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ALiEM AIR Series | OBGYN Module (2025)

 

Welcome to the AIR OBGYN Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to OBGYN emergencies in the Emergency Department. 3 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 2 Honorable Mentions. We recommend programs give 1.5 hours of III credit for this module.

 

AIR Stamp of Approval and Honorable Mentions

 

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

 

Take the OBGYN Module at ALiEMU

 

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

 

Highlighted Quality Posts: OBGYN 2025

 

SiteArticleAuthorDateLabel
EMDocsTachyarrhythmias in PregnancyDr. Derick Tompkins, Dr. Jordan Boggs, Dr. Patrick GraceMay 20, 2024

AIR

EMCritPulmonary and cardiac complications of pregnancyDr. Josh FarkasMarch 5, 2024HR
EMDocsEM@3AM: Amniotic Fluid EmbolismDr. Kyle Smiley, Dr. Brit LongJune 22, 2024HR

 

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Reference

    1. Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275

 

 

By |2025-11-03T04:54:06-08:00Nov 3, 2025|Approved Instructional Resources (AIR series), Cardiovascular|
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ALiEM AIR Series | Vascular Module (2025)

 

Welcome to the AIR Vascular Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to HEENT emergencies in the Emergency Department. 8 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 3 AIR and 5 Honorable Mentions. We recommend programs give 4 hours of III credit for this module.

 

AIR Stamp of Approval and Honorable Mentions

 

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

 

Take the Vascular Module at ALiEMU

 

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

 

Highlighted Quality Posts: Vascular 2025

 

SiteArticleAuthorDateLabel
EMCritPulmonary embolism diagnosis and treatment of low-risk PEDr. Josh FarkasMarch 5, 2024

AIR

EMCritAortic dissectionDr. Josh FarkasSeptember 28, 2024AIR
EMDocsAcute chest syndromeDr. Rachel BridwellJune 27, 2024AIR
EMCritApproach to chest painDr. Josh FarkasJanuary 15, 2024HM
Rebel EMDon’t forget the IO in the critically ill patientDr. Kristen WileyApril 29, 2024HM
RCEMlearningCervical artery dissectionDr. Jason LouisJanuary 22, 2024HM
CanadiEMIs IO cannulation an underutilized method of emergency vascular accessDr. Ming LiOctober 15, 2024HM
PedEM MorselsKounis syndromeDr. Christyn MagillMarch 22, 2023HM

 

(AIR = Approved Instructional Resource; HM = Honorable Mention)

 

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

Reference

    1. Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275

 

 

By |2025-07-09T07:01:25-07:00Jul 9, 2025|Approved Instructional Resources (AIR series), Cardiovascular|
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PEM POCUS Series: Pediatric Cardiac

PEM POCUS pediatric cardiac

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric cardiac evaluation. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List the indications and limitations of pediatric cardiac point-of-care ultrasound (POCUS)
  2. Describe the technique for performing cardiac POCUS
  3. Identify anatomical landmarks accurately on cardiac POCUS
  4. Interpret abnormal findings on cardiac POCUS
  5. Describe the basic literature behind pediatric cardiac POCUS

Case Introduction: Child with respiratory distress

You are in the emergency department evaluating a 2-month-old full-term male infant presenting with worsening respiratory distress over the past few days. He has had no fever, rhinorrhea, congestion, or cough. He is feeding poorly and has only had two wet diapers in the past 24 hours.
On arrival, his vital signs are:

Vital SignFinding
Temperature36.4 C
Heart rate190 bpm
Blood pressure97/63
Respiratory pate62
Oxygen saturation (room air)95%

Exam

He is ill-appearing. The cardiac exam is notable for tachycardia and 2+ femoral pulses. There is no appreciable murmur. Pulmonary exam shows tachypnea, clear lungs, and mildly increased work of breathing. The abdomen is mildly distended with a liver palpable 2 cm below the costal margin. Capillary refill is 2 seconds.

Diagnostics and Management

You order a chest x-ray and labs, and order blood and urine cultures. You start a fluid bolus and empiric antibiotics. While waiting for your initial work-up, you perform a cardiac POCUS.

Cardiac POCUS can help providers rapidly identify significant cardiac pathology and drastically change management. The major POCUS questions are qualitative evaluation of:

  1. Ventricular function
  2. Pericardial effusion
  3. Relative chamber sizes
  4. Fluid tolerance (or volume status)

In the context of cardiac arrest, POCUS can assess the presence of cardiac activity. Additionally, performing repeat cardiac POCUS exams can help providers gauge response to interventions.

Limitations

Cardiac POCUS is NOT a replacement for comprehensive echocardiography. A number of applications are beyond the scope of cardiac POCUS and should be evaluated by comprehensive echocardiography, including:

  • Valvular pathology
  • Structural abnormalities
  • Congenital heart defects
  • Quantitative measurements (i.e., quantitative ventricular function, flow measurements)

Like other POCUS applications, sonographer skill and experience can influence the sensitivity/specificity of the exam to detect abnormalities.

 

  • Supine positioning as tolerated. Raise head of bed if needed for comfort.
    • Left lateral decubitus position can improve the A4CH and parasternal views.

Figure 1. Phased array ultrasound probe

  • Phased array probe: Smaller footprint for intercostal windows and useful for moving objects.
  • Cardiac setting on the machine (if available). Can improve temporal resolution of the images.
  • Tips for young children:
    • If fearful of staff, consider seating the child in the guardian’s lap.
    • Distract the child with a video or toy.
    • Obtain the subxiphoid view last (as this sometimes requires pressure).
    • Warmed gel can be very helpful!

A cardiac POCUS includes five standard views of the heart and inferior vena cava (below). Sonographers should recognize each of the ideal views and limitations of suboptimal views.

  • Parasternal long axis (PSLA or PLAX)
  • Parasternal short axis (PSSA or PSAX)
  • Apical four chamber view (A4CH)
  • Subxiphoid view (SUBX)
  • Inferior vena cava (IVC)

A note on probe marker orientation:

Probe marker orientation varies across pediatric disciplines, including cardiology, pediatric emergency medicine, critical care, and neonatology. This especially differs for the parasternal long axis view (discussed in more detail below). This may result in an image that appears “flipped,” or rotated 180 degrees, on the screen. Practice obtaining the views in your local environment, but also gain comfort interpreting a flipped image.

(Although all views can be used to evaluate gross ventricular function and for pericardial effusion, highlights of each view are listed below.)

