Tag Archives: cardiology

Murmurs for the Learners: An approach to pediatric heart murmurs

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Murmurs for the Learners: An approach to pediatric heart murmurs – A Medical Student Clinical Pearl

Luke MacLeod, Med IV

DMNB Class of 2022

Reviewed by Dr. Tushar Pishe

Copyedited by Dr. Mandy Peach

Case:

You are a senior medical student working in the emergency department and are asked to see Charlie, a 3-year-old boy who had a fall.  He is accompanied by his uncle Kevin, who gives you the history.  About one hour ago, Charlie was climbing onto a chair when he fell off and hit his head.  The chair was only a few feet off the ground and the floor was covered with a rug.  Charlie cried for several minutes after the fall, but there was no loss of consciousness or vomiting following the event.

Kevin tells you that Charlie is a healthy boy with no known medical issues or surgical history. There have been no concerns with his growth or development thus far.  He has no allergies, does not take any medications, and is up to date on his immunizations.  Kevin is unable to tell you much about Charlie’s family history.  He recently adopted Charlie, whose biological parents are no longer involved.

On exam, you observe an active and responsive 3-year-old.  He is afebrile with stable vital signs.  He has normal colour and shows no signs of respiratory distress.  There is a small bump on the top of his head, but no other injuries are noted.  His neurological exam reveals no focal neurological deficits.  To complete the exam, you feel his abdomen, which is soft and non-tender with no organomegaly, and auscultate his heart and lungs.  His lungs are clear with no crackles or wheeze. On auscultation of the heart, you detect a soft, non-radiating systolic murmur that seems to go away with inspiration.

You are reassured from the history and exam that Charlie’s head injury was very minor and that no further investigations or interventions are necessary, but you wonder about the significance of his heart murmur.

 

What is a heart murmur?

 

A heart murmur is an additional sound, often described as whooshing or blowing noise, heard between heart beats that is generated by turbulent blood flow in or near the heart.1,2  Heart murmurs are very common, with up to 90% of children having one either during infancy or later in childhood.  However, less than 1% of these murmurs are due to congenital heart disease.3  If the heart murmur is related to a serious underlying condition, the child may have signs or symptoms such as cyanosis, cough, shortness of breath, or light-headedness.1  Most murmurs are asymptomatic, but the absence of symptoms does not always mean that the murmur is benign.3 In some cases a murmur may be the only sign of an underlying heart condition.4

 

How to describe a murmur

 

Before picking up your stethoscope, you’ll want to make sure you have clean ear canals so you can pick up subtle murmurs.  The characteristics use to describe a murmur can be remembered with the pneumonic Q-TIP ROLS (note: this is not a recommendation to clean your ears with cotton swabs).

 

Quality

The quality of a murmur can be described as harsh, blowing, musical, rumbling, or vibrating.3

 

Timing

Timing describes when the murmur occurs in the cardiac cycle.  A systolic murmur occurs between S1 and S2.  These can be further categorized into four sub-types:

  • Early systolic: heard with or immediately after S1 and ends about halfway through systole.
  • Mid-systolic/systolic ejection murmur: heard midway between S1 and S2. Increases then decreases in volume (crescendo-decrescendo).
  • Mid-to-late systolic: heard about halfway through systole and ends before S2
  • Holosystolic/pansystolic: heard throughout systole.

Click here to listen to a holosystolic murmur: https://www.youtube.com/watch?v=MzORJbyHTT0

 

A diastolic murmur occurs between S2 and S1.  These can be further categorized into three sub-types:

  • Early diastolic: a high-pitched murmur heard with or immediately after S2.
  • Mid-diastolic: heard soon after S2 and ends before S1.
  • Late diastolic/presystolic: heard just before S1.

 

A continuous murmur is heard throughout the cardiac cycle.3

 

Intensity

A grading system from 1-6 is used to describe a murmur’s intensity, with higher values representing greater volumes.3  The following table details what each grade indicates:5

Pitch

A murmur can have low, medium, or high pitch.  High pitch murmurs are best detected using the diaphragm of the stethoscope, while low pitch murmurs are easier to hear using the bell.3

 

Radiation

This is the furthest point from the location (see below) where the murmur can still be detected.3

 

Other sounds

S3: heard in early diastole (shortly after S2).  S3 can be present in hyperdynamic states or with a large VSD.  This sound is best heard with the bell over the apex (for blood flow to the left ventricle) or the lower left sternal border (for blood flow to the right ventricle). When an S3 is present, the heart beat cadence is often described using the word “Kentucky” where “Ken” is S1, “tuc” is S2, and “ky” is S3.5

 

S4: heard late in diastole (just before S1) when there is turbulent blood flow into a stiff ventricle, such as in hypertrophic cardiomyopathy, myocardial dysfunction, semilunar valve stenosis, or tachycardia-induced cardiomyopathy.  S4 is best heard with the bell and is a pathologic exam finding.  When an S4 is present, the heart beat cadence is often described using the word “Tennessee,” where “Ten” is S4, “nes” is S1, and “see” is S2.5

 

Click below to listen to S3 and S4 heart sounds

https://www.youtube.com/watch?v=o8eqYHCy7dw

 

Ejection clicks

These are high pitch sounds that are often generated by abnormal heart valves.  The affected valve is determined based on the location, timing, and nature of the click as shown in the table below:5

Pericardial friction rub

A coarse grinding sound heard with pericarditis. This is best heard along the left sternal border.5

 

Location

This is the point where the murmur is most easily heard.3

 

Shape

Shape describes a murmur’s volume pattern. A few examples are shown below:6

What are the characteristics of benign and pathological murmurs?

