
AFib with Rapid Ventricular Rate (RVR) – Rate >110



Primary AFib – Patients symptoms or their hemodynamic instability is due to the AFib itself.  Treatment is by rate or rhythm control.



Secondary AFib – Patients AFib rate or their hemodynamic instability is due to an underlying secondary process (eg thyrotoxicosis, PE, sepsis, drugs, etc).  Treatment is by treating the underlying process.



Unstable Primary AFib – The presence of hypotension, altered mental status, or pulmonary edema.  Treatment is immediate cardioversion, second line agents include digoxin or amiodarone.



Stable Primary AFib (<48 hours duration ) – Treatment is by cardioversion in the ED



Stable Primary AFib ( >48hours or unknown duration) – Treatment is by rate control by CCB (diltiazem or verapimil), or by BB (metoprolol or esmolol)



Anticoagulation – Calculate CHADS2VASC and HASBLED score. Weigh risk of stroke versus risk of major bleeding prior to starting anticoagulation



Further Reading:



Atrial Fibrillation (EMCrit)



Atrial Fibrillation (ACEP Guidelines)



CHADS2VASC Score (MD Calc)



HASBLED Score (MD Calc)





Atrial Fibrillation (Deep Dive R30)

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Symptoms of stroke – weakness, facial droop, slurred speech. vision loss, vertigo, ataxia, confusion or changes to mental status.   



The “typical” stroke workup – blood glucose level, CTH non-con, CTA head/neck, CT Perfusion, CBC BMP Troponin EKG CXR and Coags.  



Common stroke mimics – hypoglycemia, drug/alcohol intoxication, Bell’s palsy, aortic dissection, complex migraines, and seizure with Todd’s paralysis.  



Management/treatment – thrombolytics (within 4.5 hrs), thrombectomy (within 24 hrs) , and blood pressure control (<185/110 if treating, <220/120 if no treatment).  



Remember that time is brain, so move fast! 



  AAEM tPA Infographic



AHA Stroke – “Getting the Gist Across Is Enough for Informed Consent for Acute Stroke Thrombolytics”

Ischemic Stroke (Deep Dive MW R20)


You are working at Clerkship General when one of the nurses comes and grabs you. “Hey doc, we need you in bed 10. I think this patient is having a stroke.” 



Initial Vitals:



HR: 51



BP: 201/98



Temp: 98.0F



RR: 18



O2: 99% (Room Air)



Critical Actions:




* Check a Blood Glucose



* Activate a Stroke Alert



* Assess Contraindications to tPA



* Consent for tPA



* Transfer via Air for Thrombectomy


Round 20 (MW) Stroke Symptoms



* Common during the first year of life as well as during puberty



* Presents with nausea/vomiting, abdominal pain, and/or testicular pain



* ALWAYS examine a child for signs of torsion who presents with abdominal pain (especially lower abdominal pain)



* Look for tenderness, firmness, high riding testicle or testicle with unequal lie, swelling, and the absence of a cremasteric reflex   



* Consult Urology IMMEDIATELY if you have high suspicion, otherwise proceed to ultrasound



* Ultrasound is only 85% sensitive, so clinical gestalt can trump even a negative US



* Attempt manual detorsion if there will be a significant delay to surgery


Testicular Torsion (Deep Dive MW R19)


You are working at Clerkship General when the next patient is put into your rack. It is an 8 year-old male with vomiting



Initial Vitals:



HR: 119



BP: 104/63



Temp: 98.0F



RR: 20



O2: 99% (Room Air)



Critical Actions:




* Finger Stick Blood Glucose



* Treat Patient’s Pain



* Diagnose Testicular Torsion



* Immediate Urology Consult



* Perform Manual Detorsion




References:



Mellick LB, Sinex JE, Gibson RW, Mears K. A Systematic Review of Testicle Survival Time After a Torsion Event. Pediatr Emerg Care. 2019 Dec;35(12):821-825. doi: 10.1097/PEC.0000000000001287. PMID: 28953100.

Round 19 (MW) Tummy Ache in Child with Diabetes


Phase One: CNS




* Ataxia, Slurred Speech, Confusion, N/V, Seizures




Phase Two: Cardiopulmonary 




* CHF, Cardiogenic Shock/Hypotension, Pulmonary Edema, ARDS




Phase Three: Renal




* Flank pain, Hematuria, Oliguria, Renal Failure




Diagnosis:




* HIGH INDEX OF SUSPICION



* Ethylene Glycol Serum Level



* Elevated Osmolar Gap



* Serial Anion Gap Measurements




Treatment:




* Fomepizole or Ethanol to prevent breakdown to toxic glycolic acid/oxalic acid



* Hemodialysis



* Consider Bicarb drip, pyridoxine, and thiamine








Further Reading:



 EMCrit Toxic Alcohols





Atrial Fibrillation (Deep Dive R30)

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