Cardiovascular & PVD (Feb-March 2015)
LLSA
For the first installment of the new asynchronous learning curriculum, please read
Chen EH, Hollander JE. When do patients need admission to a telemetry bed. J Emerg Med. 2007
AND
Both of these are Review articles. Refer to the questions on the Asynchronous Learning main page and submit them as comments to this post. Comments will remain hidden during the submission period. Once that has ended, responses will be made public and open for discussion via the same comment mechanism.
AIR
http://www.aliem.com/air-series-peripheral-vascular-disease-module-2014/
14 comments
■How has reading the article changed your practice?
The article gave a useful approach to evaluating and manging supraventricular tachycardias.
■What information had you believed in previously that were debunked by reading this article?
I did not have anything debunked by reading this article. There were good, practical tips though, such as putting pads on a patient before giving adenosine and using a lower dose for pts with a central line.
■What new information did you learn from reading this article?
My favorite thing is the approach to evaluating SVTs. I previously broke these down into “irregular” and “regular.” The article gave two additional strategies to break them down including wide and narrow-complex and onset.
■What are current areas of uncertainty on this topic that can be potential areas for research?
I want to know why they’re called antidromic and orthodromic. Why such weird confusing terms for AVRT. Maybe there could be some drug development to look into therapy for SVTs that doesn’t make you feel like you’re dying..that’d be nice for patients.
■How has reading the article changed your practice?
I thought this was a fantastic article. I really like the evidence-based discussion for various diagnoses for telemetry. At BMC, we are lucky and have tons of telemetry beds. This will not be the case for other hospitals we may work at. I will definitely think more carefully about whether a patient requires Tele.
■What information had you believed in previously that were debunked by reading this article?
PEs, COPD exacerbations, low-risk chest pain, AICD patients without cardiac admiting dx all do not require telemetry.
■What new information did you learn from reading this article?
See above. Some of the diagnoses which require telemetry and are well-backed by evidence are obvious (AICD firing, arrythmias) but I was surprised to know that patients with CVA had such high rates of ventricular arrythmias.
■What are current areas of uncertainty on this topic that can be potential areas for research?
All the areas under “may benefit from telemetry monitoring” are potential areas for future research. I’m especially interested in the subacute, “mild” CHF or atrial arrhtyhmia patients to see if they would benefit from Telemetry.
Chen, Hollander: Telemetry monitoring
– How has reading the article changed your practice?
In our resource constrained setting, I will think a little harder about which patients really need constant cardiac monitoring while in the hospital. I liked how the authors framed the discussion simply: if they can walk around the mall safely, they don’t need to be monitored on telemetry.
– What information had you believed in previously that were debunked by reading this article?
I assumed that patients on ACS rule out pathways needed telemetry but the authors state that “chest pain patients with an initial normal or non-specific ECG and normal cardiac markers have a less than 1% risk of life-threatening dysrhythmias, 0% risk of sudden death, and do not benefit from continuous cardiac monitoring.”
– What new information did you learn from reading this article?
I learned about the PESI (Pulmonary Embolus Severity Index) and using that to not only stratify PE patients that don’t need telemetry but, taking it one step further, maybe those patients don’t need to be in the hospital at all.
– What are current areas of uncertainty on this topic that can be potential areas for research?
The authors’ comment that “Patients with a neurogenic etiology for their syncope (e.g., vasovagal syncope) or a normal ECG are low risk for dysrhythmias and have not been shown to benefit from monitoring” was difficult for me because when we admit patients for syncope, we often can’t say whether the event was simply vasovagal or if there was a more sinister cardiac etiology. While the risk for dysrhythmia may be low, if we are admitting them because we are concerned about the possibility of a dysrhythmia causing their syncope, it makes sense that they should stay on telemetry. It seems further research on the management of syncope in general would hopefully shed more light on this area.
1) Review Article: Evaluation and Initial Treatment of Supraventricular Tachycardia
• How has reading the article changed your practice? I have a more guided diagnostic approach with the flow charts in the paper. Before reading the paper my approach was pretty simplistic for supraventricular tachycardias.
