EKG of the Week 2018 4-15

This EKG comes courtesy of Dr. Ross Hardy.

A 91 y/o female presents with chest pain. Vital signs: Pulse 35, BP 80/50. The EKG is below:

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1.       What findings does the EKG demonstrate?

2.       What is the rhythm?

3.       What is the appropriate management for this patient?

 

ANSWER:

The EKG demonstrates ST elevations in leads II, III and AVF with reciprocal depressions in V2-V6, I and aVL. This is consistent with an inferior wall (or inferoposterior) STEMI.

The rhythm is sinus with a 2nd degree 2:1 AV block.

The MI should initially be treated with antiplatelet drugs (aspirin, clopidogrel/prasugrel). The bradycardia with AV block should be treated with a pacemaker, as the patient is hypotensive. Initially, a transcutaneous pacer should be placed followed by a transvenous pacer. Once appropriate capture is obtained and the heart rate normalizes, the patient should go to the cath lab for emergent PCI.

 

ST elevations are a sign of acute MI. When you identify both ST depressions and ST elevations on the same EKG, that represents an acute MI in the area of the ST elevations. The ST depressions in that case are only reciprocal changes. Leads II, III and aVF look at the inferior wall of the heart.

Inferior wall MI’s can be associated with bradycardia and AV block. This EKG demonstrates bradycardia with dropped P waves. Some of the P waves are conducted through and some are not (best seen in lead V1). That is characteristic of 2nd degree AV block. Differentiating 2nd degree AV block from 3rd degree AV block can sometimes be difficult, as in this EKG. The following algorithm may be helpful. In this EKG, the RR intervals are regular and the PR intervals are regular. So, we are dealing with 2nd degree AV block.

Algorithm 2nd degree vs 3rd degree AV block (1).jpg

2nd degree AV block comes in two types – type I (AKA Mobitz I, Wenckebach) and type II (AKA Mobitz II). In type I, the PR intervals progressively lengthen followed by a dropped P wave. Then the PR interval shortens again and the cycle repeats. In type II, all PR intervals are the same and there are some dropped P Waves. To differentiate 2nd degree type I from type II, you must see two consecutive beats where the sinus impulse conducts through. This allows you to determine if the PR interval is progressing (type I) or not (type II). In our EKG, every second sinus beat is dropped (best seen in lead V1). So, you do not see two consecutive sinus beats conducting through. This prevents you from differentiating 2nd degree type I from 2nd degree type II. This EKG pattern is referred to as a 2:1 AV block (every second beat is blocked by the AV node). In general, in 2:1 AV block, the presence of a prolonged PR interval makes type I block more likely, whereas the presence of wide QRS complexes makes type II block more likely. However, this is not entirely reliable.

When faced with a 2:1 AV block, running a long rhythm strip may allow you to see two consecutive conducted beats. You can then measure consecutive PR intervals to see if they are prolonging (type I) or the same (type II).

 

Ultrasound Liver Rounds!

Now that we have your attention - let's talk about liver ultrasound.  A topic that we do not deal with often in the ER setting, but due to all of those FAST exams and RUQ studies that we do, it's important to be able to recognize when the liver isn't normal! 

And now, onto....

The Basics of Liver Ultrasound

The liver is a large solid vascular organ that is best visualized with a curvilinear transducer with a (low) frequency between 2-5 MHz. The patient can be examined in a supine position with normal respirations.  The normal liver has a homogenous echogenic appearance.  Any heterogenous appearance should be concerning for pathology.  Here are a few non-traumatic pathologies to be aware of during your scanning.  

Cysts

  • Simple cysts are considered the most common focal liver lesion. They are anechoic with increased through transmission, and a well-defined back wall.
  • Complex cysts are identified by internal echoes, a thick wall, septations that are numerous or thick, solid elements, or calcification and are most often due to hemorrhage
  • Vascular lesions such as aneurysms, arterioportal fistulas, and portal hepatic vein fistulas can simulate cysts on gray-scale sonography but are easily distinguished with Doppler analysis

Benign Tumors

Hemangiomas:

  • The most common benign liver neoplasm found most commonly in women.. They are classified by multiple, small, blood-filled spaces are separated by fibrous septations and lined by endothelial cells that typically do not bleed or cause symptoms. Therefore, they are usually an incidental finding on ultrasound.
  • They are defined by sharp and smooth margins that may be round or slightly lobulated. 
  • Only 2% of hemangiomas enlarge on follow-up scans and they usually remain stable overtime. If the patient does not have chronic liver disease or risk of malignancy, a homogeneous hyperechoic liver lesion requires no further evaluation.
 hemangioma

hemangioma

Focal nodular hyperplasia (FNH):

