Monday Back to Basics

Bradycardia, Part 2 with Dr. Allison Cash

  1. Treat possible underlying cause if known 
  1. 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 
  1. 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. 
  1. 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. 
  1. 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 
Friday Board Review

Board Review by Dr. Alex Hilbmann (Edited by Dr. Parikh)

A 66 year old female reports to the emergency department with right arm pain after slipping on ice and trying to catch herself while falling forward. The patient is in incredible pain and has an obvious deformity of the right forearm upon presentation. An x-ray of the right forearm is shown below. What injury does the patient have?

A. Colles Fracture

B. Monteggia Fracture

C. Galeazzi Fracture

D. Smith Fracture

Answer is C. The x-ray shows a distal third radial fracture with disruption of the distal radioulnar joint space, which is a Galeazzi fracture. A Colles Fracture (A) is a distal radius fracture with dorsal displacement whereas a Smith Fracture (D) is a distal radius fracture with volar displacement. Both fractures frequently do not involve significant disruption of the radioulnar joint. A Monteggia fracture (B) is a fracture of the proximal ulna which results in radial head dislocation. For a Galeazzi fracture, the anterior osseous nerve (a branch of the median nerve) is often affected and function should be assessed by asking the patient to perform an “Okay” sign with first and second digit of affected arm.  Orthopedic Surgery consultation is necessary in adults as treatment is an open reduction and internal fixation (ORIF). If open fracture is present Cefazolin should be administered and if the wound is > 10 cm, appears contaminated, or involves seawater/freshwater/farming equipment Gentamicin should also be administered.

Picture from:

https://www.orthobullets.com/trauma/1029/galeazzi-fractures

Resources:

Atesok KI, Jupiter JB, Weiss AP. Galeazzi fracture. J Am Acad Orthop Surg. 2011 Oct;19(10):623-33. doi: 10.5435/00124635-201110000-00006. PMID: 21980027.

Garg R, Mudgal C. Galeazzi Injuries. Hand Clin. 2020 Nov;36(4):455-462. doi: 10.1016/j.hcl.2020.07.006. PMID: 33040957.

Mills, Trevor J.. “Forearm Fractures.” (2013). https://www.semanticscholar.org/paper/Forearm-Fractures-Mills/dead0398468fc50a88349251a8cb8a49b88f838f

Wednesday Image Review

What’s the Diagnosis? By Dr. Katie Selman

A 2 year old female presents to the ED with fever and difficulty swallowing. Mom reports she has been fussy with intermittent fever and rhinorrhea for 4 days but today did not want to eat or drink much, talking in a whisper and complaining of pain when eating. On exam, the patient is febrile, drooling, and has a swollen posterior oropharynx. A soft tissue neck x-ray is shown below. What’s the diagnosis?

Answer: Retropharyngeal Abscess

  • Most common in children under 5 years
  • May be preceded by URI symptoms or trauma to posterior pharynx
  • Xray finding = widened prevertebral space
    • In children, consider abscess when the prevertebral space is >6mm at C2 or >22mm at C6
    • Accurate assessment requires neck extension during x-ray
  • Common organisms involved – often polymicrobial, Staph aureus, Strep pyrogens, Strep viridans, Fusobacterium, Haemophilus specieas or other respiratory anaerobes
  • Management:
    • Admission 
    • IV antibiotics
    • Consult ENT for possible I&D
    • Definitive airway if any respiratory compromise
  • Complications include airway obstruction and mediastinitis

References:

Jain H, Knorr TL, Sinha V. Retropharyngeal Abscess. [Updated 2019 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK441873/

Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016.

Tuesday Advanced Cases

Critical Cases – The Red Eye!

By Stephanie Smith M.D.

