Just Some Broken Ribs

Just Some Broken Ribs

The phone was ringing incessantly. I barely woke up. In my pitch dark bedroom, the ringing phone was the only light source. I slowly grabbed my phone while involuntarily rubbing my eyes. I looked at the caller I.D. It was my father. And what time was it? 1:30 am! In a typical day, this might be an early hour for me, but I was attending a local Emergency Medicine conference that day; so I went to bed early.

I cradled the phone between my ear and shoulder. My father’s voice was fussy. “Someone lies unconscious on the street,” he said hastily. “Can you come and help us?” I asked him to call for an ambulance by that time. He said that he already called. 

While I was preparing in a hurry, my heart started to beat faster and my mind swelled with CPR guidelines, syncope algorithms and my past experiences.

My home is down the block from my parents. I ran there and saw a crowd gathered around a man who was lying on the street. When I passed through I realized someone was doing CPR. I have spotted my parents standing in the crowd and my eyes met with my father. He pointed my younger brother, a trainee surgeon also lives in the same area and was taking his turn on the CPR and checking his pulse. I rushed near them and he filled me in with all they know about the citizen at that point.

The first responder to the cries of the patient’s wife was an ambulance driver with ten years of experience. He said he pulled the patient out of his vehicle. He laid down the man in his 50s suffered from heartburn for the last couple of hours and was about to go to the hospital but lost his consciousness as soon as he started the engine. Since the man wasn’t responding, the former driver started the CPR. About 3 minutes later, my brother showed up along with my father and he took the turn while they kept checking for any response. He said that the rhythm never lasted longer than 10 seconds. So I asked them to keep it up and I took my turn till the ambulance shows up.

It was clear that the patient endured a heart-related condition, probably a myocardial infarction. And I knew by experience that with a proper CPR and early defibrillation, these patients have a high chance of returning of spontaneous circulation, and survival.

The ambulance arrived in a couple of minutes. Paramedics jumped out of the vehicle and rushed to the scene and recognized that I am an Emergency Medicine resident at the State Research and Education Hospital. They let me control the situation. The first rhythm was read on the screen as ventricular fibrillation (VF) and we delivered a shock and started chest compressions again. With the equipment they’ve brought, I intubated the patient while they monitored him with the defibrillator from the ambulance. The nearest hospital was 10 minutes away, and we have shocked-compressed for at least 4 or 5 times in an ambulance moving fast. IT-WAS-HARD!

We have arrived at the hospital. After 10 minutes of additional CPR and proper mediations, spontaneous circulation of the patient returned spontaneous circulation. And a control ECG was consistent with Inferior MI. In a couple of minutes, we were in a different ambulance, headed to the nearest hospital with a coronary angiography unit and ICU.

I took a deep breath after we have delivered the patient to the ICU safe and sound. It was over, for now. One week later, he returned to his home with full recovery, without any neurological sequelae. They were very thankful.

Later on, I’ve heard many funny words people were chattering about this incident. One has particularly given me the giggle. It was coming from an ENT specialist. He said, “So that was no big deal, they probably overreacted and caused him a couple of broken ribs.”

Yeah, there were just some broken ribs… and a life saved.

Further Reading

Cite this article as: Ibrahim Sarbay, "Just Some Broken Ribs," in International Emergency Medicine Education Project, August 16, 2019, https://iem-student.org/2019/08/16/just-some-broken-ribs/, date accessed: October 16, 2019

A 19-year-old female presents with sharp right flank pain and shortness of breath

by Stacey Chamberlain

A 19-year-old female presents with sharp right flank pain and shortness of breath that started suddenly the day prior to arrival. The pain is worse with deep inspiration but not related to exertion and not relieved with ibuprofen. She denies anterior chest pain, cough, and fever. She denies leg pain or swelling and recent travel, immobilization, trauma, or surgery. She has no anterior abdominal pain, no dysuria or hematuria and no personal or family history of gallstones, kidney stones, or blood clots. She’s never had this pain before, has no significant past medical history and her only medication is birth control pills. On exam, her vital signs are within normal range, she has normal cardiac and pulmonary exams, no costovertebral angle tenderness, no chest wall or abdominal tenderness and no leg swelling.

Do you need to do any studies to evaluate this patient for a pulmonary embolism?

Pulmonary Embolism Rule-Out Criteria (PERC)

  • Age ≥ 50
  • Heart rate ≥ 100
  • O2 sat on room air < 95%
  • Prior history of venous thromboembolism
  • Trauma or surgery within 4 weeks
  • Hemoptysis
  • Exogenous estrogen
  • Unilateral leg swelling

The PERC CDR was originally derived and validated in 2004 and with a subsequent multi-study center validation in 2008. In the larger validation study, the rule was only to be applied in those patients with a pre-test probability of < 15%, therefore incorporating clinical gestalt prior to using the rule. PERC is a one-way rule, as mentioned above, which tried to identify patients who are so low-risk for pulmonary embolism (PE) as to not require any testing. It does not imply that testing should be done for patients who do not meet criteria, and it is not meant for risk stratification, as opposed to the Wells’ and Geneva scores.