Highlights of View

  • Excellent overall assessment
  • Gross LV function
  • Pericardial effusion
  • General chamber sizes

Probe Placement

Figure 2 PSLA probe placement

Figure 2. PSLA probe placement with phased array probe. (Image from Dr. Margaret Lin-Martore)

  1. Place the probe to the left of the sternum, near the 3rd-4th intercostal space.
  2. Point the probe marker towards the patient’s left hip.
  3. Slide the probe up and down intercostal spaces to obtain an ideal window.
  4. Make subtle adjustments to optimize the view.

In this image and the ones below, note that the probe is larger than a typical phased-array probe (Figure 1).

Note: The direction of the probe marker, especially for the parasternal long axis, may vary across specialties and institutions. Some specialties point the probe marker towards the left hip and others towards the right shoulder. This may result in an image that appears “flipped” (or rotated 180 degrees) on the screen.

Normal View and Landmarks

normal pediatric cardiac POCUS PSLA view

Video 1: Normal PSLA cardiac view (Image from thepocusatlas.com. Images: Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti)

Color labels in video:

  • Right ventricle (green)
  • Left ventricle (violet)
  • Left atrium (teal)
  • Mitral valve (yellow-brown), visualize both leaflets with the anterior leaflet centered and hitting or nearly hitting the septum
  • Aortic valve (pink)
  • Descending aorta (black circle behind pericardium)
  • Pericardium (pink), note tapering anterior to the descending aorta

Troubleshooting and Tips

  • If the left ventricle is oblique (and not horizontal across the screen), slide up a rib space.
  • The patient can hold breath in exhalation to decrease lung artifact.
  • Ensure adequate depth to see the descending aorta.
  • Try subtle micro-adjustments (fan and rotate the probe until you obtain the ideal image).
  • If the lung is obscuring the view, try rolling the patient into the left lateral decubitus position.

Normal Ultrasound Video (PSLA)

Video 2. Normal PSLA view

Highlights of View

  • Gross LV function
  • Interventricular septum position

Probe Placement

PSSA probe placement

Figure 3. Probe placement for PSSA. From the PLSA view, center the left ventricle (LV) on the screen then rotate the probe 90° clockwise towards the right hip.

 

Normal View and Landmarks

video normal PSSA view

Video 3: Normal PSSA view (Image from thepocusatlas.com – Dr. Lindsay Davis, Dr. Hanna Kopinski. Image editing: Michael Amador and Dr. Matthew Riscinti.)

 

Color labels in video:

  • Left ventricle (red)
  • Mitral valve (blue)
  • Right ventricle (top of the screen)

The ideal view is at the mid-papillary level, meaning both papillary muscles are visible in the LV at approximately 4 and 8 o’clock.  Note that this video starts with the “fish mouth” view of the mitral valve and ends with the mid-papillary view.

Additional views: Fanning through the PSSA view, starting at the apex → mid-papillary view → “fish mouth” view of the mitral valve → “Mercedes-Benz” view of the aortic valve (video 3A).

 Video 3a. Troubleshooting the PSSA view with the “PSSA sweep”

 

Troubleshooting and Tips

  • If you see the “fish mouth” view of the mitral valve, fan the probe towards the apex to visualize the papillary muscles.
  • If you only see one papillary muscle, anchor that side of the probe and move the other side of the probe back-and-forth (like a windshield wiper) until you find the second papillary muscle.
Video 3b. Troubleshooting the PSSA View -The Windshield Wiper:
If you cannot find the view, try sliding the probe towards the apex. Alternatively, you can return to the PSLA view and rotate from there. Rock the probe to center the LV on the screen.

 

Video 3c. Troubleshooting the PSSA view: Rocking the probe

Normal Ultrasound Video (PSSA)

Video 4. Normal PSSA view

Highlights of View

  • Gross chamber sizes
  • Interventricular septum position

Additional Uses:

  • Global assessment of function
  • Another view for pericardial effusion
  • Can be useful in cardiac arrest during active compressions (though SUBX most commonly used)
  • Pro tip: often helpful for advanced applications (calculations and evaluation for valvular dysfunction)

Probe Placement

Probe placement for apical 4-chamber view (A4CH)

Figure 4. Probe placement for apical 4-chamber view (A4CH). Image from Dr. Margaret Lin-Martore.

  1. From the PSSA view, slide the probe towards the apex of the heart, keeping the probe marker towards the patient’s right hip.
  2. Flatten the probe to point it towards the right shoulder.
  3. For patients with breast tissue, place the probe near the inframammary line.

Normal View and Landmarks

Normal A4CH view

Video 5: Normal A4CH view (Image from thepocusatlas.com. Images: Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti.)

Color labels in video:

  • Left ventricle, left atrium, mitral valve (blue, screen right)
  • Right ventricle, right atrium, tricuspid valve (red, screen left)
  • A5CH view includes the aortic outflow tract (video 5 above initially shows the A5CH view before becoming the A4CH view)
Normal A4CH view with labels

Figure 5. Normal A4CH view with labels

Troubleshooting and Tips

Ventricle differentiation: Regardless of probe marker orientation, you can still differentiate the 2 ventricles in a number of ways:

  1. The tricuspid valve inserts more apically (towards the top of the screen) than the mitral valve.
  2. The LV connects to the aortic outflow tract.
  3. The LV occupies the most apical point of the heart.
  4. The RV contains the moderator band near the apex.
Figure 5 Probe placement A4CH left lateral decub

Figure 6. Left lateral decubitus positioning for A4CH probe positioning

Optimize views:

  1. Roll the patient onto their left side (left lateral decubitus) to bring the heart towards the chest wall and decrease lung artifact (figure 5). This maneuver improves PSLA and PSSA views too, but can be essential to acquire the A4CH view.
  2. If the heart appears oblique, you are likely too medial.
    1. Slide laterally.
    2. Flatten the probe.
    3. Point the probe towards the right shoulder.

Normal Ultrasound Video

Video 6. Normal apical 4-chamber (A4CH) views

Highlights of View

  • Pericardial effusion (most sensitive view)
  • Cardiac arrest (most commonly used)

Probe Placement

Figure 6 subxiphoid view probe

Figure 7. Subxiphoid view probe placement (Image from Dr. Margaret Lin-Martore)

  1. With the probe marker pointing to the patient’s right, place the probe inferior to the xiphoid process.
  2. Switch to an overhand grip, flatten the probe, apply adequate pressure, and point towards the patient’s left shoulder.

