Question Of The Day #59

question of the day
38 - atrial fibrillation

Which of the following is the most likely cause for this patient’s respiratory condition?

This patient presents to the Emergency Department with palpitations, generalized weakness, and shortness of breath after discontinuing all her home medications.  She has hypotension, marked tachycardia, and pulmonary edema (crackles on lung auscultation).  The 12-lead EKG demonstrates atrial fibrillation with a rapid ventricular rate.  This patient is in a state of cardiogenic shock and requires prompt oxygen support, blood pressure support, and heart rate control. 

Pulmonary embolism (Choice A) can sometimes manifest as new atrial fibrillation with shortness of breath and tachycardia, but pulmonary embolism initially causes obstructive shock.  If a pulmonary embolism goes untreated, it can progress to right ventricular failure, pulmonary edema, and cardiogenic shock.  This patient has known atrial fibrillation and stopped all her home medications.  The abrupt medication change is a more likely cause of the patient’s cardiogenic shock.  Dehydration (Choice D) and systemic infection (Choice D) are less likely given the above history of abruptly stopping home maintenance medications.  Untreated cardiac arrythmia (Choice B) is the most likely cause for this patient’s pulmonary edema and cardiogenic shock. 

The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #59," in International Emergency Medicine Education Project, October 15, 2021, https://iem-student.org/2021/10/15/question-of-the-day-59/, date accessed: October 17, 2021

What you should know before your first ED shift

what you should know before your first ED shift

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed thing you should know before your first emergency department shift. Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaid were the guest speakers of this episode. Dr. Dr. Arif Alper Cevik was the hosts of this session.

Dr. Ana Paula Freitas, Dr. Gregor Prosen, Dr. Joe Bonney and Dr. Rasha Buhumaid shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.

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Fight against superdrugs

This is an essay I wrote for the Antibiotic Week celebrated at Patan Hospital back when I was a medical student. Here I portray myself as a happy bacterium that is thriving in a world where antibiotic stewardship is not followed.

Anti-Antibiotics week has been being celebrated in the bacteria world since the first beta-lactamases were invented. This year, an adolescent staphylococcus with a lot of wisdom is giving a speech.

VRSA, the vice president of Fight against Super Drugs Development (FSDD), has been actively advocating (mechanisms of antibiotic resistance) among less privileged groups of bacteria. “Triumph of hope over desperation,” said the vice-president of the FSDD club, pointing towards the antimicrobial week that humans celebrate. Then he invited a bacterium on the stage to shed some light on the glorified FSDD club.

“Hello! I am a bacterium. I belong to the staphylococcus group according to the classification done by another species here on earth. An anecdote; they consider themselves superior enough to fight against us. They are that foolish a species. Today, I’ll tell you about my daily activities and my life goals. Now, it’s a known fact that we fit in the grand scheme of things better than any other species. Well, maybe viruses are debatably our competitors in that regard, but that’s an issue I’ll consider later. My parents tell me that I am a very happy and brave bacterium, just like them. As you all know, we, staphylococci, are very social bacteria. We like in clusters and love keeping cats as pets. It’s funny how human beings think we’re catalase positive. But anyhow, Almighty didn’t make them as bright as us! They’re bad!

I love traveling. I stay in people’s homes, their dishes, food, and all the places you can imagine. I love dirty hands. I hide just under a dirty nail and say goodbye to my siblings as they go to all the places the unclean hand touches. And you’d be amazed if I tell you where people let us go without washing their hands. This one time, I was talking with my cousin Roy the streptococci under a thumb-nail, and the man under whose thumb-nail we were discussing our career option touched a tiny human being. They call them neonates, I guess. After a week,  Cousin Roy wrote to me that his career goals are being met and that he has a thriving business of causing impetigo on that small neonate’s cheeks. He is also thinking of extending his business. Chains of impetigo maybe, like chains of hotels humans came up with so that we can harbor on leftovers and unhygienic food.