 

Some red flag characteristics of pathologic murmurs are listed below.4,7

  • Holosystolic
  • Diastolic
  • Grade 3 or higher
  • Harsh quality
  • Systolic click
  • Max intensity at upper left sternal border
  • Abnormal S2
  • Greater intensity with standing

 

Characteristics of benign murmurs can be remembered using The Seven S’s.4,8

  • Systolic
  • Soft
  • Short (not holosystolic)
  • Small (non-radiating)
  • Sweet (not harsh)
  • Single (no clicks or gallops)
  • Sensitive (changes with position or respiration)

 

Click below to listen to an innocent heart murmur

https://www.youtube.com/watch?v=uFyWHPfrRak

 

Here are some examples to practice differentiating innocent from pathological murmurs:

https://teachingheartauscultation.com/pediatric-murmur-recognition-program-intro

 

What are some of the more common pediatric heart murmurs?

 

Innocent9

  • Classic vibratory parasternal-precordial stills murmur
  • Pulmonary ejection murmur
  • Systolic murmur of pulmonary flow in neonates
  • Venous hum
  • Carotid bruit

 

Pathologic4

  • Ventricular septal defect
  • Atrial septal defect (example: https://www.youtube.com/watch?v=W8gg2S-mvSQ)
  • Patent ductus arteriosus
  • Teratology of Fallot
  • Pulmonary stenosis
  • Coarctation of the aorta
  • Aortic stenosis
  • Transposition of the great arteries

 

Next steps

 

In patients with a heart murmur and an abnormal chest X-ray or ECG, an echocardiogram is indicated.  The echocardiogram is the gold standard test to diagnose congenital heart defects.  While the chest X-ray and ECG are low cost tests and can help rule out other diagnoses, they are not particularly useful in identifying the cause of a heart murmur. 3

An innocent heart murmur in an asymptomatic patient with an otherwise normal exam does not require referral to cardiology.  However, the patient should be followed by their family physician to monitor the murmur.

Patients who are symptomatic, have a pathologic murmur, and/or have other concerning exam findings should be referred to a pediatric cardiologist.10

 

Case Conclusion

 

Charlie’s heart murmur lacked any of the red flag characteristics.  It was soft (grade 2) systolic murmur that did not radiate and changed with inspiration, which are all reassuring signs.  He was also asymptomatic and had an otherwise normal exam.

You explain to Kevin that Charlie looks well and that there are no signs of serious head trauma.  You mention that you did notice a heart murmur that is likely benign.  Charlie does not need to see a specialist, but you recommend that he have a follow up appointment with his family doctor in the next few weeks to monitor the heart murmur.

 

 

References:

  1. Heart Pulse Sound Wave Icon Stock Vector – Illustration of blood, healthcare: 91331428. Accessed November 19, 2021. https://www.dreamstime.com/stock-illustration-heart-pulse-sound-wave-icon-background-image91331428
  2. Heart Murmur | NHLBI, NIH. Accessed November 18, 2021. https://www.nhlbi.nih.gov/health-topics/heart-murmur
  3. Heart murmurs: MedlinePlus Medical Encyclopedia. Accessed November 18, 2021. https://medlineplus.gov/ency/article/003266.htm
  4. Pediatric Heart Murmurs: Evaluation and management in primary care. Accessed November 18, 2021. https://oce-ovid-com.ezproxy.library.dal.ca/article/00006205-201103000-00006/HTML
  5. Frank JE, Jacobe KM. Evaluation and Management of Heart Murmurs in Children. Am Fam Physician. 2011;84(7):793-800.
  6. Approach to the infant or child with a cardiac murmur – UpToDate. Accessed November 18, 2021. https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-a-cardiac-murmur?search=heart%20murmurs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
  7. Physical Examination – Textbook of Cardiology. Accessed November 18, 2021. https://www.textbookofcardiology.org/wiki/Physical_Examination
  8. Pediatric Heart Murmur Recognition Program intro. Teaching Heart Auscultation to Health Professionals. Accessed November 19, 2021. https://teachingheartauscultation.com/pediatric-murmur-recognition-program-intro
  9. Bronzetti G, Corzani A. The Seven “S” Murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713. doi:10.1177/0009922810365101
  10. Begic E, Begic Z. Accidental Heart Murmurs. Med Arch. 2017;71(4):284-287. doi:10.5455/medarh.2017.71.284-287
  11. McConnell ME, Adkins SB, Hannon DW. Heart murmurs in pediatric patients: When do you refer? Am Fam Physician. 1999;60(2):558-565.

 

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Modified Valsalva maneuver in the treatment of SVT – REVERT Trial

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Falling heels over head: you make my heart skip a beat

Resident Clinical Pearl (RCP) November 2019

 

Patricia Marks – PGY1 (FRCPC) Dalhousie University, Halifax, NS

Reviewed by Dr David Lewis

 

 

Introduction:

Supraventricular tachycardias (SVT) is a common presentation to the emergency room, and most patients will require treatment with adenosine or electrical cardioversion, as vagal maneuvers are less than 20% of the time in clinical practice. Adenosine and electrical cardioversion both require additional hospital resources, and adenosine is poorly tolerated by patients.