  • A benign tumor of the liver that is composed of Kupffer cells, hepatocytes, and biliary structures. FNH is usually detected as an incidental mass.
  • On ultrasound, most FNHs are isoechoic to liver parenchyma
  • Unlike hepatic adenomas, they are not related to birth control pills, although birth control pills may promote their growth. They seldom bleed or cause any clinical symptoms, although pain may be encountered when the lesions are large.
  • The differential diagnosis of FNH includes fibrolamellar carcinoma, hepatic adenoma, HCC, hemangioma, and vascular metastases. 

Hepatic adenoma:

  • Adenomas are rare benign tumors that contain normal (or occasionally slightly abnormal) hepatocytes but few Kupffer cells and virtually no bile ductules. Adenomas occur most commonly in patients taking birth control pills or anabolic steroids.
  • Their propensity to bleed makes them surgical lesions despite their benign histology. They also have a low but real risk of malignant degeneration.
  • Simple, small uncomplicated adenomas tend to be homogeneous, varied and nonspecific. In most cases additional imaging is necessary to confirm the diagnosis. 

Malignant Tumors

Metastases:

  • The lungs and liver are the most frequent sites of distant metastatic disease and usually involve both lobes of the liver.
  • Liver function tests are unreliable in detecting liver metastases.
  • Metastatic lesions have a target appearance with an echogenic or isoechoic center and a hypoechoic halo while thick halos represent proliferating tumor.
  • CT and MRI are also helpful in confirming suspected diffuse metastases. In  many clinical situations when metastatic disease is suspected biopsy is required for diagnosis.

Hepatocellular carcinoma:

  • HCC is the most common primary malignancy of the liver.
  • The growth pattern of HCC is quite variable: it may be solitary, multifocal, or diffuse and infiltrating. A typical pattern of HCC is a large dominant lesion with scattered smaller satellite lesions.
  • Most HCCs are hypervascular and variable; however, this is not always evident on Doppler, particularly in deep lesions.
  • Any solid mass detected on an initial sonogram in a patient with cirrhosis should be con­sidered malignant until proved otherwise 

Middleton WD, Kurtz AB, Hertzberg BS. Ultrasound: The Requisites. 2nd ed. Philadelphia, PA: Elsevier, Inc; 2016.

 

EKG of the Week 2018 3-18

This EKG comes courtesy of Dr. Litvak.

 

An 83 year old female with a history of COPD and CAD presents to the ED with a brief episode of right sided CP associated with palpitations. Patient denies syncope. No nausea, vomiting. No SOB.

Vital signs: Pulse – 80, R – 18, BP - 144/92, O2 sat 98%.

Her EKG is below.

2018 3-18.jpg

1.    What is the rhythm?

2.    How would you manage this patient?

 

ANSWER:

The rhtyhm is sinus rhythm with non-conducted PAC’s

Non-conducted PAC’s are treated the same as patients with PAC’s – look for a cause, check electrolytes, usually no emergent intervention needed.

 

The EKG demonstrates a sinus rhythm at a rate of approximately 80. After beats #4, 7 and 11, there are P waves with no QRS complex following them (See below). However this is NOT 2nd degree AV block.

2018 3-18b.jpg

 

If you map out the P waves, the “dropped” P waves come earlier than expected. In fact, they come right after the preceding T wave. Since the P waves come so early, the ventricles are still refractory so they do not conduct.

The way we know this is not AV block is because the P waves come earlier than expected. This patient needs no emergent intervention and should not have a pacemaker placed.

Non-conducted PAC’s may appear like a 2o AV block. You see P waves with no QRS complex following them and a pause on the rhythm strip. However, to call something 2o AV block, the P waves must come on time (i.e. the P-P interval must be regular). So, whenever you diagnose AV block, measure the P-P intervals and make sure they are regular. If the “dropped” P wave comes early, it is likely a non-conducted PAC and not AV block.

Non-conducted PAC’s are a very common cause of pauses on EKG. Whenever you encounter a pause, look back at the preceding T wave before the pause to see if there is a P wave buried in there.