If you are starting to think that humans might be actually helping us take over the world, wait till I tell you about some more kind human beings. But first I’d want to tell you about some human beings that are rude and unhelpful. They belong to no specific place and are very hard to recognize. Most of them wear this white coat and carry some long rope around their neck. They’ve invented and are using chemicals to kill us. The funny thing is, even after we had a head start in evolution; they came up with such powerful substances. But thanks to our brave ancestors who used all their wit to figure out ways to survive. (Mechanism of resistance and things like transposons etc.) that our vice president advocated at the beginning was their gift to us.

This is where the kind among these white coats-wearing people fit in the story. It would sound unbelievably funny, but they started using those chemicals so rampant that we had enough samples to bring to our labs, test them with our brightest minds and make changes in us that would render these chemicals useless. I mean, why would you use only the power you have against your strongest enemy so carelessly? They started prescribing antibiotics to people harboring our friend viruses and fungi; they started taking fewer doses of these chemicals, which helped us take samples and conduct more studies on them. As ridiculous as it may sound, they started giving them to other animals even when they weren’t sick. There are plenty of journals written by our bacteria brothers who live in pigs about inventing different approaches to render these chemicals useless. Thanks to an ample number of samples provided by the pig farmers.

Talking about researches, some are going on the human side of the battlefield too. That’s our greatest threat. But here’s the good news; we are inventing new tricks and tweaks to get by the chemicals humans use to kill us with. They are not creating more chemicals as efficiently. Once I was on the hand of this biochemist who forgot to wash his hands after touching a petri-dish; that’s my birthplace, by the way. He was in this conference where people were discussing hurdles to the development of super drugs. I was tiny then, so I couldn’t catch all of what they were speaking, but things like insufficient funding and pharmaceuticals being more interested in modifying the same drug and making it earn more for them came up repeatedly.

I would like to end with a quote I heard at that very conference. “With great power comes great responsibilities.” So, let’s remember when we come up with great ideas to get by every weapon humans have against us, we have a responsibility to share it with our offspring. Let’s rule the world!”

Cite this article as: Sajan Acharya, Nepal, "Fight against superdrugs," in International Emergency Medicine Education Project, October 11, 2021, https://iem-student.org/2021/10/11/fight-against-superdrugs/, date accessed: October 17, 2021

Question Of The Day #58

question of the day
720 - variceal bleeding

Which of the following is the most appropriate next step in management?   

This cirrhotic patient presents to the Emergency Department with epigastric pain after an episode of hematemesis at home.  His initial vital signs are within normal limits.  While waiting in the Emergency Department, his clinical status changes.  The patient has a large volume of hematemesis with hypotension and tachycardia.  This patient is now in hemorrhagic shock from an upper gastrointestinal bleed and requires immediate volume resuscitation.  The most common cause of upper gastrointestinal bleeding is peptic ulcer disease, but this patient’s cirrhosis history and large volume of hematemesis should raise concern for an esophageal variceal bleed.  IV Pantoprazole (Choice D) is a proton pump inhibitor that helps reduce bleeding in peptic ulcers, but it does not provide benefit in esophageal varices.  Volume repletion is also a more important initial step than giving pantoprazole.  IV Ceftriaxone (Choice C) helps reduce the likelihood of infectious complications in variceal bleed patients.  This has a mortality benefit and is a recommended adjunctive treatment.  However, rapid volume resuscitation is a more important initial step.  IV crystalloid fluids, like normal saline (Choice A), are helpful in patients with hypovolemic shock (i.e., dehydration, vomiting), distributive shock (i.e., sepsis, anaphylaxis), and obstructive shock (i.e., tension pneumothorax, etc.).  Hypovolemic shock due to severe hemorrhage (hemorrhagic shock) requires blood products, not crystalloid fluids which can further dilute blood and cause coagulopathy.  Administration of packed red blood cells (Choice B) is the best next step in management in this case.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #58," in International Emergency Medicine Education Project, October 8, 2021, https://iem-student.org/2021/10/08/question-of-the-day-58/, date accessed: October 17, 2021

