39 y/o male with no significant past medical history presents status post syncopal episode while getting a tattoo. Vitals and physical exam unremarkable. EKG, when compared to prior, notes new changes. Admit or discharge?

Prior and new EKG.  Click image to enlarge.

scroll down for answer 

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Discharge after correcting left arm - left leg EKG lead reversal and obtaining a repeat EKG which will look exactly like the prior EKG, with no significant change noted.  The big tip off here for misplaced leads is the significant change in axis of the QRS complex in leads III and aVF.

Patient likely had vasovagal syncope from painful stimulus of tattoo.

Left arm - left leg lead reversal causes lead I and II to switch places, aVL and aVF to switch places and III to invert.  Click image to enlarge.

Source

Codagan, M.  "The power of social media leads to reversal." Life in the Fastlane.  26 Sept 2011.   

Trick of the Trade: Rare earth magnets for metallic FB removal

A child presents to your Emergency Department with a small button battery up her nose. Your usual tricks fail:

• Occluding the other nostril and having the mother blow in the patient's mouth forcefully.
• Using a small curette or forceps to scoop or pull it out.

Trick of the Trade:
Use a Rare Earth Magnet

This YouTube video (apparently, you CAN find anything on YouTube) shows an amazing demonstration of how simple foreign body removal can be. It seems to be much less traumatic than if one were to actually go digging into the cornea for the little metallic bits.

One of the conference attendees our recent High Risk EM Conference in Hawaii came up to tell me of his success in using rare earth magnets for metallic foreign body removals in the nose, ears, and even deep lacerations. I wish I had caught his name to give him credit! Cool tip.

I recently bought some Rare Earth Magnets from eBay for $8. I bought a set of 20 mini-magnets which can be stacked together into a wand. Here is a video showing how strong these little magnets are in picking up random things in my house:

I do not have any financial ties or disclosures with eBay or the sellers of these cool rare-earth magnets.

16 y/o female with no significant past medical history presents with sharp/pleuritic chest pain which improves when sitting up and leaning forward. EKG demonstrates changes consistent with pericarditis. Does this patient have pericarditis? If so, what is the work up?

Yes, she has pericarditis.  Acute pericarditis is diagnosed by the presence of at least two of the following four criteria:

1. typical chest pain
2. suggestive changes on the EKG 
3. pericardial friction rub 
4. new or worsening pericardial effusion

Workup includes:

• EKG
• chest x-ray 
• cbc, troponin, ESR, CRP
• echo
• if febrile, blood cultures
• if on coumadin or at risk of coagulopathy,  INR/PT/PTT

Purpose of workup is to identify pericarditis patients at high risk of tamponade (ie malignancy, TB, purulent pericarditis, anticoagulation, large pericardial effusion greater than 20 mm) and arrhythmia (ie patients with concomitant myocarditis as suggested by an elevated troponin or new ventricular systolic dysfunction).   High risk patients should be admitted to the hospital for further evaluation. 


Source

 Imazio, M. "Clinical presentation and diagnostic evaluation of acute pericarditis"  Up to Date.  Jan 2012.

Video: Crash course on Prezi

Dr. Rob Rogers has started a great series of videos which highlight resources and tools which medical educators may find useful and innovative. This video takes you on a guided tour through making a Prezi presentation. Although I am still torn about using Prezi as a delivery tool because of the excessive motion-based transitions, I do like such features as:

• Really professional looking templates
• The presentations can live online and/or on your desktop
• Ability to easily embed videos 
• Ability to see your entire presentation on the canvas
• Allows more flexibility in content delivery
• It just looks cool.

You can look for more excellent videos on the Academic Emergency Medicine Education Masters site. Hey maybe you can next teach people how to use Google Reader, Evernote, Dropbox!

Is this EKG of a 19 y/o male with chest pain more suggestive of early repolarization or pericarditis?

click on image to enlarge

Based on this EKG alone it is hard to tell but if I had to guess I would place my bet on early repolarization.  Here's why:

• There is no PR segment deviation (relative to the TP segment), neither PR elevation in aVR nor PR depression in the other leads.
• Compared to an old EKG (not shown) there are no evolving changes.  Pericarditis causes a typical progression of EKG changes from onset of disease to resolution. 
• The ratio of ST elevation to T wave amplitude in V6 is less than 0.24.  If it is greater, than pericarditis is present.
• Finally, the ST elevations are primarily located in the precordial leads.  Pericarditis generally causes diffuse ST elevations in BOTH limb and precordial leads whereas about half of patients with early repolarization have no ST deviations in the limb leads.   

