SurvivED      Windy City EM

This week's Conference was a City -Wide meeting of all the EM Programs in Chicago.  Each Program presented one great "Save"  I will give just a few learning points from the day.

ACMC's own Mitch Lorenz      

 Severe hypokalemia and hypomagnesemia from GI losses can cause prolonged QT and torsades.  Torsades can result in cardiac arrest.  Keep severe electrolyte abnormalities such as hyperkalemia, hypokalemia, and hypomagnesemia in your differential for patients with arrhythmias.

Editors note: Another setting that can result in profound hypokalemia and malignant arrhythmia is when treating DKA with IV insulin and the potassium level is not carefully managed. 

Everyone else:

In hypotensive patients, the bedside ultrasound is your friend.  You can't see pericardial tamponade on CXR and it is hard or impossible to diagnosetamponade with physical exam.  Ultrasound at the bedside will drastically shorten the time to diagnosis of pericardial tamponade.  In the setting of hypotension it can also identify tension pneumothorax, a big RV due to PE, cardiogenic shock, intra-peritoneal blood, and AAA.

If you do identify a pericardial effusion in a patient with chest or back pain consider CTA of the chest to evaluate for aortic dissection.  Proximal aortic dissections can cause pericardial tamponade.

All the presented cases emphasized the importance of continually re-assessing your patients.

There is some data and anecdotal experience that ant/post placement of defib pads is more effective than shoulder/apex placement.  There was great save case discussed that hinged on placing the defib pads in the anteror/posterior position.  We may want to consider doing this in all cases.

Exerpt from Supporting Reference: Botto, BMJ Heart 1999;82:726–730

This reference discusses AFIB but the message I think would be similar for any arrhythmia.  CONCLUSIONS An antero-posterior defibrillator paddle position is superior to an antero-lateral location with regard to technical success in external cardioversion of stable atrial fibrillation, and permits lower dc shock energy requirements. Arrhythmia duration is the only clinical variable that can limit the restoration of sinus rhythm.

Patients who have experienced violence will internally feel severe anxiety, anger, and hyper-vigilance or awareness for future violence.  Healthcare providers can alleviate this somewhat by speaking in a friendly manner with the patient prior to delving into the medical issues at hand. Ask permission to examine them before touching their body.  The patient appreciates being treated as a person and having some small talk prior to doing the H&P.