Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

Edward GuoLeave a comment

A 40 year old female presents to the emergency department via EMS for shortness of breath. Prior to arrival to the ED, the patient was hypoxic and in severe respiratory distress with absent left lung sounds prompting needle thoracostomy and rapid sequence intubation by EMS. Vital signs are BP 108/70, HR 102, Temp 98F, RR 16, SpO2 99% on 50% FiO2. A left sided chest tube is placed without complication. Chest x-ray confirms appropriate positioning of the endotracheal tube and chest tube with expansion of the left lung. Four hours later, the ventilator is alarming due to elevated peak and plateau pressures. SpO2 is 90%. There is no change with suctioning. A new chest x-ray is obtained and is shown below. What’s the diagnosis?

Answer: Reexpansion pulmonary edema

  • Reexpansion pulmonary edema is a rare but potentially fatal complication following drainage of a pneumothorax or pleural effusion. The pathophysiology is poorly understood but is thought to involve an inflammatory response leading to increased pulmonary capillary permeability.
  • Risk factors include large size pneumothorax, large volume pleural effusion, rapid reexpansion, and prolonged duration of symptoms (> 72 hours).
    • Prevention includes limiting drainage of pleural effusions to a maximum volume of 1.5 liters in one attempt.
  • Imaging will demonstrate unilateral airspace opacities in portions of the lung that were previously collapsed.
  • Treatment is supportive with supplemental oxygen and observation. Most patients recover without adverse outcomes.

References:

Nicks BA, Manthey DE. Pneumothorax. 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.

Asciak R, Bedawi EO, Bhatnagar R, et al British Thoracic Society Clinical Statement on pleural procedures Thorax 2023;78:s43-s68.

Morioka H, Takada K, Matsumoto S, Kojima E, Iwata S, Okachi S. Re-expansion pulmonary edema: evaluation of risk factors in 173 episodes of spontaneous pneumothorax. Respir Investig. 2013;51(1):35-39. doi:10.1016/j.resinv.2012.09.003

https://radiopaedia.org/articles/re-expansion-pulmonary-oedema

Tuesday Advanced Cases & Procedure Pearls

Hypothermia Arrhythmia by Dr. Edward Guo

Edward GuoLeave a comment

Case: A 29 year old male with a past medical history of polysubstance use presents to the ED in December via EMS for a suspected overdose. History is limited due to patient cooperation. EMS states that he was found outside in a puddle, minimally responsive. He was given 2mg IM naloxone by EMS and became acutely agitated and combative afterward, requiring 5mg IM midazolam and 5mg IM haloperidol upon arrival. Fingerstick glucose 226. EKG is obtained and shown below.

Exam: BP 182/84, HR 111, T 86.1F, RR 18, SpO2 100%
Disheveled appearing male in wet clothes, intermittently thrashing. Cold to touch. Pupils 5mm bilaterally. No signs of trauma. GCS E3 V2 M5. Moves all extremities equally. Heart rate is tachycardic and irregular.

EKG interpretation: atrial fibrillation with rapid ventricular response with Osborn waves

Differential diagnosis: polysubstance use, environmental cold exposure, severe sepsis, hypothyroidism

Case continued: Active rewarming is initiated by removing wet clothes, administering warmed IV fluids, and placing a bair hugger. Labs are notable for a creatinine kinase of 3966. The patient’s temperature, heart rate, and mental status significantly improve within 5 hours, and his repeat EKG shows normal sinus rhythm without Osborn waves. He is ultimately admitted to medicine.

