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51 year old male, PMH significant only for hypertension presents with sudden onset, heavy chest pain and diaphoresis after running to a code blue in the hospital. Vital signs are normal. He looks pale and sweaty.

Here’s his ECG:

Patient ECG

Although the ST segments in V3 appear concerning, this ECG is ultimately nondiagnostic. Based on the patient’s presentation, there was still significant concern for an acute coronary syndrome. The patient was uncertain he was willing to undergo cardiac catheterization. A bedside ultrasound was performed by the emergency physician.

Here’s a sample:

As you can see in the clips shown, there is apical hypokinesis, indicative of regional ischemia.

After discussing the findings of his bedside echocardiogram with the patient and cardiology consultant, the patient agreed to immediate cardiac catheterization where he had PCI to his completely occluded LAD. The remainder of his course was unremarkable.

Bedside echocardiogram is a powerful tool that can assist the emergency physician in making critical diagnoses, adding information beyond history, physical, and ECG. If you order an ECG, you should strongly consider performing a bedside echocardiogram.

So if you don’t know what a meme is, you probaby should. Its basically a picture with a backstory that people add text to to fit their own inside joke or amusement (better explanation here). So you would think with how involved the emergency medicine community is with the internet through twitter / facebook / podcasts / Life in the Fast Lane, that there would be a plethora of EM memes that docs have created.

Sadly, there are few if any.

I’m wanting this to change; mainly because I’m a dork and like these sorts of things (Im a frequent flyer to Reddit and Imgur). This may just be a fad and die quickly, but Im currently enjoying them and hoping others will jump on as well.

Heres just a few I have made recently. Also the last one was done recently by Joe Lex of Free Emergency Talks. You’re interested in making one, just go to memegenerator.net and find the pic you want that matches your joke. Feel free to tweet me yours @emchatter and I’ll likely retweet it or place it on the site. Enjoy!

The JAMA article he is referring to is here.

So I recently completed this video below on using capnography during cardiac arrest. If you’ve been following #FOAMed for the past several months, there really isn’t any new material for it. It basically sums up everything I learned from various sources like ScanCrit, St. Emlyn’s, and Resus.Me. I actually entered into the SMACC conference PK Talk contest. I actually enjoyed making it quite a bit and plan on making similar videos in the future, if nothing else to force me to understand the literature/material.

There is a reason why there hasn’t been any updates to this site.

I decided to put EMchatter on hold for the past month or two to work on another project. Myself as well as several other physicians who are heavily involved with the online EM world have started a new project we are all pretty excited about.

Emergency Board Review Podcast

We noticed there isn’t much material or tools available online for the emergency medicine inservice and board exams that are 100% FREE. We wanted to change that with this project.

The site (emergencyboardreview.com) is dedicated to everything inservice/board review. It is currently a work in progress, but the plan is for every section (Cardiovascular, Trauma, etc..) will include short to-the-point videos as well as PDF cheatsheets to supplement a resident’s/physician’s study plan. It also includes advice on the best books/question banks/other material available.

Here is a sample of one of the videos for Gastrointestional Disorders:

25 year old female presents with sudden right lower quadrant pain. The pain is sharp and does not radiate. She has a history of kidney stones, but this feels different. She has nausea and loss of appetite. No fever, urinary, or GU symptoms. No chest pain or dyspnea. PMH -asthma and seasonal allergies. PSH – right inguinal hernia repair as infant.

Vital signs normal. Appears in some pain. Diffuse right abdominal tenderness without peritoneal signs. No flank tenderness.

Pretty broad differential for a young female with sudden right abdominal pain. Most concerning would be adnexal torsion or ruptured ectopic pregnancy. Kidney stones and ruptured ovarian cyst would also be high on the list. Appendicitis must be considered, but the sudden onset makes it seem less likely. Biliary colic or cholecystitis also would seem less likely with the sudden onset and symptoms not related to eating. Other less common intestinal or vascular conditions should also be considered.

Here are some samplings of her bedside ultrasound to further explore that differential.

Have to be more careful with that right ovarian cyst . . .

Then back to that gallbladder . . .

Final Diagnosis – acute cholecystitis.

Dispostion – admitted to surgery, OR next day.

Findings of cholecystitis – thickened GB wall, pericholecystic fluid, sonographic Murphy’s sign. This patient had a small stone vs. polyp in the body of the GB.

More importantly, a wide differential explored and final diagnosis reached before labs drawn and without the patient ever leaving her room. No need for other time consuming, costly imaging studies.

All of her labs, including liver enzymes, bilirubin, WBC did come back normal.

Make US a part of your initial bedside eval – save time, save resources, make diagnoses. The whole reason we got in this business.

