The EKG Case of No Symptoms

the ecg case of no symptoms

Case Presentation

A 52-year-old woman presents to the ED from an outpatient dialysis center with a rather vague history. She has no symptoms and feels normal, but she was told something “was either too low or too high” on her vital signs at dialysis, so dialysis staff did not perform her scheduled dialysis session. No one had called ahead to alert the emergency department, and the patient had driven herself to the ED, as she was instructed. Vitals show a normal temperature, respiratory rate, oxygen saturation, blood pressure of 102/47 mm Hg, and a heart rate of 138 beats per minute. The physical exam is normal besides a mild regular tachycardia and a working AV dialysis fistula on the right arm. EKG is done, and a representative portion is shown below:

EKG from the prior year is shown for comparison.

How would you interpret the first EKG, and what are your next steps?

Discussion

While you are thinking, I will discuss a few of my practical observations from working in the pit. I want to focus not so much on the diagnosis but on working with these types of scenarios.

Treat the patient and not the chief complaint, vitals, labs, EKGs, studies, or referral information.

When they are feeling great and have no symptoms, they are feeling great and have no symptoms! Your nurses will not necessarily think this way, but one does not feel great while having a real STEMI apparent on the triage EKG. So what is it then, if the patient is here for a contact lens stuck in their eye, but has an EKG STEMI? Worst case – a prior STEMI that never corrected or evolved on the EKG. A ventricular aneurysm? Leads misplaced? Did your EKG tech do an EKG on themselves? A silent MI can occur, but an incidental STEMI is unlikely. 

Of course, the patient has to be alert, competent, and not intoxicated. They should not be lying about or hiding their symptoms and should not have a secondary interest like the need to make it to a daughter’s wedding - live or die. The easiest thing is to ask directly.

What is the rhythm's rate doing when it is left alone?

Afibs and MATs will tend to vary greatly in the second to second heart rate, sinus tachycardias will fluctuate some, while A-flutters and SVTs will tend to stick to a single number no matter what you do and no matter if the patient is walking, talking, or snoozing. Stable Vtachs will depend on a number of factors like being monomorphic or polymorphic – but we are talking about narrow QRS dysrhythmias or ones with an obvious bundle. 

So if you cannot tell from the EKG – observe what the thing does while left alone. As long as the patient is otherwise stable or has had symptoms for a while, you have some time.

Adenosine – not just for SVT conversion

“SVT = adenosine” should not be an automatic equation. First of all, there are contraindications to adenosine based on past history or current medications taken. But adenosine can also be used to “stretch out” weird or equivocal fast rhythms to make flutter waves or hidden P waves come out, so you can see and diagnose the arrhythmia vs. sinus. 

You have to have continuous EKG recording going or printing the monitor strip to spot the temporary effect.

Hypotension + tachy-dysrhythmia: does not necessarily add up to Joules.

The textbook mantra of shocking any dysrhythmia associated with hypotension does not hold up in reality. In reality, you will find that most of your Afibs with a rapid response, your new-onset atrial flutters and your SVTs will have a lousy blood pressure: systolic of 80s and 90s are almost to be expected, and may even dip down to 70s on occasion. It also depends on a prior BP baseline, if the person is petite or dehydrated. But if the patient is mentating well and is not suffocating or experiencing crushing chest pain with diaphoresis, please don’t feel like you have to shock them. The body is not used to the new arrhythmia, and the rapid rate compromises the cardiac output. 

Yes, you can still use your rate and rhythm controllers. Give the patient a gentle fluid bolus if you must. Of course, pacer pads do have to be on ahead of time.

Be afraid of shocking dialysis patients. Check electrolytes.

Hypotension with normal mentation is much better than a PEA arrest. Shocking extremes of electrolyte and acid/base abnormalities, whether due to TCA and other overdoses or in dialysis patients, will give you exactly that. This is especially true for the so-called “slow-X” arrhythmias: slow Afib, slow SVT, or even V-slow (Vtach with a rate of 130) that dialysis patients like to present in. 

Just like airplane travel in transportation, electricity is in general the safest rhythm conversion strategy. But there are exceptions, and you only need to crash once.

A-flutter and the stuck rate of 150

You already know this, but just as a reminder. If the rate is a steady 150, plus or minus, and it is stuck there, you should think of atrial flutter. 

Even if you do not see obvious classic flutter waves, there is a high chance of 2:1 conduction. In this case, I thought of it. Fortunately, it did not think of me.

Adenosine (again)….the 6, the 12…the 24??

Sometimes adenosine is not pushed correctly, but sometimes it just does not work or only works for a few seconds. Sometimes the patient’s Mom knows best what works, so you should listen. Sometimes the last time it was used, the patient really did feel like they were going to die – so they do not ever want it again. Ever. That you should try 6mg, then 12mg, then stop is generally true, but it is also a dead-end. What is your back up plan? Electricity? In the past I have given the doses in reverse, combined 6mg with the Valsalva maneuver and had given a preemptive beta-blocker or calcium channel blocker dose 10-15 minutes before adenosine to massage a stubborn heart into adenosine submission. It is ok to experiment a little. Another practical point – how much does your ED freak an SVT patient out while he or she is being triaged and roomed? I still do not completely understand why an SVT tends to be rushed up in the same fashion as a STEMI with cardiogenic shock and bradycardia, judging from staff adrenaline levels. 

Calm the patient down, turn the lights off and let them change. It's like a kid with croup. Remember, it is lack of the sympathetic influx that we want, not an excess. Otherwise, why try the Valsalva at all? Has anyone attempted a stellate ganglion block Vfib-style for a refractory SVT? An overkill, I know….but could be fun, and practice for the real deal.

Aren’t all AVNRTs verapamil sensitive?

Years ago, in my first year of solo practice, I had a case of a refractory SVT in a young teenager, which a pediatric cardiologist consulting by phone called a “verapamil-sensitive AVNRT” based on the EKG alone. I was impressed. Hours later, I decided to flash my newly acquired cool knowledge and relayed the same to my in-house cardiologist, who looked at me with a grin and a raised eyebrow and said, “Anthony, all AVNRTs are verapamil sensitive”. At that time, I was also sensitive, and so my feelings were hurt. Lately I have gotten into the habit of treating my SVTs with diltiazem – as a purer verapamil relative. With generally good results and no need to stand in front of the patient during administration by the nurse. 

The bottom line is – you have choices. Especially, if the patient is already on a beta-blocker or a calcium channel blocker, give them a beta or a calcium blocker IV, see what happens.