Case Discussion

In order to apply the PERC CDR to the case study patient, the ED physician pre-supposes a pre-test probability of < 15%. If the ED physician has a higher pre-test probability than that, he/she should not use the PERC CDR. If the ED physician, in this case, did indeed have a pre-test probability of < 15%, the case study patient would fail the rule-out due to her use of oral contraceptives. In that case, the ED physician would need to determine if he/she would do further testing which could include a D-dimer, CT chest with contrast, ventilation/perfusion scan, or lower extremity Doppler studies to evaluate for deep vein thromboses (DVTs). The PERC CDR gives no guidance in this case.

Cite this article as: iEM Education Project Team, "A 19-year-old female presents with sharp right flank pain and shortness of breath," in International Emergency Medicine Education Project, June 17, 2019, https://iem-student.org/2019/06/17/a-19-year-old-female-presents-with-sharp-right-flank-pain-and-shortness-of-breath/, date accessed: October 16, 2019

Sinus Tachycardia: Think Simple!

You walk into a patient’s room and notice on the monitor: heart rate of 135. Your patient appears alert and oriented, speaking in full sentences, and telling you, “I have no pain, doctor.”

755.3 - tachycardia

You leave the room, scratching your head, wondering,

“why is the heart rate so high?”

Sinus tachycardia is one of the most common presentations you will find in the Emergency Department, defined as a heart rate greater than 100 beats per minute. Remember, sinus tachycardia will always include p-waves on EKG and telemetry monitoring. This rhythm can be a ‘great masquerader’ in emergency medicine, given that many different etiologies can cause it.

Often, sinus tachycardia – equivalent to an elevated heart rate (HR) – is a compensatory response to an underlying etiology. To explain this concept, let’s recall the delivery of oxygen equation:

CaO2 = (1.34 x Hb x SaO2) + 0.003 x PaO2

The equation for oxygen delivery (CaO2 = arterial oxygen content, Hb = hemoglobin, SaO2 = arterial saturation of oxygen, PaO2 = partial pressure of oxygen in the arterial blood).

All cells require oxygen to survive, and In the lungs, oxygen attaches to hemoglobin molecules so that it can be transported – courtesy of the cardiac output – to the rest of the body. When the delivery of oxygen diminishes, the cardiac output (equal to HR multiplied by the stroke volume) may increase to help compensate for the total delivery of oxygen (as seen by the above equation) (1).

How does this concept apply to sinus tachycardia and the patient in front of you?

Firstly, you want to consider whether your patient has adequate oxygenation and circulation. Check their airway, pulse oximetry, and work of breathing to ensure they are not hypoxemic. Could your patient have a pulmonary embolism? Consider checking for right ventricular dilation with an ultrasound machine or determining whether they may have missed their regularly prescribed anticoagulation.

Enlarged Right Ventricle is seen apical 4 chamber view of the heart and in Para-Sternal short axis (on the right) D shape Left Ventricle. These findings should warn physicians to think about massive pulmonary embolism in a patient with appropriate history, physical examination or risk factors.

For perfusion, check their capillary refill (normal is less than 3 seconds) and palpate their distal extremities to ensure they are warm and not likely in cardiogenic shock. Ensure they are not dehydrated and do not simply need more fluid. Without adequate volume, the body fails to deliver a sustainable amount of oxygen to its tissues. 

Make sure they are not experiencing acute coronary syndrome, either, since sinus tachycardia can occur in one-third or more of patients suffering from ACS due to either pain, hypoxia, anxiety or impending cardiogenic shock(2).

Have you considered whether they may be experiencing a GI bleed, or have an abnormal hemoglobin result with your basic lab studies? Remember: if their oxygen content (as determined by their respiratory and circulatory systems) falls below normal, their cardiac output will try to compensate. Hemoglobin is an important component of the oxygen delivery equation.

720 - variceal bleeding

Image: 17 years old girl, previously healthy, vomited blood suddenly at night, and in the ED.

Secondly, think of non-oxygen related causes including drug and hormone-related effects. Drug intoxication (including amphetamines, cocaine, TCAs plus others) plus opiate, benzodiazepine and/or alcohol withdrawal can lead to sinus tachycardia, too. Albuterol and epinephrine are other common precipitants.

Abnormal glucose and thyroid hormone regulation can also lead to sinus tachycardia. Is your patient hypoglycemic? Remember that low glucose can lead to tachycardia in response to stress (and be associated with altered mental status plus seizure activity). Have your patient’s thyroid levels been checked recently? Hyperthyroidism can easily lead to sinus tachycardia.

