Ticks Suck (Literally)!!

ahhh, summer time! Baseball, hikes, beer, ticks. Ticks in and of themselves don't really create a problem. They don't cause pain, only take a tiny amount of blood, then they leave. Problem is, ticks carry and transmit a fair amount of nasty dieases, like Lyme and Rocky Mountain Spotted Fever. These diseases can be a nightmare to diagnose and treat because they have a dizzying constellation of symptoms, including potential neurological complications, malaise, and fever. Best to avoid being bitten if possible, and do frequent tick checks. DEET is still the repellent of choice, placed at the cuffs of pants, long sleeved shirts, and even on hats. If a tick is found attached, the recommendation is removal right away with tweezers placed really close to the person's skin. Continued, even pressure applied straight up is the way to go. Experts do not recommend burning them off, or putting any lotions or petroleum jelly on them to loosen them first, as this can make them regurgitate into their host. Don't twist the tick out!. If any jaw parts are left in, these can be removed with a needle or by scraping. Ticks can be saved for identification, and possible testing if needed. Lyme disease, the biggest risk in the U.S. for "vector-borne" disease, (a disease transmitted to humans through an animal host) is an east coast disease primarily transmitted by very small deer ticks, and actually takes at least 24 hours of the tick being attached to transmit it to a human. Some say it takes 48 hours or more. Unfortunately, it does have a high prevalence due to the fact that the ticks are so small and hard to see, which means they can remain on longer undetected. Rocky Mountain Spotted Fever can be transmitted in just an hour or two. Don't be misled by the name, this disease is prevalent on the east coast as well.

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SIDS reduction

The first step in the AHA's Pediatric Chain of Survival is prevention and safety. With that in mind, and the fact that everyone I know is having a baby, let's talk a little about SIDS. Sudden Infant Death Syndrome is a fairly poorly understood mechanism of "crib death" usually seen in infants two to four months of age. Statistics show that there are many modifiable things that can be done to reduce SIDS death rates. Among them are: Placing the baby on the back to sleep. Not smoking during pregnancy, and keeping smoke out of the home. Keeping the environment cool. (In other words, don't let the baby get too warm). Minimize blankets and stuffed animals, (and anything else) in the crib to make sure the baby can't suffocate. Maintaining a good flow of fresh air in the room. Use a breathable, mesh type crib bumper. The research and thinking points to SIDS related deaths being caused by a few factors. Rooms with minimal air flow, or lots of blankets, heavy bumpers, and stuffed animals can create dead spaces, where the carbon dioxide can build up, ultimately causing respiratory failure due to the baby's own exhalations. A warm room also can contribute to this due to creating less of a buoyant quality on the exhaled air. Placing a fan in the room can help circulate air. (Of course, don't blow the air directly on the baby!) Other factors that may contribute to SIDS deaths are less clear, but the numbers point to actions that can reduce risk. Breastfeeding reduces SIDS deaths by up to 50%. . Keeping your baby in the room with you during this time (NOT in the same bed!) has been shown to reduce SIDS deaths. Baby sleeping with a pacifier may reduce SIDS. The recommendation is NOT to replace it if it falls out of the baby's mouth while sleeping. For some reason, children with up to date immunizations have a lower SIDS rate. This may be reflective also of up to date pediatrician visits. Congratulations to all of the new mothers out there, and here's to safe sleep and healthy kids!

Torsades de Pointes

Why is Torsades everyone's favorite arrhythmia? Maybe because if you see it once and you will never forget it? Because IV Magnesium can provide dramatic reversal of the arrhythmia right before your eyes? Because the algorithm is so easy to remember? Let's look at it in a little more detail.... Torsades de Pointes, translated as "twisting of the spikes," is an irregular polymorphic wide complex tachycardia typically caused by one of two things. Most commonly it is triggered from prolonged QT syndrome. Prolonged QT is exacerbated by hypokalemia and hypomagnesemia as well as many medications, including some antiarrhythmics. When a PVC takes place during the relative refractory period between the QRS wave and T wave in the EKG, ventricular tachycardias can result. In the case of Torsades, the treatment of choice is Magnesium Sulfate, 1 to 2 grams IV. Another potential cause of Torsades is ischemia. In this instance, IV Magnesium will have no effect, and the ischemia will need to be reversed. (Cath Lab!) IV Magnesium probably will do no harm, and is still the initial treatment per the algorithm. When a patient presents with Torsades, an old EKG showing a previous prolonged QT would be one way to differentiate between the potential underlying cause of the disorder.