 

The REVERT trial published in 2015 in the Lancet by Appelboam et al. proposed a modified Valsalva maneuver in the treatment of SVT.  The study was a multicentre randomized control trial in England involving 433 patients with stable SVT. According to an intention to treat analysis, the authors found a 43% success rate of conversion to sinus rhythm with the modified Valsalva maneuver compared to 17% with standard Valsalva. No significant dangerous adverse effects occurred in this study.

 

Modified Valsalva: The How-To

  1. Patient identification:

    1. Is my patient eligible for Valsalva?
      • Stable SVT
      • Age > 18 years
      • Able to perform Valsalva
      • Able to lie flat and have legs lifted
    2. Contraindications:
      • Unstable or indication for immediate cardioversion
      • Atrial fibrillation, atrial flutter, sinus tachycardia
      • Recent MI
      • Aortic stenosis
      • Glaucoma
      • Retinopathy
      • Third trimester of pregnancy

  2. Materials

      • 10cc syringe
      • Manometer (optional)

  3. Performing the modified Valsalva maneuver

    1. Position the patient in a semi-recumbent position (45º)
    2. Instruct the patient to blow into the tip of a 10cc syringe for 15 seconds. The patient should be targeting a pressure reading on the manometer of 40mmHg, or blowing hard enough to move the plunger tip*
    3. Lower the patient flat and passively raise their legs to a 45º angle for 15 seconds
    4. Return the patient to a semi-recumbent position for an additional 45 seconds
    5. Assess the rhythm
    6. Repeat x1 if unsuccessful before moving on to adenosine or electrical cardioversion (provided the patient remains stable)

*The REVERT trial used a manometer to measure 40mmHg of pressure, however Smith and Boyle have demonstrated that 40mmHg of pressure is generated when a patient is instructed to blow into a 10cc syringe until the plunger moves

Image obtained from https://www.ecgmedicaltraining.com/wp-content/uploads/2016/06/REVERT-Trial-SVT.jpg on February 21, 2020.

 

Watch the REVERT authors perform the maneuver:

 

 

Benefits of this method:

  • Easy to instruct patients; can try at home
  • Higher success rate than standard Valsalva
  • Similar ED length of stay compared to standard Valsalva
  • Less patients require adenosine or cardioversion

Additional considerations

  • No formal studies exist for pediatric patients, however a recent case report by Rayburn and Wagers did demonstrate successful conversion to sinus rhythm with this maneuver

 

Bottom Line 

In adults with stable SVT, the modified Valsalva maneuver as published in the REVERT trial achieves a high rate of conversion to sinus rhythm with a NNT of 3.8 and without significant adverse effects. In patients without contraindications, the modified Valsalva maneuver is a low-cost and easy to teach strategy that should be trialled to convert patients in SVT prior to adenosine or electrical cardioversion.

 

 

References

  • Appelboam A, Reuben A, Mann C, Gagg J, Ewings P, Barton A, Lobban T, Dayer M, Vickery J, Benger J; REVERT trial collaborators. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet. 2015 Oct 31;386(10005):1747-53. doi: 10.1016/S0140-6736(15)61485-4.
  • Rayburn D, Wagers B. Modified Valsalva Maneuver for Pediatric Supraventricular Tachycardia. Pediatr Emerg Care. 2020 Jan;36(1):e8-e9. doi: 10.1097/PEC.0000000000002023
  • Smith G, Boyle MJ. The 10 mL syringe is useful in generating the recommended standard of 40 mmHg intrathoracic pressure for the Valsalva manoeuvre. Emerg Med  Australas. 2009 Dec;21(6):449-54. doi: 10.1111/j.1742-6723.2009.01228.x
  • Smith GD, Fry MM, Taylor D, Morgans A, Cantwell K. Effectiveness of the Valsalva Manoeuvre for reversion of supraventricular tachycardia. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD009502. DOI: 10.1002/14651858.CD009502.pub3
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PoCUS in Pericardial Effusion

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Medical Student Clinical Pearl – October 2019

 

Alex Pupek

Faculty of Medicine
Dalhousie University
CC4
Class of 2020

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual

Case

A 70F with a history of bladder CA, HTN and 4.9cm AAA presented to the Emergency Department (ED) and was Triaged as Level 3 with a chief complaint of generalized weakness. Initial assessment was significant for hypotension and low-grade fever with dysuria elicited on history; she was started on Ceftriaxone with a working diagnosis of urosepsis. Bloodwork and imaging studies were sent to rule out other potential sources of infection.

She had a mild leukocytosis of 12.4, pH of 7.23 and a lactate of 5.0. Point-of-care urinalysis was unremarkable. The chest x-ray revealed an enlarged cardiothoracic ratio of 0.62 compared to 0.46 ten months previously, concerning for a pericardial effusion.

Upon reassessment, the patient appeared unwell with slight mottling to the skin, cool extremities and tenuous blood pressure; point of care ultrasound revealed a large pericardial effusion.  Interventional cardiology was paged; the patient was moved to the trauma area and an emergent pericardiocentesis was performed: 360cc of bloody fluid was removed. The pericardial drain was left in situ.

Post-procedure bloodwork included a troponin of 216 and CK of 204. The patient was admitted to the Cardiac Care Unit and discharged within a week’s time.

