Management of AICDs in the Emergency Department
What is the Diagnosis? By Dr. Cevallos
A 5 week old male with no significant PMH and an uncomplicated gestational/birth history presents to the ED after multiple episodes of projectile non-bilious vomiting. Vital signs include a HR of 165, Temp of 98.5F, RR 35, SpO2 100%. Exam is notable for a dry mucous membranes but otherwise is unremarkable. You perform an abdominal ultrasound and find the image below. What is the diagnosis?
Pyloric Stenosis:
– It is caused by hypertrophy of the pylorus leading to gastric outlet obstruction
– Presents with non-bilious projectile vomiting
– Can lead to hyperchloremic, hypokalemic, metabolic alkalosis
– Most commonly presents between 3-6 weeks of age
– Physical exam may reveal an “olive” sized mass in the epigastric region
– Patients may appear dehydrated with protracted disease but generally patients appear well without any signs of peritonitis or even abdominal tenderness
Diagnosis: Ultrasound is the test of choice (97-100% sensitivity and specificity of 99-100%)
– Think Pi: 3.14!
– In the longitudinal view: Length greater than 14mm and pyloric muscle wall thickness greater than 3mm is abnormal.
This patient underwent a pylorotomy without any complications and was successfully discharged.
Resources:
https://www.acep.org/sonoguide/advanced/pediatric-pyloric-stenosis#:~:text=Hypertrophic%20pyloric%20stenosis%20is%20an,2%2D12%20weeks%20of%20age.&text=Classic%20findings%20include%20projectile%20non,%25%20of%20the%20time%2C%20respectively.
https://www.emrap.org/corependium/chapter/recZCk7ICgxcy7hbM/Infantile-Hypertrophic-Pyloric-Stenosis#h.whcpdchy1ovf
Evolution of STEMI Criteria and How it is Changing, by Dr. Pallavi Patil
Friday Board Review with Dr. Ethan Anderson
A 55-year-old man with end-stage renal disease (ESRD) on hemodialysis presents to the emergency department with complaints of shortness of breath, chest pain, and confusion. His vital signs are as follows: BP 170/100 mm Hg, HR 105 bpm, RR 26 breaths/min, SpO2 88% on room air. His physical exam reveals jugular venous distension, diffuse crackles on lung auscultation, and pitting edema in his lower extremities. A chest X-ray shows bilateral pulmonary edema. His most recent dialysis session was 4 days ago.
Which of the following is the most appropriate initial management for this patient?
A) Administer intravenous nitroglycerin
B) Initiate noninvasive positive pressure ventilation (NIPPV)
C) Administer intravenous furosemide
D) Perform emergent hemodialysis
E) Administer intravenous morphine
Answer: D) Perform emergent hemodialysis
Explanation: This patient is presenting with symptoms of acute volume overload and pulmonary edema, a life-threatening complication in patients with ESRD on dialysis who miss or delay dialysis sessions. His history of missed dialysis, elevated blood pressure, jugular venous distension, pulmonary crackles, and pitting edema all point toward hypervolemia. Additionally, his symptoms of confusion and shortness of breath raise concern for uremic encephalopathy and pulmonary edema.
Emergent hemodialysis is the most definitive treatment in this case, as it addresses both fluid overload and potential uremia by rapidly removing excess fluid and toxins. Other options may provide temporary relief and may be initiated in the ED while awaiting initiation of hemodialysis, but do not address the underlying cause.