755.1 - exophthalmos

A 23 yo female presented with palpitation. Palpitation for 3 days and fever (reaching 39C at home). Weight loss of 24kg (90 to 66) and fatigue in the past three months. ROS: hair loss, heat intolerance, tremor, inability to close her eyes properly, irritability and anxiety. Check the thyroid hormone levels!

Finally, pain and fever! These two important aspects can easily be missed. With pain, your body implements a stress response, often leading to tachycardia. With fever and/or infection, cells require more oxygen.

There are many causes to sinus tachycardia but remember the basics: human cells need oxygen, and if it does not receive this critical element, the body will attempt to compensate by elevating the heart rate. Sometimes, your patient may be experiencing a life-threatening issue (like ACS or pulmonary embolism) or may simply be anxious!

Regardless, always think hard about potential causes and do not anchor on a presumed diagnosis too early. If you follow the basic rules, you can save a life!


  1. Patil, A, Ranjit, S. Hemodynamic Monitoring in PICU. In: Journal of Pediatric Critical Care. New Delhi : Intensive Care Chapter of India Academy of Pediatrics; 2014:267-292.
  2. DeSanctis RW, Block P, Hutter, Jr AM. Tachyarrhythmias in myocardial infarction. Circulation. 1972 Mar;45(3):681-702.

Further Reading

Cite this article as: Erik Blutinger, "Sinus Tachycardia: Think Simple!," in International Emergency Medicine Education Project, May 27, 2019, https://iem-student.org/2019/05/27/sinus-tachycardia-think-simple/, date accessed: October 16, 2019

Bat Sign

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.


The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).

To learn more about it, read chapter below.

Read "Blue Protocol" Chapter

Causes of ST Elevation

Stanford A or B?

In case you didn’t encounter a patient with sudden onset chest pain today!

68.2 - AD CT2

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Audio files – Selected Cardiovascular Emergencies

What is your next action?

In case you didn’t encounter an elderly with chest discomfort today!

A 78-year-old male patient presented with chest discomfort and SOB. BP: 89/48 mmHg, HR: 128 bpm, RR: 26/min, T: 37, SpO2: 92% in room air. He has a history of lung cancer, hypertension and diabetes mellitus. Bed side ECG is done. What is your next action?

Feel free to give your answers at the comment box below.

608 - Figure3 - pericardial effusion - ECG

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Cardiac Monitoring Pearls

Cardiac Monitoring chapter written by Stacey Chamberlain from USA is just uploaded to the Website!

Procedure – Pericardiocentesis

From experts to our students...

Pericardiocentesis chapter written by David Wald and Lindsay Davis from USA is just uploaded to the Website!

Selected Cardiovascular Emergencies

Cardiovascular Emergencies selected from SAEM and IFEM undergraduate curriculum recommendations are uploaded into the website. You can read, listen or download all these chapters freely. More specific disease entities are on the way.

Abdominal Aortic Aneurysm (AAA)

by Lit Sin Quek Case Presentation A 75-year-old obese man comes to the emergency department. He has history C.O.P.D., hypertension. He is a smoker and on

Read More »

Acute Coronary Syndrome (ACS)

by Khalid Mohammed Ali, Shirley Ooi – Singapore Case Presentation A 46 years old man with a past medical history of hypertension and hyperlipidemia developed

Read More »

Acute Heart Failure (AHF)

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

Read More »

Aortic Dissection

by Shanaz Sajeed Introduction Aortic dissection carries high morbidity and mortality. Although patients generally present with acute symptoms and classic signs, a subset of patients

Read More »

Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

Read More »

Hypertensive Emergencies

by Sadiye Yolcu Introduction Systemic hypertension is a common medical problem. It affects over 1 million people worldwide. ER clinicians commonly encounter this problem. Rapid

Read More »

Pulmonary Embolism

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

Read More »

Do you need more?

X-ray findings of AD

In case you didn’t encounter a patient with sharp inter scapular pain today!

A 67-year-old male patient presented with sharp interscapular pain. BP: 189/107 mmHg, HR: 118 bpm, RR: 26/min, T: 37, SpO2: 93% in room air. He has a history of hypertension and diabetes mellitus. The chest x-ray is shown below.

Let’s remember findings of aortic dissection in the chest x-ray.

  1. Depression of the left mainstem bronchus
  2. Displaced intimal calcification
  3. Indistinct or irregular aortic contour
  4. Left apical pleural cap
  5. Opacification of the “AP window” (i.e., clear space between the aorta and the pulmonary artery)
  6. Pleural effusion (left > right)
  7. Tracheal or esophageal deviation
  8. Widened aortic knob or mediastinum (present in only 63% and 56% of patients with type A and type B dissections, respectively)
71.1 - AD1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!