{"id":1764,"date":"2017-09-13T11:45:44","date_gmt":"2017-09-13T15:45:44","guid":{"rendered":"https:\/\/www.roshreview.com\/?p=1764"},"modified":"2017-09-13T11:45:44","modified_gmt":"2017-09-13T15:45:44","slug":"ep-31-ventricular-fibrillation-wolff-parkinson-white-syndrome-traumatic-brain-injury-torsades-de-pointes-healthcare-associated-pneumonia-multifocal-atrial-tachycardia","status":"publish","type":"post","link":"https:\/\/www.roshreview.com\/blog\/ep-31-ventricular-fibrillation-wolff-parkinson-white-syndrome-traumatic-brain-injury-torsades-de-pointes-healthcare-associated-pneumonia-multifocal-atrial-tachycardia\/","title":{"rendered":"Podcast Ep 31: Ventricular Fibrillation, Traumatic Brain Injury, &amp; More"},"content":{"rendered":"\n<figure class=\"wp-block-audio\"><audio controls src=\"https:\/\/media.blubrry.com\/thereveal\/s\/media.blubrry.com\/roshcast\/s\/content.blubrry.com\/roshcast\/Ep_31_Roshcast_Emergency_Board_Review.mp3\"><\/audio><\/figure>\n\n\n\n<blockquote class=\"wp-block-quote is-layout-flow wp-block-quote-is-layout-flow\"><p>The only journey is the one within.<\/p><cite>-Rainer Maria Rilke<\/cite><\/blockquote>\n\n\n\n<p><strong>Welcome back to Episode 31!<\/strong> We are continuing our collaborative effort with the <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"http:\/\/emclerkship.com\/\" target=\"_blank\">EM Clerkship podcast<\/a>, focusing this week on tachydysrhythmias in addition to a mixture of random topics. We start the episode off with another rapid review of a few of the recent <a rel=\"noreferrer noopener\" aria-label=\"blog (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/rapid-review\/rapid-review-polycystic-ovarian-syndrome\/\" target=\"_blank\">blog<\/a> <a rel=\"noreferrer noopener\" aria-label=\"posts (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/blog\/rapid-review\/rapid-review-fundal-height\/\" target=\"_blank\">posts<\/a> by <a rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\" href=\"https:\/\/www.roshreview.com\/author\/yehudawolf\/\" target=\"_blank\">Yehuda Wolf<\/a>.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li>In a <strong>gravid female<\/strong>, the <strong>uterus<\/strong> will be <strong>palpable<\/strong> at the <strong>umbilicus<\/strong> at around <strong>20 weeks<\/strong>. At <strong>12 weeks<\/strong>, the fundal height will be around the <strong>pubic symphysis<\/strong>. Lastly, at <strong>36 weeks<\/strong> the fundus will be at the <strong>xiphoid process<\/strong>.<\/li><li>Patients with <strong>polycystic ovarian syndrome<\/strong> are often <strong>obese<\/strong> and complain of <strong>hirsutism<\/strong>, <strong>irregular menses<\/strong>, <strong>acne<\/strong>, and <strong>sleep disordered breathing<\/strong>. You might also notice <strong>acanthosis nigricans<\/strong> and <strong>fatty liver disease<\/strong>.<\/li><li><strong>Management<\/strong> for <strong>PCOS<\/strong> is typically done in an <strong>outpatient setting<\/strong>, but a common regimen could include <strong>OCPs<\/strong>, <strong>metformin<\/strong>, and <strong>lifestyle modification<\/strong>.<\/li><\/ul>\n\n\n\n<p><strong>Now onto this week\u2019s podcast<\/strong><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 1<\/strong><\/p>\n\n\n\n<p>A 58-year old man is brought to the ED for chest pain that started 30 minutes prior to arrival while he was jogging in the park. Initially, the patient\u2019s cardiac monitor shows sinus tachycardia with a rate of 120 beats per minute. However, while you are interviewing the patient in the resuscitation bay, he suddenly becomes pale, pulseless, and the below rhythm is seen on the cardiac monitor. Which of the following is the definitive next step to manage this rhythm?