Acute Atrial Fibrillation in the ED: Almost all goes home

Atrial fibrillation (AF) is the most common dysrhythmia presenting to ED. The management options depend on patient stability, presence of underlying causes and factors in the patient history. In stable patients presenting in AF with a rapid ventricular response, both rate and rhythm control are acceptable approaches. Physicians often tend toward rate control because evidence has shown no mortality benefit between the two approaches. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial contributed to this trend when it concluded no survival advantage and higher risk of adverse drug effects with rhythm control. However, rhythm control is the preferred approach for the management of acute stable AF in Canadian guidelines. The advantages are a higher rate of symptom resolution, restoration of sinus rhythm and avoiding the need for rate control prescriptions, decreased ED length of stay, and hospital admissions.

In the electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2) trial, it was found that both drug–shock and shock-only strategies were effective, rapid, and safe with 96% of patients discharged home in sinus rhythm. The drug infusion worked for 50% of patients avoiding procedural sedation.

The evidence that supports the management of acute AF in the ED without hospital admission is increasing. Implementing practices to achieve that will markedly decrease the burden on the health care system.

ED Management

Approach of Atrial fibrillation

AF might be secondary to variable causes, including ACS, Heart failure, PE, sepsis and bleeding. In patients with secondary AF, cardioversion might be harmful, and the mainstay of treatment is tackling the underlying cause. Those patients will require hospital admission. For primary AF, if the patient is unstable, electrical cardioversion should be done without delay. Stable primary AF may be managed with rate or rhythm control.

Rate control can be achieved with the following:

CCB: Diltiazim 0.25 mg/kg over ten mins, repeat q15-20 mins, up to three doses (avoid in heart failure)

BB: Metoprolol 2.5-5 mg q15-20 mins

Digoxin: 0.25-0.5 mg loading dose then 0.25 mg q4-6 hs (if hypotension or acute HF occur)

Target is HR <100 at rest or <110 walking

Rhythm control is safe with the following according to The CAEP AF best practice guidelines:

  1. Anticoagulated for three or more weeks.
  2. No valvular heart disease, prior stroke or TIA plus: 
  • Onset in 12 hours or less
  • Onset more than 12 hours but less than 48 hours plus less than two of :
    • Age less than 65, DM, HTN, HF.
  • Cleared by TOE

Methods:

  • Procainamide 15mg/kg in 500 ml of NS over an hour.

Other agents: Amiodarone, Ibutilide, flecainide, etc.

  • Electrical: 150-200 J synchronized. Requires sedation.

Anticoagulation:

If CHADS positive then discharge on DOAC or Warfarin.

Disposition:

Almost all patients can be discharged home after cardioversion or effective rate control with appropriate follow up: within a week if warfarin or rate control agent prescribed, otherwise in 4 weeks.

Patients will require admission if one of the following:

  • Highly symptomatic after treatment.
  • ACS
  • Acute heart failure not improved in the ED

