Author: Yenis Paez-Perez

Emergency Medicine Symposium – Seventh Annual St. Joseph�s Regional Medical Center

Resident: D’Amore/Clayton

CC: “My heart is racing.”

HPI: 26 year old male with no past medical history presents to the Emergency Room with complaints of palpitations. Patient states that while exercising at the gym just prior to arrival, he suddenly developed palpitations along with associated lightheadedness. He reported one similar episode in the past that self-remitted. He denies chest pain, shortness of breath, nausea or vomiting but was experiencing intermittent lightheadedness. He denies taking any medication prior to arrival. Patient states he drinks ETOH infrequently with his last drink several days ago. He denies tobacco or illicit drug use. Patient also denies any family history of heart disease or arrhythmias.

Physical Exam:
Vitals: HR: 221 BP: 117/74 RR: 20 T: 98.8 Pulse Ox 100% on Room Air
General: Patient is awake, appears uncomfortable
Respiratory: No respiratory distress. Lungs are clear to auscultation.
Cardiovascular: +S1/+S2, tachycardic, irregular. No murmurs, rubs or gallops.
Abdomen: Soft, non-tender, non-distended
Extremities: Palpable, rapid pulses. No cyanosis, clubbing, or edema.
Neurological: Alert and oriented to person, place, time, and situation, following all commands, strength and sensation intact and equal bilaterally.

Laboratory Data:
Lab work and radiography including troponins, complete blood count, complete metabolic panel, thyroid stimulating hormone, chest x-ray, and urine drug screen were all within normal limits. Image 1 is the EKG on presentation. The patient quickly became hypotensive 90/52 and complained of lightheadedness. The patient was quickly sedated and cardioverted with 150 joules. He returned to sinus rhythm at which time the underlying conduction was more apparent.

Questions

1. What EKG abnormalities do you notice?
2. EMS requests permission to administer 6mg of Adenosine to treat the arrhythmia.

What is your recommended treatment plan?

Answers:

1. This EKG demonstrates Wolff-Parkinson-White Syndrome with Atrial Fibrillation.
2. Advise EMS not to treat with Adenosine or other A-V nodal blocking agents as this may precipitate ventricular tachycardia or ventricular fibrillation.

Discussion:

Wolff-Parkinson-White Syndrome is a pre-excitation syndrome where myogenic bundles known as the Bundles of Kent directly link the atria to the ventricles, bypassing the atrioventricular (AV) node and the organized infranodal system [source: Tintinalli]. Atrial Fibrillation (AFib) in Wolff-Parkinson-White Syndrome (WPW) is a presentation of this syndrome in up to 20% of cases.

Features include an irregularly irregular rhythm, very rapid ventricular rates often in the range of 250 to 300, and widened QRS complexes that differ in duration and morphology from one to the next.The accessory pathway present in patients with WPW allow for the multitude of additional ectopic atrial impulses present in AFib to bypass the AV node and conduct to the ventricles, accounting for the unusually rapid ventricular rates. The variation in QRS duration and morphology can also be attributed to simultaneous conduction through the traditional AV node-His-Purkinje pathway as well as the Bundle of Kent-Ventricle route.

WPW with AFib is often misdiagnosed as a supraventricular tachycardia (SVT), ventricular tachycardia (VT) or atrial fibrillation with a bundle branch block, all of which can be safely treated with AV nodal blockers such as Adenosine, Diltiazem, and Amiodarone. WPW in the presence of atrial fibrillation makes degeneration into ventricular fibrillation more likely and thus synchronized cardioversion, delivering 0.5 – 2 Joules/kilogram, is the first-line treatment. Second-line treatments include Procainamide or Ibutilide whose mechanism prolongs the refractory period of the accessory pathway and whose dosing is weight-based. Stable WPW in the presence of narrow-complex SVT can be treated with the traditional vagal maneuvers, adenosine, and calcium channel- or betablockers [source: Tintinalli]. Patients with WPW should undergo ablation as this syndrome can lead to sudden cardiac death by means of ventricular fibrillation.

Take Home Pearls:

• Wolff-Parkinson-White with Atrial Fibrillation presents as an irregularly irregular tachycardia with widened QRS complexes that vary in morphology and result in ventricular rates often greater than 250.