• What information had you believed in previously that were debunked by reading this article? I thought that with suspected WPW in a stable patient, adenosine could precipitate an unstable rhythm, but the example case in the paper, they advocated a trial of adenosine with cardio version pads in place incase a VT occurred.
• What new information did you learn from reading this article? I learned more than I expect to remember about the different variants of SVTs without reading it over and over again occasionally.
• What are current areas of uncertainty on this topic that can be potential areas for research? I would like to know if in stable patients with SVT, if sedation+cardioversion is better/worse/the same as a trial of drugs including adenosine in terms of success, safety, patient experience, and time.
2) Review Article: When do patients need admission to a telemetry bed?
• How has reading the article changed your practice? I will be ordering tele beds more judiciously, specifically low risk CP with normal/non-specific EKG and negative CEs since they have “less than 1% risk of life-threatening dysrhythmias, 0% risk of sudden death, and do not benefit from continues cardiac monitoring.”
• What information had you believed in previously that were debunked by reading this article? Per above, I believed that standard practice was to admit all chest pain r/o pts to tele beds.
• What new information did you learn from reading this article? I was surprised by the evidence that stable patients with PE receiving anticoagulation therapy don’t benefit from being on tele.
• What are current areas of uncertainty on this topic that can be potential areas for research? The article didn’t specifically address several patient groups that we see at BMC requiring hospitalization that are often admitted to tele beds: patients with sepsis and patients with alcohol withdrawal. My instinct is that comorbidities and severity will guide my decision for tele or not with septic patients and for patients with withdrawals, I am really not sure what criteria would trigger a decision to order tele for a floor-level-of-care patient admitted for alcohol withdrawal.
Great answers and comments so far!
While we may not be as short on Tele beds as compared to smaller community hospitals, we actually run out Tele beds frequently IN THE ED.
So perhaps we can extrapolate this data and apply it to our ED patients. For instance, low risk Chest pain, small PE’s, COPD exacerbations, and AICD patients without cardiac dx, may be able to be placed into hallway beds without a monitor.
Considering how busy we are on a regular basis, this approach may really open up some monitor beds for our sicker patients in the ED.
Just some food for thought.
Keep up the great work all!
Sorry for the late arrival…
Re: Telemetry article – It did reinforce many of our current practice habits (placing all patients w/ CHF/GIB/metabolic disturbance and CVA on tele). That syncope patients with a normal EKG, low risk CP patients and stable PE patients appear to NOT need tele is certainly interesting. A couple of thoughts come to mind here;
1 – In my mind, many of the low risk chest pain patients with normal EKG could and should walk ‘around the mall’, RIGHT AFTER YOU DISCHARGE THEM FROM THE ED! I personally think this will become a more acceptable practice approach in the coming years as healthcare reimbursement patterns impact decision-making re: Admit vs. Obs vs. D/c with close follow-up…..for example, I think the future we may see ‘Chest pain follow-up clinic’ in our careers in the future.
2 – I long for the time where telemetry isn’t ordered ‘just because I’m afraid he’ll be ignored in a floor bed’ , which unfortunately appears to be accurate on certain inpatient floors.
3 – It is important to remember that ‘Absence of Evidence is not Evidence of Absence’. In other words, the article suggests that stable PE patients can likely go home, but refers to a study of but 51 patients. It is tough to take that as a generalizable finding when arguing over tele with the admitting team when you are trying to admit your next stable PE patient.
Re: the SVT article, I think it is worthwhile to remind ourselves of some of the pathophysiology, as it helps to understand how to manage some of these conditions.
That we should NOT prescribe adenosine in the setting of wide-complex SVTs should be etched in your brain permanently. Taking a stable SVT and converting it to VT would be a scarring experience for any provider.
I would have liked the article to culminate in more explicit recommendations re: disposition of these patients (for example, very few folks will d/c a pt who comes in with AF with RVR, many of us are comfortable d/c a pt with AVNRT that has resolved). That there were no recommendations likely reflects that the ACC and AHA have not been explicit with recs in this realm.