Case Concluded

Despite a single nadir of blood pressure of 75 systolic, the rest holding steadily in the high 90s, the patient received a single dose of IV diltiazem and a small IV fluid bolus. Labs reviewed prior showed normal potassium, calcium, sodium, magnesium and the rest of them. Her average heart rate reduced to about 106 and a repeat EKG is shown, accidentally capturing an event: 

She, of course, had a “verapamil sensitive” SVT. The patient’s new right bundle block had also improved to an incomplete, proving to be either SVT- or rate-related. The patient had never experienced any symptoms while in the ED. She was observed for a short time, scheduled for an out-of-sequence dialysis the next day and discharged home with a normal heart rate. I guess, in this case, we did treat the EKG and not the patient.

Cite this article as: Anthony Rodigin, USA, "The EKG Case of No Symptoms," in International Emergency Medicine Education Project, October 26, 2020, https://iem-student.org/2020/10/26/the-ekg-case-of-no-symptoms/, date accessed: October 28, 2020

Want to read more, take a look this post from September

Question Of The Day #18

question of the day
qod18
839 - diffuse ST elevation - pericarditis?

Which of the following is the most appropriate next step in management for the patient’s condition?

This patient presents to the emergency department with signs and symptoms consistent with acute pericarditis from a likely viral etiology. Common causes of acute pericarditis include idiopathic, infectious (viral, bacterial, or fungal), malignancy, drug-induced, rheumatic disease-associated (lupus, rheumatoid arthritis, etc.), radiation, post-MI (Dressler’s Syndrome), uremia, and severe hypothyroidism. The chest pain associated with this diagnosis is typically worse with supine positioning, improved with sitting forward, worse with inspiration, and may radiate to the back. A pericardial friction rub may be heard on auscultation of the chest, and there may be a low-grade fever on the exam. The hallmark EKG demonstrates diffuse ST-segment elevation with PR segment depression, although normal ST segments or T wave inversions can be seen on EKG later in the disease process. The treatment of acute pericarditis depends on the underlying cause of the disease. This patient has likely viral pericarditis with no clinical signs of myocarditis (i.e. fluid overload, cardiogenic shock, etc.) or cardiac tamponade (i.e. obstructive shock, distended neck veins, muffled heart sounds, low voltage QRS complexes or electrical alternans on EKG). A cardiac sonogram would be prudent to evaluate for a pericardial effusion. This patient’s disease course likely will resolve with NSAIDs in 1-2 weeks. Ibuprofen (Choice C) is the preferred treatment over aspirin (Choice A) or steroids (Choice B). Colchicine (Choice D) can be useful in recurrent episodes of pericarditis to reduce recurrence and in acute pericarditis not responding to NSAIDs. Correct Answer: C 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #18," in International Emergency Medicine Education Project, October 23, 2020, https://iem-student.org/2020/10/23/question-of-the-day-18/, date accessed: October 28, 2020

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Suicide – An Emergency Priority of Public Health Care

Suicide An Emergency

A significant number of emergency department visits annually arise as a result of intentional self-harm. Although no accurate description explains what leads to suicide or what comes after, it is a multifaceted phenomenon of public health urgency during a global health crisis. In the United States alone, suicide is the 10th leading cause of death and worldwide claims up to 800,000 lives each year. The international community must unite to come up with solutions to prevent the loss of life, as every single life lost is one too many.

With the COVID-19 pandemic, such an emergency naturally affects both individuals’ health and well-being and the communities in which they live. Unprecedented times unleash various emotional reactions from isolation, grief and trauma to other unhealthy behaviours, noncompliance with public health guidelines and the exacerbation of mental health conditions. While those who’ve been emotionally, sexually or physically abused in the past are more vulnerable to the psychosocial effects of a crisis, supportive interventions such as the Zero Suicide program and Cognitive Behavioural Therapy designed to promote wellness and enhance coping should be implemented [1]. 

In honour of World Suicide Prevention Week, and World Suicide Prevention Day held on the 10th of September every year, it is important to raise attention to the global importance of suicide prevention. Suicide impacts all people and particularly the world’s most marginalized and discriminated groups. It is a huge problem in developed countries and just as serious in low-and middle income countries where resources and access to healthcare professionals are scarce. In many regions of the world, the taboo and stigma surrounding suicide persist, causing people in need of help to be left alone. 

Suicide prevention with awareness campaigns ought to be prioritized on the global health and public policy agendas as a major public health issue. Routine screening for suicidal ideation by health care professionals providing care should identify and assess suicide risk among populations. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), risk factors of suicide include mental illness, substance use diagnoses, trauma or conflict, loss, family history of suicide, and previous suicide attempts [2].

Effectively implementing suicide prevention strategies at the populational, sub-populational and individual level requires ensuring patients’ lethal means are restricted, reduced, and that all accesss to weapons of self-harm are removed from the nearby environments. Healthcare providers should keep up to date with new developments, research, and technologies screening for suicidal ideation, allowing them to effectively serve patients beyond their clinics’ walls. Key to prevention are strong physician patient relationships that help ensure care transitions allow for physicians to act as supportive contacts reaching out with calls, texts, letters and visits to their patients particularly when services are interrupted. With access to technology the role of psychiatrists, and psychologists may continue uninterrupted as telemedicine serves as an effective platform providing patients with access to care, even during lockdowns. Besides these objectives, greater awareness and education into the community means encouraging the responsible portrayal of suicide in mainstream media. A sensitive issue of this magnitude ought to be communicated responsibly placing special attention to not trigger susceptible individuals. With school based interventions, professionals may act sooner before worsened prognosis’ effectively ensuring that access to peer support services is available. 

Suicide prevention is a responsibility of healthcare systems, medical professionals and communities. All countries must stand in solidarity and unify in collaboration to battle this common threat as preventing the tragic loss of life to suicide is of utmost importance. 

References & Further Reading

  1. In Health and Behavioral Healthcare. (n.d.). Retrieved September 14, 2020, from http://zerosuicide.edc.org/toolkit/treat/interventions-suicide-risk 
  2. Psychiatry Online: DSM Library. (n.d.). Retrieved September 15, 2020, from https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425596 
Cite this article as: Leah Sarah Peer, Canada, "Suicide – An Emergency Priority of Public Health Care," in International Emergency Medicine Education Project, October 19, 2020, https://iem-student.org/2020/10/19/suicide-an-emergency-priority-of-public-health-care/, date accessed: October 28, 2020

Question Of The Day #17

question of the day
qod17

Which of the following is the most likely cause for the patient’s elevated cardiac troponin level in the emergency department?

