Pacemaker-Related Emergencies – Part 1

pacemaker related emergencies

After the initial implementation of a pacemaker in the 1950s, implanted cardiac devices have become the mainstay therapy for life-threatening arrhythmias and severe congestive heart failure (1). Thanks to technological advancements, the devices become cheaper and smaller, now improving the lives of millions of patients (2). As physicians who serve in an acute setting, we started to take care of patients with implanted cardiac devices on a daily basis. Therefore, we must know how to manage implanted cardiac devices-related emergencies.

The three most common implanted cardiac devices are pacemakers (PMs), implantable cardioverter-defibrillators (ICDs), and left ventricular assist devices (LVADs). PMs generate rhythmic electrical stimuli and consequent heart contractions when the intrinsic electrical activity is below a threshold. ICDs recognize and treat ventricular tachyarrhythmias electrically. Newer generation ICDs also function as pacemakers (3). While the PMs and ICDs mainly support the cardiac electrical function, LVADs support the mechanical function of the heart.

Pacemaker related emergencies are divided into two broad groups as complications of implantation and device malfunction. In this post (part 1), we will summarize complications of implantation.

Complications of Implantation

Although modern technology and technique have significantly decreased the complication rates., we as acute care providers still must be aware of the perioperative complications related to pacemaker implantation. Relatively common complications include pocket, lead-related, thromboembolic, mechanical complications, and pacemaker syndrome (1,4).


Hematomas are formed by perioperative arterial and venous bleeding and can spread tracking the pacemaker leads (5). Palpable hematomas require surgical evacuation as needle aspiration is ineffective, poses pacemaker damaging risk, and does not reveal the underlying source (6). Hematomas increase infection risk.

Pocket Infections

The infections of pocket or leads can occur, mostly due to cutaneous flora, namely, Staphylococcus aureus and Staphylococcus epidermidis (4). The presence of foreign bodies and hematomas contribute to the infectious process (4). Local infections may progress to lung infections, sepsis, skin erosion, and wound dehiscence. The clinical picture may vary from local inflammation and fluctuation to vague systemic complaints and even to sepsis/septic shock without origin (1, 5). Therefore, a clinician should always suspect pacemaker and lead-related infections as a source in patients with a pacemaker. In the ED, after taking blood cultures, intravenous wide-spectrum antibiotics should be started. Pocket cultures should be obtained under fluoroscopy (4). Pocket infections generally necessitate long admissions with IV antibiotics therapy and removal of the pacemaker (7).

Lead-related complications

Lead-related complications include lead malposition, dislodgment, fracture, and damage to the insulation, all of which cause various malfunctions (8, 9). Among them, lead malposition and dislodgement have some additional clinical implications.

Lead malposition

Lead malposition refers to when a lead is inadvertently placed into the left ventricle (9). Lead may land in the left ventricle through a natural orifice of intracardiac variants and defects (atrial-septum defect, patent foramen ovale, sinus venosus defect, malpositioned coronary sinus or its tributaries) or perforation of the intraventricular septum (9). Also, the operator may erroneously place the lead through the subclavian artery and aortic valve.

Lead malposition significantly increases thromboembolic event risk, including transient ischemic attack and stroke (9). Even though there are rare nonpathological right bundle branch block causes, in the acute care setting, if pacing rhythm is right bundle branch block, especially in a patient, whose previous rhythm is known to be left bundle branch block, lead malposition should be suspected (9, 10). A chest X-ray shows the lead position.

 Lead dislodgement

Leads can be dislodged from the endocardial interface, mostly, days or months after implantation (11). In dual-chamber pacemakers, atrial leads get more frequently dislodged than the ventricular leads (11). Such dislodgement produces various rhythm problems due to malfunctions. Additionally, two lead dislodgement-related syndrome is defined below:

  • Lead displacement dysrhythmia refers to when free-floating ventricular leads cause episodes of malignant arrhythmias (12). When a lead is dislodged from the endocardial interface, the patient’s pacemaker dependency determines the symptoms (11). While pacemaker-dependent patients experience episodes of bradycardia- and ventricular tachyarrhythmia-related symptoms, if the native rhythm is favorable, lead dislodgement may stay unknown until malignant arrhythmia episode. Additionally, hiccups may occur due to vagal pacing (11).
  • Macrodislocation lead-dysfunctioning syndromes include Twiddler’s syndrome (coiling of the pacemaker leads due to rotation of the pacemaker generator on its long axis), Reel syndrome (coiling of the pacemaker leads around the pacemaker generator due to rotation of the pacemaker generator on its transverse axis) and Rachet syndrome (13). For further information, please check links 13 – 14.

Thromboembolic complications

The presence of leads in the venous system may cause thrombosis in axillary, subclavian, innominate, and upper arm veins or the superior vena cava up to varying degrees (4). Extensive collateralization masks symptoms. The most common symptoms include swelling and pain of the arm on the lead insertion side (5). However, pacemaker induced thrombosis may even lead to superior vena cava syndrome (5). Standard diagnostic and therapeutic measures apply.

Mechanical complications

Pacemaker and leads implantation may cause many mechanical complications, including tricuspid regurgitation, pneumothorax, hemothorax, air embolism, pericarditis, cardiac tamponade, and perforation (1, 7). All entities have distinct clinical courses and treatments. However, acute care providers should keep in mind all these differential diagnoses when a patient with a pacemaker presents with chest pain and shortness of breath.

Pacemaker Syndrome

It refers to when a patient’s symptoms progressively worsen after pacemaker implantation due to loss of AV synchrony and subsequent reduced cardiac output (15). These symptoms include fatigue, exertional dyspnea, paroxysmal nocturnal dyspnea, orthopnea, orthostatic hypotension, presyncope, and syncope (16). The syndrome is more frequent in patients with single-chamber ventricular pacing systems; however, it also occurs in patients with dual-chamber systems. If the patient has a single-chamber device, the treatment is upgrading the pacemaker to a dual-chamber system. If the patient has a dual-chamber device, the pacemaker programming should be adjusted (17).

