Modern Resident - The newsletter of AAEM/RSA
August/September 2011
Volume 3: Issue 2


2011-2012 Leadership

President
Teresa Ross, MD

Vice President
Zachary Repanshek, MD

Secretary-Treasurer
Leana Wen, MD MSc

Immediate Past President
Ryan Shanahan, MD

At-large Board Members
Ali Farzad, MD
Stephanie Gardner, MD
Sarah Terez Malka, MD
Taylor McCormick, MD
Ketan Patel, MD

Medical Student Council President
Meaghan Mercer

Modern Resident Contributors

Copy Editor: Taylor McCormick, MD
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this month's contributors: Casey Grover, MD; Veronica Tucci, MD JD; Namita Kedia, MD FACEP; Matthew DuMouchel, MSIV; Alan Sielaff, MSIV; and Christopher DeClue, MSII.

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by October 15th for the October/November edition.

Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM or AAEM/RSA.


Image of the Month
Casey Grover, MD
Stanford/Kaiser Emergency Medicine

A 17 month old female is brought to the ED by her mother for emesis and fever. The mother thinks that her daughter may have swallowed something last night because the child had made a "wheezing sound" while breathing and appeared uncomfortable. There was no witnessed ingestion. The child appears well with normal vital signs and is playful and interactive. Her physical exam, including pulmonary examination, is normal.

You order a PA and lateral chest X-ray. What does it show (figure 1)?

Click on image to enlarge photo.

Image of the Month

  1. A coin in the esophagus
  2. A coin in the trachea
  3. A bottle cap in the esophagus
  4. A button battery in the esophagus

Click here for the answer


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Board Review - GI
Matthew DuMouchel, MSIV
Veronica Tucci, MD JD
Namita Kedia, MD FACEP
University of South Florida College of Medicine

Q1. 23 year old female with no significant past medical history presents to the ED with a 2 day history of fever, nausea, vomiting and periumbilical pain that has lateralized to the right lower quadrant and has progressively increased in intensity. Physical examination findings include positive McBurney's point sign and tachycardia; lab results indicate a mild leukocytosis. What is the most sensitive modality in detecting appendicitis when a clear diagnosis cannot be made clinically?

  1. Abdominal series plain radiograph
  2. Abdominal ultrasound including imaging of the appendix
  3. Abdominal CT scan with contrast
  4. Transvaginal ultrasound
  5. ECG

Answer: C is correct. Abdominal CT with contrast has an overall sensitivity in patients over the age of 2 of 96% with a positive predictive value of 96%. Noncontrast CTs have a sensitivity of 94% with a positive predictive value of >95% and will likely be used with increasing frequency in future practice. Choices A, B, D and E are incorrect. Abdominal plain films are useful in detecting viscous perforation with peritoneal free air or obstruction, but are not very helpful in diagnosing appendicitis; while abdominal US can be a useful tool in detecting appendicitis (sensitivity reported to be as high as 86% with a 95% positive predictive value), sensitivity can vary with sonographer's experience, and it is more useful in children and thin adults. Transvaginal US is not useful in detecting appendicitis, but may be useful in the evaluative process if gynecology pathology is suspected. There are no changes on ECG with appendicitis.

Reference:

  1. DeKoning E. P. Chapter 84. Acute Appendicitis. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th ed.

Q2: 54 year old alcoholic male presents to the ED with a 3 day history of progressively worsening periumbilical and epigastric pain that radiates to his back, along with nausea, vomiting and mild fever. Pt reports a 2-week history of daily alcohol use. Physical examination findings include epigastric tenderness to deep palpation. What lab result is most specific to this patient's diagnosis?

  1. Elevated Amylase
  2. Elevated Lipase
  3. Leukocytosis
  4. Elevated CRP
  5. Abnormal LFTs

Answer: Choice B is correct. Lipase is the most specific marker for pancreatitis and has an estimated specificity of 93% when drawn at time of ED presentation and 90% sensitivity. Choice A is incorrect because, although amylase is increased in pancreatitis, it is also found in salivary secretions and therefore less specific to pancreatic disease. Elevation in inflammatory markers such as WBC or CRP is common and is not specific to pancreatic pathology alone, making choices C and D incorrect. Although gallstones are a common reason for pancreatitits, transaminitis/elevated liver function tests frequently accompany excessive alcohol use with a classic 2:1 pattern for AST and ALT, and such elevations are not specific for pancreatitis.