• If the QRS complex is widened, avoid use of any AV nodal blockers as they can precipitated ventricular arrhythmias.

• Procainamide and synchronized Cardioversion are the treatment of choice for WPW with AFib.

CC: Hand Injury-Job Related

HPI: 35 yo otherwise healthy male presents to the Emergency Dept. (ED) with a laceration over the palmar surface of the left hand, proximal to the PIP joint and extending over the MCP joints of the 4^th and 5^th digit. He sustained this injury at work one hour ago. He is a firefighter and was responding to a house fire when he accidently tripped over an object in a smoke filled room while putting on his glove. He states his left hand went through a glass door. At the scene, patient washed it out with sterile saline and a dressing was applied. Pt also complaints of decreased sensation to the distal aspect of his left 5^th digit. He denies any other trauma, preceding symptoms of chest pain, dizziness, feeling lightheaded, palpitations, inhalation injury or difficulty breathing. Denies head injury, neck pain or LOC. Last tetanus is unknown.

Physical Exam:

Vitals: BP 155/97   Pulse 97   RR 15     T 98.6F   SpO2 100% on RA
MSK/extremities: 2.5cm complex “V” shaped laceration over the palmar MCP of the left 5th digit that is oozing blood; no arterial bleeding noted. Tissue flap noted. 1.5 cm laceration over the left palmar aspect of the 4th digit between the MCP and PIP joint. Hemostasis noted. Small tissue flap noted. Sensation intact over the distal left 4th digit; Sensation mildly decreased over the distal left 5th digit. Cap refill brisk both digits. Pt is able to flex and extend both digits.

Location of laceration

:

Pertinent Labs (if any): N/A
Pertinent Imaging/EKG: No displaced fracture or dislocation. No radiopaque foreign body is identified.

Working Diagnosis: Prior to x-rays: possible FB, dislocation/subluxation, fracture. Possible Partial flexor tendon laceration.

 ED/Hospital course: Pt received Toradol for pain and a tetanus shot

• Digital block was performed on the 4th and 5th digits of the left hand by injecting lidocaine into the web spaces as well as local was performed on the palm where the digital block was ineffective.
• Moderate bleeding/oozing noted of the 5th left finger laceration. Upon lifting the tissue flap of the 5th digit the flexor tendon was exposed but not lacerated. The 4th left digit wound more superficial. No tendon exposed. No FB found in either laceration.
• 4th finger closed w/ six 4-0 Ethilon sutures
• 5th finger closed w/ ten 4-0 Ethilon sutures
• Pt discharged w/ Rx for: Bacitracin Ibuprofen Keflex F/u w/ employee health F/u in 7-10 days for suture removal

 Pearls & Takeaways:

• For lacerations to the hand or other injuries that may or may not involve a tendon always ask:
  • Position of hand injury?
  • Crush, burn, injection, chemical injury?
  • Other trauma or preceding symptoms?
• Exam for hand/wrist lacerations
  • Check and compare Bilateral grip strength
  • Check sensation
    • Compare bilaterally with 2 point discrimination to the volar aspect of each fingertip
    • Normal 2 point discrimination on the hand is 5-6 mm
    • Review of nerve distribution :
    • 
  • Check Motor function
    • Ask them to make a clenched fist— The middle and distal phalanges should all be parallel to each other with the nails positioned in the same plane and pointing toward the Scaphoid when fist is clenched
    • Ulnar Nerve innervates the Lumbricals and Adductor Pollices Muscles
      • Lumbricals: Have patient abduct their fingers and have them resist the force of you pushing their fingers back to midline
      • Adductor Pollices Test: Have patient hold a piece of paper with the volar pulp of the thumb and PIP of index finger. If you pull away at the paper, and pt is able to maintain the key pinch of paper against resistance then adductor pollicis is strong.
        • Look for Froment’s Sign ( Flexes IP joint of thumb to compensate for weak Adductor Pollices)
        • https://www.youtube.com/watch?v=yJTIhm1VfSI

