Modern Resident - The newsletter of AAEM/RSA
October/November 2012
Volume 4: Issue 3  |  FacebookTwitterLinkedIn


Your 2012-2013 Leaders:

President
Leana S. Wen, MD MSc

Vice President
Stephanie Gardner, MD

Secretary-Treasurer
Taylor McCormick, MD

Immediate Past President
Teresa M. Ross, MD

At-Large Board Members
Rachael Engle, DO
Ali Farzad, MD
Megan Healy, MD
Sarah Terez Malka, MD
Meaghan Mercer, DO

Medical Student Council President
Mary Calderone

Publications Advisor - Ex-Officio Board Member
Joel Schofer, MD RDMS FAAEM

Modern Resident Contributors

Copy Editor: Rachael Engle, DO
Managing Editor: Jody Bath, AAEM/RSA Staff

Special thanks to this issue's contributors:
Joshua Batt, DO; Rachael Engle, DO; Ali Farzad, MD; Michael Gisondi, MD; Geoff Jara-Almonte, MD; David Orban, MD FACEP; Alicia Rech, DO; Veronica Tucci, MD JD; Victoria Weston, MD; Ashley Grigsby, MSIII; Nate Haas, MSIII; Dylan Hendy, MSIV; Justin Rizer, MSIV; and Jason S. Zeller, MSIV

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by November 24th for the December/January edition.

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


Publications Committee Update
Ali Farzad, MD
University of Maryland

The RSA Publications Committee is committed to helping make the lives of EM residents and students as simple and successful as possible.  We have been highlighting how you can use technology to become a more efficient and effective learner in recent Common Sense articles. Don't miss what some of the biggest names in EM education like Drs. Mel Herbert, Amal Mattu and Scott Weingart are saying to help you save time while saving lives!

On that same note, we are working to convert our most popular publications into e-Books for your convenience. Soon you will be able to access all your favorite RSA books on the tablet or mobile device of your choice! We are also excited to tell you that we are working on a new way for you to study for your boards and in-training exams. RSA is creating a new HIGH-YIELD board review podcast series that is based off the highly acclaimed Emergency Medicine: A Focused Review of the Core Curriculum.  These easy-to-use podcasts will cover every chapter and topic, highlighting all the critical concepts and must-know information. They are specifically designed to save you time and improve your score by teaching you everything you need to know and none of what you don't. 

Make sure you are following RSA on Facebook and Twitter to read our "Fact of the Day" and stay up-to-date with the latest news and information that is important to you. Committee members are working hard to provide you with useful EM related pearls on a daily basis for free!  We are also working on a new RSA blog that will not only archive our most popular articles from the past, but will also be your one stop shop for all the information you need to stay current with the EM issues that matter to you most.  

Please send us your feedback, and let us know what you like and what you want to see more of. We are always looking for good ideas and future leaders to help make RSA as beneficial to our members as possible.  

Remember AAEM/RSA is with you all the way! 


Program Director of the Year Award
AAEM/RSA is currently accepting nominations for its annual EM Program Director of the Year Award. This award recognizes an EM program director who has made an outstanding contribution to the field of emergency medicine and AAEM. Nominations will be accepted until November 4, 2012, at midnight CST. The award presentation will be made at the 19th Annual Scientific Assembly to be held in Las Vegas, NV, February 9-13, 2013. Please email us your nomination.

Medical Student Scholarships
AAEM/RSA is offering students the chance to apply for scholarships! Each year, up to two students who demonstrate a dedication and passion for emergency medicine will be selected as recipients of a $500 scholarship. Nominations will be accepted from Sept 15th-Nov 15th. The winner(s) will be announced between January 15th and February 1st with acknowledgement at the Student Track at the Annual AAEM Scientific Assembly. Click here for more information and to apply today!


Photo of the Month #1 – Eye Emergencies
Dylan Hendy, MSIV
Arizona College of Osteopathic Medicine
Joshua Batt, DO
Arrowhead Regional Medical Center

Patient Vignette:
A 60-year-old male visits the emergency department with four days of increasing loss of peripheral vision in the right upper quadrant of his left eye and describes it as being painless and blurry. Patient denies history of trauma. Patient states he does see floaters but denies pain, flashing lights or photophobia.  Corrected visual acuity showed OD=20/20, OS=20/200, OU=20/20.  The following image was captured on ultrasound using the linear transducer. 