Elevated cardiac troponin levels, or troponinemia, are one sign that the myocardium may be infarcting or under some type of stressful condition. Cardiac troponin levels are assessed in conjunction with the clinical history, physical exam, EKG, and another laboratory testing in deciding if troponinemia is due to cardiac ischemia or another condition. Conditions associated with elevated cardiac troponin levels include cardiac ischemia (i.e. STEMI, NSTEMI), cardiac contusion, cardiac procedures, congestive heart failure, renal failure, aortic dissection, tachy- or bradyarrhythmias, rhabdomyolysis with cardiac injury, Takotsubo syndrome, pulmonary embolism, acute stroke, myocarditis, sepsis, severe burns, extreme exertion, and other conditions. It is unlikely that this patient had elevated troponin levels from Acute coronary syndrome (Choice D) as her cardiac catheterization results showed no significant occlusive lesions in the coronary arteries. D-Dimer levels do increase with patient age, but cardiac troponin levels do not increase with patient age (Choice B). Sepsis (Choice C) is a cause for elevated troponin levels, but this patient has no clinical signs or sepsis symptoms. Atrial fibrillation with a rapid rate (Choice A) is the most likely cause of this patient’s elevated troponin level. Correct Answer: A 

References

Cite this article as: iEM Education Project Team, "Question Of The Day #17," in International Emergency Medicine Education Project, October 16, 2020, https://iem-student.org/2020/10/16/question-of-the-day-17/, date accessed: October 28, 2020

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Mindsores

Mindsores

The patient said he did not care about his stage IV ulcers. He refused antibiotics for chronic osteomyelitis until we gave him opiates. He denied all other non-opiate alternatives. “The patient has an opiate use disorder but also has pain,” said the pain and palliative doctor. In medicine, we try our best to explain all that a patient is experiencing with one diagnosis. A patient suffering from two different diseases as a diagnosis is frowned upon. But here was a seasoned doctor, speaking with his years of precious experience reflected in his white beard and even whiter apron, telling me that the patient I have barely started to present to him, had two diagnoses.

I had taken care of this patient for some days now. In my head, I would associate all the requests he makes, everything he says, and every single complaint he has, to his addiction. “I do not have an opiate use disorder, I have a pain problem!” said the patient as soon as “addiction” was mentioned. The doctor said, “I know you don’t think you have opiate use disorder.” I thought that was clearly mentioned to calm the patient down. Later I would be surprised to know that the doctor actually meant it.

He gave me an ‘overly simplistic heuristic’ that had helped him remember what patients with substance use disorder are going through. “The first time a patient takes a substance, he feels the intended high. The effect remains for a couple times more. As the effect due to the same dose decreases with subsequent exposure, the patient increases the dose to get the intended effect. This seemingly linear relationship is a tricky one. Soon the patient will depend on the substance only to feel okay. Which, let us remind ourselves, the patient felt before starting to take any substance. Hence, many patients with substance use disorder, claiming they do not do it for the high, they do it because they cannot tolerate “normal” without it. Substance use disorder is a complex topic and one that deserves much more effort and attention than is the scope of this conversation but I hope this ignited an enthusiasm to learn more, in you” That night I read some papers on opiate use disorder.

I sometimes wonder if I am not as sensitive to suffering as my patients are. I wonder if what they taught me about signal transduction in my first year of medical school holds true for day-to-day emotions like it held true for addiction’s pathophysiology. The more we are exposed, the more we desensitize. “Being emotional is understandable but unnecessary and unhelpful”, says Sherlock Holmes in one of his many palimpsests. Maybe I was trying to objectively look at this patient of mine. So much so that it did not occur to me that the patient had stage IV ulcers. All I heard was a cry for the high, which, mistake not, was there. But there was something more, something that was hidden to my objective eyes. In focusing my attention on the patient’s mindsores, I was ignoring his very physical and painful bedsores. I dare say Sherlock was wrong. Only emotions can drive passion. People who are so passionate about the pathways and mechanisms of addiction and people who are emotional about the patients’ problems are the ones who we rely upon to solve this tangled problem of pain and addiction. I appeal to you to acknowledge that this is a complex issue. That is the sole intention of this article. And that is the first step in trying to understand and hopefully help patients with multiple sores.

Cite this article as: Sajan Acharya, Nepal, "Mindsores," in International Emergency Medicine Education Project, October 12, 2020, https://iem-student.org/2020/10/12/mindsores/, date accessed: October 28, 2020

Question Of The Day #16

question of the day
qod16

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient sustained a penetrating traumatic injury to the left chest and presented to the emergency department with hemodynamic instability (tachycardic and hypotensive). Some differential diagnoses to consider on arrival include tension pneumothorax, cardiac tamponade, aortic injury, or aero-digestive tract injury. Prior to taking a detailed history on any trauma patient, a primary survey should be performed. The goal of the primary survey in a trauma patient is to identify and treat any life-threatening injuries as soon as possible. The primary survey is also known as the “ABCs.” Sometimes it is referred to as the “ABCDEFs.” This acronym stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (How to learn eFAST exam for free). Each letter is addressed and assessed in the order they exist in the alphabet. This creates a methodical, algorithmic approach to assist the practitioner in assessing the trauma patient for life-threatening injuries. The sonographic view shown in this question is the subxiphoid (cardiac) view and demonstrates the presence of free fluid. Free fluid on ultrasound appears black, or “anechoic” and is assumed to be blood in the setting of trauma. The free fluid is highlighted by red stars in the image below. The collapse of the right ventricle is shown by the yellow arrow in the below image.

cardiac tamponade - explained
SS Video 3 Pericardial Tamponade

In conjunction with hemodynamic instability and a history of penetrating chest trauma, this sonographic view strongly supports the diagnosis of cardiac tamponade. Consulting the general surgery team for exploratory laparotomy (Choice A) would be the correct course of action for a patient with hemodynamic instability and free fluid on the other abdominal views of the FAST exam. Needle decompression of the chest (Choice B) would be the correct initial treatment for a tension pneumothorax. The patient described in the case has clear bilateral lung sounds, no tracheal deviation mentioned, normal O2 saturation on room air, and sonographic demonstration of cardiac tamponade. A CT scan of the chest, abdomen, and pelvis (Choice D) would be indicated in this patient if he had normal vital signs and no free fluid on the FAST exam. A pericardiocentesis (Choice C) is the most appropriate next step in the management of this patient with cardiac tamponade to relieve signs of obstructive shock. It should be noted that this procedure has limitations and is not always effective. Pericardiocentesis is a temporizing treatment with pericardiotomy being the definitive therapy. Blood in an acute hemopericardium may clot and be unable to be aspirated with a large-bore needle. The procedure may injure surrounding organs, such as the liver, intestines, or heart itself. Ultrasound-guidance should be used whenever possible to avoid injury to surrounding organs. Emergent thoracotomy to relieve the cardiac tamponade should be performed on any patient with confirmed cardiac tamponade and cardiac arrest in the Emergency Department. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #16," in International Emergency Medicine Education Project, October 9, 2020, https://iem-student.org/2020/10/09/question-of-the-day-16/, date accessed: October 28, 2020

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Oxygenation and Oximetry

Oxygenation and Oximetry

Authors: Job Rodríguez Guillén, Chief of Emergency Department. Hospital H+ Querétaro, México. Regina Pineda Leyte Internal Medic, Anahuac Querétaro University, Mexico. 

