The forgotten lead- aVR

By Chris Paul MD, OSU EM Assistant Professor // Edited by Michael Barrie MD, OSU EM Assistant professor

54 yo F presented with chest pain and shortness of breath for two days
past medical history included prosthetic aortic valve, endocarditis, MI, DM, HTN, HLD, cough variant asthma and stroke

Vital signs -HR 130’s, bp – 110’s, spO2 – low 90s/high 80’s

initial EKG

IMG_2843 copy

What’s your interpretation? Plan for management?

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ED Thoracotomy

By Dr. Daniel Zach Adams, OSUEM resident // edited by Michael Barrie OSUEM Assistant Professor

Out of all the various procedures we’re expected to be able to perform in the ED, a resuscitative thoracotomy (EDT) has to be the most intense but least common, depending on your demographic.  EM:RAP did a great job this past month on going through indications, contraindications, and some of the finer details (EM:RAP January Edition – Trauma Surgeons Gone Wild: When to Crack the Chest).  My summary:

  1. Use of bedside US can determine who may benefit from a thoracotomy – i.e. those without evidence of cardiac motion have a survival rate of ZERO (the skinny).
  2. EAST trauma and the Western Trauma Association guidelines differ:
    • EAST
      • Pulseless thoracic penetrating injury WITH signs of life – strong recommendation for EDT
      • Pulseless thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
      • Pulseless EXTRA-thoracic penetrating injury (not including isolated cranial injuries – obviously)  WITH signs of life – conditional recommendation for EDT
      • Pulseless EXTRA-thoracic penetrating injury WITHOUT signs of life – conditional recommendation for EDT
      • Pulseless BLUNT trauma WITH signs of life – conditional recommendation
      • Pulseless BLUNT trauma WITHOUT signs of life – DO  NOT PEFORM EDT
    • Western Trauma Association 
      • CPR is utilized as a time marker for performance – check out the algorithm
        • Blunt trauma, CPR >10 minutes – no go
        • Penetrating trauma, CPR >15 minutes – no go

In our center we rarely do EDT, likely because we see less penetrating thoracic injury than other settings. That said, there’s some good resources out there to stay sharp on this potentially life saving procedure.  Something worth watching by Dr. Raul Comibra on YouTube – link – if you’re bored and looking for some more insight.  Pretty long, but it goes through a lot to include some technique and covers the Western Trauma Association guidelines in some more detail.  As with anything, mental preparation and a solid understanding of the indications, contraindications and how to proceed is key.  The details of how to proceed after you get into the chest seems to be the more difficult task – glad we have great trauma colleagues!

…angioedema of what?

A middle-aged African American female presents to your emergency department with two days of diffuse abdominal pain, distention, nausea, emesis and watery diarrhea.  She has a history of asthma and hypertension, for which she was recently started on amlodipine/benazeprilat.  On physical exam she is mildly tachycardic with non-peritoneal mid-epigastric and LLQ abdominal pain. Initial laboratory investigation is unremarkable other than for mild hypokalemia.  An acute abdominal series is ordered demonstrating a non-specific bowel gas pattern.  You suspect a small bowel obstruction, but what might you consider given the patient’s history?  Surgical adhesions?  Diverticulitis? 

A CT of the abdomen and pelvis is ordered demonstrating marked small bowel wall thickening.  The WBC was normal.  Could this be infectious?  Lactate – normal, certainly unlikely ischemic.  What in the patient’s history could point you towards the cause?

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