8nfk4MuoqtT-gXRDOWj8ny-jC7_3UOfa2cdRICkYB9HCzvvs1ipLnUsshArMPuSFykBfA6QJWNUvR0mU2ZLaFMtuGlXKT2i1MVtf3SEtO0hvPQpietobMIDsRijcqMEqdKc/s400/screenshot108.jpg" width="400" /></a></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">What's an appropriate next step? Call in the (cardiology) cavalry, or do a little sleuthing?</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC4J10qV2WeP0P09lZXKJZc7WJQZEbWt7wu9EanetSfeKEmnOPnlsShFxAX628Y3I6DZKQbGj_Yz0-AYPer2CFwqH1209-tIwH05jtCeUy6t6Y6r95hc59IWp0xoMKQ37JDKdsHRfCl3s/s1600/aas_batphone.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="211" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjC4J10qV2WeP0P09lZXKJZc7WJQZEbWt7wu9EanetSfeKEmnOPnlsShFxAX628Y3I6DZKQbGj_Yz0-AYPer2CFwqH1209-tIwH05jtCeUy6t6Y6r95hc59IWp0xoMKQ37JDKdsHRfCl3s/s320/aas_batphone.jpg" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;">Call for a bat-stent? (<a href="http://www.allaboutsymbian.com/news/item/8884_Its_So_Top_Secret_I_Cant_Even_.php"><b>source</b></a>)</span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Resolution</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">If you look closely at few of the leads, especially V3, you can see small spikes preceding the QRS. Since the computer hadn't seemed to notice, I adjusted the settings to recognize pacemakers. A second ECG then showed pretty much the same complexes, but a very different interpretation.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwoMbwcsqeXXDlYPkfWVFkbiOscTY-lImsDNCOfhX45Q3KC0JgsDOuwoVbJQJZoDBfwj5VnjlMNg8MWccRhUDGVY4E6-woXYm_6qYZ6WP5Xmn2mGeSZeAYk-IOpQsIdLDxszydZatu4VU/s1600/screenshot110.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="273" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjwoMbwcsqeXXDlYPkfWVFkbiOscTY-lImsDNCOfhX45Q3KC0JgsDOuwoVbJQJZoDBfwj5VnjlMNg8MWccRhUDGVY4E6-woXYm_6qYZ6WP5Xmn2mGeSZeAYk-IOpQsIdLDxszydZatu4VU/s400/screenshot110.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fixed!</td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;"></span></div>
<span style="font-family: Georgia,"Times New Roman",serif;">She turned out to have a fairly ordinary case of COPD.</span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">How about case #1? </span><br />
<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>
<span style="font-family: Georgia,"Times New Roman",serif;">Evidently the patient was first transported to a non-PCI capable hospital. About 2 hours later she was on her way to a different hospital for an urgent cardiac catheterization. This gave EMS a unique opportunity to capture the evolution of the ECG over a time frame that we don't often find in urban/suburban EMS.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLLpUvvXbTZsz8oMO3vXxO5uhealZBM1WyugeXsWcAwA4GbqSAgCluSukI2Bu6TubvGjawj6kaiLdDF37P0ksQWGhba9f7BvgOun8bK-aRSCAH-7PtUNpY9RVOnwLTK5uNs4NslwHxjwA/s1600/screenshot107.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="157" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjLLpUvvXbTZsz8oMO3vXxO5uhealZBM1WyugeXsWcAwA4GbqSAgCluSukI2Bu6TubvGjawj6kaiLdDF37P0ksQWGhba9f7BvgOun8bK-aRSCAH-7PtUNpY9RVOnwLTK5uNs4NslwHxjwA/s400/screenshot107.jpg" width="400" /></a></span></div>
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<span style="font-family: Georgia,"Times New Roman",serif;">Frankly, I'm inclined to agree with the computer this time! But what did the computer "miss" on the first ECG?</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><span style="font-size: large;"><u><b>Hyperacute T waves</b></u></span></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">As Peter found after analysis of his system's STEMIs, computers aren't good at recognizing the earliest sign of an MI on an ECG, the<a href="http://ecg.bidmc.harvard.edu/maven/dispcase.asp?rownum=165&ans=1&caseid=166"><b> hyperacute T-wave</b></a>. These are transient features, before the ST segment has had a chance to elevate, and EMS is in a unique position to find these on their initial ECG.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">Stephen Smith has some great examples, some of which look very similar to case #2 here. For instance, this ECG was acquired by EMS, and was instrumental in suggesting ACS to the emergency physician:</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnso4qH4Od9F0-kvFBPOA7cqyPdMyhQqVI_tbJa5OIEZEC4F9PtDQLaauZF3zbBYXQvVrHlvdxbjmjIR_X442rQEbcgveESgaJAkSX_QyhWpl-utiSZKnD_8efmK9_J05NhTC49Gc783M/s1600/1-1535+prehospital+ECG.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="113" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnso4qH4Od9F0-kvFBPOA7cqyPdMyhQqVI_tbJa5OIEZEC4F9PtDQLaauZF3zbBYXQvVrHlvdxbjmjIR_X442rQEbcgveESgaJAkSX_QyhWpl-utiSZKnD_8efmK9_J05NhTC49Gc783M/s400/1-1535+prehospital+ECG.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://hqmeded-ecg.blogspot.com/2011/06/transient-stemi-serial-ecgs-prehospital.html"><b>Dr Smith's ECG Blog - 6/2011</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Another case involved an anterior MI that was misdiagnosed as hyperkalemia because of the magnitude of the hyperacute T-waves:</span><br />
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<tr><td style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHKfuPIeLXQlBxWBgr7_K7VlgIJpZL1g-pNWK_2dExZfGua9PpSRWYyMCQo8t8Eoe8Fmn7qPVpERJu6Jr3avGb7cmDsCUARfjNZ19I2MjK5f3jdS4eW7gpeKv5AVTp1cdgQpm0iDvX2eg/s1600/Second+EKG+now+without+ST+depression.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="193" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgHKfuPIeLXQlBxWBgr7_K7VlgIJpZL1g-pNWK_2dExZfGua9PpSRWYyMCQo8t8Eoe8Fmn7qPVpERJu6Jr3avGb7cmDsCUARfjNZ19I2MjK5f3jdS4eW7gpeKv5AVTp1cdgQpm0iDvX2eg/s400/Second+EKG+now+without+ST+depression.png" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Georgia,"Times New Roman",serif;"><a href="http://hqmeded-ecg.blogspot.com/2009/02/hyperacute-t-waves.html"><b>Dr Smith's ECG Blog - 2/2009</b></a></span></td></tr>
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<span style="font-family: Georgia,"Times New Roman",serif;">Very similar to our patient #2!</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><u><b><span style="font-size: large;">The Bottom Line</span></b></u></span><br />
<span style="font-family: Georgia,"Times New Roman",serif;">For more teaching on hyperacute T-waves, follow the links above to the blogs written by <a href="http://medicscribe.com/"><b>Peter Canning</b></a> or <a href="http://hqmeded-ecg.blogspot.com/"><b>Dr Smith</b></a>, or check out <a href="http://www.consultantlive.com/display/article/10162/1338176"><b>this review</b></a>.</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;">And remember - sometimes you have to treat the monitor, not just the patient. Just make sure you're not treating a mistaken computer!</span><br />
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<span style="font-family: Georgia,"Times New Roman",serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com4