Actively Seizing Patient

• Consider Status Epilepticus in patient seizing for >5min
  
• Progression of Rx: Benzos -> Fosphenytoin/Valproate -> Propofol (with an ETT)
  

Patient with hx of Sz who presents after Sz

• Get drug levels
  
• For the patient who is not at therapeutic Dilantin level, PO load 1-2 doses. 
  

New Onset Seizure Pt

• History is crucial in new onset seizure
  
• Always get Head CT!
  
• Don't forget about the Urine Pregnancy Test! Pregnancy can lower Sz threshold... plus Eclampsia needs to on DDx.
• EEG if available (EEGs done shortly after Sz have better prognostic implications than ones done later in follow-up).
  

1. Infectious disease still is a large contributor to morbidity and mortality in developing countries, but cancers and heart disease are on the rise.

2. In a resource challenged environment, efforts should focus on empiric treatment when confirmatory diagnostic testing is unavailable.

3. In addition to malaria, consider dengue fever in your differential for fever in the returned traveler. Management is supportive care.

4. Mortality remains high for pediatric congenital heart disease in a large portion of the world where surgical intervention is unavailable.

5. Always confirm the location of a newly-diagnosed pregnancy and be aware of the complications and risks involved in post-partum ABDOMINAL pregnancy.

-NPH is a potentially reversible cause of dementia and early intervention can be life-changing for patients

-The terms hydrocephalus and vetriculomegaly are not synonymous. All patients with NPH should have enlarged ventricles, not all elderly patients with enlarged ventricles have NPH.

-Emergency department management should focus on maintaining a broad differential and managing post-shunt complications.

3 Major “can’t miss” causes of AFib

·      Acute myocardial infarction
·      Congestive heart failure
·      Pulmonary embolus

Other common causes of AFib

·      Thyrotoxicosis
·      Hypertensive crisis
·      Valvular disease
·      Hypokalemia/Hypomagnesaemia
·      Drugs e.g. sympathomimetics
·      Pericardial disease
·      Cardiomyopathies
·      Pheochromocytoma
·      “Holiday heart” - too much ETOH


Treatment of AF in the ED

Unstable
·      Emergency Direct Current Cardioversion (DCC)
       o   Biphasic 120J -200J
       o   Pads in the AP position

·      Reasons DCC may not work
        o   Underlying illness – CHF, thyrotoxicosis, valvular disease
        o   Dilated left atrium
        o   Longer duration of atrial fibrillation
        o   Too low energy

·      Meds:
        o   Suspicion for accessory pathway, consider one of the following:
              -  Procainamide
              -  Ibutilide
              -  Amiodarone

        o   No suspicion for accessory pathway, consider one of the following:
              -  Ibutilide
              -  Diltiazem
              -  Magnesium
              -  Amiodarone
              -  Procainamide

Stable
Start with rate control then consider disposition
·      Rate control
        o   Calcium Channel Blockers – 1st line treatment
             -  Diltiazem - 0.25 mg/kg IV over two minutes then 0.35 mg/kg IV over two minutes, if there is no response at 15 minutes      
             -  Veramamil - 2.5-5.0 mg over 2-3 minutes, then 5-10 mg in 15-30 minutes if necessary ± drip 5 mg/h

        o   β-blockers – good in increased adregnergic states
             -  Metoprolol - 5 mg IV every 5 minutes up to 15 mg
             -  Esmolol - 500 mcg/kg IV bolus over 1 minute followed by a 50-200 mcg/kg/min IV infusion. 
                                  Repeat cycle and increase drip if no effect

        o   Cardiac Glycosides – not used as monotherapy anymore
              -  Digoxin - Load 0.5 mg IV  repeat 0.25 mg every 4-6 hours for three doses

        o   Class III Antiarrythmic – beware of unintended rhythm control
              -  Amiodarone - 150 mg IV over 10 minutes followed by infusion of 1 g over six hours. May repeat bolus if needed

        o   Magnesium Sulfate - beware of unintended rhythm control
              -  MgSO4 - 2 g bolus over 10-15 minutes followed by 1 g/h infusion

