Episod 28: US in Dyspnea – Part 1

She’s short of breath.  Has a history of CHF, COPD, cancer, and has had a cough today…

Sound familiar?  Undifferentiated dyspnea can be a challenge.  But you know me, I’m a sucker for anything 1,540 m/s, and US is usually the answer.  Fortunately, EM Chief Resident, FOAM US superstar, and resident US guru Jacob Avila (@UltrasoundMD) agrees, and he wanted to teach you all how to use US to solve this concerning clinical conundrum.  The possibilities are endless, but Dr. Avila shows you how to simplify your clinical decision making and make the right call. 

How good is physical exam in this very scenario?  Can you tell the difference between CHF and COPD with US?  What about pneumothorax?  And how to you figure out if that effusion is causing tamponade?  Dr. Avila has got it all covered in Part 1.  And in part 2, coming next week, there will be even more goodness - PE, DVT, pneumonia - we’ve got it all.  

Make sure to check out Jacob and his great blog, 5 Minute Sono.  While you’re at it, Jacob works a bunch with Ben Smith, who has a great US blog himself - give him a look as well.  Also, check out the EM Res Podcast Google Community.  Check out our example videos and Dr. Avila’s References below, and then enjoy the podcast!

This episode and part two will be eligible for Asynchronous Learning - look for the quiz after part 2.  After answering the short questions in the quizzes, you can print out a certificate that says you spent time listening to the podcast and doing the quiz.  My hope is, that with approval from your individual US EM Residency program directors, you can count this toward individual interactive instruction time (also known as asynchronous learning) if you are in a US EM residency program.  As stated, make sure your program director approves of this before you go chalking this up as asynchronous time.    






Check out Dr. Avila’s amazing summary of references!

Episode 27: Momentum Breakers, Part 2

In Epsiode 27, EM Resident contributor Dr. Joseph Cruz of edocc.com rounds out his top 5 ED shift momentum breakers for the EM resident.  We have talked about the importance of mental simulation and preparation for your shifts before.  It is just as important to think about what is going to slow you down or stop you in your tracks on your next shift.  

If you are interested in helping contribute to the EM Res Podcast, let me know.  I am always happy to have resident contributors as well.  Make sure to check out Joseph’s blog, The ED on Cruise Control.  Follow him on Twitter @CruzaderJC.  Our next few episodes will be coming from another guest resident contributor, Jacob Avila (@UltrasoundMD), who will be talking about the use of US in undifferentiated dyspnea.  

Also, make sure to check out the EM Res Podcast Google community, and head on over to Emergency Board Review if you are interested in helping out with a completely free resource for EM board review!  

Episode 26: Momentum Breakers, Part 1

In Epsiode 26, we have a new EM Resident contributor to the EM Res Podcast.  In Part one of a two part episode, Dr. Joseph Cruz of edocc.com discusses 5 of his 10 ED shift momentum breakers.

We have talked about the importance of mental simulation and preparation for your shifts before.  It is just as important to think about what is going to slow you down or stop you in your tracks on your next shift.  

If you are interested in helping contribute to the EM Res Podcast, let me know.  I am always happy to have resident contributors as well.  Make sure to check our Jospeh’s blog, The ED on Cruise Control at www.edcc.com.  Follow him on Twitter @CruzaderJC

Also, make sure to check out the EM Res Podcast Google community, and head on over to www.emergencyboardreview.com if you are interested in helping out with a completely free resource for EM board review!  

Podcast Episode 25: Pediatric Appendicitis

In what two age groups is perforated appendicitis most common?  If you said the very young and the very old, you would be correct.  As we all know, the workup and diagnosis of appendicitis in kids can be extremely difficult.  There are communication barriers, distractors, and mimickers.  So how do we tease out the right history and get to the correct conclusion?

In this episode, we discuss many of the more difficult and important aspects of the workup for a child with possible appendicitis.  Can physical exam change your pretest probability?  Can you do labs without imaging, or is it an all or nothing workup?  what about documentation and follow up?  How do you handle the indeterminate ultrasound?  Do you use oral contrast if CT is needed, or IV only?  