Introduction

One of the main goals of mechanical ventilation is oxygenation. Both hypoxemia and hyperoxemia must be avoided and the objectives must be individualized according to the clinical situation and comorbidities of each patient. Oxygenation monitoring is possible at the bedside by physical examination (late clinical signs), pulse oximetry (non-invasive continuous monitoring), and arterial blood gas analysis (gold standard for arterial oxygenation analysis).

Determinants of oxygenation

The main determinant of oxygenation is the mean airway pressure (Paw) and the inspired fraction of oxygen (FiO2). Paw is the average pressure to which the lung is exposed during inspiration and expiration mechanical ventilation (Figure 1). Paw improves oxygenation by allowing the redistribution of oxygen from highly compliant alveoli to less compliant alveoli.(1,2)
Oxygenation and Oximetry - figure 1
Figure 1: Mean airway pressure (Paw) is the integral (area under the curve) of pressure and time. PIP: peak inspiratory pressure; PEEP: positive pressure at the end of expiration; Ti: inspiratory time; Te: expiratory time.
According to the determinants of Paw and the relationship between them, there are five different ways to increase it (Figure 2)
Oxygenation and Oximetry - figure 2
Figure 2: Maneuvers to increase the mean airway pressure (Paw). PEEP: positive pressure at the end of expiration. Only maneuvers 3 and 4 are used in clinical practice to increase Paw and improve oxygenation.

The second determinant of oxygenation is Inspired Oxygen Fraction (FiO2). The use of supplemental oxygen at the hospital level is a common practice and a critical element of intensive care in patients with mechanical ventilation for the management of hypoxemia. However, in recent years it has been shown that higher oxygenation is not the goal. (3) In the same way that hypoxemia should be avoided, hyperoxia should be prevented. (4)

Although the FiO2 can be adjusted in ranges of 21% and up to 100% the lowest value required must be set (preferably <60%) to reach the desired oxygen saturation (SO2) target.

Oxygenation monitoring

Pulse oximetry allows non-invasive monitoring of oxygenation (SpO2), it is simple and reliable in many areas of clinical practice. SpO2 has a confidence rate of 95% ± 4%, so readings ranging between 70% and 100% are considered reliable.(5) In patients with mechanical ventilation, the objective is to identify hypoxemia.

It is important to remember that oximeters do not measure arterial oxygen pressure (PaO2), for this reason, they cannot directly diagnose hypoxemia or hyperoxemia (PaO2 <60 mmHg and PaO2> 120 mmHg respectively).(6)  What they do is “estimate” hypoxemia when SpO2 falls <90%, which would correspond to a PaO2 <60 mmHg according to the oxyhemoglobin dissociation curve (Table 1). (7)  However, it must be taken into account that changes in temperature and pH cause changes in this relationship. As the pH increases (alkalosis) or the temperature decreases (hypothermia), the shift of the curve is to the left since hemoglobin binds more strongly with oxygen, delaying its release to the tissues. Acidosis and fever shift the curve to the right as the hemoglobin molecule decreases its affinity for oxygen, facilitating the release of oxygen to the tissues.

Oxygenation and Oximetry - Table 1
Table 1: Estimation of the oxygenation state according to SpO2. SpO2: oxygen saturation by pulse oximetry; PaO2: arterial oxygen pressure.

SpO2 values <70% are not reliable. If necessary, the oxygenation assessment should be supplemented by arterial gas analysis. The arterial oxygen saturation (SaO2) is the oxygen saturation obtained by this test.

Oxygenation Goals

According to the oxyhemoglobin dissociation curve, the goal of oxygen titration is to achieve a PaO2 in the range of 60-65 mmHg or an SpO2 of approximately 90-92%. However, the objectives must be individualized and the current recommendations for oxygen therapy in critically ill patients. (8) are as follows (Table 2).

Table 2: Recommendations for oxygenation by SpO2. O2: oxygen; SpO2: oxygen saturation by pulse oximetry; AMI: Acute myocardial infarction; EVC: Cerebral vascular event; VM: mechanical ventilation; SIRA: Acute respiratory distress syndrome. Some exceptions apply like carbon monoxide poisoning.

It has been suggested that critically ill patients can tolerate lower levels of PaO2 (“permissive hypoxemia”) (9-10), however, studies are limited to make a recommendation to routine clinical practice.

Conclusions

Oxygenation goals should be established once the requirement for mechanical ventilation is indicated according to the clinical condition of each patient and monitoring that these objectives are met. Pulse oximetry allows continuous, non-invasive monitoring at the bedside. It should be remembered that hyperoxemia, as well as hypoxemia, should be avoided.

References

  1. Marini JJ,Ravenscraft SA. Mean airway pressure: physiologic determinants and clinical importance–Part 1: Physiologic determinants and measurements. Crit Care Med. 1992 Oct;20(10):1461-72.
  2. Marini JJ,Ravenscraft SA. Mean airway pressure: physiologic determinants and clinical importance–Part 2: Clinical implications. Crit Care Med. 1992 Nov;20(11):1604-16.
  3. Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: the Oxygen-ICU Randomized Clinical Trial. JAMA. 2016;316(15):1583-1589.
  4. Bitterman, Haim. “Bench-to-bedside review: oxygen as a drug.” Critical Care1 (2009): 205.
  5. Chan MM,Chan MM, Chan ED. What is the effect of fingernail polish on pulse oximetry?. Chest. 2003 Jun;123(6):2163-4.
  6. Wandrup JH. Quantifying pulmonary oxygen transfer deficits in critically ill patients. Acta Anaesthesiol Scand Suppl 1995;107:37–44
  7. Allen J. Photoplethysmography and its application in clinical physiological measurement. Physiol Meas 2007;28:R1–39
  8. Siemieniuk Reed A C, Chu Derek K, Kim Lisa Ha-Yeon, Güell-Rous Maria-Rosa, Alhazzani Waleed, Soccal Paola M et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline BMJ 2018;  363 :k4169
  9. Gilbert-Kawai ET, Mitchell K, Martin D, Carlisle J, Grocott MP. Permissive hypoxaemia versus normoxaemia for mechanically ventilated critically ill patients. Cochrane Database Syst Rev 2014;5:CD009931.
  10. Capellier G, Panwar R. Is it time for permissive hypoxaemia in the intensive care unit? Crit Care Resusc 2011;13:139–141.
Cite this article as: Job Guillen, Mexico, "Oxygenation and Oximetry," in International Emergency Medicine Education Project, October 5, 2020, https://iem-student.org/2020/10/05/oxygenation-and-oximetry/, date accessed: October 28, 2020

Question Of The Day #15

question of the day
qod 15 - pleuritic chest pain

Which of the following is the best course of action to further evaluate for a diagnosis of pulmonary embolism?

