UMEM Educational Pearls

Category: Critical Care

Title: Noninvasive Ventilation Pearls

Keywords: noninvasive ventilation (PubMed Search)

Posted: 7/15/2008 by Mike Winters, MD (Updated: 8/12/2020)
Click here to contact Mike Winters, MD

 Noninvasive Ventilation Pearls

  • Multiple studies support the use of noninvasive positive pressure ventilation (NPPV) in acute exacerbations of COPD, acute cardiogenic pulmonary edema, and immunocompromised patients (organ transplant) with hypoxic respiratory failure.
  • The timing of NPPV initiation is important.  NPPV should be started as soon as possible, as delays increase the likelihood of intubation
  • The best predictor of success is a favorable response to NPPV within the first 1 to 2 hours
    • reduction in respiratory rate
    • improvement in pH
    • improved oxygenation
    • reduction in PaCO2
  • Also crucial to NPPV success is a well fitting interface (mask)
  • Although patients report greater comfort with nasal masks, they also permit more air leakage through the mouth and have been associated with a higher rate of initial intolerance in the acute setting.
  • For acute applications of NPPV in the ED, a full face mask is preferred 

Show References


Category: Vascular

Title: Ruling Out Pulmonary Embolism During Pregnancy

Keywords: Pulmonary Embolism, Pregnancy (PubMed Search)

Posted: 7/14/2008 by Rob Rogers, MD (Updated: 8/12/2020)
Click here to contact Rob Rogers, MD

Evaluating for Pulmonary Embolism During Pregnancy

Highest risk of PE is within the first week postpartum

Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:

  • Pulmonary CTA-this strategy is safe and accepted. Plenty of data to support you if you choose this strategy. Some evidence recently that shielding the baby may actually increase scatter radiation to the fetus. Check with your Radiologist. 
  • V/Q scan-also an acceptable strategy. Probably more radiation to the fetus. If you choose this test, remember that many experts recommend you insert a foley to drain the bladder (reduces radiation exposure to the fetus). 
  • Negative PERC (Pulmonary Embolism Rule Out Criteria) + Negative, trimester adjusted d-dimer level. Adjusted trimester cutoffs for d-dimer in pregnancy are: 1st 750 ng/dL, 2nd 1000 ng/dL, and 3rd 1250 ng/dL. So, figure out what trimester your patient is and if they are PERC - and the d-dimer falls below the cutoff,  you are done. Remember to adjust the pulse to 105 bpm if using the PERC rule for rule out as heart rate goes up in pregnancy.
  • Start with lower extremity US, if DVT +, you are done

**For explanation of PERC rule, see earlier pearl.

Show References


Category: Cardiology

Title: ECG changes in myopericarditis

Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)

Posted: 7/13/2008 by Amal Mattu, MD (Updated: 8/12/2020)
Click here to contact Amal Mattu, MD

The pericardium is electrically silent, and so true acute pericarditis should not be associated with ECG changes. STE actually implies concurrent involvement of the myocardium; i.e. myopericarditis. The greater the degree of myocardium involved, the more ECG changes will develop, including STE, AV blocks, and dysrhythmias. Additionally, myocardial involvement is implied by elevated troponin levels, the magnitude of which is related to the amount of myocardial involvement.

[Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.]


Category: Orthopedics

Title: Scaphoid Fracture

Keywords: scaphoid, fracture (PubMed Search)

Posted: 7/13/2008 by Michael Bond, MD (Updated: 8/12/2020)
Click here to contact Michael Bond, MD

SCAPHOID FRACTURE:

  • One of the most frequently missed fractures in the ED
  • Most common carpal fracture.
  • 10-20% fractures are “occult”
  • Significant long-term complications:
    • Non-union
    • Avascular necrosis
  • Complications more common due to the fact the blood supply comes form from the distal end of the bone.
  • The more distal the fracture, the greater risk of complications
  • MR remains the best test for occult fx.

