#FOAMed Review 46th Edition

Welcome to the forty-sixth edition of the #FOAMed Review! The idea of the FOAMed review is to give you a digestible selection of reliable content from the online EM/CC world that you can fit into your busy weekly schedule. Each review will include highlights from the highest yield blog, podcast, video and web sources around. Over a year's span we will be sure to include topics from all core EM content areas...even the ones that may not be the coolest. Check out our indexing section #FOAMED REVIEW which allows you to view previous weekly reviews by edition or by selecting from CORD curriculum categories.


Onto the FOAMed


USING ULTRASOUND TO IDENTIFY THE CRICOTHYROID MEMBRANE: [VIDEO]: Thank you PHARM for finding this excellent instructional video by AirwayOnDemand on ultrasound anatomy of the trachea for surgical airway planning. 

B-LINES USING ULTRASOUND FOR HEART FAILURE [PODCAST]: Are B-lines identified by ultrasound of the lungs useful for diagnosing heart failure? The breakdown on the evidence @ The SGEM

THE P-VALUE [BLOG]: 3 weeks ago we featured the Pulm Crit post discussing the issues currently faced with the p-value as the prototype of statistical prowess. This week EM Nerd brings us a side dish of skepticism with his take on our p-value obsession. 

THE EXTERNAL JUGULAR IV [VIDEO]: This is a life saving peripheral line I find extremely useful in difficult access patients. Dr. Whit Fisher brings you some Procedurettes pearls on optimizing your technique. 


More Foamed

YES, MORE DISCUSSION ON SAH

THE SUBARACHNOID ENIGMA: [PODCAST]: An enticing title for a worthy podcast with Rob Orman discussing the continuously evolving literature on subarachnoid hemorrhage. Is CT only in 6 hours is ready for prime time? Listen hereER Cast

BURN THIS INTO YOUR MEMORY

BLOATED & UPSET [BLOG POST]: An excellent imaging case regarding x-ray findings that should concern you in a patient presenting with abdominal pain, bloating and vomiting. Sinai EM

HEMOGLOBIN HAZARDS

TOXIC HEMOGLOBINOPATHIES [VIDEO]: A fine review of two classic hemoglobinopathies, by Dr. Hong Kim. Do you know the causes of methemoglobinemia? How do you manage carbon monoxide poisoning? Watch this lecture here @ Maryland CC Project

HOT, RED, AND TENDER

SEPTIC JOINT [BLOG]: EM Docs brings us a well versed update on the septic joint, including key history and background, diagnostic work up strategy, and management. Check this post out right here


 

See you next week

Ping Tom Park Chinatown, Chicago

Ping Tom Park Chinatown, Chicago

 

KT Evidence Bite: Cardioversion and Thromboembolism

Editor’s note: This is a series based on work done by three physicians (Patrick ArchambaultTim Chaplin, and our BoringEM Managing editor Teresa Chan)  for the Canadian National Review Course (NRC). You can read a description of this course here.

The NRC brings EM residents from across the Canada together in their final year for a crash course on everything emergency medicine. Since we are a specialty with heavy allegiance to the tenets of Evidence-Based Medicine, we thought we would serially release the biggest, baddest papers in EM to help the PGY5s in their studying via a spaced-repetition technique. And, since we’re giving this to them, we figured we might as well share those appraisals with the #FOAMed community! We have kept much of the material as drop downs so that you can quiz yourself on the studies.

Paper: The FinCV (Finnish CardioVersion) study of cardioversion of acute atrial fibrillation

Citation: 

Airaksinen KE, GronbergT, NuotioI, et al. The FinCV (Finnish CardioVersion) study. J Am Coll Cardiol. 2013;62(13):1187-1192. PMID: 23850908

Summarized by: Tim Chaplin
Reviewed by: Teresa Chan & Patrick Archambault

Clinical Question

What is the incidence of and risk factors for thromboembolic events after ED cardioversion of acute atrial fibrillation?

Population Adult patients with primary diagnosis of atrial fibrillation who were successfully cardioverted in the ED within 48hrs of atrial fibrillation onset. Atrial fibrillation of cardiac cause.
Comparison factors (observational study)Large number of clinical characteristics including: age, gender, hypertension, heart failure, diabetes, other comorbidities, medications, time to cardioversion, method of cardioversion etc.
OutcomeThromboembolic events (clinically stroke or systemic embolism confirmed by CT or MRI, surgery, or autopsy) within 30 days after cardioversion.

Methods

This was a retrospective database analysis of adult (>18yo) patients who presented to 3 large EDs in Finland with a primary diagnosis of acute (<48hrs) atrial fibrillation and who were cardioverted successfully in the ED. These patients did not receive peri-procedural anticoagulation. Baseline characteristics were recorded. A univariate analysis followed by multivariable logistic regression was performed to identify risk factors. 

Results

n= 2481 patients with a total of 5116 successful cardioversions (patients were included multiple times if multiple successful cardioversion occurred within study period) of which 88% were electrical cardioversions.