<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"490\" height=\"65\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-Vfib.jpg\" alt=\"\" class=\"wp-image-1771\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Vfib.jpg 490w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Vfib-300x40.jpg 300w\" sizes=\"auto, (max-width: 490px) 100vw, 490px\" \/><\/figure><\/div>\n\n\n\n<p>A. Chest compressions<\/p>\n\n\n\n<p>B. Defibrillation<\/p>\n\n\n\n<p>C. Epinephrine<\/p>\n\n\n\n<p>D. Synchronized cardioversion<\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-ECG-Vfib.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 2<\/strong><\/p>\n\n\n\n<p>Which of the following treatments is contraindicated in a young person who has Wolff-Parkinson-White (WPW) syndrome with atrial fibrillation?<\/p>\n\n\n\n<p>A. Adenosine<\/p>\n\n\n\n<p>B. lbutilide<\/p>\n\n\n\n<p>C. Procainamide<\/p>\n\n\n\n<p>D. Synchronized cardioversion<\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-WPW.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 3<\/strong><\/p>\n\n\n\n<p>In a patient with traumatic brain injury, which of the following secondary insults should be given the highest priority for correcting in the ED?<\/p>\n\n\n\n<p>A. Hypercarbia<\/p>\n\n\n\n<p>B. Hyperpyrexia<\/p>\n\n\n\n<p>C. Hypotension<\/p>\n\n\n\n<p>D. Hypothermia<\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 4<\/strong><\/p>\n\n\n\n<p>A 45-year-old man with a history of opioid abuse presents to the ED with new onset syncope. While you are evaluating the patient, he becomes unresponsive and you note the rhythm below on the monitor. Which of the following medications is the most likely cause of this presentation?<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"461\" height=\"352\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-Torsades-De-Pointes.jpg\" alt=\"\" class=\"wp-image-1769\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Torsades-De-Pointes.jpg 461w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Torsades-De-Pointes-300x229.jpg 300w\" sizes=\"auto, (max-width: 461px) 100vw, 461px\" \/><\/figure><\/div>\n\n\n\n<p>A. Buprenorphine\/naloxone<\/p>\n\n\n\n<p>B. Fentanyl<\/p>\n\n\n\n<p>C. Ketorolac<\/p>\n\n\n\n<p>D. Methadone<\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-Torsades-De-Pointes2.jpg\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 5<\/strong><\/p>\n\n\n\n<p>An 84-year-old man presents from a nursing home. The patient is lethargic and unable to provide any history. The transfer record reports a new cough and chills. His vital signs are T 102\u00b0F, BP 88\/42, HR 118, RR 22, and oxygen saturation 95% on room air. In addition to an intravenous normal saline bolus of 30 cc\/kg, which of the following is the most appropriate empiric treatment?<\/p>\n\n\n\n<p>A. Cefepime, vancomycin, and azithromycin<\/p>\n\n\n\n<p>B. Ceftriaxone and azithromycin<\/p>\n\n\n\n<p>C. Ceftriaxone, vancomycin, and azithromycin<\/p>\n\n\n\n<p>D. Ciprofloxacin and metronidazole<\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-HCAP-Treatment.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<p><strong>Question 6<\/strong><\/p>\n\n\n\n<p>What is the most likely underlying chronic medical problem in the patient with the following ECG?