SAEM Clinical Images Series: Found Down

found down

A 67-year-old caucasian male experiencing homelessness was “found down” in a parking lot. EMS reported that he had a GCS of 6 with a systolic blood pressure in the 80’s, finger stick glucose of 100, and no response to intranasal naloxone. He was intubated in the field and arrived to the emergency department unresponsive with a BP of 95/60, HR 125, T 38°C, and O2 Sat 100%. Hemodynamic stabilization was achieved with central venous access, and laboratory and imaging studies for the evaluation of altered mental status ensued.

General: Disheveled male

HEENT: Normocephalic; PERRLA 3-2 mm; dried blood in nares

Skin: Warm; dry; no visible signs of trauma

Cardiovascular: Tachycardic with no murmurs, rubs, or gallops

Respiratory: Bilateral breath sounds on ventilator; diffuse rales

Gastrointestinal: Soft; non-distended; bowel sounds present

Musculoskeletal: No deformities

Neurologic: Unresponsive; GCS 3

COVID-19 rapid antigen: Detected

Complete Blood Count (CBC): WBC 17 k; Hemoglobin 15; Platelets 185

Comprehensive Metabolic Panel (CMP): Na 133; K 4.6; Cl 91; CO2 21; BUN 18; Cr 2.2; Ca 8.4; Alb 2.1; Tbili 0.4; Alk phos 112; AST 242; ALT 68

ABG on FiO2 100%: 6.99/>95/405/23/100%

Lactate: 16.4

Ammonia: 90

CK total: 716

Trop I HS: 809

PT: 14

INR: 1.05

PTT: 45

Urinalysis: Unremarkable

EtOH, Acetaminophen, Salicylate: Negative

UDS: Negative

Chest Radiograph: Diffuse ground-glass opacities

Air embolism to the right ventricle and pulmonary artery. As little as 20 mL or less of air rapidly infused may cause obstruction, ischemia, and hemodynamic collapse.

Risk factors include central venous catheterization, lung trauma, ventilator usage, hemodialysis, surgery (esp. coronary, neurosurgery), childbirth, and scuba diving barotrauma.

Take-Home Points

  • In the appropriate clinical scenario, especially those involving respiratory, cardiac, and neurologic findings where invasive procedures were utilized, the diagnosis of venous air embolism should be entertained.
  • Immediate management of an air embolism involves administration of 100% oxygen by nonrebreather mask (NRM) or ventilator and placement of the patient in the left lateral decubitus (Durant maneuver) and Trendelenburg positions. Hyperbaric oxygen therapy has also been used if there is no clinical improvement.
  • The purpose of the Durant maneuver and Trendelenburg position is to trap air along the lateral right ventricular wall, preventing right ventricular outflow obstruction and embolization into the pulmonary circulation.

  • Gordy S, Rowell S. Vascular air embolism. International Journal of Critical Illness and Injury Science. 2013;3(1):73. doi:10.4103/2229-5151.109428 Malik N, Claus PL, Illman JE, Kligerman SJ, Moynagh MR, Levin DL, Woodrum DA, Arani A, Arunachalam SP, Araoz PA. Air embolism: diagnosis and management. Future Cardiol. 2017 Jul;13(4):365-378. doi: 10.2217/fca-2017-0015. Epub 2017 Jun 23. PMID: 28644058.

ACMT Toxicology Visual Pearl: Hypertension and Rash

mercury poisoning toxicity

Which toxic exposure can present with the pictured rash along with hypertension and tachycardia mimicking pheochromocytoma?

