ICE 014

A 24 year old woman presents to ED with a 12 hour history of shortness of breath and left sided pleuritic chest pain. She has no significant past medical history and is on no regular medications. Her vital signs are normal.

  • Describe and interpret her chest X-Ray
  • What treatment is required ?
  • What follow up management and advice is needed ?

CXR

The CXR shows a large left sided pneumothorax. The rim of lung is visible about 3cm from the chest wall at the lung apex and 2cm from the mid/upper zone laterally. There is no obvious underlying lung abnormality or chest wall trauma, and no displacement of midline structures that can indicate tension. Estimating pneumothorax size is well known to be difficult, with only broad estimates generally possible unless volume is formally measured with a CT scan (and this isn’t usually needed). As a rule, if the lung rim is only visible at the apex it is small (< 2 cm), if visible and larger than this it is large or complete.

The most appropriate management for spontaneous pneumothoraces of this size (and indeed of any size) is an area that generates substantial debate. Opinions will range from just observe and await spontaneous resolution at one extreme to insertion of a large bore intercostal catheter connected to underwater seal drainage at the other extreme. Unfortunately the evidence on which to base treatment for spontaneous pneumothorax is weak. What is clear is that needle aspiration and small intercostal catheters can be effective and the only absolute indications for drainage are significant underlying lung disease or respiratory compromise.

A follow up CXR (timed to document expected complete re-inflation) is useful. Consider issues like flying, diving and advice re smoking cessation.

More information:

BTS guideline 2010

Life in the Fast Lane

 ICE Ian's Clinical Emergencies

RSR 002

 

Here’s the latest literature surf from Associate Professor Michael Ragg.
Check out his take on the studies below, and the PDF summary RSR 002

tahiti surf

3waveEarly cardiac cath improved survival in cardiac arrest without STEMI [1]

I have given this paper published in Resuscitation ‘3 waves’  as it supports our push to get these patients to the cath lab even if the ECG does not show a STEMI. An impressive reduction in the risk of death.

3waveEndovascular or open repair for ruptured AAA: outcomes from IMPROVE [2]

So basically in 613 patients in 30 different vascular units, there were no statistically significant differences between endovascular and open management of ruptured AAAs in terms of 30 day mortality.

3waveTargeted Temperature Management at 33 C versus 36 C after Cardiac Arrest [3]

A potential game changer ?  Why are we cooling patients? Or is it saying just don’t let them get warm ( > 37.5C). Most definitely worth a read, my take is to continue doing what we do now and await expert consensus. There has been much discussion about this paper in relation to the clinically relevant benefit of preventing the development of fever as well the impact of healthcare workers not being blinded during the study.

2waveUltrasonography by emergency physicians for proximal lower extremity DVT   [4]

2wavePrehospital Mild Hypothermia on Survival of Adults With Cardiac Arrest    [5]

2waveMeta-analysis of myocardial infarction from oral direct thrombin inhibitors      [6]

2waveSaline Versus Plasma-Lyte A in Initial Resuscitation of Trauma Patients      [7]

2waveLimited transthoracic echocardiogram (LTTE) as a monitoring tool in trauma      [8]

2waveInduced Hypothermia in Severe Bacterial Meningitis      [9]

2waveColloids v Crystalloids for hypovolaemic shock      [10]

1waveHyperglycemic Control in Pediatric Intensive Care [11]

1waveMechanical Compressions and Defibrillation vs CPR in Cardiac Arrest  [12]

1waveOutpatient Versus Hospital Management for Uncomplicated Diverticulitis [13]

1waveHES Reduces Coagulation and Increases Blood Loss During Major Surgery [14]

1waveChest compression depth and survival in out-of-hospital cardiac arrest  [15]

1wavePelvic fracture management with a pelvic “blush” on early CT [16]

 

 

References

1. Hollenbeck R. et al   Early cardiac catheterization is associated with improved survival in comatose survivors of cardiac arrest without STEMI. Resuscitation Volume 85, Issue 1, Pages 85-95, January 2014 doi:10.1016/j.resuscitation.2013.07.027