Category: Pediatrics

Title: Intussusception

Keywords: Intussusception (PubMed Search)

Posted: 7/12/2008 by Don Van Wie, DO (Updated: 8/12/2020)
Click here to contact Don Van Wie, DO

 

      Intussusception
  •  Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.
  • 90 % occur at the terminal ileum (ie, ileocolic).
  • Male-to-female ratio is approximately 3:1.
  • Usually seen between 5-9 months of age and 66% of all cases are in the first year of life.
  • The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases
  • Currant jelly stools are observed in only 50% of cases.
  • Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
  • If intussusception is strongly suspected, perform a contrast or air  enema without delay.
  • Mortality with treatment is 1-3%.
  • If untreated, this condition is uniformly fatal in 2-5 days.

Category: Toxicology

Title: Metformin Toxicity - An Emergency Department Diagnosis

Keywords: lactic acidosis, metformin, renal failure (PubMed Search)

Posted: 7/10/2008 by Fermin Barrueto, MD (Updated: 8/12/2020)
Click here to contact Fermin Barrueto, MD

 

 

  • Metformin is the most commonly prescribed oral diabetic mediction in US
  • Relative contraindication is in renally impaired patients, they are susceptible to the lactic acidosis
  • Lethal adverse effect is the increase production of lactate
  • ED patient with an anion gap metabolic acidosis, check for metformin and check the lactate
  • The lactic acidosis is often severe (>10 mmol/L) and carries a high mortality rate that has been estimated at >40%
  • Correction of pH and emergent hemodialysis are essential

Show References


Category: Neurology

Title: Reasons to Call your Neurointerventionalist

Keywords: neurointerventionalist, vascular dissection, ischemic stroke, subarachnoid hemorrhage (PubMed Search)

Posted: 7/9/2008 by Aisha Liferidge, MD (Updated: 8/12/2020)
Click here to contact Aisha Liferidge, MD

Top Reasons to call your Neurointerventionalist:

  1. Vascular "blowouts" (i.e carotid tumor or trauma). 
  2. Symptomatic dissections within 6 hours of onset (i.e. carotid or vertebral).
  3. Ischemc Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window.
  4. Ischemic Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window or with contraindication for tPA (i.e may be MERCI Device candidate).
  5. Subarachnoid hemorrhage of aneurysmal origin.

Category: Critical Care

Title: Redefining Hypotension

Keywords: hypotension, trauma, elderly (PubMed Search)

Posted: 7/7/2008 by Mike Winters, MD (Emailed: 7/8/2008) (Updated: 8/12/2020)
Click here to contact Mike Winters, MD

Hypotension begins at 110 mmHg?

  • Many of us use the historical SBP cut-off point of 90 mmHg or less to identify hypotension and shock
  • Importantly, there is no data to support this arbitrary value
  • Particularly in older patients, hypotension, hypoperfusion, and increased mortality may begin sooner than previously realized
  • In this study of over 80,000 patients from the National Trauma Data Bank, a SBP < 110 mmHg was found to be more clinically relevant for identifying hypotension and hypoperfusion
  • Take Home Point: strongly consider raising your threshold for identifying hypotension and initiating resuscitation, especially in the older trauma patient.

Show References


Category: Critical Care Literature Update

Title: Etomidate and adrenal suppression

Keywords: etomidate, adrenal insufficiency (PubMed Search)

Posted: 7/7/2008 by Mike Winters, MD (Updated: 8/12/2020)
Click here to contact Mike Winters, MD

Recent Articles from the Critical Care Literature

Duration of adrenal insufficiency following a single dose of etomidate in critically ill patients

