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Sinus tachycardia or is it flutter?

A 39 year old woman presents to the Emergency Department with palpitations. She has seen her local doctor 3 days previously with the complaint of a ‘racing heart’. The local doctor has done an ECG in the practice, diagnosed Atrial Flutter and commenced a beta blocker; ‘Metoprolol’. The patient now presents to the Emergency Department because her heart is still ‘racing’.
Following some investigations this patient is sent home.[…]

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Electrical injury – who needs to be monitored?

Electrical injury, although not a common occurence can present with significant injury. Often the extent of the injury can be under-estimated as it mostly occurs below the skin, with little more than an entry and exit wound to see.
The very fact that patients with these injuries don’t present often, can result in management challenges. These can range from resuscitation approaches, to decision making as to who needs to be monitored.

The obvious high voltage exposure, with significant burn and injury, is not really a challenge in terms of monitor/non-monitor decision making. The challenge is from that group of patients that are well, with minimal injuries. Who, if any, of these patients do we monitor?

Electrical burns have a trimodal distribution:
1. The first peak is in children. This is primarily due to behaviors such as cord biting.
2. The second peak is in adolescents who engage in risky behaviour and the third group is:
3. Those whose work involves electricity and potential exposure.

Childhood injuries are usually biting injuries, where the child will chew through an electric cord. The result will be a burn to the lips or mouth. These burns are usually bloodless and painless as the vessels have been cauterised and the nerves damaged. One of the main issues in dealing with this kind of elelctrical injury is […]

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Ventricular tachycardia and methadone

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Here’s an interesting cardiac case we had the other day.

A 42 year old male with a past history of IVDU and alcohol abuse and brain injury, presents with what looks like withdrawal. Current medications included methadone and earlier on the same day, he was commenced on naltraxone.

Initially he is found to be becoming progressively more agitated and having brief episodes of depressed conscious state, with improvement between. He is ‘jittery’ with myoclonic movements in the bed. On vitals, he is found to be afebrile with a fluctuating Glascow Coma Score, bradycardic, and to have a systolic blood pressure of 80mmHg, and so he is taken to a resuscitation cubicle.

Is he in withdrawal?
Is he seizing?

As I enter the resus cubicle to find out why the patient is there, I notice a wide complex tachycardia at a rate of about 230bpm. He is still moving. It is self limited after a few seconds. Then a further episode.

In between episodes we do this ECG:[…]

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Could this be a pulmonary embolism?

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In a previous blog we looked at the following patient who presented to the emergency department:

62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure.

He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours. He states that he feels very tired.

He is a well looking man with normal vitals Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves. Chest clear Abdomen soft His ECG and CXR are normal Bloods including a troponin are normal.

I’m unsure of the diagnosis, but given he hasn’t taken his frusemide, I treat him with that. I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight. In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4.

He is diagnosed with a NSTEMI and sent to cardiology.

I now ask the question could it have been a pulmonary embolism and not a NSTEMI?

Certainly if we look at this case we see that the patient had dyspnoea with a normal chest on auscultation and on chest X-ray. Hmmm…

What are the risk factors for pulmonary embolism? Well we know of the classic ones of anything affecting Virchow’s triad. There are the hereditary factors of Protein C and S deficiency as well as others and the acquired factors such as immobility, recent surgery, cancer and others.

This patient had congestive cardiac failure(CCF). Is that a risk factor? As it turns out it is. In a population based study by Helt et al (Arch Intern med. 2002;162:1245-1248), the attributable risk associated with venous thromboembolism was 9.5%. So there is an increased risk in CCF.

What about symptoms and signs? Surely they would help.

Stein et al (Chest 1991;100:598-603), looked at patients with a suspected pulmonary embolism(PE) and with no previous evidence of cardiac or respiratory disease.

He then looked at the symptoms in patients […]

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How good are we at predicting ischaemic chest pain?

Here’s a case I had recently:

62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure. He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours.

He states that he feels very tired.

His examination is as follows:

He is a well looking man with normal vitals

Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves.

Chest clear

Abdomen soft

His ECG and CXR are normal

Bloods including a troponin are normal.

I’m unsure of the diagnosis, but given he hasn’t taken his frusemide, I treat him with that.

I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight.

In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4.

He is diagnosed with a NSTEMI and sent to cardiology.

So the question I posed was, “How good are we at diagnosing cardiac chest pain?” and “Are there some signs or symptoms such as shortness of breath that are more important than we may initially think they are?”

Pope et al(NEJM 2000;343:1167-1170) looked at the rate of missed diagnoses of cardiac ischaemia in the emergency department.

This was a study of some 10689 patients and the conclusion was that there was a subgroup of patients more likely not to be admitted, who had ischaemia or infarction.

Those more likely to not be admitted were: […]

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Syncope

This is one of my favourite areas, as patients present very frequently with this symptom. That very fact makes syncope a challenge. It is a symptom, not a condition in itself. We have to find the cause of the syncope. We need to be experts in this area as syncope presents some 5% of all emergency department visits and comprises 6-10% of admissions[…]

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Seizure, Syncope and Sudden Collapse

Here is a link to a GP website, where a recent video is set up. The lecture is on Syncope and its differentiation from seizures. It talks about how to risk stratify patients so that we minimise our chances of missing the cardiac cases. Enjoy.

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How well does atrial fibrillation and electricity mix?

Hello Everyone, greetings and welcome. The approach to treatment of atrial fibrillation is still one of the most controversial areas in emergency arrhythmia management. Is it rate control or is it rhythm control? When do you shock back to sinus, or at least attempt it? Who do you give anticoagulation to? Given that it affects…

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