Bradycardia
Rapid Review
- Differentials
- Medication/intoxication
- Beta-blocker/Calcium channel blocker
- Central alpha-2 agonists
- Cholinergic agents
- Antiarrhythmics
- Benzodiazepines/alcohol/opiates
- Metabolic
- Hyperkalemia
- Hypermagnesemia
- Hypothyroidism
- Hypothermia
- Hypoglycemia
- Severe hypoxia
- Cardiac
- Myocardial infarction
- Sick sinus syndrome
- Environmental
- Hypothermia
- Medication/intoxication
- History
- Recent excessive ingestion of medications or substances
- Consider toxicologic etiologies
- Hx of renal disease or endocrine related disease
- Consider electrolyte abnormalities
- Hx of cardiac disease
- Consider MI
- Recent excessive ingestion of medications or substances
- Physical Exam
- Altered mental status
- Suggests hemodynamic instability; warrants rapid response
- Pinpoint pupils
- Suggests toxic ingestions
- Signs of pulmonary congestion (rales, B-lines)
- Suggests cardiac failure
- Cushing’s triad (Hypertension, bradycardia, irregular respirations)
- Suggests elevated intracranial pressure
- Altered mental status
- Work-Up
- EKG
- Determine type of bradycardia
- Labs
- CBC, BMP, Troponin, TSH/FT4
- Imaging
- Chest X-ray
- Head CT (if in setting of head injury)
- EKG
Pearls
Deep Dive
Tachycardia
Rapid Review
- Differentials
- Narrow Complex Tachycardia
- Regular
- Sinus tachycardia
- Atrial tachycardia
- AVNRT
- Irregular
- Atrial fibrillation
- Multifocal atrial tachycardia
- Atrial flutter
- Regular
- Wide Complex Tachycardia
- Ventricular tachycardia
- Antidromic AVRT
- LBBB w/ aberrancy
- Accelerated idioventricular rhythm
- Non-cardiac causes
- Fever
- Pericarditis
- MI
- PE
- Asthma/COPD
- Anemia
- Anxiety
- Dehydration
- Electrolyte imbalance
- Pain
- Trauma
- Sympathomimetics
- Narrow Complex Tachycardia
- History
- Hx of arrhythmias
- Consider atrial fibrillation/flutter, PSVT, etc.
- OCP’s, prolonged immobilization, recent trauma/surgery
- Consider PE
- Substance abuse
- Consider cocaine use
- Hx of mental illness
- Consider anxiety/depression as diagnosis of exclusion
- Fever/chills
- Consider sepsis
- Hx of arrhythmias
- Physical Exam
- Hypotension/AMS
- Hemodynamic instability; requires rapid intervention
- Dry mucous membranes
- Suggests dehydration
- Abnormal lung sounds (ex. rales)
- Suggests pulmonary edema; L-sided heart failure
- Chest pain when leaning back
- Suggests pericarditis
- Hypotension/AMS
- Work-Up
- EKG
- Determine type of tachycardia
- Labs
- CBC, BMP, Troponin, TSH/FT4, Urine drug screen
- Imaging
- Chest X-Ray
- EKG
Pearls
Hypotension
Rapid Review
- Differentials
- Distributive
- Sepsis
- Anaphylaxis
- Neurogenic
- Addisonian Crisis
- Cardiogenic
- Arrhythmia
- Myocardial infarction
- Congestive Heart Failure
- Obstructive
- Cardiac tamponade
- Tension Pneumothorax
- Pulmonary Embolism
- Hypovolemic
- Hemorrhage
- Dehydration
- Neurogenic
- Spinal cord injury
- Distributive
- History
- Chest pain or dyspnea on exertion
- Consider cardiogenic shock
- Recent viral/bacterial illness
- Consider septic shock
- Allergies
- Consider anaphylaxis
- Recent injury
- Consider hemorrhagic or neurogenic shock
- Hx of endocrine conditions
- Consider adrenal insufficiency
- Chest pain or dyspnea on exertion
- Physical Exam
- Signs of trauma
- Suggests hemorrhagic shock
- Beck’s triad (muffled heart tones, JVD, hypotension)
- Suggests cardiac tamponade
- Urticaria or angioedema
- Suggests anaphylactic shock
- Diminished breath sounds unilaterally, JVD, tracheal deviation
- Suggests tension pneumothorax
- Dry mucous membranes
- Suggests dehydration
- Signs of trauma
- Work-Up
- EKG
- Labs
- CBC, CMP, hCG, blood cultures, UA, ABG
- lactate, troponin, type and cross
- Imaging
- Ultrasound (RUSH exam)
- CXR
- CT (Head, chest, abdomen)
Pearls
Hypertension
Rapid Review
- Differentials
- Neurological
- Hypertensive encephalopathy
- Ischemic/hemorrhagic stroke
- Cardiac
- CHF
- ACS
- Aortic dissection
- Pulmonary
- Pulmonary edema
- Renal
- Renal artery stenosis
- Nephritic/Nephrotic syndrome
- Endocrine
- Hyperthyroidism
- Hyperaldosteronism
- Cushing’s syndrome
- Toxicological
- Sympathomimetic ingestion (cocaine)
- Obstetric
- Pre-eclampsia/eclampsia
- Neurological
- History
- History of heart disease
- Consider ACS/CHF
- History of endocrine disease
- Consider hyperthyroidism or hyperaldosteronism
- Using blood pressure medications
- Consider lack of adherence
- Pregnant
- Consider (pre)-eclampsia
- History of heart disease
- Physical Exam
- Presence of end-organ damage (AMS, AKI, pulmonary edema, MI)
- Indicates hypertensive emergency; warrants rapid intervention
- Abnormal lung sounds (rales, wheezing)
- Suggests L-sided heart failure
- JVD, peripheral edema
- Suggest R-sided heart failure
- Neurological deficits (facial droop, hemiplegia, etc.)