Vinclair M, Broux C, Faure P, Brun J, Genty C, et al. Intensive Care Med 2008;34:714-9.
            Etomidate has become a favored first-line induction agent for intubation in the emergency department.  Given its excellent hemodynamic tolerance, etomidate is especially useful in hemodynamically unstable patients. A known side effect of etomidate is adrenal suppression, due to inhibition of 11β-hydroxylase, the enzyme that converts 11β-deoxycortisol into cortisol. As a result, recent literature has raised concerns that etomidate may worsen patient outcomes in those with relative adrenal insufficiency, namely those with septic shock.
            The current study is a prospective, observational study conducted in France from October 2005 to January 2006. The purpose of the study was to assess the duration of adrenal suppression following a single dose of etomidate, given either in the field or in the emergency department for RSI. Importantly, patients with septic shock, or those with preexisting adrenal insufficiency, were excluded from this study. To diagnose adrenal insufficiency, the investigators measured total cortisol and 11β-deoxycortisol following a high-dose cosyntropin stimulation test (250 mcg). Values were obtained at 12, 24, 48, and 72 hours following etomidate administration. An accumulation of 11β-deoxycortisol with a lack of cortisol rise was used to establish etomidate-related adrenal insufficiency.
            A total of 40 patients were included in this study. The majority of patients required intubation as a result of either trauma or subarachnoid hemorrhage. At hour 12, 80% of patients fulfilled the investigators definition of etomidate-related adrenal insufficiency, whereas by hour 48, only 9% met criteria. In addition, at hour 24, patients with etomidate-related adrenal suppression required larger doses of norepinephrine that those without adrenal inhibition. From their data, the authors conclude that a significant proportion of patients without septic shock have adrenal suppression for at least 12 hours following a single dose of etomidate. This effect, however, appeared reversible in that most patients recovered adrenal function by hour 48. Finally, the authors recommend that systemic steroid supplementation be considered during the first 48 hours in hemodynamically unstable patients who have received etomidate for intubation.
            There are a number of limitations with this study. The most important limitation is, perhaps, the authors’ definition of etomidate-related adrenal insufficiency. Diagnosing adrenal insufficiency in critically ill patients remains controversial. The cosyntropin test (high- or low-dose) has many recognized limitations. In addition, measurement of 11β-deoxycortisol is difficult because reference values for critically ill patients are rare. The authors also chose to measure total serum cortisol, rather than the more biologically active free serum cortisol. Lastly, data for all 40 patients at 72 hours was not complete.
            Take Home Points: This small, observational study found a high incidence of adrenal suppression for at least the first 12 hours in unstable patients receiving etomidate for intubation. Importantly, this study excluded patients with sepsis or septic shock. Given the limited number of patients and the difficulty in defining adrenal insufficiency in the critically ill, this study provides some interesting results and is hypothesis-generating at best. Their recommendation for systemic steroid supplementation during the first 48 hours following etomidate administration in unstable patients cannot be supported by this study.

Category: Vascular

Title: Ruling Out Pulmonary Embolism in Cancer Patients

Keywords: Pulmonary Embolism, Cancer (PubMed Search)

Posted: 7/7/2008 by Rob Rogers, MD (Updated: 8/12/2020)
Click here to contact Rob Rogers, MD

Ruling Out PE in Cancer Patients: Use D-Dimer??

Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.

Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?

The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.


Abstract
PURPOSE: To prospectively evaluate (a) the diagnostic performance of D-dimer assay for pulmonary embolism (PE) in an oncologic population by using computed tomographic (CT) pulmonary angiography as the reference standard, (b) the association between PE location and assay sensitivity, and (c) the association between assay results and clinical factors that raise suspicion of PE. MATERIALS AND METHODS: This HIPAA-compliant study had institutional review board approval; informed consent was obtained. Five hundred thirty-one consecutive patients were clinically suspected of having PE; 201 were enrolled (72 men, 129 women; median age, 61 years) and underwent CT pulmonary angiography and D-dimer assay. Relevant clinical history, symptoms, and signs were recorded. CT images were interpreted, and the location of emboli was recorded. The negative predictive value (NPV), positive predictive value (PPV), sensitivity, specificity, and diagnostic likelihood ratios of the D-dimer assay results were calculated. RESULTS: Forty-three patients (21%) had pulmonary emboli at CT. D-Dimer results were positive in 171 patents (85%). The NPV and sensitivity were 97% and 98%, respectively. The specificity and PPV were 18% and 25%, respectively. No association was shown between clinical history, symptoms, or signs and NPV, PPV, sensitivity, or specificity or between location of PE and sensitivity.
CONCLUSION: D-Dimer results have high NPV and sensitivity for PE in oncologic patients and, if negative, can be used to exclude PE in this population. Combining the assay with clinical symptoms and signs did not substantially change NPV, PPV, sensitivity, or specificity.

Whether this is ready from prime time or not remains to be determined, but it is interesting that we might be able to do this in the future to r/o PE in cancer patients.
 

Show References


Category: Cardiology

Title: Myopericarditis

Keywords: myocarditis, pericarditis, myopericarditis (PubMed Search)

Posted: 7/7/2008 by Amal Mattu, MD (Updated: 8/12/2020)
Click here to contact Amal Mattu, MD

Both acute pericarditis and myopericarditis are intensely inflammatory. As a result, CRP testing is extremely sensitive for these conditions and is excellent for evaluating their presence or absence.