• Median Nerve
  • Make the “OK” Sign (Flexor Pollicus Longus)
  • Opposition (Thenar Muscles): As them to touch their pinky with their thumb
  • Ask pt to abduct their thumb with palm up and have the pt resist a force to redirect the thumb toward the palm (Abductor Pollicis longus)
• Radial Nerve
  • With palm on the table, hyperextend all fingers against resistance from can have them lay their palm flat on a table, and lift each digit straight up and extend up from the table while keeping the palm flat
• Vascular
  • Check for capillary refill and pulses
• Flexor Tendor Testing
  • 90% of the tendon can be severed/lacerated with preservation of ROM without RESISTANCE.
  • Apply resistance when testing for tendon function
  • Pain along course of tendon during resistance testing suggest partial laceration even if pt has FULL ROM
  • Test for Flexor Digitalis Profundus (FDP): Ask the to flex their DIP joint against resistance while holding their MCP and PIP joint in extension
  • Test for Flexor Digitalis Superficialis (FDS): Ask to flex their PIP joint against resistance while ALL the rest of the fingers are held in full extension (Hyperextension disengages FDP and the FDS function is isolated).
  • 
• Imaging
  • If isolated fingers involved, get a AP, oblique and lateral view of the designated finger as well as the hand
• Digital Blocks
  • Web Space– Inject 1-3 mL of Anesthetic
  • 
  • 
  • Transthecal
    • Inject into flexor Tendon sheath
    • ID distal palmar crease and tendon
    • Insert needle at 45 degrees just distal to crease
    • Inject
    • If resistance, withdraw slightly
    • Apply proximal pressure
    • Pros: Only 1 poke and numbs entire finger
    • Cons: It’s over most sensitive part of the hand
    • 
  • Method to get a bloodless field
    • Use tourniquet or Penrose drain at base of finger secured by hemostat
    • Use another tourniquet or gauze to wrap around distal end of finger and wrap w/ moderate compression down from most distal part to laceration milking out the blood in the distal finger
    • Do not leave tourniquet on for >20 minutes
  • What If there is a stellate laceration?
    • Great video on the corner stitch! Try it next time!
    • https://lacerationrepair.com/techniques/basic-suturing-techniques/the-corner-stitch/
  • When to refer tendon lacerations:
    • 
  • Splinting tendon Injuries:
    • General rule is to splint in the direction of function
      • Extensor tendons splinted in extension
      • Flexor tendons splinted in flexion
    • Flexor Tendon Injuries specifically:
      • Dorsal splint
      • Wrist flexed to 30 degrees
      • 70 degree MCP flexion
      • 30-45 degree PIP flexion
      • 
    • Antibiotics
      • NO Great guidelines
      • ACEP Clinical guidelines
        • Looks ok-à No ABX
        • Looks bad-à ABX
      • If simple laceration -à no ABX
      • If not simple (contaminated, infected, bone, tendon, joint involvement)-à ABX
        • 1^st line: Cephalosporin
        • Consider Context:
          • Human, Cat, Dog Bites: Amoxicilin/Clavulanic Acid (Augmentin)
          • Open fractures: Cefazolin (Ancef)
          • Visibly dirty and open wound: Ancef + Gentamycin

Case presented by Dr. Jessica Williams

Scavenger Hunt in Hoboken ! 

CC: Shortness of breath

HPI: 7 day old female presents to the Emergency Dept. (ED) after being seen earlier in clinic. Mother is rom Nigeria and arrived to the U.S a few weeks prior to delivery. Prenatal care is unclear. Patient was delivered via C-Section at 39 weeks at another nearby hospital. Both mother and baby spent one day in the hospital after delivery being discharged home. Mother states that since last night, the baby appears to “ not breathing right.” She also hasn’t’ been eating much and is crying more often than usual, during which her lips start to turn blue.

Physical Exam:
Obvious respiratory distress, hypoxic on RA, saturating in the middle to low 80’s on NC 3 L
HR 176,   RR 60.    Accuchek 96.
BP: (RA) 69/45    BP (LA) 91/64     BP (LL) 84/64     BP (RL) 71/58

Pertinent Imaging/ECG

ECG in the ED:

Working Diagnosis: Shock secondary to congenital cardiac pathology.

ED/Hospital course:  Patient was admitted to PICU, underwent Echocardiogram and further imaging and was diagnosed with Coarctation of the Aorta. The patient was transferred to Mt. Sinai for operative repair.