A 2 y/o male was transferred to our facility for evaluation and treatment following foreign body (FB) ingestion.  The patient swallowed the FB after he was playing outside in the yard.  His parents witnessed him placing the metallic FB into his mouth, but he apparently swallowed it before they could take it away from him.

Initial abdominal radiographs from the referring facility revealed the presence of an irregularly-shaped/amorphous, metallic FB located within the stomach.  The referring ED had discussed the case with our pediatric GI doc who was on call and advised that the patient be transferred to our ED for evaluation and possible endoscopic retrieval.

Upon arrival to the ED the patient's vital signs were age-appropriate.  He was awake, alert, and in no distress.  He had a completely benign abdominal exam.  Given that it had been several hours since the initial radiographs were obtained at the referring facility, repeat x-rays were ordered to see if the FB had progressed beyond the stomach.  Here is the patient's x-ray that was obtained in my ED several hours after the original x-ray:

What is this FB?  Does it require emergent endoscopic retrieval?  What is your next move? 

15 year old male presents via EMS after a moderate speed MVC. Vital signs are HR 118, BP 84/56, RR 20, T 36.3, Pulse ox 98%. He complains of abdominal pain. Primary survey shows:

A-intact

B-equal breath sounds

C-palpable distal pulses, awake

D-anxious, in pain, awake, no gross deficits, no obvious deformities or severe wounds

Primary Survey-reveals only abdominal tenderness, otherwise negative

FAST image (please click picture to enlarge on screen):

This image shows Morrison’s pouch to be clear with no free fluid.

Completion of the FAST exam to include the paracolic gutters shows the 2nd image:

There is clearly fluid in the right paracolic gutter.  With these findings, this patient was taken to the operating room for exploratory laparotomy where he had hemostatic measures to control bleeding from a mesenteric injury. He was eventually able to be discharged from the hospital and made a full recovery.

This case is a good illustration of how the FAST exam is a sonographic examination and more than snapping 4 select pictures. Intraperitoneal blood may lie just beneath the diaphragm, around the solid organs or kidneys, in the paracolic gutters, or within the pelvis. It is important to perform a complete examination of all of these areas. Too often, important traumatic injury may be missed due to an inadequate FAST exam. A complete exam of each side of the abdomen may be accomplished by obtaining views from the diaphragm all the way past the lower poles of the kidneys with multiple wide anterior-posterior sweeps of the transducer.

Some may refer to this as an extended FAST, but I think more should be more correctly called a complete FAST which should include views of the anterior chest to examine for pneumothorax, the heart for cardiac activity and pericardial effusion, the posterior chest for hemothorax, and the abdomen and pelvis for hemoperitoneum. With a little practice, a complete FAST can be done in about 2 minutes and gives valuable information not otherwise available at the bedside via history and physical.

Joseph Minardi and myself created a video a little while back on DVT ultrasound. It was a part of a study we’re currently working on the effectiveness of teaching through video. Its about 15 minutes long and contains just about every you need to know to do a DVT ultrasound at the bedside.

There were a few things we left out I figured I’d mention.

- If you have moderate to high suspicion for DVT and the bedside ultrasound is negative, they will need followup either in the next day or 1 week from then for repeat ultrasound either formal or another bedside. There’s potential for ‘propagation’ where a small segmental DVT which would be missed on the 2-point compression ultrasound will grow and show up later.

- If you have an extremely high suspicion for DVT, most books don’t push for admission, but you can be conservative and lovenox them and then get a formal study in the morning with ultrasound is available.

Feel free to share the video as much as you like.

You are handed the following EKG.

The patient is a middle aged male, complaining of palpitations, mild shortness of breath.  You take a look at it, realize the patient is normotensive, then think to yourself, it is fast, narrow and regular.  Thus the differential is sinus tachycardia, atrial flutter w/ 2:1 block, SVT, or orthodromic WPW.  In further differentiating these you realize the p wave morphology of NSR ( upright in II, down in AVR) is absent.  The rate, around 150 is compatible with any of these 4 rhythms.  Flutter being common at 150, sinus tachycardia (220-age= max sinus tachycardia).  Astutely you watch the monitor and notice the rate does not change, this makes sinus tachycardia less likely, as this will have subtle rate variation.  You also see what you think are retrograde p waves, and no evidence of flutter waves.  Thus you are gaining confidence that this is SVT, and have called for 6mg of adenosine.

As the nurse is pushing the drug, the patients says, “I also was told I have WPW.”  To which you think, hmm.  What to do now. You vaguely remember an online lecture that said this was OK, and lets be honest, giving adenosine is cool, so you go for it.  The patient converts to NSR, and all is well.  Due to some other cormobidities you feel the patient should be observed overnight, and page your friendly cardiology consultant (upper level IM resident).  This resident is appalled at your cavalier treatment, and sasses you up and down about the dangers of giving AV nodal blocking drugs in the setting of WPW.  Not remembering the online lecture too well, you stutter something and say, well, “He’s OK now, please admit.”  After an audible sigh and being hung up on, the patient is admitted.

