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Valsalva Maneuver

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122. CRACKCast E171 – Pediatric Cardiac Disorders

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 (...) ) ● HR < 180 (children) ● Variable beat-to-beat ● HR changes with activity Mgmt ● See next question! Treat the underlying cause Trial of analgesia, fluids and antiemetics [10] Describe the management of SVT in the infant/child. Unstable (poor perfusion, AMS, long cap refill, pallor, cyanosis, hypotension) CARDIOVERSION! 5 – 1 J/kg; if no success then increase to 2 J/kg Stable Vagal attempts Vagal maneuvers (eg, a bag containing a slurry of crushed ice and water to the face, digital rectal exam

2018 CandiEM

123. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease

further sympathetic activation in a harm- ful feedback loop. 46,54,55 Manipulation of PVR. If the shunt is inadequately restrictive, maneuvers to increase PVR by manipulat- ing ventilation and gas exchange might not be well tolerated and could contribute to further deterioration and even cardiac arrest. In the period before single- ventricle palliation, cautious use of a hypoxic inspired gas mixture or inspired carbon dioxide with controlled hypoventilation can reduce Qp:Qs 56–59 ; however, a hypoxic (...) ) admin- istration of vasoactive agents to maximize shunt per- fusion pressure (eg, phenylephrine, norepinephrine, epinephrine); (3) anticoagulation with heparin (50–100 U/kg bolus) to prevent clot propagation 22,24 ; (4) shunt intervention by catheterization or surgery; and (5) sta- bilization with ECLS. In patients with shunt obstruc- tion, maneuvers to decrease PVR (eg, oxygen, inhaled nitric oxide [iNO]) will provide little benefit and could delay the diagnosis of the actual problem. Reduction

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2018 American Heart Association

124. Evaluation and Management of Right-Sided Heart Failure: A Scientific Statement From the American Heart Association

to generate sequential PV loops obtained by a decrease of venous return via stepwise inflation of an inferior vena cava balloon or a Valsalva maneuver. Reprinted from Guazzi and Naeije with permission from Elsevier. Copyright © 2017, Elsevier. Unlike the predominantly diastolic coronary flow of the LV, normal RV coronary perfusion occurs during both systole and diastole. The pressure-overloaded RV is at increased risk for developing ischemia as a result of decreased perfusion pressure in the setting

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2018 American Heart Association

125. CRACKCast E143 – Diving Injuries and Dysbarism

compression limits **most common complaint of scuba divers** – 10-30% experience this Most divers attempt to stent the Eustachian Tube open, but if it collapses – symptoms of tinnitus, vertigo develop Damage to the cochleovestibular apparatus. If the diver is unable to equalize the pressure in the middle ear during descent – the pressure is transmitted to the perilymph of the cochlea If it suddenly equilibrates with a valsalva can lead to inner ear hemorrhage or labyrinthine window tear. Due (...) , positional vertigo, ataxia, vomiting. PERSISTENT symptoms: +ve rhomberg, persistent hearing loss Nystagmus, emesis, TM injury, nausea Usually self limited. Descent Descent “Difficulty equilibrating or tried performing a vigorous valsalva” At depth OR During ascent Ascent – or soon after surfacing *diver approached decompression limits; onset on ascent or soon after; other neurological symptoms” ***IEBT may be nearly impossible to distinguish from DCS Type II – and should not delay decompression

2018 CandiEM

126. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association

colitis, polyarteritis nodosa, sarcoidosis, Churg-Strauss syndrome, Wegener granulomatosis, rheumatoid arthritis, Kawasaki disease, celiac disease Migraine headache NR Coronary artery spasm NR Precipitating factors >50% Patients recall a precipitating factor Intense exercise (isometric or aerobic) Intense Valsalva Retching, vomiting, bowel movement, coughing, lifting heavy objects Intense emotional stress Labor and delivery Recreational drugs (cocaine, methamphetamines) Exogenous hormones/hormone

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2018 American Heart Association

127. Adults With Congenital Heart Disease

of this, it is generally believed that prophylactic root replacement strategies based on sinus of Valsalva diameters can be less aggressive after a Ross procedure than in a native BAV patient, but practice patterns vary. Most patients with a Ross repair had underlying congenitally abnormal aortic valves (BAV or unicuspid aortic valve) and, therefore, are at risk of the ascending aortic dilation typical of those abnormalities. Thus, in addition to the dilation at the sinuses of Valsalva associated with the Ross repair