Click to enlarge

Question:        
What is the diagnosis?

  1. Globe rupture
  2. Intraocular foreign body
  3. Vitreous hemorrhage
  4. Retinal detachment

Answer:
D is correct. This patient presents with a retinal detachment as illustrated by the hyperechoic membrane in the posterior globe and anterior to the choroid. Retinal detachment occurs most frequently in patients between the ages of 50 and 75. However, myopia is a major risk factor, and retinal detachment can occur as early as the third decade of life in patients who are severely myopic.

Patients may present clinically with new-onset flashing lights and/or floaters.  Flashing lights are caused by an aging vitreous gel tugging on the retina before separation which stimulates the retina and is perceived as flashes of light. Floaters occur when the retina has detached from the choroid and now moves into and out of the visual axis. Floaters may also be seen with vitreous hemorrhages and intraocular foreign bodies; however, these would have different sonographic findings.

The prognosis and subsequent urgency of evaluation by an ophthalmologist may be influenced by the degree of retinal detachment. Although not shown in our picture, it is important to visualize the optic nerve and determine if the detached retina is still tethered to the macula that is located just lateral to the optic nerve sheath. 

Macula-on, or “Mac-on” for short, refers to a retinal detachment that has not yet extended into the macula. Symptoms of “Mac-on” may be described as only partial loss of peripheral vision.  This warrants an emergent evaluation and correction by an ophthalmologist. “Mac-off” states the retina has detached beyond the macula. These patients may present with complete vision loss in the affected eye, and their prognosis is poor.  

This patient was evaluated the same day by ophthalmology. He was diagnosed with a “Mac-off” detached retina and had surgery two days later. The patient followed-up as an outpatient two weeks later, and there was no improvement in his vision. 

References:

  1. Arroyo, JG.  Retinal Detachment.  In:  UpToDate, Trobe,  J (Ed), Sokol, HN (Ed), UpToDate, Waltham, MA, 2012. http://www.uptodate.com/
  2. Mallin, M., & Dawson, M. (Producer). Fox, C. (Narrator). (2012). Ocular Ultrasound [Online video]. Ultrasoundpodcast.com. Retrieved September 17, 2012, from http://www.ultrasoundpodcast.com/2012/04/episode-26-ocular-ultrasound-with-chris-fox/
  3. Walker RA, Adhikari S. Chapter 236. Eye Emergencies.  In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

Journal Club Article
Geoff Jara-Almonte, MD
Hennepin County Medical Center

Airway management is a core emergency medicine competency.  Physicians are expected to be able to intubate both adult and pediatric patients safely with a minimum of adverse events.  A new study published in September’s Annals of Emergency Medicine by Dr. Benjamin Kerry and colleagues provides new insight into how well we accomplish this.  

This study is retrospective and observational, looking at first pass success of endotracheal intubation and frequency of adverse events.  It was done at a large academic, urban pediatric emergency department.  Subjects were drawn from the nearly 3,000 resuscitation cases run in the ED over a 12-month period.  Of these, 145 patients required endotracheal intubation, and 123 of those patients were intubated with rapid sequence induction and included in the study.

Researchers then reviewed video footage taken with ceiling-mounted cameras present in all resuscitation bays.  From this, they determined rates of first pass success and occurrence of adverse events.  The written medical record for all patients was then reviewed to determine congruence with the video recording.  

The first pass success rate in their study cohort was 52%; 26% of patients required three or more attempts.  Sixty-one percent of patients experienced at least one adverse event; most common was oxygen desaturation (33%) and right mainstem intubation (30%). Two patients (2%) experienced physiologic deterioration requiring CPR. When results were broken down by training level, they found that staff physicians had a 10-fold higher likelihood of first pass success compared to trainees.