Disposition - “Elective” Cardioversion in the ED

“Pro-ED Converters”
o   Safe if arrhythmia present for <48h and studies show that patients can reliably tell when their symptoms began (i.e within 48h or not)
o   Cardioversion – electrical, pharmacologic or spontaneous – of patients with recent onset atrial fibrillation carries a less than 1% embolism risk if performed within the first 48h of symptom onset
o   Early conversion ↓ need for anticoagulation
o   Many patients discharged means ↓ costs

“Anti-ED Converters”
o   Risk of thromboembolism too great
o   Patients need heparin prior to cardioversion
o   New onset AFib patients need a complete diagnostic workup
o   Use of chemical agents requires prolonged observation in ED after successful cardioversion.
o   Shouldn’t risk conversion agents or electricity when 40-71% convert spontaneously in the first 24h

Rhythm Control (a.k.a. Cardioversion)

·      Direct Current Cardioversion  is the traditional Gold Standard
       o   90% to 100% acute success rate
       o   IV/O2/Monitor/Sedation
       o   Propofol/Fentanyl or Fentanyl/Versed
       o   Airway Equipment
       o   Defib pads in the AP position

·      Chemical Cardioversion
        o   Class IA Antiarrythmic
              -  Procainamide - 100 mg IV q 5-10 minutes to maximum of 1000 mg, or 20 mg/kg IV infusion to a maximum of 20 mg/kg
        o   Class IC Antiarrythmic – “Pill in the Pocket Technique”
              -   Flecanaide – 2 mg/kg IV over 10 minutes, or 300 mg PO x1
                   -      Conversion rate 60-70% at 3 hours
                   -      91% at eight hours
              -  Propafenone - 2 mg/kg IV over 10 minutes, or 600 mg PO x1
                  -  Conversion rate up to 76% at 8 hours
         o   Class III Antiarrythmic
              -  Ibutilide - 0.01 mg/kg IV over 10 minutes (max 1 mg), may Repeat times 1 if no response after 10 minutes.
                  -      Cardioversion 33-45% in first 70 min
                  -      Risk of torsades as high as 8%

Ottawa Aggressive Protocol for emergency department patients with recent-onset atrial fibrillation

1.     Assessment
·       Stable without ischemia, hypotension or acute CHF?
·       Onset clear and less than 48 hours?
·       Severity of symptoms?
·       Previous episodes and treatments?
·       Anticoagulated with warfarin and INR therapeutic?

2.     Rate control
·       If highly symptomatic or not planning to convert
·       Diltiazem IV (0.25 mg/kg over 10 min; repeat at 0.35 mg/kg)
·       Metoprolol IV (5 mg doses every 15 min)

3.     Pharmacologic cardioversion
·       Procainamide IV (1 g IV over 60 min; hold if blood pressure < 10 mm  Hg)

4.     Electrical cardioversion
·       Consider keeping patient NPO × 6 h
·       Procedural sedation and analgesia given by emergency physician (propofol IV and fentanyl IV)
·       Start at 150–200 J biphasic synchronized*
·       Use anterior–posterior pads, especially if not responding

5.     Anticoagulation
·       Usually no heparin or warfarin for most patients if onset clearly < 48 h or if therapeutic INR for > 3 wk

6.     Disposition
·       Home within 1 h after cardioversion
·       Usually no antiarrhythmic prophylaxis or anticoagulation given
·       Arrange outpatient echocardiography if first episode
·       Cardiology follow-up if first episode or frequent episodes

7.     Patients not treated with cardioversion
·       Achieve rate control with diltiazem IV (target heart rate < 100 beats/min)
·       Discharge home on diltiazem (or metoprolol)
·       Discharge home on warfarin and arrange INR monitoring
·       Arrange outpatient echocardiography
·       Follow-up with cardiology at 4 wk for elective cardioversion

8.     Recommended additions to protocol
·       Consider transesophageal echocardiography if onset unclear
·       Alternate rhythm-control drugs: propafenone, vernakalant, amiodarone
·       If TEE-guided cardioversion > 48 h, start warfarin