2018 American College of Cardiology

128. Postmenopausal Subacute or Chronic Pelvic Pain

in the setting of pelvic congestion. When pelvic venous disorders are suspected clinically, color and spectral Doppler evaluation may be used to document engorged periuterine and periovarian veins ( =8 mm), low-velocity flow, altered flow with Valsalva maneuver, retrograde (caudal) flow of the ovarian veins, and direct connection between engorged pelvic veins and myometrial arcuate veins [9-11]. Increased pelvic vascularity may also be present in the setting of uterine or tubo-ovarian neoplasia

2018 American College of Radiology

130. Evaluation and Management of Right-Sided Heart Failure

drawn from the end-systolic to end-diastolic PV relationship (to end-diastolic volume [EDV] at P=0). The relationship of these 2 parameters (Ees:Ea) provides a ratio defining RV-PA coupling, which reflects contractility in the context of afterload. Determinations of Ees and Ea require instantaneous measurements of RV pressure and volume to generate sequential PV loops obtained by a decrease of venous return via stepwise inflation of an inferior vena cava balloon or a Valsalva maneuver. Reprinted

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2018 International Society for Heart and Lung Transplantation

131. Adult Urodynamics

Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing. ( Recommendation ; Evidence Strength: Grade C ) × Discussion Patients who do not demonstrate SUI during Valsalva maneuvers or cough during urodynamics but who nevertheless complain of SUI symptoms or in whom SUI is suspected based on their history or in whom the presence of documented SUI would (...) inclusion of all possibly relevant studies. Multiple reports on the same patient group were carefully examined to ensure inclusion of only non-redundant information. Urodynamic Tests, Conditions and Outcomes Reviewed During this Process . This systematic review evaluated the following urodynamic tests: post-void residual, uroflowmetry, cystometry, pressure-flow studies, videourodynamics, EMG, urethral function tests (e.g., Valsalva leak point pressure (VLPP), urethral pressure profile) or any

2018 American Urological Association

132. An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome

support accounts for 7% to 17% of TRA PCI failures, , but this is less relevant as operator experience increases. For the left coronary artery, most operators prefer the extra backup single-curve guide catheters they usually use with TFA (eg, EBU, XB, Voda). These catheters offer passive backup support from the contralateral sinus of Valsalva and provide deep-seating capability. Alternatively, Amplatz left (1 or 2) catheters also can provide excellent passive backup support and may be preferred

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2018 American Heart Association

133. CRACKCast E175 – Neurologic Disorders

history! REMEMBER: Red Flags History of head trauma Symptoms of increased ICP – Valsalva/cough/strain Awakening from sleep Chronic progressive h/a Headache on awakening Occipital h/a No family headache of migraines [11] With regards to presentation and management, how are migraines different in children? ANSWER: Pediatric migraine headaches are more commonly bilateral Atypical or migraine variants are more common in children: Hemiplegic migraine Ophthalmoplegic migraine Basilar migraine “Alice (...) positional vertigo is rare in children,but can occur spontaneously as well as after trauma. The earliest age at which it has been reported is 11 years. It is believed to be due to otoliths that have moved out of their normal positions in the utricle and is corrected by canalith repositioning maneuvers (e.g., Epley maneuver). Ménière’s disease, a syndrome with a combination of vertigo, fluctuating hearing loss, and tinnitus, is responsible for 1.5% to 4% of cases of pediatric vertigo. Vestibular

2018 CandiEM

134. Neuro-urology

prospective mortality study in the spinal cord injured patient: comparison with the long-term living paraplegic. J Urol, 1977. 117: 486. 143. Rodrigues, P., et al. Involuntary detrusor contraction is a frequent finding in patients with recurrent urinary tract infections. Urol Int, 2014. 93: 67. 144. Bauer, S.B. Neurogenic bladder: etiology and assessment. Pediatr Nephrol, 2008. 23: 541. 145. Barbalias, G.A., et al. Critical evaluation of the Crede maneuver: a urodynamic study of 207 patients. J Urol, 1983 (...) . 130: 720. 146. Reinberg, Y., et al. Renal rupture after the Crede maneuver. J Pediatr, 1994. 124: 279. 147. Wyndaele, J.J., et al. Neurologic urinary incontinence. Neurourol Urodyn, 2010. 29: 159. 148. Menon, E.B., et al. Bladder training in patients with spinal cord injury. Urology, 1992. 40: 425. 149. Furusawa, K., et al. Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. Spinal Cord, 2011. 49: 49