References and Further Reading

  1. Cabrera, D., & Decker, W.W. (2013). Management of Emergencies Related to Implanted Cardiac Devices. In: J.G. Adams, E.D. Barton, J.L. Collings, P.M.C. DeBlieux, M.A. Gisondi, E.S. Nadel (Eds.), Emergency Medicine: Clinical Essentials (2nd ed., pp. 547-557). Philadelphia: Elsevier. 
  2. Birnie, D., Williams, K., Guo, A., Mielniczuk, L., Davis, D., Lemery, R., … & Tang, A. (2006). Reasons for escalating pacemaker implants. The American journal of cardiology98(1), 93-97.
  3. Beyerbach, D. M. (2019). Pacemakers and Implantable Cardioverter-Defibrillators. Retrieved October 20, 2019 from
  4. Niemann, J. T. & Squire, B. Implantable cardiac devices. (2014). In: J. A. Marx, R. S. Hockberger, R. M. Walls (Eds.), Rosen’s emergency medicine: Concepts and clinical practice (8th ed., pp. 1064-1074). Philadelphia: Elsevier. 
  5. McMullan, J., Valento, M., Attari, M., & Venkat, A. (2007). Care of the pacemaker/implantable cardioverter defibrillator patient in the ED. The American Journal of Emergency Medicine25(7), 812-822.
  6. Trohman, R. G., Kim, M. H., & Pinski, S. L. (2004). Cardiac pacing: the state of the art. The Lancet364(9446), 1701-1719.
  7. Mulpuru, S. K., Madhavan, M., McLeod, C. J., Cha, Y. M., & Friedman, P. A. (2017). Cardiac pacemakers: function, troubleshooting, and management: part 1 of a 2-part series. Journal of the American College of Cardiology69(2), 189-210.
  8. Aguilera, A. L., Volokhina, Y. V., & Fisher, K. L. (2011). Radiography of cardiac conduction devices: a comprehensive review. Radiographics31(6), 1669-1682.
  9. Ohlow, M. A., Roos, M., Lauer, B., Von Korn, H., & Geller, J. C. (2015). Incidence, predictors, and outcome of inadvertent malposition of transvenous pacing or defibrillation lead in the left heart. Ep Europace18(7), 1049-1054.
  10. Erdogan, O., & Aksu, F. (2007). Right bundle branch block pattern during right ventricular permanent pacing: Is it safe or not?. Indian pacing and electrophysiology journal7(3), 187.
  11. Fuertes, B., Toquero, J., Arroyo-Espliguero, R., & Lozano, I. F. (2003). Pacemaker lead displacement: mechanisms and management. Indian pacing and electrophysiology journal3(4), 231.
  12. Burns, E. (2019). Pacemaker Malfunction. Retrieved October 20, 2019 from
  13. Alvarez-Acosta, L., Garrido, R. R., Farrais-Villalba, M., & Afonso, J. H. (2014). Reel syndrome: a rare cause of pacemaker malfunction. British Medical Journal Case Reports2014, bcr2014204545.
  14. Munawar, M., Munawar, D. L., Basalamah, F., & Pambudi, J. (2011). Reel syndrome: A variant form of Twiddler’s syndrome. journal of arrhythmia27(4), 338-342.
  15. Prinzen, F. W., Vernooy, K., Lumens, J., Auricchio, A.(2017). Physiology of Cardiac Pacing and Resynchronization. In: K. A. Ellenbogen, B. L. Wilkoff, G. N. Kay, C. Lau, A. Auricchio. (Eds.), Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy (5th Ed., pp. 213-248). Philadelphia: Elsevier. 
  16. Gillis, A. M. (2017). Pacing for Sinus Node Disease. In: K. A. Ellenbogen, B. L. Wilkoff, G. N. Kay, C. Lau, A. Auricchio. (Eds.), Clinical Cardiac Pacing, Defibrillation and Resynchronization Therapy (5th Ed., pp. 375-398). Philadelphia: Elsevier. 
  17. Stephenson, E. A. & Davis, A. M. (2009). Electrophysiology, Pacing, and Devices. In: R. H. Anderson, E. J. Baker, D. Penny, A. N. Redington, M. L. Rigby, G. Wernovsky (Eds.), Paediatric Cardiology (3rd Ed., pp. 379-413). Philadelphia: Churchill Livingstone.
Cite this article as: Elif Dilek Cakal, "Pacemaker-Related Emergencies – Part 1," in International Emergency Medicine Education Project, November 20, 2019,, date accessed: November 21, 2019

Home Made IV Access Ultrasound Phantoms

home made IV access ultrasound phantom

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.


  • A plastic container (dimensions used here 8 x 5.5 x 5inches)
  • Long balloons
  • Assorted food colors
  • Gelatin
  • Metamucil (psyllium)
  • Powdered household detergent
  • Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
  • Filler syringes
  • Gloves
Ingredients for making the mixture
Ingredients for making the mixture
Food coloring dye
Food coloring dye
Equipment for making vessels
Equipment for making vessels

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
Cooling in the refrigerator, note the plastic food wraps used as seal here and the knots
6 hours after refrigeration
6 hours after refrigeration
Final product
Final product

And finally, the images that you will have on ultrasound.

Short axis/transvers view
Short axis/transvers view
Long/longitudinal axis view
Long/longitudinal axis view
TACEM - IV access workshop under US guidance
TACEM - IV access workshop under US guidance
Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019,, date accessed: November 21, 2019

The SICK in Emergency Medicine

The SICK in Emergency Medicine

Who are the SICK?

Whenever I bring my two kids to their pediatrician, there are two entrances labeled “sick kids” and “well kids”. Self-explanatory – except that both doors lead to the same shared air… so go figure.

But in emergency medicine, the word SICK takes on a very different meaning.

By SICK, we do not mean “ill” or “not-well,” “not feeling all-right,” or just having a complaint. In EM, SICK means something is very wrong with the patient, regardless of the body system affected or injured. “This particular person is sick” is how you would start your sign out to a colleague. Translation – I am actually worried about this one.

