Happy New Year… Come work with us!

2015 is about to arrive, and the year ahead promises to be an exciting one for INTENSIVE and The Alfred ICU.

We plan to continue creating engaging educational ICU content on INTENSIVE, including more echo/ ultrasound, labs and lytes, journal club, “everything ecmo”, exam resources and lots more.

The education programme at The Alfred ICU continues to evolve as we try to provide the best possible learning opportunities for our trainees. 2015 will see more simulation, more trainee and interprofessional involvement in education and even more fun!

The Alfred ICU Courses for 2015 are filling fast, and includes a few new options this year: the ‘Critically Ill Airway’ course, ‘The Science & Art of Intensive Care Research’ Course as well as the 2015 Infectious Diseases & Critical Care Conference. Check out all the courses and conferences here.

Finally, and most importantly, there are still Senior Registrar and Fellow positions available for 2015, including a position starting in February 2015. If you meet the criteria, we’d love to welcome you to the team. To learn more about the position and how to apply click here.

Happy New Year!

The post Happy New Year… Come work with us! appeared first on INTENSIVE.

ICE 016

The previous evening, a 59 year old man experienced an hour long episode of chest pain which resolved spontaneously. He has had no further chest pain, but encouraged by his family he presents to ED the next morning. A bedside cardiac troponin test is negative. This is his ECG taken at the same time.

ECG 1Describe his ECG

What do the ECG findings signify ?

How should this patient be managed?


The ECG shows sinus rhythm at 60 /minute, with abnormal ST/T wave changes in V1 through V5 but most marked in leads V2, V3 & V4. There are biphasic T waves in V2 & V3 with the negative component of the T wave being deeply so. In V4 there is very deep T wave inversion.

These particular ECG findings are called a Type 1 Wellens’ pattern. (The other and more common Type 2 Wellens’ pattern with only deep T inversion in V2 – V4 is shown in the ECG underneath this answer) Wellens’ pattern ECGs very likely signify severe stenosis of the left anterior descending coronary artery. They were only first described as an ECG syndrome in the early 1980s and named after the author of the first publication on it. At other times it has been called Wellens’ sign or Wellens’ warning. The last name emphasises the usual clinical course, which is to progress to full occlusion and a completed anterior infarct unless intervention occurs.

This patient should be admitted, not sent for outpatient follow-up. Stress testing should be avoided as it may precipitate a completed infarct. Antiplatelet agents and heparin should be commenced but the key intervention is early coronary angiography/angioplasty.


Wellens type 2 ECG

ECG 2More information on Wellens syndrome: LITFL

 ICE Ian's Clinical Emergencies

A Brief History of Today

By @BenAzan

What pearl could I possibly find worthy of continuing tweets and dissemination? The last two posts, one of which was retweeted by both @M_Lin and @precordialthump (thanks!), are a tough act to follow.

So first I thought about maybe high flow nasal cannula, the forgotten oxygenation method. I could highlight those magical nasal prongs that can deliver up to 60 Liters per minute of humidified O2 and up to 6 mmHg of PEEP while keeping patient comfortable (relatively), eating and likely swearing at you. But then a quick FOAM search showed that @emupdates had a great post from 2012 and that @cliffreid already blogged about it‘s application during RSI for apneic oxygenation.

Then a sick LVAD patient roles in and I became tempted to write a small review of the approach to the LVAD patient. Does anyone know how to measure their blood pressure? You can’t do it with a BP cuff. But again, a great review by @FTeranmd was right there on the MayoEM blog.

So then, as I was standing around contemplating potential interesting subjects for this post, my chairman asks me to look at this Xray of an adult s/p elbow trauma:

Img_3239                           Img_3237


Easy, there are fat pads. Enlarged anteriorly (sail sign) and seen posteriorly, so there is definitely an occult fracture. As I stood triumphantly, he followed up with a second questions. Where is the fracture? Supracondylar are the words that came to my mind and mouth as most of the elbow effusions I had seen were from supracondylar fractures. “Absolutely wrong” said Mr. Chairman. As it turns out, supracondylar fractures are the most common elbow fracture (60% of fractures) in children (1). In adults the most common cause is radial head fracture (~50% of elbow fractures).  (1). All the while, the answer was just sitting in front of me. A close inspection of the radial head reveals what is very likely a fracture line. I should have spent more time with @ABargren‘s emin5 review of elbow Xrays.