2. IMPROVE trial investigators Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial  BMJ 2014;348:(Published 13 January 2014) doi: http://dx.doi.org/10.1136/bmj.f7661

3. Neilsen M., et al Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest N Engl J Med 2013; 369:2197-2206 December 5 2013  DOI: 10.1056/NEJMoa1310519

4. Crowhurst T, Dunn R  Sensitivity and specificity of three-point compression ultrasonography performed by emergency physicians for proximal lower extremity deep venous thrombosis  Emergency Medicine Australasia  Volume 25, Issue 6, pages 588–596, December 2013 doi:  10.1111/1742-6723.12155

5. Kim F. et al Effect of Prehospital Induction of Mild Hypothermia on Survival and Neurological Status Among Adults With Cardiac Arrest : A Randomized Clinical Trial  JAMA. 2014;311(1):45-52. doi:10.1001/jama.2013.282173

6.  Artang R. et al  Meta-analysis of randomized controlled trials on risk of myocardial infarction from the use of oral direct thrombin inhibitors  Am J Cardiol. 2013 Dec 15;112(12):1973-9 http://dx.doi.org/10.1016/j.amjcard.2013.08.027

7. Young et al  Saline Versus Plasma-Lyte A in Initial Resuscitation of Trauma Patients: A Randomized Trial  Annals Surg 2014 February 2014 – Volume 259 – Issue 2, doi: 10.1097/SLA.0b013e318295feba

8.  Ferrada P et al,  Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay.  Journal of Trauma and Acute Care Surgery. 76(1):31-38, January 2014. doi: 10.1097/TA.0b013e3182a74ad9

9.  Mourvillier B et al   Induced Hypothermia in Severe Bacterial Meningitis: A Randomized Clinical Trial  JAMA. 2013;310(20):2174-2183  doi: 10.1001/jama.2013.280506

10.  Annane D et al, Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock  The CRISTAL Randomized Trial JAMA. 2013;310(17):1809-1817. doi:10.1001/jama.2013.280502

11.  MacRae D et al A Randomized Trial of Hyperglycemic Control in Pediatric Intensive Care.  N Engl J Med 2014; 370:107-118 DOI: 10.1056/NEJMoa1302564

12. Rubertsson S et al, Mechanical Chest Compressions and Simultaneous Defibrillation vs Conventional Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest : The LINC Randomized Trial  JAMA. 2014;311(1):53-61. doi:10.1001/jama.2013.282538

13  Biondo S et al  Outpatient Versus Hospitalization Management for Uncomplicated Diverticulitis: A Prospective, Multicenter Randomized Clinical Trial (DIVER Trial)  Annals surg January 2014 Vol 259, Issue 1, p 38-44 doi: 10.1097/SLA.0b013e3182965a11

14.  Rasmussen, K, et al  Hydroxyethyl Starch Reduces Coagulation Competence and Increases Blood Loss During Major Surgery: Results From a Randomized Controlled Trial  Annals of Surgery. 259(2):249-254, February 2014. doi: 10.1097/SLA.0000000000000267

15:  Vadeboncouer T et al,  Chest compression depth and survival in out-of-hospital cardiac arrest Resuscitation Volume 85, Issue 2, Pages 182-188, February 2014 doi:10.1016/j.resuscitation.2013.10.002

16.  Verbeek D. et al ,  Management of pelvic ring fracture patients with a pelvic “blush” on early computed tomography, Journal of Trauma and Acute Care Surgery. 76(2):374-379, February 2014 , doi: 10.1097/TA.0000000000000094

Final prep for the ACEM Fellowship exam

 

ACEM logoHere are some suggestions for ACEM trainees on how to get the best out of the last few weeks leading up to their Fellowship examination. The first hurdle of the two exam sections is the written paper; a big leap is required with three separate papers on the one day, and being in peak form for this is essential for overall success. I’m going to assume that leading up to these final weeks, you’ve committed yourself consistently to study (preferably in a group) for > six months, written practice answers under examination conditions, had at least some of these viewed and marked by an ACEM examiner, and sat a full practice written exam to time to test your technique under fire. I can’t emphasise enough the importance of writing multiple back to back SAQ and VAQ answers to the ACEM time limits.

