Erythema Types in Medicine – Rapid Review For Medical Students

Our skin, the largest organ in the human body, is crucial for maintaining life and overall health. It serves as an airtight, watertight and flexible barrier with the outside world and helps with temperature regulation, immune defense, vitamin production and sensation.

However, the skin is unique in that no other organ demands as much attention in states of disease and health. Our skin’s quality and condition significantly contribute to health, wellness, youth, and beauty perceptions. Such a focus even causes self-esteem and mental health problems stemming from scars, acne, and inflammation to abnormal redness of the skin known as erythema.

Erythema stems from the dilation and irritation of the superficial capillaries and the augmented blood flow that imparts a reddish hue to the skin. Often presenting as a rash, erythema can be caused by environmental factors, infection, or overexposure to the sun.

Since exam season is here, this serves as a rapid review to recall the most common types of Erythema!

Erythema Ab Igne (EAI)

  • The skin reaction stems from chronic exposure to infrared radiation in the form of heat. Once considered a common condition of the elderly who stood or sat closely to open fires or electric space heaters. EAI has reduced significantly with the advent of central heating, although it is still found in individuals exposed to heat from other sources. In EAI, the skin and underlying tissue begin to atrophy, causing patients to complain of mild itchiness and a burning sensation.
  • To prevent the progression of EAI, discontinuing contact with the heat source is necessary.
  •  

Hotbottlerash.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Chronicum Migrans

  • The primary manifestation of Lyme Disease, erythema chronicum migrans appears 7 to 14 days after the infected tick bite. As an expanding red patch of skin, the size of the rash can reach several centimetres in diameter. The central spot surrounded by clear skin ringed by an expanding red rash known as a bull’s-eye is the most typical appearance.
  • Successful treatment of erythema migrans may be accomplished with 20 days of oral doxycyclineamoxicillin, or cefuroxime axetil.
  •  

Bullseye Lyme Disease Rash.jpg
By Hannah Garrison – <a href=”https://en.wikipedia.org/wiki/User:Jongarrison&#8221; class=”extiw” title=”en:User:Jongarrison”>en:User:Jongarrison</a>, CC BY-SA 2.5, Link

Erythema Induratum

  • Erythema induratum from Bazin disease presents as recurring nodules or lumps on the back of the legs in mostly women that ulcerate and scar.
  • Drugs for treatment include isoniazid, rifampicin, and pyrazinamide, that may be administered orally or intravenously in combination.

An introduction to dermatology (1905) erythema induratum 2.jpg
By Norman Purvis Walker – Walker, Norman Purvis (<span style=”white-space:nowrap”>1905</span>) <a rel=”nofollow” class=”external text” href=”https://books.google.com/books?id=fnYoAAAAYAAJ”>An introduction to dermatology</a> (3rd ed.), William Wood and company Retrieved on 26 September 2010., Public Domain, Link

Erythema Infectiosum or Fifth Disease

  • Erythema infectiosum is also known as the Fifth disease. It is caused by Parvovirus B19 that affects mostly children. The main clinical feature is the “slapped face” appearance along with a sore throat, mild fever and malaise, and signs of Fifth Disease’s prodrome period. The confluent netlike rash begins on the cheeks and spreads to the trunk and extremities.
  • Children may be given NSAIDs to alleviate and relieve fever, headache and achiness.

Fifth disease.jpg
By Andrew Kerr – <span class=”int-own-work” lang=”en”>Own work</span>, Public Domain, Link

Erythema Marginatum

  • Erythema marginatum rheumaticum occurs in about 10% of first attacks of Acute Rheumatic Fever (ARF) in children appearing on their trunk, upper arms and legs as pink or red macules or papules spreading in a circular shape. As the lesions advance, the edges become raised, red, and persist intermittently for weeks to months, even after successful ARF treatment.
  • There is no treatment for erythema marginatum specifically as the rash fades on its own.

Erythema Multiforme

  • Erythema multiforme is a cell-mediated cytotoxic reaction in the skin and mucous membranes triggered by Mycoplasma Pneumoniae or Herpes Simplex Virus or even drugs as sulfonamides, penicillin, barbiturates, NSAIDs, & phenytoin. Vesicles and bullae on the soles, palms, and extensor surfaces with a “targetoid” appearance are characteristic of the rash. Without treatment and care by dermatologists, Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) occur as they are severe forms of erythema multiforme.
  • Treatment includes oral antihistamines, analgesics, local skincare, and soothing mouthwashes.