  1. Arsenic
  2. Lead
  3. Mercury
  4. Silver
  5. Thallium

(more…)

Blood Pressure Differences in Patients with Acute Aortic Dissections

Background

An acute aortic dissection (AAD) can be a life-threatening emergency which frequently requires rapid and precise control of the patient’s heart rate and blood pressure. The 2010 guidelines for management of patients with thoracic aortic disease suggest a heart rate goal of <60 bpm and a systolic blood pressure between 100-120 mmHg. In order to achieve this, a rapid-acting beta-blocker (i.e., esmolol) may be used in combination with an IV calcium channel blocker (i.e., nicardipine or clevidipine). These medications need to be monitored closely to avoid overshooting these goals and causing hemodynamic compromise. Ideally, an arterial line would be used to monitor the patient’s blood pressure, however this may not always be feasible so a traditional, noninvasive blood pressure cuff can be used. This may be complicated if the patient has the classic, but not universal, finding of unequal systolic blood pressure values between their left and right extremities. This raises the question, in a patient with an AAD and disparate blood pressures in each arm, which arm reading should be used for monitoring?

Evidence

A 2018 study from Um et al. evaluated 111 patients with an AAD and compared them with 111 control patients. This study found that while a systolic blood pressure difference of >20 mmHg between sides was a positive predictor for an AAD, the presence of a pulse deficit had a higher diagnostic accuracy. For the purpose of this study, a pulse deficit was defined as “any recorded difference in volume/force or difference in obvious signs of malperfusion”. The cause of an unequal blood pressure or pulse deficit in the upper extremities in this population is typically due to dissection of the brachiocephalic or subclavian arteries. In order to properly achieve the desired blood pressure reduction in patients with divergent blood pressure values, the higher value should be used for titration of antihypertensives. This is due to the occurrence of pseudohypotension occurring in the limb with the dissected artery.

Bottom-line

  • Aggressive and precise heart rate and blood pressure control are critical for patients with an acute aortic dissection
  • The presence of a pulse deficit may provide better diagnostic accuracy than a difference in systolic blood pressure
  • When titrating blood pressure medications in patients with unequal blood pressure readings between extremities, the higher value should be utilized

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References:

  1. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease Circulation. 2010;121(13):e266-369. doi: 10.1161/CIR.0b013e3181d4739e. PMID: 20233780.
  2. Um SW, Ohle R, Perry JJ. Bilateral blood pressure differential as a clinical marker for acute aortic dissection in the emergency department. Emerg Med J. 2018;35(9):556-558. doi: 10.1136/emermed-2018-207499. PMID: 30021832.
By |2022-03-18T07:53:35-07:00Mar 19, 2022|Cardiovascular, EM Pharmacy Pearls|

ALiEM AIR Series | ACS 2022 Module

This image has an empty alt attribute; its file name is AIR-logo-2016-transparent-SAEM-CORD-586x650.jpg

Welcome to the AIR ACS Module! After carefully reviewing all relevant posts from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to ACS emergencies in the Emergency Department. 7 blog posts met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 4 AIR and 3 Honorable Mentions. We recommend programs give 4 hours (about 30 minutes per article) 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 AIR ACS Quiz at ALiEMU

Interested in taking the ACS 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: ACS Emergencies

SiteArticleAuthor(s)DateLabel
EM CasesReciprocal Change and Occlusion MIJesse McLaren, MD10 Aug 2021AIR
EM CasesWellen’s Syndrome, Re-occlusion, and MIJesse McLaren, MD13 Jul 2021AIR
EM CasesHyperAcute T waves and Occlusion MIJesse McLaren, MD4 May 2021AIR
EM CasesST elevations mnemonic and Occlusion MIJesse McLaren, MD12 Jan 2021AIR
Rebel EMThe OMI/NOMI ParadigmSalim Rezaie, MD and Tarlan Hedayati, MD3 Oct 2021HM
Dr. Smith’s ECG blogAccuracy of OMI ECG findings versus STEMI criteria for diagnosis of acute OMISteve Smith, MD and Pendell Myers, MD12 Apr 2021HM
emDocsCocaine and ST elevationBrannon Inman, MD and Lloyd Tannenbaum, MD10 Dec 2020HM

(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! More in-depth information regarding the Social Media Index.