Source

Imazio, M.  "Clinical presentation and diagnostic evaluation of acute pericarditis"  Up to Date.  Jan 2012.

Paucis Verbis: Anaphylaxis

Image from WebMD

Anaphylaxis is one of the most under-appreciated and under-treated conditions in the Emergency Department. A common misperception is that you need hypotension to diagnose it. Below is a brief summary of the diagnostic criteria and ED treatment protocol. Immediate administration of IM epinephrine is critical.

A major challenge is deciding which patients can go home and which need to be admitted, because of the risk of "rebound" or a biphasic anaphylactic response. This may occur as late as 72 hours later, but typically occur within the first 24 hours. There isn't a good answer for this.

What's your practice in dispositioning these patients? Personally, I admit at least those patients who present with severe hypotension, require more than 1 epinephrine dose, or have poor social support.

NOTE: Unlike the photo on the top, warn patients not to rest their thumb on the device because of the risk inadvertent needle puncture.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Reference

Simons FE. Anaphylaxis. J Allergy Clin Immunol. 2010 Feb;125(2 Suppl 2):S161-81. .

Arnold JJ, Williams PM. Anaphylaxis: recognition and management. Am Fam Physician. 2011 Nov 15;84(10):1111-8. .

Advanced ECG by Amal Mattu in Singapore

Attended the Advanced ECG workshop tomorrow conducted by Prof Amal Mattu in the Society for Emergency Medicine in Singapore 2012 Annual Scientific Conference (SEMS ASC).

A number of good streaming video ECG lectures by him in this website. Click here to assess.

Some highlights from the class:


 


Sgarbossa's criteria

The dictum that "in the presence of LBBB, one cannot diagnose myocardial

Grey-Turner Sign

Grey-Turner’s sign simply refers to the bluish discoloration of the flanks. The interesting thing about this sign is that whenever this sign is found, medical students are alerted to the fact that there is a possible underlying retroperitoneal bleeding going on.  Obviously, this sign could also indicate a possible intraperitoneal bleed besides the possibility of retroperitoneal bleed. The

On vacation

Had an exciting week making new friends and learning about hot topics in Emergency Medicine at our department's UCSF High Risk Emergency Medicine Hawaii conference.

Will be back next Friday!

Live-blogging: UCSF High Risk EM Hawaii conference

Today is the pre-day for our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. Keep a lookout below as I try to live-blog some of the clinical pearls that I glean from the day (using Google Docs).

Elderly Abuse in Malaysia

The official visit by the undergraduate students and their lecturers from Tzu Chi University from Taiwan ended a week ago.
 
During that visit, I talked about elderly care and abuse, particularly within the Malaysian context because I feel this is one area which is not very much talked about, not easily detected, and in fact, what we know is probably the tip of the iceberg only. This forum

Live blogging tomorrow

Tomorrow is the beginning of our department's 2nd annual High Risk Emergency Medicine conference in Hawaii. The day's focus is on ultrasonography. I'm going to try to live-blog some of the clinical pearls that I glean from the day.

Article review: New assessment method for medical students - A Script Concordance Test

What different ways can we assess learners?

This fascinating study assesses a new tool - Script Concordance Test (SCT).

Assessing clinical reasoning skills in scenarios of uncertainty: Convergent validity for a Script Concordance Test in an Emergency Medicine clerkship and residency

What are Scripts?

Scripts are organized networks of knowledge. Integrating them improves decision making. Using scripts, experts see associations while novices struggle with causality. In ambiguous cases, experts process multiple scripts with influx of new information.

What is the format of a Script Concordance Test?

The learners are presented with a short clinical vignette with a series of proposed diagnoses and/or plans. The learners are then presented one new piece of information and asked what effect this information has on the proposed diagnoses and/or plans. They score their decisions on a Likert scale, ranging from -2 to +2.

What did this paper study?

An observational study comparing the scores of 4th year med students (n=314) , residents (n=40) and faculty (n=12) on a SCT with scenarios in Emergency Medicine. The student score was compared to USMLE Step 2 score, and resident score with their ABEM in-training exam score.

What were the results?

The SCT scores were able to differentiate students from residents and residents from faculty. 

• Students vs residents: 60% +/- 6.2 vs 70% +/- 5.4
• Residents vs faculty: 70% +/- 5.4 vs 79% +/- 2.9

There was a significant correlation between resident score and ABEM exam score and a modest correlation between student score and USMLE Step 2 score.

What were the limitations?

It is a single centre study. The internal reliability of the assessment tool was suboptimal.

What were the conclusions?