Radial Head


Beaten down, I was walking away when a fellow resident asks: “Hey, do you remember the dose for Otic mineral oil?”. Me: “What? Humm…no, what are you prescribing it for?” Co-resident: “I just diagnosed a guy with dry ears”. Yes, I thought to myself, this is by far the best diagnosis of the day, and this will be the theme of my post. The diagnosis and management of dry ears. A small but bothersome affliction for which waiting to go see your PMD or a quick google search just doesn’t cut it.

So, turns out one can get dry ear canals from over cleaning, hearing aids, or a primary lack of production of ear wax. Risk factors include hx of dermatitis, psoriasis and eczema. Be careful to also consider otitis externa, as the two can be confused.  Treatments include (ironically) keeping the ear dry from water. Patient can try a few drops of vegetable, olive or mineral oil as well. Beyond that they need to follow up with their PMDs or ENT doctors.

Behold FOAMed community, a subject that I bet has never been addressed, dry ear canals.


(1) Goswami, Gaurav K. “The Fat Pad Sign 1.” Radiology 222.2 (2002): 419-420.

Research and Reviews in the Fastlane 064

Research and Reviews in the Fastlane

Welcome to the 64th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the R&R Archive, read more about the R&R project or check out the full list of R&R contributors

This Edition’s R&R Hall of Famer

Emergency Medicine, ResuscitationR&R Hall of Famer - You simply MUST READ this!
Panesar SS et al. Errors in the management of cardiac arrests: An observational study of patient safety incidents in England. Resuscitation. 2014;85(12):1759-1763. PMID: 25449347

  • This is a retrospective review of a national patient safety database in England looking at cognitive and systems errors that occurred during cardiac arrest resuscitations.
  • The most common missteps included indecisiveness by senior clinicians, lack of recognition of deteriorating patients, and equipment deficits (equipment failure; missing or unavailable vital equipment; wrong equipment; and a lack of access to the resuscitation location)
  • Bottom line: The results of this review point out the continued, significant impact of human factors that occur during resuscitations. Also, the second most frequent error involves lack of equipment preparation & availability. This underscores the importance of meticulously checking your resuscitation room to make sure all your equipment is ready.
  • Recommended by: John Greenwood

The Best of the Rest

Neurology, Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisBerkhemer OA et al. A Randomized Trial of Intraarterial Treatment for Acute Ischemic Stroke. NEJM 2014. PMID: 25517348

  • Published in the NEJM with all the fan fair that only the medical industry could provide, MR CLEAN marks the first successful demonstrated of interventional therapy for acute ischemic stroke. In direct contrast to IMS-3, SYNTHESIS and MR RESCUE, MR CLEAN is a significantly positive trial demonstrating success in their primary outcome, improved neurological outcomes at 90 days with an adjusted odds ratio of 1.67. why MR CLEAN was positive when the 3 trials which came before were negative is still unclear. Though it may be simply due to better equipment and faster recanulization times it may just as likely be due to the placebo group performing so poorly. Additional trials confirming these results are required before excepting this as a beneficial therapy
  • Recommended by: Rory Spiegel
  • Read More: MR CLEAN & the New Golden Age (Emergency Medicine Literature Note), A Secondary Examination of the Adventure of the Cardboard Box-Addendum (EM Nerd) and Intra-arterial Treatment for Stroke (St. Emlyn’s)

Neurology, Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisPaciaroni M et al. Intravenous thrombolysis or endovascular therapy for acute ischemic stroke associated with cervical internal carotid artery occlusion: the ICARO-3 study. J Neurol. 2014. PMID: 25451851

  • The ICARO-3 study is a real-world observational study of effectiveness of intra-arterial therapy for proximal internal carotid artery occlusions. The study authors showed no benefit for the primary outcome at 90 days and a marked increase in intracranial bleeding (37% vs. 17.3%) and fatal intracranial hemorrhage (6% vs. 2.2%). Despite the positive outcomes for intra-arterial management in the MR CLEAN study, we should continue to be skeptical of this management approach.
  • Recommended by: Anand Swaminathan
  • Read More: Endovascular Therapy, Unproven Efficacy, Unproven Effectiveness (Emergency Medicine Literature of Note)

Pediatrics, Emergency MedicineR&R Game Changer? Might change your clinical practiceMunde A et al. Lactate clearance as a marker of mortality in pediatric intensive care unit. Indian Pediatr. 2014 Jul;51(7):565-7. PMID: 25031136

  • Lactate Levels are becoming ubiquitous… even in the Peds ED. Are they really useful though? Well, that is still debatable, but there is evidence that serial measures may be helpful in guiding resuscitation.
  • Recommended by:  Sean Fox
  • Read More: Lactate Level in Kids (Pediatric EM Morsels)

