Emergency Medical Minute

Carepoint Journal Club is a quarterly series with discussions about a medical topic, brought to you by Carepoint's Emergency Physicians.

Contributor: Taylor Lynch, MD
Educational Pearls: 
 
Conduction abnormalities are a common and clinically significant complication in patients who undergo transcatheter aortic valve replacement (TAVR)
 
Clinical Features
The most common abnormalities include high grade AV block and new onset LBBB 

Due to the close proximity of the aortic annulus to the AV node and His-Purkinje system

More common in males, the elderly, and those with pre-existing conduction disease (RBBB or LBBB)

Sinus pauses and sinus arrest are a rare post-TAVR rhythm disturbances

Temporary failure of sinus node firing with absent P waves, followed by return of sinus rhythm

Sinus Pauses: Typically last Sinus Arrest: Typically last > 3 seconds

Not due to direct mechanical injury from the valve, but may occur in patients as a result of pre-existing disease or other external factors:

Medications

Beta blockers, calcium channel blockers, digoxin

Pre-existing damage to the SA node

Fibrosis from a previous MI

 
Treatment
If the patient is asymptomatic, provide ongoing surveillance

If the patient is symptomatic, treatment should be aimed at the underlying cause:

For medication-induced abnormalities, stop the offending medication

For acute, unstable bradycardia:

Medications: Atropine, Dopamine Infusion, Epinephrine Infusion

If cardiology is not immediately available, initiate transcutaneous pacing or insert a temporary transvenous pacemaker

Definitive treatment: Pacemaker

~10–15% of patients may develop a bradyarrhythmia post TAVR, with ~8-15% later requiring a pacemaker

 
Due to the risk of conduction abnormalities post TAVR, many patients are discharged with ambulatory rhythm monitoring such as a ZioPatch or Holter monitor, and may present to the emergency department for evaluation of rhythm disturbances.
 
References:
Kusumoto FM, Schoenfeld MH, Barrett C, et al. 2018 ACC/AHA/HRS guideline on the evaluation and management of patients with bradycardia and cardiac conduction delay. Heart Rhythm. 2019;16(9):e128-e226.

Lilly, S, Deshmukh, A, Epstein, A. et al. 2020 ACC Expert Consensus Decision Pathway on Management of Conduction Disturbances in Patients Undergoing Transcatheter Aortic Valve Replacement: A Report of the American College of Cardiology Solution Set Oversight Committee. JACC. 2020 Nov, 76 (20) 2391–2411.

https://doi.org/10.1016/j.jacc.2020.08.050
Sammour, Y, Krishnaswamy, A, Kumar, A. et al. Incidence, Predictors, and Implications of Permanent Pacemaker Requirement After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol Intv. 2021 Jan, 14 (2) 115–134.

https://doi.org/10.1016/j.jcin.2020.09.063
Tarakji KG, Patel D, Krishnaswamy A, et al. Bradyarrhythmias detected by extended rhythm recording in patients undergoing transcatheter aortic valve replacement (Brady-TAVR Study). Heart Rhythm. 2022;19(3):381-388.

 
Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Alec Coston, MD
Educational Pearls:
What are nasal intubations and when do we use them?
Nasal intubations function similarly to oral intubations with the end goal of passing an endotracheal tube (ETT) through vocal cords and into the trachea to allow for a patent and secure airway, but differ in the main access point for the ETT (nare v.s. mouth).

Nasal Intubations are seldom preferred to oral intubations as they carry risk for inducing bleeding from trauma to the nasal passages. 

Indications for nasal intubations include:

Anatomical abnormalities that may make access through the mouth difficult (i.e. tumors, macroglossia, or rare dental hardware that clenches the jaw shut).

Physiological states such as severe angioedema. 

Nasal intubations are often done with the patient awake and could be advantageous if the patient is presenting in a severely hypoxic state such that prolonged hypoxia in a traditional RSI protocol may be detrimental.

A 2023 retrospective analysis in Germany found that nasal intubations were associated with requiring less sedation than oral intubations and had more spontaneous breathing during hospitalization than oral intubations.

How is a nasal intubation performed?
Consider the use of an anxiolytic medication such as versed to calm the patient down but not fully sedate them.

If there is adequate time without immediate patient compromise, consider glycopyrrolate to reduce airway secretions and dry up the mucous membranes.

Consider the use of Afrin or other local vasoconstrictor in target nare to minimize epistaxis.   

Use 5% lidocaine ointment and lubricate an NPA and place it into the target nare. This will allow for local anesthesia as well as help to open up the nare slightly more. 

Take 5% lidocaine ointment and place it on a tongue depressor and move it around the back of the tongue, allowing it to further anesthetize the oropharynx. 

Remove the NPA and atomize/nebulize 4% lidocaine liquid into the nare and into the oropharynx for further anesthesia. 

Insert the ETT without the bronchoscope through the nare and allow it to pass about 10 cm until visible in the oropharynx. This allows for a "clean" plastic tunnel to pass the bronchoscope through.

Advance both the ETT and bronchoscope, spraying lidocaine through the bronchoscope while advancing to allow for continued numbing. 

Pass the ETT through the cords and inflate. 

At this point, stronger sedation medications such as ketamine and propofol may be considered but the use of a paralytic like succinylcholine and rocuronium may not be needed to allow the patient to maintain their own negative pressure ventilation. 

Which nare is the best to go through?
Most patients will have their right nare be the best (away from the septal deviation) according to a meta-analysis by Tan et al. 

The right nare was generally associated with less epistaxis and lower intubation times. 