Pulmonary embolism (PE) is a potentially lethal diagnosis evaluated by a combination of a thorough history, physical exam, and the use of risk stratification scoring tools. The Wells criteria and the PE rule-out criteria (PERC) are two well-accepted risk stratification tools for PE. These criteria are each listed below (Wieters et al., 2020).

Wells’ Criteria for Pulmonary Embolism

CriteriaPoint Value
Clinical signs and symptoms of DVT+3
PE is #1 diagnosis, or equally likely+3
Heart rate > 100+1.5
Immobilization at least 3 days, or Surgery in the Previous 4 weeks+1.5
Previous, objectively diagnosed PE or DVT+1.5
Hemoptysis+1
Malignancy w/ Treatment within 6 mo, or palliative+1
Interpretation
Score >4 = High probability
Score 2–4 = Moderate probability
Score <2 = Low probability

Pulmonary Embolism Rule Out Criteria

All Variables Must Be Present for <2% Chance of PE
Pulse oximetry >94% (room air)
HR <100
No prior PE or DVT
No recent surgery or trauma within prior 4 wk
No hemoptysis
No estrogen use
No unilateral leg swelling
The patient in this clinical vignette would have a Wells score of 1.5 (low risk) due to her persistent tachycardia of unknown etiology. The PERC rule can not be applied to this patient as she is over 50-years-old and has tachycardia. If the patient was low risk on Wells score and meet all the PERC rule criteria, she would have a less than 2% likelihood of her symptoms being due to a PE. It is important to note that only patients with a low-risk Wells score (low pretest probability for PE) can be subjected to the PERC rule. A low-risk Wells score (<2) is investigated with a D-Dimer test (Choice B), while moderate to high-risk Wells scores are investigated with a CT Pulmonary Angiogram (CTPA) (Choice C). A V/Q Scan (Choice A) is not a first-line test for the diagnosis of PE as it is less sensitive than a CTPA scan. Unlike a CTPA scan, a V/Q scan may be nondiagnostic in the setting of lung consolidation, effusions, or other airspace diseases. V/Q scans are second-line tests to CTPA when there are contraindications to a CTPA (i.e., renal failure). Lorazepam (Choice D) is a benzodiazepine that may be helpful in reducing tachycardia, which is secondary to anxiety. However, this therapy does not help further discern if the patient may have a PE. Correct Answer: B 

References

Wieters J, McDonough J, Catral J. Chest Pain. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165059275

Nickson, C. (2019). Pulmonary Embolism. Life in the Fastlane. Accessed on August 17, 2020. https://litfl.com/pulmonary-embolism/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #15," in International Emergency Medicine Education Project, October 2, 2020, https://iem-student.org/2020/10/02/question-of-the-day-15/, date accessed: October 28, 2020

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Exercise is Medicine

Exercise is Medicine

Overview

I strongly believe that exercise is medicine. Exercise has been proven to improve cognitive functioning, reduce burnout rates, and support sound mental well-being. However, developing an exercise regimen can be difficult, especially in a demanding academic program such as medicine where time is limited, or after a long shift in the emergency department (ED). Some common barriers to exercise reported in published studies include lack of time and laziness. Though laziness was the term used in these research studies, I prefer fatigue or burnout. Many classmates and colleagues I know, that do not work out, work themselves to the bone, therefore limiting the excess energy available for working out. While I have yet to experience the fatigue of a long ED shift, I have experienced long workdays, and for me, no matter how tired I am, a quick work out can always help me get back into the zone, feel more productive or improve my mood.  

In university students, physical activity has been linked with decreased rates of burn-out, decreased perceived stress, and higher academic performance. As mentioned in my previous post, burnout is not good for physician performance. Burnout can increase the risk of medical errors, and more importantly, reduce the patient-physician experience. Imagine attending an event with a group of friends or colleagues. Would you be drawn to those who are happy, energetic, and lively; or would you rather spend your time with someone who seems so tired and disengaged, someone who keeps asking you to repeat yourself or do not respond to your social cues in an appropriate manner. I would prefer the former, though I have experienced the latter, and do not want to become victim to compassion fatigue because I could not support my own health and wellness. Compassion fatigue, a term I recently learned, is an inability to empathize or show compassion to others due to physical or mental burn out.

Overall, I believe that exercise is important to support one’s health and avoid compassion fatigue or other signs of burnout. However, when it comes to incorporating exercise into your daily routine, there is no one size fits all. The goal of this article is to share three of my favorite styles of exercise, that can be short and effective if done at a proper intensity. At the end of the article, I will have a list of YouTube Channels that provide free workouts, that I am using during COVID-19 as I wait for the gyms to safely open. All these channels have some videos on Tabata, HIIT, and AMRAP training (described below). These can be shared with patients as well, if appropriate, knowing that at times, exercise can be one of the best forms of medicine out there.

Tabata – Named after the Man, the Myth, the Legend

Tabata training is named after the creator, Dr. Izumi Tabata, and his lab, located in Tokyo. Tabata is a specific form of high-intensity interval training. Each exercise (i.e. push-up) is performed for 4 minutes. Within each 4-minute block, the exercise will be performed for 20s with a 10s rest. Overall, the exercise will be performed 8 times in the 4-minute window frame. The workout can be tailored with as many exercises as one wishes. An example of a 16-minute full-body workout can look like the following:

  1. 4 minutes push-ups (20s on – 10s off x8)
  2. 4 minutes of body-weight squats (20s on – 10s off x8)
  3. 4 minutes of sit-ups (20s on – 10s off x8)
  4. 4 minutes of burpees (20s on – 10s off x8)

Don’t forget that exercises always have modifications. For example, if a lunge or squat hurts your knees or your legs are beat after standing in the ED for a long shift, then a wall sit can always be a substitute.

exercise is medicine

HIIT – High-Intensity Interval Training

HIIT often gets mixed up with Tabata training. While they are very similar, HIIT is not as specific as the Tabata framework. HIIT training is similar in which you perform an exercise at a high intensity for a given amount of time followed by a rest period. The rest is important to prevent injury and give your body time to recover from the previous spurt of exercise. There are two ways this can be incorporated:

  1. One exercise at a time (rest in between every single exercise)

For this style of HIIT, you perform one exercise, the work period, and then rest, the rest period. I remember when I used to run or bike, I would start with a 1:2 ratio of work to rest (30 second sprint, 1 minute rest), and slowly work to a 1:1 ratio (30 second sprint, 30 second rest). The example I gave was a form of cardio, but the principles can apply to weights. For example, bicep curl for 2 minutes and rest for 2 minutes. Squat for 30s, rest for 30s.