Pediatrics, GastroenterologyR&R Eureka
R&R WTF Weird, transcendent or funtabulous!” width=
Walker GM et al. Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study. BMJ 2006; 332(7554):1363. PMID: 16737979

  • Everyone says they’ve been “throwing up bile” but neither patients nor physicians can agree on what that means, and they quantify it well here. I’ve been taught it needs to look like avocado skin to be bile; this paper simplifies it to “green = bad.” Credit to Damien Roland (@Damian_Roland) for sharing.
  • Recommended by: Seth Trueger

Pre-hospital/Retrieval, NeurologyR&R Hot Stuff - Everyone’s going to be talking about thisAsimos AW et al. Out-of-Hospital Stroke Screen Accuracy in a State With an Emergency Medical Services Protocol for Routing Patients to Acute Stroke Centers. Ann Emerg Med 2014; 64(5): 509-15. PMID: 24746847

  • tPA in stroke believers continue to look for ways to get the drug to more patients earlier. Prehospital drug administration is being investigated to reach this end. This study showed a poor specificity (48%) for two tools in identifying stroke patients in the field speaking to the need for better tools and/or better training. A low specificity means lots of patients without disease may be treated.
  • Recommended by: Anand Swaminathan

Emergency Medicine, NeurologyR&R Landmark
Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia. 2011 Dec;66 Suppl 2:65-80. PMID: 22074081

  • How to access the cricothyroid membrane….or not! – a great review of the literature for different ways of gaining emergency airway access via the cricothyroid membrane
  • Recommended by: Soren Rudolph

Emergency Medicine, ResuscitationR&R Hot Stuff - Everyone’s going to be talking about thisBennett C et al. Management of pulmonary embolism: recent evidence and the new European guidelines. Eur Respir J 2014;44(6):1385-90. PMID: 25435521

  • This easily digestible paper reviews the European guidelines for the management of pulmonary embolism (PE). The pearls:
    • The clinical implication of a single subsegmental PE is unknown, but it often probably doesn’t need aggressive treatment.
    • The FOAM world abounds with discussions of thrombolysis for intermediate risk PE (submassive) but these guidelines and this paper are far less enthusiastic given the risk of bleeding and use of a composite outcome in the PEITHO study.
    • Outpatient PE management, for the right patient (based on PESI/sPESI and follow up) is here.
  • Recommended by: Lauren Westafer

Pre-Hospital/Retrieval, Emergency MedicineR&R Hot Stuff - Everyone’s going to be talking about thisSundström B et al. A pathway care model allowing low-risk patients to gain direct admission to a hospital medical ward: a pilot study on ambulance nurses and Emergency Department physicians. Scand J Trauma Resusc Emerg Med. 2014; 22(1):72. PMID: 25491889

  • This papers attempts to define a certain population that is sick enough to be admitted to the hospital but safe enough NOT to be assessed in the ED, i.e., direct admission. The novel thing about this “direct admission” process is that is initiated by the patient or EMS provider. The main outcomes were LOS in the ED and 30 day mortality. The LOS of the traditional treatment was just over 4 hours while the rapid-pathway group was 57 minutes. Interestingly the mortality of the control group was 4% and the rapid group was 20%. This paper shows that a direct admission from the field was faster than the regular EM process, but associated with 5 times higher mortality. I think this shows the importance of the cognitive process of diagnosis, risk stratification and disposition that EM providers offer to the patients. Bottom line: keep doing what you are doing and don’t cut corners.
  • Recommended by: Daniel Cabrera

Trauma, Ophthalmology, Emergency Medicine
Rowh AD et al. Lateral Canthotomy and Cantholysis: Emergency Management of Orbital Compartment Syndrome. J Emerg Med 2014. PMID: 25524455

  • Nice case presentation and review of an important Emergency Medicine procedure. Lateral canthotomy is a rare, but sight saving procedure we all must be familiar with and ready to perform. This brief article provides a succinct review of the technical details as well as some wonderful pictures demonstrating the procedure itself.
  • Recommended by: Jeremy Fried

The R&R iconoclastic sneak peek icon key

Research and Reviews The list of contributors R&R in the FASTLANE 009 RR Vault 64 The R&R ARCHIVE
R&R in the FASTLANE Hall of Famer R&R Hall of famer You simply MUST READ this! R&R Hot Stuff 64 R&R Hot stuff! Everyone’s going to be talking about this
R&R in the FASTLANELandmark Paper R&R Landmark paper A paper that made a difference R&R Game Changer 64 R&R Game Changer? Might change your clinical practice
R&R Eureka 64 R&R Eureka! Revolutionary idea or concept R&R in the FASTLANE RR Mona Lisa R&R Mona Lisa Brilliant writing or explanation
R&R in the FASTLANE RR Boffin 64 R&R Boffintastic High quality research R&R in the FASTLANE RR Trash 64 R&R Trash Must read, because it is so wrong!
R&R in the FASTLANE 009 RR WTF 64 R&R WTF! Weird, transcendent or funtabulous!