<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter is-resized\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-Mulitfocal-Tachycardia.jpg\" alt=\"\" class=\"wp-image-1767\" width=\"632\" height=\"304\" srcset=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Mulitfocal-Tachycardia.jpg 702w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Mulitfocal-Tachycardia-300x144.jpg 300w, https:\/\/www.roshreview.com\/wp-content\/uploads\/sites\/2\/Ep31-Mulitfocal-Tachycardia-600x289.jpg 600w\" sizes=\"auto, (max-width: 632px) 100vw, 632px\" \/><\/figure><\/div>\n\n\n\n<p>A. Cardiomyopathy<\/p>\n\n\n\n<p>B. COPD<\/p>\n\n\n\n<p>C. Hyperthyroidism<\/p>\n\n\n\n<p>D. Mitral stenosis<\/p>\n\n\n\n<p><a href=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/Ep31-Multifocal-Atrial-Tachycardia.png\">Teaching Image<\/a><\/p>\n\n\n\n<hr class=\"wp-block-separator\" \/>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"201\" height=\"74\" src=\"https:\/\/www.roshreview.com\/wp-content\/uploads\/RapidReview-2-e1475624722961.png\" alt=\"\" class=\"wp-image-818\" \/><\/figure><\/div>\n\n\n\n<ul class=\"wp-block-list\"><li>In a <strong>witnessed cardiac arrest<\/strong> for a patient in <strong>ventricular fibrillation<\/strong>, <strong>immediate<\/strong> <strong>defibrillation<\/strong> should be performed.<\/li><li>In an <strong>unwitnessed cardiac arrest<\/strong> with an <strong>unknown downtime<\/strong>, regardless of rhythm, <strong>chest compressions<\/strong> should be initiated <strong>immediately<\/strong>.<\/li><li>The <strong>defibrillating dose<\/strong> for a <strong>biphasic<\/strong> defibrillator is <strong>200 J<\/strong>, whereas <strong>360 J<\/strong> are required with a <strong>monophasic<\/strong> defibrillator. &nbsp;<strong>Biphasic<\/strong> defibrillators are <strong>preferred<\/strong> as they cause <strong>less cardiac damage<\/strong> and have <strong>higher first shock success<\/strong>.<\/li><li>In <strong>atrial fibrillation with WPW<\/strong>, <strong>avoid AV nodal blocking agents<\/strong>, like amiodarone, beta-blockers, calcium channel blockers, and digoxin.<\/li><li>For an <strong>unstable patient<\/strong> in <strong>atrial fibrillation with WPW<\/strong>, <strong>synchronized cardioversion<\/strong> should be performed.<\/li><li>In patients with <strong>traumatic brain injury<\/strong>, <strong>hypoxia<\/strong> and <strong>hypotension<\/strong> are associated with <strong>worse outcomes<\/strong>.<\/li><li><strong>Torsades de Pointes<\/strong> is often caused by <strong>drugs<\/strong> that <strong>prolong the QT<\/strong>. Other <strong>risk factors<\/strong> for Torsades de Pointes include <strong>female gender<\/strong>, <strong>hypokalemia<\/strong>, <strong>hypomagnesemia<\/strong>, <strong>structural heart disease<\/strong>, <strong>stroke<\/strong>, <strong>brain injury<\/strong>, and <strong>bradyarrhythmias<\/strong>.<\/li><li><strong>Torsades de Pointes<\/strong> should be treated with <strong>magnesium<\/strong> if the <strong>patient is stable<\/strong>. &nbsp;In an <strong>unstable patient<\/strong>, <strong>synchronized cardioversion<\/strong> or <strong>overdrive pacing<\/strong> should be performed.<\/li><li>There are <strong>four criteria<\/strong> to think of for <strong>healthcare-associated pneumonia<\/strong>: <ul><li><strong>Infection occurring <\/strong>within<strong> 90 days <\/strong>of a 2-day or longer <strong>hospitalization<\/strong>.<\/li><li><strong>Resident <\/strong>from a<strong> nursing home <\/strong>or<strong> long-term care facility<\/strong>.<\/li><li><strong>Infection <\/strong>within<strong> 30 days <\/strong>of receiving<strong> IV antibacterial therapy, chemo, or wound care<\/strong>.<\/li><li>A patient on <strong>hemodialysis<\/strong>. <\/li><\/ul><\/li><li><strong>HCAP<\/strong> should be treated with <strong>three drugs<\/strong>: one covering <strong>gram negatives including <em>Pseudomonas<\/em><\/strong>, one for <strong>MRSA<\/strong> coverage, and lastly a third for <strong>atypical<\/strong> coverage.