Erythema multiforme minor of the hand.jpg
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Nodosum

  • Erythema nodosum is an acute inflammatory reaction involving the subcutaneous fat where the skin becomes red, raised and painful on the anterior portions of the shins and wrist. It is more common in women than men, and although the most identifiable cause is streptococcal pharyngitis, it is associated with coccidioidomycosis, histoplasmosis, tuberculosis, leprosy, sarcoidosis, ulcerative colitis, and pregnancy.
  • Anti-inflammatory drugs and corticosteroids by mouth or local injection may serve as treatment options. Colchicine is also administered to reduce inflammation.

ENlegs.JPG
By <a href=”//commons.wikimedia.org/wiki/User:Jmh649″ class=”mw-redirect” title=”User:Jmh649″>James Heilman, MD</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 3.0, Link

Erythema Toxicum Neonatorum

  • Erythema toxicum neonatorum is a self-limited skin eruption occurring in newborns due to an unknown cause. Erythematous papules, macules and plaques present in all sites except the soles and palms and may last approximately 2-3 weeks.
  • No treatment is necessary for erythema toxicum neonatorum as the lesions regress after 5 days to 2 weeks.

Erythema Elevatum Diutinum (EED)

  • Erythema elevatum diutinum (EED) is a type of necrotising vasculitis characterised by red, purple, or brown papules, plaques, or nodules. It is a rare form of erythema usually found on extensor surfaces overlying the joints, and the buttocks. It is a chronic and progressive skin disease that may last as long as 25 years.
  • The drug of choice for EED is Dapsone because of its rapid onset of action; however, it is possible for lesions to recur the following withdrawal promptly.

Erythema elevatum diutinum on hand.jpg
By <a href=”//commons.wikimedia.org/w/index.php?title=User:Dswierc&amp;action=edit&amp;redlink=1″ class=”new” title=”User:Dswierc (page does not exist)”>D Swierczek</a> – <span class=”int-own-work” lang=”en”>Own work</span>, CC BY-SA 4.0, Link

Erythema Gyratum Repens

  • Erythema gyratum repens is a rare paraneoplastic type of annular erythema with a ‘wood-grain’ appearance associated with malignancy. Furthermore, almost half of the patients with erythema gyratum repens have lung cancer and less commonly, oesophageal, breast, and stomach cancer.
  • The rash usually resolves once the malignancy has been removed with surgical resection.

References and Further Reading

Cite this article as: Leah Sarah Peer, Canada, "Erythema Types in Medicine – Rapid Review For Medical Students," in International Emergency Medicine Education Project, January 4, 2021, https://iem-student.org/2021/01/04/erythema-review-for-medical-students/, date accessed: January 18, 2021

Question Of The Day #24

question of the day
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738.1 - Prior ECG before 738.2 - STEMI

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient is suffering from severe bradycardia with signs of poor cardiac output, shock, and diminished perfusion to the brain. Bradycardia is defined as any heart rate under 60 beats/min. Many individuals may be bradycardic at rest with no danger to the patient (i.e. young patients or athletes). Bradycardia in these scenarios is physiologic and is not associated with difficulty in perfusing the brain and other organs. This patient’s 12-lead EKG shows sinus bradycardia since there is a P wave prior to every QRS complex. Sinus bradycardia is the most common type of bradycardia. Other types of bradycardia include conduction blocks (i.e. type 2 or type 3 AV blocks), junctional rhythms (lack of P waves with slow SA nodal conduction), idioventricular rhythms (wide QRS complex rhythms that originate from the ventricles, not atria), or slow atrial fibrillation or atrial flutter. About 80% of all bradycardias are caused by factors external to the cardiac conduction system, such as hypoxia, drug effects (i.e. beta block or calcium channel blocker use or overdose), or acute coronary syndromes.  