- Option A (IV nitroglycerin) may reduce preload and afterload, providing some symptomatic relief, but it does not directly treat the excess fluid or uremia
- Option B (NIPPV) can help improve oxygenation in acute pulmonary edema but is an adjunct and not a definitive therapy for fluid overload in ESRD
- Option C (IV furosemide) is ineffective in patients with ESRD as their kidneys cannot produce urine, making diuresis impossible
- Option E (IV morphine) may reduce dyspnea but is rarely used due to potential side effects like respiratory depression and worsening hypercapnia
References:
- Tintinalli’s Emergency Medicine Manual, 9th Edition
Rib Fractures part 2/Serratus Anterior Nerve Block: By Dr. DeMarzo
A 57 yo F with no relative PMH who presented to the ED one day after experiencing a sudden onset, right anterior chest pain after leaning over into her deep freezer. The pain was sudden onset, not relieved with Tylenol, and made it difficult to take a deep breath as well as sleep the night prior. On physical exam, the patient was uncomfortable, with minimal movement She was tachycardic but otherwise vitals wnl. She had tenderness across her right anterior chest at approximately the 6th or 7th rib. A rib series X-ray was suggestive of a minimally displaced acute fracture of the right anterior 7th rib without a pneumothorax. Despite pain medications, the patient remained in debilitating pain and the ultrasound team was called into action!
Serratus Anterior Block:
Anesthetic can be delivered to either of two locations; either the superficial plane between the latissimus dorsi and the serratus anterior muscles; or the deep plan below the serratus anterior muscle, just above the ribs and intercostal muscles. The deep plane is typically preferred as it can deliver anesthetic directly to the rib near the fracture location, thus increasing anesthetic effects. However, it is also more difficult to reach, especially in patients with large habitus, and has higher risk of secondary injury due to closer proximity to the pleural space. To help reduce this risk, the rib can be used as a “backstop” to help prevent the needle from entering pleura. This can be a very effective way to provide pain relief as Figure 1 below demonstrates the target anatomy.
Figure 1
After identifying the location. A needle specific for ultrasound guided nerve blocks with more echogenicity was utilized in plane with the linear probe in a transverse orientation. The needle was slowly advanced with 1cc of Bupivacaine delivered to the skin surface for initial anesthetic before advancing the needle into deeper layers. Hydro-dissection with saline was done at each plane encountered to verify needle location as well as separate planes for easier viewing and targeting. While the deep plane below the serratus anterior was the original target, the patient’s habitus and needle length was unable to reach the deep plane. Therefore, the superficial plane between the serratus anterior and latissimus dorsi was visualized. Bupivacaine Liposome (Exparel), which can be expected to give 48-72 hrs of relief, was injected into this plane without complication.
Within 5-10 minutes, the patient began to feel immediate relief of her excruciating pain. When the primary team reassessed her shortly thereafter, the patient was almost jumping up and down with relief. She experienced no pain and no dyspnea. On a follow-up phone call 3x days later, the patient continued to endorse being pain-free and was amazed at her remarkable turnaround. This case was a perfect example of the extraordinary benefits that a serratus anterior nerve block can provide.
For a detailed step-by-step video on performing a serratus anterior nerve block please watch the following video:
Resources:
1. Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources?. Am Surg. 2002;68(5):449-453.
2. Gilbertson J, Pageau P, Ritcey B, et al. Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis. Ann Emerg Med. 2022;79(6):529-539. doi:10.1016/j.annemergmed.2022.02.006
3. Serra, S., Santonastaso, D.P., Romano, G. et al. Efficacy and safety of the serratus anterior plane block (SAP block) for pain management in patients with multiple rib fractures in the emergency department: a retrospective study. Eur J Trauma Emerg Surg(2024). https://doi.org/10.1007/s00068-024-02597-6
Advanced Cases: Visual Changes
By Dr. Edward Guo
Case: A 70 year old male with a past medical history of hypertension, type 2 diabetes, and atrial fibrillation on warfarin presents for visual changes. He is accompanied by his daughter who states that about one hour ago, his vision on the right side became blurry. There is associated right facial numbness and headache. His daughter believes that he has become more confused over this time period. Fingerstick glucose is 220. An EKG is obtained which shows atrial fibrillation at a rate of 92.