  1. A series of exercises with rest after the series

In this second form of HIIT, you perform a series of exercises, as shown in the example below, and only rest after completing the entire series. The duration of the exercise time for each exercise is variable, but the entire series is usually the same.

AMRAP – As Many Reps as Possible

In AMRAP exercises, you pick one or two exercises and alternate between the two, until the timer tells you it’s time to rest. For example, say you choose squats and lunges (12 reps each) for the exercises, and you pick a 4-minute work period, then you would alternate between 12 squats and 12 lunges until the 4 minutes had passed. You then rest and can repeat with the same two exercises, or two new exercises for as many rounds as you wish. I love this style because you feel like you got an awesome workout in such a short period of time! It was the closest thing I could get to a runner’s high when I couldn’t run, and I could usually do a shorter workout, and feel satisfied. For the timer, I like the website linked below, which allows you to play with the number of intervals and the work/rest periods. The best part is it’s free and provides audio alerts to let you know when the work or rest period is complete. https://fitlb.com/tabata-timer

Here is an example of a workout I put together this summer. After working out, I always found myself to be more productive during the day.

Note: Reverse lunges reduce strain on knee compared to forward. Also, all channels have low impact workout options.

AMRAP #1 (2-minutes each round + 1-minute rest in between; Repeat series #1-8 workout twice)

  1. Air squats
  2. Plank
  3. Reverse lunge left leg
  4. Reverse lunge right leg
  5. Push-ups
  6. Sit-Ups
  7. Calf Raises
  8. Glute bridge

How to increase the intensity of an exercise: 

  1. Increase the number of reps
  2. Increase the speed of an exercise (make sure form is intact)
  3. Add resistance (weights, bands)
  4. Decrease the rest duration
  5. Perform moves that focus on more than one muscle group

Closing Remarks

I hope you learned a bit more about the three styles of exercise described above. They can be done with or without equipment and can be structured based on your goals. I know I would use a quick ten-minute bout of exercise in between a long spurt of studying whenever I would notice my mental fogginess causing careless errors or diminish my quality of work.  

While I encourage exercise as medicine, I also support a healthy mindset; do not hate yourself if you miss a workout, do not hate yourself if a workout is too hard, do not hate yourself if you need to rest. We are all human. Importantly, we are using our time and energy every week in school to study or in the ED to make sure that we can rapidly diagnose, treat and decide what the next steps in a patient care plan are. This takes energy, and so we need to make sure we use exercise to increase our wellbeing, not inch closer to burn out. My mentor, who is an ED physician in Toronto Western, always told me that the moment you don’t have the time or energy to exercise and socialize with loved ones is the moment you are starting to enter burnout territory. 

Finally, inspired by a classmate, I would like my next article to focus on the impact of shiftwork on sleep hygiene and health, in addition to tactics to overcome the detrimental effects of shiftwork on sleep. Send me a message if you want different wellness topics to be discussed. I am always open to feedback. I look forward to learning alongside the iEM community. Happy exercising!

References and Further Reading

  1. Al-Drees A, Abdulghani H, Irshad M, et al. Physical activity and academic achievement among the medical students: A cross-sectional study. Med Teach. 2016;38 Suppl 1:S66-S72. doi:10.3109/0142159X.2016.1142516
  2. Alexandrova-Karamanova, A., Todorova, I., Montgomery, A., Panagopoulou, E., Costa, P., Baban, A., Davas, A., Milosevic, M., & Mijakoski, D. (2016). Burnout and health behaviors in health professionals from seven European countries. International archives of occupational and environmental health, 89(7), 1059–1075. https://doi-org.cmich.idm.oclc.org/10.1007/s00420-016-1143-5
  3. Costa, E. C., Hay, J. L., Kehler, D. S., Boreskie, K. F., Arora, R. C., Umpierre, D., Szwajcer, A., & Duhamel, T. A. (2018). Effects of High-Intensity Interval Training Versus Moderate-Intensity Continuous Training On Blood Pressure in Adults with Pre- to Established Hypertension: A Systematic Review and Meta-Analysis of Randomized Trials. Sports medicine (Auckland, N.Z.)48(9), 2127–2142. https://doi-org.cmich.idm.oclc.org/10.1007/s40279-018-0944-y
  4. Cuthill, J. A., & Shaw, M. (2019). Questionnaire survey assessing the leisure-time physical activity of hospital doctors and awareness of UK physical activity recommendations. BMJ open sport & exercise medicine5(1), e000534. https://doi.org/10.1136/bmjsem-2019-000534
  5. Pereira, E. S., Krause Neto, W., Calefi, A. S., Georgetti, M., Guerreiro, L., Zocoler, C., & Gama, E. F. (2018). Significant Acute Response of Brain-Derived Neurotrophic Factor Following a Session of Extreme Conditioning Program Is Correlated With Volume of Specific Exercise Training in Trained Men. Frontiers in physiology9, 823. https://doi-org.cmich.idm.oclc.org/10.3389/fphys.2018.00823
  6. Rao, C. R., Darshan, B., Das, N., Rajan, V., Bhogun, M., & Gupta, A. (2012). Practice of Physical Activity among Future Doctors: A Cross Sectional Analysis. International journal of preventive medicine3(5), 365–369.
  7. Vankim, N. A., & Nelson, T. F. (2013). Vigorous physical activity, mental health, perceived stress, and socializing among college students. American journal of health promotion : AJHP, 28(1), 7–15. https://doi-org.cmich.idm.oclc.org/10.4278/ajhp.111101-QUAN-395
  8. Wewege, M., van den Berg, R., Ward, R. E., & Keech, A. (2017). The effects of high-intensity interval training vs. moderate-intensity continuous training on body composition in overweight and obese adults: a systematic review and meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity18(6), 635–646. https://doi-org.cmich.idm.oclc.org/10.1111/obr.12532
  9. Wolf MR, Rosenstock JB. Inadequate Sleep and Exercise Associated with Burnout and Depression Among Medical Students. Acad Psychiatry. 2017;41(2):174-179. doi:10.1007/s40596-016-0526-y
Cite this article as: Brenda Varriano, Canada, "Exercise is Medicine," in International Emergency Medicine Education Project, September 28, 2020, https://iem-student.org/2020/09/28/exercise-is-medicine/, date accessed: October 28, 2020

Question Of The Day #14

question of the day
question of the day 14
40.1 - Pneumothorax 1

Which of the following is the most appropriate treatment for this patient’s condition?

