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Fetal Tachycardia

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181. CRACKCast Episode 142 – Electrical and Lightning Injuries

, mottled, and pulseless, may persist up to 24 hours . The lower extremities are more commonly involved, and the typical pattern is recovery over minutes to days. 4) Describe the management of a pregnant patient (1st trimester and 2nd /3rd trimester) in the setting of electrical injury. For obstetric patients, the overall risk to the fetus is small, but a spontaneous abortion can occur. Secondary trauma may lead to placental abruption. Obstetric consultation and fetal monitoring are essential. 5) How (...) findings / burns (see Question 4) Cardiac Arrest Due to induced VF or asystole Arrhythmias Bradycardia, tachycardia. A fib, ectopy Respiratory arrest Tetanic paralysis of thoracic respiratory muscles Causing apnea CNS: Direct injury to brainstem respiratory centres Seizure disorder Secondary vascular injury (stroke/CVT) from blood vessel injury Vertigo Delayed and chronic manifestations include ascending paralysis, transverse myelitis, and amyotrophic lateral sclerosis. Peripheral neuropathies

2018 CandiEM

182. Anamorelin (Adlumiz) - Anorexia, Cachexia, Non-Small-Cell Lung Carcinoma

in micronuclei in bone marrow erythroblasts clinical signs: 1 dead in 200 mg/kg dose group, clinical adverse effect signs: hunched posture, subdued behavior Carcinogenicity No studies were submitted. Reproduction Toxicity The reproductive and developmental toxicity of anamorelin HCl was evaluated in a fertility and early embryonic development study in rats and embryo-fetal development studies in rats and rabbits. Table 5. Summary of fertility/ early-embryo-fetal development toxicity study in rats Study type (...) / Study ID / GLP Species; Number group Route & dose(mg/k g/day) Dosing period Major findings NOAEL (mg/kg/day) Study No.: 8002-107 Fertility and embryo-fetal development study GLP Sprague Dawley Rat (Crl:CD(SD)) 22/sex/group 0, 15, 30, 60 oral Males: 28 days prior to mating until necropsy Females: 14 days prior to mating and up to day 7 of gestation Control: 1 death 15 mg/kg/d: 1 death = 30 mg/kg: 2 deaths, ?body weight gain, ? body weight, ? food consumption NOAEL reproductive parameters: 60 NOAEL

2017 European Medicines Agency - EPARs

184. Blood and Clots Series: Diagnosing pulmonary embolism in pregnancy

pulmonary embolism in pregnancy? The problem with diagnosing pulmonary embolism in pregnancy is that dyspnea and tachycardia are very common during normal pregnancy, particularly in the third trimester. It’s true that the risk of VTE is higher during pregnancy by 5 to 10 times (with the highest risk in the postpartum period). However, given the low baseline risk of VTE in young women overall (1 in 10,000), the absolute risk of VTE in pregnancy is still not very high. For example, in Canadian (...) the incidence of PE is 5.4 cases per 10,000 pregnancies 1 . Unfortunately, our usual clinical prediction rules (such as the Wells Score for PE) are not applicable to pregnant females because the studies that derived these scores excluded them. The specificity of the Wells criteria is questionable in pregnancy as tachycardia and leg edema are common in normal pregnancy. The ability to assess an “alternative diagnosis” is also difficult in pregnancy 2 .For these reasons, most obstetrical guidelines suggest

2018 CandiEM

185. CRACKCast E178 – Co-Morbird Medical Emergencies During Pregnancy

these conditions balancing risks to both mother and fetus. Shownotes – Key Concepts The physiologic demands of pregnancy may cause previously occult medical conditions to become apparent and known problems to deteriorate rapidly. The physiologic adjustments of pregnancy alter the normal ranges for certain laboratory values. The adjusted values need to be considered in the interpretation of results. The possibility of pregnancy should be considered in the differential diagnosis of certain conditions, including (...) . Certain medical conditions in the mother result in neonatal complications that require special resuscitative measures. This is particularly true of many chemical dependency states, and anticipatory management of these patients is essential. Rosen’s in Perspective The enormous breadth of physical and physiologic changes that occur in pregnancy may overwhelm a woman’s compensatory mechanisms and lead to deterioration of pre-existing disease. This has implications for the mother, the fetus

