Core Emergency Medicine

Medial Collateral Ligament (MCL) Injuries

This post explores the presentation, diagnosis and management of MCL injuries.

Button Battery Ingestion

Button battery ingestions can have disastrous complications. This post is a guide to management.

Core Podcast See More →

Episode 132.0 – Air Embolism

This week we dive into the rare but potentially fatal, and difficult to diagnose, air embolism.

Core Procedures See More →

Digital Nerve Block

This is a brief video detailing how to do regional anesthesia for the fingers.

Read more

How to Apply a Pelvic Binder

This post discusses the application of both a commercial pelvic binder as well as a sheet for pelvic stabilization.

Read more

Core Blog See More →

Nov172017

The Paradox

“Go take a break.” “Let me quickly pick up these two patients.” “Go grab some food and come back.” “I’m fine, I’ll just…” “Sanjay, get the hell out and don’t come back for fifteen minutes.”

It was my sixth overnight in a row. After having struggled for over 15 minutes with trying to place an ultrasound guided IV in a sickle cell patient,
Read More

Oct062017

Teaching on a clinical shift can sometimes be difficult: it’s busy, everyone’s running around and it’s hard to capture a trainees attention. Recently, on twitter, Amal Mattu (@amalmattu) has been posting pictures of his white board teaching: discrete pearls written down and shared with anyone who walks by. The pearls are often prompted by patients presenting during that shift but they don’t have to be.
Read More

Sep122017

The MDCalc Fellows program is a 2-year longitudinal engagement for residents and medical students passionate about EBM and knowledge translation. 
Read More

Core Journal Club See More →

: Effect of US on CPR Pauses in Cardiac Arrest

Point-of-care ultrasound use in patients with cardiac arrest is associated with prolonged cardiopulmonary resuscitation pauses: a prospective cohort study Resuscitation, 2017

The provision of high-quality compressions with minimal interruptions is central to the management of cardiac arrest. Along with defibrillation, high-quality compressions are the only interventions proven to improve patient-oriented outcomes.
Read More

: The Ottawa SAH Decision Instrument

Validation of the Ottawa Subarachnoid Hemorrhage Rule in Patients with Acute Headache CMAJ, 2017

Acute headaches account for 1-2% of all ED visits. Of these patients, 1-3% will actually have a subarachnoid hemorrhage (SAH) (Goldstein 2006).
Read More

Core Case of the Month More Cases →

CC

Chest pain

HPI

50yM no PMH, active smoker presents by ambulance with chest pain. Six hours ago he developed substernal chest pressure and nausea, no vomiting. Pain was moderate and constant, but he had a presyncopal episode 1hr prior and severe worsening of chest pain which led him to call 911. He was given ASA en route.

PMH / PSH

No medications or known PMH

Physical Exam

BP 109/44 | HR 95 | RR 18 | T 98.5F | SpO2 92% RA → 97% 4L NC
GEN: diaphoretic, pale, grimacing, clutching his chest in pain, speaking in incomplete sentences
CV: tachycardic, regular, 3/6 systolic ejection murmur
PULM: CTAB
ABD: soft, non-tender, non-distended
NEURO: no focal deficits, moves all extremities equally

Labs

CBC: 17.6 > 15.4 / 43.9 < 189
BMP: 140 / 4.4 / 107 / 23 / 21 / 1.4 < 139
LFT: 91 / 37 / 90 / 1.6 / 0.0 / 4.2 / 7.5
Troponin: 4.33
VBG: 7.50 / 34.3 / 26.7 Lact 2.95

Questions

  1. What are your next steps in management of this patient?

    STEMI team was activated and the patient was started on heparin and promptly taken for cardiac catheterization. He had normal coronary arteries but was noted to have severe aortic insufficiency and a dissection flap in the ascending aorta consistent with type A aortic dissection.

  2. What additional therapies would you consider administering?

    He was started on labetalol and as the patient was being consented for emergent operative repair by CT surgery, he admitted to longstanding and recent crystal meth use. Intraoperatively, an intimal tear was noted 2-3cm above the sinotubular junction with the intimal flap dissecting through the aortic valve; graft repair was performed with good outcome.

More Info

Aortic dissections have a highly variable presentation, which makes diagnosis challenging.  It is much rarer than ACS, with an incidence of 5-30 cases per million people, and a high risk of mortality (classically 1-2% increase in mortality with each passing hour) (Hagan 2000).  There is no information in the literature regarding the incidence of aortic dissection among cases that present as myocardial infarctions. 
Read More