Practicing ethically in research

Fundamentals of Research in Medicine - Episode 2

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The first episode is “Practicing ethically in research.”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "Practicing ethically in research," in International Emergency Medicine Education Project, October 6, 2021, https://iem-student.org/2021/10/06/research-ethics/, date accessed: October 17, 2021

Cryptic Shock – Identifying the Unseen (PART 1)

Case Presentation

A 68-year-old man presented to the Emergency Department with complaints of breathing difficulty and fever for three days. The patient is a known diabetic and hypertensive.

After detailed history taking, clinical examination, and radiological workup, the patient was diagnosed with right-sided lobar pneumonia (Community-acquired) and immediately started on intravenous antibiotics. In addition, necessary cultures and blood samples were taken for evaluation.

At the time of presentation, his vitals were HR – 92/min, BP – 130/70mmHg, RR – 30/min, SpO2 – 90% with RA à 96% with 2L O2. He underwent bladder catheterization.

During the 1st hour in the ER, the patient had a very low urine output, which continued for the next few hours. Lactate levels were more than 4mmol/L.

Based on the symptoms, oliguria, and hyperlactatemia, the patient was diagnosed to have sepsis and was initiated on fluid resuscitation. After 2 hours, the patient remained oliguric still, and his BP declined to 120/70mmHg.

After 6 hours, the patient’s BP became 110/60mmHg (MAP – 77). He became anuric and developed altered sensorium. Since he did not meet the criteria of septic shock, he was continued on IV fluids and antibiotics.

After 12 hours, the BP became 80/40mmHg (MAP – 63mmHg) à developed Multiorgan Dysfunction Syndrome. He was then started on vasopressors and mechanical ventilation.

By day 3, the patient further deteriorated and went into cardiac arrest. ROSC was not achieved.

Case Analysis

The treatment initiated was based on protocols like Surviving Sepsis Guidelines and Septic Shock management. So how did the process fail in order to adequately resuscitate this patient? Could something have been done more differently?

The case you read above is a very common scenario. Approximately 30% of the people coming to the ER are hypertensive, and around 10% have diabetes mellitus. They form a huge population, among whom the incidence of any other disease increases their morbidity and early mortality.

Before we delve into the pathology in these patients, let us look at the basic definitions of shock/hypotension.

  • SBP < 90mmHg
  • MAP < 65 mmHg
  • Decrease in SBP > 40mmHg
  • Organ Dysfunction
  • Hyperlactatemia
  • Shock: A state of circulatory insufficiency that creates an imbalance between tissue oxygen supply (delivery) and demand (consumption), resulting in end-organ dysfunction.
  • Septic Shock: Adult patients can be identified using the clinical criteria of hypotension requiring the use of vasopressors to maintain MAP of 65mmHg or greater and having a serum lactate level greater than 2 mmol/L persisting after adequate fluids resuscitation.
  • Cryptic Shock: Presence of hyperlactatemia (or systemic hypoperfusion) in a case of sepsis with normotension.

Based on all the information given above;

  1. what do you think was wrong with our patient?
  2. What kind of shock did he have?
  3. Could we have managed him any other way?
  4. When should we have started inotropes?
  5. Did the fact that he was hypertensive and diabetic have to do with his early deterioration? If so, how?
  6. When did the patient-first develop signs of shock?
  7. What are the different signs and symptoms of shock, and how are they recognized in the ER?