  • Overall incidence for thromboembolism was 0.7% with events occurring at an average of 2 days post cardioversion

Risk factors for thromboembolism

  • cardioversion > 12 hrs after onset of atrial fibrillation (1.1%) vs <12 hrs after onset( 0.3%)
  • Multivariable regression identified independent factors:
    • >12 hrs from symptom onset
    • advancing age
    • female sex
    • heart failure
    • diabetes

Conclusions

Early cardioversion (<12hrs) is associated with lower thromboembolic events. High risk patients should be considered for peri-procedural and long-term anticoagulation. This is in accordance with the 2010 Europena guidelines.

Take Home Point

1. Earlier cardioversion (<12hrs) may be safer than later (12hrs) cardioversion for patients who present with acute onset atrial fibrillation.

2. Peri-procedural anticoagulation (i.e. with IV heparin) may reduce the risk of thromboembolic events in high risk patients undergoing ED cardioversion of acute atrial fibrillation


EBM Considerations

  • Retrospective study:  This large database review was retrospective which makes the jump from association to causation difficult to make and introduces opportunity for bias including the completeness of collected information.
  • Multiple comparisons: The large number of variables evaluated in the initial univariate analysis puts the study at risk for Type II error. The authors did use a conservative estimate to include variables in the multivariable logistic regression but even with such correction the risk of error related to multiple comparisons is quite high.
  • Identifying onset of atrial fibrillation: The ability of patients to accurately identify the onset of atrial fibrillation is debatable and as such the 12 hour cutoff point is difficult to accurately identify.

For a pdf version of this summary click NRC – BoringEM – FinCV

Author information

Eve Purdy
Medical Student Editor at BoringEM
Fourth year medical student at Queen's University-happily consuming, sharing, creating and researching #FOAMed

The post KT Evidence Bite: Cardioversion and Thromboembolism appeared first on BoringEM and was written by Eve Purdy.

JC: One Benzo Fits All? Lorazepam vs Diazepam for Paediatric Status Epilepticus

St Emlyns - Meducation in Virchester #FOAMed

It’s been a little quiet of late here in the lofty towers of St Emlyn’s Virtual Hospital, not because the patients have stopped coming (trust me, they haven’t) but because many of the clinicians have spent their non-working hours squirreled away desperately designing talks for SMACC. Now that the 1st May submission deadline has passed I’m […]

The post JC: One Benzo Fits All? Lorazepam vs Diazepam for Paediatric Status Epilepticus appeared first on St Emlyns.

Ultrasonido Pulmonar parte 1

IMG_2914

Estimados, este es el debut del recién egresado del programa de MDU, Nicolás Vargas en la página.

Nos hablará sobre el ultrasonido pulmonar y otros temas en el futuro

 

Resumen:

Vemos solo la pleura, después es solo interpretación de artefactos

2 artefactos: Lineas A y Líneas B

Captura de pantalla 2015-05-14 a las 0.44.57

Lineas A: normal, es solo la reverberancia (repetición) de la imagen de la pleura. Podemos verlas en pulmón normal, neumotorax, TEP y EPOC.

 

 

Captura de pantalla 2015-05-14 a las 0.45.21

 

Líneas B: anormal, es la presencia de ocupación del intersticio pulmonar por líquido. Normal en las zonas dependientes (menos de 3). Difuso en EPA y fibrosis, Parches en SDRA, Localizado en Neumonía.

 

Captura de pantalla 2015-05-14 a las 0.45.11

Lung Sliding: 100% específico para DESCARTAR NEUMOTÓRAX.

Ausencia de Lung Sliding: Neumotórax, bulas, pleurodesis, intubación monobronquial, atelectasia.

 

Lung Point: 100% específico para DIAGNOSTICAR NEUMOTÓRAX.

Por otra parte la presencia de Lineas B descartan neumotórax. 

Spontaneous Coronary Artery Dissection

Spontaneous Coronary Artery Dissection

By Krystle Shafer MD, William Fields MD, and Mark Gonzales DO, MPH
(Chief Residents, Dept of Emergency Medicine, WellSpan York Hospital in York, PA)

Edited by Alex Koyfman MD (@EMHighAK) and Stephen Alerhand MD (@SAlerhand)

 

Case 1:

A 26 year-old M presents to the ED with a chief complaint of chest pain that started acutely at 3 am. His pain is constant and located in the center of his chest. Nothing makes his pain better or worse, and it is not positional. He woke up vomiting this morning while also feeling short of breath. He has no PMH, takes no medications, and has no significant family or social history. Vital signs: HR 111, BP 166/106, RR 18, oral temp 98.0F, oxygen saturation is 100%. On exam he is pale and diaphoretic, leaning forward and clutching his chest. Lungs are clear to auscultation bilaterally, heart has a regular rate and rhythm without murmurs/rubs/gallops. EKG reveals diffuse ST elevation. Bedside echocardiogram reveals normal ejection fraction, but there are concerns for wall motion abnormalities at the apex. Pertinent labs revealed a WBC count of 19.5, troponin 3.05, lactic acid 3.9, BNP 66. Eventual cardiac catheterization revealed spontaneous LAD dissection, which was subsequently stented.