References and Further Reading

  1. Stiell, I. G., Macle, L., & CCS Atrial Fibrillation Guidelines Committee (2011). Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. The Canadian journal of cardiology27(1), 38–46. https://doi.org/10.1016/j.cjca.2010.11.014
  2. Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg, Y., Schron, E. B., Kellen, J. C., Greene, H. L., Mickel, M. C., Dalquist, J. E., Corley, S. D., & Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators (2002). A comparison of rate control and rhythm control in patients with atrial fibrillation. The New England journal of medicine347(23), 1825–1833. https://doi.org/10.1056/NEJMoa021328
  3. Baymon, D. E., & Baugh, C. E. (2020). Patients with Atrial Fibrillation in the Emergency Department: Strategies to Achieve Best Outcomes. https://www.hmpgloballearningnetwork.com/site/eplab/patients-atrial-fibrillation-emergency-department-strategies-achieve-best-outcomes
  4. Martín, A., Coll-Vinent, B., Suero, C., Fernández-Simón, A., Sánchez, J., Varona, M., Cancio, M., Sánchez, S., Carbajosa, J., Malagón, F., Montull, E., Del Arco, C., & HERMES-AF investigators (2019). Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine26(9), 1034–1043. https://doi.org/10.1111/acem.13703
  5. Stiell, I. G., Sivilotti, M., Taljaard, M., Birnie, D., Vadeboncoeur, A., Hohl, C. M., McRae, A. D., Rowe, B. H., Brison, R. J., Thiruganasambandamoorthy, V., Macle, L., Borgundvaag, B., Morris, J., Mercier, E., Clement, C. M., Brinkhurst, J., Sheehan, C., Brown, E., Nemnom, M. J., Wells, G. A., … Perry, J. J. (2020). Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet (London, England)395(10221), 339–349. https://doi.org/10.1016/S0140-6736(19)32994-0
  6. Ian G. Stiell, et al. (2021). 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.https://caep.ca/wp-content/uploads/2021/06/2021-CAEP-AAF-Checklist-FINAL-6-June-2021.pdf
Cite this article as: Israa M Salih, UAE, "Acute Atrial Fibrillation in the ED: Almost all goes home," in International Emergency Medicine Education Project, September 13, 2021, https://iem-student.org/2021/09/13/acute-atrial-fibrillation-in-the-ed-almost-all-goes-home/, date accessed: October 18, 2021

STEMI Limitations

STEMI Limitations

In 2000, the ST-Elevation Myocardial Infarction (STEMI) paradigm revolutionized the management of Acute Coronary Syndrome (ACS), substituting the previous dichotomy between Q-wave versus non-Q wave myocardial infarcts (MI). Subcategorizing aimed to predict completely occluded arteries and the need for immediate intervention, namely, emergent cardiac catheterization to open an occluded coronary artery in STEMI. However, literature has shown that STEMI and occlusion myocardial infarction (OMI) are not interchangeable, with clear evidence of benefit from early reperfusion in both entities. Moreover, definitions STEMI and Non-ST-elevation myocardial (NSTEMI) can miss a large proportion of acute coronary occlusions; STEMI as a category can miss 30% of occlusion MI up to 50% in left circumflex, and NSTEMI was only associated with total MI in a quarter of cases.

As any Emergentologist at any level can relate, it was only recently when my ED held a morbidity and mortality meeting for a presumably delayed cath lab activation. The patient had all the risk factors, a typical chest pain which resolved in the ED, normal vitals and an ECG that didn’t meet the STEMI criteria; however, when he went for urgent angiography, the LAD was totally occluded.

A new paradigm: OMI vs. NOMI

The OMI manifesto, introduced by Dr Stephen Smith, Dr Pendell Myers, and Dr Scott Weingart might provide a better solution in the management of ACS. The fundamental question is: Does the patient have an acute coronary occlusion that would benefit from immediate intervention? Based on this question, the following diagram was suggested to substitute STEMI versus NSTEMI paradigm. The manifesto also contains rules to diagnose acute MI in certain categories of patients, such as patients with left bundle branch block (LBBB), left ventricular paced rhythm, terminal QRS distortion, normal ST-elevation vs. left anterior descending artery (LAD) occlusion, anterior ventricular aneurysm vs. acute MI, ST depression in aVL.

Basic concepts

ACS is a spectrum of clinical presentations divided into STEMI, NSTEMI and unstable angina, based on ECG findings and cardiac markers. The American Heart Association/American College of Cardiology (AHA/ACC) and European Society of Cardiology (ESC) define STEMI as new ST elevation at the J point in the absence of LV hypertrophy or LBBB in at least 2 contiguous leads. The elevation must be at least 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or 1 mm (0.1 mV) in other contiguous chest leads or the limb leads.

AHA/ACC recommends primary percutaneous coronary intervention (PCI) for patients with STEMI and ischemic symptoms of less than 12 hours’ duration. In NSTEMI, the recommendation is to perform urgent/immediate angiography with revascularization if appropriate in patients who have refractory angina or hemodynamic or electrical instability.

