Wide Complex Tachycardias and Dual Sequence Defibrillation

Wide complex tachyarrhythmias refer to abnormal rapid heart rhythms characterized by widened QRS complexes on an electrocardiogram (ECG). These arrhythmias can be life-threatening and require prompt evaluation and management. The etiology, clinical features, and management strategies for stable and unstable patients differ, and in some cases, an electrical storm may occur, necessitating advanced interventions like dual sequential defibrillation.

Etiology:

Wide complex tachyarrhythmias can have various causes, including:

1. Ventricular Tachycardia (VT): Most common cause, often associated with structural heart disease, myocardial infarction, or scar tissue. Appropriate medical care is to assume that any wide complex tachycardia is VT until proven otherwise.

2. Supraventricular Tachycardia (SVT) with Aberrancy: When a supraventricular origin rhythm encounters a conduction abnormality, it may result in a wide complex appearance on the ECG.

3. Pre-excited Atrial Fibrillation: In the presence of an accessory pathway (WPW), atrial fibrillation can conduct rapidly to the ventricles, leading to a wide QRS complex.

Management for Stable Patients:

1. Identification of Underlying Cause: Determine if the arrhythmia is ventricular or supraventricular in origin.

2. Antiarrhythmic Medications: Administer medications such as amiodarone, procainamide, or lidocaine depending on the underlying rhythm.

1. Amiodarone (preferred agent in setting of AMI or LV dysfunction) – dosing is 150mg over 10min, followed by 1mg/min drip over 6 hr.

2. Procainamide is a potential agent. Did better in the PROCAMIO trial over amiodarone. Initial dosing is 20-50mg/min until arrythmia breaks (max 17mg/kg or 1 gram) then maintenance of 1-4mg/min x 6hr.

3. Electrolyte Correction: Address any electrolyte imbalances, especially potassium and magnesium.

Management for Unstable Patients:

1. Immediate Cardioversion: Synchronized electrical cardioversion is the treatment of choice. The usual dosage for synchronized cardioversion is 100-200J. (Note if the patient loses a pulse, in conjunction with started ACLS, the treatment option becomes unsynchronized cardioversion, or defibrillation).

2. IV Antiarrhythmic Medications: Amiodarone or procainamide may be administered while preparing for cardioversion. Lidocaine is also a potential agent.

3. Advanced Cardiovascular Life Support (ACLS): Follow ACLS guidelines for managing cardiac arrest, including chest compressions and airway management.

Electrical Storm and Dual Sequential Defibrillation:

An electrical storm is a term used to describe the occurrence of multiple sustained ventricular arrhythmias within a short period. It is a life-threatening situation that may be refractory to standard treatments.

Dual Sequential Defibrillation (DSD):

• In cases of resistant ventricular arrhythmias, dual sequential defibrillation involves using two defibrillators almost simultaneously to deliver two shocks.

• The goal is to increase the energy delivered to the heart, potentially terminating the arrhythmia.

• This approach is considered in refractory cases where conventional defibrillation has failed.

Procedure for DSD:

1.       Apply both sets of pads, adjacent to one another, and not touching (see the diagram from RebelEM).

2.       Charge both monitors to max dosage (200J for biphasic, 360J for monophasic).

3.       Charge and simultaneously activate the defibrillation/shock button on each monitor.

4.       Continue with compressions and ACLS.

5.       Consider a beta-blocker (esmolol) bolus, and consider holding epinephrine dosing to limit cardiac excitation.

Sources:

 https://rebelem.com/dual-sequential-defibrillation-dsd/

https://pubmed.ncbi.nlm.nih.gov/27354046/

https://pubmed.ncbi.nlm.nih.gov/8144780/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4711501/#:~:text=A%20wide%20complex%20tachycardia%20(WCT,%3E120%20milliseconds%20(ms).

POTD: Sexual Assault Forensic Exam (SAFE)

This POTD will be regarding sexual assault forensic examiner (SAFE) exams. Keep in mind that these patients have obviously just undergone a traumatic event. However, also consider that the ED course and examination in itself can also add onto this trauma, and so there are several steps we should undertake to mitigate this as much as we can.

• Conduct interviews in a private setting. If available, please make use of a private room, such as an OBGYN room.

• In addition to placing a SAFE consult, also consult a social work. 

• Even if a patient does not want a forensic examination performed, SAFE consults are useful in providing resources to patients, including resources for safe shelters, resources for applying to the state victim’s compensation fund, and mental wellness helplines.

• When using translators, consider using audio-only translation or facing the video away from the patient, especially during the examination itself, to respect patient privacy.

General medical workup:

• If the patient has not changed clothes, do not change the patient into a hospital gown.