Normal View and Landmarks

Video 7 SUBX view normal

Video 7. Normal subxiphoid view (Image from thepocusatlas.com by Dr. Lindsay Davis, Dr. Hanna Kopinski. Image Editing: Michael Amador and Dr. Matthew Riscinti)

Anatomy in video:

  • Liver (top of the screen)
  • Left ventricle and atrium (red)
  • Right ventricle and atrium (blue) (RV = most anterior chamber)

Troubleshooting and Tips

  • Position the patient supine if possible.
  • Have the patient bend knees to relax abdominal muscles.
  • Have the patient hold breath in inhalation to move the heart inferiorly.
  • Slowly apply moderate pressure to displace bowel gas. Sometimes children cannot tolerate the pressure needed for an adequate view.
  • Using the liver as an acoustic window, try sliding the probe to the patient’s right and pointing the probe towards the patient’s heart through the liver.

Pro tip: Sweeping through this view can allow further assessment for pericardial effusions

Normal Ultrasound Video

 Video 8. Normal subxiphoid view

Highlights of View

  • Rough estimate of fluid tolerance / volume status
  • Adjunct to overall hemodynamic assessment

Probe Placement

Figure 7. Probe placement for IVC transverse view

Figure 8. Probe placement for IVC transverse view. Tilt the probe perpendicular to the patient in a similar location as the subxiphoid view with probe marker to patient’s right. (Image from Dr. Margaret Lin-Martore)

Figure 8. Probe placement IVC sagittal

Figure 9. Probe placement for IVC sagittal view. Center the IVC on the screen, then rotate the probe 90 degrees with probe marker to patient’s head. Slide the probe cephalic until you see the IVC entering the right atrium.  (Image from Dr. Margaret Lin-Martore)

Notes:

  • It is important to evaluate the IVC at its maximum diameter. If you are off-axis in this view, the IVC may appear artificially narrower.
  • Practice obtaining both views, as occasionally it can be difficult to obtain one of the two views depending on patient comfort and the presence of bowel gas.

Normal View and Landmarks

Figure 9. IVC transvere view with anatomy labels

Figure 10. IVC transverse view with anatomy labels. Locate the spinal column (shadowing posteriorly). This shadowing can be seen even in a patient with a larger body habitus. Just anterior to the spinal column, locate the IVC (screen left, patient right) and abdominal aorta (screen right, patient left).

Figure 10 IVC sagittal view labelled

Figure 11. IVC sagittal view with anatomy labels. Visualize the IVC entering into the right atrium (note the hepatic vein draining into the IVC). Examine for collapsibility just distal to the hepatic vein.

Measurements

Various IVC measurements exist, including IVC collapsibility index and IVC-aorta ratio.

1. IVC Collapsibility Index

In the sagittal plane at the level of the IVC just distal to the entry of the hepatic vein, measure the maximum and minimum IVC diameters. A collapsibility index of >50% may represent volume responsiveness.

  • IVC collapsibility index = [Max IVC diameter – Min IVC diameter] / Max IVC diameter

2. IVC-Aorta Ratio

In the transverse plane near the entry of the renal vein, measure the maximum IVC and aorta diameters. Numerous cutoffs for IVC/Ao ratio exist, and can vary by patient age. An IVC/Ao ratio < 0.8 may be suggestive of dehydration.

  • IVC/Ao ratios vary by age, ranging from 0.83 (young infants) to 1.22 (older children) [1].

Please see Facts and Literature Review section for more information on IVC and volume status.

Troubleshooting and Tips

Transverse

  • Many structures can be mistaken for the IVC, including the aorta, portal vessels, and gallbladder. Locate the IVC using the spinal column (shadowing deep on the screen). In a patient without situs inversus, the IVC will be located on screen left (patient right), and the aorta is located on the other side. Both vessels may appear pulsatile, and the IVC shape can change depending on a variety of hemodynamic factors.

Sagittal

  • A common mistake is misidentifying the aorta as the IVC. The aorta is located more to the patient’s left and dives more posteriorly as it crosses the diaphragm. “Prove” that the vessel is the IVC by showing:
    1. The IVC entering the right atrium
    2. The hepatic vein draining into the IVC
  • Because the IVC is a cylindrical structure, it can look like it is completely collapsing if you are located on the edge of the vessel.

Serial IVC Exams:

  • Repeating the IVC exam after interventions (like giving a fluid bolus) can be more helpful than evaluating the IVC at a single point in time.

Normal Ultrasound Video

Video 9: Inferior vena cava (transverse view)
Video 10. Inferior vena cava (sagittal view)

Cardiac POCUS is used primarily to detect significant abnormalities, including:

  1. Gross ventricular dysfunction
  2. Pericardial effusion +/- cardiac tamponade
  3. Gross chamber dilation
  4. Completely collapsed or plethoric IVC

Left Ventricular Systolic Dysfunction

  •     Goal is to identify clinically significant moderate/severe dysfunction.
  •     Qualitative assessment is sufficient, and pattern recognition is important!
  •     As with any diagnostic test, clinical correlation is key
  •     Views: Best assessed on PSLA and PSSA
  •     PSLA:
    • Qualitative assessment of overall “squeeze,” including wall thickening and decrease in chamber size
    • Anterior leaflet of mitral valve excursion: The anterior leaflet should touch or nearly touch the interventricular septum during diastole. Adult POCUS commonly measures this distance, known as EPSS (E-point septal separation); however, age-specific norms are not yet defined in children.
      • Pitfall – An oblique view can underestimate mitral valve movement.
  •     PSSA: 
    • Qualitative assessment of overall “squeeze.”
    • The LV chamber diameter should shorten by ~1/3 and have uniform concentric contraction.

Note: Lung POCUS views may show diffuse B-lines. These vertical white lines originating from the pleura can suggest pulmonary edema in the presence of heart failure. Please see ALiEM PEM POCUS Series: Pediatric Lung Ultrasound for more information.

Ultrasound videos of severe LV dysfunction

Video 11. PSLA view – Severe LV dysfunction in a teenager with new diagnosis of cardiomyopathy. Note the poor overall squeeze, poor excursion of the anterior leaflet of the mitral valve, and lack of thickening of the LV free wall.

 

Video 12. PSSA view in the same patient – note the poor concentric squeeze of the left ventricle

 

Video 13. PSLA view – Severe LV dysfunction in a young infant presenting with failure to thrive and ALCAPA (anomalous left coronary artery from the pulmonary artery). Again note the poor overall squeeze, poor excursion of the anterior leaflet of the mitral valve, lack of thickening of the LV free wall, and dilation of the LV.

 

Video 14. PSSA view – Again note the poor concentric squeeze of the LV and the LV dilation.

  • Views: An effusion should be visible on multiple views.
  • SUBX view:
    • Most sensitive view
    • Pericardial effusion is located between the liver and the right ventricle.
  • PSLA view:
    • Both pericardial and pleural effusions can be seen posterior to the heart.
    • Pericardial effusions track anterior to the descending aorta.
    • Pleural effusions stop posterolateral to the descending aorta and do not cross anteriorly.

