BostonCityEM Blog is a Free Open Access Medical Education (FOAMed) blog brought to you by the emergency medicine residents and faculty at Boston Medical Center. Their goal is to provide high yield educational content, driven by EM medicine residents and reviewed by faculty. They will feature hot topics in clinical emergency medicine, ultrasound, critical care, pediatric emergency medicine etc.
Disclaimer: This piece is satirical. On purpose. Please
do not interpret all words literally.
Alert: I sometimes have mental health struggles!
And probably so do you.
TW: Anxiety, depression, occasional swearing,
poop jokes (How inclusive is this meant to be?)
Oh, hello there. How are you? Do you have a
moment to learn about the uncomfortable details of my anxiety?
Surprise!! I have it.
Actually, we all have it. We may not label it ‘anxiety’. Maybe we call it stress or insomnia or ineptitude (when it’s really really bad).
I’m here as your friendly neighborhood ER doctor
to tell you that it’s normal. No, really! I’m not just saying that because I have to. In
the interest of full disclosure, this piece was not sponsored by Big PharmaTM (although if the
makers of sertraline would like to step up, you know where to find me).
Around 20% of all adults in the US1
have some form of an anxiety disorder, which includes social anxiety, panic
attacks, agoraphobia, hypochondriasis and just plain old, garden-variety
generalized anxiety disorder; “GAD” for short.
GAD is a great example of how medical terminology
and particularly medical acronyms can be very dumb. Imagine trying to
nonchalantly explain to your Tinder date that you have a thing called GAD. Not
even Gal Gadot could pull that off with charisma.
all its forms is actually estimated to be the most common chronic mental health
condition in the US1. I’m convinced the number is MUCH higher than 1
out of 5, but I’m also pretty sure nobody likes telling themselves they have a
“disorder.” What kind of weird and ridiculous word is that, disorder?
If you’re not in the medical field (or if you are),
it might surprise you to learn that the incidence of anxiety & depression
are actually higher in doctors2
than in the general population. Ironically enough, the stigma around mental
health issues in doctors is like the stigma around these issues in your gossipy,
digital friend groups, multiplied by like, I don’t know, 17.
Probably people don’t like to think of their
doctors as having mental illness. But honestly, my doctor probably has high
blood pressure and hey, I’m not judging. It’s a hard job to take care of your
The reality is, when I became a doctor, I didn’t
magically become a not-human-being, though it seems that was kind of the
So, in the interest of taking care of myself,
I’ve decided that I shouldn’t feel embarrassed that I sometimes struggle with
anxiety and other negative emotions. That’s
just dumb! Or Wait; I’ll try to practice
better positive self-talk:
embarrassment is not super productive and is literally bad for my health.
There, much better.
Anxiety and depression are normal emotions.
However, feeling so unable to acknowledge them that you begin to question
reality and find yourself awake at 2am, eating Doritos, and somehow sobbing and
laughing at the same time for no apparent reason? That is decidedly not ideal.
But also, sometimes Doritos are kind of the best medicine, you know?
So anyway. This is a thing that happens to me, a real-live actual doctor who does doctor things as her job.
your mind blown? It’s okay, try to act natural.
say that I am not anxious about sharing this but… obviously I am. Please
don’t read this and just like/love/panic-wow-face it as your (imperceptibly
subtle) way of showing solidarity. Please don’t comment to tell me how brave I
am, because I’m not (I mean thanks, but nah). I spent literal days agonizing
over this piece, and then several weeks agonizing about whether it was too
self-centered or unprofessional to share in this forum.
even doctors still have to be afraid that disclosing mental health issues will
cost them their jobs.
not actually joking about that part. Pretty messed up irony, huh?
stigma is real. The idea that being honest about struggling with anxiety or
depression could negatively impact your work or relationships or whatever else¾ that idea is actually not an
irrational paranoia that only you have.
how the hell do I get patients to trust that they can safely confide in me
about mental illness if I can’t even admit to myself that sometimes I have it?