 

Pericardial Effusions and The Role of Point-of-Care Ultrasound (POCUS)

The normal pericardial sac contains up to 50 mL of plasma ultrafiltrate [1]. Any disease affecting the pericardium can contribute to the accumulation of fluid beyond 50mL, termed a pericardial effusion. The most commonly identified causes of pericardial effusions include malignancy and infection (Table 1).

 

Table 1 – UpToDate, 2019 – Diagnosis and Treatment of Pericardial Effusions

 

Evaluation of the pericardium with point-of-care ultrasound includes one of four standard views: parasternal long axis, parasternal short axis, subxiphoid and apical (Figure 1). A pericardial effusion appears as an anechoic stripe or accumulation surrounding the heart. Larger effusions may completely surround the heart while smaller fluid collections form only a thin stripe layering out posteriorly with gravity. Seen most commonly post-cardiac surgery, pericardial effusions may be loculated and compress only a portion of the heart. [1,2] (Table 2)

Figure 1[1]

Table 2 [2]

 

Both the pericardial fat pad and pleural effusions can be mistaken for pericardial effusions. The parasternal long-axis view is most helpful to accurately define the effusion with the descending aorta, posterior to the mitral valve and left atrium, serving as a landmark: the posterior pericardial reflection is located anterior to this structure. Fluid anterior to the posterior pericardial wall is pericardial, whereas a pleural effusion will lie posterior. The pericardial fat pad is an isolated dark area with bright speckles, located anteriorly; unlike fluid, it is not gravity dependent. Rather than competing with the cardiac chambers for space within the pericardial sac, the fat pad moves synchronously with the myocardium throughout the cardiac cycle. [1,2] (Figure 2)

Figure 2[1]

A pericardial effusion discovered on POCUS in the ED may be mistaken for tamponade, leading to inappropriate and invasive management in the form of pericardiocentesis.[2]

Patient tolerance of pericardial effusions depends on the rate by which they accumulate. As little as 150-200 mL of rapidly accumulating effusion can cause tamponade whereas much larger amounts of slowly accumulating fluid can be well tolerated. Pericardial effusions formed gradually are accommodated by adaptations in pericardial compliance. A tamponade physiology is reached once the intrapericardial pressure overcomes the pericardial stretch limit.[2] (Figure 3)

Figure 3[2]

The core echocardiographic findings of pericardial tamponade consist of:

  • a pericardial effusion
  • diastolic right ventricular collapse (high specificity)
  • systolic right atrial collapse (earliest sign)
  • a plethoric inferior vena cava with minimal respiratory variation (high sensitivity)
  • exaggerated respiratory cycle changes in mitral and tricuspid valve in-flow velocities as a surrogate for pulsus paradoxus

In the unstable patient with clinical and echocardiographic findings of tamponade, an emergent pericardiocentesis is indicated.[2]

A retrospective cohort study of non-trauma emergency department patients with large pericardial effusions or tamponade, ultimately undergoing pericardiocentesis, found that effusions identified by POCUS in the ED rather than incidentally or by other means saw a decreased time to drainage procedures, (11.3 vs 70.2 hours, p=0.055).[3]

Point of care ultrasound is a valuable tool during the initial evaluation of the undifferentiated hypotensive emergency department patient but should be interpreted judiciously and within clinical context to avoid unnecessary emergency procedures.

Additional Images

From GrepMed



 




echocardiogram-pericardial-tamponade-alternans-effusion


 




References


    

  1. Goodman, A., Perera, P., Mailhot, T., & Mandavia, D. (2012). The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade. Journal of emergencies, trauma, and shock, 5(1), 72.
    2. 

  2. Alerhand, S., & Carter, J. M. (2019). What echocardiographic findings suggest a pericardial effusion is causing tamponade?. The American journal of emergency medicine, 37(2), 321-326.
    3. 

  3. Alpert, E. A., Amit, U., Guranda, L., Mahagna, R., Grossman, S. A., & Bentancur, A. (2017). Emergency department point-of-care ultrasonography improves time to pericardiocentesis for clinically significant effusions. Clinical and experimental emergency medicine, 4(3), 128.
    4. 



 

			

		

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EM Reflections – December 2019


				

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Thanks to Dr Joanna Middleton for leading the discussions this month


Edited by Dr David Lewis 




Discussion Topics










    

  1. 

    Cardiopulmonary Resuscitation In Patients With Mechanical Circulatory Support
    

      

    • Patient with mechanical circulatory support devices have unique clinical signs of cardiac arrest
      • 

    • Understanding the function of these devices ids critical to the management of these complex cases
      • 

    

    2. 

  2. 

    Aortic Dissection
    

      

    • Remains a commonly missed or delayed diagnosis
      • 

    • Once diagnosed, meeting the therapeutic goals requires a careful and considered approach
      • 

    

    3. 














Cardiopulmonary Resuscitation In Patients With Mechanical Circulatory Support


Case


A 70yr male presents with cardiac arrest. He has an LVAD. What are the implications for emergency management and cardiopulmonary resuscitation?












Introduction


Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure.


It is important to understand the difference between blood flow and perfusion when assessing any patient with suspected cardiovascular hemodynamic instability, especially patients with an LVAD, in whom the peripheral arterial pulse is not a reliable indicator. Flow represents the forward movement of blood through the systemic circulation. It can be either adequate or inadequate to provide sufficient oxygen delivery to sustain tissue per- fusion. Assessment of adequate tissue perfusion is the most important factor in determining the need for circu- latory assistance such as chest compressions.










What is a Left Ventricular Assist Device?


