Out of Proportion: Acute Leg Pain

Case Presentation

A 48-year-old male, with history of hypertension and diabetes and prior intravenous drug use (now on methadone) presents with acute onset right leg pain from his calf to the ankle, that woke him from sleep overnight. The pain has been constant, with no modifying or relieving factors. He hasn’t taken anything other than his daily dose of methadone. He hasn’t had any fevers or chills and denies any recent trauma or injuries.

Any thoughts on what else you might want to ask or know?

  • Any recent travel or prolonged immobilization?
  • Have you ever had a blood clot?
  • Are you on any blood thinners?
  • Have you used IV drugs recently?
  • Any numbness or weakness in your leg?
  • Any associated rash or color change?
  • Any back pain or abdominal pain? Any bowel or bladder incontinence?
  • Any recent antibiotics (or other medication changes)?
  • Have you ever had anything like this before?
[all of these are negative/normal]

Pause here -- what is your initial differential diagnosis looking like?

  • Deep vein thrombosis
  • Superficial vein thrombosis
  • Pyomyositis
  • Necrotizing fasciitis
  • Muscle sprain or tear
  • Arterial thromboembolism
  • Bakers cyst
  • Achilles tendonitis, Achilles tendon rupture

What are some key parts of your targeted physical exam?

  • VITAL SIGNS! [BP was slightly hypertensive, and he is slightly tachycardic, normothermic]
  • Neurologic exam of the affected extremity (motor and sensory)
  • Vascular exam of the affected extremity (femoral/popliteal/posterior tibialis/dorsalis pedis)
  • Musculoskeletal exam including ranging the hip, knee, ankle and palpating throughout the entire leg
  • Skin exam for signs of injury or rashes etc.
  • Consider a cardiopulmonary and abdominal exam, particularly the lower abdomen

On this patient’s exam, he was overall uncomfortable appearing and had slight tachycardia (110s, EKG shows normal sinus rhythm), normal cardiopulmonary exam, normal abdominal exam. He had a 2+ right femoral pulse and faintly palpable DP pulse that had a good biphasic waveform on doppler. His hip/knee/ankle all have painless range of motion. The compartments are soft in the upper and lower leg. He does have some diffuse calf tenderness and the medial aspect feels slightly cool compared to the contralateral side, but his foot is warm and well perfused. There isn’t any spot that is most tender. There is no rash, no crepitus, no bullae or bruising or other evidence of injury.

What diagnostic studies would you like to send?

  • CBC, BMP
  • CPK, lactate
  • DVT ultrasound?
  • Anything else?

What treatments would you like to provide?

  • Analgesia (mutli-modal)?
  • Maybe a bolus of IV fluids to help with the tachycardia?

The patient is having a lot of pain despite already getting NSAIDs, acetaminophen, and a dose of morphine. You decide to re-medicate the patient with more morphine and send him for DVT ultrasound. As soon as he gets back, he’s frustrated that you still haven’t treated his pain “at all” and he really does look uncomfortable and in a lot of pain.  You start to wonder if he’s faking it giving his history of IV drug use.

His DVT ultrasound comes back as normal. The lab work is also coming back and unrevealing. A normal CBC, metabolic panel, normal CPK, normal lactate. His pain is not really improving. You reexamine the leg, and the exam is unchanged. It really seems like his pain is out of proportion to the exam.

Pain is out of proportion to the exam should catch your attention every time. While we always need to keep malingering and less emergent causes for pain that seems to be more than expected in the back of our minds. But! Several emergent diagnoses have patients presenting in pain in a way that doesn’t fit what you can objectively identify as a cause. Diagnoses like compartment syndrome and mesenteric ischemia can be erroneously dismissed by emergency providers, and it is crucial you don’t just stop looking for the cause of pain out of proportion. In fact, it’s important you dig in deeper and rule out all potentially life and limb threatening causes.

In this case, the pain was recalcitrant to multiple doses of IV opiates and several other modes of treatment. The patient was getting so frustrated that he pulled out his IV and threatened to leave the ED. After talking with him further, he agreed to stay and a new IV was placed, more pain medication given, and a CTA with lower extremity run-off was performed, which showed the acute thrombus of the proximal popliteal artery, just below the level of the knee.

He was started on a heparin infusion and vascular surgery was consulted; the patient was admitted from the ED and taken for thrombectomy. No source of embolism was identified, and his occlusion was presumed to be thrombotic (most commonly from a ruptured atheromatous plaque leading to activation of the coagulation cascade), with particular attention to his history of diabetes and hypertension raising his risk for this. He had a fair amount of collateralization from other arteries around the occlusion, such that his foot wasn’t cold, and he had a doppler-able DP pulse. 

