Page 203 - TNFlipTest

Toronto Notes 2019 Approach to Common ED Presentations Table 16. Common Life-Threatening ECG Changes
Emergency Medicine ER23
Pathology
Dysrhythmia
Torsades de pointes Ventricular tachycardia
Ventricular flutter Ventricular fibrillation
Conduction
2nd degree heart block (Mobitz Type II)
3rd degree heart block Left bundle branch block
Ischemia
STEMI
Metabolic
Hyperkalemia Hypokalemia
Digitalis Toxicity
Syndromes
Brugada
Wellens
Long QT syndrome
Headache
• seeNeurology,N44
Etiology
• commonandlessserious
■ common migraine (without aura)/classic migraine (with aura)
◆ common: unilateral, throbbing, aggravated by activity, moderate/severe intensity, N/V, photo-/
phonophobia
◆ classic: fully reversible aura symptoms that precede headache, e.g. flashing lights, pins and
needles (paresthesia), loss of vision, dysarthria
◆ treatment: simple analgesics (NSAIDs, acetaminophen, aspirin), antiemetics, triptans ◆ family doctor to consider prophylactic treatment
■ tensionheadache
◆ bilateral, non-throbbing, not aggravated by routine physical activity, mild-moderate intensity. ◆ can last between 30 minutes to 7 days
◆ triggered with stress, sleep deprivation
◆ treatment: modify stressor(s), simple analgesics (NSAIDs, acetaminophen, aspirin)
• lesscommonbutpotentiallyfatal
■ subarachnoid hemorrhage (SAH) (see Neurosurgery, NS18)
◆ sudden onset, “worst headache of life,” maximum intensity within minutes ◆ increased pain with exertion, N/V, meningeal signs
◆ diagnosis
– new generation CT 100% sensitive within 6 h of onset (hyperattentuating signal around Circle of Willis)
– LP if suspected SAH and normal CT after 6 h ◆ management: urgent neurosurgery consult
ECG Findings
Ventricular complexes in upward-pointing and downward-pointing continuum (160-250 bpm) 6 or more consecutive premature ventricular beats (>100bpm, QRS >120ms)
Smooth sine wave pattern of similar amplitude (>200bpm) Erratic ECG tracing, no identifiable waves
PR interval stable, some QRSs dropped
Total AV dissociation, but stable P-P and R-R intervals
Prolonged QRS complex (>0.12 s) RSR’ in V5 or V6
Monophasic I and V6
May see ST elevation
Difficult to interpret, new LBBB is considered STEMI equivalent
ST elevation in leads associated with injured area of heart and reciprocal lead changes (depression)
Tall T waves
P wave flattening
QRS complex widening and flattening U waves appear
Flattened T waves
Gradual downward curve of ST
At risk for AV blocks and ventricular irritability
RBBB with ST elevation in V1, V2, and V3 Susceptible to deadly dysrhythmias, including VFib
Marked T wave inversion in V2 and V3 Left anterior descending coronary stenosis
QT interval longer than 1⁄2 of cardiac cycle Predisposed to ventricular dysrhythmias
Immediate Treatment of Acute MI BEMOAN
β-blocker Enoxaparin Morphine Oxygen ASA Nitroglycerin
Common Therapeutic Approach to Severe Migraine
• 1LbolusofNS
• prochlorperazine 10 mg IV
• diphenhydramine 25 mg IV
• ketorolac 30 mg IV
• dexamethasone 10 mg IV
• Other options include haloperidol,
metoclopramide, ergotamine, sumatriptan, analgesics
Ottawa SAH Rule
JAMA 2013;310(12): 1248-55
• Useforalertpatientsolderthan15yrwith
new severe non-traumatic headache reaching
maximum intensity within 1 h
• Not for patients with new neurologic
deficits, previous aneurysms, SAH, brain tumours, or history of recurrent headaches (≥3 episodes over the course of ≥6 mo)
• Investigateif≥1high-riskvariablespresent:
• Age ≥40 yr
• Neck pain or stiffness
• Witnessedlossofconsciousness
• Onsetduringexertion
• Thunderclapheadache(instantlypeaking
pain)
• Limited neck flexion on examination
Subarachnoid hemorrhage can be predicted with 100% sensitivity using this rule.
Meningitis
• Do not delay IV antibiotics for LP
• Deliver first dose of dexamethasone with or
before first dose of antibiotic therapy