With an LVAD, blood enters the device from the LV and is pumped to the central aortic circulation, “assisting” the heart.  The outflow cannula is typically anastomosed to the ascending aorta, just above the aortic valve. RA/RV still working




 




Blue Arrow – Important point as patients often present with iGel in place…


 


Unique Patient Properties


    

  • Pulses often absent

      

    • BP measured manually with a Doppler – MAP (50-90)
      • 

    

    • 

  • SpO2 may not be measurable
    • 

  • Anticoagulated
    • 

  • Need power!
    • 

  • Very reliant on RV function/preload
    • 

  • Leading cause of death – sepsis and stroke
    • 



Further Reading


Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support. A Scientific Statement From the American Heart Association





Aortic Dissection


Aortic dissection remains difficult to diagnosis with 1 in 6 being missed at the initial ED visit. Why? The diagnosis is rare with and incidence of only 2.9/100,000/year, and the presentation is often atypical mimicking other more common diagnoses such as ACS and stroke.


View The SJRHEM  – Aortic Dissection – Resident Clinical Pearl here:


Aortic Dissection




Diagnosis




The most common initial misdiagnoses are acute coronary syndrome, pulmonary embolism, and stroke. Patients with these suspected diagnoses should also be screened for high-risk features of acute aortic dissection. If none are present, they are unlikely to have an acute aortic dissection. If high-risk features are present, balance your clinical suspicion for an aortic dissection with the likelihood of an alternative diagnosis using an approach such as RAPID


How Do I rule Out Aortic Dissection – Just the Facts – CJEM


PoCUS


Early Screening for Aortic Dissection With Point‐of‐Care Ultrasound by Emergency Physicians


A total of 127 patients were enrolled: 72 in the US group and 55 in the control group. In the US group, compared with CTA, the sensitivity of EP POCUS was 86.4%, and the specificity was 100.0%.


 




 


Treatment Goals




From EMCases.com


 


Further Reading


Episode 92 – Aortic Dissection Live from The EM Cases Course




 

			

		

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Palpitations – A Paroxysmal Pearl


				

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Palpitations – A Paroxysmal Pearl


Medical Student Clinical Pearl




Scott Fenwick


Class of 2021




Faculty of Medicine


Dalhousie University






Reviewed and Edited by Dr. David Lewis




Case Presentation:


A 49-year-old female presented with palpitations for the past 2 hours. She had two similar episodes in the last 2 weeks, both of which resolved within 1-2 minutes. She had no other symptoms. She was otherwise healthy, with no past medical history. She was a non-smoke and non-drinker who leads an active lifestyle. She denied weight loss, diarrhea, and heat intolerance.


On physical exam, she was tachycardic at 130bpm with an irregularly irregular pulse. She did not display any tremor or diaphoresis. On auscultation, S1 and S2 were audible, with no murmurs or extra sounds. Respiratory and abdominal exams were unremarkable.




What to ask on History?


Common Symptoms: palpitations, tachycardia, fatigue, weakness, dizziness, light-headedness, reduced exercise capacity, mild dyspnea, and polyuria. It is essential to know when exactly the symptoms started. AF that presents before 48 hours can be safely rhythm controlled without anticoagulation.(1)


Severe/Secondary Symptoms: angina, dyspnea at rest, presyncope and, uncommonly, syncope. Embolic events and heart failure can be severe complications of AF.


Past Medical History: cardiovascular or cerebrovascular disease, diabetes, hypertension, COPD, obstructive sleep apnea, and hyperthyroidism.




What to look for On Examination?


ABCs and vitals: particularly pulse rate and rhythm.


General Assessment: look for signs of thyroid disease, PE, pulmonary disease, alcohol withdrawal, and signs of liver disease from excessive alcohol ingestion.


CVS: precordial scars from prior cardiac surgery, JVP, peripheral edema, and auscultation for murmurs or additional sounds that might suggest valvular AF. There is often an apical-radial pulse deficit where not every apical beat has an associated radial beat due to lack of left ventricular stroke volume.(2)




Case Continued – Testing: 


The patient was put on a cardiac monitor and an ECG was performed, demonstrating atrial fibrillation. There was also a right bundle branch block that was consistent with a previous ECG performed in 2017. Laboratory testing was unremarkable.


Depending on clinical suspicion, initial testing may include CBC, electrolytes, blood glucose, PT/INR, creatinine, BUN, TSH, cardiac enzymes, LFTs, and chest x-ray.2




See Basic ECG interpretation Pearl for a great guide to ECGs


Basic ECG Interpretation






 


Classifying Atrial Fibrillation: 


AF is classically described as an irregularly irregular heartbeat, as can be observed from the variable RR intervals in the ECG above. In AF, there are no distinct P-waves due to the uncoordinated atrial activity. Broadly, AF can be divided into valvular and non-valvular subtypes. Non-valvular AF can be classified into the following categories:(1)


    

  • Paroxysmal – AF terminates spontaneously or with intervention within 7 days of onset.
    • 

  • Persistent – AF fails to terminate within 7 days of onset; often a progressive disease.
    • 

  • Long-Standing Persistent – AF has persisted for greater than 12 months.
    • 

  • Permanent – Joint decision between patient and provider to no longer pursue rhythm control.
    • 



AF commonly progresses from paroxysmal to persistent states. The above classification only refers to primary atrial fibrillation, not AF that is secondary to cardiac surgery, pericarditis, myocardial infarction, valvulopathy, hyperthyroidism, pulmonary embolism, pulmonary disease, or other reversible causes.