So whats the answer, who is the ignorant ass, you or the consultant?

WPW is a pre-excitation syndrome that is due to an accessory pathway that bypasses the AV node, this manifests on an EKG as a short PR interval, delta wave, slightly prolonged QRS (>100msec), often L axis, q waves in inferior leads.  Though patients may have normal EKG as well ( see EMRAP July 2012).  The terms orthodromic and antidromic are used to describe the route of conduction.  Orthodromic (from the greek “orthos” meaning straight) implies the initial depolarization is down the AV node, and will have normal QRS as the ventricles are conducting as usual.  Antidromic implies the initial depolarization is down the accessory pathway, and the ventricles are conducting abnormally, similar to bundle b, and thus will have wide QRS.  Why you ask do I clutter your foggy brain w/ such words as orthodromic, one b/c it is fun to lord these over consultants, and also b/c it helps you understand the disease process.

The picture above depicts what is likely happening in our patient.  He is having a re-entrant tachycardia via his accessory pathway.  The complex is narrow b/c the conduction is orthodromic.  If the conduction were reversed/clockwise, this would be antidromic, and he would have a regular wide complex tachycardia.

So getting back to our clinical question, were we wrong to given adenosine.  No.  This is a reciprocating tachycardia, that once broken by a AV nodal blocker such as adenosine will convert to NSR.  Even if this was orthodromic, and thus wide, adenosine would be safe, as this would break circuit, or its V tach, but thats another talk.

So when is it not OK to give AV nodal blockers to patients w/ hx of WPW.  In the setting of atrial fibrillation w/ WPW.  This is due to the fact that there is no circuit to break, only the chaotic fibrillation of the atria sending depolarizing currents down the AV node and accessory node.  So if you block the AV node, you will force all conduction down the accessory pathway, that has no node to block conduction, and will thus conduct a fib at 1:1, around 500bpm, and the patient will suffer accordingly.

The ekg will be fast, rates around 190 and above, will have varying QRS morphology (due to variable conduction down AV node and accessory), and will have wide QRS.  See below:

So how do you treat this.  If unstable, electricity.  If stable you can try procainamide (20mg/min up to 17mg/kg, then infusion at 2-6mg/min).  Why procainamide?  It blocks sodium channels, and can prolong refractory period of accessory pathway.

Why not amiodarone?  This is recommended as 2nd line drug is some algorithms.  I would stay away from it in this setting.  It has strong AV nodal blocking properties, which is just what you want to avoid.

So hope this case helps you with your management of tachydysrhythmias and intellectually deficient consultants.

A few days ago, I picked up a patient who was transferred to our facility for urology consult. Patient had a suprapubic catheter for various reasons and was having gross hematuria. The outside facility had taken out the catheter and replaced it with a new one. Per report, while the patient waiting for lab results for her new hematuria, she was complaining of some groin discomfort.

The nurse did a quick pelvic inspection and saw the foley balloon coming out of the vagina. The physician checked himself and concluded the patient must have a vesicovaginal fistula. The patient was transferred primarily for this abnormality on exam.

Vesiocovaginal what?

A vesicovaginal fistula is a connection between the vagina and the bladder. It usually occurs after vaginal surgery, most common after open hysterectomies. The patients present with watery (urine) vaginal discharge a few weeks after the surgery.

So how do you go about confirming it? And what do you do if you do? Call urology for emergent surgery?

So we placed another suprapubic catheter and flushed 60 cc of our improvised concoction of methylene blue and 250cc of normal saline. Then we did a speculum pelvic exam and looked for blue staining anywhere. And what did we find?

Nothing. No signs of urine or bluish stain. We waited a bit and still nothing.

We came to the conclusion that when the outside hospital nurse initially placed the suprapubic catheter, the end must have came back out of urethra without anyone seeing it. When they filled the balloon, it was already outside the urethra around the entrance of the vagina.

We called the urologist just to confirm our suspicion and they mentioned it’s not uncommon for a suprapubic catheter to accidentally come out of the urethra on initial insertion.They stated it happens all the time in the OR.

Either way, methylene blue was the test of choice to figure out whether or not there was a fistula or not. Rather than a speculum exam, a tampon could be used as well for assessment. Tintinalli mentions if methylene blue can not confirm a fistula, indigo carmine dye should be used as well.

If a fistula is found or highly suspected, the treatment isn’t emergent surgery or even admission. A urethra foley is kept in place to keep the bladder drained with likely fistula repair in the next few weeks in an outpatient setting. The patient can still be discharged (which I always find as a win in my book).

We kept the catheter in and sent the patient back home.