Pearls:

• 7 day olds are terrifying, especially if they are sick.
• Take a breath! Start with your ABCs.
• Coarctation of Aorta(CoA) is a congenital aortic narrowing which most commonly occurs at the level of ductus arteriosis. There are Pre-ductal and Post-ductal types. Pre-Ductal CoA is a Truncus dependent lesion and most patients present within 2 weeks of birth once duct closes. Aortic narrowing leads to increased LV function and dilation. Post-ductal are commonly identified in adulthood.
• Obtain a BP/pulse Ox in all 4 extremities
• Perform the Hyperoxia test
  • Obtain ABG on RA. Then, apply 100% supplemental oxygen with a NRB for 10-15 minutes. Repeat the ABG on the NRB.
    • On repeat ABG
      If PaO2 > 250mmHg = Lung problem
      If PaO2 < 100mmHg = Congenital Heart Disease
      If PaO2 100-250: Assume the worst situation first
• You may also apply supplemental oxygen and assess the infant’s response. If saturation increases to at least 5-10%, it’s most likely a Lung problem. If it remains the same, think about Congenital Heart Disease
• Prostaglandin (pt is less than 4 weeks old typically 1-2 weeks of life) start at 0.05 mcg/kg/min.
• Dr. Hochman rule #11, call consultants early “don’t be the captain of a sinking ship”
• Additional medications: Lasix 1 mg/kg if evidence of volume overload.Ductal dependent lesions, pulmonary presentation cyanosis/hypoxia use phenylephrine . If systemic SX, shock, pulmonary congestion on CXR Milrinone (decrease afterload + inotropic support).

The SICK NEONATE!

Case presented by Dr. Daniel Poor

 3-year-old boy presents to the ED with a 4-day history of cough and 1-day history of fever. Per family patient has been having rigors and chills with vomiting. He also reports chest pain with coughing. His immunizations are UTD. The child does not appear toxic,

VS: Temp 103.3F,  BP 90/65,  HR 100,  RR 30,  96% O2 Saturation on RA.
Patient has some intercostal retractions, with decreased air entry on the right side with audible crackles.

Questions for EM physician

• How do you make the diagnosis of pneumonia?
• Distinguishing patients with bacterial pneumonia, who would benefit from antibiotics, from those with nonbacterial pneumonia who would not.
• Who requires inpatient management vs. patients that can be safely discharged home on oral antibiotics.
• Pneumonia is the number 1 killer of children worldwide.
• Pneumonia occurs more often in early childhood than at any other age and causes significant morbidity and mortality.
• Identifying the cause of pneumonia in children is difficult due to a lack of rapid, accurate, commercially available laboratory tests for most pathogens. Empirical therapy based on patient’s age, clinical scenario and risk factor is the most common course in most cases.

Diagnosis of pneumonia:

• • Definition: Essentially it is infection of lower respiratory tract in the presence of radiographic abnormalities on CXR.
  • WHO guidelines for pneumonia in children is cough and tachypnea
    • Age < 2 months: Tachypnea is >60 RR
    • Age 2 months to 5 months: Tachypnea is >50 RR
    • Age >12 months: Tachypnea is > 40 RR

• • Clinical features
    • Fever and tachypnea are sensitive but not specific
    • Cough
    • Productive cough is rarely seen before late childhood
    • Consider pneumonia in any child presenting with prolonged fever, prolonged cough, high fever, as well as focal respiratory findings not including wheezing, especially with the presence of multiple symptoms.

Evaluation
Absence of tachypnea, respiratory distress, and rales/decreased breath sound rules-out pneumonia with 100% sensitivity

• CXR: Cannot differentiate between viral and bacterial (but lobar infiltrate more often bacterial)
  • • Consider for:
      • Age 0-3mo (as part of sepsis work up)
      • <5yr with temperature >102.2, WBC >20K and no clear source of infection
      • Ambiguous clinical findings
      • Pneumonia that is prolonged or not responsive to antibiotics
  • Consider RSV, Influenza 

Treatment

Disposition

• Consider Admission For
  • Age: <2-3 months old (Consider up to 6 months)
  • History of severe or relevant congenital disorders (Cystic fibrosis)
  • Suspected complication (Empyema)
  • Vomiting, dehydration, unable to tolerate PO
  • Immune suppression (HIV, SCD, malignancy)
  • Toxic appearance/respiratory distress
  • SpO2 <90-93%
  • Social circumstances

Post by Dr. Michael Hong

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