These results are markedly discordant from success and complication rates of endotracheal intubation reported in prior studies.  For example, in a report from the National Emergency Airway Registry, 78% of intubations were successful on the first attempt, and only 16% experienced an adverse event.

Kerry’s study introduces a novel methodology for assessment of first pass success by using video recordings of resuscitation cases to objectively determine intubation success and adverse events as opposed to relying on the written medical record. The authors hypothesize that this is likely to be more accurate than prior studies. Indeed, in their own study cohort, the authors found that the medical record over-estimated first pass success and under-estimated frequency of adverse events when compared to the video recordings.


Clinical Pearl – Bruxism and Bath Salts
Nate Haas, MSIII
Loyola University Chicago Stritch School of Medicine

We’ve all heard about bath salts from news outlets, social media and the internet, and we’re well aware of the potential for life-threatening complications secondary to bath salts ingestion. Severe psychosis, homicides and suicides have all been attributed to one of the latest in a long line of designer drugs. But, how do we as health care providers recognize an acute bath salts intoxication?

The active ingredient in most formulations of bath salts is 3,4-methylenedioxypyrovalerone, better known as MDPV.  MDPV is a potent inhibitor of dopamine and norepinephrine re-uptake transporters and is thought to inhibit each transporter with a potency much greater than that of cocaine.1 Thus, many of the signs and symptoms associated with intoxication mimic sympathetic overstimulation, including tachycardia, hypertension, hyperthermia, diaphoresis and arrhythmias.2

Bruxism, a clenching of the jaw and/or grinding of the teeth, has been noted as a relatively common presentation of bath salts intoxication.3 Bruxism can be caused by a wide array of conditions and substances ranging from sleep disorders to SSRI’s to Obsessive-Compulsive Disorder to MDMA (Ecstasy).  However, the combination of the above sympathetic overdrive signs and symptoms with bruxism should raise suspicion for a bath salts intoxication.

Just remember, bruxism and bath salts!

References:

  1. Coppola M, Mondola R. 3,4-Methylenedioxypyrovalerone (MDPV): chemistry, pharmacology and toxicology of a new designer drug of abuse marketed online. Toxicol Lett. 2012; 208:12-15.
  2. Ross, Edward A., Mary Watson, and Bruce Goldberger. "“Bath Salts” Intoxication." New England Journal of Medicine 365.10 (2011): 967-68. Web. 28 July 2012.
  3. Nordt, S., & Swadron, S.  (October 2011). Bath Salts - A new and BAD street drug.  EM:RAP Podcast.  Podcast retrieved from www.emrap.org

Critical Care Board Review: Vasopressors for Septic Shock
Rachael Engle, DO
Temple University Hospital

An 82-year-old female with past medical history of hypertension, hyperlipidemia and diabetes is transferred from her nursing home with a cough and the following vital signs: temp: 103.2°F (rectal), HR: 140, RR: 28, BP: 84/54, weight of 80kg. You give 3 liters of normal saline solution and 650mg of Tylenol. The patient is noted to have a leukocytosis with a 20% bandemia, worsening renal failure, and a lactate of 5.2. A chest X-ray is consistent with lobar pneumonia. You begin treatment to cover health care acquired pneumonia. The following vital signs are obtained after the Tylenol and fluid resuscitation: temp: 101.2°F, HR: 120, RR: 24 and BP of 80/62. The next step would be:

  1. Place a triple lumen catheter, an arterial line, and start lactate ringer’s solution.
  2. Ask the nurses to place another 18G IV, and start 2 more liters of normal saline solution.
  3. Place a triple lumen catheter, an arterial line, and start norepinephrine at 8mcg/min.
  4. Place a triple lumen catheter, an arterial line, and start dobutamine at 125 mcg/min.

Answer:
C is correct. The correct answer is to place a triple lumen catheter, an arterial line, and start norepinephrine. The patient has refractory hypotension that is not responding to IV fluids. There are signs of end organ damage (worsening renal failure and lactate >4) plus a confirmed infectious process; therefore, the patient is in septic shock. This patient needs an arterial line to properly measure arterial blood pressure. A triple lumen catheter is an essential part of the management of a septic patient since the patient will be receiving multiple IV medications: antibiotics, vasopressors, possibly more IV fluids and possibly insulin. A TLC can be used to measure central venous pressure as well. Most vasopressors can cause necrosis if extravasation occurs through a peripheral line.

