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 < 3 seconds

    • 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.

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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

1. 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.
2. 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.
3. 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

1. 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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Contributor: Aaron Lessen, MD

Educational Pearls:

• Burns range in complexity from minor first-degree burns to more severe full-thickness burns.
• Initial basic burn management:
  • Run the burn under cool running water for 20 minutes.
  • Do not scrub the skin.
  • Do not use ice water.
  • Ideally initiated as soon as possible, but no later than 3 hours after injury.
  • Applicable to all burns ranging from superficial to full thickness.
• Then apply a non-adherent dressing or sterile gauze.
• Can be done at home or upon presentation to the emergency department.
• These steps decrease pain and minimize tissue damage.
• A study published in Annals of Emergency Medicine found that, out of 371 EMS and emergency medicine providers,
  • 90% had not heard of the recommendation to run burns under cool water for 20 minutes.
  • The majority of providers interviewed expressed motivation to implement this burn cooling practice but cited barriers such as:
    • Difficulty immersing certain body parts (e.g., chest).
    • Critically ill patients requiring other urgent interventions.

References:

1. Holbert MD, Singer Y, Palmieri T, et al. Cool Running Water as a First Aid Treatment for Burn Injuries. Annals of Emergency Medicine. 2025;S0196-0644(25)01138-2. doi:10.1016/j.annemergmed.2025.08.003.
2. Olawoye OA, Isamah CP, Ademola SA, et al. Effect of Prehospital Topical Application of Water and Other Agents on Outcome in Burn Injured Patients: A Prospective Study. Burns. 2025;51(2):107357. doi:10.1016/j.burns.2024.107357.

Summarized by Ashley Lyons, OMS3 | Edited by Ashley Lyons & Jorge Chalit, OMS4

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Contributor: Travis Barlock, MD

Educational Pearls:

What is an internal jugular catheter (IJ) and when do we use it?

• IJs are catheters that can be placed in either the left or the right internal jugular vein to provide central venous catheter (CVC) access. CVCs can be placed in other locations other than the internal jugular vein (i.e. subclavian vein or femoral veins).
• IJs are used when the patient may require long-term venous access or have to receive hyperosmolar solutions (such as solutions with high glucose content for parenteral nutrition); solutions with extreme pHs (<5 or >9); or vesicant drugs (drugs that can cause tissue necrosis with extravasation).
• They are not to be confused with EJs (external jugular vein catheters) which can be placed in difficult to peripherally catheterize patients. EJs function similarly to a peripheral IV.
• The advantage of IJs is their location in larger veins brings them closer to direct access to the heart (i.e. the right internal jugular vein will provide immediate/quicker access to the right atrium to the heart.)

What are concerns of using a right internal jugular catheter versus one in the left?

• The right internal jugular vein provides quick access to the heart via the right atrium, making it ideal in critically ill patients who may require vasopressor support.
• However it is also the site commonly used for additional cannulation procedures such as hemodialysis, pulmonary artery pressure measurements, extracorporeal membrane oxygenation (ECMO) and transvenous pacemaker placement.
• These procedures are not uncommon in critically ill patients who also required a CVC for initial hemodynamic support via vasopressors.
• Gharaibeh et al. found that patients who received a right IJ and hemodialysis had a higher need for re-insertion of the hemodialysis catheter (40% compared to 2.6% in the left IJ group).
• Furthermore, it was found that with a right IJ, hemodialysis catheters had to be exchanged by a guidewire in 23% of those with a right IJ as opposed to 0.9% in the left IJ group (a guidewire exchange is often considered a salvage technique to try and maintain access).

Big Takeaway?

• If you are able to obtain an IJ on the right, you can likely obtain one on the left, and if considering longitudinal care for your patient, consider obtaining an IJ on the left to allow for future critical access in the right IJ.

References

1. Gharaibeh KA, Abdelhafez MO, Guedze KEB, Siddiqi H, Hamadah AM, Verceles AC. Impact of initial jugular vein insertion site selection for central venous catheter placement on hemodialysis catheter complications. Journal of Critical Care. 2025;87:155011. doi:10.1016/j.jcrc.2024.155011
2. Gallieni M, Pittiruti M, Biffi R. Vascular access in oncology patients. CA: A Cancer Journal for Clinicians. 2008;58(6):323-346. doi:10.3322/CA.2008.0015

Summarized by Dan Orbidan, OMS2 | Edited by Dan Orbidan & Jorge Chalit, OMS4

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Contributor: Aaron Lessen, MD

Educational Pearls:

How long do we need to watch patients with a presumed overdose who were treated with naloxone in the field?

• A 2025 study in the Annals of Emergency Medicine took a look at this question
• Methods
  • Prospective, multi-institutional cohort study
  • Included ED patients with suspected acute opioid overdose with biologic testing to confirm substances.
  • This paper performed a secondary analysis evaluating the risk of "delayed intubation," defined as intubation occurring >4 hours after ED arrival.
• Results
  • 1,591 patients with presumed opioid overdose were included.
  • Delayed intubation occurred in only 9 patients (0.6%).
  • 8 of the 9 cases had non-respiratory causes contributing to intubation.
  • Only 1 patient had respiratory-related deterioration, presenting with respiratory acidosis after receiving 6.4 mg naloxone prior to intubation.
• Key Takeaway
  • Delayed respiratory deterioration requiring intubation after 4 hours of ED monitoring is extremely rare, suggesting prolonged monitoring may not be necessary for most stabilized overdose patients.

How else can we mitigate risk?

• Give patients take-home naloxone at discharge and educate them on how to use it (See Episode 673: Leaving the ED with Naloxone).

When are naloxone drips necessary?

• If a patient requires repeated naloxone boluses, consider a drip
• To get the dose, take the total naloxone dose that restored adequate breathing and give two-thirds of that dose per hour
• Typically these patients are admitted to the ICU

References

1. McCabe DJ, Gibbs H, Pratt AA, Culbreth R, Sutphin AM, Abston S, Li S, Wax P, Brent J, Campleman S, Aldy K, Falise A, Manini AF; ToxIC Fentalog Study Group. Risk of Delayed Intubation After Presumed Opioid Overdose in the Emergency Department. Ann Emerg Med. 2025 Jun;85(6):498-504. doi: 10.1016/j.annemergmed.2025.01.022. Epub 2025 Mar 4. PMID: 40047773; PMCID: PMC12955731.

Summarized and edited by Jeffrey Olson MS4

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