Pearls:

  • The cardiovascular response to cold is peripheral vasoconstriction and initial increase in heart rate and blood pressure. As core temperature drops below 32C, there is myocardial irritability and risk of cardiovascular collapse.
    • Atrial fibrillation and flutterare common arrhythmias associated with hypothermia.
    • Rescue collapse is a term to describe cardiac arrest that occurs during extrication or transport of a profoundly hypothermic patient due to profound myocardial irritability.
  • Osborn waves are positive deflections at the end of the QRS complex that are non-specific but may occur in temperatures below 32C.
    • Size of the wave correlates with the degree of hypothermia but has no prognostic value.
  • As temperature continues to drop, EKG changes are variable but classically include bradycardia with prolonged PR, QRS, and QTc. Heart block or ventricular dysrhythmias may be encountered as well. Asystole is the common final dysrhythmia.
  • Rewarming is the treatment of choice.
    • Atrial dysrhythmias such as atrial fibrillation will often resolve with warming.
    • Cardioversion for unstable arrhythmias should be attempted but may be refractory in severe hypothermia.

References:

Brown DA. Hypothermia. 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.

Hoek T. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010. 122:5829-5861

Friday Board Review

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

Vidhi ParikhLeave a comment

A postpartum 34 year old female with a past medical history of hypertension presents for shortness of breath. Symptoms have been progressive over one month. She called EMS today when she was too short of breath to walk up one flight of stairs to care for her 13 week old infant. She denies fever, cough, chest pain, or recent illness and is not taking any oral contraceptives. Vital signs include Temp 99.0F, HR 96, BP 170/90, RR 22, SpO2 95% on room air. On exam, she has conversational dyspnea with no increased work of breathing. There are rales at the bilateral lung bases and 2+ pitting edema of the bilateral lower extremities. A bedside echocardiogram is notable for a dilated left ventricle with reduced ejection fraction. Which of the following is the most likely etiology of her symptoms? 

A: Cardiac infiltrative disease

B: Coronary artery atherosclerosis

C: Venous thromboembolism

D: None of the above

Answer: None of the above

This patient is likely presenting with peripartum cardiomyopathy, a rare but potentially fatal complication of pregnancy. The cause is unknown and most commonly occurs in the last month of gestation or within 5 months of delivery. The presenting symptoms and overall management of the condition are similar to other causes of congestive heart failure. Most patients will recover normal ejection fraction within the first 6 months of delivery. Ventricular dysrhythmias caused by persistent dilated cardiomyopathy may warrant an implantable defibrillator-pacemaker.

Cardiac infiltrative diseases such as amyloidosis or sarcoidosis most commonly cause diastolic dysfunction, not systolic dysfunction. Coronary artery disease is the most common cause of congestive heart failure but is unlikely in a 34 year old with minimal risk factors. A pulmonary embolism would cause right heart failure, not left ventricular systolic dysfunction.

 

Peripartum Cardiomyopathy
Most commonly occurs in last month of pregnancy or within 5 months of delivery
Dilated cardiomyopathy without previous heart disease
Treat similarly to other causes of congestive heart failure
Majority of patients recover normal ejection fraction

References:

Young JS. Maternal Emergencies After 20 Weeks of Pregnancy and in the Peripartum Period. 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.

Arany Z, Elkayam U. Peripartum Cardiomyopathy. Circulation. 2016 Apr 5;133(14):1397-409. doi: 10.1161/CIRCULATIONAHA.115.020491. PMID: 27045128.

“Peripartum Cardiomyopathy – Summary 1. Definition …” GrepMed, 16 Sept. 2020, www.grepmed.com/images/10231/peripartum-treatment-diagnosis-management-cardiomyopathy. Accessed 4 Apr. 2024.

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Thursday Conference Content & EKG Review

From the archives: Trigger points for pain control with Dr. Christine Collins

Meg ChamberlainLeave a comment

Question: Do trigger point injections with lidocaine lead to lowering pain for patients with point tenderness in their neck or back when compared to standard therapies?

Clinical Importance? Musculoskeletal neck and back pain can pose a challenge to treat when patients do not respond to NSAIDs or have a contraindication to NSAID use, and trigger point injections pose a solution to this. 