HPI

  • 53 y/o male p/w complaints of L eyelid swelling and redness
  • Started 4 days PTA as small pimple which he popped, and slowly progressed to “softball” sized area of swelling with pus drainage
  • Subjective fevers

Physical Exam

  • BP 153/90, pulse 80, temp 98.6, RR 17
  • PERRL, EOMI
  • Extensive soft tissue erythema and edema of the L upper eyelid, 5×5 area of fluctuance with active pus draining from small laceration
  • Visual acuity: 20/40 R, 20/70 L
  • No corneal abrasions or ulceration on fluorescein staining 
  • IOP 21 bilaterally 

DDx

  • Preseptal / periorbital cellulitis
  • Orbital cellulitis
  • Abscess

Workup 

  • Labs: CBC, BMP, lactate, wound culture
  • Started empirically on broad spectrum abx: 2g vancomycin + 3g unasyn
  • CT orbits w/ contrast: significant soft tissue swelling of the L periorbital region consistent with inflammatory/infectious process, and involvement of the medial orbital wall along the lamina papyracea 

Clinical Course

  • Admission for continued IV antibiotics
  • Repeat CT orbits
  • Consults: OMFS, ophthalmology, ENT, ID 

Take home points

  • MUST differentiate orbital vs preseptal cellulitis given the increased morbidity and mortality a/w orbital (see table)
  • Confirm clinical suspicion with CT imaging
  • Orbital cellulitis complications: subperiosteal abscess, orbital abscess, vision loss, cavernous sinus thrombophlebitis, and/or brain abscess 
Monday Back to Basics

Bradycardia, Part 1 with Dr. Allison Cash

A ACS Myocardial infarction, also consider cardiomyopathies, myocarditis 
T Thyroid Hypothyroidism 
Rhythms  Second degree AV block (type I & II), complete AV block 
O Overdose Digoxin, beta blockers, calcium channel blockers, amiodarone, clonidine, organophosphates, naturally occurring cardiac glycosides (e.g. foxglove), opioids 
P Pressure Increased intracranial pressure (Cushing’s response) 
Infection Lyme disease, diphtheria, typhoid fever, aortic root abscess 
N Nippy  Hypothermia  
E Electrolytes Glucose, potassium, calcium, and magnesium 

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

Board Review by Dr. Guo (Edited by Dr. Parikh)

A 28 year old male presents for finger pain. He works in construction and accidentally poked his right index finger with a stray nail a few days ago. Since then, the palmar aspect of his fingertip has become progressively more swollen and painful. Vital signs are within normal limits. On exam, the right upper extremity is neurovascularly intact with full range of motion. There is erythema, fluctuance, and severe pain to palpation over the distal pulp of his second digit. There is no pain to palpation proximally along the finger. What organism is the most common cause of this patient’s diagnosis?

A: Methicillin-resistant S. aureus (MRSA)

B: Methicillin-sensitive S. aureus (MSSA)

C: Pseudomonas aeruginosa

D: Streptococcus pyogenes

Answer: Methicillin-resistant S. aureus (MRSA)

This patient is presenting with a felon, a subcutaneous pyogenic infection of the distal finger or thumb. The infection typically results from a minor puncture wound which later becomes an abscess confined to the small compartments of the finger pad. Treatment commonly involves incision and drainage in addition to oral antibiotics. Thus, it is extremely important that the antibiotics appropriately cover MRSA as improperly treated felons may worsen to cause flexor tenosynovitis or osteomyelitis. MSSA and Streptococcus pyogenes are other common causes of felons but not as common as MRSA. Pseudomonas is not a common cause of felons.

References:

Wilson  PC, Rinker  B: The incidence of methicillin-resistant Staphylococcus aureus in community-acquired hand infections. Ann Plast Surg 62: 513, 2009. [PubMed: 19387151]  
Germann CA. Nontraumatic Disorders of the Hand. 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.

Wednesday Image Review

What’s the Diagnosis? By Dr. Dan Fullerton

A 45 year old woman with past medical history of DM and nephrolithiasis s/p ureteral stent placement presents with right flank pain. Pain is progressive and associated with nausea and vomiting. She has had subjective fevers at home and dysuria. She denies polyuria or increased urinary frequency. Physical exam is significant for right CVA tenderness and right-sided abdominal pain radiating to the groin. Point of care bilateral renal ultrasound demonstrates the findings below. What’s the diagnosis?

Answer: Bilateral Staghorn Calculi

Patient had a hospital admission 2 weeks prior to this presentation and underwent cystoscopy and right retrograde pyelogram with ureteral stent placement. Urine cultures grew gram-negative rods, she was treated with ceftriaxone.