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

SAEM Clinical Image Series: Painful Blue Arm

arm swelling

A 68-year-old male with a past medical history of hypertension, hyperlipidemia, and recent ileostomy secondary to small bowel obstruction presented for acute left arm swelling, discoloration, and numbness since last night. He endorses sudden onset of painful edema with the development of purple discoloration. He denies trauma, history of similar problems, chest pain, or shortness of breath. He endorses difficulty flexing at the elbow secondary to the amount of swelling, pain, and numbness to the arm. The patient had a peripherally inserted central catheter (PICC) line placed in the left upper extremity two weeks ago.

Vitals: T 37.1°C; HR 80; BP 154/82; RR 18; O2 sat 100% on RA

General: Moderate distress secondary to pain but non-toxic appearing

Cardiovascular: Regular rate and rhythm; no murmurs; left ulnar artery 2+; left radial artery 1+ to palpation; bedside doppler—triphasic left ulnar artery and biphasic left radial artery; capillary refill three seconds

Respiratory: Lungs clear to auscultation bilaterally; no adventitious breath sounds

Musculoskeletal: Left upper extremity with global nonpitting edema from fingers to shoulder; skin with purple cyanotic discoloration; moderately tender to palpation throughout the entire limb; no crepitus or bullae; pain is not out of proportion; soft compartments throughout the left upper extremity

Neurologic: Alert and oriented to person, time, and place; Glasgow Coma Scale 15; cranial nerves II-XII grossly intact; sensation decreased in left upper extremity; all other extremities intact

Complete blood count (CBC): Unremarkable

Partial thromboplastin time (PTT) and International normalized ratio (INR): Unremarkable

Phlegmasia cerulea dolens (PCD) of the Upper Extremity. It’s just a deep venous thrombosis (DVT) right?

PCD is not just another DVT, it’s a severe limb-threatening (12-25% amputation rate) and life-threatening (25-40% mortality rate) disease that presents with marked swelling in the extremity, pain, and cyanosis.

The pathophysiology of PCD involves complete obstruction of both superficial and deep venous return, resulting in increased interstitial tissue pressure, arrest of capillary flow, tissue ischemia, and ultimately, gangrene. Upper extremity involvement is rare and only occurs in approximately 2-5% of all phlegmasia cases. PCD presents with key characteristics: marked edema, severe pain, pathognomonic blue discoloration/cyanosis, and eventually ischemia.

Ultrasound is the best initial modality for suspected PCD and bedside ultrasound with two-point compression can be quickly performed by the emergency physician.

Management should include fluid resuscitation, systemic anticoagulation, and emergent vascular surgery or interventional radiology consult for possible thrombectomy or catheter-directed thrombolysis.

Take-Home Points

  • PCD is a rare, life-and-limb-threatening disease that can rapidly progress to gangrene and tissue death.
  • Phlegmasia cerulea dolens literally translates to “painful blue inflammation.” Large clot burden causes severe pain, cyanosis, and marked edema.
  • Prompt evaluation with ultrasound, treatment with anticoagulation, and emergent vascular surgery or interventional radiology consultation are essential.

  • Chaochankit W, Akaraborworn O. Phlegmasia Cerulea Dolens with Compartment Syndrome. Ann Vasc Dis. 2018 Sep 25;11(3):355-357. doi: 10.3400/avd.cr.18-00030. PMID: 30402189; PMCID: PMC6200621.
  • Kommalapati A, Kallam A, Krishnamurthy J, Tella SH, Koppala J, Tandra PK. Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia Leading to Gangrene. Cureus. 2018 Jun 21;10(6):e2853. doi: 10.7759/cureus.2853. PMID: 30148006; PMCID: PMC6104908.
  • Kou CJ, Batzlaff C, Bezzant ML, Sjulin T. Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis. Cureus. 2020 Jun 12;12(6):e8587. doi: 10.7759/cureus.8587. PMID: 32670722; PMCID: PMC7358928.
  • Onuoha CU. Phlegmasia Cerulea Dolens: A Rare Clinical Presentation. Am J Med. 2015 Sep;128(9):e27-8. doi: 10.1016/j.amjmed.2015.04.009. Epub 2015 Apr 22. PMID: 25910785.