For any patient with a bradyarrhythmia or tachyarrhythmia, it is crucial to determine if the arrythmia is “stable” or “unstable”. Signs that an arrhythmia is unstable include altered mental status, hypotension with systolic blood pressure under 90mmHg, chest pain, or shortness of breath. Patients with a stable arrhythmia can be managed supportively with observation and less invasive medical management. Patients with unstable arrhythmia are managed more aggressively with the use of electricity, often in combination with other medical treatments. This patient has an unstable bradyarrhythmia, given her altered mental status and hypotension. Intravenous metoprolol (Choice D) would make the patient more bradycardic since this medication blocks beta-adrenergic receptors of the heart that control heart rate and contractility. Intravenous Amiodarone (Choice C) is an antiarrhythmic agent used often in wide complex tachyarrhythmias (i.e. Ventricular Tachycardia). Intravenous atropine or epinephrine are agents that can be used in this patient prior to preparing for electric pacing. Transcutaneous pacing (Choice A) should always be attempted prior to Transvenous pacing (Choice B), as Transcutaneous pacing is less invasive and quicker to set up. If Transcutaneous pacing does not result in electrical “capture” or change the heart rate, the next step is Transvenous pacing. Correct Answer: A 

References

  • Brady W.J., & Glass III G.F. (2020). Cardiac rhythm disturbances. Tintinalli J.E., Ma O, Yealy D.M., Meckler G.D., Stapczynski J, Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=218687685
  • Burns, E. (2020). Sinus Bradycardia. Life in the Fast Lane. Retrieved from https://litfl.com/sinus-bradycardia-ecg-library/
Cite this article as: Joseph Ciano, USA, "Question Of The Day #24," in International Emergency Medicine Education Project, December 11, 2020, https://iem-student.org/2020/12/11/question-of-the-day-24/, date accessed: January 18, 2021

Question Of The Day #23

question of the day
qod23
3. PEA

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presented to the emergency department with acute pleuritic chest pain, dyspnea, and experienced a cardiac arrest prior to a detailed physical examination. The cardiac monitor shows a narrow complex sinus rhythm morphology. In the setting of a cardiac arrest and pulselessness, this cardiac rhythm is known as pulseless electric activity (PEA). PEA includes any cardiac rhythm that is not asystole, ventricular fibrillation, or pulseless ventricular tachycardia. The ACLS algorithm divides the management of patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole. Assuming adequate staff and medical resources are present, patients with all of these rhythms receive high-quality CPR, IV epinephrine, and airway management. Patients with pVT or VF receive electrical cardioversion, while patients with PEA or asystole do not receive electrical cardioversion. Patients with PEA or asystole generally have a poorer prognosis than those with pVT or VF. Out of hospital cardiac arrests that present to the emergency department with PEA or asystole on initial rhythm have a survival rate of under 3%. The etiology of PEA in cardiac arrest includes a wide variety of causes. A traditional approach to remembering the reversible causes of PEA are the “Hs & Ts”. The list of the “Hs & Ts” along with their individual treatments are listed in the table below.

PEA treatments

Sodium bicarbonate (Choice A) would be the correct choice for a patient whose PEA arrest was caused by severe acidosis. This can occur in severe lactic acidosis (i.e. sepsis), diabetic ketoacidosis, certain toxic ingestions (i.e. iron, salicylates, tricyclic antidepressants), as well as other causes. Calcium gluconate (Choice B) would be the correct choice for a patient whose PEA arrest was caused by hyperkalemia. This can occur in renal failure, in the setting of certain medications, rhabdomyolysis (muscle tissue breakdown), and other causes. Blood products (Choice D) would be the correct choice for a patient whose PEA arrest was due to severe hemorrhage, such as gastrointestinal bleeding or in the setting of traumatic injuries. This patient has symptoms and risk factors for pulmonary embolism, including pleuritic chest pain, dyspnea, and a cancer history. These details make pulmonary embolism the most likely cause of PEA arrest in this scenario. The best treatment for this diagnosis would be thrombolysis (Choice C).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #23," in International Emergency Medicine Education Project, December 4, 2020, https://iem-student.org/2020/12/04/question-of-the-day-23/, date accessed: January 18, 2021

Question Of The Day #22

question of the day
qod22
1. VFib

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient presents to the Emergency Department after a cardiac arrest with an unknown medical history. Important components of Basic Life Support (BLS) include early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (5 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the Advanced Cardiovascular Life Support (ACLS) algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive additional medications or receive unsynchronized cardioversion (defibrillation, or “electrical shock. The ACLS algorithm divides management in patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.