Although giving the patient more fluids (answer A and B) is not entirely wrong, this patient has shown no improvement, and in fact, worsening hypotension. To prevent further end organ damage and to improve morbidity and mortality, a vasopressor must be started.

Dobutamine (answer D) is a beta-1 adrenergic agonist that causes increased contractility and heart rate. This is used primarily in heart failure and cardiogenic shock.

Norepinephrine (Levophed) is the correct answer with this patient given the refractory hypotension. Norepinephrine (NE) stimulates beta-1 adrenergic and alpha adrenergic receptors, which in turn will increase heart rate and increase systemic vascular resistance through vasoconstriction. There are more alpha affects than beta affects of NE. Dosage for septic shock starts at 0.01-0.3mcg/kg/min. Dosage for post-ACLS code starts at 0.01-0.5mcg/kg/min. For other conditions it can be started at 8-12mcg/min with a maintenance range of 2-4mcg/min.

Take Home Points:
-If 30-40cc/kg IV fluids does not have response in blood pressure, start a vasopressor through central access.
-In septic shock, first line agents are Norepinephrine or Dopamine.
-Norepinephrine starting dose: 0.01-0.3mcg/kg/min
-Dopamine starting dose: 2-20mcg/kg/min

References:

  1. Gooneratne, N and Manaker, S.  Use of vasopressors and inotropes. In: UpToDate, Parsons, PE (Ed.), Waltham, MA, 2012.
  2. De Backer, Daniel, et al. (March 4, 2010). "Comparison of Dopamine and Norepinephrine in the Treatment of Shock". NEJM. 362 (9): 11.
  3. Mink, S and Sharma, S. Septic shock (August 13, 2012). Emedicine. Retrieved October 1, 2012, from http://emedicine.medscape.com/article/168402-overview

Tox Talks: Krokodil
Ashley Grigsby, MSIII
Arizona College of Osteopathic Medicine

Krokodil has been coined “the drug that eats junkies.” Sounds a little dramatic, but one Google image search for Krokodil (pronounced crocodile) and you will understand why this label has stuck. I warn you, these images are not for the faint of heart. The name Krokodil was aptly given. It causes reptilian-like effects on the skin, causing it to turn scaly and green and can eventually cause it to fall off. Many users have bones exposed, with multiple rotting sores covering their body. The drug causes immediate damage to, and even rupture of, blood vessels with subsequent necrosis of the surrounding tissue. Complications include abscesses, thrombophlebitis and gangrene.1

The drug first surfaced in Russia in 2003 as a “kitchen laboratory” produced opioid. It consists of a mixture of several substances including codeine, paint thinner, gasoline, hydrochloric acid, iodine and red phosphorus. The core agent seems to be the narcotic desomorphine, a substance with potency 8-10 times that of morphine and with a faster onset of action.1 Krokodil has become a cheap replacement for heroin, with an estimated 2 million users in Russia and parts of Europe.2 In Russia, “Krokodil” has shown a survival rate of 2-3 years.3

The DEA is currently monitoring the drug as it travels through Europe; there has yet to be any cases in the U.S. According to Gahr, et. al, recent reports of Krokodil in European countries should prompt U.S. physicians to pay attention for signs of this designer drug.1 Acute management seems to be similar to heroin, including naloxone, but significant scientific data is unavailable at this time. Clinical manifestations are also similar to heroin, with effects lasting 4-6 hours. The half life of the drug seems to be shorter than that of morphine, but the “kitchen laboratory” production of the drug makes effects difficult to predict.1 The difference between Krokodil and heroin will be evident in the physical evidence of tissue damage at injection sites. It is not unusual for users to present to the emergency department with exposed skeletal anatomy, ligaments and tendons.2 Clinical management of these patients should also include identification and treatment of infections, as this is a major cause of death in Krokodil users.