That’s it for this week…

That should keep you busy for a week at least! Thanks to our wonderful group of editors and contributors Leave a comment below if you have any queries, suggestions, or comments about this week’s R&R in the FASTLANE or if you want to tell us what you think is worth reading.

The post Research and Reviews in the Fastlane 064 appeared first on LITFL.

UOTW #31

The patient is an 11 year old male who was leaving soccer practice when his family witnessed him suddenly collapse.  He was then noted to have left sided hemiparesis associated with a headache and nausea/vomiting, and was airlifted to your emergency department.  Noncontrast CT of the brain was negative, but CTA revealed a complete proximal right M1 occlusion.  You perform a bedside echocardiogram:


Biocompatible Adhesive Gel Patch for Sensing and Monitoring EP Signals in Biological Tissues

stretchable sensor Biocompatible Adhesive Gel Patch for Sensing and Monitoring EP Signals in Biological Tissues

Sheet-type sensors are made by forming an adhesive gel pattern only on the electrodes after an organic transistor integrated circuit is made on an extremely thin polymeric film. The sensors did not break even after they were affixed to a balloon and 100% compression was applied.

The market for wearable electronic devices has exploded in recent years, with a concomitant increase in their sophistication due to the integration of complex electronic circuits. However, devices that are worn on the body are rigid and do not respond well to the body’s movement. A team of biomedical engineers based in Japan has devised a biocompatible, flexible, adhesive gel patch that senses internal or external electrophysiological biological signals. The adhesive gel fixes a delicate grid of detectors in place, even while in contact with a surface that is not static, such as a joint or an internal organ. The precision with which the detector acquires readings depends on an array of sensors printed 4 mm apart on a thin sheet of plastic. The result is a flexible patch that fits in the palm of your hand and can house as many as 144 sensors.

flex compress Biocompatible Adhesive Gel Patch for Sensing and Monitoring EP Signals in Biological TissuesWhile still in its preclinical testing phase, this technology shows promise as a sophisticated, comfortable, long-term biometric measurement device that can be applied internally or externally. The researchers have shown proof of principle with the device attached to the surface of a rat’s heart. They demonstrated that the device adheres to the wet, dynamic surface of heart muscle for more than 3 hours, facilitating the reliable measurement of biological signals. The multielectrode array was shown to be sensitive and flexible, conforming to the dynamic characteristics of complex tissue.

More details about the technology according to the Japan Science and Technology Agency:

The research group first fabricated high-performance organic transistor integrated circuits on 1.4 micrometer extremely thin polyethylene terephthalate (PET) polymeric film, then coated only the electrodes that come into direct contact with the living body with adhesive gel pattern. On their prototype integrated circuits, 144 (12 × 12) sensors are distributed 4mm apart from each other on a surface area of 4.8 × 4.8cm2. Gel-coated Electrodes function as sensors that measure electronic signals directly from a living body. The integrated circuits stay functional even when the subject moves dynamically. It was proved in the following experiment where integrated circuits were placed on the surface of an inflated balloon. 100% compressive strain was applied, but their electrical performance did not fail.

The decisive factor in the research was the success in making adhesive gel that can fabricate patterns with light using only materials with superior biocompatibility. This new type of gel material is created by evenly distributing polyvinyl alcohol (PVA) in a rotating gel called. Since the pattern can be fabricated by light, this new type of gel can be coated only on the electrodes of sensors arranged in a grid pattern. Good adhesiveness is maintained even with wet living tissue since the new gel itself is adhesive. The adhesiveness of the gel resolves the problem found in the conventional methods where the electrode in contact with the living surface slips or peels off as the living tissue moves.

Their prototype device maintained a good contact for over 3 hours when affixed to the surface of a rat heart due to the astounding flexibility of the organic device and the adhesive gel. This resulted in an electrocardiograph with good quality signals. Since PVA loses flexibility by melting, the device can be easily removed without imposing a burden on the heart after measurement. Furthermore, the team built a supersensitive, flexible strain sensor with the same design method. They were able to measure dynamic body movements such as the moving of fingers by directly applying the

Study in Nature Communications: A strain-absorbing design for tissue–machine interfaces using a tunable adhesive gel

More from Japan Science and Technology Agency: Biometric Information Sensor that directly adheres to the Body like a Compress