Figure 12. Pericardial and pleural effusion on PSLA view

Beware of 2 potential false positives when evaluating for pericardial effusion.

1. Pericardial fat pad

In the PSLA view, this looks like a hypoechoic rim anterior to the heart (closest to probe marker) but NOT posterior to the heart. Typically a fat pad will move in sync with the heart while an effusion does not.

Video 15. Pericardial fat pad and effusion (From thepocusatlas.com by Dr. Dimitri Livshits; Dr. Jane Belyavskaya; Dr. Chris Hanuscin)

2. “Myocardial dropout”

Myocardial dropout occurs when ultrasound waves strike cardiac muscle fibers at specific angles, causing alterations in echogenicity. This acoustic phenomenon can result in the myocardium appearing as a hypoechoic rim. It’s important to note that this rim represents actual myocardial tissue rather than an external collection such as a pericardial effusion. By adjusting the probe angle during the examination, the echogenicity of the myocardium will correspondingly shift, confirming that the hypoechoic area is indeed myocardial tissue rather than a fluid collection (e.g., pericardial effusion).

Figure 13. “Myocardial dropout” effect with asterisks marking drop out area – Changes in echogenicity of the myocardium can sometimes look like a hypoechoic rim. This rim is within the myocardium and not external to the heart as expected for a pericardial effusion. (Image: Dr. Margaret Lin-Martore)

Ultrasound videos of pericardial effusion

Video 16. Pericardial effusion (PSLA view) – The anechoic pericardial effusion is anterior to the heart and also posterior to the heart, tapering just in front of the descending aorta.
Video 17. Pericardial effusion (PSSA view) – Note the circumferential pericardial effusion. A pathologic pericardial effusion should be visualized in multiple views.
Video 18. Pericardial effusion (A4CH view) – Note the pericardial effusion at the apex, right, and left sides of the heart.
Video 19. Pericardial effusion (SUBX view) – Note the pericardial effusion between the liver and the heart. This effusion also surrounds the apex of the heart. Remember that the subxiphoid view is the most sensitive view for detecting pericardial effusion.
Video 20. Trace pericardial effusion (PSLA view) – There is a trace pericardial effusion between the LV free wall and the pericardium. A trace effusion will disappear during part of the cardiac cycle.
Video 21. Pericardial and plerual effusions (PSLA view) – Note both the pericardial and pleural effusions. The pericardial effusion tapers anteriorly to the descending aorta. The pleural effusion stops laterally / posteriorly to the descending aorta.

Definitive diagnosis of cardiac tamponade is beyond the scope of this module, and immediate specialist consultation is recommended if there is clinical concern. However, some concerning ultrasound features would include:

Features:

  1. Circumferential pericardial effusion
  2. Right atrial systolic collapse (earliest sign)
  3. Right ventricular diastolic collapse (*most specific*)
  4. Plethoric IVC

Views:

  • Any view can be used, but the A4CH view shows right-sided structures best.
Video 22. Cardiac tamponade (A4CH view)

Right ventricular function assessment is beyond the scope of this module and typically cardiac POCUS is used as a general assessment. If there is clinical concern for this, specialist consultation is recommended.

Etiologies include pulmonary hypertension, pulmonary embolism, and right heart failure.

  • Increased RV size can suggest increased right heart pressures.
  • Views: Best assessed on A4CH and PSSA.
  • A4CH:
    • A dilated RV will be equal to or larger than the LV
    • Increased RV pressures cause flattening or bowing of the interventricular septum.
  • PSSA view:
    • Increased RV pressures cause flattening of the interventricular septum.
    • “D-sign” = The LV looks like the letter “D” from septal flattening

Figure 13. The D-sign (Image from thepocusatlas.com by Drs. Ronald Rivera, Elizabeth Hanson, Melanie Malloy, Kelly Maurelius, Kings County/SUNY Downstate Emergency Medicine.)

Pitfall:

Beware the “Pseudo D-Sign”. If only one papillary muscle is in view due to probe rotation, the interventricular septum may appear artificially flattened.

Figure 14. Pseudo D-Sign

Video 23. Pseudo D-Sign mimicking right ventricular dilation
Video 24. Right ventricular dilation (PSSA view) – Note the dilation of the right ventricle and flattening of the interventricular septum (D-sign).
Video 25. Right ventricular dilation (A4CH view) – Although this video is intermittently off axis, you can still appreciate right ventricular (RV) dilation. Note the enlarged right ventricle and bowing of the inter ventricular septum into the left ventricle. In a normal heart, the RV should be approximately 2/3 the size of the LV in the apical four chamber view. In infants, the RV can be equal to the size of the LV.
Video 26 RV dilation PSLA

Video 26. RV dilation (PSLA view) – Note the enlarged right ventricle at the top of the screen.

Video 27 McConnells sign PE

Video 27. McConnell’s sign in acute massive pulmonary embolism, showing akinesia of the lateral wall of the right ventricle and hypercontractility of the apical wall. (Image from thepocusatlas.com by Dr. Kelly Maurelus, Matthew Riscinti – Kings County Emergency Medicine)

In general, IVC assessment is most useful at the extremes:

  • Completely collapsed: Walls touch with inhalation.
    • Suggests the patient may benefit from fluid resuscitation.
    • Could be consistent with hypovolemia or distributive shock.
  • Completely plethoric (full): Minimal respiratory variation.
    • Suggests the patient may not need or tolerate significant fluid resuscitation.
    • May consider other medications or treatment.
    • Could be consistent with cardiogenic or obstructive shock.

When evaluating the IVC, it is important to interpret in the overall context of the patient’s presentation. For example, a plethoric IVC with minimal XXX

Video 28. Plethoric IVC – The IVC is very large and does not change in size with respiration.
Video 29. Flattened IVC – The IVC is flat and the walls completely collapse during inspiration.

Cardiac POCUS Literature

Much of the foundation for pediatric cardiac POCUS use is extrapolated from adult studies. Marbach et al. provide an excellent summary of the adult literature and highlights that cardiac POCUS improves clinicians’ bedside diagnostic accuracy, which influences management decisions, expedites time to diagnosis, and decreases resource use [2].

Pediatric-specific studies are summarized below. In general, cardiac POCUS demonstrates adequate sensitivity and specificity in evaluating for pericardial effusion and left ventricular systolic dysfunction [3]. POCUS may even be a promising adjunct to cardiology consultation for children with a variety of preexisting cardiac conditions [4]. These studies are primarily retrospective and warrant further future study.

In pediatric septic shock, cardiac POCUS can help clinicians characterize hemodynamics and often changes clinical management [5].