Remember

Go with your gut and don’t minimize pain that is out of proportion to the exam. Keep hunting for a reasonable explanation or you may miss a life or limb threatening cause of an atypical emergency presentation.

Further Reading

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 »

Acute Mesenteric Ischemia

by Rabind Antony Charles Case Presentation A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with

Read More »

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »
Cite this article as: J. Austin Lee, USA, "Out of Proportion: Acute Leg Pain," in International Emergency Medicine Education Project, October 18, 2021, https://iem-student.org/2021/10/18/acute-leg-pain/, date accessed: October 18, 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.

Want More on ED shift work?

what you should know before your first ED shift
iEM Education Project Team

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

Read More »
sleep and shiftwork
Brenda Varriano, Canada

The emergency department is open 24/7, meaning that most ED physicians experience shift work. Shift work means that service is provided around the clock, whether

Read More »
Things You Should Know Before Your First ED Shift
Ibrahim Sarbay, Turkey

I recently posted a question to the Twitterverse: “Imagine that an Emergency Medicine intern asked you for advice before his/her FIRST SHIFT. What would be

Read More »

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 18, 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 18, 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 18, 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.

Want More on Wellness?

things you should know about wellness and emergency medicine
iEM Education Project Team

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

Read More »
Coping with an Emotional Crisis
Sheza Qayyum, Canada

In the ED, we often see patients presenting amid an emotional crisis – whether it’s a panic attack, or a period of extreme anxiety or

Read More »
Who Takes Care of You While You Take Care of Others
Arthur Martins, Brasil

The COVID-19 Pandemic has changed our lives in so many ways that sometimes it is difficult to remember how life was without all these changes.

Read More »
Why Me? The Story of My Burnout - Part 3
Jule Santos, Brasil

The story continues from link (Part 2). I must take a deep breath. I must ask for help. The Self-Knowledge Path I could go away

Read More »
Why Me? The Story of My Burnout - Part 2
Jule Santos, Brasil

The story continues from link (Part 1) I had already been tired and sad. Now, I was also feeling wronged. The Dangers of Burnout It meant

Read More »
why me - the story of my burnout
Jule Santos, Brasil

This story starts like almost every other: I fell in love. The thing is, I LOVE heart attacks! I know this is a weird statement,

Read More »
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 18, 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 18, 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 18, 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 18, 2021

The State of Emergency Medicine in Ecuador

Ecuador is fast approaching its 30th anniversary of recognizing emergency medicine as a specialty. Within these three short decades, the country has achieved significant milestones in advancing the field of emergency medicine, including the development of a national EM society and implementation of post-graduate training programs. However, there is still much work to be done.  I was lucky enough to have a conversation with the ACEP Liaison to Ecuador, Augusto Maldonado, to learn of recent advancements of emergency medicine in the country. 

“Igual que todos los países del mundo, el rol los que responden inicialmente y la organización de los servicios de emergencia frente a esta emergencia de salud ha sido muy especial.”

The COVID-19 pandemic certainly affected the specialty in the scope of medical practice, as well as highlighted some of the limitations of the medical system that were already present. Following the global trend, emergency care providers came to the forefront of medical attention with the manifestation of the pandemic. Dr. AM says that many emergency departments were forced to adapt in the face of the pandemic, as some hospitals became designated ‘COVID hospitals’ requiring emergency departments to coordinate care for the remaining patients. For example, some emergency physicians suddenly found themselves providing postoperative care when patients would be transferred directly from surgery back to the emergency department. In other places, emergency departments were transformed into intensive care units, staffed by emergency physicians. Dr. AM explains that the COVID-19 pandemic has given the specialty the push it needs, stating “ . . regarding the issue of the pandemic, it really has given us a very big boost as a specialty and I believe that to the authorities it is now very clear the importance of emergency medicine as a specialty to face this type of complex situation”. 
This increased visibility of the specialty is mirrored by the substantial popularity of the country’s national emergency medicine society, Sociedad Ecuatoriana de Medicina de Emergencias, which has increased in number by over 500%! 
The country has also seen an increase in the number of residency training programs over the last year.  In addition to the two already running in Quito, a third and fourth have been established in the city of Cuenca, and a fifth is set to open in Guayaquil. Furthermore, a critical care fellowship is in the works at Universidad San Francisco de Quito. This project stems from a recent study which identified a high demand for a critical care fellowship in Ecuador. 
A distribution of the five emergency medicine residency programs found in Ecuador
The impact of COVID on trainees’ education has, thankfully, not been substantial. Unfortunately, the pandemic did result in residents not being recruited to the Quito programs for 2020, but the programs in Cuenca did start a new class of trainees last year. As with many training institutions across the world, the residents were initially barred by the health authorities from treating COVID patients. However, the creation of ‘COVID’ and ‘mixed’ hospitals has resulted in an increased workload for residents serving the non-COVID population – “I believe that the residents have more work than before . . . and have more procedures because of the overhang generated by the creation of ‘mixed’ hospitals. There’s a lot to do.” He states that residents are on-track for completion of their programs, with ample procedures logged to graduate.
Another aspect of residency training is the required completion of a scholarly project. Research has been slowed across the country as a result of the pandemic. Interest in COVID investigations sparked the Ministry of Health to establish an ADHOC committee explicitly tasked with expediting the review of research proposals. The committee was mandated to review proposals within five days of submission, but in reality, approvals are taking upwards of three to four months. La Universidad San Francisco de Quito explored this roadblock and revealed that some twenty studies had been published through alternative review processes due to the lengthy process of gaining official approval. Dr. AM views COVID as a potential kick-start for encouraging providers to do research, saying “I see it as a great opportunity to better focus [on] research, which is one of the things that we have been looking to do for a long time . . . with the pandemic, [we see] the importance of doing clinical research [in being] able to give adequate treatment to our patients.” 