The cardiac rhythm seen during the pulse check for this patient is ventricular fibrillation. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Continuing chest compressions (Choice A) with minimal interruptions is a crucial component of BLS, however, this patient’s cardiac rhythm is shockable. Defibrillation (Choice B) takes precedence over CPR in this scenario. Amiodarone (Choice C) is an antiarrhythmic agent that is recommended in patients with pVT, in addition to unsynchronized cardioversion. This patient has VF, not pVT. Sodium bicarbonate (Choice D) is an alkaline medication that is helpful in cardiac arrests caused by severe acidosis or certain toxins (i.e. salicylates or tricyclic antidepressants). The next best step in this patient scenario would be defibrillation for the patient’s VF (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #22," in International Emergency Medicine Education Project, November 27, 2020, https://iem-student.org/2020/11/27/question-of-the-day-22/, date accessed: January 18, 2021

Pathological Brain CT Findings – Illustration

Pathological Brain CT Findings

In this post, we will share the traumatic (Epidural, subdural, cerebral contusion, subarachnoid hemorrhage, cerebral edema) and atraumatic (intracranial parenchymal hemorrhage, subarachnoid hemorrhage) brain computerized tomography (CT) findings. We will also provide GIF images and one final image, which includes all pathologies in one image.

ATRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS

TRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS

ATRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS – GIF

TRAUMATIC PATHOLOGICAL BRAIN CT FINDINGS  – GIF

PATHOLOGICAL BRAIN CT FINDINGS  – ONE POST

References and Further Reading

  1. https://iem-student.org/2019/09/04/cranial-ct-anatomy-a-simple-image-guide-for-medical-students/
  2. The Atlas of Emergency Radiology
Cite this article as: Murat Yazici, Turkey, "Pathological Brain CT Findings – Illustration," in International Emergency Medicine Education Project, November 18, 2020, https://iem-student.org/2020/11/18/pathological-brain-ct-findings-illustration/, date accessed: January 18, 2021

Question Of The Day #21

question of the day
qod21

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient experienced a witnessed cardiac arrest at home, after which pre-hospital providers initiated cardiopulmonary resuscitation (CPR, or “chest compressions”) and Advanced Cardiovascular Life Support (ACLS). ACLS includes the tenets of Basic Life Support (BLS), such as early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (2 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the ACLS algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive defibrillation (“electrical shock”) or additional medications. The ACLS algorithm divides management into patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.

The cardiac rhythm seen during the pulse check for this patient is a wide complex tachycardia with a regular rhythm. In the setting of cardiac arrest, chest pain prior to collapse, and a history of acute coronary syndrome, ventricular tachycardia is the most likely cause. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Watching the cardiac monitor for a rhythm change (Choice A) or checking for a pulse (Choice D) are not recommended after defibrillation. A major priority of both BLS and ACLS is to avoid interruptions to CPR, so the best next step in management is to continue CPR (Choice B) after defibrillation. Administration of intravenous adrenaline (Choice C) is helpful for cardiac arrests to initiate shockable rhythm and should be repeated every 3-5 minute or every 2 cycle of CPR, particularly valuable in asystole patients. Calcium gluconate is another drug that can be used in patients with hyperkalemia and indicated in a patient with known kidney disease, missed hemodialysis sessions, or a history of usage of medications that can cause hyperkalemia. Magnesium can be used for patients who show polymorphic VT, particularly Torsades de Pointes. The next best step in this scenario is to continue CPR, regardless of the etiology of the cardiac arrest. Correct Answer: B.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #21," in International Emergency Medicine Education Project, November 13, 2020, https://iem-student.org/2020/11/13/question-of-the-day-21/, date accessed: January 18, 2021

Question Of The Day #20

question of the day
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608 - Figure3 - pericardial effusion - ECG

Which of the following is the most appropriate next investigation for this patient’s condition?