In this conference, we have a panel of five of our best and brightest attendings discussing these issues and more.  You’ll hear from:

  • Dan Kaminstein, MD: You’ve heard him before, international medicine and ultrasound expert
  • Tom Kehrl, MD: From the Airway tips and tricks episode, and our EUS fellowship director
  • Andy Kepner, MD: Emergency Physician with a surgical background and director of our sim center
  • Erik Kochert, MD: Also a frequenter of the EM Res podcast, APD and Research director
  • Jess Riley, MD: Emergency physician with both academic and community experience
  • Bob Stuntz, MD: You know me

This episode does run longer than the typical episode, but it is chock full of good pearls.  Let us know what you think in the comments below, or head over to the Google Community to discuss this episode.

References:  

  1. Bundy DG1, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.  Does this child have appendicitis?  JAMA. 2007 Jul 25;298(4):438-51.
  2. Ebell MH1, Shinholser J2.  What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review.  Ann Emerg Med. 2014 Apr 11.
  3. Ohle R1, O’Reilly F, O’Brien KK, Fahey T, Dimitrov BD.  The Alvarado score for predicting acute appendicitis: a systematic review.  BMC Med. 2011 Dec 28;9:139.
  4. Meltzer AC1, Baumann BM, Chen EH, Shofer FS, Mills AM.  Poor sensitivity of a modified Alvarado score in adults with suspected appendicitis.  Ann Emerg Med. 2013 Aug;62(2):126-31.
  5. Ross MJ1, Liu H, Netherton SJ, Eccles R, Chen PW, Boag G, Morrison E, Thompson GC.  Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound.  Acad Emerg Med. 2014 May;21(5):538-42.
  6. Estey A1, Poonai N, Lim R.  Appendix not seen: the predictive value of secondary inflammatory sonographic signs.  Pediatr Emerg Care. 2013 Apr;29(4):435-9.
  7. Bachur RG1, Dayan PS, Bajaj L, Macias CG, Mittal MK, Stevenson MD, Dudley NC, Sinclair K, Bennett J, Monuteaux MC, Kharbanda AB; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.  The effect of abdominal pain duration on the accuracy of diagnostic imaging for pediatric appendicitis.  Ann Emerg Med. 2012 Nov;60(5):582-590.
  8. Leeuwenburgh MM1, Stockmann HB, Bouma WH, Houdijk AP, Verhagen MF, Vrouenraets B, Cobben LP, Bossuyt PM, Stoker J, Boermeester MA; OPTIMAP Study Group.  A simple clinical decision rule to rule out appendicitis in patients with nondiagnostic ultrasound results. Acad Emerg Med. 2014 May;21(5):488-96.
  9. Elikashvili I1, Tay ET, Tsung JW.  The effect of point-of-care ultrasonography on emergency department length of stay and computed tomography utilization in children with suspected appendicitis.  Acad Emerg Med. 2014 Feb;21(2):163-70.
  10. Yu CW1, Juan LI, Wu MH, Shen CJ, Wu JY, Lee CC.  Systematic review and meta-analysis of the diagnostic accuracy of procalcitonin, C-reactive protein and white blood cell count for suspected acute appendicitis.  Br J Surg. 2013 Feb;100(3):322-9.
  11. Kwan KY1, Nager AL.  Diagnosing pediatric appendicitis: usefulness of laboratory markers.  Am J Emerg Med. 2010 Nov;28(9):1009-15.

Either click here to listen to the podcast, or check out the episode embedded below:


Asynchronous learning quiz: Coming Soon!

A Young woman with chest pain: The Conclusion

Let’s welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Here is a link to the original post in case you missed it, and here is the answer…

-Bob

Diagnosis: Spontaneous LAD dissection

This is an unusual diagnosis that is mainly described as case reports in the literature.  In 1996 only 100 cases in the world had been identified (2). Of these reported cases, 75% were diagnosed at autopsy and the rest were diagnosed with coronary angiography (1). The majority of these cases (approximately 75%) were in women, and of these cases, 32% of the patients were pregnant, post-partum, or taking oral contraceptives (2). One study in 2009 observed that one out of ten women under the age of 50 who clinically presented with ACS instead had a coronary dissection on coronary angiography (3). 