• All patients should be offered HIV PEP, STI prophylaxis, and pregnancy prophylaxis +/- pregnancy testing per patient preferences.

  • HIV PEP courses are 28 days. The Office of Victim Services funds the emergency department for a 7-day starter pack to take home. The patient will need to follow up with PMD or ID clinic for the rest.

  • STI testing may be considered if the patient asks for it, although will not have forensic value in the timeframe most patients show up after an assault. You should just treat empirically.

• On physical exams, extra attention should be placed on signs of physical trauma, with imaging as indicated by history and exam.

Pediatric patients

• All suspected sexual assaults or abuse of patients younger than 18 years are required to be reported to child protective services. All hospital staff are legally considered to be mandated reporters.

  • CPS reports may be made at 1-800-342-3720.

  • A written reports needs to be filed within 48 hours of calling. Forms are found at https://ocfs.ny.gov/programs/cps/

• Mature minors may choose to consent or not consent to a forensic exam without parental involvement.

Financial resources for patients

• Victims of sexual assault can apply to the Office of Victim Services for out-of-pocket expenses not covered by insurance.

• Examples of covered expenses are listed in the application form, but include lost wages, medical/ambulance costs, crime scene cleanup, purchasing a security system.

• An English form is included in the SAFE exam kit, part A. Other languages may be printed from https://ovs.ny.gov/victim-compensation

How to perform a SAFE examination and Sexual Offence Evidence Collection Kits (SOECK). Please allot up to 4 hours for this.

A powerpoint of these instructions, with pictures may be found at https://apps.criminaljustice.ny.gov/ofpa/pdfdocs/Sexual%20Offense%20Evidence%20Collection%20Kit%20Training%201-2023.pdf. 

• Two different kits.

  • Once the kit is opened, the chain of custody begins and you should not leave the kit until it has been sealed, signed, and handed off to the next custodian.

  • SOECK part A (larger kit)

    • Contains consent forms, victim compensation application form, STI/HIV prophylaxis educational forms, and an evidence seal.

    • Contains envelopes and swabs for specimen samples.

  • SOECK part B

    • Supplementary kit containing x2 blood tubes and x1 urine cup for suspected drug facilitated sexual assault.

    • Requires completion of part A in addition to part B. Should not be collected on its own.

    • Requires its own consent form.

• Items to obtain prior to exam, that are not included in kits.

  • x4 pages of patient labels with patient full name and DOB

  • Paper bags if collecting patient clothes.

  • Exam table paper (i.e. the paper found on the peds ED triage bed)

  • Clean bed sheets and blankets

  • Disposable cups

  • Consider bringing an extra kit in case you make a mistake and need to recollect a sample.

• Determine and obtain consent for the following:
  An English consent form is available in each kit. Consent forms in other languages may be printed from https://apps.criminaljustice.ny.gov/evidencekit.htm

  • Collection of evidence.

    1. Samples have the highest forensic value when collected within 120 hours after incident, but examiner discretion may be used for collections after this window.

  • Collection of photographs

    1. We do not regularly collect photographs as part of our exam, so this part is not relevant for us.

  • Release of evidence to the police.

    1. If the patient does not want to release evidence, it will be held for 20 years in either our hospital forensic storage room or a storage facility at the Office of Victim Services, which is not a law enforcement agency2. The patient may later elect to release the kit or destroy the kit.

• Supplemental information form

  • Information to obtain from the patient that is relevant for the forensic laboratory.

• Evidence collection

  • There should always be a chaperone in the room.

  • Part A contains 12 envelopes, each labelled with instructions for obtaining specimens (See example below). They are ordered from least invasive to most invasive samples.

• For each step:

  • The patient may consent or decline each step and skip to the next step.

  • Change gloves between each step.

  • Attached a patient label to each envelope, fill out any relevant fields. Date & timestamp & initial each envelope.

• Part A

  • Step 1 – Trace evidence and debris

  • Step 2 – Underwear

  • Step 3 – Clothing

    • If they release their clothes for collection. You can ask social work or mental health workers for replacement clothes.

    • This step requires a separate paper bag for each article of clothing (not included in kit)

  • Step 4 – Oral swabs

  • Step 5 – Buccal swabs

    1. This step serves as a reference sample for the patient’s own DNA and should be recommended to all patients.

  • Step 6 – Fingernail swabs

  • Step 7 – External dried secretions and bitemarks

  • Step 8 – Pubic Hair Combing

  • Step 9 – Perianal/Anal Sample

  • Step 10 – Vulvar or Penile Swab

  • Step 11 – Vaginal/Cervical Swab

  • Step 12 – Tampon/Pad/Liner Collection

• Part B (if applicable)

  1. Collect x2 blood samples, x1 urine sample. Label and seal each sample with the provided seal.

• Attach patient label to box. Seal all envelopes. Make copies of relevant forms (each form includes at bottom how many copies to make, where each copy goes)

• Seal and initial each kit with the provided seal.