2018 European Association of Urology

135. CRACKCast E103 – Headache Disorders

, pregnancy, immunocompromised state including HIV) Neurologic symptoms or abnormal signs (eg, confusion, impaired alertness or consciousness, papilledema, focal neurologic symptoms or signs, meningismus, or seizures) Onset is new (particularly for age >40 years) or sudden (eg, “thunderclap”) Other associated conditions or features (eg, head trauma, illicit drug use, or toxic exposure; headache awakens from sleep, is worse with Valsalva maneuvers, or is precipitated by cough, exertion, or sexual activity (...) strategy for SAH Coles notes version: Think about the dx Get a non-contrast CT head Do an LP in CT negative patients if SAH is still suspected. If > 100 RBCs in tube 4 get a CT angiogram to hunt for any aneurysms. Now for more detail…. Clinical features: Thunderclap h/a, kaboom, WHOML – 80% of people Exertional onset h/a – 20% Valsalva Sex Non-strenuous physical activity *peaking intensity in seconds to minutes* – pearl Associated symptoms: N/V Syncope Neck stiffness Photophobia Seizures Physical exam

2017 CandiEM

136. Headache ? Child

with syringohydromyelia) or headache worsened by the Valsalva ACR Appropriateness Criteria ® 8 Headache — Child maneuver are typical findings. Most literature agrees that occipital headache in children is rare and calls for diagnostic caution; however, isolated occipital and cervical pain are not characteristic symptoms of any headache group in the pediatric age group, and their presence or absence does not correspond to changes on conventional brain MRI [37]. Children with sickle cell anemia are a special subgroup

2017 American College of Radiology

138. Management of Pregnancy in Patients With Complex Congenital Heart Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

, cautious incremental dosing is advised, especially in gravidas whose maternal cardiac output is sensitive to falls in preload. The pelvic descent of the fetus in the second stage of labor elicits pressure and an urge to bear down against a closed glottis in a gravida without effective epidural anesthesia. When performed in the absence of contractions or between contractions, the Valsalva maneuver typically elicits a moderate transient fall in cardiac output resulting from decreased venous return (...) . Minimizing maternal expulsive effort by passive delivery and facilitating the second stage by assisted delivery (forceps or vacuum extraction) to avoid the Valsalva maneuver and thereby minimize hemodynamic perturbations should be considered in those with critical obstructive lesions (eg, aortic stenosis [AS]), fragile aortas (bicuspid aortic valve with aortopathy, coarctation), and pulmonary hypertension. Postpartum Further challenges to maternal cardiac reserve occur at delivery, that result from

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2017 American Heart Association

139. SCAI/HFSA Clinical Expert Consensus Document on the Use of Invasive Hemodynamics for the Diagnosis and Management of Cardiovascular Disease

be an alternative provocative maneuver. However, direct comparative studies have revealed that in patients with heart failure, increases in cardiac filling pressures are nearly Twofold higher with exercise compared with saline loading alone, indicating that exercise is the more sensitive (and clinically relevant) provocative maneuver. Figure 8 Exercise‐induced changes in LV filling pressures in patients with heart failure and normal EF. Patients with normal EF and exertional dyspnea displayed normal ventricular (...) of the aortic pulse pressure on provocation (e.g., post‐ectopic beat, Valsalva strain, amyl nitrate inhalation, or isoproterenol administration). Significant LVOT obstruction is defined as >30 mm Hg, with >50 mm Hg commonly required to proceed with surgical therapies for relief of obstruction - . Shock and Ventricular Assist Devices In the setting of decompensated heart failure or cardiogenic shock, LV contractility (i.e., Ees) and SV are reduced, whereas LV end‐diastolic volume (LVEDV) and Ea are increased

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2017 Society for Cardiovascular Angiography and Interventions

140. AIUM Practice Parameter for the Performance of a Transcranial Doppler Ultrasound Examination for Adults and Children

. For ? ?detection ? ?of ? ?right-to-left ? ?shunts, ? ?TCD ? ?monitoring ? ?is ? ?performed ? ?during ? ?the ? ?intravenous injection ? ?of ? ?agitated ? ?saline ? ?or ? ?a ? ?contrast ? ?medium ? ?and ? ?patient ? ?performance ? ?of ? ?a ? ?Valsalva maneuver ? ?to ? ?enhance ? ?flow ? ?across ? ?the ? ?shunt. ? ?The ? ?degree ? ?of ? ?shunting ? ?is ? ?quantitatively ? ?assessed by ? ?the ? ?number ? ?of ? ?detected ? ?HITS. ? 56 VI. Documentation Adequate ? ?documentation ? ?is ? ?essential ? ?for ? ?high

2017 American Institute of Ultrasound in Medicine

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