SQTS - short QT syndrome

As you you know, I read EKG' on the side ( and any interesting tracings send them my way, please). I read an EKG fir the first time the other day with Short QT < 360 ms . I was aware SQTS is an arrhythmogenic disease associated with paroxysmal atrial and ventricular fibrillation, syncope and sudden cardiac death.
What I didn't know is that the the first one to describe this syndrome is Preben Bjerregaard , originally from Denmark, but moved to the USA in 1989 ( Professor at Washington University in St Louis, Mo until 2012) and discovered the syndrome in 1999.
His website is quite interesting. also there is a nice summary on Life in the Fast Lane.
It is still considered quite rare, but then was amyloid also 50 years ago. The more dangerous genotypes are the ones associate with QT of <320 and <340 ms, respectively.

Therapy is an ICD, but has a lotof problems with over sensing of the large T -wave. Type Ia drugs appear promising therapies

Be on the look-out ! Let me know if you find a tracing 💫

• QTc intervals < 330 ms in males or < 340 ms in females should be considered diagnostic of SQTS
• QTc intervals < 360 ms in males or < 370 ms in females should only be considered diagnostic of SQTS when supported by symptoms or family history

Pain Management in the ICU

Refer to the following  analgo-sedation protocol (PDF) from The London Science Centre

Burnout in HealthCare

Presented by Dr Srinivasan, CMO- Advanced ICU Care

2019 ESC Guidelines for Acute Pulmonary Embolism

The following are key points to remember from the 2019 European Society of Cardiology (ESC) and European Respiratory Society (ERS) Guidelines for the Diagnosis and Management of Acute Pulmonary Embolism (PE):

1. D-dimer cut-offs should be adjusted to age and pretest probability rather than fixed values.
2. Terminology such as “provoked” vs. “unprovoked” PE/venous thromboembolism (VTE) is no longer supported by the guidelines; instead they propose using terms like “reversible risk factor,” “any persistent risk factor,” or “no identifiable risk factor.”
3. A revised risk-adjusted management algorithm is proposed accounting for clinical severity, right ventricular dysfunction, and other comorbidities with emphasis on multidisciplinary teams (Class IIa) and early PE risk stratification.
4. Hemodynamic instability is now clearly defined as presence of cardiac arrest needing resuscitation or obstructive shock or persistent hypotension not caused by other pathologies.
5. Rescue intravenous (IV) thrombolysis is now a Class I recommendation (previously Class IIa), and interventional thrombus removing therapy (catheter-based or surgical) is now a Class IIa (previously Class IIb) recommendation in hemodynamically deteriorating PE.
6. Direct oral anticoagulants (DOACs) are now recommended as first choice anticoagulants over warfarin even in those who are warfarin eligible.
7. A reduced dose of apixaban or rivaroxaban for extended anticoagulation should be considered after the first 6 months of treatment.
8. Edoxaban or rivaroxaban should be considered as an alternative to low molecular weight heparin in patients with cancer, with caution in gastrointestinal cancer due to the increased bleeding risk with DOACs.
9. A dedicated diagnostic algorithm is proposed for suspected PE in pregnancy. Using D-dimer and other clinical prediction rules to rule out PE during pregnancy is now Class IIa recommendation (previously Class IIb). DOACs are not recommended in pregnancy (Class III).
10. Routine follow-up with an integrated inpatient-outpatient care delivery model 3-6 months after as well as referring symptomatic patients with mismatched perfusion defects (on V/Q scan) >3 months post-PE to an expert chronic thromboembolic pulmonary hypertension center is a Class I recommendation.

A Rare Disease Process

Vaping Webinar SCCM

"Unpublished on You Tube" only available via above Link. 

Vaping follow- up Webinar

ACS and Atrial Fibrillation and Triple Anti-coagulation Therapy

The above video is an important clinical topic. We have now much more date on D(N)OAC therapy in patients with combined ACS and Afib. Knowledge of the guidelines, although soon to change is important for safe practice in this population. The first slide shown is very interesting and something that was totally unknown during my postgraduate training: anticoagulation and antiplatelet pathways are intimately connected. An example is the effect of thrombin on PAR receptors and platelet activity. Choice, duration  and combination of treatment are presented in this excellent webinar.

The below webinar is probably of less significance to the Intensivist, but again compared to how we used TEE 10 years ago is somewhat baffling.The presented guidelines for use of TEE are helpful.