When it comes to interpretation errors, learners struggle more with evaluation for cardiac dysfunction and ventricle abnormalities than for pericardial effusion [6]. Additionally, novice trainees are more likely to make interpretation errors in real-time at the bedside than when reviewing images remotely [7]. These studies may inform future educational curricula surrounding pediatric cardiac POCUS.

YearAuthorsStudy Type, N, AgesFindings
2021Hamad et al. [9]Case series

  • 10 cases
  • Age 0-21 years
Examples of acute heart failure in children
2022Miller et al. [3]Retrospective review, single center (2015-2017)

  • 456 scans
  • Median age 14.7 years (IQR 9.1-17.5)
Test characteristics for cardiac POCUS interpretation by pediatric emergency medicine (PEM) physicians for detection of pericardial effusion (16 cases) and LV systolic dysfunction (18 cases)

PEM physicians compared to POCUS experts:

  • Pericardial effusion: Sn 100% / Sp 99.5%
  • LV dysfunction: Sn 100% / Sp 99.5%

PEM physicians compared to echocardiography done within 96 hours:

  • Pericardial effusion: Sn 88% / Sp 89%
  • LV systolic dysfunction: Sn 79% / Sp 96%
2024Hoffman et al. [4]Retrospective review,
single center (2015-2017)

  • 104 scans
  • Median age 16.3 years (IQR 8.6-20.1)
Test characteristics for cardiac POCUS interpretation by (PEM physicians for detection of pericardial effusion and LV systolic dysfunction in children with preexisting cardiac disease, including:

  • Congenital heart disease
  • Acquired cardiac disease
  • Arrhythmias

PEM physicians compared to POCUS experts:

  • Pericardial effusion: Sn 100% / Sp 98%
  • LV dysfunction: Sn 100% / Sp 99%

PEM physicians compared to echocardiography done within 96 hours:

  • Pericardial effusion: Sn 88% / Sp 87%
  • LV systolic dysfunction: Sn 100% / Sp 96%

Test characteristics were lower when including technically limited studies (5/104 studies).

Limitations:

  • Possible selection bias: POCUS may have been avoided in more complex cardiac patients
  • Exams with uninterpretable images were excluded (though were not common)
  • Only 1 patient with single ventricle included
2024Scott et al. [9]Retrospective review (pilot study)

  • 21 cases (9 POCUS)
  • Median age 11.8 years (IQR 4.9-16.8)
Examined time-based metrics if POCUS used in ED for pediatric heart failure.

  • Trend towards faster time to 1st IV heart failure medication (p<0.1).
  • No difference in ED or CICU length of stay.
Table 4. Key published studies on pediatric cardiac POCUS

IVC Literature

The evidence is highly variable for using IVC measurements (size, collapsibility index, IVC/Ao ratio) in isolation for predicting fluid responsiveness or central venous pressure [11-13]. A systematic review and meta analysis suggested IVC respiratory variation did not seem to reliably predict fluid responsiveness (AUC 0.71, Sn 71%, Sp 75%) [14]; however, this review also acknowledged high study heterogeneity.

Below are a few best practices when using the IVC assessment in your clinical care:

  • Avoid using the IVC in isolation. It is a data point in the overall clinical picture of your patient.
  • IVC size is most likely helpful at the extremes (completely plethoric or completely collapsing).
  • Serial (repeated) IVC assessments can help evaluate the patient’s response to your interventions.

Case Resolution

Your cardiac POCUS (5 videos below) shows severe left ventricular dysfunction and dilation.


PSLA view

PSSA view

A4CH view

SUBX view

IVC view

The chest X-ray shows cardiomegaly with pulmonary edema. Labs are notable for severe hypocalcemia to 4.2 mg/dL (thought to be secondary to congenital hypoparathyroidism in the setting of 22q11 syndrome). The labs are otherwise unremarkable.

You suspect his cardiac dysfunction is secondary to severe hypocalcemia, give him calcium gluconate, and emergently transfer him to the nearest pediatric center with cardiac intensive care.

Note: The IVC view does have some respiratory variation, although we more commonly see a plethoric IVC in the setting of heart failure. This is a reminder to avoid making decisions based solely on the IVC view. It’s an extra data point in the overall context of the other POCUS views.

Learn More…

References

  1. Mannarino S, Bulzomì P, Codazzi AC, et al. Inferior vena cava, abdominal aorta, and IVC-to-aorta ratio in healthy Caucasian children: Ultrasound Z-scores according to BSA and age. J Cardiol. 2019;74(4):388-393. https://doi.org/10.1016/j.jjcc.2019.02.021
  2. Marbach JA, Almufleh A, Di Santo P, et al. A Shifting Paradigm: The Role of Focused Cardiac Ultrasound in Bedside Patient Assessment. Chest. 2020;158(5):2107-2118. PMID: 32707179 DOI: 10.1016/j.chest.2020.07.021
  3. Miller AF, Arichai P, Gravel CA, et al. Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care. 2022;38(1):e300-e305. doi:10.1097/PEC.0000000000002271
  4. Hoffmann RM, Neal JT, Arichai P, et al. Test Characteristics of Cardiac Point-of-Care Ultrasound in Children With Preexisting Cardiac Conditions. Pediatr Emerg Care. 2024;40(4):307-310. doi:10.1097/PEC.0000000000003050
  5. Arnoldi S, Glau CL, Walker SB, et al. Integrating Focused Cardiac Ultrasound Into Pediatric Septic Shock Assessment. Pediatr Crit Care Med. 2021;22(3):262-274. doi:10.1097/PCC.0000000000002658
  6. Kwan C, Weerdenburg K, Pusic M, et al. Learning Pediatric Point-of-Care Ultrasound: How Many Cases Does Mastery of Image Interpretation Take?. Pediatr Emerg Care. 2022;38(2):e849-e855. doi:10.1097/PEC.0000000000002396
  7. Thomas-Mohtat R, Sable C, Breslin K, et al. Interpretation errors in focused cardiac ultrasound by novice pediatric emergency medicine fellow sonologists. Crit Ultrasound J. 2018;10(1):33. Published 2018 Dec 9. doi:10.1186/s13089-018-0113-4
  8. Hamad A, Ng C, Alade K, D’Amico B, et al. Diagnosing Acute Heart Failure in the Pediatric Emergency Department Using Point-of-Care Ultrasound. J Emerg Med. 2021 Sep;61(3):e18-e25. doi: 10.1016/j.jemermed.2021.03.015. Epub 2021 Jun 4. PMID: 34092442.
  9. Scott C, Alade K, Leung SK, Vaughan RM, Riley AF. Cardiac Point-of-Care Ultrasound and Multi-Disciplinary Improvement Opportunities in Acute Systolic Heart Failure Management in a Pediatric Emergency Center. Pediatr Cardiol. 2024;45(6):1353-1358. doi:10.1007/s00246-023-03125-w
  10. Ng L, Khine H, Taragin BH, Avner JR, Ushay M, Nunez D. Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children?. Pediatr Emerg Care. 2013;29(3):337-341. doi:10.1097/PEC.0b013e31828512a5
  11. Modi P, Glavis-Bloom J, Nasrin S, et al. Accuracy of Inferior Vena Cava Ultrasound for Predicting Dehydration in Children with Acute Diarrhea in Resource-Limited Settings. PLoS One. 2016;11(1):e0146859. Published 2016 Jan 14. doi:10.1371/journal.pone.0146859
  12. Via G, Tavazzi G, Price S. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016;42(7):1164-1167. https://doi.org/10.1007/S00134-016-4357-9
  13. Orso D, Paoli I, Piani T, Cilenti FL, Cristiani L, Guglielmo N. Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis. J Intensive Care Med. 2020;35(4):354-363. https://doi.org/10.1177/0885066617752308