Looking forward, Dr. AM says that there are many remaining opportunities for growth in the field of emergency medicine, much of which he hopes can be better addressed once the economic situation in Ecuador recovers. He says there is much desire for innovation within the field, but many EM providers are having to work two to three jobs to have a sufficient income to live, leaving little time for research, teaching, or collaboration. There are many lessons to be learned world-wide from the pandemic, but Dr. AM says that in order to address future issues international cooperation is key.

Cite this article as: Global EM Student Leadership Program, "The State of Emergency Medicine in Ecuador," in International Emergency Medicine Education Project, September 18, 2021, https://iem-student.org/2021/09/18/the-state-of-emergency-medicine-in-ecuador/, date accessed: October 18, 2021
Halley J. Alberts, MD
Halley J. Alberts, MD

Halley is a first year resident training in Emergency Medicine at Prisma Health - Midlands at the University of South Carolina. She was a GEMS LP mentee for the class of 20-21 and has now joined the leadership team by managing the new GEMS LP blog page and assisting with journal club.

Welcome from GEMS LP!

Hello and welcome to the first blog post from ACEP’s International Section’s Global Emergency Medicine Student Leadership Program. We are thrilled to partner with iEM in the hosting of this blog, and we thank them for their collaboration and enthusiasm.

Global EM is a young, quickly growing field in the world of health care, but there remains much work to be done. The GEMS LP program was designed to involve students in this exciting and fulfilling specialty. The program itself falls under ACEP’s International Section in conjunction with the International Ambassador Program. All of these entities share a common goal: the advancement of the emergency medicine specialty worldwide.

Through this blog, we hope to educate, inspire, update, and collaborate on all things global EM.  Every couple of weeks, you can expect to read the ‘key points’  from our journal clubs. In each meeting, we review fundamental global health topics through a book chapter and a research paper, followed by a dynamic discussion with a diverse group ranging from medical students to attendings, working both in the US and abroad. Additionally, you can look forward to interviews with some of ACEP’s International Ambassador team members, interesting case discussions, GEMS LP project highlights and other fun commentaries from our mentees and team! 

We look forward to providing you relevant content that will encourage discussion, contemplation, and promotion of the field of global emergency medicine. Thank you for joining us on this new adventure! Please visit our page (https://iem-student.org/gems-lp/) for more information about our leadership team, awesome mentors, and upcoming events and meetings. 

Comments, suggestions, additions? Please reach out to us!

Cite this article as: Global EM Student Leadership Program, "Welcome from GEMS LP!," in International Emergency Medicine Education Project, September 16, 2021, https://iem-student.org/2021/09/16/welcome-from-gems-lp/, date accessed: October 18, 2021

Acute Atrial Fibrillation in the ED: Almost all goes home

Atrial fibrillation (AF) is the most common dysrhythmia presenting to ED. The management options depend on patient stability, presence of underlying causes and factors in the patient history. In stable patients presenting in AF with a rapid ventricular response, both rate and rhythm control are acceptable approaches. Physicians often tend toward rate control because evidence has shown no mortality benefit between the two approaches. The Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial contributed to this trend when it concluded no survival advantage and higher risk of adverse drug effects with rhythm control. However, rhythm control is the preferred approach for the management of acute stable AF in Canadian guidelines. The advantages are a higher rate of symptom resolution, restoration of sinus rhythm and avoiding the need for rate control prescriptions, decreased ED length of stay, and hospital admissions.

In the electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2) trial, it was found that both drug–shock and shock-only strategies were effective, rapid, and safe with 96% of patients discharged home in sinus rhythm. The drug infusion worked for 50% of patients avoiding procedural sedation.

The evidence that supports the management of acute AF in the ED without hospital admission is increasing. Implementing practices to achieve that will markedly decrease the burden on the health care system.