I’m no chef, but I know that’s not a recipe for success.
can easily relay empathy to patients who come to the ER with food poisoning by
saying things like:
really sorry you’ve had so much diarrhea that you’re up to your eyeballs in it. And you’ve vomited so many times the bottom
of your toilet seat looks like some repulsive crime scene ¾except, you know, in a doctory and uber-professional
sort of way.
when patients come to the ER with symptoms that I suspect or even am sure are related
to anxiety, depression, bipolar disorder, schizophrenia and other manifestations
of extreme and/or chronic stress, I am so afraid of relating to them TOO much
that my words of comfort ring hollow.
they know it too. Because they, like I, feel very ashamed.
am often afraid to even mention those capitalized words ‘Anxiety’ or ‘Depression’when treating patients because the
stigma that we as people ALL feel is so unbearably potent that we would rather
act personally offended by the words than admit it’s something we can all
instead, if you’ve stuck with me this long; if this lengthy mass of words
resonates with you in any way, form, or poop-shaped emoticon, please…
a minute to put on your bravery cape and talk to somebody about it.
can even just share this rant if you want
¾it’s okay, you’re not lazy, even
though I bet you’re sitting there contemplating it and telling yourself that
you are. You’re so lazy you can’t even click a share button.
Look at how anxiety makes us treat ourselves.
though, share it wherever you want. Print it out and tape it on a cool looking
tree in the park. You have my permission. Tell your kids, tell your wife, tell
your best friend or your worst friend or your boss’s weird cousin at the
my partner likes to say (in a way that used to make me roll my eyes but now I
realize is probably the sagest advice I ever heard in my damn life):
only awkward if you make it awkward.”
true it hurts and I don’t even mean that sarcastically.
you ever feel like you’re struggling with anxiety or depression, and you’re
worried (ha) that it’s reaching a breaking point, PLEASE go see a doctor. Any
doctor. If it’s too awkward to see your doctor, see my doctor. I’ll give you
have a doctor? Get one.
an ER doctor, my professional medical opinion is that primary care doctors are THE. BEST. DOCTORS. for this and any
other unsettling human dysfunctions you’re experiencing.
I promise I won’t ever be mad if you show up in the ER instead. Mental health
can be an emergency too.
love you guys, and I don’t mean that in the fake-cheesy social media way. I
mean it like I became a doctor because I want to help people. And if talking
about my own adventures with the ups and downs of mental illness can normalize
it even a teensy tiny bit, I’m in.
Oh! And one last thing – because
if high school taught me anything ,it’s that the cleverest way to end an essay
is with a thoughtful quote. Here is one
by my favorite author and secret personal hero, Tom Robbins:
“I see nothing particularly courageous in risking one’s life.
So you lose it, you go to your hero’s heaven and everything is milk and honey
’til the end of time. Right? You get your reward and suffer no earthly
consequences. That’s not courage. Real courage is risking something you have to
keep on living with, real courage is risking something that might force you to
rethink your thoughts and suffer change and stretch consciousness. Real courage
is risking one’s clichés.”
So take care of yourselves. Because if you don’t, I’ll have to. Just kidding, but also not really.
Be able to list major structures in the anterior, medial, lateral and posterior compartments of the knee
Learn components of a basic ultrasound of the knee
Understand the current literature involving ultrasound for detection of meniscal tears
-Suprapatellar joint recess
-Prepatellar & infrapatellar bursitis
-Medial Meniscus (incompletely visualized)
-Lateral Meniscus (incompletely visualized)
-Popliteal neurovascular bundle
Anterior compartment Start with the patient in supine position and the knee slightly flexed (figure 1). Place the probe in the sagittal plane just proximal to the patella, along the long axis of the quadriceps tendon. Evaluate the complete quadriceps tendon, medial to lateral, in both the long and short axes (figures 2, 3). The tendon can be follow proximally to evaluate its four muscular components: rectus femoris, vastus medialis, vastus lateralis, and vastus intermedius (figure 4). Just deep to the quadriceps tendon is the suprapatellar recess (figure 6). Positioning the knee in slight flexion preferentially drives fluid into this recess, making it a sensitive area to evaluate for knee effusions. From here, the transducer is moved inferiorly in the sagittal plane, just distal to the patella until the patellar tendon is identified. Again evaluate the entire tendon in longitudinal and transverse orientations. This region is also evaluated for bursal fluid superficial to the patella (prepatellar bursa), and anterior to the patellar tendon (infrapatellar tendon). Remember to use light pressure in order to avoid displacing and missing fluid in this area. Lastly flex the knee to 90° and evaluate the femoral trochlear cartilage by placing the probe in a transverse orientation. The cartilage should appear hypoechoic and of uniform thickness.
Figure 1. Probe/knee positioning for evaluation of anterior knee. Knee should be flexed 20-30°.