Reference:

  1. Atilla Ridvan, Oktay Cem. Chapter 82. Pancreatitis and Cholecystitis. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th ed.

Q3. 65 year old male presents to the ED with severe abdominal pain (10/10) for the last day associated with nausea, vomiting and anorexia. PMHx is significant for hypertension, stroke and myocardial infarction x2 with 2 vessel coronary artery bypass grafting four years ago. Physical examination findings include VS: BP 110/75; Temp 99.8 degrees; R 19; P 110. Abdominal exam is essentially normal with normoactive bowel sounds and only mild tenderness to palpation diffusely, no rebound or guarding, and no hepatosplenomegaly. Cardiovascular exam reveals an irregular rhythm, no murmurs rubs or gallops and lungs are clear to auscultation bilaterally; the rest of the exam is within normal limits. Fecal occult blood is positive. What is the most likely diagnosis?

  1. Enterocolitis infection with E. coli
  2. Hemorrhagic pancreatitis
  3. Mesenteric adenitis
  4. Mesenteric ischemia
  5. Diverticulitis

Answer: D is correct; mesenteric ischemia from cardiac emboli secondary to atrial fibrillation is commonly seen with severe abdominal pain out of proportion to exam findings, and physicians must maintain a high index of suspicion. Laboratory testing including serum lactate may be normal in up to 25% patients on initial presentation. Choices A and E are incorrect. Fecal occult blood is commonly positive in Meckel's diverticulitis (not usually seen in elderly populations) and enterocolitis with hemorrhagic E coli; however, the history of atrial fibrillation and pain out of proportion is more likely mesenteric ischemia. Choices B and C are incorrect. There is no evidence of Grey Turner's or Cullen's sign, and the history is not congruent with hemorrhagic pancreatitis or mesenteric adenitis.

Reference:

  1. Lo Bruce M. Chapter 79. Lower Gastrointestinal Bleeding. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th ed.

Cardiology Pearl: Wellens' Syndrome
Alan Sielaff, MS IV
Loyola University Chicago, Stritch School of Medicine

A 63 year old female with a history of hepatitis C and diabetes mellitus presents to the emergency department after experiencing acute substernal chest pain, SOB and emesis during a routine visit to her PCP earlier this afternoon. All symptoms spontaneously resolved shortly prior to her arrival in the ED. She has no other complaints and a normal physical exam. Her EKG is shown below.

Click on image to enlarge photo.

Cardiology Pearl

Wellens' syndrome is a critical diagnosis for the emergency physician as it represents a high-grade lesion in the proximal left anterior descending artery. Classically, patients will present with complaints of unstable angina, but women, elderly and diabetics may present atypically. It has been demonstrated that patients with Wellens' syndrome rapidly progress to anterior infarction, with a mean of 8.5 days from the time of development of the syndrome to acute infarction.¹ A set of criteria has been established in the diagnosis of Wellens' syndrome which include symmetric and deeply inverted T waves in leads V2 and V3, sometimes in leads V1, V4, V5, and V6 or biphasic T wave in leads V2 and V3; plus isoelectric or minimally elevated (1mm) ST segment; no precordial Q waves; history of angina; pattern present in pain-free state; normal or slightly elevated cardiac serum markers.2-6 It is key to note in the above criteria that patients with Wellens' syndrome typically display the characteristic EKG changes during chest pain-free intervals.6 Patients with suspected Wellens' syndrome should have immediate cardiology consultation. The above patient was taken to the cardiac catheterization lab where it was revealed that she had a >95% occlusive lesion in her proximal LAD requiring stent placement.

References:

  1. de Zwaan C, Bar FW, Wellens HJ. Characteristic electrocardiographic pattern indicating a critical stenosis high in left anterior descending coronary artery in patients admitted because of impending myocardial infarction. Am Heart J. Apr 1982;103(4 Pt 2):730-6.
  2. Tandy TK, Bottomy DP, Lewis JG. Wellens' syndrome. Ann Emerg Med. Mar 1999;33:347-51.
  3. Ondrusek RS: Spotting an MI before it's an MI. RN 1996;59: 26-30.
  4. Kahn EC, Keller KB. Wellens' syndrome in the emergency department. J Emerg Nurs 1991;17:80-84.
  5. Paul S, Johnson P: Early recognition of critical stenosis high in the left anterior descending coronary artery. Heart Lung 1990;19:27-29.
  6. Rhinehardt J, Brady WJ, Perron AD, Mattu A. Electrocardiographic manifestations of Wellens' syndrome. Am J Emerg Med. Nov 2002;20:638-43.