Exam: VS: BP 151/75, HR 92, T 97.8F, RR 18, SpO2 98%. Pt is comfortable appearing in no acute distress. GCS E4 V4 M6. No facial droop. Decreased sensation to right side of face. 5/5 strength and sensation in all extremities. No difficulty with rapid alternating movements. Extraocular motion intact. Left gaze preference with right sided homonymous hemianopia.
Differential diagnosis: acute ischemic stroke, spontaneous intracranial hemorrhage, complex migraine, toxic-metabolic encephalopathy
Case continued: Neurology is emergently consulted and a stroke alert is activated. CT/CTA of the head and neck shows no acute intracranial hemorrhage and no large vessel occlusion. Labs are notable for an INR of 1.6. The decision is made in conjunction with neurology to administer thrombolytics, and the patient is admitted to neurology critical care. Repeat head CT 24 hours later demonstrates a left parieto-occiptal infarct.
Pearls:
- This patient’s neurologic deficits including right sided facial numbness, right homonymous hemianopsia, left sided gaze preference, and aphasia localize to a cortical distribution as noted above.
- Warfarin use alone is not a contraindication to thrombolytics for acute ischemic stroke. The INR must be > 1.7 in addition to be an exclusion criterion.
- This patient had multiple previous subtherapeutic outpatient INR levels which likely precipitated an embolic stroke.
- In patients without contraindications, the decision to administer thrombolytics for acute ischemic stroke should be clinical without waiting for results of laboratory testing with the exception of a point of care glucose and patients with suspected coagulopathy.
- Other common exclusion criteria to use of thrombolytics in acute ischemic stroke include previous head trauma or stroke within 3 months, any previous intracranial hemorrhage, SBP > 185 or DBP > 110, or known intracranial mass such as neoplasm or aneurysm.
References:
Go S, Kornegay J. Stroke Syndromes. 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.
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association [published correction appears in Stroke. 2018 Mar;49(3):e138] [published correction appears in Stroke. 2018 Apr 18;:]. Stroke. 2018;49(3):e46-e110. doi:10.1161/STR.0000000000000158
Hyperkalemia with Dr. Brett DerGarbedian
Friday Boad Review with Dr. Ethan Anderson
A 65-year-old male presents to the emergency department with complaints of severe shortness of breath and chest pain. He has a history of myocardial infarction and congestive heart failure. On physical exam, he is diaphoretic, hypotensive with a blood pressure of 80/50 mmHg, heart rate of 120 bpm, and jugular venous distension. His lungs reveal crackles bilaterally. An ECG shows ST-segment elevation in the anterior leads, and troponin levels are significantly elevated. Bedside echocardiography reveals an ejection fraction of 25% with global hypokinesis.
Which of the following is the most appropriate immediate treatment?
A) Intravenous fluids bolus
B) Nitroglycerin infusion
C) Norepinephrine infusion
D) Non-invasive positive pressure ventilation
Answer: C) Norepinephrine infusion
Explanation:
This patient is in cardiogenic shock, likely secondary to acute myocardial infarction (AMI) based on his history, clinical presentation, and ECG findings.
Norepinephrine is widely recommended as a front-line agent for cardiogenic shock. Norepinephrine will improve the blood pressure, but there is a risk that excessive afterload could drop the cardiac output. The cath team should be notified ASAP if MI is the suspected cause of cardiogenic shock. Early consultation of the heart failure team can help guide further management if available at your institution.
Key Points:
- Cardiogenic shock occurs when there is inadequate tissue perfusion due to the failure of the heart as a pump. It is typically characterized by hypotension, signs of poor perfusion (cold extremities, altered mental status), and pulmonary congestion.
- The most common cause is an acute myocardial infarction (AMI), leading to severe left ventricular dysfunction. Other causes include Takotsubo, Peripartum Cardiomyopathy, Myocarditis, and Tachymyopathy
Choices:
- A) Intravenous fluids bolus: Fluid boluses are generally avoided in cardiogenic shock because the failing heart cannot effectively pump the excess fluid, which can worsen pulmonary edema. This patient already shows signs of volume overload (crackles in the lungs and jugular venous distension).