Figure 2. Quadriceps tendon longitudinal. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 3. Quad tendon transverse – VM is vastus medialis. C is Femoral trochlear cartilage. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 4. Quadriceps muscles. VM is vastus medialis. RF is rectus femoris, VI is vastus intermedius, VL is vastus lateralis.Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 5. Patellar Tendon longitudinal. HF is hoffa fat pad. TT is tibial tuberosity. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 6. Simple joint effusion in suprapatellar recess, deep to quadiceps tendon.Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Evaluation is begun in coronal plane by finding the MCL along the medial aspect of the joint line. Evaluate the entire extent of the MC in long & short axes. The medial meniscus can also be seen deep to the MCL, between the femur and tibia (figure 8). The medial meniscus should appear triangular and hyperechoic. The probe can then be moved anteriorly and posteriorly to evaluate the anterior & posterior horns of the meniscus. Finally, evaluate the pes anserine tendons by moving distally along the MCL to about 4-5cm beyond the joint line and slightly anteriorly (figure 9). Here the insertions of the pes anserine tendons (sartorius, gracilis, and semitendinosus) can be evaluated, as well as the bursal fluid below them. The sartorius is the most anterior tendon, the semitendinosus is the most posterior tendon, and the gracilis is between the two.
Figure 7. Position the leg in external rotation and slightly flex knee (Line represents probe position)
Figure 8. MCL Longitudinal. MM is medial meniscus. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 9. Pes Anserine tendons in longitudinal, superficial to MCL. Appears as single entity at this level but can be followed proximally to see demarcation of the different tendons. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Start on the patellar tendon in long axis and move probe laterally. The first longitudinal structure will be the IT band (figure 11). Follow the IT band proximally, focal thickening or surrounding fluid at the distal femur can indicate IT band friction syndrome. Once evaluation of the IT band is finished, the transducer can be moved further laterally in the coronal plane until the LCL is visualized (figure 13). Along the joint line the lateral meniscus should also be visualized. Move the probe anteriorly and posteriorly to observe the anterior and posterior horns. As with the medial meniscus, the lateral meniscus should appear triangular and hyperechoic.
Figure 10: Position the leg in internal rotation and slightly flex knee (Rectangle represents probe position). Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
Figure 11. T band longitudinal view. Just lateral to patella. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016. Figure 12. Probe placement for LCL evaluation. Proximal end of transducer at popliteal groove (surface of lateral femoral condyle where popliteus muscle originates)
Figure 13. LCL in longitudinal. Image from Alves et al. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. RadioGraphics. 2016.
30 mg SC
May repeat 2nd dose in 6 hr
(max of 3 doses/day)
Slow SC preferably in the abdomen
3 doses/24 hr
Bradykinin B2 receptor antagonist
Local injection site reactions, Abdominal
pain, Nausea, Headache, Dizziness, Fever, Asthenia, Increased transaminases
Frozen Plasma (FFP)
~2 units IV
Administer via standard Y blood
Inhibits plasma kallikrein, coagulation
factors XIIa and Xia, C1s, C1r, MASP-1, MASP-2, and plasmin
Sudden worsening of HAE attacks,
Infusion reactions, Possible transmission of infectious agents
HAE attacks are a potentially life-threatening
Early recognition and treatment of HAE attacks
Be familiar with which HAE on demand treatments
are available at your institution
Due to cost and utilization considerations, FFP
may be the only option at your institution
Consider establishing patient-specific treatment
protocols in patients with known HAE that utilize your institution
Zuraw BL, et al. US hereditary angioedema association
medical advisory board 2013 recommendations for the management of hereditary
angioedema due to C1 inhibitor deficiency.
J Allergy Clin Immunol: In
Craig T, et al. A focused
parameter update: hereditary angioedema,
acquired C1 inhibitor deficiency, and angiotensin-converting enzyme inhibitor
associated angioedema. J Allergy Clin Immunol 2013;131(6):1491-3.
Craig T, et al.
WAO Guideline for the Management of Hereditary Angioedema. World Allergy Organ
Nasr IH, et al. Optimizing hereditary angioedema
management through tailored treatment approaches. Expert Rev Clin Immunol 2015;
Wu MA, et al. Current treatment options for hereditary
angioedema due to C1 inhibitor deficiency. Expert Opinion on Pharmacotherapy
2015; doi: 10.1517/14656566.2016.1104300
Zanichelli A, et al. The safety of treatments for
angioedema with hereditary C1 inhibitor deficiency. Expert Opin Drug Safety
Technology in medicine is advancing at ever faster rates, thanks to impressive (and exponential) progress in both cost and scale. Connected “Things” are getting smaller, cheaper, and more ubiquitous. If you don’t believe me, check your heart rate on your smartwatch.