A SICK story

I was a junior resident co-managing the Trauma Bay with my senior, when among multiple other patients a middle aged man was brought in by EMS with a chief complaint of “struck by a car”. It turned out that after finishing their mutual project, a fellow handyman was backing out from the client driveway in a van and inadvertently hit his buddy. Low speed, no head injury, stable vitals and no real complaints beyond some abrasions: no problem, right?

Within 10 minutes, the patient had developed tachycardia, dumped his pressure and then became altered. “This guy is sick!” blurted by chief with some dismay, as he was already busy with several other traumas that were much more obvious. Within a minute, we had intubated the patient and activated the surgical team response. Needless to say, the FAST was very positive.

Unfortunately, the patient never made it to the OR. He coded and died in the ED before any surgical intervention could be done from what was later determined to be a massive splenic injury. No external signs for concern on the initial physical exam. It was the unlucky height of the rear bumper and the force of the van that did it.

Searching for the SICK

Hunting for the SICK remains the cornerstone of EM. Like seeping through muddy waters, we first have to find them – before “stabilizing, treating and dispositioning”, as our mandate proclaims.

Many tools are, of course, available for this task. They range from internationally accepted nursing triage scales, abnormal vitals and “scary” labs like bandemia, sky-high CRPs and lactates to sophisticated risk stratification systems. But no lab or objective score algorithm can replace your high level of suspicion, formal training, experience and clinical gestalt.

In your EM rotations, you will hopefully encounter and be taught from all of the following: high risk chief complaints (testicular pain, sudden onset headache, tearing chest pain, etc.); susceptible populations (neonates, dialysis patients, elderly, IV drug users, returning patients and so on); ominous physical exam signs (anisocoria, tongue bed elevation, extremity pallor, Cullen’s and Grey-Turner’s, abdominal rigidity, Cushing’s triad, etc.).

The hidden SICK

Not too far from the Trauma Bay within my residency’s ED resided the Behavioral Care Unit also known as the BCU. A designated holding place for patients requiring a psychiatric evaluation, the BCU was a favorite place to go to for any resident who desired to increase her productivity numbers via rapid medical clearance of multiple psychiatric holds.

Yet for many trainees, especially seniors, BCU was also a place to hunt for the SICK amongst the crazy. Many a hypoglycemia, a hyponatremia, a sepsis or a subdural hematoma were found there on numerous occasions, often with a delay from the ideal timeline.

Here are a few more phenomena to be on the lookout for:

  • The very quiet elderly – grandma is not peacefully asleep…she’s morbidly ill
  • Inappropriate and unexplained vitals – especially tachycardia at intended discharge
  • Lack of GCS improvement with time – the alcoholic who is not really intoxicated at all
  • Worse after IV fluids – is there tamponade-type physiology, a ruptured heart valve, or internal bleeding?
  • Will not walk – no one should be discharged in a wheelchair who did not come in one
  • First-time migraine or psychosis at age forty – nope! thou shalt look again
  • Anxiety – the real anxiety should be claiming that as your sole diagnosis

This list is yours to expand.

Finding the SICK - it’s you and your environment

Two things –
First, as a trainee, you should always be more paranoid and suspicious of hidden pathology than your supervisors and teachers, not less so. They have the mentioned training, experience and gestalt in their arsenal, you don’t. You are thus stuck with the first item. I am often responsible for teaching newly graduated physician assistants at my work – and it really rocks my boat when I hear “I think it’s just a cold” theme from a newbie.

Second, chances are your training is currently happening at the happening place: some huge university hospital. It is currently very likely and thus very easy to find the SICK. But you are not really honing your skills for working at such places. EM life in virtually any other setting will be much more like trying to find the needle in a haystack. Think about it.

Cite this article as: Anthony Rodigin, "The SICK in Emergency Medicine," in International Emergency Medicine Education Project, November 15, 2019,, date accessed: November 21, 2019

ACEM2019 and Incredible India

ACEM 2019 and increadible India

The 10th Asian Conference on Emergency Medicine was successfully completed in New Delhi, India, during the last couple of days. The conference hosted around 1700 attendees around the globe, mainly Asia. There were approximately 300 speakers from all continents. Dr. Tamorish Kole and Dr. Sirinath Kumar were the two Emergency Medicine professionals who behind the success of this conference. Both experts are also a member of the board of directors of the Asian Society for Emergency Medicine (ASEM). At the end of the conference, Dr. Kole took over the presidency from Prof.Dr. Yildiray Cete (Turkey) who served to ASEM for two years.

ASEM board
Asian Society for Emergency Medicine, Board of Directors

Vice-President of India, Venkaiah Naidu, opened the conference with promising support to the improvement of Emergency Medicine care in India as well as highlighting the implementation of Emergency Medicine into the undergraduate curriculum. As many countries in Asia, Indian medical graduates are working in acute care settings after graduation. Therefore, focusing on undergraduate education can help many countries in the same context. 

Venkaiah Naidu
Venkaiah Naidu, Vice-President of India

This topic one of the items discussed in the ASEM Board of Directors meeting. Creating a widely acceptable undergraduate curriculum is a necessity for Asian countries, especially those in the development stage of Emergency Medicine. ASEM board formed a sub-committee to work on this highly significant problem. Dr. Mohan Tiru (Singapore) and I will be leading board members to continue and finalize the process. Because the International Federation for Emergency Medicine (IFEM) currently working on a comprehensive update process for its’ undergraduate curriculum, there is no need to reinvent the wheel for ASEM. Taking the updated version of the IFEM undergraduate curriculum as the main framework and working on it to create a precise Asian undergraduate curriculum will be enough and probably the fastest way. However, there is a need to understand the current situation and needs in Asian countries. Therefore, the sub-committee of ASEM will work on learning needs assessment and current situation analysis until the IFEM undergraduate curriculum finalized. The expected time for the new updated version of the IFEM undergraduate curriculum is April-May 2020. Completing learning needs assessment and current situation analysis of Asia by March-April 2020 will give the Asian board a chance to move forward with updated IFEM undergraduate curriculum. Probably, developing the Asian curriculum will be possible in a short period of time until the end of 2020.