Additional Reading

  • Marbach JA, Almufleh A, Di Santo P, et al. Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis. Ann Intern Med. 2019;171(4):264-272. doi:10.7326/M19-1337

By |2025-05-20T23:09:38-07:00May 21, 2025|Cardiovascular, Pediatrics, PEM POCUS|
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SAEM Clinical Images Series: Painful Great Toe

great toe

A 63-year-old-male with a past history of hypertension, renal failure with dialysis three times per week, and prior infective endocarditis appropriately treated with a regimen that ended four weeks ago presented with left great toe pain that started three weeks ago. The toe began swelling two weeks ago with continued pain and tenderness, becoming discolored approximately one week ago. He noted subjective fever and chills, but had no other complaints.

 

Vitals: Heart Rate 104, BP 111/69 mmHg, Temperature oral 38.1°C, Respiratory Rate 16; SpO2: 99% on room air

Skin: The plantar surface of the left great toe has violaceous discoloration extending to the dorsum of the distal phalanx around the nail. It is tender to touch at the plantar surface only. There is dark brown to black discoloration 16 mm x 8 mm at the distal medial aspect of the toe without ulceration.

Musculoskeletal: Good range of motion at all joints without pain.

Cardiovascular: 3/6 systolic murmur noted at the right sternal border.

The rest of the examination is normal.

BMP: BUN 19 mg/dL, Creatinine  5.21 mg/dL

Hemoglobin: 12.3 g/dL

WBC: 12.28 x 10^9/L

Imaging: X-ray of the left foot is unremarkable

Osler node

Yes, the patient should be admitted; an Osler node or Janeway lesion is indicative of active endocarditis. An Osler node is a painful, tender, nodular lesion that is bluish-purple and is located on the distal phalanx of the fingers or toes. Classically, pain precedes any swelling, with subsequent discoloration occurring with skin pigmentation being described as reddish, cyanotic, bluish-purple, vivid pink, or erythematous. The skin may desquamate or darken, but ulceration is rare. Histologic evaluation reveals necrotizing vasculitis and inflammatory infiltration of the vascular channels. Aspiration and culture of the lesions typically yields no organisms, though several case reports note positive bacterial growth with organisms that match the underlying endocarditis bacteria. Whether an Osler node is caused by micro-septic emboli or by an immune response is a controversy that has not yet been settled. Janeway lesions, also seen in endocarditis, are similar discolored macules on the palms or soles. However, Janeway lesions are normally painless, which is a key factor that differentiates them from Osler nodes. Osler nodes or Janeway lesions are indicative of active endocarditis. Patients with these lesions, such as the patient in this case, should be admitted for blood cultures, echocardiography, and intravenous antibiotics. This patient was admitted, and his echo confirmed multiple vegetative lesions with severe aortic valvular disease. The patient was subsequently transferred for valve replacement surgery after three weeks of intravenous antibiotics.

Take-Home Points

  • Osler nodes are tender, violaceous nodules located on the finger or toe pads.

  • Janeway lesions, located on the palms or soles, have similar discoloration but are not tender.

  • Osler nodes and Janeway lesions are uncommon but important manifestations of infective endocarditis.

  • Farrior JB, Silverman ME. A consideration of the differences between a Janeway’s lesion and an Osler’s node in infectious endocarditis. Chest. 1976 Aug;70(2):239-43. doi: 10.1378/chest.70.2.239. PMID: 947688.

  • Philip J, Bond MC. Emergency Considerations of Infective Endocarditis. Emerg Med Clin North Am. 2022 Nov;40(4):793-808. doi: 10.1016/j.emc.2022.07.001. Epub 2022 Oct 7. PMID: 36396222.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-04-23T10:53:56-07:00Apr 25, 2025|Cardiovascular, Infectious Disease, SAEM Clinical Images|
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SAEM Clinical Images Series: A Rare Cause of Dyspnea

pneumopericarditis

A 73-year-old female with past medical history significant for Roux-en-Y gastric bypass 14 years prior complicated by gastro-jejunal ulcers, rheumatoid arthritis on daily prednisone for six months, coronary artery disease, history of remote pulmonary embolism no longer on anticoagulation, GERD, non-insulin dependent type 2 diabetes, morbid obesity, and chronic obstructive pulmonary disease, presented with two-week progression of dyspnea after a ground level fall. She endorsed pain to her neck, back, and stomach. She denied any chest pain, cough, hemoptysis, fevers, chills, leg pain, leg swelling, wheezing, recent surgeries or hospitalizations, recent travel, or history of tobacco use.

 

Vitals: Temp 98.4°F; HR 81; BP 61/46; RR 19; O2 sat 96% on 6L nasal cannula

General: Not in acute respiratory distress. Appears ill.

Neurologic: A&OX4. Face is symmetrical. Following commands. Moves all four limbs spontaneously.

Cardiovascular: Normal rate and rhythm without murmurs, gallops, or rubs. Heart sounds are muffled. Unable to assess for JVD due to body habitus.

Pulmonary: Lungs clear to auscultation bilaterally. No wheezing, rhonchi, rales. No accessory muscle use. Speaking in full sentences.

Abdominal: Diffusely tender to deep palpation. No rebounding, guarding, or tenderness.

Extremities: DPs 2+ and radials 2+. No asymmetric leg swelling. Legs non-tender.