EKG 1
Case 1 EKG: diffuse ST elevation

Case 2:

A 38 year-old F presents to the ED with a chief complaint of chest pain that started approximately 12 hours prior to arrival. The pain is intermittent but progressively worsening. It is a constant, mid-sternal, 10/10 sharp pain present for the past 30 minutes. She has no exacerbating or relieving factors, and her pain is non-radiating. She had nausea and vomiting throughout the day as well as dyspnea and diaphoresis. PMH includes atrial fibrillation and hypertrophic cardiomyopathy. Vital signs: HR 87, BP 156/114, RR 24, oral temp 97.3F, oxygen saturation is 100%. On exam she is pale, diaphoretic, and writhing in distress. Lungs are clear to auscultation bilaterally, heart has an irregularly irregular rhythm and is without murmurs. There is no peripheral edema. EKG reveals ST elevation in the anterolateral leads.  Pertinent labs revealed WBC count of 22.1, troponin 0.13, and BNP 924. She immediately went to the catheterization lab, which revealed a spontaneous LAD dissection. This was unable to be stented and required an emergent CABG.

EKG 2
Case 2 EKG: anterolateral ST elevation

Echo 2
Case 2 Echo: akinetic apical wall

Background

Chest pain is a common complaint among patients presenting to the Emergency Department (ED). In patients <50 years old, chest pain is more likely to be benign. However, spontaneous coronary artery dissection (SCAD) is an uncommon diagnosis that uniquely targets the younger population and is potentially fatal if misdiagnosed. In 1996, only 100 cases in the world had been identified1. Of these reported cases, 75% were diagnosed at autopsy and the rest were diagnosed with coronary angiography2. The majority of these cases were found in women —approximately 75% — and of these cases, 32% of the patients were pregnant, post-partum, or taking oral contraceptives, suggesting that hormonal factors potentially have an effect1.

A more recent retrospective study revealed 87 patients diagnosed at the Mayo Clinic from 1979-20113. 82% of these patients were female and the mean age was 42.6, with 18% of the female patients being postpartum. STEMI was apparent in 49% of patients, NSTEMI in 44%, and the rest had unstable angina. Fibromuscular dysplasia was found to be a potential causative factor as well. The LAD was involved in 71% of cases and multi-vessel disease was apparent in 23%. The pathophysiologic 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 wall2. SCAD may also be a source for sudden cardiac death in athletes or those suffering blunt, shear-force trauma and may be under-reported in this regard4. A high index of suspicion is essential in these cases. This article focuses on the key identifying factors about this disease to help prevent the ED physician from missing this diagnosis.

Physical Exam

SCAD patients will raise your “sick” feelers that all ED physicians develop. They will look like the textbook heart attack patient except they are generally a young age for MI. Patients will be diaphoretic, pale, and typically experience significant chest pain. It is not typical for patients to experience new dysrhythmias in the setting of coronary dissection. Severe cardiac ischemia due to the dissecting artery can potentially result in acute CHF.

Imaging/Labs

  • EKG will traditionally reveal ST elevation in the leads of the dissecting artery.
  • Troponin will be elevated after 4-6 hours from symptom onset due to ischemia.
  • Lactic acid can be elevated as well but depends on the degree of heart dysfunction and organ ischemia.
  • Bedside US will commonly reveal wall motion abnormalities related to the dissecting vessel.
  • Diagnosis is made definitively with cardiac catheterization, intravascular ultrasound, optical coherence tomography, or at autopsy.

Management

Treatment options for SCAD patients include medical management, stenting, or bypass surgery. There are no guidelines or standard treatment at this time, and the prognosis of these patients who survive is unknown. However, the case reports overall seem to demonstrate that the one year post-event survival rate is quite high. One study found a 17% recurrence rate (all of which were female) as well as a long-term survival rate that was comparative to patients with acute coronary syndrome (ACS)3.

Summary

Spontaneous coronary artery dissection is a rare diagnosis with high potential for mortality or significant morbidity. SCAD should be considered in the differential diagnosis of acute chest pain patients, with heightened clinical suspicion in young female patients under age 50 who present like ACS. Peripartum status, fibromuscular dysplasia, and shear stress from blunt trauma are also potential causative factors that should increase clinical suspicion. SCAD will mimic ACS with ST elevations on EKG, troponin increase, and wall motion abnormalities on bedside echo. These patients are diagnosed in the catheterization lab and typically managed with either a stent or bypass surgery.

 

References / Further Reading

The post Spontaneous Coronary Artery Dissection appeared first on emdocs.

Hip Fracture, Xray negative, what’s next?

I usually review a question on my board review series regarding a patient with trauma and negative x-ray of hip, what is the next step? The answer is usually CT scan, and I have to admit that this is my routine practice that I do not rely on X-ray, if my patient still is symptomatic,

I will do confirmatory test and that is usually CT. It is faster and easier to be done in ED,  but Injury published this study in May, 2015  observed that MRI has a higher diagnostic accuracy than CT in detecting occult fractures of the hip, Just for resident who needs resource for our board review discussion.

 

Link to article