ASEM board meeting
Asian Society for Emergency Medicine, Board of Directors Meeting

While ACEM2019 continues, I was able to meet a couple of contributors to the International Emergency Medicine Education Project. I visited Rob Rogers’ well-known course, Medutopia, which aims to increase the quality of the teaching skills of educators. According to Dr. Rogers, this is the most enthusiastic and knowledgable group since the Medutopia journey has begun. Dr. Andy Little and Dr. Mike Giosondi were other two experts who gave the course with Dr. Rogers. You can read and listen to Dr. Rogers’ contributions to the International Emergency Medicine Education Project here.

I also came across to Dr. Simon Carley from Manchester, who is well-known for ST.EMLYN’s blog. He gave a couple of amazing talks during the conference, including one plenary presentation.

Simon Carley, plenary session
Simon Carley, plenary session
Arif Alper Cevik and Simon Carley
Arif Alper Cevik and Simon Carley

One of the surprising things was meeting with one of our blog authors Dr. Kaushila Thilakasiri (Sri Lanka) and her team. This energetic group was not only coming for ASEM to attend meetings, but they also came to compete in SimWars. And of course, they won the first prize.

Kaushila Thilakasiri and Sri Lanka team

Two days of workshops and three days of the busy scientific program passed like lightning. In addition to scientific activities, ACEM 2019 team prepared many social events for participants. I think, socially and scientifically, ACEM 2019 was a very busy conference. This created many networking opportunities.

One of the final event was graduation ceremony of 2018-2019 class of Emergency Medicine residents. Around 120 new graduated were appreciated with a nicely setted up ceremony with attendence of leaders of Emergency Medicine such as Prof. Lee Wallis (Past President of IFEM), Dr. Taj Hassan (Pas President of Royal College of Emergency Medicine) and Prof. James Ducharme (President of IFEM) as well as local leaders of Emergency Medicine of India.

2018-2019 Indian Emergency Medicine Graduates
2018-2019 Indian Emergency Medicine Graduates

As a summary, ACEM2019 was a successful gathering for international Emergency Medicine experts and Asian emergency physicians, residents and medical students.

ACEM 2021 will be in Hong Kong. ASEM board of directors decided to give ACEM2023 to Manila, Phillipines and ACEM2025 to Dubai, United Arab Emirates. We hope to see you all in these upcoming events.

Cite this article as: Arif Alper Cevik, "ACEM2019 and Incredible India," in International Emergency Medicine Education Project, November 13, 2019,, date accessed: November 21, 2019

Torus Fracture – Diagnosed with ultrasound

torus fracture

Case Presentation

A 9-years old male patient brought to the ED by his parents because of the right forearm pain. The patient is alert, oriented, and moderately in distress. He described that he stepped on the ball and fell while playing soccer with his friends. He denies any other injury, loss of consciousness, etc.

Physical Exam

Torus Fracture - right arm 2

The patient complaints right forearm pain, especially distal 1/4 of the radius. There was no deformity or swelling recognized on inspection. 

Torus Fracture - right arm 1

The patient refuses any movement on the right arm because of pain during the movement, especially in rotational movements. He prefers to stay in the rest position, as shown in the picture.

There was no visible deformity and swelling in the inspection. However, the patient described palpation tenderness over the forearm, especially point tenderness over the distal 1/4 – 1/5 of the radius. The patient also described minimal pain on elbow and wrist movements. The neurovascular examination was unremarkable. There are no other findings regarding trauma. Patient parents deny any disease, medication, operation, etc. He has received 250 mg paracetamol in the school after consultation with the family. However, he still shows distress because of pain.

After the physical exam, 200 ibuprofen was given. X-ray is planned, and musculoskeletal ultrasound was applied while he waits for an X-ray.

We used Butterfly iQ to investigate the radius by using musculoskeletal settings. The ultrasound showed periosteal discontinuity with a 2-3 mm step-off sign at the distal radius. 

Diagnosing fractures with ultrasound

Ultrasound showed high pooled sensitivity (91%) and specificity (94%) (Schmid et al., 2017). It is a very effective modality, especially in the detection of long bone fractures such as humerus, forearm, tibia, fibula, etc.

In forearm fractures, its’ sensitivity is between 64 and 100%, its’ specificity is between 73-100% (Katzer et al., 2016). Besides, ultrasound provides 25 minutes earlier diagnosis advantage compared to other modalities, namely X-rays. Ultrasound’s effectiveness has elbow, been shown in many articles, its’ best performance is on diaphysis fractures of long bones (Weingberg et al., 2010).

After the detection of Torus (Buckle) fracture by ultrasound, the patient was sent to X-ray in order to investigate elbow, forearm and wrist in more detail. X-rays showed Torus fracture at the distal radius, which the diagnosis aligned with the ultrasound result.​

Torus Fracture - right arm 4

Torus Fracture - right arm 3

AP X-ray showed minor periosteal step-off/bulging on both sides. Lateral X-rays showed periosteal discontinuity with a 2-3 mm step-off on the dorsal side of the radius.

The final diagnosis of the patient was Torus (Buckle) fracture.

A long arm splint was applied in the ED because of his elbow and wrist pain. The patient discharged with pain medication, ice and elevation recommendations. On the 4th day, the patient visited the orthopedic clinic, and his splint changed to short arm splint. He was pain-free on the elbow and wrist.