Anticoagulation (Choice A) would be the proper treatment for pulmonary embolism, NSTEMI/STEMI, and other conditions. This patient is dyspneic and hypoxemic on the exam, but his chest X-ray offers an alternative explanation for his symptoms. IV antibiotics (Choice D) would be helpful for pneumonia and COPD exacerbation, both of which are possible in this patient, but his chest X-ray offers an alternative explanation for his symptoms. Needle decompression of the left chest (Choice B) would be the appropriate initial treatment for a left-sided “tension” pneumothorax. This patient does have a large left-sided pneumothorax, but the X-ray lacks tracheal deviation, mediastinal shift, and left hemidiaphragm flattening, which can be attributed to tension pneumothorax. Most importantly, the patient lacks the hemodynamic instability that defines tension physiology (i.e. hypotension and tachycardia). In addition, the diagnosis and treatment of tension pneumothorax should be made clinically prior to chest radiography. Signs of hemodynamic instability along with tracheal deviation, absent unilateral lung sounds, and a history of trauma all support a diagnosis of tension pneumothorax. The treatment of a tension pneumothorax requires prompt recognition, needle decompression at the 3rd intercostal space at the midclavicular line, and a tube thoracostomy at the 4-5th intercostal space the anterior axillary line. The recommended needle decompression location is recently shifted to 4-5th intercostal space at the mid-anterior axillary line because the studies showed lower success rates in anterior – mid clavicular approach in adults. This patient has a spontaneous left-sided pneumothorax, not a tension pneumothorax. This is likely secondary to his coughing episodes and severe COPD. The treatment for this would be supplemental oxygen and the placement of a small-bore chest tube (i.e. “pig tail) in the left chest. Correct Answer: C. 

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Nickson, C. (2019) Pneumothorax CCC. Life in the Fastlane. Accessed August 17, 2020. https://litfl.com/pneumothorax-ccc/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #14," in International Emergency Medicine Education Project, September 25, 2020, https://iem-student.org/2020/09/25/question-of-the-day-14/, date accessed: October 28, 2020

Developing Clinical Research Ethics in the Developing World

Developing Clinical Research Ethics in the Developing World

“You are a research fellow working on a clinical trial for cryptococcal meningitis (CM) in Ugandan AIDS patients. If a patient is diagnosed with CM and enrolled in this trial, they receive free care for treatment duration and reimbursement for non-medical expenses. Seventy-five percent of this population lives on less than two dollars per day and cannot afford these costs otherwise. A woman presents with CM symptoms, but after testing her cerebrospinal fluid, she is instead diagnosed with deadly bacterial meningitis. She cannot be enrolled in the trial and is too poor to buy antibiotics. ”

What do you do?

I recently presented this case at a classroom discussion about global health research ethics. When this dying woman’s mother pulled on my lab coat and pleaded for help one day at the government-run Mbarara Regional Referral Hospital (MRRH), where I worked as a clinical research fellow for nearly a year, I did not know what to do, and neither did my peers.

Like many global health-oriented physicians, my career began with short-term medical mission trips as a pre-medical student. However, I found these trips to be self-serving and unsustainable; indeed, the ethical shortcomings of these trips have long been argued because often participants’ benefits outweigh those receiving of their “help.“[1] Thinking research might be a way to develop an ethical global health career, I completed a summer clinical research project in India, which I found more productive and substantial than short-term mission trips. Galvanized by the belief I could change the world through ethical research, I applied for the clinical research fellowship in Uganda.

Ultimately, I found my experience as ethically fraught as the short-term missions I swore to avoid. I am not alone in these sentiments: others have noted that AIDS in Africa has paradoxically been both a source of significant tragedy and significant academic opportunity. Unfortunately, these opportunities are distributed unevenly, producing fresh inequalities. In their efforts to reduce suffering in Africa, some global health researchers have inadvertently capitalized on the intellectual opportunities provided by those same African sufferers.[2]

At MRRH, where the shortages of gloves, saline, and basic medications reflect the hospital’s poverty and its patients, research-based medical care is often the only care people receive. Academic collaborations between western and sub-Saharan African institutions enable African researchers to publish in journals viewed by western audiences. As of 2017, patients presenting to MRRH with tuberculous meningitis or CM were enrolled in American-run clinical trials and treated without charge by experts with effective medications. Western-based surgical teams have improved MRRH’s surgical capacity, where sophisticated procedures are now performed with modern equipment. In 2004, after multinational research programs dedicated to tackling AIDS, tuberculosis, and malaria (ATM) worldwide were launched in the late 1990s, clinics started supplying HIV-positive Ugandans with free antiretrovirals and other services, causing a significant decline in HIV-related mortality.[3]

However, inequities in patient care are apparent in the areas of MRRH that have not yet benefitted from foreign research dollars, particularly the intensive care unit and the emergency department. The two working ventilators in the hospital are usually occupied by neurosurgical patients. Deaths due to trauma and road traffic accidents in Africa cause the loss of more life-years than AIDS and malaria combined [4], which is also true at MRRH. Like the woman in the case above, patients suffering from other non-ATM infectious diseases are sometimes victims of these inequalities at MRRH.
This unequal distribution of research wealth in a resource-limited setting such as MRRH troubles me. At MRRH, often, patient care follows research dollars; when the money runs out, so does the patient care. The Declaration of Helsinki requires control groups to receive the ‘best’ current treatment, not the local one – and while in developed countries the difference between ‘best’ and ‘local’ may be small, in settings like MRRH this difference is profound and may result in severe ethical consequences.[5]

In March of 2018, I watched a presentation by researchers who conducted a CM clinical trial in eastern Uganda, similar to ours at MRRH. A conference attendee voiced concern that the trial had violated the Helsinki Declaration, since many participants in the control group had not received any treatment. The presenter responded that the standard of care treatment for CM at this hospital was often no treatment, because the hospital had nothing to treat its patients. And, in late 2017 when the CM clinical trial at MRRH ended, CM patients there no longer received free treatment.