Keep your answers ready… 

Part 2 of Cryptic Shock Series – Vascular Pathology and What is considered ‘Shock’ in Hypertensive patients

Part 3 of Cryptic Shock Series – Individualised BP management

Part 4 of Cryptic Shock Series – Latest Trends

References and Further Reading

  1. Ranzani OT, Monteiro MB, Ferreira EM, Santos SR, Machado FR, Noritomi DT; Grupo de Cuidados Críticos Amil. Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock. Rev Bras Ter Intensiva. 2013 Oct-Dec;25(4):270-8. doi: 10.5935/0103-507X.20130047.
  2. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, Bellomo R, Bernard GR, Chiche JD, Coopersmith CM, Hotchkiss RS, Levy MM, Marshall JC, Martin GS, Opal SM, Rubenfeld GD, van der Poll T, Vincent JL, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):801-10. doi: 10.1001/jama.2016.0287.
  3. Shankar-Hari M, Phillips GS, Levy ML, Seymour CW, Liu VX, Deutschman CS, Angus DC, Rubenfeld GD, Singer M; Sepsis Definitions Task Force. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016 Feb 23;315(8):775-87. doi: 10.1001/jama.2016.0289.
  4. Education Resources – Sepsis Trust
  5. The Research of Predicting Septic Shock – International Emergency Medicine Education Project (iem-student.org)
  6. Sepsis – International Emergency Medicine Education Project (iem-student.org)
  7. Empiric Antibiotics for Sepsis in the ED Infographics – International Emergency Medicine Education Project (iem-student.org)
  8. Sepsis – An Overview and Update – International Emergency Medicine Education Project (iem-student.org)
Cite this article as: Gayatri Lekshmi Madhavan, India, "Cryptic Shock – Identifying the Unseen (PART 1)," in International Emergency Medicine Education Project, October 4, 2021, https://iem-student.org/2021/10/04/cryptic-shock/, date accessed: October 17, 2021

Question Of The Day #57

question of the day

Which of the following is the most likely cause for this patient’s condition?  

This young female presents with dizziness, fatigue, nausea, generalized abdominal pain, hypotension, tachycardia, and a positive urine pregnancy test.  The anechoic (black) areas on the bedside ultrasound indicate free fluid (blood) in the peritoneal space.  See the image below for clarification. Yellow arrows indicates free fluids.

This patient is in a state of physiologic shock.  Shock is an emergency medical state characterized by cardiovascular or circulatory failure.  Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure.  Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic.  The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap.  The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam.  Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management. 

This patient’s condition is caused by a presumed ruptured ectopic pregnancy and intraperitoneal bleeding.  This is considered hypovolemic/hemorrhagic shock (Choice A). The other types of shock in Choices B, C, and D are less likely given the clinical and diagnostic information in the case.  The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.  

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #57," in International Emergency Medicine Education Project, October 1, 2021, https://iem-student.org/2021/10/01/question-of-the-day-57/, date accessed: October 17, 2021

Things you should know about wellness and emergency medicine

things you should know about wellness and emergency medicine

In this episode of Coffee Chat With Emergency Medicine Experts, we discussed wellness and emergency medicine for medical students. Dr. Tracy Sanson, Dr. Al’ai Alvarez were the guest speakers of this episode. Dr. Janis Tupesis and Dr. Arif Alper Cevik were the co-hosts of this unique session.

Dr. Sanson and Dr. Alvarez shared their experiences and lessons learned during their career. We believe medical students and junior EM trainees can learn many from this episode.

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Cite this article as: iEM Education Project Team, "Things you should know about wellness and emergency medicine," in International Emergency Medicine Education Project, September 29, 2021, https://iem-student.org/2021/09/29/wellness-and-emergency-medicine/, date accessed: October 17, 2021

Alcohol Poisoning

What We Know From Current Statistics

Alcohol (ethyl alcohol), also known as ethanol, is one of the most abused substances worldwide, and alcohol poisoning is one of its varying manifestations. Furthermore, alcohol is psychoactive and is known for its ability to induce dependence. Therefore, misuse of alcohol has detrimental effects neurologically and systemically on an individual’s body, and it impacts their sphere of life psycho-socially and economically, the effects of which are generally negative within households and countries on a wider scale.