For persistent and permanent AF, the CHADS2 score can be used to estimate a patient’s 1-year risk of ischemic stroke without anticoagulation (0 = low risk, 1-2 = moderate risk, 3+ = high risk).(1)




Calculate it here


 


CAEP and CCS now recommend using the CHAD-65 Score to determine anticoagulation requirement.




 




 


Treatment


DC and chemical (e.g. procainamide) cardioversion are two well-described methods of treating uncomplicated AF. The goal of treatment is to return patients to NSR. Some important points about the two methods include:


    

  • DC cardioversion can be administered at an initial energy dose of 100J and increased up to 360J as needed.(2)
    • 

  • Procainamide is often given in doses of 15-18mg/kg, or more simply, 1g over 60 minutes. Average time to cardioversion is about 1 hour.(1)
    • 

  • DC cardioversion requires procedural sedation; whereas, chemical cardioversion does not.
    • 

  • In a recent RCT, combination therapy achieved NSR in 99% of patients; Attempting DC cardioversion first decreased length of hospital stay by 1.2 hours.(3)
    • 

  • Both therapies are generally well-tolerated by patients.
    • 







Case Continued – Treatment: 


The patient was diagnosed with paroxysmal atrial fibrillation. The arrhythmia did not spontaneously resolve in the ED. DC and chemical cardioversion methods were considered and discussed with the patient. Direct Current (DC) cardioversion was performed under procedural sedation with propofol and fentanyl. Shocks of 100J and 200J were unsuccessful in converting the patient into normal sinus rhythm (NSR). A third shock at 300J was ultimately successful. The following ECG was obtained demonstrating NSR. As in the initial ECG, there is a RBBB present.


 




CHADS2 score was 0. Therefore anticoagulation or antithrombotic therapy not indicated.




 


Case Conclusion:


The patient was discharged home within 4 hours of arriving to hospital, anticoagulation was not prescribed. It is likely that she will experience AF again and require anticoagulation later in life.




 


References:


    

  1. January, C. T., Wann, L. S., Alpert, J. S., Calkins, H., Cigarroa, J. E., Cleveland, J. C., et al. (2014). 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: Executive summary. Journal of the American College of Cardiology, 64(21), 2246. doi:10.1016/j.jacc.2014.03.021
    2. 

  2. Wakai, A., & Neill, J.O. (2003). Emergency management of atrial fibrillation. Postgrad Med J, 79(932), 313. doi:10.1136/pmj.79.932.313
    3. 

  3. Scheuermeyer, F. X., Andolfatto, G., Christenson, J., Villa-Roel, C., & Rowe, B. (2019). A multicenter randomized trial to evaluate a chemical-first or electrical-first cardioversion strategy for patients with uncomplicated acute atrial fibrillation. Academic Emergency Medicine, 26(9), 969-981. doi:10.1111/acem.13669
    4. 


			

		

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Color Flow Doppler to Assess Cardiac Valve Competence


				

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Color Flow Doppler to Assess Cardiac Valve Competence


Resident Clinical Pearl (RCP) April 2019




Dr. Scott Foley – CCFP-EM PGY3 Dalhousie University, Halifax NS


Reviewed by Dr. David Lewis


 




 


Background:


When colour Doppler is initiated, the machine uses the principals of the Doppler effect to determine the direction of movement of the tissues off which it is reflecting.


The Doppler effect is the change in frequency of a wave in relation to an observer who is moving relative to a wave source. It was named after the Austrian physicist Christian Doppler who first described the phenomenon in 1842. The classic example is the change in pitch of a siren heard from an ambulance as it moves towards and away from an observer.


These principles are applied to POCUS in the form of colour Doppler where direction of flow is reflected by the colour (Red = moving towards the probe, Blue = moving away from the probe), and the velocity of the flow is reflected by the intensity of the colour (brighter colour = higher velocity).

*Note: the colour does not represent venous versus arterial flow.


 




The use of colour Doppler ultrasound can be useful in the emergency department to determine vascular flow in peripheral vessels as well as through the heart. It is one way to determine cardiac valve competency by focusing on flow through each valve.




 


Obtaining Views:


To optimize valve assessment, proper views of each valve must be obtained. It is best to have the direction of the ultrasound waves be parallel to the direction of flow. External landmarks for the views used are seen below:




    

  • Mitral Valve and Tricuspid Valve: The best view for each of these is the apical 4 chamber view. If unable to obtain this view, the mitral valve can be seen in parasternal long axis as well.
    • 

  • Aortic Valve: The best view is the apical 5 chamber or apical 3 chamber but are challenging to obtain. Instead, the parasternal long axis is frequently used.
    • 

  • Pulmonic Valve: Although not commonly assessed, the parasternal short axis can be used.
    • 

  • Visit 5minutesono.com for video instruction on obtaining views
    • 







Parasternal long axis: MV, AV




Parasternal short axis: PV, TV




Apical 4 chamber: TV, MV




 


Assessing Valvular Competency:


How to examine valvular competency:


    

  1. Get view and locate valve in question
    2. 

  2. Visually examine valve: opening, closing, calcification
    3. 

  3. Use colour Doppler:

      

    1. Place colour box over valve (as targeted as possible (resize select box) to not include other valves)
      2. 

    2. Freeze image and scroll through images frame by frame
      3. 

    3. Examine for pathologic colour jets in systole and diastole
      4. 

    

    4. 