ED Management

Approach of Atrial fibrillation

AF might be secondary to variable causes, including ACS, Heart failure, PE, sepsis and bleeding. In patients with secondary AF, cardioversion might be harmful, and the mainstay of treatment is tackling the underlying cause. Those patients will require hospital admission. For primary AF, if the patient is unstable, electrical cardioversion should be done without delay. Stable primary AF may be managed with rate or rhythm control.

Rate control can be achieved with the following:

CCB: Diltiazim 0.25 mg/kg over ten mins, repeat q15-20 mins, up to three doses (avoid in heart failure)

BB: Metoprolol 2.5-5 mg q15-20 mins

Digoxin: 0.25-0.5 mg loading dose then 0.25 mg q4-6 hs (if hypotension or acute HF occur)

Target is HR <100 at rest or <110 walking

Rhythm control is safe with the following according to The CAEP AF best practice guidelines:

  1. Anticoagulated for three or more weeks.
  2. No valvular heart disease, prior stroke or TIA plus: 
  • Onset in 12 hours or less
  • Onset more than 12 hours but less than 48 hours plus less than two of :
    • Age less than 65, DM, HTN, HF.
  • Cleared by TOE

Methods:

  • Procainamide 15mg/kg in 500 ml of NS over an hour.

Other agents: Amiodarone, Ibutilide, flecainide, etc.

  • Electrical: 150-200 J synchronized. Requires sedation.

Anticoagulation:

If CHADS positive then discharge on DOAC or Warfarin.

Disposition:

Almost all patients can be discharged home after cardioversion or effective rate control with appropriate follow up: within a week if warfarin or rate control agent prescribed, otherwise in 4 weeks.

Patients will require admission if one of the following:

  • Highly symptomatic after treatment.
  • ACS
  • Acute heart failure not improved in the ED

References and Further Reading

  1. Stiell, I. G., Macle, L., & CCS Atrial Fibrillation Guidelines Committee (2011). Canadian Cardiovascular Society atrial fibrillation guidelines 2010: management of recent-onset atrial fibrillation and flutter in the emergency department. The Canadian journal of cardiology27(1), 38–46. https://doi.org/10.1016/j.cjca.2010.11.014
  2. Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J., Rosenberg, Y., Schron, E. B., Kellen, J. C., Greene, H. L., Mickel, M. C., Dalquist, J. E., Corley, S. D., & Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) Investigators (2002). A comparison of rate control and rhythm control in patients with atrial fibrillation. The New England journal of medicine347(23), 1825–1833. https://doi.org/10.1056/NEJMoa021328
  3. Baymon, D. E., & Baugh, C. E. (2020). Patients with Atrial Fibrillation in the Emergency Department: Strategies to Achieve Best Outcomes. https://www.hmpgloballearningnetwork.com/site/eplab/patients-atrial-fibrillation-emergency-department-strategies-achieve-best-outcomes
  4. Martín, A., Coll-Vinent, B., Suero, C., Fernández-Simón, A., Sánchez, J., Varona, M., Cancio, M., Sánchez, S., Carbajosa, J., Malagón, F., Montull, E., Del Arco, C., & HERMES-AF investigators (2019). Benefits of Rhythm Control and Rate Control in Recent-onset Atrial Fibrillation: The HERMES-AF Study. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine26(9), 1034–1043. https://doi.org/10.1111/acem.13703
  5. Stiell, I. G., Sivilotti, M., Taljaard, M., Birnie, D., Vadeboncoeur, A., Hohl, C. M., McRae, A. D., Rowe, B. H., Brison, R. J., Thiruganasambandamoorthy, V., Macle, L., Borgundvaag, B., Morris, J., Mercier, E., Clement, C. M., Brinkhurst, J., Sheehan, C., Brown, E., Nemnom, M. J., Wells, G. A., … Perry, J. J. (2020). Electrical versus pharmacological cardioversion for emergency department patients with acute atrial fibrillation (RAFF2): a partial factorial randomised trial. Lancet (London, England)395(10221), 339–349. https://doi.org/10.1016/S0140-6736(19)32994-0
  6. Ian G. Stiell, et al. (2021). 2021 CAEP Acute Atrial Fibrillation/Flutter Best Practices Checklist.https://caep.ca/wp-content/uploads/2021/06/2021-CAEP-AAF-Checklist-FINAL-6-June-2021.pdf
Cite this article as: Israa M Salih, UAE, "Acute Atrial Fibrillation in the ED: Almost all goes home," in International Emergency Medicine Education Project, September 13, 2021, https://iem-student.org/2021/09/13/acute-atrial-fibrillation-in-the-ed-almost-all-goes-home/, date accessed: October 18, 2021