Learning Points
Staghorn calculi
– Large, complex stones filling the majority of the renal pelvis and calyces.
– Increased rates of infection, urosepsis, and kidney injury leading to increased morbidity and mortailty.
– Often struvite in composition and associated with Proteus mirabilis; a gram-negative rod. Other urease-producing bacteria are potential sources.
– Treatment can be conservative with antibiotics and percutaneous procedures. More often surgical intervention is necessary to prevent complications and mortality.

POCUS – is there hydronephrosis?
– Bedside ultrasound is useful in identifying and grading severity of hydronephrosis.
– Studies have demonstrated a sensitivity of 77-90% and specificity of 71-96% for detecting hydronephrosis for emergency physicians

Retrieved from: https://www.pocus101.com/renal-ultrasound-made-easy-step-by-step-guide/

References:

  1. Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol. 2019;11:1756287219847099. Published 2019 May 9. doi:10.1177/1756287219847099
  2. 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.
  3. Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J 2020; 12(1):31.
  4. Riddell J, Case A, Wopat R, Beckham S, et al. Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 2014; 15(1).
  5. Watkins S, Bowra J, Sharma P, et al. Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australasia 2007;19(3):188-95.
  6. Nixon G, Blattner K, Muirhead J & Kerse N. Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of primary health care 2018; 10(4), 324–330.
Tuesday Advanced Cases

Advanced Cases – Pericardial Tamponade as a Sequelae of Hypothyroidism!

By: Alexander Hilbmann MD

HPI:

52 year old female with pmhx of hypothyroidism who presents to Emergency Department with bilateral leg swelling and SOB with exertion. Reports swelling began one week ago and has progressively worsened. Denies any other symptoms. Patient has not seen a cardiologist/had an echo performed before. Reports she has not taken her prescribed levothyroxine for two years now.  

Physical Exam:

Vitals BP 128/82 HR 80 BPM Temp 92.8F Oral Resp 29 SpO2 99%

Abnormalities on physical Exam:

Periorbital Swelling of bilateral eyes

Rales present in bilateral lower lungs

Distension of abdomen

Bilateral lower extremities with non pitting edema

12 Lead ECG:

Interpretation: Sinus bradycardia, low voltage ECG

Bedside subxiphoid cardiac ultrasound:

Interpretation: Circumferential pericardia effusion, RV collapse consistent with pericardial tamponade physiology

For a FANTASTIC review of ultrasound guided emergency pericardiocentesis, check out the Ultrasound Podcast Youtube video HERE

Case continued:

  • Patient found to be hypoglycemic at 50 mg/dL, D10 administered
  • Patient found to be hyponatremic at 125, likely in setting of fluid overload
  • Cardiology consulted for cardiac tamponade, pericardiocentesis performed with 1.4 L drained. 
  • Ascites drained via paracentesis, other diagnoses ruled out with hypothyroidism most likely cause.
  • Patient restarted on levothyroxine and began liothyronine (T3)in hospital
  • Patient discharged home in stable condition after 10 days in hospital with levothyroxine, has not returned to hospital since

Pearls:

  • Consider hypothyroidism if patient has pmhx or classical physical exam findings: bradycardia, hypothermia, hypotension, lethargy, constipation, hair loss/thinning, facial swelling, coarse skin, pretibial myxedema(thickened, nonpitting edema), menstrual changes, decreased reflexes.
  • Hypothyroidism increases permeability in the blood vessels of the body and decreases drainage of lymphatic system, causing an accumulation of fluid outside of blood vessels and can present as pretibial myxedema, pericardial effusion, or pleural effusion.
  • Precipitating factors of hypothyroidism include medication nonadherence, infection, cold exposure, stroke, autoimmune disorders, thyroid radiation/surgery,  and medications (amiodarone, lithium).
  •  Management of hypothyroidism includes supportive, hydrocortisone(prevents adrenal crisis), levothyroxine (T4) and +/- Liothyronine (T3) supplementation.

References:

Chahine J, Ala CK, Gentry JL, et al Pericardial diseases in patients with hypothyroidism Heart 2019;105:1027-1033.

Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/