  1. Schmid GL, Lippmann S, Unverzagt S, Hofmann C, Deutsch T, Frese T. The Investigation of Suspected Fracture-a Comparison of Ultrasound With Conventional Imaging. Dtsch Arztebl Int. 2017 Nov 10;114(45):757-764. doi: 10.3238/arztebl.2017.0757. PubMed PMID: 29202925; PubMed Central PMCID: PMC5729224.
  2. Katzer C, Wasem J, Eckert K, Ackermann O, Buchberger B. Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care. 2016 Jun;32(6):401-7. doi: 10.1097/PEC.0000000000000446. Review. PubMed PMID: 26087441.
  3. Weinberg ER, Tunik MG, Tsung JW. Accuracy of clinician-performed point-of-care ultrasound for the diagnosis of fractures in children and young adults. Injury. 2010 Aug;41(8):862-8. doi: 10.1016/j.injury.2010.04.020. Epub 2010 May 13. PubMed PMID: 20466368.
Cite this article as: Arif Alper Cevik, "Torus Fracture – Diagnosed with ultrasound," in International Emergency Medicine Education Project, November 6, 2019,, date accessed: November 21, 2019

iEM Monthly – November 2019

monthly newsletter

Monthly Newsletter November 2019

Welcome to the iEM Education Project Monthly Newsletter. We will share the achievements, information about top posts, chapters, activities and future plans of the project.

Hot News!

iEM will attend the Asian Conference on Emergency Medicine held in New Delhi, India. The conference is on 7-10 November and organized by the Society of Emergency Medicine, India. We are looking forward to meeting members of the #FOAMed family at the conference.

iEM Visitors

october 2019
One hundred fifty-nine countries visited iEM content in October 2019. The total number of countries visited iEM platform is 189.

Top Countries in October

Top Blog Post in October

October Blog Posts

Free EM Clerkship Book

iEM Free Book (2018e) reached to >3500 downloads. The book is written by 133 authors from 19 countries. It includes 106 topics, 841 pages, 454 images.

Death on the Roads

Death on the Roads

Save the date:

Why? Because road victims will be remembered that day. Starting from 2005, The World Day of Remembrance for Road Traffic Victims is held on the third Sunday of November each year to remember those who died or were injured from road crashes (1).

Road traffic injuries kill more than 1.35 million people every year and they are the number one cause of death among 15–29-year-olds. There are also over 50 million people who are injured in non-fatal crashes every year. These also cause a real economic burden. Total cost of injuries is as high as 5% of GDP in some low- and middle-income countries and cost 3% of gross domestic product (2). It is also important to note that there has been no reduction in the number of road traffic deaths in any low-income country since 2013.

The proportion of population, road traffic deaths, and registered motor vehicles by country income, 2016 (Source: Global Status Report On Road Safety 2018, WHO)

Emergency care for injury has pivotal importance in improving the post-crash response. “Effective care of the injured requires a series of time-sensitive actions, beginning with the activation of the emergency care system, and continuing with care at the scene, transport, and facility-based emergency care” as outlined in detail in World Health Organization’s (WHO) Post-Crash Response Booklet.

As we know, the majority of deaths after road traffic injuries occur in the first hours following the accident. Interventions performed during these “golden hours” are considered to have the most significant impact on mortality and morbidity. Therefore, having an advanced emergency medical response system in order to make emergency care effective is highly essential for countries.

Various health components are used to assess the development of health systems by country. Where a country is placed in these parameters also shows the level of overall development of that country. WHO states that 93% of the world’s fatalities related to road injuries occur in low-income and middle-income countries, even though these countries have approximately 60% of the world’s vehicles. This statistic shows that road traffic injuries may be considered as one of the “barometer”s to assess the development of a country’s health system. If a country has a high rate of road traffic injuries, that may clearly demonstrate the country has deficiencies of health management as well as infrastructure, education and legal deficiencies.

WHO has a rather depressing page showing numbers of deaths related to road injuries. (Source: Death on the Roads, WHO, )

WHO is monitoring progress on road safety through global status reports. Its’ global status report on road safety 2018 presents information on road safety from 175 countries (3).

We have studied the statistics presented in the report and made two maps (All countries and High-income countries) illustrating the road accident death rate by country (per 100,000 population). You can view these works below (click on images to view full size).

References and Further Reading

  1. Official website of The World Day of Remembrance,
  2. WHO. Road traffic injuries –
  3. WHO. Global status report on road safety 2018 –
Cite this article as: Ibrahim Sarbay, "Death on the Roads," in International Emergency Medicine Education Project, November 1, 2019,, date accessed: November 21, 2019

The Medical Emergency Simulation Olympics – G.SEM

the emergency medical simulation olympics

The use of realistic simulation on medical teaching is increasingly being used in the universities of Brasilia. The controlled environment training brings important benefits and develops the non-technical skills of participants. Therefore, the Congress of Medical Emergencies of the Federal District that took place this month in Brasilia, Brazil, promoted a realistic MEDICAL EMERGENCY SIMULATION OLYMPICS (literal translation: Gincana de Simulação em Emergências Médicas – G.SEM) with medical and nursing students. The participants felt tremendous satisfaction and acknowledgment of their own flaws that must be improved before they graduate.

However, what does realistic simulation mean? By definition, “it is the technique, not technology, for reproducing or amplifying real experiences by guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive way.” That is, we set up environments of low, medium or high complexities that mimic reality. This way, the participant can emerge in practice without putting the patient at risk.

Through Kolb’s experiential learning cycle, we can understand how learning occurs during simulation.

kolb learning cycle

During the simulation, the participant takes part in concrete experience, being able to identify knowledge gaps in which he can work. At the debriefing, the instructor helps the gamer to contemplate his performance.

When the participant gives meaning to what has happened, he becomes able to abstract and modify his mental model, which will be tested with active experimentation, generating a concrete reaction.

When simulating, not only theoretical knowledge is required, but also practical knowledge, such as how to do and how to act when facing the proposed situation. Doing this kind of exercise, we can better assimilate the content in a playful and effective way. Through error, and the reframing of debriefing, the participant can retain the content with the experience that will come across in the real environment.