Yanuck et al: This is a single blind, prospective, randomized trial conducted at a single level I academic Emergency Department (n=62) with the goal to assess whether trigger point injection with 1% lidocaine results in decreased pain scores when compared to conventional therapy in the treatment of myofascial pain syndrome of the neck/back. For the primary outcome, the mean difference in NRS score when comparing trigger point to control was reported as a statistically significant different (ANCOVA, F[1,50]=25.97, p<0.001). The length of ED stay was also statistically lower in the trigger point injection group. Finally, trigger point injection patient received less opioid prescriptions compared to standard therapy. 

Limitations:  not double blinded, study personnel were in room with treating physician while doing injections, variability in competence of treating physicians, no sample size calculated before the study was done, loss of study participants/drop-outs (especially in the control arm), no tests run for normality of data, pain scores reported as means (outliers can significantly affect), “standard therapies” were broad and not clearly discussed or reported, significant amount of opioid prescriptions, convenience sampling limiting generalizability, 20 minute timeline may have favored injections over other therapies, no follow up period after ED, did not discuss adverse events or side effects reported   

Kocak et. al: This is a randomized prospective study (n=80) at a single Emergency Department which aimed to compare trigger point injections with 2% lidocaine to IV NSAID (dexketoprofen) in the treatment of lower back pain.The study found a statistically significant difference in pain scores reported by the trigger point injection group and the NSAID group (mean pain score trigger point: 7.55, NSAID 7.22, p<0.05), with a significantly higher response to treatment recorded in the trigger point group, with 21 out of 22 responding to trigger points and only 20 out of 32 responding to NSAIDs (p=0.008)

Limitations: Not blinded, no longer term follow up, no conclusions can be made about side effects/adverse effects, no definition of “experienced and trained professionals”

  • Although both studies supported that trigger point injections can reduce pain, both were limited. They did not follow up long enough to suggest a duration of therapeutic effect or address adverse effects adequately. Both studies also did not describe in detail a standardized training process for providers performing the injections. 
  • Trigger point injections are a promising treatment for musculoskeletal pain, however based on my review of the literature, I would not routinely use trigger point injections to treat musculoskeletal back or neck pain. More research should be dedicated to address the length of time the therapy lasts as well as adverse effects that are possible.
  1. Yanuck, Justin, et al. “Pragmatic Randomized Controlled Pilot Trial on Trigger Point Injections with 1% Lidocaine versus Conventional Approaches for Myofascial Pain in the Emergency Department.” The Journal of Emergency Medicine, vol. 59, no. 3, 2020, pp. 364–370., https://doi.org/10.1016/j.jemermed.2020.06.015. 
  2. Kocak AO, Ahiskalioglu A, Sengun E, Gur STA, Akbas I. Comparison of intravenous NSAIDs and trigger point injection for low back pain in ED: A prospective randomized study. Am J Emerg Med. 2019 Oct;37(10):1927-1931. doi: 10.1016/j.ajem.2019.01.015. Epub 2019 Jan 15. PMID: 30660342.
Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

Edward GuoLeave a comment

A 50 year old male with a past medical history of Crohn disease with ileocolectomy presents via EMS for shortness of breath. Prior to arrival to ED, patient was found to be hypoxic and in acute respiratory distress prompting rapid sequence intubation by EMS. Vital signs are notable for hypotension and tachycardia. On exam, there are equal breath sounds bilaterally. His abdomen is distended with bruising on the left flank. GCS is 3T. A portable chest x-ray is obtained to confirm endotracheal tube placement and is shown below. What’s the diagnosis?

Answer: Pneumoperitoneum

  • Most commonly caused by gastrointestinal perforation from etiologies such as peptic ulcer disease, traumatic injury, bowel obstruction, or infection.
  • While CT is the gold standard for diagnosis, a chest x-ray may be utilized to quickly assess for presence of subdiaphragmatic air.
    • Sensitivity of upright chest x-ray to detect pneumoperitoenum varies across studies but is up to 80%.
    • Upright positioning for 10 minutes prior to radiograph or lateral upright positioning may increase sensitivity to over 90%.
    • Specificity is approximately 90%.
  • Management includes emergent surgical consultation, broad spectrum antibiotics with anaerobic coverage, and gastric decompression.