  • Aim to feel healthy, well rested, and mentally ready when the big day arrives. This means you must quarantine a little time to spend with your partners, friends and family, and do the non-medical things that make you happy (eg sport, leisure…) as well as study. Clearly not to excess, but I believe it’s a grave mistake to become a hermit for the last two weeks memorising slabs of Rosen whilst maintaining your GCS with coffee and adrenaline.
  • Knowledge-wise, you shouldn’t be acquiring large chunks of new information now, rather transitioning into revision of key topics of the curriculum. This means becoming fluent in your understanding of all frequently used in ED / ACEM-examined algorithms and guidelines, and immediate management of sentinel critical illnesses. Not just simple management steps, try to always consider the departmental and broader issues relating to staff, education and quality therein. Highlight areas of controversy or emerging information, or where management is complex and not evidenced based, as these represent higher level analysis of issues and earn higher marks.
    One good technique is to divide up revision topic areas within your study group so all contribute, particularly with an eye towards recently / recurrently / never used topics in the FE curriculum. (especially those marked “expert” level in the curriculum) Often you will predict and be prepared for several of the questions in your exam this way.
  • All of us have certain areas of knowledge that are hard to remember yet still important – make some simple flow diagrams of these or flash cards and try to review them frequently in the last week to top up your short term memory. Try and make some ordered lists of commonly encountered data, for example long QT in ECGs, causes of hyponatraemia or drugs adsorbed by charcoal… Share them within your group.
  • Overall there aren’t many possible different ECG and blood gas questions that can be asked, so you can be on top of these by reviewing say, the last 10 exam’s questions on these topics in the archive in Life in the Fast Lane, ensuring you can handle them comfortably in the time allowed.
  • I think it wise to avoid the more up to date podcasts, blogs, and social media reviews in the last few weeks, as whilst informative and entertaining, are unlikely to be the core material tested in the quiz.
  • Finally, visualise and plan every detail beforehand to ensure that you’ll arrive at the exam site seamlessly. This includes travel, accommodation, meals, timers, pens etc. Plan it like an assault on the summit of Mt FACEM, leave no details to the last minute, and factor in a little time for unexpected last minute issues. This will give you the best chance of optimally demonstrating your hard earned knowledge to the examiners.

Clearly this list of recommendations isn’t exhaustive – ask your recently successful colleagues and teachers for strategies that worked for them, and employ the ones that suit you personally. I’d love to hear these too…

ICE 013

A 36 year old man has just completed a marathon. He develops chest heaviness, shortness of breath, nausea and feels dizzy and faint.

He has no known past medical history and considers himself to be in excellent health, regularly competing in long distance running events.

His current basic observations are normal. This ECG was performed on his arrival in the ED.

  • What are the abnormal findings on his ECG?
  • What conditions could explain the ECG findings?
  • What further diagnostic tests are appropriate?

ECG ICE 013

 

The ECG shows:

  • Sinus bradycardia at 54 bpm
  • PR interval 200 msec
  • Elevated ST segments inferiorly and anteriorly with raised / notched J point
  • Slightly concave upward ST segment morphology, except straight in V2
  • Voltage criteria for LVH
  • Prominent and peaked T waves especially in V2 – 6

 

These ECG findings could be consistent with acute anterolateral myocardial ischaemia and this needs to be the working diagnosis until proven otherwise. They could also be due to an as yet undiagnosed hypertrophic cardiomyopathy. The most probable cause however is so called “athletes heart”, a benign condition characterised by increased left ventricular muscle mass and cavity size due to athletic conditioning. As well as producing repolarisation abnormalities as seen on this ECG it can also produce bradycardia, first & second degree AV heart block, and RBBB .