• Storage or release of kit

  • If police are at bedside and patient consents to release evidence, you may release the completed kit to the police office and have them sign off on the chain of custody on the box.

  • Otherwise your hospital should have a secured and temperature controlled storage facility for storage pending transport to the storage facility at the Office of Victim Services.

POTD: 2023 AHA ACLS Updates

I’m surprised this hasn't been done sooner, but I'm going to use this POTD to quickly delve into some of  the important changes in the new 2023 AHA ACLS guidelines. Some of these are pretty surprising, some of them - not so much. But remember that these updates are crucial for ensuring our patients best outcome.

Calcium: Not the Hero We Thought

Recent Insights: Class 3 Recommendation (No Benefit)

These new guidelines mark a pivotal shift in our understanding of calcium's role in cardiac arrest management. While it remains critical in cases of hyperkalemia and calcium channel blocker overdose, recent studies have shown that its routine use in other scenarios may be associated with potential harm. This revelation underscores the importance of context-specific interventions in cardiac emergencies.

Magnesium: The Unfilled Promise

Evidence from Randomized Controlled Trials: Class 3 Recommendation (No Benefit) 

Magnesium, once hypothesized to enhance outcomes in cardiac arrest, has been scrutinized in recent randomized controlled trials. Contrary to previous assumptions, these studies reveal no significant improvement in Return of Spontaneous Circulation (ROSC), survival rates, or neurological outcomes, irrespective of the initial rhythm. This finding challenges existing protocols and emphasizes the need for evidence-based practices.

ECPR: A Selective Savior

Updated Guidelines: Class 2a Recommendation (Moderate)

The guidelines now advocate for the judicious use of Extracorporeal CPR (ECPR) in specific scenarios of ACLS refractory cardiac arrests. This recommendation is based on the premise that ECPR, when utilized within a well-equipped and trained healthcare system, can offer a lifeline in otherwise dire circumstances. It highlights evolving resuscitation science and the importance of tailored emergency response.

Coronary Angiography: Choose Wisely

Strategic Approaches Recommended: Class 3 Recommendation (No Benefit) 

A significant update pertains to the use of emergent coronary angiography. The guidelines now recommend a more cautious approach, favoring a delayed or selective strategy in patients without ST-segment elevation, absent indications like shock or significant myocardial damage. This nuanced stance reflects a growing appreciation for patient-specific strategies in post-cardiac arrest care.

Temperature Management: Chill Out Bro, But Not Too Much

New Standard of Care: Class 1 Recommendation (Strong) 

Post-ROSC temperature control has been underscored as a vital aspect of patient management. The guidelines recommend maintaining a constant temperature between 32-37.5°C for all adults unable to follow commands post-ROSC. This approach, supported by robust evidence, marks a significant step forward in neuroprotective strategies following cardiac arrest.

TL;DR:

• Calcium use is now limited to hyperkalemia and calcium channel blocker overdose.

• Magnesium doesn't improve outcomes in cardiac arrest, regardless of rhythm.

• Extracorporeal CPR (ECPR) is recommended in select, refractory cardiac arrests within equipped systems.

• Emergent coronary angiography post-cardiac arrest is advised only with specific indications.

• Strict temperature control (32-37.5°C) post-ROSC is emphasized for all adults unable to follow commands.

References for In-Depth Exploration

1. American Heart Association. 2023 ACLS Guidelines

2. Hsu CH, Couper K, Nix T, Drennan I, Reynolds J, Kleinman M, Berg KM; Advanced Life Support and Paediatric Life Support Task Forces at the International Liaison Committee on Resuscitation (ILCOR). Calcium during cardiac arrest: A systematic review. Resusc Plus. 2023 Mar 27;14:100379. doi: 10.1016/j.resplu.2023.100379. PMID: 37025978; PMCID: PMC10070937.

3. Reis AG, Ferreira de Paiva E, Schvartsman C, Zaritsky AL. Magnesium in cardiopulmonary resuscitation: critical review. Resuscitation. 2008 Apr;77(1):21-5. doi: 10.1016/j.resuscitation.2007.10.001. Epub 2007 Nov 26. PMID: 18037222.

4. Wongtanasarasin W, Krintratun S, Techasatian W, Nishijima DK. How effective is extracorporeal life support for patients with out-of-hospital cardiac arrest initiated at the emergency department? A systematic review and meta-analysis. PLoS One. 2023 Nov 7;18(11):e0289054. doi: 10.1371/journal.pone.0289054. PMID: 37934739; PMCID: PMC10629644.