CBC: WBC 12.5 k/µL, hemoglobin 10.3 g/dL

Lactate: 5.0 mmol/L

ABG: pH 7.34, PaCO2 28.3 mmHg, PaO2 78.5 mmHg, O2 sat 94.5%, bicarb 14.8 mmol/L

Blood glucose: 125 mg/dL

Troponin: 132, 133 ng/L.

EKG: Normal sinus rhythm with low voltage and ST-segment elevations in lead II, V3-V6

The diagnosis is pyopneumopericarditis from a pericardial-jejunal fistula. The differential diagnosis for pneumopericarditis includes a history of blunt or penetrating trauma, thoracic surgery or pericardial fluid drainage, positive pressure ventilation, and infectious pericarditis. In this case, the cause was a fistula likely as a side effect of chronic steroid use, which increases the risk of peptic ulcer disease.

Definitive management requires operative intervention with thoracic surgery. Pneumopericarditis carries a high mortality risk and a high risk for tamponade or cardiogenic shock from myopericarditis, as well as septic shock if infection is also present. Therefore, disposition for these patients usually requires surgical intensive care for close hemodynamic and respiratory monitoring and support. It is prudent to start broad-spectrum antibiotics and obtain blood cultures, as well as intraoperative pericardial fluid cultures to narrow antibiotic selection. CT esophagram and/or endoscopy is often indicated to rule out a pericardial-enteric fistula if there are no other immediate causes unveiled on history and examination. The patient should also receive aspirin and colchicine if concomitant myopericarditis is present.

Take-Home Points

  • Pneumopericarditis requires early, aggressive operative intervention and intensive care management.

  • Use steroids judiciously in patients with known gastritis or peptic ulcer disease.

  • Azzu V. Gastropericardial fistula: getting to the heart of the matter. BMC Gastroenterol. 2016 Aug 19;16(1):96. doi: 10.1186/s12876-016-0510-8. PMID: 27542946; PMCID: PMC4992300.
  • Davidson JP, Connelly TM, Libove E, Tappouni R. Gastropericardial fistula: radiologic findings and literature review. J Surg Res. 2016 Jun 1;203(1):174-82. doi: 10.1016/j.jss.2016.03.015. Epub 2016 Mar 15. PMID: 27338548.
  • Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease. N Engl J Med. 2002 Jan 31;346(5):328-32. doi: 10.1056/NEJMoa010259. PMID: 11821509.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T21:57:21-07:00Mar 14, 2025|Cardiovascular, Gastrointestinal, SAEM Clinical Images|
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SAEM Clinical Images Series: Short of Breath and Short on Time

A 62-year-old female presented with shortness of breath that started two days ago which she described as mild to moderate, worse with activity. She denied chest pain, abdominal pain, fever, diaphoresis, syncope, cough, wheezing, sputum production, or emesis. Past medical history was significant for rectal adenocarcinoma metastatic to liver. She was status post radioembolization of liver metastasis from the left lobe and her last chemotherapy was approximately one month prior to presentation.

pneumopericardium

Vitals: T 36.5°C; BP 87/57; HR 91-115; RR 12; O2 sat 94% on 2L NC

General: Ill-appearing.

Cardiovascular: Normal rate and regular rhythm, diminished heart sounds.

Chest: Pulmonary effort normal, normal breath sounds.

Gastrointestinal: Abdomen flat, soft, nontender.

MSK: Cyanotic toes bilaterally with decreased capillary refill.

Neurologic: Diffuse motor weakness, no focal deficit present.

CBC: WBC 18.0, Hgb 9.6, Plt 348

PT: 19.4

INR: 1.6

BMP: Na 126, K 4.4, Cl 100, CO2 13 (20-29), Anion Gap 13, Glucose 107, BUN 54 (7-25), Cr 1.96, Ca 7.7

BNP: 410 (0-100)

Lactic acid: Initial 2.5, repeat 4.0 (0.5-2.0)

EKG: Normal sinus rhythm, normal rate, low voltage QRS.

Pneumopericardium, the presence of air within the pericardial sac, is discovered on imaging. The accumulation of air can result in compression of the heart and interfere with normal functioning. Pneumopericardium on imaging can appear as a characteristic radiolucency around the heart on chest X-ray and CT scan, or as direct visualization of air within the pericardial sac on ECHO. Causes include trauma introducing air into the pericardial sac, infection with gas-producing organisms, procedural complications, barotrauma, or spontaneous occurrence.

Gastropericardial fistula is a rare, life-threatening condition whereby an abnormal communication is created between the stomach and pericardial sac, with less than 100 cases reported in modern literature. This condition usually occurs in the setting of prior gastroesophageal surgery, ulcer perforation, or as in this case, malignant perforation due to breakdown of malignant implants between the liver and the gastric wall adherent to the diaphragm and pericardium. This can lead to frank pneumopericardium and tension physiology, ultimately resulting in death if not promptly diagnosed and treated with urgent pericardial drain placement to ameliorate tension physiology. Definitive therapy is surgical repair.

Take-Home Points

  • Gastropericardial fistula is a rare cause of pneumopericardium, usually in the setting of patients with prior gastroesophageal surgery, gastric ulceration, or malignancy of the stomach.

  • Diagnosis is usually made with a combination of imaging modalities including esophagram/upper GI, CT with water soluble oral contrast, and echocardiogram.

  • Prompt diagnosis and treatment are necessary to prevent the onset of tension physiology.

  • Azzu V. (2016). Gastropericardial fistula: getting to the heart of the matter. BMC gastroenterology, 16(1), 96. https://doi.org/10.1186/s12876-016-0510-8

  • Rathur, A., Al-Mohamad, H., Steinhoff, J., & Walsh, R. (2021). Chest Pain from Pneumopericardium withGastropericardial Fistula. Case reports in cardiology, 2021, 5143608. https://doi.org/10.1155/2021/5143608

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-02-26T14:43:04-08:00Feb 27, 2025|Cardiovascular, Gastrointestinal, SAEM Clinical Images|
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SAEM Clinical Images Series: Male Weightlifter with Chest Pain

hyperacute

An otherwise healthy 45-year-old male presented to the emergency department (ED) with substernal chest pain radiating down his left arm over the previous two days. On the first day of symptoms, his pain began several hours after using a new pre-workout supplement and weightlifting. The symptoms lasted for a few hours and self-resolved. The pain returned the following day under the same conditions, although this time persistent, which brought him in for evaluation. Associated symptoms included shortness of breath, nausea, and one episode of emesis. He denied pleuritic pain, lower extremity edema, hemoptysis, syncope, cough, or chest wall trauma. On further history, he reported prior use of anabolic steroids, with the last being six weeks prior to presentation. It was unclear what were the contents of the pre-workout supplement, but he denied any tobacco or illicit drug use. Notably, he had a significant family history of heart disease with his father having undergone coronary bypass at age 47. His initial ECG (Image 1) and interval ECG (Image 2) are shown.