Tox Talks: EUROPA/2C-E, One of the "Magical Half Dozen"
Christopher DeClue, MSII
Veronica Tucci, MD JD
University of South Florida College of Medicine

"Let it (2C-E) rest as being a difficult and worthwhile material."
-Alexander "Sasha" Theodore Shulgin

Created by American pharmacologist Alexander Shulgin, Europa (2C-E) is a hallucinogenic amphetamine that is a derivative of the 2C-family. It is a white crystalline powder that is generally ingested or insufflated. Although Europa's mechanism of action is poorly understood, it has been found to activate the sympathetic nervous system through the stimulation of catecholamine, dopamine and serotonin receptors. What distinguishes Europa from other psychedelics is the strength, duration and oddity of the hallucinations experienced. Many users report extreme synesthesia, sound distortion, euphoria and enhanced visual hallucinations lasting anywhere from six to ten hours. As with many of the hallucinogenic amphetamines, buyers and medical practitioners beware. A negative "trip" is not the worst outcome for would-be Europa users. Indeed, the first reported death from 2-CE in the United States occurred in March 2011.

Patients with mild to moderate Europa toxicity may present with mydriasis, tachycardia and hypertension. Progressive toxicity can lead to hepatic and renal dysfunction including electrolyte disturbances, disseminated intravascular coagulation and rhabdomyolysis. Severe poisonings can present with dysrhythmias, seizures, hyperthermia, cardiovascular collapse and death.

Laboratory findings can include elevated BUN, creatinine, CPK, myoglobinuria, elevated liver enzymes, hyperkalemia, hyponatremia and thrombocytopenia. It can be difficult to diagnose Europa toxicity through a routine urine drug screening because, like many of its brethren (e.g., ectasy/MDMA), it may not produce a positive result for amphetamines, and a high index of suspicion should be maintained. The presence of other substances or contaminants including caffeine, acetaminophen or ketamine may confuse the diagnostic results and requires evaluation of the entire clinical picture.

The management of Europa toxicity is generally supportive. Activated charcoal can be given within one hour of ingestion if the patient's airway is protected. All acute metabolic derangements should be controlled, and early, aggressive fluid resuscitation should be utilized to minimize renal dysfunction. Hyperthermia can be life threatening, and the patient must either be placed in a cool room and/or have evaporative cooling measures initiated. Both dantrolene and benzodiazepenes can also be given to control agitation and decrease the patient's core body temperature. Hypertensive emergencies should be treated with either a nitroprusside or nitroglycerine drip with labetolol and phentolamine reserved for use in refractory cases. Patients who are actively seizing may be given lorazepam, diazepam or midazolam. Second line medications for seizure activity include phenobarbital or propofol. For refractory cases, neuromuscular paralysis should be considered.

References:

  1. Lussenhop, Jessica. "2C-E: One dead, 10 hospitalized after mass drug overdose in Blaine." Citypages 17 March 2011.
  2. Marx: Rosen's Emergency Medicine, 7th Edition.
  3. Poisindex and Micromedex (2011).
  4. Shulgin, Alexander and Ann Shulgin (1991). PiHKAL: A Chemical Love Story First Edition. Transform Press.
  5. "Synthetic Cathinones." European Center for Drugs and Drug Addiction.
  6. Tintinalli: Emergency Medicine: A Comprehensive Study Guide, 7th Edition.

Image of the Month

Answer: D. A button battery in the esophagus

Ingestion of button batteries is increasingly common and carries a high risk of complications. Mucosal injury may occur within 1 hour of ingestion, which can progress to esophageal perforation and tracheoesophageal fistula. As such, removal of a suspected button battery in the esophagus should be done as soon as possible.¹

On the PA radiograph, an esophageal button battery will demonstrate a double density because of its bilaminar structure. On the lateral radiograph, a button battery will demonstrate a step-off or tapering at the junction of the anode and cathode.² These features can easily be seen on zoom images of the initial radiographs on this patient (figure 2).

Click on image to enlarge photo.

Image of the Month

References:

  1. Amanatidou V, Sofidiotou V, Fountas K, et al. Button battery ingestions: the Greek experience and review of the literature. Pediatr Emerg Care. 2011; 27: 186-8.
  2. Jarugula R, Dorofaeff T. Oesophageal button battery injuries: think again. Emerg Med Australas. 2011; 23: 220-3.