- B) Nitroglycerin infusion: Although nitroglycerin can reduce preload and improve ischemia in stable patients with myocardial infarction, it is contraindicated in this case due to the patient’s hypotension. Reducing preload or blood pressure further would worsen the shock.
- C) Norepinephrine infusion: This is the correct answer. In cardiogenic shock, vasopressors such as norepinephrine are used to maintain perfusion by increasing systemic vascular resistance and cardiac output. Norepinephrine is often preferred because it has strong vasoconstrictive effects and some inotropic support, making it suitable for patients in cardiogenic shock with hypotension.
- D) Non-invasive positive pressure ventilation (NIPPV): While NIPPV can help manage pulmonary edema and improve oxygenation, it does not address the underlying hypotension or poor cardiac output, which are the primary concerns in this case. This may be useful in conjunction with vasopressors but is not the initial definitive treatment for shock.
Takeaway: In patients with cardiogenic shock, the first-line treatment often includes vasopressors, such as norepinephrine, to stabilize blood pressure and ensure adequate organ perfusion while addressing the underlying cause (e.g., revascularization in myocardial infarction).
References:
- Tintinalli’s Emergency Medicine Manual, 9th Edition
- Internet Book of Critical Care
Journal Club: Analgesia for Renal Colic
Rib Fractures Part 1: Dr. DeMarzo
Rib fractures can be an incredibly painful condition for patients that is not only painful but also can make breathing difficult and lead to atelectasis and pneumonia. Correct diagnosis of a rib fracture as well as the exact location can help narrow down a differential as well as guide targeted treatments. Diagnosis of fractures can be clinical, but most providers will order imaging. According to the American College of Radiology, in minor blunt trauma that results in only an injury to the ribs, a chest X-ray is rated as “Usually Appropriate” while a rib view radiography is designated a step lower at “May Be Appropriate”. Of note, a rib view radiography is rated as “Usually Appropriate” for any pathologic fractures (i.e Underlying malignancy, metabolic disorders). While useful in identifying secondary injuries such as pneumothorax or flail chest, a chest x-ray can have sensitivities as low as 50% [1]. In the ED CT scans is the standard method through which rib fractures are identified.
A lesser known and utilized diagnostic method is the use of ultrasound, which is becoming more commonly employed in Emergency Departments. While skill level varies and heavily affects results, ultrasound is an effective tool to not only diagnose rib fractures, but also can help deliver a nerve block which provides much needed relief. In fact, in the hands of an experienced provider, ultrasound can be more effective than radiographs; a 2022 meta-analysis of 7 studies with 660 patients demonstrated chest ultrasonography achieving a pooled sensitivity of 89.3% and specificity of 98.4%. [2]
What are we looking for on Ultrasound?
- A rib fracture is best visualized in a long view of the rib which would be best classified as a transverse view.
- A fracture is best visualized by tracing the outer edge of the rib to visualize any breaks, bulges, or mismatched ends.
- The best way to find the fracture: Ask the Patient! Ask them to point to the spot of their worst pain and begin probing there.
- Some compression given to the probe may identify buckle fractures as seen in Figure 2 below:
Figure 1: Transverse fracture
(Source: https://doi.org/10.1002/sono.12176)
Figure 2: Buckle fracture (visualized w/ compression)
(https://radiopaedia.org/cases/buckle-rib-fracture-on-ultrasound)
Resources:
- Bansidhar BJ, Lagares-Garcia JA, Miller SL. Clinical rib fractures: are follow-up chest X-rays a waste of resources?. Am Surg. 2002;68(5):449-453.
- Gilbertson J, Pageau P, Ritcey B, et al. Test Characteristics of Chest Ultrasonography for Rib Fractures Following Blunt Chest Trauma: A Systematic Review and Meta-analysis. Ann Emerg Med. 2022;79(6):529-539. doi:10.1016/j.annemergmed.2022.02.006