Core Emergency Medicine

Jones Fractures

This post reviews the common Jones fracture (base of the 5th metatarsal) and some pearls + pitfalls in management.

Spontaneous Bacterial Peritonitis (SBP)

This post explores the diagnosis and management of SBP

Core Podcast See More →

Episode 141.0 – Journal Update

This week we discuss some recent publications relevant to EM: ADRENAL, Idarucizumab and Time to Furosemide.

Episode 140.0 Disutility of Orthostatics in volume Loss

This week we discuss the disutility of orthostatic vital signs as a diagnostic tool in patients with suspected volume loss.

Core Procedures See More →

Digital Nerve Block

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

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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.

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Core Blog See More →

Apr062018

“Code Blue in the waiting room!”

As my co-resident, attending, and I sprinted down the hall, I vividly remember thinking to myself that I probably shouldn’t be here right now. I was working upstairs in the surgical ICU. On a particularly slow overnight, I decided to head down to the ED to visit some friends.
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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,
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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.
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Core Journal Club See More →

: PE Rule-Out Criteria RCT

Effect of the Pulmonary Embolism Rule-Out Criteria on Subsequent Thromboembolic Events Among Low-Risk Emergency Department Patients, The PROPER Randomized Clinical Trial JAMA, 2018

The diagnosis of a pulmonary embolism (PE) in the Emergency Department (ED) is complicated. Many different decision rules have been developed to help risk stratify patients coming into the ED with some level of suspicion for PE. 
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: Door-to-Furosemide Time

Time-to-Furosemide Treatment and Mortality in Patients Hospitalized with Acute Heart Failure J Am Coll Cardiol, 2017

Acute congestive heart failure (AHF) results in nearly 1 million emergency department (ED) visits in the US per year and is associated with high morbidity,
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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. 
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