LAD dissection is considered especially disastrous and results in malignant arrhythmias, severe CHF, extensive infarct and sudden death (2). The clinical presentation of coronary dissection is similar to that of a patient having an acute MI, but they are usually younger and without the cardiac risk factors.  It is important to note that spontaneous coronary dissection can be recurrent. The etiology of this disease is unclear, but some autopsies have demonstrated an eosinophilic penetration of the tunica adventitia and it is postulated that this subsequently causes damage to the collagen, elastin and smooth muscle wall (2). Treatment options for these patients include medical management only versus stenting versus bypass surgery. There is no treatment standard at this time and the prognosis of these patients who survive is unknown. However, the case reports overall seem to demonstrate that at least one year post-event survival rate is quite high. 

For our case presentation, the patient was emergently taken to the cath lab where her diagnosis of spontaneous LAD dissection was made. She was stented at this time and started on Aspirin, Metoprolol, and Effient.  She had a complicated hospital course, developing pericarditis, a small pericardial effusion,  and a new apical thrombus. Ultimately, however, after a week her symptoms had dramatically improved and she was discharged home. 

Spontaneous coronary dissection is a rare but rapidly fatal diagnosis that should be considered in the differential diagnosis of young patients who present with symptoms of ACS; it can be both diagnosed and treated in the cath lab.  Remember that diffuse ST segment elevation in the younger patient with chest pain will not always equate to a diagnosis of pericarditis.

  1. Spontaneous Coronary Artery Dissection, Aneurysms, and Pseudoaneurysms: A Review. Echocardiography. 2004: 21(2), 175-182.
  2. Zampieri et al. Follow up after spontaneous coronary artery dissection: a report of five case series; Heart.1996: 75, 206-209.
  3. Vanzetto, et al. Prevalence, therapeutic management and medium-term prognosis of spontaneous coronary artery dissection: results from a database of 11,605 patients. European Journal of Cardio-thoracic Surgery. 2008: 35 (3), 205-254. 

A young woman with chest pain

Let’s welcome Dr. Shafer back to the blog.  Between being a chief resident and being accepted in to a critical care fellowship, she has another interesting case presentation for you.  Some really interesting learning points on this one.  Stay tuned for the answer! 

-Bob

Dr. Shafer: 

    A 28 year old female presents to the ED with a chief complaint of chest pain that started acutely at 3am this morning and awoke her from sleep. She reports that pain is in the center of her chest and is constant, nothing makes it better or worse, and it is not positional.  She woke up vomiting this morning and additionally feels short of breath and is diaphoretic. She states that she feels weak all over and has bilateral arm numbness. She has not had any recent URI symptoms. She does not abuse alcohol but she does use marijuana occasionally. She smokes ½ pack of cigarettes per day. There is no family history of cardiac disease or of sudden deaths. She has no prior past medical history and takes no medications. 

    Vital signs are as follows: HR 108, BP 165/98, RR 18, Oral Temp 98.6F, oxygen saturation is 100%. On exam she pale, diaphoretic, is leaning forward clutching her chest and appears uncomfortable. Lungs are clear to auscultation bilaterally, heart is normal rate and rhythm without murmurs/rubs/gallops. She has normal strength and sensation to light touch in bilateral upper and lower extremities, cranial nerves are intact, and has 2+ radial pulses bilaterally. 

    Her EKG is shown below. Cardiology was immediately consulted due to the patient’s appearance; they evaluated the patient at the bedside and diagnosed the patient with pericarditis. CT thorax was obtained which revealed no dissection or PE.  A bedside echocardiogram reveals a normal EF with concerns for apical wall motion abnormalities.  Pertinent labs revealed a white count of 18.8, troponin 3.15, lactic acid 3.6, and a normal BNP.



What is on your differential at this point?

What further testing could be done to evaluate the patient?  

Have a diagnosis in mind?