Disaster Preparedness: Emergency Physicians Respond to the Call


By Dr. Nicholas Kman @DrNickKman, OSU EM Associate Professor and Medical Student Clerkship Director // Editor Dr. Michael Barrie @MikeBarrieMD, OSU EM Assistant Professor

I was sitting in the study lounge at the Ohio State University College of Medicine in between lectures on September 11, 2001.  Knee-deep in my second year of medical school, I could clearly remember dreading going back into the lecture hall to hear another stimulating hour on Aspergillosis.  Then, Wolf Blitzer or Anderson Russell or some other CNN anchor, broke in with terrible news.

Two planes had crashed into the twin towers of the World Trade Center.  Later that day, we learned of the news that another plane had struck The Pentagon while yet another crashed on its way to Washington.  I remember my disbelief and strong desire to help.

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New Attending Lessons: Activate the Cath Lab?

An 85-year-old female presents from her nursing home in the respiratory failure. EMS found the patient in agonal respirations. On arrival to the ED the patient is intubated, heart rate 150, blood pressure 40/palp, and she has palpable femoral pulses. As I run through possible next steps to keep this patient from impending arrest, EMS shows me the EKG. Should we activate the cath lab?
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The pupils are fixed and dilated. The pupils are fixed and dilated?!

Written by Zach Adams, OSUEM resident // edited by Michael Barrie, OSUEM Assistant professor

EMS brings in an unconscious man. They are bagging the patient in the hallway of the ED and tell you that they found the patient “down” at home, unresponsive, and with agonal respirations. The patient is obviously altered, unresponsive, and not protecting his airway. You and the team respond rapidly, performing rapid assessment on this undifferentiated patient. Rapid sequence intubation is performed to protect the airway, and you go down your algorithm. The patient was not moving spontaneously, and you’d like to assess pupillary status. But he’s intubated, sedated, and just received etomodate and rocuronium. The pupils appear dilated and unresponsive. But is the pupil exam reliable after a paralytic?

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Does D-dimer rule out PE? YES, but…

Written by Zach Adams, OSU EM resident // Edited by Michael Barrie EM Assistant Professor.

Bottom line: D-dimer reliably excludes PE in low/moderate risk patients, however use clinical history/exam to guide pursuing advanced imaging.

An otherwise healthy 23 year-old presents with worsening shortness of breath for the past 7 days.  Shortness of breath began suddenly while at rest, has been continuous, and with associated reduced exercise tolerance.  Five days ago she was seen in the ED with a negative d-dimer and CXR and discharged with return precautions.  Since then, she states that the symptoms have progressed. She says she cannot lie flat.  ROS reveals a history of antecedent URI 10 days ago.  She is a non-smoker, takes no birth control pills, does not have a personal or family history of DVT or PE, and denies recent prolonged travel.  She appears uncomfortable and takes deep inspirations every 3-5 seconds.  Her physical exam reveals tachypnea with otherwise normal exam.  ECG shows normal sinus rhythm.  CXR is normal and repeat d-dimer is negative.

The patient has bounced back with worsening symptoms.  I struggled with this clinical question: should we obtain a CT PE to rule out PE despite a negative d-dimer in this low risk patient?

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Intern Review – Parapneumonic Effusions

Written by Patrick Sylvester, OSU EM/IM Resident // Edited by Michael Barrie OSU EM Assistant Professor

“Never let the sun set on a…”

During a recent scanning shift performing point of care ultrasounds, we came across an old adage that we had to google to confirm was true: “Never let the sun set on a…”  We each inserted our own ending based on the wise words we had heard in medical school.  I suppose from the title of this post, you can guess what we ended up talking about—after some googling, that is.  While our argument was settled that one was not to let the sun set on a parapneumonic effusion, we were unsure best practice in more ambiguous cases.

Consider this: you’re called to the bedside of a 60 year-old patient who presented with hypotension, subjective fever, and in Afib w/ RVR.  A rapid assessment with the ultrasound probe can provide critical information; a subxiphoid view for cardiac contractility and evaluation of pericardial effusion, the IVC for preload assessment.  Perhaps you sweep by one of the costodiaphragmatic angles and find something like what’s shown in following video:

In the undifferentiated ill patient, the cause of the pleural effusion is not always clear. Is it secondary to decompensated CHF or is this a parapneumonic effusion? Obviously the clinical history and exam, imaging studies, (and perhaps the other sonographic views we mentioned), labs studies, etc that would lead you to the most likely conclusion. But…

Can bedside thoracic ultrasound diagnose a parapneumonic effusion?  Or are we doomed to google Light’s criteria once more and prepare for a rather uncomfortable bedside procedure?

It turns out that there have been a number of studies attempting to correlate the sonographic assessment of an exudative effusion and formal definition by Light’s criteria on thoracentesis.  While clinical decision rules have not been studied in large prospective trials, the following are some features of thoracic ultrasound that have been commonly used to classify pleural effusions as transudative or exudative in nature.

Transudates Features Exudate
No septations Anatomy Septations Septations present
Anechoic B-Mode Echogenicity Hypoechoic, heterogeneous internal echoes
< 3 mm Calipers Pleural thickness >3 mm

This is consistent with recommendations from 2012 that arose from the International Liaison Committee on Lung Ultrasound (more casually known as the ILC-LUS, of course).  Interestingly, of these characteristics, it turns out that echogenicity can be somewhat misleading.  While it would appear that the finding of internal echoes and/or hypoechoic fluid is highly suggestive of an exudative effusion, the absence of these findings does not guarantee that it is a transudate.  In one study, 14% of anechoic pleural effusions were eventually found to be exudates by pleural fluid analysis. Like many findings on POC ultrasound, finding Hypoechoic, heterogeneous internal echoes is specific for parapneumonic effusions, however not sensitive enough to exclude when the effusion is anechoic.

Based upon our newly found visual Light’s criteria, you might consider that the effusion in the video above is consistent with an exudative process based on the somewhat hypoechoic fluid with heterogenic echoes.  In the setting of presumed pneumonia, it might be reasonable to observe these expectantly based on guidelines from both the American College of Chest Physicians (ACCP) and American Thoracic Society (ATS) which describe characteristics of effusions that do not warrant immediate thoracentesis:

  • Effusions <10 mm thickness based on decubitus X-ray (surely a common order into today’s ED’s), CT, or thoracic ultrasound.
  • Free-flowing effusion, without evidence of loculations

Of course, if an effusion did not fit the criteria mentioned above, it would then be appropriate to perform thoracentesis.  And if one of the following characteristics were found, consider the placement of a small (<18 Fr) chest tube for drainage. (Luckily, only about 10% of all parapneumonic effusions will meet this criteria)

Consider placement of small chest tube:

A Anatomy Large (> ½ hemithorax), loculated effusions
B Bacteriology Positive gram-stain
C Chemistry pH <7.20

In the end, what started as a discussion of “things our attendings said in medical school” turned into a great review of a disease process for which we can do a great deal in the way of work-up quickly at the bedside.


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