Topics in this EM Quick Hits podcast

Anand Swaminathan on GI balloon tamponade preparation and indications (1:30)

Jesse McLaren on why troponin is rarely useful in SVT (8:45)

Christina Shenvi on why we should not use the term “mechanical fall” in older patients (15:25)

Nour Khatib & Jonathan Wallace on rural vertical vertigo case (25:24)

Reuben Strayer on VAFEI – Video-Assisted Flexible Endoscopic Intubation (32:56)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Reuben Strayer & Anton Helman

Cite this podcast as: Helman, A. Swaminathan, A. McLaren, J. Shenvi, C. Khatib, N. Wallace, J. Strayer, R. EM Quick Hits 40 – GI Balloon Tamponade, SVT and Troponin, Falls in Older Patients, Vertical Vertigo, VAFEI Airway. July, 2022. https://emergencymedicinecases.com/em-quick-hits-july-2022/. Accessed August 10, 2022.

GI balloon tamponade preparation and indications

  • Employ mental preparation with deliberate practice well before the procedure
  • If your ED does not have a GI balloon tamponade kit with all the necessary gear, consider getting involved in creating one for your ED
  • Airway control is usually necessary before placing the GI balloon
  • Potential indications for placing GI balloon tamponade before the patient decompensates include:
    • Recurrent hemodynamic instability
    • Activation of massive transfusion
    • Recurrent or active hematemesis
    • Delay to endoscopy

Overview of Linton, Blakemore and Minnesota GI tube video

Placement of Blakemore tube video

Placement of Minnesota tube video

Placement of Linton tube video

  1. Bridwell RE, Long B, Ramzy M, Gottlieb M. Balloon Tamponade for the Management of Gastrointestinal Bleeding. J Emerg Med. 2022 Apr;62(4):545-558.
  2. Morgenstern, J. Balloon tamponade of GI bleeding, First10EM, May 23, 2016. Available at:
    https://doi.org/10.51684/FIRS.2147

Is there any value in troponin for SVT?

  • Evidence suggests that troponin testing in patients with paroxysmal SVT who present to the ED with an episode of SVT does not improve outcomes and may increase length of stay, admission rates and increase potentially harmful downstream testing
  • The palpitations and chest pain in patients with SVT are rarely symptoms of ACS
  • ST depression in multiple ECG leads is common in SVT and is thought to be rate related/demand ischemia unless it persists after cardioversion; when the ST depression resolves after cardioversion this confirms the diagnosis of SVT and essentially rules out ACS as a cause of ST depression
  • The pathophysiology of SVT is sufficient to explain a bump in troponin without the presence of CAD
  • The prognosis of SVT is not significantly changed with an elevated troponin level compared to a normal troponin level

  1. Allen R, deSouza IS. Troponin Testing in Patients With Supraventricular Tachycardia—Are We Overtesting? A Teachable MomentJAMA Intern Med. 2021;181(6):842–843.
  2. Ben Yedder N, Roux JF, Paredes FA. Troponin elevation in supraventricular tachycardia: primary dependence on heart rate. Can J Cardiol. 2011 Jan-Feb;27(1):105-9. doi: 10.1016/j.cjca.2010.12.004.
  3. Chow GV, Hirsch GA, Spragg DD, Cai JX, Cheng A, Ziegelstein RC, Marine JE. Prognostic significance of cardiac troponin I levels in hospitalized patients presenting with supraventricular tachycardia. Medicine (Baltimore). 2010 May;89(3):141-148.
  4. Ghersin I, Zahran M, Azzam ZS, Suleiman M, Bahouth F. Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias. J Electrocardiol. 2020 Sep-Oct;62:200-203.
  5. Carlberg DJ, Tsuchitani S, Barlotta KS, Brady WJ. Serum troponin testing in patients with paroxysmal supraventricular tachycardia: outcome after ED care. Am J Emerg Med. 2011 Jun;29(5):545-8.