Although a troponin would almost certainly be performed in this man it is unlikely to help initially as most endurance athletes have elevated troponins at race end. The most useful test would be an echocardiogram, as this will definitively diagnose hypertrophic cardiomyopathy and the wall motion abnormalities of acute ischaemia. It is particularly important to fully investigate such patients if they have QT prolongation on the ECG or a family history of cardiomyopathy or sudden premature cardiac death.

 

More information at ECGpedia

 ICE Ian's Clinical Emergencies

RSR 001

tjdogma is excited to welcome a new regular contributor to the team!

Associate Professor Michael Ragg will post a regular RSR report of his latest surf of the important journal articles relevant to emergency and critical care medicine, with his rating of their importance to practising clinicians. He’ll score them one, two or three “waves” to help highlight the most worthwhile and important.

There will be a PDF of the summary (e.g. RSR 001) and a short synopsis posted on the site…

bells 2

3wave Severe Sepsis and Septic Shock [1]

Derek Angus’ article is a fabulous review of this subject. It has an evidence based approach as well as talking about new strategies in severe sepsis. A must read for anyone managing this group of patients.

3wave A Randomized Trial of Colchicine for Acute Pericarditis [2]

In this multicentre, double blind study of 240 patients, colchicine significantly reduced the rate of symptom persistence at 72 hours, the number of recurrences per patient and the hospitalisation rate. Adverse effects and rates of study drug discontinuation were same between colchicine and control groups. Worth a read of full paper.

3waveEffect of Heart Rate Control With Esmolol [3]

Though only a small study, this is real food for thought. It is an open label study which means no blinding occurred. As a result we cannot really rely on the results such as the dramatic difference in 28 day mortality ( 49.4% esmolol group vs 80.5% control group). It definitely needs a further definitive study however I have given it 3 “waves” because of the future implications of how we might (I repeat might) treat severe sepsis

3waveAcute Cholecystitis: Early Versus Delayed Cholecystectomy [4]

Once again randomised but open label so risk of selection bias. Nonetheless, in over 600 patients with acute cholecystitis, having an early ( <24 hour) laparoscopic cholecystectomy led to improved morbidity rate and shortened hospital length of stay when compared with initial IV antibiotics followed by a later (days 7-45) procedure. The conversion rate to an open procedure was the same in the 2 groups

2waveEdoxaban versus Warfarin [5]

1waveTaking blood cultures from a newly established intravenous catheters [6]

 

If you have any comments or suggestions for the new series? Michael and I would love to hear them!

References:

  1. Angus DC, van der Poll, T. Severe Sepsis and Septic Shock. N Engl J Med 2013; 369:840-851 doi 10.1056/NEJMra1208623
  2. Imazio M et al. A Randomized Trial of Colchicine for Acute Pericarditis. N Engl J Med 2013; 369:1522-1528 October 17, 2013 doi: 10.1056/NEJMoa1208536
  3. Morelli A et al. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock A Randomized Clinical Trial. JAMA. 2013;310(16):1683-1691. doi:10.1001/jama.2013.278477.
  4. Gutt CN, Encke J et al. Acute Cholecystitis: Early Versus Delayed Cholecystectomy, A Multicenter Randomized Trial (ACDC Study, NCT00447304). Ann Surg. 2013 Sep;258(3):385-93. PMID 24022431
  5. Hokusai-VTE Investigators. Edoxaban versus Warfarin for the Treatment of Symptomatic Venous Thromboembolism. N Engl J Med 2013; 369:1406-1415 October 10, 2013 DOI: 10.1056/NEJMoa1306638
  6. Kelly AM, Klim S. Taking blood cultures from a newly established intravenous catheter in the emergency department does not increase the rate of contaminated blood cultures. Emergency Medicine Australasia Volume 25, Issue 5, pages 435–438, October 2013 DOI: 10.1111/1742-6723.12121