1. Treat possible underlying cause if known 

2. Atropine
   •  Class 2a treatment
   • Dose 0.5 mg IV every 3-5 minutes, up to total dose 3 mg 
   • Can produce paradoxical worsening bradycardia 
   • Less effective in patients with cardiac transplant 
   • Skip if unstable, move directly to pacing 

3. Transcutaneous pacing  
   • Class 1a recommendation
   • Place pads in anterior lateral or anterior posterior position 
   • Consider sedation or pain control  
   • Set monitor to “Pacer” 
   • Set rate, usually around 60 bpm 
   • Start current at 0 mA and slowly increase until capture is obtained. Consider different placement of pads if capture not achieved by 130 mA 
   • Confirm capture by feeling pulse or cardiac ultrasound 
   • Transcutaneous pacing is ultimately a bridge to transvenous pacing or permanent pacemaker – discuss with cardiology or transfer to center with these capabilities  
   • Capture (pictured below) shows pacer spike followed by a wide QRS and then ST and/or T wave  

References: 

1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 

2. Doukky R, Bargout R, Kelly RF, Calvin JE. Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications. J Crit Illn. 2003 May;18(5):219-225. PMID: 30774278; PMCID: PMC6376978. 

3. Holger J S, Lamon R P, and Minnigan H J et al.: Use of ultrasound to determine ventricular capture in transcutaneous pacing. Am J Emerg Med.  2003; 21: 227 

Other Considerations:

• Hypoxia
• Infiltrative Disorders (Amyloidosis, Sarcoidosis, Hemochromatosis)
• Autoimmune disorders (SLE)
  

References: 

1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 

2. Briggs, Blake & Husain, Iltifat. (2024, Jan 16) Bradycardia: “But my Apple Watch…?” (208). Emergency Medicine Board Bombs. 

While most cases of measles are mild and will self-resolve, the high infectivity of the virus is a public health hazard due to rare complications of the disease that can cause long-term morbidity and mortality. Particularly high risk populations include unvaccinated individuals, children < 5 years, adults > 20, pregnant women, and immunocompromised patients.  

Look forward to part 2 for more details on measles management, treatment, and complications! 

References: 

https://www.nj.gov/health/cd/topics/measles.shtml

https://www.cdc.gov/measles/hcp/index.html

Takhar SS, Moran GJ. Serious Viral Infections. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Nguyen M, Dunn AL. Rashes in Infants and Children. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020. 

Use these medications for aggressive blood pressure control

Load patients with magnesium early

Ultimate treatment is delivery – involve OB/NICU teams early, transfer patients if these teams are not available

Referneces:

• Episode 113.0 – Preeclampsia + Eclampsia – Core EM
• Preeclampsia and Eclampsia – Core EM
• Pre-eclampsia and Eclampsia • LITFL • CCC Obstetrics 
• Eclampsia • LITFL • CCC Obstetrics 
• ED Management of Severe Preeclampsia — EM Curious
• ACOG PRACTICE BULLETIN
• Pre-eclampsia – The Lancet
• Preeclampsia pathophysiology and adverse outcomes during pregnancy and postpartum – PMC
• Maternal Hemorrhage and Severe Hypertension/Pre-eclampsia: Identification and Management in the Emergency Department 

References:

1. Shakur H, Elbourne D, Gülmezoglu M, et al. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010;11:40. doi:10.1186/1745-6215-11-40.

2. American College of Obstetricians and Gynecologists (ACOG). Postpartum hemorrhage: ACOG practice bulletin no. 183. Obstet Gynecol. 2017;130:168-186.

The Basics

• On average, approximately 1300 Americans die of hypothermia each year 
• These don’t all occur in cold mountain regions. Homelessness, mental illness and substance abuse are important risk factors, particularly in urban areas. 
• Not all hypothermia cases are related to exposure! Other causes include hypoglycemia, hypothyroidism, hypoadrenalism, hypopituitarism, CNS dysfunction, drug intoxication, sepsis and dermal disease 
• Hypothermia = core body temperature < 35 degrees C (95 degrees F) 
• Mild hypothermia (32-35 degrees C): present with shivering, tachycardia, tachypnea and hypertension 
• < 32 degrees C: shivering stops and HR and BP decrease; patients become confused, lethargic and then comatose; Reflexes are lost, RR increases; bronchorrea occurs; aspiration is common; cold diuresis and hemoconcentration occur 
• As temp lowers, sinus bradycardia develops into atrial fibrillation with slow ventricular response to ventricular fibrillation to asystole. At temps < 30 degrees C, the risk for dysrhythmias increases

Rewarming and Management

• Type of rewarming is based on cardiovascular status, NOT temperature 
• Passive rewarming: removal from cold environment and wet clothes, insulation 
• Active external rewarming: warm water immersion, heating blankets set at 40 degrees C, radiant heat, forced air 
• Active core rewarming at 40 degrees C: Inhalation rewarming (warm air via the vent), heated IV fluids, GI tract lavage, bladder lavage, peritoneal lavage, pleural lavage, extracorporeal rewarming, mediastinal lavage by thoracotomy 
• Remember to handle these patients gently to avoid precipitation of ventricular fibrillation!

ECMO in Hypothermic Arrest

• The use of ECMO has been recommended as the rescue therapy of choice for hypothermic cardiac arrest for its ability to rapidly rewarm patients (8-12 degrees/hour) and provide complete cardiopulmonary support 
• Studies have shown that patients with cardiac arrest have a rate of survival of 50% with the use of ECMO, whereas, at centers without ECMO, these same types of patients have a survival rate of only 10% 
• Cases of survival with a good clinical outcome have been reported with core temperatures as low as 13 degrees Celsius and in cases requiring long transport with more than 5 hours of CPR!

Risk Factors for Poor Prognosis Despite Aggressive Therapy (ECMO, etc):

• Clear history of cardiac arrest before cooling 
• Obvious signs of irreversible death 
• Core body temperature higher than 32 degrees Celsius with asystole 
• Potassium greater than 12 mEq/L