References:

Bogle AM, Gratton MC. Peptic Ulcer Disease and Gastritis. 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.

Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713–16.

Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. Am J Roentgenol 1995;165:45–7.

Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Compartment Syndrome!

Richard ByrneLeave a comment

by Carlos Cevallos M.D.

Case:

A 60 year old male with a PMH of DM, HTN, HLD, MI presents to the ED after being found down with waxing and waning mentation. The patient complains of abdominal pain and diffuse myalgias.

BP 76/56, HR 92, Temp 98.4F, RR 22. 

Physical exam

Pressure wounds of the right rib cage, right side of his forehead

Right calf tenderness with a firm anterior compartment, cool/pale right lower extremity, dorsalis pedis and posterior tibial pulses were unable to be palpated.

ECG:

ECG interpretation: Peaked T waves, widened QRS concerning for hyperkalemia

Clinical course:

1L bolus of LR

IV calcium gluconate for possible hyperkalemia

Surgery was immediately consulted due to concern for compartment syndrome

Labs were notable for a potassium of 7.2, creatinine of 3.49, creatinine kinase of 188,760, a lactate of 4.0, and ALT/AST in the 3,000s/5,000s

Given intermittent hemodynamic instability a dialysis line was placed for definitive hyperkalemia management

Patient underwent emergent lower extremity fasciotomy with surgery

Compartment syndrome learning points:

·       Diagnosis is both clinical and by compartment pressure measurements

·       Compartment pressure >30mmHg or a delta pressure <30mmHg (diastolic BP – compartment pressure) is diagnostic

·       Clinical findings: 6Ps. Pain is the earliest and often only symptom, the rest are late findings.

o   Pain out of proportion to the exam (most common finding)

o   Pallor

o   Paresthesia

o   Paresis/paralysis

o   Pulselessness

o   Poikilothermia

·       Management: Immediate surgical consult for fasciotomy

Friday Board Review

Board Review by Dr. Vidhi Parikh

Vidhi ParikhLeave a comment

43-year-old with woman with history of insulin dependent diabetes and HTN who presents with vision loss of her L eye. Patient states 1 day prior she initially had blurred vision, followed by sudden vision loss 2 hours after the onset of symptoms. Patient with a frontal headache but denies any weakness or numbness. Vitals are as follows: BP- 145/90; HR- 98; T- 98.7; SpO2- 98% on RA; RR- 17. Visual acuity: 20/60 on the R, 20/200 on the L. Patient with intact extra ocular movements and pupils are equal and reactive to light. Fundoscopic exam of the L eye is shown below: 

Acute CRVO

What is the diagnosis? 

  1. Central retinal vein occlusion 
  2. Central retinal artery occlusion 
  3. Bacterial Endocarditis 
  4. Diabetic Retinopathy 
  5. Macular Degeneration 

Answer: A

Patient initially started with blurred vision which then progresses to sudden vision loss which is characteristic of central retinal vein occlusion whereas in central retinal artery occlusion it presents with sudden vision loss. What is pathognomonic on the fundoscopic exam is the blood and thunder appearance. Usually with retinal artery occlusion, a macular cherry red spot is seen. Cotton wool spots are pathognomonic for diabetes/HTN and Roth spots for Endocarditis. 

Central Retinal Artery Occlusion (CRAO) vs Central ...

“Central Retinal Artery Occlusion (CRAO) vs Central …” GrepMed, 1 Oct. 2018, www.grepmed.com/images/3719/centralretinal-management-crao-crvo-ophthalmology.

Diagnosis and management of central retinal vein occlusion. (2020, May 28). American Academy of Ophthalmology. https://www.aao.org/eyenet/article/diagnosis-of-central-retinal-vein-occlusion