Show References


Category: Orthopedics

Title: Joint Fluid Analysis

Keywords: Arthrocentesis, Joint, Fluid, Septic (PubMed Search)

Posted: 7/6/2008 by Michael Bond, MD (Updated: 8/12/2020)
Click here to contact Michael Bond, MD

Joint Fluid Analysis:

This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain.  For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.

 

Synovial Fluid Interpretation
Diagnosis Appearance WBC PMNs Glucose % of
Blood Level
Crystals
 Normal  Clear  <200  <25  95 - 100  None
 Degenerative
Joint Disease
 Clear  <4000  <25  95 - 100  None
 Traumatic
Arthritis
 Straw colored  <4000  <25  95 - 100  None
 Acute Gout  Turbid  2000 - 50,000  >75  80 - 100  Negative birefringence
 PseudoGout  Turbid 2000 - 50,000  >75  80 - 100  Positive birefringence  
 Septic Arthritis  Purulent / turbid  5000 - > 50,000  >75  < 50  None
 Rheumatoid
Arthritis
 Turbid  2000 - 50,000  50-75  ~75  None

 To view a gout crystal click this link.

To view a pseudogout crystal. Click this link

Pearls: 

  • A WBC Count >50,000 is septic arthritis until cultures are negative. 
  • Due to the wide range of WBC for septic arthritis have a high index of suspicion and do not discount the diagnosis because the WBC count is only 10,000.

Show References


Category: Critical Care Literature Update

Title: recombinant Factor VIIa for ICH

Keywords: intracerebral hemorrhage, recombinant factor VIIa (PubMed Search)

Posted: 7/6/2008 by Mike Winters, MD (Updated: 8/12/2020)
Click here to contact Mike Winters, MD

 

Recent Articles from the Critical Care Literature

Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.

Mayer SA, Brun NC, Begtrup MSc, Broderick J, Davis S, et al. NEJM 2008;358:2127-37.
            Intracerebral hemorrhage (ICH) accounts for approximately 10% to 15% of all strokes, yet has the highest morbidity and mortality, with up to 40% of patients dying within 30 days. Aside from age, size, location, intraventricular extension, and GCS, hematoma expansion is an independent determinant of morbidity and mortality. Hematoma expansion is reported to occur in up to 70% of patients within the first several hours of the ICH. Recent research has focused on therapies to limit hematoma expansion. One such therapy is recombinant human activated Factor VII (rFVIIa). Excitement regarding this expensive drug came from a single phase 2 trial (Mayer SA, et al. NEJM 2005:352:777-85.) that demonstrated rFVIIa significantly reduced hematoma expansion and improved patient mortality.
            The FAST trial (Factor Seven for Acute Hemorrhagic Stroke), was a manufacture sponsored, phase 3 trial performed by the same investigators to confirm the findings of their previous phase 2 study. The FAST trial was a multi-center, randomized, double-blind, placebo-controlled trial conducted at 122 sites in 22 countries. Patients had to be at least 18 years of age with a spontaneous ICH documented by CT within 3 hours of symptom onset. Important exclusion criteria included GCS < 5 at presentation, secondary ICH (trauma, AVM), current anticoagulant therapy, thrombocytopenia, DIC, previous disability from CVA, or a thromboembolic event < 30 days prior to symptom onset. The primary end-point was disability or death defined by a modified Rankin score of 5 or 6 at day 90. The modified Rankin score evaluates global disability and handicap and ranges from 0 to 6. A score of 5 indicates a patient who is bed-bound and incontinent, whereas a score of 6 indicates death.
            Of 8,886 patients screened, 821 underwent randomization and received placebo, 20 mcg/kg of rFVIIa, or 80 mcg/kg of rFVIIa. Treatment had to start within 1 hour of the baseline CT and no more than 4 hours after the onset of symptoms. Patients then underwent a repeat CT at 24 hours and 72 hours to evaluate for hematoma expansion. Of note, the majority of the patients in this study were Caucasian males, older than 65 year of age who had deep gray matter ICHs. 
            As reported by the trial investigators, rFVIIa did reduce hematoma expansion at 24 hours compared to placebo. In the placebo arm, 26% of patients had hematoma growth, whereas only 11% of patients who received 80 mcg/kg of rFVIIa had hematoma expansion. In addition, the investigators report that the reduction in hematoma growth was even greater in those treated in less than 2 hours from onset of symptoms. However, when you look at the data for 72 hours, there was no significant difference in total hematoma volume or edema volume. More importantly, mortality at 90 days did not differ between placebo and the treatment groups. In fact, a higher percentage of patients who received 80 mcg/kg of rFVIIa had a worse outcome than compared with placebo. Furthermore, there was an absolute increase of 5% in the frequency of arterial thromboembolic serious events (MI, ischemia CVA) in the group receiving 80 mcg/kg of rFVIIa.
            Take Home Point: This phase 3 trial failed to demonstrate improved 90 day mortality in patients with spontaneous ICH who received rFVIIa. Although hematoma expansion was reduced at 24 hours in the rFVIIa groups, total lesion volume and edema volume at 72 hours remained unchanged. Although rFVIIa has been used in a variety of clinical settings, the results of this study indicate that it does improve mortality in patients with spontaneous ICH. Given the expense of the drug and lack of benefit, this should not be a drug we are using in the ED to treat patients with spontaneous ICH.