- Suggests CVA
- Presence of end-organ damage (AMS, AKI, pulmonary edema, MI)
- Work-Up
- EKG
- Labs
- CBC, BMP, troponin, BNP, UA
- Imaging
- CXR
- Head CT
Pearls
Hypothermia
Rapid Review
- Differentials
- Decreased heat production
- Hypothyroidism
- Adrenal insufficiency
- Hypopituitarism
- Nutritional deficiencies
- Increased heat loss
- Burns (loss of skin insulation)
- Cold water immersion
- Cold/freezing weather
- Trauma
- Sepsis
- Decreased heat production
- History
- Prolonged cold weather exposure
- May have frostbitten extremities
- Alcohol/drug use
- May induce vasodilation, precipitating heat loss
- History of endocrine disorders
- Consider hypothyroidism or adrenal insufficiency
- Homeless
- Consult social work/case management prior to discharge
- Prolonged cold weather exposure
- Physical Exam
- Mild hypothermia (90 – 95 degrees F)
- Tachycardia, shivering, impaired cognition
- Moderate hypothermia (82.4 – 90 degrees F)
- Bradycardia, hypertension, stupor, sluggish reflexes
- Severe hypothermia (< 82.4 degrees F)
- Unresponsive, ventricular dysrhythmia, marked hypotension
- Mild hypothermia (90 – 95 degrees F)
- Work-up
- EKG
- Identify ventricular arrhythmias
- May see Osborn waves at temperatures < 89 degrees F
- Labs
- CBC, BMP, fingerstick glucose, toxicology screen
- Imaging
- CXR
- Pneumonia is a common complication
- CXR
- EKG
Pearls
Deep Dive
Fever
Rapid Review
- Differentials
- Infectious
- Meningitis
- Pneumonia
- UTI
- Skin/Soft-tissue infection
- Osteomyelitis
- Influenza
- Gastroenteritis
- Cholecystitis
- Pancreatitis
- Toxicological
- Sympathomimetics
- Anticholinergics
- Alcohol withdrawal
- Serotonin syndrome
- Neuroleptic Malignant Syndrome
- Endocrine
- Thyroid storm
- Pheochromocytoma
- Diabetic Ketoacidosis
- Neurologic
- Status epilepticus
- Stroke
- Environmental
- Heat exhaustion
- Heat Stroke
- Infectious
- History
- Respiratory symptoms
- Consider influenza, COVID-19, pneumonia
- GI symptoms
- Consider gastroenteritis
- History of thyroid disease or diabetes
- Consider endocrine etiology
- Recent physical activity or environmental exposure
- Consider heat injury
- Recent ingestions of new or excessive medications
- Consider sympathomimetics, serotonin syndrome, etc.
- Urinary symptoms
- Consider UTI or pyelonephritis
- Respiratory symptoms
- Physical Exam
- Abnormal lung exam
- Suggests pulmonary infections
- Tender abdomen
- Consider pancreatitis, appendicitis, cholecystitis, etc.
- (+) Kernig’s or (+)Brudzinski sign
- Suggests meningitis
- Exophthalmos
- Suggests hyperthyroidism
- Abnormal lung exam
- Work-Up
- Labs
- CBC, CMP, Lactate, Urinalysis, Blood cultures, CK
- Imaging
- Chest X-Ray
- RUQ Ultrasound
- Labs
Pearls
Physician assistant graduate from Duke University (Class of 2022). Army National Guard Medic. Former paramedic. Devoted to learning and sharing evidence-based medicine.