Review Article: Telemetry Monitoring
* How has reading the article changed your practice?
I found this article really interesting and it definitely made me take a second look at who I order for telemetry beds. It would be interesting to pass this information to other departments who also order telemetry pretty liberally, and see if they are open to making changes in the way they practice. In patients with low risk chest pain rule out, there is no need to have continuous telemetry monitoring, and checking the telemetry during episodes of chest pain while admitted to the floor do not appear to have much diagnostic yield.
* What information had you believed in previously that were debunked by reading this article?
In the past I reflexively would have order telemetry for anyone being admitted with chest pain, but with a 0.9% chance of any arrhythmia, and 0 cases of major cardiac complications, this article made me take a second look at that.
* What new information did you learn from reading this article?
The information regarding GI bleed patient was new to me, that complications from sclerotherapy and vasopressin are significant enough to indicate monitoring on telemetry.
* What are current areas of uncertainty on this topic that can be potential areas for research?
I think it would be interesting to take a look at how incorporating these stricter criteria for telemetry into practice would affect the systems of the hospital, with regards to ED crowding and cost/resource utilization.
Review Article: Supraventricular Tachycardias
* How has reading the article changed your practice?
This article gave me a clear framework for evaluating SVTs, and I found the images depicting the bypass tracts in the AVNRT and AVRTs to be helpful in understanding their etiologies.
* What information had you believed in previously that were debunked by reading this article?
Nothing in particular was debunked, but it provided additional information on treatment guidelines for tachycardias.
* What new information did you learn from reading this article?
They gave some helpful diagrams and flowcharts for the evaluation and then treatment of tachycardias, but I definitely found it challenging to follow the complex descriptions of each type of AVRT and how their treatment differs. I would probably be calling for help at this point.
* What are current areas of uncertainty on this topic that can be potential areas for research?
They didn’t get into prognosis and rate of recurrence of the different types of tachycardias, and what to do with the patient after you have cardioverted (with adenosine or electricity) them. I would have liked a section on how and where to monitor them at that point as well.
SVT article
• How has reading the article changed your practice?
It reminded me to think a little more about potential causes of the tach, as opposed to the “it’s not wide complex so lets give some adenosine” approach (though sometimes this thinking should happen after treating the patient if unstable, and the ecg should always be reviewed once in sinus)
• What information had you believed in previously that were debunked by reading this article?
Nothing clearly debunked, but the reminder about no adenosine in a wide complex tach can never be given too often.
• What new information did you learn from reading this article?
Also good to be reminded to place pads before giving adenosine when possible for the occasional surprise; in my experience this has been attending dependent. I still don’t feel that I understand AVRTs well, maybe the explanation in this article wasn’t the right type for me, but I’m also not sure that this should be a particularly high priority for me to learn…
• What are current areas of uncertainty on this topic that can be potential areas for research? Not sure if this is a research question or a summarizing question, but clearer recs on what to do with different patients after conversion would be helpful. Also the article notes adenosine should be “avoided in patients with bronchospastic lung disease” – all of them? Only if severe?
Tele article
• How has reading the article changed your practice?
The idea that CP ruleout admission ≠ tele bed is new and helpful!
• What information had you believed in previously that were debunked by reading this article?
See above.
• What new information did you learn from reading this article?
Helpful to have reminders on which syncope patients really should be admitted with tele (age>45, HF, abnormal ECG, hx ventricular arrhythmias)
• What are current areas of uncertainty on this topic that can be potential areas for research? I think our +/- tele decisions when requesting a bed in patients with many of the diagnoses discussed are so often guided by clinical acumens and the comorbidities present that it would be difficult to assess each of these diagnoses individually…
Tele Article
1. Practice change: I definitely put patients on tele, as Jordan noted, because I’m afraid they’ll otherwise be ignored. I’ve seen this as the MICU resident (“6 am code”), and I’ve also seen it with my own family members in the hospital, e.g., an elderly person who becomes dehydrated and tachycardic and nobody is paying attention — out of sight; out of mind. But after reading this, I will now be more systematic about how I use this resource. One group, I’ll probably use tele for less now is patients with “pulmonary” disease, including PNA/COPD and stable PE. For the former, I probably had no reason to put them on tele in the first place; for the latter; the data here are suggest against it.