 

By |2022-01-04T11:48:50-08:00Jan 10, 2022|Cardiovascular, SAEM Clinical Images|

SAEM Clinical Image Series: A Young Woman with Chest Pain

ECG

A 35-year-old female with a history of intermittent palpitations who is three months post-partum presented to the emergency department (ED) with three days of sharp, substernal chest pain radiating down her left arm. She reportedly had a normal electrocardiogram (ECG) at an outside hospital on the first day of symptoms. The pain returned and was associated with one episode of vomiting the night prior to presenting to our ED. Initial ECG on arrival is shown.

Vitals: Tachycardic; afebrile; normotensive; no tachypnea or hypoxemia on room air

General: Mild distress, appears uncomfortable

Cardiovascular: Tachycardic to 100s, regular rhythm, no murmur, normal peripheral perfusion, no edema

Pulmonary: Lungs clear to auscultation, no respiratory distress

Neuro: Alert and oriented, neurologically intact

Complete blood count (CBC) and basic metabolic panel (BMP): unremarkable

Partial thromboplastin time (PTT) and international normalized ratio (INR): normal

Troponin: 42

Spontaneous coronary artery dissection (SCAD).

The patient underwent emergent coronary angiography demonstrating multivessel coronary dissection including a distal left anterior descending (LAD) hematoma with lumen compression as well as obtuse marginal (OM1) and posterior descending artery (PDA) lesions consistent with spontaneous coronary artery dissection (SCAD). She was admitted to the intensive care unit on a heparin drip, had decreasing troponin levels, and ultimately was discharged home on enalapril, metoprolol, aspirin, and clopidogrel.

SCAD is a rare but important diagnosis in the ED as it conveys serious morbidity and mortality risk. Patients present with chest pain, dyspnea, diaphoresis, and potentially signs or symptoms of heart failure from severe ischemia. Most patients are women under the age of 50, and many are pregnant, postpartum, or taking oral contraceptives. This may be mistaken for other diagnoses on presentation, such as ST-segment elevation myocardial infarction (STEMI) or takotsubo cardiomyopathy, which usually presents in post-menopausal patients, but SCAD differs in its typical patient population. Wall motion abnormalities on an echocardiogram are present, but there are not always signs of heart failure as in post-partum cardiomyopathy. Patients are often taken for urgent coronary angioplasty, though in cases with marked ischemia or hemodynamic instability, emergent coronary artery bypass graft (CABG) may be indicated. Recurrence is common; patients should be counseled on mitigating cardiovascular risk factors, particularly smoking and hypertension, and to be cautious with intense exertion and future pregnancies.

Take-Home Points

  • ECG typically shows ST elevation in the leads of the dissecting artery or arteries. Important risk factors include oral contraceptive use, being pregnant or postpartum, and fibromuscular dysplasia.
  • ED management includes aspirin, heparin, and immediate cardiology consultation, as a definitive diagnosis will be made in the cath lab.

  • Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015 Feb;5(1):37-48. doi: 10.3978/j.issn.2223-3652.2015.01.08. PMID: 25774346; PMCID: PMC4329168.
  • Macaya F, Salinas P, Gonzalo N, Fernández-Ortiz A, Macaya C, Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart. 2018 Nov 5;5(2):e000884. doi: 10.1136/openhrt-2018-000884. PMID: 30487978; PMCID: PMC6241978.

 

By |2021-10-26T20:58:04-07:00Nov 1, 2021|Cardiovascular, ECG, SAEM Clinical Images|
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