  4. Estimating severity:

      

    1. Grade 1 – jet noticeable just at valve
      2. 

    2. Grade 2 – jet extending out 1/3 of atrium/ventricle
      3. 

    3. Grade 3 – jet extending out 2/3 of atrium/ventricle
      4. 

    4. Grade 4 – jet filling entire atrium/ventricle
      5. 

    

    5. 



See video tutorial below for more






Mitral Regurgitation A4C




Tricuspid Regurgitation A4C




Aortic Stenosis PSLA




Bottom line:


Color flow Doppler on POCUS is a straightforward way to assess for valvular competency in the Emergency Department. A more detailed valvular assessment requires skill, knowledge and experience.


 




Useful Video Tutorials:


Mitral Regurgitation




 


Aortic Stenosis vs Sclerosis






Tricuspid Valve






References:


    

  1. https://www.radiologycafe.com/medical-students/radiology-basics/ultrasound-overview
    2. 

  2. By Patrick J. Lynch and C. Carl Jaffe – http://www.yale.edu/imaging/echo_atlas/views/index.html, CC BY 2.5, https://commons.wikimedia.org/w/index.php?curid=21448310
    3. 

  3. 5minutesono.com
    4. 

  4. ECCU ShoC 2018 powerpoint, Paul Atkinson, David Lewis
    5. 


			

		

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EM Reflections – January 2018


				

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Thanks to Dr Joanna Middleton for leading the discussion this month and providing these tips and references.


Edited by Dr David Lewis 


 


    

  1. 

    Occult Fractures of the Upper Limb
    

    2. 

  2. 

    Door to Needle/Balloon Times
    

    3. 

  3. 

    Mycotic Aneurysms
    

    4. 

  4. 

    CME Quiz
    

    5. 





Occult Fractures of the Upper Limb


In patients (particularly the elderly)who present with upper limb pain following a fall or other trauma, be careful not to miss an occult fracture. Localization may be impaired by dementia, acute confusion or other soft tissue injuries. Commonly missed fractures of the upper limb include:


    

  • Clavicle fracture
    • 

  • Supracondylar fracture
    • 

  • Radial Head/Neck fracture
    • 

  • Buckle fractures of the radius/ulna
    • 

  • Scaphoid fracture
    • 

  • Carpal dislocation
    • 

  • Any impacted fracture
    • 



Impacted fractures of the humeral neck may still allow some shoulder joint movement. Pain can be referred to the elbow (just as some hip injuries have pain referred to the knee).


When a fracture is strongly suspected ensure that the entire bone is included in the radiograph. If localization is impaired consider obtaining radiographs of the entire limb, starting with the most symptomatic area. Also follow the old mantra – “include the joint above and below” when ordering radiographs for suspected fracture.


Commonly missed fractures in the ED


Misses and Errors in Upper Limb Trauma Radiographs


 




Strategies to reduce door to ballon time


Delays in door to balloon time for the treatment of STEMI have been shown to increase mortality.


 


 




JACC 2006 Click on here for full text


 




BMJ 2009 – Click here for full text


 


This evidence has led to an international effort to establish strategies that can reduce door to balloon times


This rural program in the USA published their strategy for reducing door to ballon times below 90mins over a 4 year period. https://www.sciencedirect.com/science/article/pii/S0735109710043810. Their strategies included the following:


2005

• Community hospital physicians visited by interventional cardiologist with recommendations to:


∘ Perform ECG within 10 min of arrival for chest pain patients


∘ Communicate with PCI center physicians via dedicated STEMI hotline


∘ Treat and triage patients without consulting with primary physicians


∘ Give aspirin 325 mg chewed, metoprolol 5 mg IV × 3 when not contraindicated, heparin 70 U/kg bolus without infusion, sublingual nitroglycerin or optional topical nitropaste without routine intravenous infusion, and clopidogrel 600 mg PO


∘ Eliminate intravenous infusions of heparin and nitroglycerin.


2006

• Nurse coordinator hired to oversee program and communicate with emergency department personnel at all referring hospitals.


• Recommendations for medications listed above were formally endorsed for all STEMI patients.


• Formal next-day feedback provided to referring hospitals, including diagnostic and treatment intervals and patient outcomes.


• Quarterly “report cards” issued to each referring hospital emergency department.


2007

• PCI hospital emergency physicians directly activated the interventional team (instead of discussing it first with the interventional cardiologist on call).


• A group page was implemented for simultaneous notification of all members of the interventional team and catheterization laboratory staff of an incoming STEMI patient.

ECG = electrocardiogram; IV = intravenous; PCI = percutaneous coronary intervention; PO = by mouth; STEMI = ST-segment elevation myocardial infarction.


 


However recent commentaries have highlighted the pitfall of this metric


 


The Challenges and Pitfalls of Door-to-Balloon Time as a Performance Metric


https://www.medscape.com/viewarticle/537538


 


and further evidence has shown no improvement in mortality despite reducing door to balloon times. However, it should be noted that these centres were already achieving < 90 min.




http://www.nejm.org/doi/full/10.1056/NEJMoa1208200


This may be a result of multiple confounding factors:


total ischemic time may be a more important clinical variable than door-to-balloon time


it has been suggested that the association between door-to-balloon time and mortality may be affected by an “immigration bias” – healthier patients are likely to have shorter door-to-balloon times than are sicker patients with more complex conditions, for whom treatment may be delayed because of the time needed for medical stabilization


 


Whilst strategies to ever reduce door to balloon times may not be the correct focus to reduce overall mortality, it is clear that the presence of significant delays (>90mins) is associated with increased mortality.