Why should we abandon the term “mechanical fall” in older patients

  • Falls are the leading cause of trauma related admissions and mortality in older adults
  • One approach to falls in older patients is to consider what happened before, during and after the fall which will help assess for acute medical illnesses and injuries as a result of the fall
  • After ruling out acute medical events related to falls (eg. stroke, syncope, seizure, volume depletion, GI bleed etc), rather than attributing falls in older patients to whatever mechanical stimulus that might have been present at the time of the fall, it behooves the ED doc to identify and address the potential long standing underlying causes/falls risk factors such as: polypharmacy, cognitive impairment, visual/hearing deficits, postural hypotension, poor muscular tone, to help prevent future falls
  • Consider referrals to physiotherapy/occupational therapy, geriatric medicine for further assessment of the above issues
  • A gait test (there are multiple validated ones such as ‘Timed up and go‘) is essential in older patients who present to the ED after a fall to help in disposition decisions
  • The term “mechanical fall” minimizes the importance of addressing the contributing factors to falls in older adults; consider, instead, “multi-factorial ground level fall” or “non-syncopal fall”

  1. Goldberg EM, Marks SJ, Ilegbusi A, Resnik L, Strauss DH, Merchant RC. GAPcare: The Geriatric Acute and Post-Acute Fall Prevention Intervention in the Emergency Department: Preliminary Data. J Am Geriatr Soc. 2020 Jan;68(1):198-206. doi: 10.1111/jgs.16210. Epub 2019 Oct 17.
  2. Goldberg EM, Marks SJ, Resnik LJ, Long S, Mellott H, Merchant RC. 2020. Can an Emergency Department–Initiated Intervention Prevent Subsequent Falls and Health Care Use in Older Adults? A Randomized Controlled Trial. Annals of Emergency Medicine. 76(6):739–750.

Can vertical vertigo be from a peripheral cause?

  • Vertical vertigo (patient reports their visual environment moving in the vertical plane) and nystagmus have traditionally been associated with a central cause of vertigo, however vertical vertigo may have a peripheral cause such as BPPV of the posterior canal

Dr. Walter Himmel’s summary of vertigo talk from EMU 2017

  1. Ibekwe TS, Rogers C. Clinical evaluation of posterior canal benign paroxysmal positional vertigo. Niger Med J. 2012 Apr;53(2):94-101.
  2. Ohle R et al. Can Emergency Physicians Accurately Rule Out a Central Cause of Vertigo Using the HINTS Examination? A Systematic Review and Meta-analysis. AEM 2020.

VAFEI – Video-Assisted Flexible Endoscopic Intubation

  • Video-assisted flexible endoscopic intubation is a powerful two-operator airway technique that will allow relatively straightforward intubation of patients with very difficult anatomy by taking advantage of the strengths of video laryngoscopy and flexible endoscopy while diminishing their drawbacks
  • VAFEI can be incorporated into a breathing intubation approach such as topicalized awake or ketamine only but can also be performed quickly enough to be used with paralysis and RSI
  • Especially useful when combined with hyperangulated geometry blades
  • Consider VAFEI in the patient with challenging anatomy and as a rescue technique when video laryngoscope (VL) has failed due to difficulty with tube delivery

VAFEI

Six Steps of VAFEI:

  1. VL operator performs laryngoscopy as usual to obtain an adequate view (or, if difficult anatomy prevents an adequate view, obtain best possible view)
  2. VL operator, maintaining the laryngoscope position with their left hand, readies suction in right hand, in preparation for flexible endoscopy
  3. Flexible endoscopy operator looks in mouth, places the endoscope in the patient’s mouth and advances the endoscope to the end of the VL blade under direct visualization
  4. Endoscope operator looks at VL screen to guide the endoscope to the vocal cords and advances the scope through the cords, usually looking at the VL screen but, occasionally, if really difficult anatomy, the VL screen view may be inadequate, in which case the scope can be guided to and through the cords while looking at the flexible endoscope screen
  5. Once the scope is through the cords, the endoscopy operator looks at the endoscope screen to advance the scope down to above the carina
  6. Endoscopist or an assistant railroads the preloaded ETT to just above the carina, at which point the endoscope is removed, the ETT is attached to ventilation with capnography to confirm placement

 

  1. Mazzinari G, Rovira L, Henao L, Ortega J, Casasempere A, Fernandez Y, Acosta M, Belaouchi M, Esparza-Miñana JM. Effect of Dynamic Versus Stylet-Guided Intubation on First-Attempt Success in Difficult Airways Undergoing Glidescope Laryngoscopy: A Randomized Controlled Trial. Anesth Analg. 2019 Jun;128(6):1264-1271. doi: 10.1213/ANE.0000000000004102. Erratum in: Anesth Analg. 2019 Oct;129(4):e141.
  2. Airway Choices in the Era of Many Choices from EM Updates https://emupdates.com/choices/

None of the authors have any conflicts of interest to declare