Contributor: Travis Barlock, MD
Educational Pearls:

• Wheezing is classically heard in asthma and COPD, but it can be the result of a wide range of processes that cause airflow limitation
  • Narrowed bronchioles lead to turbulent airflow → creates the wheezing
• Crackles (rales) suggest pulmonary edema which is often due to heart failure
• Approximately 35% of heart failure patients have bronchial edema, which can also produce wheezing
• COPD and heart failure can coexist in a patient, and both of these diseases can cause wheezing
  • It’s vital to differentiate whether the wheezing is due to the patient’s COPD or their heart failure because the treatment differs
• Diagnosing wheezing due to heart failure (cardiac asthma):
  • Symptoms: orthopnea, paroxysmal nocturnal dyspnea
  • Diagnostic tools: bedside ultrasound
  • Treatment: diuresis and BiPAP for respiratory support
• Not all wheezing is asthma
  • Consider heart failure in the differential and tailor treatment accordingly

References
1. Buckner K. Cardiac asthma. Immunol Allergy Clin North Am. 2013 Feb;33(1):35-44. doi: 10.1016/j.iac.2012.10.012. Epub 2012 Dec 23. PMID: 23337063.

2. Hollingsworth HM. Wheezing and stridor. Clin Chest Med. 1987 Jun;8(2):231-40. PMID: 3304813.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/

Contributor: Jorge Chalit-Hernandez, OMS3
Educational Pearls:

• Psychedelics are being studied for their therapeutic effects in mental illnesses, including major depressive disorder, post-traumatic stress disorder, anxiety, and many others
• Classic psychedelics include compounds like psilocybin, LSD, and ayahuasca
  • MDMA and ketamine are often included in psychedelic research, but have a different mechanism of action than the others
  • Their mechanism of action involves agonism of the 5HT2A receptor, among others
  • Given their resurgence, there is an increase in recreational use of these substances
• A recent study assessed the risks of recreational users developing subsequent psychotic disorders
  • Individuals who visited the ED for hallucinogen use had a greater risk of being diagnosed with a schizophrenia spectrum disorder in the following 3 years
  • Hazard ratio (HR) of 21.32
  • After adjustment for comorbid substance use and other mental illness, the hazard ratio was 3.53 - still a significant increase compared with the general population
  • They also found an elevated risk for psychedelics when compared to alcohol (HR 4.66) and cannabis (HR 1.47)
• The study did not assess whether patients received antipsychotics or other treatments in the ED

References

1. Lieberman JA. Back to the Future - The Therapeutic Potential of Psychedelic Drugs. N Engl J Med. 2021;384(15):1460-1461. doi:10.1056/NEJMe2102835
2. Livne O, Shmulewitz D, Walsh C, Hasin DS. Adolescent and adult time trends in US hallucinogen use, 2002-19: any use, and use of ecstasy, LSD and PCP. Addiction. 2022;117(12):3099-3109. doi:10.1111/add.15987
3. Myran DT, Pugliese M, Xiao J, et al. Emergency Department Visits Involving Hallucinogen Use and Risk of Schizophrenia Spectrum Disorder. JAMA Psychiatry. 2025;82(2):142-150. doi:10.1001/jamapsychiatry.2024.3532

Summarized & Edited by Jorge Chalit, OMS3
Donate: https://emergencymedicalminute.org/donate/

Contributor: Ricky Dhaliwal, MD
Educational Pearls:

What factors are considered in a COVID-19 infection?

• The viral load: Understood as the impact of SARS-CoV-2 viral particles infecting host cell tissue itself (utilizing ACE-2 receptors).
• Pro-Inflammatory Response: Post-infection, the body's downstream systemic cytokine release (can be both normal or hyperactive, aka “cytokine storm”).

What cardiac impacts have been observed with COVID-19?

• Arrhythmias: The mechanism of COVID-19 infection and arrhythmias is believed to be multifactorial. However, evidence suggests T-cell-mediated toxicity and cytokine storm may contribute to cardiac myocyte damage, precipitating proarrhythmias instead of direct viral entry.
  • Bradycardia: Increased prevalence in patients with severe COVID-19 infection, but not associated with increased adverse outcomes.
  • Atrial Fibrillation: Most common cardiac complication and risk factor for worsened outcomes in patients with COVID-19. Biggest associated risk is strokes, and may require heightened monitoring and anticoagulation therapy to mitigate stroke risk.
• Fibrosis of Cardiac Tissue: Similar to arrhythmias, believed to be inflammation-mediated in COVID-19. Fibrosis of cardiac tissue increases the risk that any arrhythmias that develop during infection may persist after the infection has resolved.
• Ventricular damage: Also inflammation mediated by an active infection and contributes to myocarditis.
  • No evidence suggests that COVID-19 vaccination contributes to myocarditis.
• Sinus node dysfunction induced by inflammation that may lead to or be similar to Postural Orthostatic Tachycardia Syndrome (POTS).

Big takeaway?

• Patients who have had or currently have COVID-19 are at an increased risk of developing arrhythmias and sustaining them post-infection. However, a majority of patients will recover.
• Due to atrial fibrillation being the most prevalent arrhythmia associated with COVID-19 infection, increased monitoring and potential anticoagulation therapy are required.

References

1. Gopinathannair R, Olshansky B, Chung MK, Gordon S, Joglar JA, Marcus GM, et al. Cardiac Arrhythmias and Autonomic Dysfunction Associated With COVID-19: A Scientific Statement From the American Heart Association. Circulation. 2024 Nov 19;150(21):e449–65.
2. Khan Z, Pabani UK, Gul A, Muhammad SA, Yousif Y, Abumedian M, et al. COVID-19 Vaccine-Induced Myocarditis: A Systemic Review and Literature Search. Cureus. 14(7):e27408.

Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3

Donate: https://emergencymedicalminute.org/donate/