However, do not always default to the right nare, and test which nare is more patent by occluding one nare at a time and assessing which one is less resonant  (less resonant = more patent). 

Key Takeaway?
Nasal intubations are rarer than oral intubations and can be more technically difficult, but may offer advantages in patients with difficult oral airways, but should never be first line. 

 
References:
Grensemann J, Gilmour S, Tariparast PA, Petzoldt M, Kluge S. Comparison of nasotracheal versus orotracheal intubation for sedation, assisted spontaneous breathing, mobilization, and outcome in critically ill patients: an exploratory retrospective analysis. Sci Rep. 2023;13:12616. doi:10.1038/s41598-023-39768-1

Tan YL, Wu ZH, Zhao BJ, Ni YH, Dong YC. For nasotracheal intubation, which nostril results in less epistaxis: right or left?: A systematic review and meta-analysis. Eur J Anaesthesiol. 2021;38(11):1180-1186. doi:10.1097/EJA.0000000000001462

Holzapfel L. Nasal vs oral intubation. Minerva Anestesiol. 2003;69(5):348-352.

 
Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Ahmed Abdel-Hafiz, NREMT-P
 
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Contributor: Aaron Lessen, MD
Educational Pearls:
What are the common causes of agitation in the elderly?
Baseline dementia causing a behavioral disturbance
Delirium precipitated by an acute medical problem such as a UTI, pneumonia, overdose/side effect of home medications, urinary retention, constipation, pain, hypoxia, electrolyte abnormality, etc.
Exacerbation of a primary psychotic condition such as schizophrenia or bipolar disorder.
What environmental changes can help reduce agitation?
Maintain a quiet, calm, uncluttered environment
Dim the lights
Ensure the patient has their glasses, hearing aids, and dentures
Avoid excessive lines such as foleys
Minimize restraints and other forms of immobilization
Reassure the patient frequently and have the family check in with the patient
What are the best options if medications are required?
If the patient is unsafe or non-pharmacologic measures fail, consider a second-generation ("atypical") antipsychotic using the lowest effective dose: Olanzapine
Risperidone
Quetiapine

One special consideration is Dementia with Lewy Bodies, which can be very sensitive to antipsychotics. In this case, Quetiapine is the preferred agent.

Avoid when possible:
Diphenhydramine and other anticholinergics, which can worsen delirium (including urinary retention and sedation)
Benzodiazepines, which may worsen confusion, falls, and respiratory depression
Haloperidol, which has a higher risk of extrapyramidal symptoms and QT prolongation than many atypicals
References
Badwal K, Kiliaki SA, Dugani SB, Pagali SR. Psychosis Management in Lewy Body Dementia: A Comprehensive Clinical Approach. J Geriatr Psychiatry Neurol. 2022 May;35(3):255-261. doi: 10.1177/0891988720988916. Epub 2021 Jan 19. PMID: 33461372.
Kurlan R, Cummings J, Raman R, Thal L; Alzheimer's Disease Cooperative Study Group. Quetiapine for agitation or psychosis in patients with dementia and parkinsonism. Neurology. 2007 Apr 24;68(17):1356-63. doi: 10.1212/01.wnl.0000260060.60870.89. PMID: 17452579.
Shenvi C, Kennedy M, Austin CA, Wilson MP, Gerardi M, Schneider S. Managing Delirium and Agitation in the Older Emergency Department Patient: The ADEPT Tool. Ann Emerg Med. 2020 Feb;75(2):136-145. doi: 10.1016/j.annemergmed.2019.07.023. Epub 2019 Sep 26. PMID: 31563402; PMCID: PMC7945005.
Summarized and edited by Jeffrey Olson, MS4
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Contributor: Aaron Lessen, MD
Educational Pearls:
Patients with pulmonary embolism (PE) are divided into three risk categories Low risk (non-massive PE): patients are stable Treatment: prescribe anticoagulants and discharge home

Intermediate risk (submassive PE): patients are stable but display evidence of clot burden such as elevated troponin, elevated BNP, and/or right heart strain Treatment is controversial

High risk (massive PE): patients are unstable with hypotension, hypoxia, and/or respiratory distress Treatment: IV thrombolysis to prevent decompensation


A recent randomized controlled trial evaluated treatment of intermediate risk PE patients Patients were randomized to receive either thrombectomy with anticoagulation or anticoagulation alone
The primary outcome evaluated changes in right ventricular enlargement at 48 hours A controversial primary outcome because it does not speak to mortality or incidence of other necessary aggressive interventions
Low clinical significance

The study found that thrombectomy significantly reduced right ventricular enlargement faster than anticoagulation alone. However, there was no statistical difference in mortality or need for other treatments

Treatment for intermediate risk PE patient remains controversial
The same study will have second follow-up at 90 days to see if there are other benefits
References
Lookstein RA, Konstantinides SV, Weinberg I, Dohad SY, Rosol Z, Kopeć G, Moriarty JM, Parikh SA, Holden A, Channick RN, McDonald B, Nagarsheth KH, Yamada K, Rosovsky RP; STORM-PE Trial Investigators. Randomized Controlled Trial of Mechanical Thrombectomy With Anticoagulation Versus Anticoagulation Alone for Acute Intermediate-High Risk Pulmonary Embolism: Primary Outcomes From the STORM-PE Trial. Circulation. 2026 Jan 6;153(1):21-34. doi: 10.1161/CIRCULATIONAHA.125.077232. Epub 2025 Nov 3. PMID: 41183181.
Summarized by Meg Joyce, MS2 | Edited by Meg Joyce & Jorge Chalit, OMS4
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