The simulation was first used in the aerospace industry, where one mistake could cost many lives. Therefore, the practice of simulation in medicine is indispensable since we work directly with human lives. Train, train and train! This is the emergency mantra! Because by the time you are in the Emergency Department, acting, you already need to know what to do. The time to make mistakes is in the simulation. Moreover, it’s important to keep in mind that an error-free simulation is not a simulation, it is just a theater.

It is possible to divide this learning method into some levels. Through Miller Pyramid, we can analyze the clinical capacity in four levels: know, know-how, show-how, and does. Simulation is increasingly used to teach the first three levels, as it enables the programming of specific environments and conditions to the needs of each participant, promoting a favorable outcome.

Is it like playing pretend? Yes. The simulation can be compared to a pretend play. We can’t reproduce the exact reality, so we set up a fiction contract, where the instructor admits that the simulation is not real but tries to reproduce it as faithfully as possible, and the participants agree to act as they would in real situations.

Therefore, if during a high complexity simulation, a patient with low oxygen saturation needs intubation, for example, the participant must act by observing vital signs on the monitor, asking for drugs, infusing, ventilating, and intubating the doll and not just saying what he would do.

The Chiniara et al Simulation Zone Matrix, commonly used to demonstrate the teaching of simulation in pediatric emergencies, can be extended to emergencies in general. Simulation becomes advantageous over other teaching methods in low-opportunity, high-severity situations, quadrants where emergency is, due to low student exposure and increased concern for patient safety.

With simulation, it is possible to practice technical and non-technical skills, for example, interaction with the multidisciplinary team, leadership, communication and crisis management, which is almost impossible in a classroom.

When we promoted the G.SEM – Emergency Simulation Gymkhana – held by the EMIGs in Brasilia, we had many positive feedbacks from participants, and proved to be effective in exposing to participants points that they needed to improve to raise the level of their clinical practice.

Participating in G.SEM was a very exciting experience for me, as I was able to review important concepts and behaviors in various pathologies, including the approach to cardiopulmonary arrest. It was also a very interesting emotional experience, as we had a short time to make decisions since all patients had life-threatening pathologies that needed fast decisions and actions. In this context, an adrenaline over-discharge and, consequently, tachycardia were generated, generating significant stress that leads us to the real process of approaching a critically ill patient. In addition, one of the most important positive points was the team performance, as the team consisted of 2 medical and one nursing student, so we needed to work together, respect each other and make our communication were efficient and clear. Through the scenarios, it was possible to see how much we improve as a team, and in the final scenario, we were already much more intertwined and acting in a much more organized way compared to the first one. I also emphasize the importance of the evaluator’s feedback at the end of each season, as this allowed us to identify the errors and to correct them in the following simulations and, of course, to future. Finally, it was a unique opportunity that certainly made me grow very intellectually and also allowed me to improve the relationship with the team, which is indispensable in a multidisciplinary context.

says Lucas, a medical student who participated in the simulation scenarios.

There were six simultaneous scenarios, including two pre-hospital scenarios that were assembled by firefighters. G.SEM took place at the Uniceplac Realistic Simulation Center, with the support of the DF Fire Department, and the International Student Association of Emergency Medicine (ISAEM).

Content and Details

  • 4 multidisciplinary teams, each consists of 3 medical students and 1 senior nursing student.
  • 6 simultaneous scenarios. All teams exposed to all scenarios. 1) Diabetic ketoacidosis in children, 2) Intra-hospital care for multiple trauma patients, 3) Acute myocardial infarction, 4) Sepsis, 5) Pre-hospital care for multiple trauma patients (car x bicycle accident), 6) Pre-hospital care for cardiopulmonary arrest and the patient suffering from penetrating trauma.
  • Each scenario had a total duration of 20 minutes
  • Each scenario had a checklist of actions and knowledge that was expected from the team in that situation.
  • In the end of each simulation, the team went through a quick debriefing, for about 8 minutes, with the station instructors.
  • After all scenarios, there was a debriefing with the residents of emergency medicine, in order to demonstrate to participants the reality of those situations in the emergency department
  • The winning team was the one with the most checklist points.
  • The teams were awarded according to their classification.

The simulation itself already causes some anxiety in the participant, since it demonstrates its flaws and puts in check all its theoretical knowledge that should be applied in a practical way. During our emergency simulation game, we noticed an increased level of anxiety and stress from participants. It is believed that the necessity of quick decision making that the emergency requires and the short time of the season were determining factors. However, participants reported that the multidisciplinary team made the simulation environment different, that’s because nursing students do not have realistic simulations as a requirement in their course, and it’s not common the integration between the courses in a simulation scenario.

As a lesson of this event, we conclude that it is extremely important to integrate the programs in the undergraduate years, and we can use the simulations as a convergence point. It’s important to remember that the Emergency Department only works with a cohesive multidisciplinary team. One of the goals of G.SEM was to demonstrate to students this reality and break the barrier between programs by showing that the work in the Emergency Department is teamwork and that always needs team training!

References and Further Reading

  1. Gaba DM. The future vision of simulation in healthcare. Simul healthc 2007;  2(2): 126-35
  2. Cheng A, Duff J, Grant E, Kisson N, Grant VJ, Simulation in paediatrics: An educational revolution. Paediatri Child Health. 2007; 12(6): 465-8
  3. Kolb DA. Experiential learning: Experience as the souce of leatning and development.  Englewood Cliffs, NJ: Prentice-Hall; 1984
  4. Zigmont JJ, Kappus LJ, Sudikoff SN. Theoretical foundations of learning through simulation. Semin Perinatol. 2011; 35 (2): 47-51
  5. Paizin Filho A, Scarpelini S. Simulação: Definição: Medicina (ribeirao Preto). 2007; 40(2): 162-6
  6. Miller GE. The assessment of clinical skillscompetence/performance. Acad Med. 1990; 65 (9 Suppl): S63-7
  7. Couto TB. SImulação realistica no ensino de emergências pediátricas na graduação. São Paulo. 2014.