2. Debunked information: Like others, I’m struck by the data arguing against putting the low risk chest pain on tele. I like Alex’s observation that this is most relevant in our overcrowded ED. This article is 2007, before the proliferation of observation units, so it’s a little hard for me to make sense of whether or not the low risk chest pain needs tele given our work-up pathway. We admit patients to ED observation because we want them to get further cardiac evaluation before they go back out and walk around the mall. But for the most part, these patients would be just fine to leave and get a stress test next week. They’re probably in the category of people with “0% risk of VF/VT/sudden death.” Interestingly the chest pain pathway in ED obs includes tele, but the TIA pathway does not. There’s not enough information here to determine what really counts as an acute cerebrovascular event, but given the high risk of subsequent event in general after TIA/CVA, my suspicion is that TIA patients should be on tele (especially also since some of these patients may actually be syncope instead).
3. New information: CVA and arrhythmias — a much clearer understanding of the risk.
4. Uncertainty: It would be interesting to do studies in the observation unit about events captured on tele for patients admitted with chest pain, syncope, TIA, etc. The patients there are a cohort that we ‘almost’ wanted to send home. We could parse out better who really could have been sent home and change practice that way.
1: The telemetry article changed my admission practices for patients that I admit with nonspecific ECG changes for chest pain rule out. Patients with normal ECGs and atypical chest pain I did not put them in for a tele bed, but nonspecific changes tended to get a tele bed.
2: I thought all patietns with a cardiac rule out needed to be admitted on tele
3: I did not know that patients with asymptomatic AV type I block did have a benefit to pacer placement from the mentioned study. My knowledge was that that particular block was “benign”.
4: I would be interesting to see which type of trauma patients would benefit from tele monitoring. The article touched upon transfusion but it might be useful to know the evidence of what types of trauma patients would benefit from closer cardiac monitoring.
SVT Article:
1. Practice change — No real change, but a great reminder of the mechanisms, clinical picture, and algorithm for SVTs.
2. That it’s reasonable to give adenosine in a stable, regular WCT. This is something that I know but get a little nervous about. You really need to be sure that it’s regular — and not AF or WPW — but this can be tough when you’re staring at an EKG with a wide complex tachycardia. I think this article would be good to review regularly, like ACLS, to think through some of the potential diagnostic options and potential risks.
3. More about rhythms that I think about less often, e.g., atrial tachycardia.
4. I’m curious about the accuracy of cardiologists in recognizing the rhythm on the EKG. For example, they’ll often say they think it is AVNRT vs. AVRT. I wonder how often this initial diagnosis pans out in the EP lab. Is it like STEMI, where cardiologists are no better than ED physicians at identifying STEMI/non-STEMI, or are they better since they follow and manipulate rhythms in the EP lab? What could we learn from experience in the EP lab?
As usual a late arrival by Schafer.
Tele-
Practice changer: This came up at NERDS and something I am thinking about more and the relevance particularly in settings where every bed is not a tele bed as at our place. As Jordan said, I have ordered tele because I was concerned that a patient would get ignored on the floor. Is getting admitted to a floor bed similar to “walking around the mall”?
Debunked- Tele for low prob r/o. Good point though that we already knew but maybe needed a little reminder: the technology can’t identify ST changes, we can with a 12 lead and by definition, low prob means no ST abnormalities concerning for ischemia
New Info- I too was surprised by high rates of abnormalities seen on tele in CVA patients.
Uncertainty-
The patents with electrolyte abnormalities. We are taught to optimize the electrolytes and do so aggressively in cardiac patients but other patients admitted for non cardiac issues to tele vs floor- how many of them are already walking around the mall? Are we over aggressive in treating some of these mild number abnormalities just because they are getting admitted for non cardiac issues?
SVT article- Great review, not really practice changing