The National Health Institute mentions that 5.3 percent of deaths globally are related to alcohol consumption, with men being more at risk. The World Health Organization informs that this percentage approximates to around 3 million lives lost around the world.

In the United States particularly, Levine (2021) explains that “more than half of all trauma patients are intoxicated with ethanol” upon accessing the trauma center. It is also a frequent substance ingested along with other substances in suicide attempts.

As a result, it is crucial to be able to identify the presentation of alcohol poisoning or ethanol poisoning in the acute setting.

Risk Factors

Increased risk for alcohol poisoning is related to factors linked to the individual and how alcohol is consumed.

Risks Related To The Individual:

  • Body mass index
  • General health
  • Recent food ingestion
  • Alcohol tolerance level

Risks Related To Alcohol:

  • Amount of alcohol ingested
  • Co-ingestion of other drugs
  • Rate of alcohol consumption

Risk factors may also include a history of alcoholism, binge drinking, as well as mental health issues, including depression associated with suicidal ideation.

Etiology

The general cause of alcohol poisoning results from drinking too much alcohol in a short period; more specifically, binge drinking is considered the main factor, where large quantities of alcoholic beverages are consumed rapidly in less than three hours.

Clinical Presentation

Levine (2021) clarifies that identifying recent changes in the circumstances of the patient may reveal the reason for the presentation.

It is important to note that the serum concentration of ethanol along with the frequency at which the patient may ingest alcohol can influence presentation as patients with antecedents of chronic drinking may not manifest cerebellar dysfunction in comparison to new drinkers. Signs and symptoms will encompass slurred speech, disinhibition in behavior as well lack of coordination. Posteriorly, the patient may show signs of central nervous system depression. Thus, causes that may also present with depression of the central nervous system (CNS) must also be considered. Hidden injuries must be evaluated in the physical examination.

Especially in children and adolescents, the physician must also consider the hypoglycaemic effects of alcohol in the clinical presentation due to the risk of experiencing it after single use in comparison to adults.

Signs and Symptoms of Alcohol Intoxication:

  • Slurred speech
  • Behavioural disinhibition
  • Dizziness
  • Ataxia
  • Drowsiness
  • Coma

 

Differential Considerations

The following are a few causes that also present similarly to alcohol poisoning:

  • Acute hypoglycemia
  • Diabetic ketoacidosis
  • Meningitis
  • Other drug toxicities
    • Benzodiazepine
    • Barbiturates
    • Lithium
    • Opioids
    • Sedatives
  • Stroke

 

Investigations

As previously mentioned, other causes related to depression of the CNS must be considered in such a presentation. (See a list of differentials above)

However, despite various tests that correspond to alternative causes, an investigation that must be evaluated quickly is the serum glucose level. Other tests include and are not limited to:

  • Serum ethanol level. Levine (2021) notes the toxic dose of ethanol is 5 mg/dl and in children 3mg/dl.
  • Toxicology Screen
  • Routine Complete Blood Count and Chemistry to include Bicarbonate, bearing in mind that as the patient progresses, values will also change as related to the anion gap calculation.
  • Liver Function Tests
  • Arterial Blood Gas
  • Electrocardiogram
  • Imaging studies are dependent on suspicion or discovery of traumatic injuries, for example, head trauma.

Management

Treating or managing alcohol poisoning is founded on supportive care, bearing in mind the risk of respiratory depression; the patient’s airway must be protected.

Glucose must be checked frequently when the clinical presentation is severe. It should be monitored ideally every two hours in such cases. The presence of hypoglycemia must be corrected using intravenous dextrose solution. Intravenous fluids may also serve a dual effect to correct dehydration caused by the diuretic effect of alcohol on the body. Any associated traumatic injuries must also be managed. It is important to note that 100 mg of thiamine may be intravenously or intramuscularly administrated if Wernicke’s encephalopathy is suspected.