References:

  1. Gahr M, Freudenmann RW, Hiemke C, Gunst IM, Connemann BJ, Schönfeldt-Lecuona C. “Krokodil” – Revival of an Old Drug with New Problems. Substance Use & Misuse. 2012; 47 (7): 861-863.
  2. Medtox Journal on Drug Abuse Recognition. 2012. Emerging European drug problem has attention of U.S. drug experts.  [cited 2012 Sep 20]. Available from: http://www.medtox.com/Resources/Images/7060.pdf
  3. Shuster S. The curse of the crocodile: Russia’s deadly designer drug. Time [Internet]. 2011 June 20 [cited 2012 Sep 20]. Available from: http://www.time.com/time/world/article/0,8599,2078355,00.html

Board Review Questions – Musculoskeletal Part 2
Justin Rizer, MSIV, USF College of Medicine
*Veronica Tucci, MD JD, Baylor College of Medicine
David Orban, MD FACEP, USF College of Medicine

*Assistant Professor of EM at Baylor College of Medicine - Manuscript prepared while chief resident for research at USF College of Medicine

Myasthenia Gravis Crisis
1 ) 33-year-old female states that she is having trouble breathing. She struggles to report a history of myasthenia gravis (MG) diagnosed approximately one and a half years ago. She has not received any treatment since she stopped going to the doctor four months ago when her insurance ran out. Until today she has not had any trouble breathing but has had worsening fatigue at the end of the day for the past week. One exam, her vital signs are T: 98.3, P: 110, R: 28, BP: 110/68. She is sitting at the edge of the bed in obvious distress and is struggling to catch her breath. There is drooping of the left eyelid. Heart and lung sounds are normal. In the middle of your exam she states that she is feeling very tired, and it is becoming more difficult for her to breathe. You call the nurse to prepare for endotracheal intubation with rapid-sequence induction. Which of the following medications should most be avoided when performing RSI?

  1. Etomidate
  2. Succinylcholine
  3. Halothane
  4. Rocuronium
  5. Propofol

Answer:
B is correct. This patient is presenting in myasthenic crisis given her history and current respiratory distress and should be promptly intubated. MG is an autoimmune disease that destroys acetylcholine receptors, therefore, depolarizing and non-depolarizing agents should be used with extreme caution due to their action at the neuromuscular junction (NMJ). Succinylcholine is particularly unpredictable in MG patients and should be avoided. Due to resistance at the NMJ, higher doses of succinylcholine are required which can lead to prolonged paralysis. Rocuronium is a non-depolarizing agent that should be avoided if possible, but is not absolutely contraindicated, unlike pancuronium. Etomidate, halothane and propofol are all acceptable drugs to aid in intubation of MG patients.

Reference:

  1. Sloan EP, Handel DA, Gaines SA. Chapter 167. Chronic Neurologic Disorders. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011.

Inflammatory Myopathies
2 ) A 52-year-old female presents to the ED with difficulty breathing since this morning. She denies cough, fever, hemoptysis or recent travel, but does mention that she has been feeling progressively weak over the past couple of weeks and was unable to walk upstairs to her bedroom last evening. She does not smoke or drink alcohol. Her past medical history is significant only for hypertension controlled by hydrochlorothiazide. On exam, her vital signs include T: 98.9 degrees, P: 87, R: 14, BP: 122/68. She has purple discoloration around her eyes and patches of scaly roughness on her knuckles and knees. Lungs are clear with shallow inspiration, and heart sounds are present with regular rhythm. The patient states that she had “some tests” done last time she was admitted to the hospital for a similar episode. When you check her medical records, which of the following would you expect to find?