Not you, grandpa.
Technological advances impact how we deliver care in our emergency rooms. While medicine has traditionally been slow on the uptake, we are seeing increasing examples of medical technology in action in the emergency department (ED). Connectivity is rapidly embedding itself in patient care, from how patients pursue care (ex. patient self-presenting because their holter monitor registered a 6 beat pause and they were contacted by the monitoring company) to how we monitor them in the emergency department (Bay 6’s bed is beeping, he’s trying to make run for it!)
Quick, distract him with that salty goodness.
As reflected in recent pop-culture phenomena such as the
Netflix Original “Black Mirror” or USA Network’s “Mr. Robot”, the looming specter
of malicious intent is ever present when technology is involved. As our care
becomes intertwined with the internet-of-things (or recently coined internet of
medical things), security becomes
ever more important. Want can we do as emergency physicians?
Let’s start with awareness.
Imagine this scenario, you are called to the resuscitation room to evaluate a patient with symptomatic bradycardia. The patient reports that he was reading his favorite journal in a coffee shop when he suddenly began to feel palpitations and shortness of breath. He begins to lose consciousness, and you rifle through your Advanced Cardiac Life Support (ACLS) algorithms. But what caused this? Well it turns out that his pacemaker is malfunctioning, and it’s not due to lead issues (ex. dislodgment), pocket issues (ex. migration, erosion), or battery failure.
While no actual cases have been documented in the literature, these flaws were demonstrated in 2012 when hacker BarnabyJack reverse engineered a pacemaker’s transmitter to deliver an 850-volt shock. Reports of this vulnerability go back as far 2007, when Dick Cheney’s physician disabled the wireless function on the then vice president’s pacemaker, fearing a terrorist could assassinate the vice president by sending a deadly signal to his device a.
If it could happen to Dick Cheney, it could happen to that guy in Bay 7.
Despite the theoretical threat, and the paucity of literature reports, this flaw has had real world implications. In 2017, the FDA recalled nearly 500,000 pacemakers when a vulnerability was discovered that could allow hackers to reprogram pace makers to slow down or even stop b.
The old man was right!
The good news is that as of April 2018, the FDA approved a
firmware update for many Abbott (formerly St. Jude) ICDs (implantable
cardioverter defibrillator) and CRTs (cardiac resynchronization therapy)c.The update requires any external devices attempting to communicate with
the ICD/CRTs to provide authorization. This authorization can only be provided
by their proprietary programmers and transmitters, such as those found in
clinic and in their home monitoring systems. Abbott has also gone so far as to
offer the option of disabling radiofrequency communication for some of its
older devices that cannot handle an update. The downside however is that this
will prevent data from being accessed by the users and their physicians.
For now, as EM physicians, we can do our part in recognizing
the possibility of such an event occurring, and gently reminding our patients
to get their devices updated, if they have not already done so.
Consider another scenario where a patient is brought in by paramedics in a combative altered mental state. The patient is diaphoretic, screaming and needs four security guards to tie him down. You have given him intramuscular glucagon, intraosseous D50 many times and only now secured IV access to hang a continuous infusion of D50. Yet the patient remains in refractory hypoglycemia. What is going on??
“There’s a national shortage on Dextrose, so we’re just giving him saline with the word ‘sugar’ plastered on the label. Heh.”
In 2017, programmers at Rapid 7, a cybersecurity consulting firm, announced vulnerabilities in the Animas OneTouch Ping insulin pump system d. The system uses wireless communication between its pump and its glucometer to transmit glucose values in real time without requiring the user to input the amount of insulin needed. The programmers found that these communications were delivered using clear text without any encryption, opening to the possibility that anybody in close proximity could listen in to the communications and potentially trick the pump into believing that their own external messages were actually coming from the glucometer itself. This could allow ‘hackers’ to prompt the pump to deliver an extra-large dose of insulin when none was required. Consider the video below, where Jay Radcliffe wirelessly programs a OneTouch pump to deliver a 20U insulin bolus:
Insulin Pumps vulnerable to cyber attacks - YouTube
Copyright Jay Radcliffe, Rapid7
These disclosures were released after communication with Animas. For their part, Animas have relayed the warning to their customers. However, it is unclear whether security on these pumps has been tightened. What does this mean for us as emergency physicians? Well for one, it involves being more cognizant of the patient’s medical history, particularly with respect to what kind of hardware they are carrying. The risk of this sort of incident is pretty low given the relatively low prevalence of patients presenting with medical devices that are susceptible to security vulnerabilities, and it does require a significant amount of technical expertise. For now, it is an interesting tidbit of information to help keep your medical students on their toes. But it can happen.
