Acute Management of Supraventricular Tachycardias
The term “supraventricular tachycardia (SVT)” expresses all kinds of rhythms that meet two criteria: Firstly, the atrial rate must be faster than 100 beats per minute at rest. Secondly, the mechanism must involve tissue from the His bundle or above. Mechanism-wise, atrial fibrillation resembles SVTs. However, supraventricular tachycardia traditionally represents tachycardias apart from ventricular tachycardias (VTs) and atrial fibrillation (1,2).
Supraventricular tachycardias are frequent in the ED!
The SVT prevalence is 2.25 per 1000 persons. Women and adults older than 65 years have a higher risk of developing SVT! SVT-related symptoms include palpitations, fatigue, lightheadedness, chest discomfort, dyspnea, and altered consciousness.
How to manage supraventricular tachycardia?
In clinical practice, SVTs are likely to present as narrow regular complex tachycardias. Concomitant abduction abnormalities may cause SVTs to manifest as wide complex tachycardias or irregular rhythms. However, 80% of wide complex tachycardias are VTs. Most importantly, SVT drugs may be harmful to patients with VTs. Therefore, wide complex tachycardias should be treated as VT until proven otherwise (1,2).
The chart below summarizes acute management of regular narrow complex tachycardias:
References and Further Reading
- Brugada, J., Katritsis, D. G., Arbelo, E., Arribas, F., Bax, J. J., Blomström-Lundqvist, C., … & Gomez-Doblas, J. J. (2019). 2019 ESC Guidelines for the management of patients with supraventricular tachycardia: the Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). European Heart Journal, 00, 1-66.
- Page, R. L., Joglar, J. A., Caldwell, M. A., Calkins, H., Conti, J. B., Deal, B. J., … & Indik, J. H. (2016). 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 67(13), e27-e115.
Death on the Roads
Save the date: 17th November 2019!
Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).
Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.
Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.
As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.
Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.
WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).
We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).
References and Further Reading
- Official website of The World Day of Remembrance, https://worlddayofremembrance.org
- WHO. Road traffic injuries – https://www.who.int/news-room/fact-sheets/detail/road-traffic-injuries
- WHO. Global status report on road safety 2018 – https://www.who.int/violence_injury_prevention/road_safety_status/2018/en/
Vertigo in the ED
Check this out!
Amazing clinical videos related to vertigo, dizziness – https://www.youtube.com/user/peterjohns84/videos
Toxicology Pearls – Active Charcoal – Infographic
Activated Charcoal Application
- Oral intake < 60 minutes
- the life-threatening dose of the toxic substance
Multi-Dose Activated Charcoal (MDAC) Indications
- Life-Threatening Oral Intake of
- For patients with compromised airway reflexes, unless they are intubated. If the critical situation of the patient indicates intubation, then, gastric lavage may be performed. Intubation, only for decontamination, is not recommended.
- Oral intake of caustic substances
- Late presentation
- Increased risk and severity of aspiration associated with AC use (e.g., hydrocarbon ingestion)
- Need for endoscopy (e.g., significant caustic ingestion)
- Toxins poorly adsorbed by AC (e.g., metals including iron and lithium, alkali, mineral acids, alcohols)
- Presence of intestinal obstruction (absolute contraindication) or concern for decreased peristalsis (relative contraindication)
Equipment and Patient Preparation
There is no specific equipment for activated charcoal administration. However, drinking the charcoal can be very unpleasant for many patients, especially children. Therefore, mixing with fruit juice can be an option. In addition, if necessary nasogastric or orogastric tube placement can facilitate the active charcoal treatment.
- Recommended empirical single-dose of activated charcoal is as follows:
- <1 year – 0.5-1 g/kg or 10-25 g
- 1-12 years – 0.5-1 g/kg or 25-50 g
- >12 years – 1-2 g/kg or 25-100 g
- Multidose activated charcoal
- Give the recurrent dose of charcoal by 0.5 g/kg (≤50 g) every 4 hours
- How to administer:
- If the patient is awake and cooperative, AC may be given orally. Alternatively, it may be given by gastric or nasogastric tube, if these procedures are indicated.
- Mixing the activated charcoal with fruit juices increases tolerability.
- If the patient is unconscious or airway is compromised, gastric lavage should be done, and activated charcoal should be given after intubation. Tracheal intubation is not recommended solely in order to give activated charcoal. Only activated charcoal is to be given, the nasogastric tube is adequate and is preferred.
- If MDAC is indicated, the gastric tube should be withdrawn after gastric lavage and the first dose of activated charcoal. Further doses should be given via nasogastric tube.
Hints and Pitfalls
- The substances that cannot bind to activated charcoal are as follows:
- Strong acids and bases
- Metals and inorganic minerals
- Multi-dose activated charcoal enhances elimination of (But not necessarily indicated in all)
- Sustained-release thallium
- MDAC increase the risk of constipation and bowel obstruction in some cases. Therefore, consider adding a cathartic agent to the second or third dose of AC.
Post Procedure Care and Recommendations
- Control possible nausea and vomiting.
- Look for traces of aspiration or gastrointestinal complications.
Complications of AC and MDAC include:
- Constipation, diarrhea, vomiting
- Pulmonary aspiration
Pediatric, Geriatric, and Pregnant Patient Considerations
- In pediatric and geriatric patients, extra caution should be exercised to avoid and monitor complications.
- Activated charcoal is considered safe for pregnant women.