  1. Elevated ESR, elevated CK, positive ANA, muscle biopsy showing inflammatory cells surrounding the fascicle
  2. Elevated ESR, elevated CK, positive ANA, muscle biopsy showing necrosis
  3. Normal ESR, decreased FEV1/FVC
  4. Normal ESR, negative RF, negative ANA
  5. Elevated ESR, elevated CK, positive ANA, muscle biopsy showing vacuolar degeneration and inclusions

Answer:
A is correct. This patient most likely has dermatomyositis with possible early respiratory involvement. Dermatomyositis is an idiopathic skeletal muscle inflammatory disease characterized by proximal muscle weakness (difficulty walking up stairs), heliotropic rash on the face, and scaly patches over extensor surfaces. Presentation is similar to polymyositis (choice B), but the presence of rash and characteristic muscle biopsy findings make dermatomyositis more likely. Choice C could be seen in COPD patients which would explain the dyspnea but not the rash or weakness; also, the patient denied smoking. Choice D is characteristic of psoriatic arthritis which would present with psoriasis and arthritis commonly of the spine and hands. Choice E is characteristic of inclusion body myositis, another inflammatory myopathy, but does not have the rash described above.

References:

  1. Morabito GC, Tartaglino B. Chapter 279. Emergencies in Systemic Rheumatic Diseases. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6392869. Accessed June 8, 2012.
  2. Ropper AH, Samuels MA. Chapter 49. The Infectious and Inflammatory Myopathies. In: Ropper AH, Samuels MA, eds. Adams and Victor's Principles of Neurology. 9th ed. New York: McGraw-Hill; 2009.

Toxicology Review
3 ) A previously healthy 6-month-old girl is brought in by her mother after she noticed that her baby has not had a bowel movement in three days.  She explains that the patient has not been feeding as well or crying as much over the same time period but has been having wet yellow diapers. The mother reports an uncomplicated pregnancy and that her daughter’s growth and development have all been normal to this point. She was exclusively breastfeeding until last week when she began to introduce some new foods into the patient’s diet. The mother mentioned adding honey to some of the new foods so her daughter would be more likely to eat them. On exam, vital signs are T: 97.9, P: 100, R: 32, BP: 80/60. The patient is sleeping and is acyanotic; mucus membranes are moist and pink. She has a mildly distended abdomen and does not cry with palpation. She is noticeably hypotonic and does not react to being picked up. There are no petechia present, there is clear breath sounds bilaterally. What is the most likely diagnosis in this patient?

  1. Sepsis
  2. Dehydration
  3. Botulism
  4. Meningitis
  5. Rotavirus infection

Answer:
C is correct. The differential for a “floppy” baby is broad. However, in an afebrile patient with exposure to honey, the most likely diagnosis is C, botulinum intoxication due to ingestion of spores from the honey. Pediatric patients under one year old are susceptible to damage from the toxin due to decreased gastric acidity. Constipation, lethargy, poor feeding and weak cry are all symptoms of infant botulism. Fever is uncommon. Blood cultures should be obtained as well as the food source to look for the toxin. Sepsis is less likely due to stable vital signs and no history of recent illness. While this patient has decreased feedings recently, dehydration is unlikely due to the presence of wet diapers and moist mucus membranes. Meningitis can present with lethargy, weak cry and decreased feeding, but the history of source exposure makes infant botulism more likely. Rotavirus is a common cause of pediatric illness, but usually presents with diarrhea, not constipation.

References:

  1. Frackelton, M.  Chp 127 Bacteria. In: Marx: Rosen's Emergency Medicine, 7th ed. Philadelphia, PA: Mosby Elsevier; 2010. http://www.mdconsult.com.ezproxy.hsc.usf.edu/books/page.do?eid=4-u1.0-B978-0-323-05472-0..00127-4--s0240&isbn=978-0-323-05472-0&sid=1321136960&uniqId=339106563-6#4-u1.0-B978-0-323-05472-0..00127-4--s0255
  2. Andrus P, Jagoda A. Chapter 166. Acute Peripheral Neurologic Lesions. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6366162. Accessed June 11, 2012.

Image of the Month #2 – Critical EKG Findings Not to Miss
Alicia Rech, DO
Aria Health

CC: Abdominal pain

HPI: A 64-year-old male with a history of B cell lymphoma presents to the emergency department with diffuse abdominal pain after syncopal event.  Per his wife, patient fainted in hematology office while receiving chemotherapy treatment for lymphoma. Patient admits to nausea, but denies vomiting or diarrhea.  Difficult to obtain further history as patient is in acute distress from pain and continually repeats: “my stomach hurts.”

