Resuscitation of pulmonary hypertension and right ventricular failure

A guide to the initial emergency department management of patients with pulmonary hypertension and right ventricular failure


A 40 year old female presents by EMS with significant dyspnea. She has had a fever and cough for 2 days, and has been getting progressively more short of breath. Today, she almost fainted when she stood up, so she called 911. Her vital signs are HR 135, BP 88/45, RR 35, and an oxygen saturation of 90% on a nonrebreather. She is quite somnolent. As she is being transferred to the stretcher, the paramedic mentions that she has a pump of some sort to treat her pulmonary hypertension…

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Torsades de Pointes

The first 10 minutes of emergency medicine resuscitation of torsades de pointes


A 46 year old female is referred into the emergency department after multiple syncopal episodes. Her family physician did blood work and found her to be hypokalemic. She is on venlafaxine for depression and amitriptyline for sciatica. She is currently on a course of moxifloxacin for her sinusitis and this morning took a dose of fluconazole for the resultant candidiasis. On arrival, she is alert and looks well. However, as the ECG is being performed, she slumps over and you see:


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Emergent Cardiac Pacing

How to set up emergency cardiac pacing


The 67 year old bradycardic patient from the previous case has a heart rate of 38 and a blood pressure of 68/45. It is time to start pacing… Continue reading “Emergent Cardiac Pacing”

Managing unstable bradycardia

A brief overview of the initial management of unstable bradycardia in the emergency department


A 67 year old man is brought in by EMS after a syncopal episode at home. He has only partially regained consciousness, with a GCS of 12. His wife says that he has had a fast heart rate before and that he also has diabetes and high blood pressure. She isn’t sure what medications he is on. He has had flu like symptoms for a few days. The paramedic vital signs were a heart rate of 38, a blood pressure of 69/45, a respiratory rate of 22. The oxygen saturation tracing has been inconsistent, but they think it is probably about 91% on room air… Continue reading “Managing unstable bradycardia”

Management of unstable atrial fibrillation in the emergency department

An approach to the initial management of the severely hypotensive atrial fibrillation patients


You are finishing up your charts and getting ready to head home for the night, having already handed over to the night doc who is currently wrapped up with a moderately unwell trauma patient. The charge nurse asks you to just look at one patient who she thinks has SVT before you head home. You walk into the room and see a grey, diaphoretic man, who you later find out is 67 years old. The chart in your hand says that he has a history of hypertension and hyperlipidemia, but is otherwise healthy. The monitor reveals a heart rate of approximately 205, but it jumps around a lot from beat to beat, and a blood pressure of 86/43. He is satting 100%, but is on a nonrebreather. The ECG is narrow complex and irregularly irregular. His wife tells you this all started about 1 hour ago with complaints of dizziness and palpitations but no chest pain….

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The 2015 ILCOR/AHA/ERC advanced life support guidelines (ACLS)

A summary of the new 2015 ILCOR/AHA/ERC advanced life support guidelines

The 2015 ILCOR, AHA, and ERC advanced life support guidelines are now out. This will be a brief review of what I think are the most important or interesting changes in the guidelines based on my first read through them. (I noticed some minor differences between the AHA and ERC versions of these guidelines, but nothing worth spending much time on.)

If I had to take away just 2 learning points, they would be:

  1. These guidelines are very similar to the 2010 guidelines. There are no changes important enough to warrant paying for another ACLS course. If you know the 2010 guidelines, just keep providing good patient care.
  2. As always, the science is weak. Only 1% of recommendations were “level A”, meaning high quality evidence from more than one RCT. The most common phrase I encountered reading through these guidelines was “may be reasonable”. This phrase is essentially meaningless and can easily be translated into “may not be reasonable”. Tread with care.

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A simplified approach to the initial assessment and management of patients with LVADs in the emergency department


A 74 year old man is brought into the resus room at your community hospital. He has an altered level of consciousness, but is still rousable. EMS is quite concerned because he doesn’t have a pulse. He does have a large machine sticking out of his chest that his wife tells you is an LVAD. You have never seen one of these doohickeys before. Your nurse had never even heard of an LVAD before. Everyone looks at you expectantly…

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