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Update on Countries Recognize EM As A Specialty
We currently published an article about countries recognize Emergency Medicine (EM) as a specialty. There is a huge interest from the international EM community. We received feedback from many FOAMed followers/enthusiasts. There were 70 countries on our list. After the new information and feedback, the countries reached 82. What an amazing help! And, What a fantastic specialty growing and spreading all around the globe.
If you have new information or update about countries please let us know!
We will be happy to update our list.
Countries Recognize Emergency Medicine as a Specialty
As health care professionals working on Emergency medicine, our history is still being written. Let’s say you would like to learn which countries officially recognize Emergency Medicine (EM) as a specialty, and want to make a beautiful interactive infographic depicting these countries with their official EM recognition years (Because, why not?). It should be an easy task, right? WRONG.
What is your guess?
How many countries recognize Emergency Medicine as a specialty?
How many countries recognize Emergency Medicine as a specialty?— İbrahim Sarbay (@ibrahimsarbay) May 12, 2019
Acil Tıp kaç ülkede bir uzmanlık dalı olarak kabul edilmektedir?
Even though it seems like a simple question which should have a clear answer, the answer is somewhat of a conundrum. There are a few difficulties for the answer. First of all, what is the definition of “recognition”? Could it be possible to consider having an EM residency program or the presence of EM specialists in a country as recognition? Probably not. Secondly, some of the countries recognize EM as a specialty but the exact year of recognition is unclear. Also, the answer may vary between articles and makes it hard to choose one. To make things clear, we have accepted the definition of “recognition” as a country’s official approvement of Emergency Medicine as a primary specialty. Countries recognizing EM as a supra-specialty (such as Switzerland) were also considered as a recognizing country in our list.
Anyway, we have rolled our sleeves up and dug deep. Many articles and tweets later, we had all the data available on this topic. To the best of our knowledge, this is the first time an article or blog post lists EM’s official dates of recognition for the entire world. We have also taken one step further and showed them on a neat interactive map.
So here we go: As of 05/2019, there are 82 countries in the world which recognize EM as a specialty. 13 countries from Africa, 27 countries from Asia, 13 countries from the America, 27 countries from Europe, and two countries from Oceania recognize EM.
As a well-known fact, the first two countries to recognize EM as a specialty are the United States and the U.K. Which are the latest? Germany and Denmark are the most recent of these countries, as both of them recognized EM in 2018. Perhaps, one year later, there will be new countries which welcome EM specialty. Who knows?
Shall we take a look at the current situation in an eye-pleasing way? Of course! You can view our interactive map right here. You can view maps with colors corresponding to the years of EM recognition for each country in the world (darker the color, earlier the date) in Figure 1. You can also view continental maps for Africa, Asia, Americas, Europe and Oceania in Figures 2, 3, 4, 5, 6, respectively.
Figure 1. Countries Recognize Emergency Medicine as a Specialty
Figure 2. Countries Recognize Emergency Medicine as a Specialty
Figure 3. Countries Recognize Emergency Medicine as a Specialty
Figure 4. Countries Recognize Emergency Medicine as a Specialty
Figure 5. Countries Recognize Emergency Medicine as a Specialty
Figure 6. Countries Recognize Emergency Medicine as a Specialty
For the ones who believe nothing is better than a list, all countries are listed in alphabetical order in Table 1. Table 1. List of counties which recognize EM as a specialty (alphabetical order).
|Country Name||Year of Recognition|
|United Arab Emirates||2004|
* Exact year of EM recognition in Bahrain is unknown and establishing of The Bahrain Emergentologist Association (BEMASSO) in 2004 accepted as the recognition year for this infographic.
§ Cuba has an EM/intensive care unit (ICU) training program which was begun in 2000.
# EM is considered as a supra-specialty in Germany, Greece, and Switzerland.
That is all for now! Please feel free to share it and comment on this list. Also, please tell us if we had any countries left behind or if there were any mistakes. EM family grows every day!
Together we are stronger!
References and Further Reading
- Swanson RC, Soto NR, Villafuerte AG, Emergency medicine in Peru, J Emerg Med. 2005 Oct;29(3):353-6, DOI:10.1016/j.jemermed.2005.
- Garcia-Rosas C, Iserson KV, Emergency medicine in México, J Emerg Med. 2006 Nov;31(4):441-5, DOI:10.1016/j.jemermed.2006.
- Al-Azri NH, Emergency medicine in Oman: current status and future challenges,Int J Emerg Med. 2009 Dec 11;2(4):199-203. doi: 10.1007/s12245-009-0143-6.
- Sakr M, Wardrope J, Casualty, accident and emergency, or emergency medicine, the evolution, J Accid Emerg Med. 2000 Sep;17(5):314-9.
- Pek J.H., Lim S.H., Ho H.F., Emergency medicine as a specialty in Asia, Acute Med Surg. 2016 Apr; 3(2): 65–73, doi: 10.1002/ams2.154
- Fleischmann T, Fulde G.,Emergency medicine in modern Europe, Emerg Med Australas. 2007 Aug;19(4):300-2.
- Partridge R., Emergency medicine in Cuba: an update, Am J Emerg Med. 2005 Sep;23(5):705-6, DOI: 10.1016/j.ajem.2005.03.006.
- MacFarlane C, van Loggerenberg C, Kloeck W.,International EMS systems in South Africa–past, present, and future,Resuscitation. 2005 Feb;64(2):145-8,DOI:10.1016/j.