Uganda is often cited as the success story in sub-Saharan Africa in its efforts to reduce its HIV burden, largely due to funding from large international research programs.[6] But perhaps these trials reveal that acceptance of this ethical relativism in clinical research could result in the exploitation of underserved populations abroad for research programs that could not be performed in the sponsoring country.[5] Researchers must first be aware that conducting clinical research in resource-limited settings may create as many inequalities as it alleviates, particularly where the minimal standard of care for certain conditions is lacking. Secondly, research is often the conduit for medical care for impoverished people, which in turn creates unique ethical issues.

How can we global health researchers mitigate some of these ethical quandaries? I suggest that before embarking on clinical research (particularly in underserved areas), researchers assess their site’s health care needs and risk of patient exploitation, and that teams include medical anthropologists and epidemiologists well-versed in the local population’s health care needs and their receptiveness to clinical research. At MRRH, this was not a requirement of institutional review board approval for studies, so research teams must take this responsibility onto themselves.

Billions of people worldwide have benefitted from the discoveries that clinical research provides. Unfortunately, historically in our quest for valuable intellectual resources, those benefits have sometimes come at the cost of human exploitation. To maximize the benefit of clinical research for all involved, global health researchers must ensure this exciting and evolving field grows in an ethically sound manner.

References

  1. Roberts M. Duffle Bag Medicine. The Journal of the American Medical Association. 2006;295(13):1491-2.
  2. Crane JT. Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science. Ithaca and London: Cornell University Press; 2013.
  3. Wendler D, Krohmal B, Emanuel EJ, Grady C. Why patients continue to participate in clinical research. Arch Intern Med. 2008;168(12):1294–9.
  4. Hulme P. Mechanisms of trauma at a rural hospital in Uganda. Pan Afr Med J. 2010;7:5.
  5. Angell M. The Ethics of Clinical Research in the Third World. N Engl J Med. 1997;337(12):847–9.
  6.  Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Uganda [Internet]. 2004. Available from: http://data.unaids.org/publications/fact-sheets01/uganda_en.pdf
Cite this article as: Sarah Bridge, USA, "Developing Clinical Research Ethics in the Developing World," in International Emergency Medicine Education Project, September 21, 2020, https://iem-student.org/2020/09/21/clinical-research-ethics/, date accessed: October 28, 2020

Question Of The Day #13

question of the day
qod13

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presents to the emergency department after an atypical, brief episode of chest pain. The list of potential diagnoses that may have caused the pain episodes is extensive. The focus of the Emergency Medicine practitioner should not be to determine the diagnosis per say, but rather to be to identify the presence of any life-threatening conditions (i.e. Myocardial infarction, Aortic dissection, Esophageal Rupture, Pulmonary embolism, Tension pneumothorax, Cardiac tamponade, etc.). Many of these serious diagnoses can be evaluated with a detailed history, physical exam, and basic imaging and lab work if needed. Many risk stratification tools have been developed to evaluate the likelihood a patient has chest pain due to Acute Coronary Syndrome. One well-supported tool with international validation is the HEART score tool. The HEART score categorizes a patient as low (0-3), moderate (4-6), or high risk (7-10) for a Major Adverse Cardiac Event (MACE) based on the patient’s history, EKG, age, risk factors, and troponin level. The below chart from Wieters et al. (2020) outlines the HEART score categories and how to make clinical decisions based on a patient’s score.

HEART score for cardiac risk assessment of major adverse cardiac event (MACE).

CategoryScoreExplanationRisk Features
HistoryHigh-risk features
• Middle- or left-sided chest pain
• Heavy chest pain
• Diaphoresis
• Radiation
• Nausea and vomiting
• Exertional
• Relief of symptoms by sublingual nitrates

Low-risk features
• Well localized
• Sharp pain
• Non-exertional
• No diaphoresis
• No nausea and vomiting
Slightly Suspicious 0Mostly low-risk features
Moderately Suspicious+1Mixture of high-risk and low-risk features
Highly Suspicious+2Mostly high-risk features
ECG
Normal0Completely Normal
Non-specific Repolarization Disturbance+1Non-specific repolarization disturbance• Repolarization abnormalities
• Non-specific T wave changes
• Non-specific ST wave depression or elevation
• Bundle branch blocks
• Pacemaker rhythms
• Left ventricular hypertrophy
• Early repolarization
• Digoxin effect
Significant ST Depression+2Significant ST depression• Ischemic ST-segment depression
• New ischemic T wave inversions
Age
<450
45-64+1
≥ 65+2
Risk Factors• Obesity (Body-Mass Index ≥ 30)
• Current or recent (≤ 90 days)smoker
• Currently treated diabetes mellitus
• Family history of coroner artery disease (1st degree relative < 55 year old)
• Hypercholesterolemia

OR

Any history of atherosclerotic disease earn 2 points:
• Know Coroner artery Disease: Prior myocardial infarctions, percutan coronary intervention (PCI) or coronary artery bypass graft
• Prior stroke or transient ischemic attack
• Peripheral arterial disease
No known risk factors0
1-2 risk factors+1
≥ 3 risk factors or history of atherosclerotic disease+2
Initial Troponin
≤ normal limit0
1-3 x normal limit+1
> 3x normal limit+2

Score 0–3 = 2.5 % MACE over next 6 wk: Discharge home
Score 4–6 = 22.3% MACE over next 6 wk: Admit for observation
Score 7–10 = 72.7% MACE over next 6 wk: Admit with early invasive strategies

The patient’s HEART score in this question would be 2 (1 point for age and 1 point for hypertension as a risk factor). This categorizes the patient as low risk for a MACE over the next six weeks. The appropriate course of action for this patient would be discharge home with prompt outpatient follow-up (Choice B). Admission for cardiac testing (Choice D) would be warranted for a moderate-high risk HEART score. Prescribing a benzodiazepine (Choice C) would not be warranted as this patient is asymptomatic and the pain episode is vague and atypical. Benzodiazepines are sometimes useful in patients with chest pain due to anxiety. Cardiology consultation (Choice A) would not be warranted as the patient has a low HEART score, is currently asymptomatic with normal imaging, blood work and troponin, and a normal EKG. Correct Answer: B 

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Wieters J, McDonough J, Catral J. Chest Pain. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 17, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165059275

Cite this article as: Joseph Ciano, USA, "Question Of The Day #13," in International Emergency Medicine Education Project, September 18, 2020, https://iem-student.org/2020/09/18/question-of-the-day-13/, date accessed: October 28, 2020