“I don’t care if its 2019 or 2119, I’m not putting hacking on my differential”- medical student who hates you.
On another hypothetical difficult (quote horrible) shift, your charge nurse hurriedly runs over to tell you that EVERY, SINGLE infusion pump in the ED is beeping like crazy. Blood pressures are going low on nicardipine, and others are blowing through the roof on norepinephrine. As you frantically tell her to literally disconnect every line, you start to panic about how to deliver titrated medicines to patients who need them. What’s going on??
It could be gremlins. But that’s another blog post.
In 2015, the FDA released a security advisory recommending
that consumers avoid using a particular brand of wireless infusion pumps due to
security vulnerabilities that would allow those with malicious intent to access
the pump and deliver fatal doses of medications e. This security
vulnerability was demonstrated in a video produced by Blackberry (yes, that
blackberry) where a security expert was able to access a PCA pump and deliver
many times the safe dose of morphine. While that particular type of pump was
discontinued by its manufacturer for different reasons back in 2015, the threat
is still present, as evidenced when security vulnerabilities were uncovered in
a different brand of infusion pumps in 2017 f.
These examples serve to show the many ways in which cybersecurity compromises can affect patient care. While thankfully no cases of direct patient harm have been reported, the threat remains a real possibility. The FDA has been doing its part to address these cybersecurity concerns. It has held public workshops, webinars, as well as releasing new guidelines on submissions for software contained in medical devices g. Hospital systems are also preparing for potential cyber-security attacks that could threaten patient care systems. While slow on the uptake, they face many challenges including a wide array of potential targets, third-party software and hardware that make security compliance difficult. Most importantly the human element is particularly challenging to account for, as demonstrated by the uncountable phishing attacks that occur every year h. These attacks are invited in by the system’s users themselves, whenever they click on links with malicious attachments, supply their passwords to fraudulent links by accident, or reply to emails asking for more information.
Reasons is good enough for me. *Click*. Image by Selling_illegal_pepe, reddit.com
The emergence of disaster protocols similar to those put in place for natural disasters and mass shooting is necessary, as the trend is towards ever more connectivity. Is not hard to imagine a future where all medical machines are connected wirelessly. As our patients become more connected to the internet of (medical) things, it is our responsibility as providers to become more cognizant of the potential dangers they are exposed to.
An 86 year old male with a complicated past
cardiac and GI history rolls into the resuscitation bay. He has a known history
of afib on apixaban, prior esophageal cancer s/p esophagectomy and multiple
significant GI bleeds of unknown origin. He is sitting on the stretcher with a
bag of coffee ground emesis in his lap and actively vomiting dark red blood.
Quickly, 2 large bore IVs are established, 40 mg IV pantoprazole is given, GI
is stat paged and unmatched blood is on its way. As you are resuscitating the
patient and discussing the need for airway management, the nurse points out a
wide complex tachycardia on the monitor.
An EKG shows persistent monomorphic
ventricular tachycardia. BP is 110/80 and now the patient has stopped vomiting.
He is sitting up and talking to you with a seemingly normal mental status and
denying chest pain or shortness of breath.
The first critical decision point is stable vs
unstable. This patient has a high likelihood of decompensation but currently
has an appropriate blood pressure (greater than 90/60) and adequate perfusion
evidenced by a normal mental status and denial of chest pain and shortness of
breath. So, for now he can be considered stable (1).
that decision, there is the more complicated decision of what agent to reach for
to terminate the ventricular tachycardia. The
available choices are amiodarone, procainamide, lidocaine and adenosine. This
review will discuss the benefits of procainamide over amiodarone and how to
dose both in the Emergency Department.
Amiodarone is a popular choice for an antiarrhythmic that acts on sodium channels, beta adrenergic receptors, potassium channels and calcium channels (it is a class I, II, III and IV drug) to varying degrees. Despite its popularity, it carries a Class IIb recommendation from the AHA (1). Procainamide is a Class Ia antiarrhythmic agent that carries a Class IIa recommendation from the AHA (1). It is an older drug but it has been directly compared to Amiodarone in a head to head trial with favorable results (2).
the AHA recommendation and available evidence, I use it as a first line agent
for termination of stable ventricular tachycardia.
