EM Quick Hits 6 Blunt Cardiac Trauma, Atrial Fibrillation Anticoagulation, Hydromorphone vs Morphine, Myasthenia Gravis, Venous Access

Topics in this EM Quick Hits podcast Andrew Petrosoniak on diagnosis and risk stratification of blunt cardiac trauma (0:33) Clare Atzema on latest guidelines for anticoagulation in atrial fibrillation (8:53) Maria Ivankovic on hydromorphone vs morphine for acute pain (19:08) Brit Long on clinical pearls in the diagnosis of myasthenia gravis (26:37) Anand Swaminathan on venous access tips and tricks (30:11) Bonus material from EM Cases Course June 2018 with Walter Himmel and Barbara Tatham on preventing burnout and physician compassion (podcast only). Podcast production, editing and sound design by Anton Helman Podcast content, written summary & blog post by Andrew Petrosoniak, Anand Swaminathan, Brit Long, edited by Anton Helman Cite this podcast as: Helman, A. Swaminathan, A. Long, B. Petrosoniak, A. Atzema, C. Ivankovic M. EM Quick Hits 6 - Blunt Cardiac Trauma, Atrial Fibrillation Anticoagulation, Hydromorphone vs Morphine, Myasthenia Gravis, Venous Access. Emergency Medicine Cases. July, 2019. https://emergencymedicinecases.com/em-quick-hits-july-2019/. Accessed [date]. Diagnosis and Risk Stratification of Blunt Cardiac Trauma * There is no gold standard definition of blunt cardiac injury. The clinician must use clinical judgement to decide based on clinical course and mechanism. * If you suspect blunt cardiac injury, a negative ECG and troponin are sufficient to rule it out. * A positive troponin in trauma predicts worse outcomes but it does not necessarily indicate blunt cardiac injury. There is little evidence to guide how to manage patients with elevated troponins following a trauma and the conservative approach is short admission for echo and telemetry. * No need to worry about isolated sternal fracture, these really are predictably benign. * Troponin is not a required test for all trauma patients unless there’s a feature that is concerning for blunt cardiac injury. Based on expert opinion and literature review, these include: * Dysrhythmias * Abnormal echocardiogram * Unexplained hypotension * Or CT evidence of significant mediastinal or cardiac injury * Unexplained and persistent tachycardia Expand to view reference list * Joseph B et al. Identifying the broken heart: predictors of mortality and morbidity in suspected blunt cardiac injury. Am J Surg 2016, 211, 982-88. * Kalbitz M et al. The role of troponin in blunt cardiac injury after multiple trauma in humans. World J Surg 2017 Jan;41(1): 162-169. * Odell DD et al. Sternal fracture: isolated lesion versus polytrauma from associated extrasternal injuries – analysis of 1867 cases. J Trauma Acute Care Surg 2013 Sep; 75(3):448-52. Canadian Guideline Recommendations on Anticoagulation in Atrial Fibrillation * Rather than considering cardioversion of atrial fibrillation within 48 hours of onset of atrial fibrillation without anticoagulation for all patients, guidelines recommend safe cardioversion without anticoagulation only for the patients with the lowest risk profile for stroke - those with a CHADS