A meta-analysis of 46 trials with a total of 37 757 patients, including data from the International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multi-vessel Disease after Early PCI for STEMI (COMPLETE) trials demonstrated that PCI prevents death, cardiac death, and MI in patients with unstable coronary artery disease (CAD). The study defined unstable CAD as post-MI patients who haven’t received reperfusion therapy, multi-vessel disease following STEMI, non–ST-segment–elevation acute coronary syndrome.

STEMI Equivalents

For patients with persistent chest pain, hemodynamic instability and certain patterns of EKGs, it’s advisable to consider immediate/urgent PCI. The following patterns were found consistent with total occlusion or critical ischemia of the coronaries so every Emergentologist should familiarize her/himself with those: (All displayed ECGs are from Life in the Fast Lane ECG library)

De Winter T-wave: LAD occlusion.

Prominent T wave with upsloping ST depression in precordial leads
Prominent T wave with upsloping ST depression in precordial leads. https://litfl.com/de-winter-t-wave-ecg-library/

Wellen's Syndrome: Severe proximal LAD stenosis.

Biphasic or deep inverted T waves in V2 V3
Biphasic or deep inverted T waves in V2 V3 https://litfl.com/wellens-syndrome-ecg-library/

LBBB with positive Sgarbossa criteria

New LBBB without meeting Sgarbossa criteria is not considered an indication for cath lab activation any longer. Smith modified Sgarbossa criteria are:

  • Concordant ST elevation ≥ 1 mm in ≥ 1 lead
  • Concordant ST depression ≥ 1 mm in ≥ 1 lead of V1-V3
  • Proportionally excessive discordant STE in ≥ 1 lead anywhere with ≥ 1 mm STE, as defined by ≥ 25% of the depth of the preceding S-wave

Positive Sgarbossa criteria in ventricular paced rhythm

Posterior MI: Left Circumflex (LCx) Artery or right coronary artery (RCA) occlusion

Infero-lateral STEMI with ST depression in V1 to V4 suggesting posterior MI
Infero-lateral STEMI with ST depression in V1 to V4 suggesting posterior MI https://litfl.com/posterior-myocardial-infarction-ecg-library/
Same patient with posterior EKG showing ST elevation in posterior leads
Same patient with posterior EKG showing ST elevation in posterior leads https://litfl.com/posterior-myocardial-infarction-ecg-library/

Right Ventricular MI: Complicates inferior STEMI, RCA occlusion

ST elevation in V1, ST elevation in III more than II
ST elevation in V1, ST elevation in III more than II https://litfl.com/right-ventricular-infarction-ecg-library/

ST elevation in aVR with diffuse ST depression: Left Main Coronary Artery (LMCA), proximal LAD, or triple vessel occlusion

ST elevation in aVR with diffusion ST depression
ST elevation in aVR with diffusion ST depression https://litfl.com/st-elevation-in-avr/

ST depression and T-wave inversion in aVL: RCA, LCx, or LAD occlusion

Reciprocal ST depression in avL
Reciprocal ST depression in avL https://litfl.com/inferior-stemi-ecg-library/

Hyperacute T-waves: LCx occlusion

Broad asymmetrical T wave
Broad asymmetrical T wave https://litfl.com/t-wave-ecg-library/