2018 CandiEM

186. CRACKCast Episode 183 – The Immunocompromised Patient

tachypnea or tachycardia, mental status changes, metabolic acidosis, increased volume requirements, rapid changes in serum glucose or sodium concentration, or acute abdominal pain. In neutropenic cancer patients, most severe infections and almost all instances of bacteremia occur when the neutrophil count is less than 100 cells/mL. In neutropenic patients, the temperature should be measured orally or tympanically, not rectally. In neutropenic cancer patients, pneumonia and anorectal infection are more (...) the respiratory or gastrointestinal tract. Immunoglobulin E (IgE), surface of mast cells and basophils responsible for immediate-type hypersensitivity reactions important in defense against helminthic pathogens. IgG widely distributed in tissues accounts for 75% of the total immunoglobulin mass. It crosses the placenta and provides fetal immunity during the first 6 months of life Congenital or acquired deficiencies of IgG lead to infection with encapsulated organisms Complement complex interaction of 30

2018 CandiEM

187. Neonatal stabilisation for retrieval

service capability · Seek advice: o Contact RSQ o Phone 1300 799 127 Maternal risk · Severe hypertensive disorder · Antepartum haemorrhage · Other care requirements beyond service’s CSCF Fetal risk · Threatened preterm birth · Fetal anomalies · FGR · Multiple pregnancy · Other care requirements beyond service’s CSCF Yes Yes No No CSCF: Clinical services capability framework; FGR: Fetal growth restriction; QCG: Queensland Clinical Guidelines; RSQ: Retrieval Services Queensland Queensland Clinical (...) is not possible contact the Retrieval Service Queensland (RSQ) for advice regarding management prior to the baby’s birth. Early activation of the retrieval team prior to the baby’s birth can be made when indicated. Table 1. Indications for transfer Aspect Comment Antenatal 7,8 · Known congenital anomaly · Multiple birth · Suspected cardiac anomaly · Fetal growth restriction · Preterm labour (as relevant to CSCF) · Placenta praevia · Pre-eclampsia · Prolonged rupture of membranes Neonatal 8,9 · Birth weight: o

2018 Clinical Practice Guidelines Portal

188. CRACKCast E180 – Labor & Delivery

weeks’ gestation, any medical assessment should include the mother and fetus because fetal viability becomes established near that time. False labour (Braxton Hicks contractions) True labour ● Small, uncoordinated uterine contractions ● No escalation of frequency or duration ● No cervical dilation or effacement ● Intact membranes ● Relieved with analgesia, ambulation and change in activity ● Cyclic coordinated contractions ● Escalation of frequency, duration and severity ● Ruptured membranes (...) becomes firmer and rises; the umbilical cord lengthens 5 to 10 cm; or there is a sudden gush of blood. Laceration repair Oxytocin infusion Uterine checks ending with a completely dilated, fully effaced cervix. Ends with the delivery of the baby Ends with placental delivery First hour post delivery Watch for PPH! 3) List 3 techniques for monitoring the fetus. Clinical monitoring External electronic fetal monitoring Ultrasonography Let’s go through them in more detail: Clinical monitoring No real time

2018 CandiEM

189. CRACKCast E177 – Acute Complications of Pregnancy

. Chorioamnionitis is diagnosed by the findings of fever, maternal and fetal tachycardia, and uterine tenderness in a patient past 16 weeks of pregnancy. Patients are usually treated with IV ampicillin and gentamicin. Thyroid Disease Postpartum thyroiditis is characterized by transient hyperthyroidism and/or hypothyroidism in the postpartum period. Confirmation of hypothyroidism is based on an elevated serum TSH level, relying on trimester-specific TSH reference ranges. Hyperthyroidism may be associated (...) has expelled all fetal and placental material, the cervix is closed, and the uterus is contracted (not an ED diagnosis) Other terms: Missed abortion is a relatively obsolete term referring to the clinical failure of uterine growth over time. The terms anembryonic gestation (when no fetus is visualized on ultrasound), first- or second-trimester fetal death (failure to see fetal cardiac activity with at least a 5-mm crown-rump length), and delayed miscarriage are more appropriate. The severity