Reviewed by: Bruna Martins, Jule Santos and Henrique Herpich

Cite this article as: Rebeca Rios, "The Medical Emergency Simulation Olympics – G.SEM," in International Emergency Medicine Education Project, October 30, 2019,, date accessed: November 21, 2019

Macro-lensing the Emergency Department

Macro-lensing the Emergency Department

How do you remember the emergency department (ED) that trained you? Could it be that you have learned a lot more than just medicine there? Between worrying about the delayed laboratory report and explaining the need to rule out a myocardial injury to a visitor of a patient with peptic ulcer disease, you might have picked up other attributes. Subtle traits that have nudged your personality. Remembering the ED where I did my internship sparks nostalgia and makes me want to speed up my typing. As if I need to attend to something else right after this. Hopefully, I’ll give you a glimpse of what putting on different lenses can show even when we look at the same object.

Peeling yellow paint, some old cracks in the wall, and an acute sense of urgency lingering in the air are what I remember of the department. Patan Academy of Health Sciences has an ED where confused students scratching their heads to the witty professors’ question takes you to your own golden days. A subtle grin on the wise face of a grey-haired professor eagerly waiting for the next wrong answer makes you want to reach out to your old mentor. A know it all student on the verge of blurting out the answer physically holding himself behind makes you wonder what that one classmate of yours is doing these days. It is a place where teaching, helping people, running against time and having fun while at it, blends into an experience of a lifetime. Stories of eased pain, dodged suffering and narrow escapes from grave aliments enrich the history of the department.

One fine evening in the department as an intern I found myself seated in the doctor’s station, a rare but insightful experience. I found myself pondering about the lessons I can take from this part of the hospital: not just medical knowledge but lessons I can share with people from different facets of life. Below I list the common situations or sayings used in a typical ED and try to translate it for use in day to day life.

Think horses before zebras but watch out for zebras that can fly

A patient with mild fever, chest pain, and some respiratory distress probably has some sort of URTI. But the very fact that he/she landed up in the ED makes the doctor order an ECG because of the chest pain. The doctor will, of course, be leaning towards a more common diagnosis. Ruling out a diagnosis with grave prognosis, however, will be among the top priorities. 

searching zebra

This can translate into studying common exam materials while also being aware of the zebras. Zebras show up rarely, but when they do, they tend to be stubborn. Be aware of the topics that don’t usually show up in your exam but impact the outcome when they do. We can also borrow this idea while thinking about anything in general. We tend to assume the worst, but when your date is late to dinner, it probably is just the busy traffic.

Communication is the key

A medical officer reads the patient’s history to the professor using as few words as possible, pertinent negatives and a precise format. The information and condition of the patient are conveyed very accurately. When reporting history, we aim for effective communication at its best. 


I wonder how many day-to-day problems can be solved if only we communicated that efficiently outside of history taking and reporting. Using clear words, very few fillers and addressing what we don’t mean beforehand can help in getting the intended message across.


The most critical patients that visit Patan Hospital head for the ED. Recognizing them and treating the ones who need immediate attention is the second nature of a good emergency physician. Likewise, being able to focus on the most critical aspects of one’s life can be an attribute worth borrowing from the department. 


How many times do we complain that we just do not have enough time to do things that are important to us? It’s mostly about deciding what comes first.

Resource allocation

This sort of ties into the previous one. Most experienced physician attends the most critical patient. More nurses are allocated to and the best USG machine is used in the red triage area. Time, money, physical or mental effort all are resources we use to get tasks done. Sometimes success differs from failure, not in how much effort is put but where it is used. Determining which task is most resource-intensive or most productive can be a worthwhile idea to learn from the ED.

resource allocation

Did you check your tools?

Monitor connected to a gradually stabilizing patient beeps rapidly, indicating a sudden collapse. As you run towards the patient with your ACLS neurons firing at a rate more rapid than the patient’s declining pulse, do take a look if the pulse oximeter is connected correctly. Translated in the world where things go south more frequently than not, decide if it is a perceived problem or a real one. How many times have you let yourself go into flight or fight mode only to realize that the threat wasn’t even there?

Give thiamine before glucose

Hypoglycemia kills. Glucose save lives. Even then, giving thiamine before glucose is the norm in most EDs. The biochemistry behind is simple; thiamine is a cofactor used by many enzymes in glucose metabolism and depleting more thiamine can cause Wernicke Korsakoff disease. Look at it with the lens of a student who needs to start preparing for an exam. Determine your thiamine (proper sleep, good food, exercise, enough water and probably mindfulness). Only then glucose supplementation (studying) will yield results.

The loudest screamer isn’t always suffering the most

“How do you triage when there are more people than you can attend to?” asked a professor. The answer was funny but made a point firmly. “You should ask the most critical patients to come forward. Then you attend those that are left behind!”. The idea being; sickest of them all won’t even be able to advocate for themselves. Similarly, we can be tactful when overwhelmed by problems. Try to come up with ideas to segregate the screamers (problems that seem to be the biggest) from the sickest (actual problems).


Know your limits and ask for help

We manage acute exacerbation of COPD in the ED. Not all patients that feel relieved are discharged from there. Some patients require medical consultation and transfer. This, in no way, means that the ER physicians are incompetent in managing the disease throughout. Rather it is the evidence of understanding the job description and trust in the system as a whole. Asking for help when need be is critical to our wellbeing. Being able to ask for help shows courage and humility above all.

knowing limits
Cite this article as: Sajan Acharya, "Macro-lensing the Emergency Department," in International Emergency Medicine Education Project, October 28, 2019,, date accessed: November 21, 2019

Trauma in Pregnancy

Trauma in pregnancy

Trauma remains the leading cause of morbidity and mortality in pregnant women. It increases the risk of preterm delivery, placenta abruption, fetomaternal hemorrhage, and pregnancy loss. Motor Vehicle Accidents (MVAs) account for 70% of blunt abdominal trauma, then comes falls and direct assaults.

Evaluating and managing pregnant trauma patients requires knowing some physiological changes in pregnancy.