Generally "stable" Torsades is uncommon, and the rhythm tends to deteriorate quickly to VF. If electricity becomes necessary due to lack of Magnesium availability and patient instability, most likely synchronized cardioversion will be impossible due to the constantly changing nature of the rhythm, and higher difibrillation doses will be needed, unsynchronized. The rhythm is more common in white women and in patients with severe nutritional deficiencies, such as chronic alcoholics, and thus IV Magnesium could be considered as "treating the underlying cause."

Is the patient stable?

The ACLS algorithms for bradycardia and tachycardia essentially start the same way. In a nutshell, place the patient on a monitor, establish IV, apply oxygen. You can obtain a 12 lead ekg if you have time (if the patient is stable, but don’t delay therapy.) The next box in the algorithm essentially defines stability. Does the patient have persistent chest pain likely casued by ischemia, is the patient hypotensive (typically a blood pressure less than 90 WITH SYMPTOMS, in other words, are there signs of shock, altered mental status, etc? Is the patient in acute heart failure? Stability is different than "symptomatic." A patient who is generally stable may be symptomatic- orthostatic hypotension, mild shortness of breath, mild discomfort , palpitations. These are all signs that the patient may be symptomatic, (or feel the arrhythmia), but they are not overt signs of instability. For the symptomatic patient, it may be prudent to monitor, observe, and obtain expert consultation. For the unstable patient, the prudent course of action is to act. Generally, the fastest course of action for the truly unstable patient is going to be electricity, either pacing, or cardioversion, depending on the algorithm. Drugs have their place as well, and can be effective. the point is not to delay definitive therapy in the unstable patient. Check out more posts at: http://www.carpentercprsolutions.com/-blog.html or check us out on facebook: https://www.facebook.com/Carpentercprsolutions

Supra Ventricular Tachycardia versus true Ventricular Tachycardia...

I am often asked how to differentiate between SVT with abberrancy (wide complex supra-ventricular tachycardia) from a true ventricular tachycardia, which is important to decipher the appropriate treatment, and the severity of the arrhythmia. a nice, easy way is the following: "In 2010 Joseph Brugada et al. published a new criterion to differentiate VT from SVT in wide complex tachycardias: the R wave peak time in Lead II [4]. They suggest measuring the duration of onset of the QRS to the first change in polarity (either nadir Q or peak R) in lead II. If the RWPT is ≥ 50ms the likelihood of a VT very high (positive likelihood ratio 34.8). This criterion was successful in their own population of 163 selected patients and is awaiting prospective testing in a larger trial. " In other words, if the beginning of the QRS and the peak of the complex (or trough of a downward deflecting wave) in lead II is more than 0.05 seconds, the chances are very high that you are dealing with ventricular tachycardia. If you will recall, each small box on a strip equals 0.04 of a second, or 40 milliseconds. Source: http://www.heartrhythmjournal.com/article/S1547-5271%2810%2900216-X/abstract

Heatstroke

In honor of summer, how about a quick discussion of heat related emergencies..... There are a few types of heat crises that need first aid. The cause is the same, too much exposure to hot weather for too long, probably doing too much work with too little to drink. Heat emergencies exist on a continuum, from not very severe, to immediately life threatening. First comes heat exhaustion, common from exposure to hot, humid environments in particular. signs include moist, pale, clammy skin, hefty sweating, usual body temperature, dizziness, annoyance and irritation, nausea and potentially vomiting, muscle cramps, and even fainting. The treatment is generally simple: move the person to a cooler environment, offer small, frequent amounts of cool fluids, remove excess clothing, and provide cool towels and rest. If the patient is not improving or continues to vomit, get further medical treatment. Heatstroke is at the far end of the spectrum. Heatstroke is a potentially life-threatening emergency with the hallmark sign of markedly increased body temperature, potentially above 106 degrees Fahrenheit. The victim may have, warm, dry skin; tachycardia, and unconsciousness. This patient requires 911 and immediate advanced intervention. First Aid would involve calling 911, have the person lie down if possible, get clothes off, and start lowering the body temperature immediately by any means necessary. (The AHA video shows a couple of guys holding the heatstroke victim in a pool submerged to the chest. Bonus points for creativity.) Hosing the person down and applying ice packs would certainly be appropriate.