2018 CandiEM

190. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association (Full text)

account for SCAD presentation in 3% to 11% of reported series. , , , , These reports must be interpreted with care because individuals whose SCAD is not identified or is misdiagnosed, who do not survive to initial evaluation, or in whom coronary imaging or postmortem evaluation is not performed are not included in these studies. Figure 4. Frequency of presenting symptoms of acute spontaneous coronary artery dissection. VF indicates ventricular fibrillation; VT, ventricular tachycardia. Adapted from

2018 American Heart Association PubMed abstract

191. Induced Pluripotent Stem Cells for Cardiovascular Disease Modeling and Precision Medicine: A Scientific Statement From the American Heart Association (Full text)

syndrome type 2 KCNH2 Long-QT syndrome type 3 SCN5A Timothy syndrome CACNA1C Catecholaminergic polymorphic ventricular tachycardia type 1 RYR2 Catecholaminergic polymorphic ventricular tachycardia type 2 CASQ2 Brugada syndrome SCN5A Calcific aortic valve NOTCH1 Williams-Beuren syndrome ELN Familial pulmonary hypertension BMPR2 Familial hypercholesterolemia LDLR , PCSK9 Familial hypobetalipoproteinemia PCSK9 Tangier disease ABCA1 Dyslipidemia SORT1 Maturity-onset diabetes of the young type 2 GCK Insulin (...) rhythm disorder that has proven amenable to modeling with iPSC-CMs is catecholaminergic polymorphic ventricular tachycardia (CPVT). In CPVT, ventricular arrhythmias are triggered by exercise or emotional stresses in the absence of structural heart disease. Although these arrhythmias are often self-resolving, SCD does occur in many CPVT patients. The most common cause of CPVT is autosomal dominant mutations in RYR2 (ryanodine receptor 2), with the next most common being autosomal recessive mutations

2018 American Heart Association PubMed abstract

192. CRACKCast E171 – Pediatric Cardiac Disorders

of Cardiac Disorders in Infants and Children) See Box 170.3 (Key Elements to Elicit in the History of a Child with a Known Cardiac Disorder) Let’s start this sauna-sweat-shop episode with a little anatomy review: Trace the path of the RBC during foetal circulation, and describe the changes that occur following delivery. Oxygen flow: mom’s lungs/body/placenta → umbilical vein → ductus venosus → fetal heart (through IVC) → right atrium → shunted to the left atrium by the patent foramen ovale → left (...) are the main emergency department (ED) treatment of infants and children who present with congestive heart failure (CHF). If vagal maneuvers fail to convert stable paroxysmal supraventricular tachycardia in children, rapid adenosine administration (0.1 mg/kg for the first dose, followed by 0.2 mg/kg on repeated doses) is the treatment of choice. Verapamil should be avoided in children younger than 1 year old because of its profound hypotensive effects. Consider the use of lidocaine instead of amiodarone

2018 CandiEM

195. CRACKCast E165 – Sedative Hypnotics

overdoses, particularly not in regular benzodiazepine users, in whom flumazenil can precipitate seizures. Because flumazenil’s duration of action (about 1 hour) is much shorter than that of all commonly available benzodiazepines, if flumazenil is used patients should be monitored closely for recurrent respiratory depression or re-sedation. Chloral hydrate toxicity may result in sedation and cardiotoxicity, principally in the form of supraventricular tachycardias, which are best treated with a beta (...) and duration of action Only long-acting preparations have anticonvulsant effects in doses that do not cause sedation. Short- and intermediate-acting preparations are almost completely metabolized to inactive metabolites in the liver, whereas 25% of a phenobarbital (long-acting) dose is excreted unchanged through the kidney. Barbiturates cross the placenta with fetal levels approaching those of the mother. They are also excreted in low concentration in breast milk. Use during pregnancy is associated