This patient’s EKG demonstrates alternating amplitudes of QRS complexes, a phenomenon known as electrical alternans. This is caused by the heart swinging back and forth within a large pericardial effusion. The patient is tachycardic and borderline hypotensive, which should raise concern over impending cardiac tamponade. The next best investigation to definitively diagnose a large pericardial effusion with possible tamponade would be a cardiac sonogram (Choice B). This investigation could also guide treatment with pericardiocentesis in the event of hemodynamic decompensation and the development of obstructive shock. Other EKG signs of a large pericardial effusion are diffusely low QRS voltages and sinus tachycardia. Chest radiography (Choice C) may show an enlarged cardiac silhouette in this case and evaluate for alternative diagnoses (i.e. pneumothorax, pleural effusions, pneumonia, atelectasis), however, cardiac echocardiography is the best next investigation. CT pulmonary angiography (Choice D) would demonstrate the presence of a pericardial effusion along with differences in cardiac chamber size indicative of tamponade. Still, bedside cardiac sonogram is a faster test that prevents a delay in diagnosis. Sending a potentially unstable patient for a CT scan may also be dangerous. Arterial blood gas testing (Choice A) has no role in diagnosing pericardial effusion or cardiac tamponade. Correct Answer: B

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #20," in International Emergency Medicine Education Project, November 6, 2020, https://iem-student.org/2020/11/06/question-of-the-day-20/, date accessed: January 18, 2021

Question Of The Day #19

question of the day
qod19
52 - Perforated Viscus

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

All patients who present to the emergency department with chest pain should be evaluated for the top life-threatening conditions causing chest pain. Some of these include myocardial infarction, pulmonary embolism, esophageal rupture, tension pneumothorax, cardiac tamponade, and aortic dissection. Many of these diagnoses can be ruled-out or deemed less likely with a detailed history, physical exam, EKG, and sometimes imaging and blood testing. This patient presents with vague, burning chest pain, nausea, and tachycardia on exam. Pulmonary embolism (Choice A) is hinted by the patient’s tachycardia, but the patient has no tachypnea or risk factors mentioned for PE. Additionally, the chest X-ray findings demonstrate an abnormality that can explain the patient’s symptoms. Pancreatitis (Choice B) and Gastroesophageal reflux disorder (Choice D) are also possible diagnoses, especially with the location and description of the patient’s pain. However, Chest X-ray imaging offers an explanation for the patient’s symptoms. The patient’s Chest X-ray demonstrates the presence of pneumoperitoneum. In the presence of NSAID use, this radiological finding raises concern over a perforated viscus from advanced peptic ulcer disease (Choice C). Peptic ulcer disease (PUD) is most commonly caused by Helicobacter pylori infection, but NSAIDs, iron supplements, alcohol, cocaine, corrosive substance ingestions, and local infections can cause PUD. PUD is a clinical diagnosis which can be confirmed visually via endoscopy. The treatment for PUD includes initiation of a proton pump inhibitor (H2-receptor blockers are 2nd line), avoiding the inciting agent, and H.pylori antibiotic regimens in confirmed H.pylori cases. The treatment for a perforated peptic ulcer with pneumoperitoneum is IV fluids, IV antibiotics, Nasogastric tube placement, and surgical consultation for repair.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #19," in International Emergency Medicine Education Project, October 30, 2020, https://iem-student.org/2020/10/30/question-of-the-day-18-2/, date accessed: January 18, 2021

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Question Of The Day #17

question of the day
qod17

Which of the following is the most likely cause for the patient’s elevated cardiac troponin level in the emergency department?

Elevated cardiac troponin levels, or troponinemia, are one sign that the myocardium may be infarcting or under some type of stressful condition. Cardiac troponin levels are assessed in conjunction with the clinical history, physical exam, EKG, and another laboratory testing in deciding if troponinemia is due to cardiac ischemia or another condition. Conditions associated with elevated cardiac troponin levels include cardiac ischemia (i.e. STEMI, NSTEMI), cardiac contusion, cardiac procedures, congestive heart failure, renal failure, aortic dissection, tachy- or bradyarrhythmias, rhabdomyolysis with cardiac injury, Takotsubo syndrome, pulmonary embolism, acute stroke, myocarditis, sepsis, severe burns, extreme exertion, and other conditions. It is unlikely that this patient had elevated troponin levels from Acute coronary syndrome (Choice D) as her cardiac catheterization results showed no significant occlusive lesions in the coronary arteries. D-Dimer levels do increase with patient age, but cardiac troponin levels do not increase with patient age (Choice B). Sepsis (Choice C) is a cause for elevated troponin levels, but this patient has no clinical signs or sepsis symptoms. Atrial fibrillation with a rapid rate (Choice A) is the most likely cause of this patient’s elevated troponin level. Correct Answer: A 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #17," in International Emergency Medicine Education Project, October 16, 2020, https://iem-student.org/2020/10/16/question-of-the-day-17/, date accessed: January 18, 2021