Category: Pediatrics

Title: Cardiac Involvement in Kawasaki Disease

Keywords: Kawasaki Disease; Cardiac; Coronary Aneurysm (PubMed Search)

Posted: 7/4/2008 by Don Van Wie, DO (Updated: 8/12/2020)
Click here to contact Don Van Wie, DO

Cardiac Involvement in Kawasaki Disease

  • 50% can have Myocarditis (tachycardia, decreased ventricular function, arrhythmias, CHF, shock)
  • 30% can have Pericarditis In untreated patients;
  • 20 – 25% will have Coronary Artery Aneurysm during second and third week of illness Coronary Artery Aneurysms have risk of rupture, thrombosis, or stenosis
  • Myocardial Infarction is leading cause of Death due to thrombosis, rupture, or stenosis of a coronary aneurysm
  • Treatment with IVIG in the Acute Phase (within 10 days of onset of fever) reduces the risk of coronary artery dilation and aneurysms from 20-25% to < 5 % for coronary dilation and <1 % for giant coronary aneurysm. BUT NOT TO ZERO.

 

So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!

Show References


Category: Toxicology

Title: Trends in Drug Abuse

Keywords: drugs of abuse, heroin (PubMed Search)

Posted: 7/3/2008 by Ellen Lemkin, MD, PharmD (Updated: 8/12/2020)
Click here to contact Ellen Lemkin, MD, PharmD

 ADOLESCENT DRUG ABUSE

  • "Pharming" is prescription drug abuse
  • Teens will take medications from their home medicine cabinets, mix them in bags together indiscriminately and make "trail mix" to pass around parties
  • "Cheese" is a combination of heroin with cough and cold preparations. The heroin concentration in cheese is typically between 2-8% compared to 30% found in black tar heroin, and is considered "starter heroin"

Show References


Category: Neurology

Title: Differentiating Delirium from Dementia

Keywords: delirium, dementia, CAM, MMSE (PubMed Search)

Posted: 7/2/2008 by Aisha Liferidge, MD (Updated: 8/12/2020)
Click here to contact Aisha Liferidge, MD

  • The Confusion Assessment Method (CAM) and Mini-Mental State Exam (MMSE)  can be used in combination to effectively differentiate delirium from dementia, respectively.
  • CAM relies on observations by family members, caregivers, and clinicians to assess the following four symptoms:
    1. acute confusional onset
    2. inattention
    3. disorganized thinking
    4. ltered level of consciousness
  •  

  • Using CAM, the diagnosis of delirium requires the presence of both the first and second features, plus one of the two other features.
  • CAM is 95-100% sensitive and 95% specific for diagnosing delirium in the elderly.
  • MMSE is not a diagnostic tool but identifies cognitive impairment suggestive of delirium by assessing orientation, short-term memory, calculation ability, and language (score 18-26 = mild dementia).
  • A positive CAM and an MMSE score of > 25 is predictive of delirium.
  •  


Category: Infectious Disease

Title: Diabetes and Osteomyelitis

Keywords: diabetes, osteomyelitis, temperature, white blood cell count (PubMed Search)

Posted: 7/1/2008 by Mike Winters, MD (Updated: 8/12/2020)
Click here to contact Mike Winters, MD

Does this Patient with Diabetes have Osteomyelitis?

