Question Of The Day #20

question of the day
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


Cite this article as: Joseph Ciano, USA, "Question Of The Day #20," in International Emergency Medicine Education Project, November 6, 2020,, date accessed: February 25, 2021

Question Of The Day #19

question of the day
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.


Cite this article as: Joseph Ciano, USA, "Question Of The Day #19," in International Emergency Medicine Education Project, October 30, 2020,, date accessed: February 25, 2021

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Question Of The Day #11

question of the day
qod 11

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

IV antihypertensives and CT surgery consultation (Choice A) would be the best treatment for a patient with aortic dissection. This diagnosis is characterized by severe tearing chest pain that radiates to the back, along with hypertension. Risk factors include tobacco smoking, uncontrolled hypertension, trauma (i.e. rapid deceleration), and connective tissue diseases (i.e. Marfan syndrome). Other than chest pain with radiation to the back, this patient lacks the other risk factors for aortic dissection, making Choice A less likely. IV heparin (Choice B) would be the correct choice for the treatment of pulmonary embolism and acute coronary syndrome (i.e. NSTEMI). Both of these diagnoses are possible, but a chest CT scan with PO water-soluble contrast is not the gold standard for diagnosing PE or ACS. A CT Pulmonary angiogram is ideal for PE diagnosis, and an EKG along with troponin levels are ideal for ACS diagnosis. Pericardiocentesis (Choice C) is the treatment for cardiac tamponade. The patient’s vitals show no evidence of obstructive shock, and there is no history of penetrating chest trauma, pericardial effusion, end-stage renal disease, HIV, lupus, cancer, or other risk factors for cardiac tamponade. Choice D outlines the best course of action to take in a patient with esophageal rupture, which is the disease described in the question stem. This condition can occur spontaneously after forceful vomiting causing high pressures in the esophagus (Boerhaave syndrome). In this situation, the chest pain typically begins after the onset of vomiting. Other etiologies of esophageal rupture include deceleration injuries and penetrating trauma (i.e. gunshot wounds, iatrogenic via esophagogastroduodenoscopy (EGD)). A “Hamman’s Crunch”, subcutaneous emphysema, fever, and signs of shock can be seen on exam. Diagnosis is confirmed by an esophagram or a CT scan of the chest with water-soluble oral contrast (i.e. Gastrograffin). Esophageal rupture is a life-threatening diagnosis as esophageal contents can spill into the mediastinum, causing mediastinitis and septic shock. The treatment is typically surgical with the repair of the perforated segment and drainage of fluid collections. Correct Answer: D  


Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 17, 2020.

Nickson, C. (2019) Oesophageal Perforation. Life in the Fast Lane. Accessed August 17, 2020.

Cite this article as: Joseph Ciano, USA, "Question Of The Day #11," in International Emergency Medicine Education Project, September 4, 2020,, date accessed: February 25, 2021

Mnemonic for Right Lower Quadrant Pain

17 years old girl, previously known healthy, vomited blood!

720 - variceal bleeding

17 years old girl, previously known healthy, vomited blood!
This is an extremely serious symptom. Although this patient’s vitals were totally in the normal range, actively vomiting blood should warn physicians to act immediately to protect further deterioration in the patient. This may even include early airway protection because we simply do not want them to aspirate any blood. Having a normal vitals with this picture does not mean anything, and should not create a relaxing environment in the treatment/resuscitation bay. Honestly, this patient should go directly to resuscitation bed from the triage.

Steps are straightforward. Protect the airway if necessary, start oxygen like in any other critically ill patient during/for primary evaluation(survey). Open the two large bore IV line, give fluid bolus, order type, and cross, and be ready for any deterioration in the BP and starting blood (ORh-). Obviously, even starting a transfusion earlier may be appropriate. Activating GI team for emergency endoscopy is necessary. However, some institutions may not have this luxury 24 hours. Therefore, other measures such as mechanical compressions with Sengstaken-Blakemore tube and some medications can be an only option. This patients final diagnosis was Variceal Bleeding. 

To learn more about management please read two GI bleeding chapters below.

Massive Gastrointestinal Bleeding by Dan O’Brien

Gastrointestinal Bleeding by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley

Swallowed Coin

In case you didn’t encounter a 6-year-old patient who swallowed a coin today!

696 - Foreign body ingestion

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!

From Experts To Our Students! – GIB

From Experts To Our Students! – Clinical Decision Tools

Clinical Decision Rules chapter written by Stacey Chamberlain from USA is just uploaded to the Website!

How to insert NG

Nasogastric Tube Placement chapter written by Sara Nikolic and Gregor Prosen from Slovenia is just uploaded to the Website!

24 - NG tube location

RUQ pain

In case you didn’t encounter RUQ pain today!

251 - Gallbladder stone with thickened wall

Sonographic criteria for acute cholecystitis

the presence of gallstones,
thickened gallbladder wall,
pericholecystic fluid,
sonographic Murphy’s sign,
common duct dilatation.

How many did you see in the ultrasound image except sonographic Murphy’s sign? Feel free to give your answers to comment section at the bottom of the page.

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!

Selected Gastrointestinal Emergencies

Gastrointestinal 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.

Acute Appendicitis

by Ozlem Dikme Introduction About 7% of the population develops appendicitis in their lives. Males are affected 1.4 times higher than females, and teenagers more

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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

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Biliary Disease

by Dan O’Brien Introduction The biliary system can be defined as the organs and ducts that create, transport and store bile and eventually release it

Read More »

Massive Gastrointestinal Bleeding

by Dan O’Brien Introduction Despite advances in diagnosis prevention and treatment, nonvariceal upper gastrointestinal bleeding is still a serious problem in clinical practice. The incidence

Read More »

Perforated Viscus

by Ozlem Dikme – Turkey Case Presentation A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal

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Do you need more?

A 35-year-old female with abdominal discomfort

A New Chapter Is Just Uploaded To The Website!

A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria.
Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.

Her temperature is 37ºC, blood pressure: 110 / 70 mm Hg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder which called positive Murphy’s sign. Rectal exam normal, stool is hemoccult negative for blood.

Pertinent lab values: glucose 110 mg/dL, alkaline phosphatase 120 U/L, alanine aminotransferase (A.L.T.) 25 U/L, aspartate aminotransferase (A.S.T.) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.

The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.

57 - Gallstones

An I.V. was established, and the patient received an isotonic fluid bolus. In addition, ketorolac 30 mg I.V. and ondansetron 4 mg I.V. were administered.
Over the course of an hour symptoms resolved. Absent evidence of gallbladder inflammation or infection, she was discharged from the emergency department and referred to a general surgeon for elective cholecystectomy. She was advised that her pain might return but if it is prolonged, is associated with fever or jaundice she is to return to the emergency department.

by Dan O'Brien from USA.