PE:  On exam, he is a diaphoretic, obese man in obvious distress from pain.

Vital Signs: Unable to obtain blood pressure, HR bradycardic at 50bpm. Abdominal exam reveals normal bowel sounds with mild diffuse abdominal tenderness to palpation.

Lab: Laboratory studies reveal a potassium of 8.7, creatinine of 1.73, calcium 8.8, uric acid 20.4, and phosphorus 5.0. The rest of his studies are within normal limits. 

The following three EKG’s were obtained:

EKG #1:


Click to enlarge

Interventions were done, EKG #2:


Click to enlarge

More interventions were done, EKG #3:


Click to enlarge

Questions: What is your EKG finding? What is the next step in the management of this patient?

Answers: The first EKG demonstrates a sine wave pattern indicative of hyperkalemia.  This was emergently treated with calcium gluconate, sodium bicarbonate, albuterol, insulin with dextrose and kayexelate.

Discussion: Hyperkalemia presents with vague symptoms, making it difficult to diagnose; furthermore, it can lead to ventricular fibrillation or asystole if left untreated.  Several EKG findings can lead one to suspect this process.  Early changes are peaked T waves, followed by a widened QRS with increased PR intervals.  Finally, as the potassium continues to rise, the p waves are lost, and the QRS widens further leading to a sine wave pattern finding on EKG.  The EKG in photo #1 represents this sine wave morphology due to high potassium levels. The subsequent photos (EKG #2 and #3) demonstrate the return to normal rhythm post treatment with the aforementioned medications.

Take Home Points

  • Consider hyperkalemia when an EKG appears to have sine waves, and get repeat EKG’s throughout the course.
  • Initiate treatment before getting lab results to avoid worsening cardiac function such as ventricular fibrillation or asystole.
  • Consider other diagnoses after primary workup.  The cause of hyperkalemia in this patient was tumor lysis syndrome.

References:

  1. Garth, David.  “Hyperkalemia in Emergency Medicine.”  Medscape Reference Emedicine. 16 July 2010. Web.
  2. Koyamangalath, Krishnan. “Tumor Lysis Syndrome.” Medscape Reference Emedicine. 17 Jan. 2012. Web.
  3. Marx, John A., et al.  Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia: Mosby Elsevier, 2010. Print

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Image of the Month #3 – Cervical Spine Injuries
Victoria Weston, MD
Michael Gisondi, MD
Northwestern University

A male in his 30s who reports a 20-foot fall which occurred three months ago, presents for the first time for evaluation of neck pain. The patient was trimming a tree when he lost his balance, fell approximately 20 feet, and landed on his back. He notes pain when he turns his neck to the left or right and feels that his neck “locks up” for 1-2 seconds. He did not seek care until now because his pain had worsened significantly over the past week.  The patient is otherwise healthy, takes no medications regularly, and has no allergies. Prior to this week, his pain was well controlled with NSAIDs at home.

He denies hitting his head or LOC, has had no nausea or vomiting, has been able to ambulate without difficulty, and returned to work the following day. He denies any extremity weakness, numbness/tingling, difficulties with ambulation, or changes in bowel or bladder function.

The patient had a normal neurologic exam, but was placed in a c-collar, given pain on palpation over c-spine and pain with neck rotation.

The following image was obtained:


Click to enlarge

A CT c-spine was obtained showing a fracture through the C5 vertebral body. The fracture was found to extend through the full anterior-posterior dimension of the vertebral body. The patient had additional fractures through the right articular processes of C5 and through the right C5 lamina. Radiologist noted evidence for incomplete healing (partial healing with callus formation but no significant bony bridging across the fracture line).

Patient was seen by an orthopedic surgery consult in the ED. Patient had further evaluation with flexion/extension films. No MRI was obtained given normal neurologic exam. Pt was discharged home in an aspen collar with orthopedics follow-up.

Although this patient had a delayed presentation, he still was found to have a significant cervical spine injury requiring additional evaluation and treatment.

