October 17, 2019

Background: In patients with hemodynamically stable supraventricular tachycardia (SVT), vagal maneuvers are the traditional first step in management.  There are several  vagal techniques in the literature which include, standard valsalva maneuver (sVM), modified Valsalva maneuver (mVM), and carotid sinus massage (CSM). All three techniques aim to increase vagal tone to slow down conduction in the AV node and, hopefully, result in termination of Atrioventricular nodal reentry tachycardia (AVNRT)and atrioventricular reentrant tachycardia (AVRT).  The authors of this trial performed a RCT evaluating the effectiveness of sVM vs mVM vs CSM at not only terminating SVT but also having a sustained effect up to 5 minutes.

September 30, 2019

Background: Chest pain is a common chief complaint the Emergency Department, and the differential diagnosis includes life-threatening conditions from several organ systems including cardiac, pulmonary, and gastrointestinal, in addition to more benign etiologies. Historically, despite most patients not having acute coronary syndrome, there is still a high rate of medical admissions in patients with chest pain. The advent of accelerated diagnostic protocols has aided in guiding clinicians with decision making and disposition of these patients. This study aimed to address the question of whether or not an emergency medicine physician’s clinical gestalt would be sufficient to rule in or rule out acute coronary syndrome (ACS). Several studies have addressed this question with conflicting results. Given the high morbidity and mortality of acute coronary syndrome, emergency medicine physicians focus their clinical decision making on decreasing type II errors, i.e., false negatives. In clinical practice, this means having a low rule-out rate based on physician gestalt; in other words, most patients with chest pain presenting to the Emergency Department will have testing including an EKG and troponin level even for patients for whom the physicians have a low clinical suspicion for ACS.

September 23, 2019

Background: Supraventricular tachycardia (SVT) is not an uncommon condition in the emergency department. Epidemiologically, SVT has an incidence of 35/100,000 person-years in the United States.2That is roughly 89,000 new cases per year. The Valsalva maneuver is a recognized treatment for SVT, but has a low success rate (5-20%). 3,4,5 The REVERT trial showed an increase in cardioversion of SVT using a modified Valsalva maneuver, but this was done with a manometer, and adjustable bed, which may not be available in many settings.

August 15, 2019

Background: The clinical diagnosis of pulmonary embolism (PE) can be challenging given its variable presentation, thus requiring dependence on objective testing. Decision instruments such as PERC and the Wells’ score help stratify patients to low or high probability, enabling focused use of CT pulmonary angiography (CTPA) for diagnosis. However, despite these algorithms, there is evidence of increasing use of CTPA along with diminishing diagnostic rate (less than 10%). This combination results in the overdiagnosis of subsegmental PEs, unnecessary exposure to radiation and false positive results. These issues are compounded in patients with pregnancy. While we know that pregnancy increases risk of venous thromboembolism (VTE) our testing rates far exceed the added risk exposing thousands of women to the afore mentioned potential harms.

In 2017, the YEARS algorithm established a simplified algorithm for evaluation with a two-tiered D-dimer threshold in an effort to reduce the number of patients getting CTPA  (van der Hulle 2017). The YEARS algorithm asks three questions: 1) Are there clinical signs of DVT? 2) Does the patient have hemoptysis? and 3) is PE the most likely diagnosis. If the answer to all 3 questions is no, the D-dimer threshold is set at 1000 ng/mL FEU (500 ng/mL DDU) and if the answer is “yes” to any of the 3 questions, the D-dimer threshold is set at 500 ng/mL (250 ng/mL DDU). However, this study had very few pregnant women enrolled.

August 7, 2019

Take Home Points

  • There is no real distinction between syncope and near syncope.

  • Older folk with near syncope or syncope should be treated the same.

  • Patient with high risk features its reasonable to admit but if they’re low risk, well-appearing and have reasonable follow up discharge home is fine.

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