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Question Of The Day #16

question of the day
qod16

Which of the following is the most appropriate next step in management for this patient’s condition?

This patient sustained a penetrating traumatic injury to the left chest and presented to the emergency department with hemodynamic instability (tachycardic and hypotensive). Some differential diagnoses to consider on arrival include tension pneumothorax, cardiac tamponade, aortic injury, or aero-digestive tract injury. Prior to taking a detailed history on any trauma patient, a primary survey should be performed. The goal of the primary survey in a trauma patient is to identify and treat any life-threatening injuries as soon as possible. The primary survey is also known as the “ABCs.” Sometimes it is referred to as the “ABCDEFs.” This acronym stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (How to learn eFAST exam for free). Each letter is addressed and assessed in the order they exist in the alphabet. This creates a methodical, algorithmic approach to assist the practitioner in assessing the trauma patient for life-threatening injuries. The sonographic view shown in this question is the subxiphoid (cardiac) view and demonstrates the presence of free fluid. Free fluid on ultrasound appears black, or “anechoic” and is assumed to be blood in the setting of trauma. The free fluid is highlighted by red stars in the image below. The collapse of the right ventricle is shown by the yellow arrow in the below image.

cardiac tamponade - explained
SS Video 3 Pericardial Tamponade

In conjunction with hemodynamic instability and a history of penetrating chest trauma, this sonographic view strongly supports the diagnosis of cardiac tamponade. Consulting the general surgery team for exploratory laparotomy (Choice A) would be the correct course of action for a patient with hemodynamic instability and free fluid on the other abdominal views of the FAST exam. Needle decompression of the chest (Choice B) would be the correct initial treatment for a tension pneumothorax. The patient described in the case has clear bilateral lung sounds, no tracheal deviation mentioned, normal O2 saturation on room air, and sonographic demonstration of cardiac tamponade. A CT scan of the chest, abdomen, and pelvis (Choice D) would be indicated in this patient if he had normal vital signs and no free fluid on the FAST exam. A pericardiocentesis (Choice C) is the most appropriate next step in the management of this patient with cardiac tamponade to relieve signs of obstructive shock. It should be noted that this procedure has limitations and is not always effective. Pericardiocentesis is a temporizing treatment with pericardiotomy being the definitive therapy. Blood in an acute hemopericardium may clot and be unable to be aspirated with a large-bore needle. The procedure may injure surrounding organs, such as the liver, intestines, or heart itself. Ultrasound-guidance should be used whenever possible to avoid injury to surrounding organs. Emergent thoracotomy to relieve the cardiac tamponade should be performed on any patient with confirmed cardiac tamponade and cardiac arrest in the Emergency Department. Correct Answer: C

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #16," in International Emergency Medicine Education Project, October 9, 2020, https://iem-student.org/2020/10/09/question-of-the-day-16/, date accessed: January 18, 2021

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Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations

Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.

The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).

Pump

Tank

Rush Tank

Pipes

References and Further Reading

  1. By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
  2. Seif D1, Perera PMailhot TRiley DMandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
  3. https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
  4. https://iem-student.org/rush/
  5. https://iem-student.org/efast/
Cite this article as: Murat Yazici, Turkey, "Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations," in International Emergency Medicine Education Project, May 29, 2020, https://iem-student.org/2020/05/29/rush-protocol-illustrations/, date accessed: January 18, 2021

Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

Cite this article as: Murat Yazici, Turkey, "Lower Extremity Deep Venous US Imaging – Illustrations," in International Emergency Medicine Education Project, February 14, 2020, https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/, date accessed: January 18, 2021

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