 




Mycotic Aneurysms


Any kind of infected aneurysm, regardless of its pathogenesis. Such aneurysms may result from bacteremia and embolization of infectious material, which cause superinfection of a diseased and roughened atherosclerotic surface.


 


Aneurysmal degeneration of the arterial wall as a result of infection that may be due to bacteremia or septic embolization 


    

  • Symptoms:  pulsatile mass, bruit, fever
    • 

  • Risk Factors:  arterial injury, infection, atherosclerosis, IV drug use
    • 

  • #1 cause = staph, #2 = salmonella
    • 




Download (PDF, 1.14MB)


 




 


CME QUIZ

        

            
EM Reflections - Jan 18 - CME Quiz
        
                
                
                

            

                
EM Reflections – Jan 18 – CME Quiz

            


            
            

                
            

        

                
                
                
                
                
                
                
                
                

                
        
			

		

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ED Rounds – October 2015


				

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This month ED Rounds were presented by Dr Mike Howlett  , Dr James French and Dr Wendy Alexander (Pediatrician SJRH).


 


Congestive Heart Failure – Dr Mike Howlett


Dr Howlett presented 4 cases that highlighted the differences in pathophysiology and approaches to treatment for CHF in the ED.


The definition of Congestive Heart Failure (ESC 2012 Guidelines)


a syndrome in which patients have typical symptoms (e.g. breathlessness, ankle swelling, and fatigue) and signs (e.g. elevated jugular venous pressure, pulmonary crackles, and displaced apex beat) resulting from an abnormality of cardiac structure or function


Diagnosis of CHF


The diagnosis of heart failure with reduced ejection fraction (Systolic) and Heart Failure with preserved ejection fraction (Diastolic) is summarised in the box below.


Diagnosis HF


The mortality of Diastolic and Systolic HF are similar


CHF_Oct_2015_pptx


Dr Howlett’s full presentation can be downloaded / viewed below:



Download (PDF, 7.3MB)


 


How to be Awesome at Simulation – Dr James French


Dr French presented an interactive session that highlighted the important steps to designing, running and debriefing a simulation.


See our Simulation Program page for more details


Presentation to be uploaded here soon…


 


Pediatric Asthma – Dr Wendy Alexander


Dr Alexander presented pediatric pearls accumulated over her 25 years of practice.


See the SJRHEM Pediatric Asthma Guidelines


 


 


 


 

			

		

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ED Rounds –  June 2015


				

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Thanks to Dr Emily Love for preparing this useful post that summarizes the ED Rounds presentations for June 2015.




Resident Elective to South Africa. 


Dr Leanne Hewitson and Dr Sarah Compeau


This was a great presentation. The girls talked about their work in several different hospitals in South Africa where they had an opportunity to assess and treat a large volume of trauma patients. In terms of some of the ways these hospitals differed from ours, there were often less resources (for example, there would be only so many suture trays for the night and they had to be careful not to use these up unnecessarily; also there were only two bags of O negative blood in the department in one of the hospitals – if they needed more they had to call a driver who would transport the blood from a facility 45 mins down the road).  


Another difference was staffing. There typically was not an attending staff on site, and they had a lot of independence in terms of diagnosing and treating their patients. they worked closely with a junior resident, a medical student and a senior physician who was not yet an attending (I can’t remember the name they assigned to this role). 


Examples of hands-on opportunities: chest tube insertion, assessing and treating stab wounds and patients with multiple traumas 


In terms of the discussion after the presentation, we talked about safety. In one of the cities, it was not safe to go out alone at night and was necessary to always have a route planned out so they would not get lost and end up in a dangerous area. The girls did feel  that with good planning and proper cautions the benefits of the experience outweighed the risks.  


Hands on experience: We talked about how valuable this experience was in terms of seeing a large volume of trauma patients, which we don’t see here in Canada. The girls both feel they are much more comfortable treating trauma patients here after their experience and would recommend it to other residents. 


Teaching residents in other centers: Sarah and Leanne were able to both learn from house staff at the hospitals and also share some of their own skills. For example, they were able to teach ACLS protocols to the residents at one of the centers as they did not have formal  ACLS training as they did here. 




Download (PDF, 7.5MB)




ST elevation in a 33 year old in RAZ


Dr Nicola Smith


This was a very interesting prevention and a good lesson to all of us on recognizing our own biases that may affect patient care. 


When a 33 yo otherwise healthy female presented to RAZ with a headache, some potential biases were as follows 


1- the triage note mentioned that she was quiet anxious but had settled 


2-  she was in RAZ which gives the impression the patient is not acutely ill


3- it was the end of the day after a long busy day


The resident who saw this patient recognized these biases, and spent time with her to do a thorough history and physical. She was prompted to order an ECG which showed the ST elevations when the patient spoke about pain starting in her abdomen and moving up to her head and also left arm numbness.  


the patient turned out to have a pheochromocytoma. Lessons we learned about this are as follows: 


1- close blood pressure and HR control are key before any surgery as there is a risk with surgery of further release of catecholamines and  a hypertensive emergency 


2- these patients need close work-up for MENS syndromes 


3 – there are some case studies reporting ST elevations in pheochromocytoma.




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