PROCAMIO trial was a multicenter, randomized and prospective trial that
compared IV procainamide vs IV amiodarone for stable ventricular tachycardia
(2). The doses used were:
IV procainamide 10mg/kg over 20 min
IV amiodarone 5mg/kg over 20 min
It spanned six years and was a relatively small clinical study (74 patients recruited).
Major Cardiac Adverse Events
V-tach termination (within 40 minutes)
Adverse Events Within 24 Hours
is worth noting that this trial was done in Europe and the dosing was slightly
different that what you may be familiar with in the US. A more common dose at
our Trauma Center in Boston is to give procainamide at 17 mg/kg with a max rate
of 50 mg/min or to give 100 mg IV over 2 minutes every 5 minutes until you
convert the rhythm. Amiodarone can be administered by a loading dose of 150 mg
IV over 10 minutes, followed by an infusion.
most common adverse event with both drugs was hypotension (2). When this
happens, you should be ready to cardiovert, so pad placement prior to drug
administration is critical. In the above patient, we were able to convert the
patient to normal sinus rhythm with 17 mg/kg of procainamide. The patient was
intubated post conversion for emergent EGD and despite the love for it in our
department, ketamine was carefully avoided given the sympathomimetic surge
associated with its use as an induction agent.
The head-to-head trial is the best evidence available for procainamide over amiodarone. However, prior to this study, there were several retrospective case series that indicated similar results and prior studies that demonstrated the efficacy of procainamide over lidocaine (3, 4, 5). So, even though your pharmacist may have to run out of the resus bay to grab this “very old drug”, consider it for your next stable patient with ventricular tachycardia.
Ortiz M et al.
Randomized Comparison of Intravenous Procainamide vs. Intravenous
Amiodarone for the Acute Treatment of Tolerated Wide QRS Tachycardia: the
PROCAMIO Study. Eur Heart J 2016. PMID: 27354046
There are only a few things I know about the world. Sunrise in the east, sunset in the west. Death and taxes. Cheese is definitely ok to toss on to your baby in a high chair, but probably not ok to toss on somebody else’s baby.
TL:DR – You need to consider the patient when you get an ECG, and you need to look for a few specific things on an ECG ordered for syncope. Have a plan, or a mnemonic. #cheesechallenge.
Your patient came to the ED after passing out. Now what do you do? You could do a lot, including cbc for anemia, chemistry for electrolyte abnormalities, BNP for cardiogenic cause, head CT for SAH, CT PA for PE, MRI for TIA/CVA, CTA for dissection or ruptured AAA, and probably some others. We won’t go through a whole syncope algorithm tonight, but you can certainly find many out there, including some clinical decision guidelines1,2,3.
Tonight, suffice to say that everybody should get a POC glucose, POC pregnancy (women only please), and an ECG, the star of tonight’s post.
Over the last month or so of overnights, I’ve been focusing on the ECG reading in Syncope. Probably shouldn’t ever present a case of syncope without an ECG. Definitely shouldn’t ever present a case without reading the ECG that’s already done.
Again, we’re only going over how I (and maybe you) should review the ECG in the patient who has had an episode of syncope (or near syncope)
You should read the ECG – i.e. however you usually read ECGs (rate, rhythm, axis, etc.) you should start there.
You should read the ECG looking for ECG abnormalities that might explain the syncope.
This is my routine.
I start by looking at:
intervals (which is nice because it is near the end of my regular ECG routine). In particular, short PR phenomena like WPW or LGL. Which can devolve into VF/VT from aberrant conduction.
Long QT (short QT too) – over 500 QTc is interesting, over 525 might be concerning. Which can lead to TdP.
High degree blocks – 2° type 2, and 3°. Can lead to pauses that lead to syncope, which requires pacer placement. BTW, you should have already diagnosed this because you already read it already, in step 1 above.
Bundle blocks can lead to paroxysmal AV block as the cause.
Then I look for micropathology:
Brugada – Sodium channel mutation. Linked with sudden cardiac death. ‘Coved’ (I call it “shark fin”) ST into inverted T or ‘saddleback’ ST in early precordial leads.
ARVD – Arrhythmogenic Right Ventricular Dysplasia (or ARVC – cardiomyopathy) – fibrofatty deposits, leads to VT/VF arrests, young healthy sudden deaths often during exercise/stress/illness.The Epsilon wave is often hard to see (tucked in to the end of QRS), but if you have the right patient, and you think it might be there, consider zooming in. That is double the rate and amplitude of the ECG machine. 50mm/s and 20mm/mV. Or take a pic with your phone and zoom in with your fingers you crazy millennial.