Key Points

  1. Three million deaths globally are linked to alcohol use.
  2. Alcohol poisoning is related to drinking large quantities of alcohol over a short period of time. Binge drinking is a major cause of alcohol poisoning.
  3. The clinical presentation ranges from slurred speech to coma in severe presentation.
  4. Patients’ blood glucose must be monitored, and another diagnosis that may present with signs of central nervous system depression must be ruled out.
  5. Investigations related to evaluating for hypoglycemia, verifying ethanol toxicity, organ damage, assessing suspected or apparent trauma, and ruling out other possible causes of the clinical presentation.
  6. Treatment is generally supportive and includes correction of hypoglycemia, dehydration, and management of any traumatic injuries.

References and Further Reading

Cite this article as: Kohylah Piper, Antigua & Barbuda, "Alcohol Poisoning," in International Emergency Medicine Education Project, September 27, 2021, https://iem-student.org/2021/09/27/alcohol-poisoning/, date accessed: October 17, 2021

Question Of The Day #56

question of the day

Which of the following is the most likely cause of this patient’s condition?

This trauma patient arrives with hypotension, tachycardia, absent unilateral lung sounds, and distended neck veins. This should raise high concern for tension pneumothorax, which is a type of obstructive shock (Choice C). This diagnosis should be made clinically without X-ray imaging. Bedside ultrasound can assist in making the diagnosis by looking for bilateral lung sliding, if available. Treatment of tension pneumothorax should be prompt and includes needle decompression followed by tube thoracostomy. Other types of shock outlined in Choices A, B, and D do not fit the clinical scenario with information that is given.

Recall that shock is an emergency medical state characterized by cardiovascular or circulatory failure. Shock prevents peripheral tissues from receiving adequate perfusion, resulting in organ dysfunction and failure. Shock can be categorized as hypovolemic, distributive, obstructive, or cardiogenic. The different categories of shock are defined by their underlying cause (i.e., sepsis, hemorrhage, pulmonary embolism, etc.) and their hemodynamics which sometimes overlap. The diagnosis of shock is largely clinical and supported by the history, vital signs, and physical exam. Additional studies, such as laboratory investigations, bedside ultrasound, and imaging tests help narrow down the type of shock, potential triggers, and guide management. The chart below details the categories of shock, each category’s hemodynamics, potential causes, and treatments.

 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #56," in International Emergency Medicine Education Project, September 24, 2021, https://iem-student.org/2021/09/24/question-of-the-day-56/, date accessed: October 17, 2021

What makes a physician a good researcher

Fundamentals of Research in Medicine - Episode 1

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The first episode is “What makes a doctor a good researcher.”

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987.  He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.  

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE.  He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery. 

Cite this article as: Arif Alper Cevik, "What makes a physician a good researcher," in International Emergency Medicine Education Project, September 22, 2021, https://iem-student.org/2021/09/22/good-researcher/, date accessed: October 17, 2021

Focused Assessment with Sonography in Trauma (FAST): An Overview

Traumatic injuries are one of the leading causes of death, and intraperitoneal bleeds occur in approximately 12% of blunt traumas [1]. A quick assessment of trauma and detection of intraperitoneal fluid is increasingly essential in trauma patients’ assessment. The implementation of point-of-care ultrasound (POCUS) has had a significant impact on patient management, especially in a trauma setting. POCUS is easy to use at the bedside, non-invasive and inexpensive.

The Focused Assessment with Sonography in Trauma (FAST) is an ultrasound protocol used to assess hemoperitoneum and hemopericardium [2]. The FAST protocol is sensitive and specific for detecting intraperitoneal free fluid. According to previous studies, sensitivity ranges from 75-100%, and specificity ranges from 88-100% [3]. The FAST exam is rapid and can be completed in less than 5 minutes. It also has multiple advantages, including decreased time to interventions like surgery and length of stay at the hospital [4]. The Extended FAST (eFAST) protocol, which involves examinations of each hemithorax for hemothorax and pneumothoraces, has recently been introduced by several institutions [2].