 

Vitals: T 36.5°C; HR 74; RR 16; BP 161/107; SpO2 98% on RA

General: Uncomfortable and diaphoretic in moderate distress.

Cardiovascular: Normal rate and rhythm, no murmurs. Equal radial and PT pulses bilaterally.

Pulmonary: Non-labored breathing, lungs CTA bilaterally with equal breath sounds.

Extremities: Lower extremities without significant edema, symmetric in size.

Neuro: Alert and oriented, neurologically intact.

Complete blood count (CBC): mild polycythemia (Hgb 19.0 g/dL) and leukocytosis (WBC 10.1 x 10(9)/L)

Basic metabolic panel (BMP): Cr 1.22 mg/dL, GFR 75 mL/min/BSA, K 4.5 mmol/L

Troponin T, 5th generation: 97 ng/L (ref. range: <=15 mg/L)

Acute coronary syndrome (ACS) with myocardial infarction. Hyperacute T waves are seen on the initial ECG.

This patient’s initial ECG (Image 1) raised concern for hyperacute T waves, which are often described as broad-based with a large amplitude. This subtle finding is difficult to differentiate from normal variants, hypertrophy, or hyperkalemia (1,2). Hyperacute T waves have been considered an early sign of acute coronary occlusion, however, current literature is mixed regarding their clinical utility, particularly given the lack of a formal ECG definition (3,4,5). The American College of Cardiology (ACC) recommends obtaining serial ECGs in patients with hyperacute T waves to assess for progression to STEMI (3). In this patient’s case, interventional cardiology was consulted, and the patient was given aspirin and sublingual nitroglycerin. He developed worsened chest pain, and a repeat ECG showed no significant changes. Shortly after, he went into ventricular fibrillation and cardiac arrest. A post-ROSC ECG (Image 2) showed concave ST elevations in the anterolateral leads with reciprocal ST depressions in the inferior leads, meeting STEMI criteria. Coronary angiography showed severe multivessel disease and 100% occlusion of the left anterior descending (LAD) artery. A drug-eluting stent was placed, and the patient was discharged home one week later with an intact neurologic status.

History of anabolic steroid use, pre-workout supplementation, and significant family history of CAD. In more recent years, the number of younger patients (35-54 years) hospitalized for ACS has increased (6). This trend is believed to be related to the increased use of illicit drugs, including marijuana and androgenic-anabolic steroids (AAS) (6). AAS is known to increase the risk of cardiac hypertrophy, ACS, and sudden cardiac death by increasing lipoprotein production, causing intimal hyperplasia of coronary arteries, and increasing clotting factors leading to a procoagulant state (7,8). Consensus on the adverse effects and overall safety of pre-workout supplements remains under debate and they remain unregulated by the FDA. Studies suggest that synephrine, a common product found in pre-workout supplements, may raise safety concerns due to its androgenic properties (9). A 2023 systematic review of adverse outcomes related to synephrine found associations with cardiomyopathy, ACS, arrhythmias, and cerebrovascular disease (9,10).

Take-Home Points

  • Hyperacute T waves, although not diagnostic in isolation, may be an early marker for occlusion myocardial infarction and if seen, serial ECGs should be performed.

  • A high degree of clinical suspicion for ACS should be maintained among patients with a history of androgenic-anabolic steroid use, even in young and otherwise healthy individuals.

  • Pre-workout supplements, especially those that contain the compound synephrine have been associated with ACS and other cardiovascular pathology.

  • Somers MP, Brady WJ, Perron AD, et al. The prominent T wave: electrocardiographic differential diagnosis. Am J Emerg Med 2002 May;20(3):243-51

  • Levis JT. ECG Diagnosis: Hyperacute T Waves. Perm J. 2015 Summer;19(3):79. doi: 10.7812/TPP/14-243. PMID:26176573; PMCID: PMC4500486.

  • Writing Committee; Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI Jr, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2022 Nov 15;80(20):1925-1960. doi: 10.1016/j.jacc.2022.08.750. Epub 2022 Oct 11. PMID: 36241466; PMCID: PMC10691881.

  • Koechlin L, Strebel I, Zimmermann T, Nestelberger T, Walter J, Lopez-Ayala P, Boeddinghaus J, Shrestha S, Arslani K, Stefanelli S, Reuthebuch B, Wussler D, Ratmann PD, Christ M, Badertscher P, Wildi K, Giménez MR, Gualandro DM, Miró Ò, Fuenzalida C, Martin-Sanchez FJ, Kawecki D, Bürgler F, Keller DI, Abächerli R, Reuthebuch O, Eckstein FS, Twerenbold R, Reichlin T, Mueller C; APACE investigators. Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction. Ann Emerg Med. 2023 Aug;82(2):194-202. doi: 10.1016/j.annemergmed.2022.12.003. Epub 2023 Feb 10. PMID: 36774205.

  • Smith SW, Meyers HP. Hyperacute T-waves Can Be a Useful Sign of Occlusion Myocardial Infarction if Appropriately Defined. Ann Emerg Med. 2023 Aug;82(2):203-206. doi: 10.1016/j.annemergmed.2023.01.011. Epub 2023 Mar 3. PMID: 36872197.

  • Bhatt DL, Lopes RD, Harrington RA. Diagnosis and Treatment of Acute Coronary Syndromes: A Review. JAMA. 2022;327(7):662-675.

  • Melchert RB, Welder AA. Cardiovascular effects of androgenic-anabolic steroids. Med Sci Sports Exerc. 1995;27(9):1252-1262.

  • Pope HG, Jr., Kanayama G, Athey A, Ryan E, Hudson JI, Baggish A. The lifetime prevalence of anabolic-androgenic steroid use and dependence in Americans: current best estimates. Am J Addict. 2014;23(4):371-377.

  • de Jonge MLL, Kieviet LC, Sierts M, Egberink LB, van der Heyden MAG. Review of Case Reports on Adverse Events Related to Pre-workout Supplements Containing Synephrine. Cardiovasc Toxicol. 2023 Jan;23(1):1-9. doi: 10.1007/s12012-022-09777-z. Epub 2023 Jan 13. PMID: 36639595; PMCID: PMC9859859.

  • Flo FJ, Kanu O, Teleb M, Chen Y, Siddiqui T. Anabolic androgenic steroid-induced acute myocardial infarction with multiorgan failure. Proc (Bayl Univ Med Cent). 2018;31(3):334-336

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-01-30T10:12:40-08:00Feb 7, 2025|Cardiovascular, ECG, SAEM Clinical Images|
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