Physiological changes in pregnancy

  • Maternal blood volume increases at 10 weeks and reaches a peak level at 28 weeks (45%)
  • Mild anemia because of increased plasma volume (plasma > red blood cells)
  • Cardiac output increases by 1-1.5L/min at 10 weeks until the end of pregnancy
  • Heart rate increases by 10-20 beats/min at the 2nd trimester + decrease in the blood pressure (BP) by 10-15 mmHg. This explains the late deterioration in dropping BP; they may lose 30-40% of blood before signs of hypotension
  • Uterine blood flow = maternal mean arterial pressure
  • At 12 weeks, the uterus becomes an intra-abdominal organ, which is susceptible to direct injuries
  • The bladder becomes anterior
  • Gravid uterus causes stretching to the abdominal wall
  • At 18-20 weeks, an expanding mass of gravid uterus causes hypotension in the supine position by compressing the IVC. Avoid placing IV lines in the femoral/lower extremities.
  • Diaphragm elevated 4 cm, which makes the tidal volume increase by 40%, residual volume decreases by 25%, which causes the short apnea time in pregnant patients
  • Splenic injury is a common cause of hemorrhage

Important actions in pregnant trauma patients

  • Apply supplemental oxygen early because of compensation of hypoxia is limited
  • Consider early intubation
  • 50% more fluids are needed for volume replacement
  • At 20 weeks, place wedge under the right hip, tilting to 30 degrees during the transfer on trauma board
  • Early nasogastric tube placement to avoid aspiration
  • Avoid pressors, which causes uteroplacental hypoperfusion

Rhogam (Rh immunoglobulin) and Tetanus Prophylaxis

Administer RhoD (Human Rho(D) immune globulin) to Rh-negative women; 50 mcg for <12 weeks, 300 mcg for >12 weeks. Tetanus prophylaxis is safe but considered as category C.

Images and Radiation Exposure

Do not withhold needed images. The greatest risk to fetal viability from ionizing radiation is within the first 2 weeks after conception and the highest malformation during the embryogenic organogenesis at 2-8 weeks. The risk of central nervous system teratogenesis is highest at 8-16 weeks. A dose of 5 rad is the threshold for human teratogenesis. Plain radiographs is <1 rad. Abdominal CT + Pelvic angio has the highest dose of rad (2.5-3.5). One of the critical problems is the abruption of the placenta, and CT is sensitive for abruption placenta, 86%, and has 98% specificity. The iodine contrast could cross the placenta and causing neonatal hypothyroidism.

Pelvic exam can be done only after performing an ultrasound to determine the placenta location and exclude placenta previa.

Special Tests

Vaginal fluid pH. If the pH is 7, it is amniotic fluid. If the pH is 5, it is vaginal secretions. Ferning on microscope slide = amniotic fluid.

APT ( alkali denaturation) test is qualitative evaluation to determine the presence of fetal Hg in maternal blood.

Kleihauer-Betke test measures fetal hemoglobin transfer to mothers’ blood.

Specific Issues

  • Direct fetal injuries

    It is rare. It can be seen some injuries such as maternal pelvic fractures, direct trauma to the fetal skull.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine rupture

    It is less than 1%. It may be seen at late second and third trimester. It is associated with high fetal mortality. The palpation of fetal parts over the abdomen and radiological evidence of abnormal fetal location determine rupture.

  • Uterine irritability

    The sign of the onset of preterm labor. Avoid using tocolytics; it causes tachycardia for both mother and fetus.

  • Placental abruption

    1-5% from minor injuries, 40-50% of major injuries. Even simple falls can cause sudden fetal demise. Most sensitive clinical findings; uterine irritability, which can be explained by having more than 3 contractions per hour at the ED.

Fetal viability

The fetus will likely be viable at 24 weeks and above.
The normal fetal heart rate is 120-160 bpm. Heart rate below and above these limits is critical. Because ultrasound may not detect placenta abruption, nor rupture or fetal-placental injuries, high-suspicion and close monitorization are necessary.

Cardiotocography (CTG)

4-6 hours will be enough for most of the cases. Persistent contractions or uterine irritability needs an external CTG for 24 hrs. Fewer than 3 contractions per hour could indicate a safe discharge.

Indication for Emergency C-Section

  • Fetal tachycardia.
  • Lack of beat to beat on long term viability.
  • Late deceleration = fetal distress.

C-section has a 75% survival rate in 26 weeks or above. If the fetal heartbeats are present and the procedure was performed early, the success rate is higher.

References and Further Reading

  • Tintinalli, J., Stapczynski, J., Ma, O. J., Cline, D., Cydulka, R., & Meckler, G. (2010). Tintinalli’s emergency medicine: a comprehensive study guide: a comprehensive study guide. McGraw Hill Professional.


Cite this article as: AlHanouv AlQahtani, "Trauma in Pregnancy," in International Emergency Medicine Education Project, October 25, 2019,, date accessed: November 21, 2019

Top Audios of September 2019 From iEM Archive

Top Audios From iEM Archive

Thinking like an emergency physician

Abdominal pain

Massive GI Bleeding


Emergency medicine: a unique specialty

Cardiac Arrest

Altered mental status

Respiratory Distress

Ovarian Abscess

Chest Pain

Top Images From iEM Archive

Top Images From iEM Archive
17 - epidural + air

Epidural hemorrhage and free air

12.1 - central catheter misplaced

Central venous catheter misplacement

757.3 - Childhood rush - HFM disease

Childhood rush – HFM disease

26.1 - pneumocaccal meningitis 1

Pneumococcal meningitis, MRI

130.1 - SAH - subarachnoid hemorrhage

Subarachnoid hemorrhage

627.3 - Figure 03 - ICH in the right parietotemporal lobe

Intracranial hemorrhage at temporoparietal location

685.2 - electrical injury entry

Electrical injury, entry

449.3 - subacute subdural3

Subdural hemorrhage

336.5 - normal PA chest x-ray HEART BORDERS

Normal heart borders, normal chest x-ray