References and Further Reading

  • Amsterdam, E. A., Wenger, N. K., Brindis, R. G., Casey, D. E., Ganiats, T. G., Holmes, D. R., … & Zieman, S. J. (2014). 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. Journal of the American College of Cardiology, 64(24), e139-e228.
  • Chacko, L., P. Howard, J., Rajkumar, C., Nowbar, A. N., Kane, C., Mahdi, D., … & Ahmad, Y. (2020). Effects of percutaneous coronary intervention on death and myocardial infarction stratified by stable and unstable coronary artery disease: a meta-analysis of randomized controlled trials. Circulation: Cardiovascular Quality and Outcomes, 13(2), e006363.
  • Coven, D. L. (2020). Acute Coronary Syndrome. Retrieved April 9, 2021, from https://emedicine.medscape.com/article/1910735-overview
  • Khan, A. R., Golwala, H., Tripathi, A., Bin Abdulhak, A. A., Bavishi, C., Riaz, H., … & Bhatt, D. L. (2017). Impact of total occlusion of culprit artery in acute non-ST elevation myocardial infarction: a systematic review and meta-analysis. European heart journal, 38(41), 3082-3089.
  • Kreider, D., Berberian, J. (2019). STEMI Equivalents: Can’t-Miss Patterns. EMResident. Retrieved April 9, 2021, from https://www.emra.org/emresident/article/stemi-equivalents/
  • Life in the Fast Lane. (n.d.). ECG Library. Retrieved April 9, 2021, from https://litfl.com/ecg-library/
  • Meyers, P. (2018). Guest Post – Down with STEMI – The OMI Manifesto by Pendell Meyers. EM Crit RACC. Retrieved April 9, 2021, from https://emcrit.org/emcrit/omi-manifesto/
  • O’gara, P. T., Kushner, F. G., Ascheim, D. D., Casey Jr, D. E., Chung, M. K., De Lemos, J. A., … & Zhao, D. X. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction. Circulation, 127(4), 529-555.
  • Wang, T. Y., Zhang, M., Fu, Y., Armstrong, P. W., Newby, L. K., Gibson, C. M., … & Roe, M. T. (2009). Incidence, distribution, and prognostic impact of occluded culprit arteries among patients with non–ST-elevation acute coronary syndromes undergoing diagnostic angiography. American heart journal, 157(4), 716-723.
Cite this article as: Israa M Salih, UAE, "STEMI Limitations," in International Emergency Medicine Education Project, May 31, 2021, https://iem-student.org/2021/05/31/stemi-limitations/, date accessed: October 18, 2021

Recent Blog Posts By Israa Salih

Troponin and nothing more

troponin and nothin more

It’s almost impossible to have an ER shift without encountering a chest pain patient!

The first thing that always comes to mind is to rule out STEMI; well, unless the patient is having chest pain, and you see a knife stabbed in his chest!

It’s a no brainer situation; investigations wise, you will start with an EKG, and a set of labs, including cardiac markers.

Acute coronary syndrome (ACS) with its subcategories, ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), and unstable angina, is responsible for one third of total mortality in individuals more than 35 years of age.(1)

The role of cardiac markers in diagnosis and management of ACS and cardiovascular problems is vital. In the United States cardiac biomarkers testing occurs in nearly 30 million emergency department visits nationwide each year.(2)

What is a biomarker?

The National Institutes of Health defined a biomarker as “a characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention.” (3)

Biomarkers utilization in cardiovascular medicine is a wide domain; it’s used in screening, diagnosis, prognosis and monitoring. (4)

What’s available?

Numerous cardiac markers are available today and can be classified as:

  1. Biomarkers of myocardial injury, which is further divided into:
    1. Biomarkers of myocardial necrosis: CK-MB fraction, myoglobin, cardiac troponins
    2. Biomarkers of myocardial ischemia: Ischemia-modified albumin (IMA), heart-type fatty acid-binding protein (H-FABP)
  2. Biomarkers of hemodynamic stress: Natriuretic peptides (NPs): atrial natriuretic peptide (ANP), N-terminal proBNP (NT-proBNP), B-type natriuretic peptide (BNP)
  3. Inflammatory and prognostic markers: hs C-reactive protein (CRP), sCD40L, homocysteine. (4)

What’s best?