2018 CandiEM

196. CRACKCast E157 – Iron and Heavy Metals

Clinical Features Mechanism of Toxicity 1 GI 6hr Vomiting, diarrhea, hematemesis, hematochezia Corrosive effect of iron on GI mucosa 2 Latent 6-24hr Resolution of GI sx. Tachycardia, acidosis, altered mental status Ongoing cellular toxicity and organ damage 3 Systemic 12-24hr Return of GI sx, acidosis, leukocytosis, coagulopathy, renal failure, lethargy/coma, CV collapse Iron distributes to the tissues with worsening cellular toxicity and organ damage 4 Hepatic 2-5 days Fulminant hepatic failure (...) of mercury, almost completely in the form of methylmercury. Significant organic mercury exposure causes acute gastrointestinal and respiratory symptoms, followed by neurologic symptoms that include paresthesias (notably around the mouth), malaise, constriction of the visual field, deafness, and ataxia. The fetus is particularly vulnerable . Elemental and inorganic mercury, if present in elevated levels in the urine, are generally treated with a chelator. Wisecracks: 1. List 3 chelating agents for heavy

2018 CandiEM

197. Dinutuximab beta Apeiron - neuroblastoma

processing ECG Electrocardiogram ECHO Echocardiogram EEG Electroencephalogram EFS event-free survival ELISA Enzyme-linked immunosorbent assay EM(E)A European Medicines Agency EOT End of treatment EPC End of Production Cells Assessment Report - Dinutuximab beta Apeiron EMA/263814/2017 Page 5/129 ESI-TOF-MS Electrospray ionisation time-of-flight mass spectrometry FAS Full analysis set FCS Fetal calf serum Fc?R FC gamma receptor FDA Food and Drug Administration G0 Glycan without core fucose and no galactose

2017 European Medicines Agency - EPARs

198. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease (Full text)

systemic venous desaturation. 33,46 The initial symptoms of a high Qp:Qs include tachypnea and tachycardia. The tachy- pnea results from increased pulmonary interstitial ede- ma and poor lung compliance associated with elevated pulmonary venous pressure. The tachycardia represents an attempt to increase cardiac output to meet systemic oxygen requirements. Signs and symptoms of shock develop once a critical reduction of SBF is present. 54 The development of a prearrest state can be herald- ed by lactic

2018 American Heart Association PubMed abstract

199. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association (Full text)

of fetal development, the RV will account for ≈60% of total cardiac output (CO), which provides systemic perfusion via the foramen ovale and the ductus arteriosus. At birth, the LV becomes the dominant systemic ventricle while the RV adapts to provide flow through the pulmonary circulation alone, assuming that the foramen ovale and ductus arteriosus close appropriately. Figure 1. Cardiac embryogenesis. During embryogenesis, the primary heart field is formed by early cardiac progenitor cells

2018 American Heart Association PubMed abstract

200. Management of Neonates Born at ?34 6/7 Weeks’ Gestation With Suspected or Proven Early-Onset Bacterial Sepsis

is complex. EOS primarily begins in utero and was originally described as the “amniotic infection syndrome.” , Among term infants, EOS pathogenesis most commonly develops during labor and involves ascending colonization and infection of the uterine compartment with maternal gastrointestinal and genitourinary flora, with subsequent colonization and invasive infection of the fetus and/or fetal aspiration of infected amniotic fluid. This intrapartum sequence may be responsible for EOS that develops after (...) diagnosis and management. A confirmed diagnosis of IAI is made by a positive result on an amniotic fluid Gram-stain, culture, or placental histopathology. Suspected IAI is diagnosed by maternal intrapartum fever (either a single documented maternal intrapartum temperature of ≥39.0°C or a temperature of 38.0–38.9°C that persists for >30 minutes) and 1 or more of the following: (1) maternal leukocytosis, (2) purulent cervical drainage, and (3) fetal tachycardia. The ACOG recommends that intrapartum

2018 American Academy of Pediatrics

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