  • Diagnosis of lower extremity osteomyelitis in the diabetic patient remains challenging
  • Bone biopsy with culture remains the gold standard for diagnosis but is not always obtainable
  • What clinical features, therefore, raise the likelihood of osteomyelitis?
  • In this review, an ulcer size > 2 cm2 (LR 7.2), ability to probe to bone using a sterile stainless steel probe (LR 6.4), and an ESR > 70 mm/h were found to be useful in predicting the presence of osteomyelitis
  • Clinical features NOT found to be useful included fever (sensitivity 19%), presence of erythema, swelling, or purulence (LR 1), elevated white blood cell count (sensitvity 14%-54%), and superficial swab culture
  • A note about radiographic studies:
    • bony changes on plain films may take up to 2 weeks to develop
    • plain films alone are only marginally useful if positive (LR 2.3)
    • MRI is more accurate than bone scan or plain films
    • If you are going to order a radiographic study, your best bet is the MRI

Show References


Category: Vascular

Title: Does a Normal D-Dimer rule out Aortic Dissection?

Keywords: Aortic Dissection, D-Dimer (PubMed Search)

Posted: 6/24/2008 by Rob Rogers, MD (Emailed: 6/30/2008) (Updated: 8/12/2020)
Click here to contact Rob Rogers, MD

Does a normal d-dimer rule out aortic dissection?

A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.

A few pearls and pitfalls regarding this:

  • Studies look very promising, but NO accepted cutoff point (d-dimer) has been defined
  • This practice has NOT been widely accepted yet
  • A d-dimer <100 ng/dL rules out aortic dissection with a sensitivity of 100%
  • A d-dimer of <500 ng/dL rules out aortic dissection with a sensitivity of 98%
  • Experts in this area seem to be advocating this as a potential rule out strategy
  • Critics of this approach point out the fact that a subset of patients with dissection (those with intramural hematomas-i.e. no intimal tear) may not release d-dimer into the circulation. But almost all studies include patients with this variant and their d-dimers are almost always elevated.

Show References


Category: Airway Management

Title: Pregnancy and Acute Pulmonary Embolism

Keywords: Pregnancy, Pulmonary Embolism (PubMed Search)

Posted: 6/30/2008 by Rob Rogers, MD (Updated: 8/12/2020)
Click here to contact Rob Rogers, MD

 Pregnancy and Acute Pulmonary Embolism

Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.

Some facts:

  • Risk of first episode of venous thromboembolism is 15 times as high in the postpartum period as during pregnancy
  • Diagnostic workup and initial ED therapy is the same as it is for non-pregnant patients
  • Although there are still some concerns about pulmonary CTA, both the American College of Obstetrics & Gynecology and the American College of Radiology agree that it is safe. It is unknown what happens to fetal nephrons after exposure to circulating contrast in the mother. Despite this, CTA can be used without fear if indicated. 
  • Warfarin is a teratogen and should not be used for anticoagulation.

 

Show References


Category: Cardiology

Title: low voltage on ECG

Keywords: low voltage, electrocardiography, effusion (PubMed Search)

Posted: 6/30/2008 by Amal Mattu, MD (Updated: 8/12/2020)
Click here to contact Amal Mattu, MD

Low QRS voltage on the ECG has various definitions; here's my simple definition for low voltage...either one of the following:
     If the added QRS amplitudes (whole R wave + S wave) in leads I + II + III total < 15 mm, OR
     If the added QRS amplitudes (whole R wave + S wave) in leads V1 + V2 + V3 total < 30 mm.

The potential causes of  low QRS voltage includes pericardial effusions, pleural effusions, obesity, COPD, infiltrative cardiac diseases (e.g. sarcoid, amyloid), end-stage cardiomyopathies, severe hypothyroidism.

If the patient has NEW low voltage compared to an old ECG, the only real possibilities are pericardial effusion, pleural effusion, and severe hypothyroidism (e.g. myxedema).