Cardiac Troponin and the B type cardiac natriuretic peptides are the two markers recommended by ACEP and AHA in diagnosis of ACS and heart failure respectively.(5)

The ACS biomarker of choice

ACS is subcategorized based on ECG and cardiac troponin. The fourth universal consensus definition of Myocardial Infarction (MI); by the European Society of Cardiology (ESC) and American College of Cardiology (ACC), takes Troponin as a detrimental parameter in case definition, because of its high sensitivity and specificity.(6)

ACEP and AHA guidelines recommend the use of Troponin as level A class 1 in diagnosis of ACS. (7) It was practiced before to consider multiple markers dealing with ACS, more precisely in NSTEMI ruling out recommendation. However, this practice is now outdated with the use of hs cT solely.(7-9)

What’s troponin and why do we like it?

It’s a protein that regulates the interaction between actin and myosin filaments, found in skeletal and cardiac myocytes. Cardiac troponin (cTn) has three subunits troponin T, troponin C and troponin I. Troponin T and I are highly specific and sensitive.(10) The half-life of troponin T and troponin I in the blood is about 2 hours and last in serum for 4 to 10 days10

For ACS, the sensitivity of troponin is about 95%, and the specificity is about 80%, higher than any other marker available.(12)

However, many causes can elevate serum troponin which includes pericarditis, myocarditis, heart failure and chest trauma; non-cardiac conditions are sepsis, renal disease, pulmonary embolism, COPD, strenuous exercise and hypertension.(14)

High-sensitivity cardiac troponin (hs-cTn T and I) can detect troponin at concentrations much lower than the old cTn tests, and has replaced it.7 For ACS, hs cT substituted and limited the roles of other markers; it’s proven to be safe, cost effective, and a valuable prognostic factor. (7-9, 14)

For all of the above and the heart score… In ACS, use Troponin and nothing more!

References and Further Reading

  1. Anumeha Singh; Abdulrahman S. Museedi; Shamai A. Grossman. Acute Coronary Syndrome. StatPearls[Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan.
  2. Alvin MD, Jaffe AS, Ziegelstein RC, Trost JC. Eliminating Creatine Kinase–Myocardial Band Testing in Suspected Acute Coronary Syndrome: A Value-Based Quality Improvement. JAMA Intern Med. 2017;177(10):1508-1512. doi:10.1001/jamainternmed.2017.3597.
  3. Biomarkers and surrogate endpoints: preferred definitions and conceptual framework. Biomarkers Definitions Working Group. Clin Pharmacol Ther. 2001 Mar; 69(3):89-95. doi.org/10.1067/mcp.2001.113989.
  4. Jacob R, Khan M. Cardiac Biomarkers: What Is and What Can Be. Indian J Cardiovasc Dis Women WINCARS. 2018 Dec; 3(4): 240–244. doi: 10.1055/s-0039-1679104.
  5. Richards AM. Future biomarkers in cardiology: My favourites. European Heart Journal Supplements, Volume 20, Issue suppl_ G, 1 August 2018, Pages G37-G44. doi.org/10.1093/eurheartj/suy023.
  6. Thygesen K, Alpert JS, Jaffe AS, et al., on behalf of the Joint European Society of Cardiology (ESC)/American College of Cardiology (ACC)/American Heart Association (AHA)/World Heart Federation (WHF) Task Force for the Universal Definition of Myocardial Infarction. Fourth Universal Definition of Myocardial Infarction (2018). J Am Coll Cardiol. 2018. Volume 72 DOI: 10.1016/j.jacc.2018.08.1038. 
  7. Ezra A. Amsterdam, Nanette K Wenger, Ralph G. Brindis, Donald E. CaseyJr, Theodore G. Ganiats, David. HolmesJr, Allan S. Jaffe, Hani Jneid, Rosemary F. Kelly, Michael C. Kontos, Glenn N. Levine, Philip R. Liebson,Debabrata Mukherjee, Eric D. Peterson, Marc S. Sabatine, Richard W. Smalling, Susan J. Zieman. 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 130:e344–e426. 2014. doi.org/10.1161/CIR.0000000000000134.
  8. Edward W Carlton, Louise Cullen, Martin Than, James Gamble, Ahmed Khattab, Kim Greaves. A novel diagnostic protocol to identify patients suitable for discharge after a single high-sensitivity troponin. Heart. 2015 Jul 1; 101(13): 1041–1046. doi: 10.1136/heartjnl-2014-307288.
  9. Ron M. Walls, Robert S. Hockberger, Marianne Gausche-Hill, Katherine Bakes, Jill Marjorie Baren, Timothy B. Erickson, Andy S. Jagoda, Amy H. Kaji, Michael VanRooyen, Richard D. Zane. Rosen’s Emergency Medicine: Concepts and clinical practice. 9th edition. Elseivier; 2018.
  10. Ooi DS1, Isotalo PA, Veinot JP. Correlation of antemortem serum creatine kinase, creatine kinase-MB, troponin I, and troponin T with cardiac pathology. Clin Chem. 2000 Mar; 46(3):338-44.
  11. Harvey D. White, DSC. Pathobiology of Troponin Elevations: Do Elevations Occur With Myocardial Ischemia as Well as Necrosis?. Journal of the American College of Cardiology. Vol. 57, No. 24, ISSN 0735-1097/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2011.01.029.
  12. John E. Brush, Jr., Harlan M. Krumholz. A Brief Review of Troponin Testing for Clinicians. American College of Cardiology. 2017 Aug 7th. acc.org/latest-in-cardiology/articles/2017/08/07/07/46/a-brief-review-of-troponin-testing-for-clinicians.
  13. Asli Tanindi, Mustafa Cemri. Troponin elevation in conditions other than acute coronary syndromes. Vasc Health Risk Manag. 2011; 7: 597–603. PMID: 22102783. doi: 10.2147/VHRM.S24509.
  14. Donald Schreiber, Barry E Brenner. Cardiac Markers. emedicine.medscape.com/article/811905-overview [Accessed 2020 March 23rd].
Cite this article as: Israa M Salih, UAE, "Troponin and nothing more," in International Emergency Medicine Education Project, August 19, 2020, https://iem-student.org/2020/08/19/troponin/, date accessed: October 18, 2021