As a reminder, the NEXUS Low-Risk Criteria and Canadian C-Spine Rule include the following criteria:

NEXUS Low-Risk Criteria:

  • No posterior midline cervical-spine tenderness
  • No evidence of intoxication
  • A normal level of alertness
  • No focal neurologic deficit
  • No painful distracting injuries

Canadian C-Spine Rule:

  • Any high risk factor that mandates radiography (age 65 or older, dangerous mechanism or paresthesias in extremities)?
  • Any low risk factor that allows safe assessment of range of motion?
  • Able to rotate neck actively (45 degrees left and right)?

Although these criteria were derived from patients presenting after acute injuries, the patient had posterior midline cervical spine tenderness on exam and had significant pain with neck rotation, as well as a dangerous mechanism (fall from elevation >3ft or 5 stairs).

Reference:

  1. Stiell IG, Clement CM, McKnight RD, et al. The Canadian C-Spine Rule versus the NEXUS Low-Risk Criteria in Patients with Trauma. New England Journal of Medicine: 2003; 349 (26): 2510-2518.

Innovations in Emergency Medical Care
Jason S. Zeller, MSIV
Drexel University College of Medicine

In emergency medicine we see changes every second, so why aren’t our devices constantly changing? Well they are, we just don’t always get the chance to see them in the ED…This is your opportunity to learn more about what is up and coming in emergency medicine.

Welkins EMT/ICU Body Cooling System
Manufactured by Welkins, Roseville, California – This device allows for early, noninvasive therapeutic hypothermia beginning in the field. As we know, therapeutic hypothermia has been a hot topic in EM research and current practice. This device allows for liquid cooling in the temperature range of 30°C (86°F) to 37°C (98.6°F) to minimize damage from hypoxia to the brain as quickly as possible. The system has two conditioning units: the field (EMT unit) is battery powered and was initially developed by the U.S. Department of Defense for use in the battlefield; the ICU unit is designed for in hospital use with a touch screen and microprocessor temperature control. Both units use a cooling headliner with pneumatic pressure, allowing for better contact and quicker cooling. This device just received FDA 501(k) clearance in August. Of the many cooling devices on the market now, this device allows for continuous cooling from the scene to the unit. Check out the many other devices to see which suits your EMS or hospital situation.

Infrascanner 1000
The Infrascanner 1000 is a portable device that allows for immediate screening of intracranial bleeding. The scanner allows for knowledge of a brain bleed prior to CT and neurosurgical intervention, further leading ER docs to evaluation within the “golden hour.” It is especially helpful in the triage of patients with possible bleeds.  The Infrascanner 1000 uses Near Infrared Spectroscopy (NIRS) by detecting hemoglobin in the brain using its light absorbing properties. The scanner is portable and linked via Bluetooth wireless to a PDA. The data is sent to the PDA allowing for further processing of the results. These results are immediate after placing the scanner on four locations on the head and comparing sides. This device is simply a screening tool! The company makes it clear that it is not a CT replacement; it is a quick way to determine immediate transportation to a trauma center for neurosurgical intervention.

From the product page:


Click to enlarge

“The basic method for Hematoma detection is based on the differential light absorption of the injured vs. the non-injured part of brain. Under normal circumstances, the brain’s absorption should be symmetrical. When additional underlying extra vascular blood is present due to internal bleeding, there is a greater local concentration of hemoglobin and consequently the absorbance of the light is greater while the reflected component is commensurately less. This differential can be detected via sources and detectors placed on symmetrical lobes of the skull. The science of diffused optical tomography used by the Infrascanner™ enables the conversion of light differential data into interpretative scientific results.”

From product brochure:

“Infrascanner Detection Abilities:
Patient measurement is completed within 2-3 minutes.
Can detect hematomas greater than 3.5 cc in volume.
Detects hematomas up to 2.5 cm deep from the surface of the brain (or 3.5 cm from the skin surface).
Accuracy: In patients with Epidural, Subdural and Intracerebral hematomas: Sensitivity = 88% / Specificity = 90.7%”

This product is now FDA approved.

Reference:

  1. http://www.infrascanner.com/common/brochures/Infrascanner_Model_1000.pdf