Regions Examined

The FAST exam assesses the pericardium and multiple potential spaces within the peritoneal cavity for free fluid. The patient is often assessed in the supine position.

The right flank or right upper quadrant (RUQ) view assesses the hepatorenal recess (also known as Morrison’s pouch), as well as the right paracolic gutter, the hepato-diaphragmatic area, and the caudal edge of the left liver lobe [2]. The pericardial view, also known as the subcostal or the subxiphoid, is usually assessed next. The liver is commonly used as a sonographic window of the heart to evaluate pericardium. Ultrasound can detect little pericardial fluid with sensitivity and specificity approaching 100% [5]. The pericardial view also helps to differentiate between pleural and pericardial effusions and visualize right ventricular collapse during diastole [2]. Next, the left upper quadrant (LUQ) is used to visualize the splenorenal recess, the subphrenic space and the left paracolic gutter. If the eFAST protocol is being conducted, the RUQ and LUQ views are also used to examine the left and right hemithorax. Lastly, the pelvic or the suprapubic view is used to assess for free fluid in the rectovesical pouch in males and rectouterine and vesicouterine pouches in women [2]. The bladder acts as a sonographic window for this view.

Complications

While there are no complications related to the FAST exam itself, the use of ultrasound does have some limitations, one of which is the requirement for at least 150-200 cc of intraperitoneal fluid for an ultrasound to be able to detect. This can lead to false negatives when free fluid is in fact present [6]. False positives in the FAST exam may also occur and can be due to the presence of ascites, pre-existing pleural or pericardial effusions unrelated to the trauma, ruptured ovarian cysts or ruptured ectopic pregnancies [2]. Healthcare workers should be aware that POCUS and the FAST protocol have limitations dependent on the provider’s experience and the patient’s body habitus.   

Further Reading and Free Online Course

References

  1. Poletti, P. A., Mirvis, S. E., Shanmuganathan, K., Takada, T., Killeen, K. L., Perlmutter, D., Hahn, J., & Mermillod, B. (2004). Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?. The Journal of Trauma57(5), 1072–1081. https://doi.org/10.1097/01.ta.0000092680.73274.e1
  2. Bloom, B. A., & Gibbons, R. C. (2020). Focused Assessment with Sonography for Trauma. https://www.ncbi.nlm.nih.gov/books/NBK470479/
  3. Brenchley, J., Walker, A., Sloan, J. P., Hassan, T. B., & Venables, H. (2006). Evaluation of focussed assessment with sonography in trauma (FAST) by UK emergency physicians. Emergency Medicine Journal23(6), 446–448. https://doi.org/10.1136/emj.2005.026864
  4. Melniker, L. A., Leibner, E., McKenney, M. G., Lopez, P., Briggs, W. M., & Mancuso, C. A. (2006). Randomized controlled clinical trial of point-of-care, limited ultrasonography for trauma in the emergency department: the first sonography outcomes assessment program trial. Annals of Emergency Medicine48(3), 227–235. https://doi.org/10.1016/j.annemergmed.2006.01.008
  5. Mandavia, D. P., Hoffner, R. J., Mahaney, K., & Henderson, S. O. (2001). Bedside echocardiography by emergency physicians. Annals of emergency medicine38(4), 377–382. https://doi.org/10.1067/mem.2001.118224
  6. Von Kuenssberg Jehle, D., Stiller, G., & Wagner, D. (2003). Sensitivity in detecting free intraperitoneal fluid with the pelvic views of the FAST exam. The American journal of emergency medicine21(6), 476–478. https://doi.org/10.1016/s0735-6757(03)00162-1
Cite this article as: Maryam Bagherzadeh, Canada, "Focused Assessment with Sonography in Trauma (FAST): An Overview," in International Emergency Medicine Education Project, September 20, 2021, https://iem-student.org/2021/09/20/sonography-in-trauma-fast/, date accessed: October 17, 2021