COVID-19 Tailored RSI Bulletin

COVID-19 Tailored RSI Bulletin

Protection

  • Safety first!
  • Perform Hand Hygiene.
  • Enhanced PPE is required for Aerosol-generating Medical Procedures (AGMP): N95 respirator or powered air-purifying respirator (PAPR) device, face shield or goggles, gown, and double gloves.
  • Minimize providers in the room to the number necessary to provide safe intubation.
  • Airborne infection isolation rooms, if available.

Preparation

  • Have an intubation plan; use a checklist.
  • Assess for intubation difficulty.
  • Early preparation of drugs and equipment.
  • All necessary equipment is assembled inside the room.
  • Standard monitoring.
  • Connect viral/bacterial filter to circuits and manual ventilators.
  • Use a closed suctioning system.
  • A rescue plan for intubation failure
  • Ensure team dynamics

Pre-oxygenation

Non-bagging approach:

  • Five minutes of pre-oxygenation with oxygen 100% using a non-rebreather mask.
  • Place hydrophobic filter between facemask and breathing circuit.
  • Recommended by experts due to less aerosol generation.
  • Might be non-sufficient.

Avoid the use of high-flow nasal oxygenation and mask CPAP or BiPAP due to a greater risk of aerosol generation.

EMCRIT mentioned the following approaches for Pre-oxygenation

NIPPV (Might be acceptable in a negative pressure room)

  • A 2-tube system (closed circuit) with two viral filters. 
  • Place on CPAP/PSV, leave the PSV at 0, PEEP only if the patient’s saturations do not come up with 100% fiO2.

BVM with Viral Filter

  • Turn BVM flow up to the flush rate.
  • Place a NIPPV mask to allow good seal with you away from the patient or just hold two hands on the mask in a thumbs-forward grip from safer airways.
  • The addition of nasal cannula underneath will allow CPAP with the PEEP valve if needed. 
  • Turn NC up to 4-6 L/m if this used. 

Paralysis and Induction

  • High-dose paralytic to inhibit cough.
  • Appropriate induction agents.