<\/li><li>Always draw <strong>blood cultures before <\/strong>giving<strong> antibiotics<\/strong> when treating <strong>suspected sepsis<\/strong> and start a <strong>30 cc\/kg bolus<\/strong> assuming they do not have contraindications.<\/li><li><strong>Multifocal atrial tachycardia<\/strong> is often associated with <strong>COPD<\/strong>.<\/li><\/ul>\n\n\n\n<p>That wraps up Episode 31. Do not forget to follow us on Twitter <a href=\"twitter.com\/roshcast\">@Roshcast<\/a> and <a href=\"twitter.com\/roshreview\">@Roshreview<\/a>. We can also be reached by email at <a href=\"mailto:roshcast@roshreview.com\">roshcast@roshreview.com<\/a>. We are open to any feedback, corrections, or suggestions. You can also help us <strong>pick questions by identifying ones you would like us to review<\/strong>. To do so, write <strong>\u201cRoshcast\u201d in the submit feedback box<\/strong> as you go through the question bank. And finally, if you have a minute, make sure to rate us and leave comments on <a href=\"https:\/\/itunes.apple.com\/us\/podcast\/roshcast\/id1156487141?mt=2\" target=\"_blank\" rel=\"noreferrer noopener\" aria-label=\" (opens in a new tab)\">iTunes<\/a> to help spread the word about Roshcast.<\/p>\n\n\n\n<p>Until next time,<br>Jeff and Nachi<\/p>\n","protected":false},"excerpt":{"rendered":"<p>The only journey is the one within. -Rainer Maria Rilke Welcome back to Episode 31! We are continuing our collaborative effort with the EM Clerkship podcast, focusing this week on tachydysrhythmias in addition to a mixture of random topics. We start the episode off with another rapid review of a few of the recent blog <a href=\"https:\/\/www.roshreview.com\/blog\/ep-31-ventricular-fibrillation-wolff-parkinson-white-syndrome-traumatic-brain-injury-torsades-de-pointes-healthcare-associated-pneumonia-multifocal-atrial-tachycardia\/\">read more&#8230;<\/a><\/p>\n","protected":false},"author":11,"featured_media":851,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"inline_featured_image":false,"footnotes":""},"categories":[2025,1999],"tags":[2164,2201,2203,2207,2246,2261,2291,2325,2330,2366,2441,2459,2492,2754,2768,2816,2843,2845,2848,2851,2873,2980,2994,3059,3062,3066,3176,3179,3381,3394,3410,3457,3523,3586,3587,3612,3617,3666,3678,3743,3783],"coauthors":[],"class_list":["post-1764","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-emergency-medicine","category-podcast","tag-antibiotics","tag-atrial-fibrillation","tag-atypical-pneumonia","tag-av-node","tag-biphasic-defribillator","tag-blood-cultures","tag-brain-injury","tag-cardiac-arrest","tag-cardiology","tag-chest-compressions","tag-copd","tag-critical-care","tag-defibrillation","tag-hcap","tag-hemodialysis","tag-hospitalization","tag-hypokalemia","tag-hypomagnesemia","tag-hypotension","tag-hypoxia","tag-infectious-diseases","tag-long-term-care-facility","tag-magnesium","tag-monophasic-defibrillator","tag-mrsa","tag-multifocal-atrial-tachycardia","tag-outcomes","tag-overdrive-pacing","tag-prolonged-qt","tag-pseudomonas","tag-pulmonary","tag-resuscitation","tag-sepsis","tag-stroke","tag-structural-heart-disease","tag-synchronized-cardioversion","tag-tachydysrhythmias","tag-torsades-de-pointes","tag-traumatic-brain-injury","tag-ventricular-fibrillation","tag-wpw"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v21.7 (Yoast SEO v26.6) - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Podcast Ep 31: Ventricular Fibrillation, Traumatic Brain Injury &amp; More | RoshReview.com<\/title>\n<meta name=\"description\" content=\"Welcome to RoshCast (Ep. 31), the first question and answer style emergency medicine podcast. 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