The SCT may be useful in assessing clinical reasoning in uncertain scenarios.

What do I think?

I enjoy the examples given in the paper. While it is different and likely will take some getting used to, it could be a useful assessment tool.

References

Humbert AJ, Besinger B, Miech EJ. Assessing clinical reasoning skills in scenarios of uncertainty: convergent validity for a Script Concordance Test in an emergency medicine clerkship and residency. Acad Emerg Med. 2011;18(6):627-34. .

78 y/o male presents with intermittent crushing chest pain for the past 20 hours but is now pain free. Vitals stable. EKG notes ST elevation in anterior precordial leads and troponin is significantly elevated. Should patient be taken for immediate percutaneous coronary intervention (PCI)?

No.  PCI should not be performed in asymptomatic patients who present more than 12 hours after symptom onset who are hemodynamically and electrically stable. 

If, however, a patient presents within 12 to 24 hours of symptom onset and is hemodynamically or electrically UNstable, has severe congestive heart failure or exhibits evidence of persistent ischemia (chest pain or anginal equivalent), immediate PCI is recommended (class IIa).


Source

Reeder, G. "Overview of the acute management of acute ST elevation myocardial infarction"  Up to Date. January 2012.

Paucis Verbis: Pediatric fever without a source (3 mo-3 yr)

In part 3 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants 3 months to 3 years old (PV cards for birth-28 days and 29 days-3 months old).

Notes:

• The algorithm below is a guideline for NON-toxic patients. More ill-appearing children require a more broad workup.
• For the under-immunized (<2 PCV immunizations) and temperature ≥39.5C, blood cultures may be falling out of favor in the near future, because the incidence of blood culture contaminants is close to exceeding the true incidence of occult bacteremia.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

45 y/o male s/p tracheostomy three days ago presents with massive bleeding of bright red blood from about his trach. A tracheo-arterial fistula is suspected. What is your next move?

DON'T remove the trach; then, hyperinflate the cuff to tamponade the bleeding.   If the trach is removed the patient will aspirate blood and asphyxiate.

Fortunately, tracheo-arterial fistula after trach is a rare complication but can occur from erosion into the brachiocephalic trunk, especially with placement of a low lying trach below the third tracheal ring. 

Pressure necrosis from a trach tube can erode into the brachiocephalic artery which runs anterior to the trachea.

Sources

Praveen, CV.  "A rare case of fatal haemorrhage after tracheostomy"  Ann R Coll Surg Engl.  2007.

Image source: http://www.hawaii.edu/medicine/pediatrics/pemxray/v6c19.html

Blog incubation project: New 2 winners!

And the winners of the first ever EM Blog Incubator competition are...

Dr. Jim Campagna (Emergency physician at St Joseph's Hospital Health Center in Syracuse, NY) and Dr. Timothy Peck (Beth Israel Deaconess EM resident in Boston, MA)

Both submitted really fascinating concepts for their blogs. I'm really looking forward to reading each of their 3-part introductory series in the upcoming weeks, as they prepare to launch their own blogs.

Dr. Jim Campagna

Jim plans to focus on the all-things-technology in Emergency Medicine. This includes reviewing and aggregating lists of medical apps and hardware which are relevant to the specialty. Furthermore, he will provide up-to-date literature reviews of other technologies, such as electronic medical records and computer physician order entry, and their impact on clinical practice.

Dr. Timothy Peck

Tim isn't a newcomer to the blogging world. He has a fantastic blog "Teach, MD: Rethinking medical education" since July 2011. On his new blog, Web 2.0 Changed My Management, will feature examples of how Web 2.0 influenced the management of specific patient encounters. Also guests will be allowed to contribute mini-case presentations where they will report how a Web 2.0 activity changed how they managed a patient.

I can't wait to see what Jim and Tim come up with!

Identify on this x-ray what is preventing the patient's picc line from being easily removed?

Arrow denotes knot at distal aspect of picc line.  Click image to enlarge.

Removed under fluoroscopy in operating theater by vascular surgery.

What is the optimal position to intubate an obese patient?

click image to enlarge

Source

Image source: http://bentollenaar.com/_MM_Book/Ch.43.htm

Mattu, A.  Emedhome.com.  EMCast.  January 2012.

Paucis Verbis: Fever without a source (29 days-3 months old)

In part 2 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that "high risk" infants get admitted with IV ceftriaxone and "low risk" infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the grey area.

Where I practice, we tend to follow a modified version of the Rochester criteria, where a lumbar puncture and antibiotics aren't always required for this age group (unlike the Boston criteria).

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.