Positioning

  • Head extension, often with flexion of the neck on the body.
  • Full sniffing position with cervical spine extension and head elevation.

Placement of Tube

  • The most experienced physician should perform the intubation.

Use video laryngoscopy rather than regular laryngoscope; to decrease exposure

  •  to patient’s aerosols.
  • Allow the needed time after administration of the NMBA to ensure relaxation.
  • Confirm placement of tube by visualization and EtCO2 rather than auscultation.
  • Apply viral filter prior to bagging or connection to ventilation.

Post-Intubation Management

  • Sedation and analgesia as indicated.
  • ARDS ventilation setting with smaller tidal volumes (6 ml/kg of IBW)

Post Procedure

  • Decontaminate and disinfect all airway equipment.
  • Appropriate doffing of PPE. 
  • Hand hygiene before and after all procedures.
Cite this article as: Israa M Salih, UAE, "COVID-19 Tailored RSI Bulletin," in International Emergency Medicine Education Project, July 3, 2020, https://iem-student.org/2020/07/03/covid-19-tailored-rsi-bulletin/, date accessed: October 18, 2021

References and Further Reading

The Pediatric patient in the ED: Peculiar and Paramount

The Pediatric patient in the ED

Children are not young adults!

This was the opening speech of the first Pediatrics lecture in my medical school.
As Emergency Physicians, we deal with everything and everyone at the same time; in some instances, the segmentation between types of patients blurs. The pediatric patient in the middle might be a challenge if you are not working in an independent Pediatrics Emergency Department.

In some situations, you will have to make decisions by conscious contemplation rather than pattern matching, which we mostly depend on in our approach.

Having had the privilege of working in an independent Pediatrics ED, I realized how much easier decision making becomes when you have a set of mind prepared to deal with a child.

Health problems for children differ from those of adults. A child’s response to disease and stress varies with age and development; therefore, it’s fundamental to approach children in a way that identifies and tackles the differences.

child response to disease

Judge by appearance

We use heuristics frequently in our practice, perhaps the most popular among which is the (sick/not sick) paradigm. When it comes to children, appearance is of particular importance.

The look might be deceptive in adults, but it’s not the case in children; as they say, the eyes don’t lie, but it can be lied to.

For its virtual implication, appearance represents the first component of the Pediatrics assessment triangle, our quick and orderly assessment tool for children.

Power and authority

Children can’t consent or advocate for themselves, a parent or legal guardian approval is required to deliver health care. The most notable exception to this is the emergency situation, in which consent is not required, and care can be delivered if parents are not present and even against their wishes. The emergency situation gives the emergency physician the highest authority in decision making in children, which is a titanic responsibility.

pediatric patient in the ed

The Math geek

Dosing for most medications in children is weight dependent. It might be good practice for your brain but can also represent a dilemma if you are giving verbal orders and your phone is not with you. My colleague once said I was terrible at Math; that’s why I went to medical school; I think she made a good point.

Baby shark

ED is a noisy environment, but the Pediatrics ED is on another level of noise. Other than natural sounds found in the ED and crying fussy children, you will also encounter countless children’s music and disturbing games. It might sound nihilistic and resentful, but I have to be forthright, the current children’s entertaining materials lack educational value and taste, and it needs resuscitation.

pediatric ed noise

Priceless outcome

In the end, the smile on a child’s face is one of the most satisfying experiences ever and a blessing. Establishing a rapport with a child is the key to a proper exam. Children won’t trust anything that’s not genuine, and care should be delivered with love and passion. You might also need to learn some tricks and give some treats to accomplish that, in the hope that you reach the fruitful outcome of drawing a smile on God’s angelic creatures.

Cite this article as: Israa M Salih, UAE, "The Pediatric patient in the ED: Peculiar and Paramount," in International Emergency Medicine Education Project, January 13, 2020, https://iem-student.org/2020/01/13/the-pediatric-patient-in-the-ed-peculiar-and-paramount/, date accessed: October 18, 2021