Pauses on EKG can be caused by 3 things: Non-conducted PAC’s, SA node disease (SA block and SA arrest), and AV block. The following algorithm may be useful to diagnose pauses:

Algorithm Pauses.jpg

Absorbable Sutures?

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By Adam Rhodes, MD

Edited by Nicholas Otts, MD

A Common Problem:

A 6-year-old male presents with a laceration on his face.  He screams, “no stitches,” and requires intranasal versed for sedation for the laceration repair.  Absorbable sutures would negate a difficult followup visit for suture removal. But what about the cosmetic outcome, the infection risk, and other complications such as dehiscence? Is there evidence to support the use of absorbable sutures versus non-absorbable sutures in this scenario?

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A Small Dose of EBM:

The literature over the last decade strongly supports the use of absorbable sutures.

A randomized controlled trial of pediatric patients in 2004 (using a wound evaluation score and a validated visual analog scale during follow up visits) determined that there was no difference in cosmetic outcome, dehiscence, or infection (1).

A caveat - the study used plain gut, whereas most PEM providers use fast absorbing plain gut.

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Thankfully,  a study in 2008 utilized fast absorbing gut with similar control trial structure (also using a visual analogue scale as well as parents and three blinded observers). It found no difference in infection, wound dehiscence, keloid formation, and parental satisfaction. (2)

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Further, a meta-analysis of randomized controlled trials compared outcomes of absorbable versus non-absorbable sutures for skin closure in 2016. They concluded that absorbable sutures for skin closure were not inferior and recommended they be considered due to lower cost and time saving benefits. (3)

References:

1. Karounis H, et. al. A randomized controlled trial comparing long term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus non absorbable nylon sutures. Acad Emerg Med 2004 Jul;11(7):730-5.

2. Luck et. al. Cosmetic outcomes of absorbable versus non absorbable sutures in pediatric facial lacerations. Pediatric Emerg Care 2008 Mar;24(3):137-42.

3. Xu B. et. al. Absorbable versus Nonabsorbable Sutures for skin closure: A meta-analysis of randomized controlled trials. Ann Plastic Surgery 2016 May;76(5):598-606.

 

 

EKG of the Week 2018 3-4

This EKG comes courtesy of Dr. Smith and Dr. Ndubuisi.

 

A 42 year old male with a past medical history of asthma, borderline diabetes, and ex smoker. Presents with complaints of left sided chest pain which began 2 days prior. The symptoms started with fever and coughing and then he developed the chest pain. The pain is worse with movement of his arms. He denies any SOB, wheezing, lightheadedness or syncope.

V/S: P – 70, R – 18, BP 128/78, O2 say 98%.

His lung and heart exam are normal.

His EKG is below.

2018 3-4.jpg

1.       What does the EKG demonstrate?

2.       How would you manage this patient?

 

ANSWER:

The EKG demonstrates ST elevations in leads II, III, aVF, V2-V6, I and aVL with PR depressions in lead II. This is consistent with pericarditis.

Pericarditis is treated with anti-inflammatory medication and colchicine and follow-up with cardiology.

 

Pericarditis can sometimes be difficult to differentiate from MI. They both present with chest pain and both can demonstrate ST elevations on EKG. They both can have elevated cardiac enzymes (if the pericarditis is associated with myocarditis). Differentiating them is important for several reasons. Pericarditis is usually self limiting and not dangerous. MI obviously requires acute treatment. One of the treatments for MI is anticoagulation. In a patient with pericarditis and a pericardial effusion, anticoagulation can be dangerous.

Some clues on the EKG can help us differentiate pericarditis from acute MI. In general, MI should have ST elevations limited to one area of the heart (i.e. you should not have ST elevations in both the inferior wall and the anterior wall). In pericarditis there is generally diffuse ST elevations in many walls of the heart. MI often presents with reciprocal ST depressions. In pericarditis, you there should not be ST depressions except in leads aVR and V1. (This rule is not perfect either. There may be reciprocal depressions in myocarditis.) In MI the PR segments should be isoelectric. In pericarditis, you may see PR depressions. They are most commonly seen in lead II. You may also see PR elevations in lead aVR.

Our patient had fever which is more common in pericarditis than in MI. This EKG demonstrates ST elevations in leads II, III and aVF as well as leads V2-V6, I and aVL. This diffuse pattern of ST elevations would not be expected in an MI. There are also PR depressions in lead II. This is consistent with pericarditis. He was treated with NSAIDs and referred to cardiology for follow-up.

 

Case 58

51 years old male with medical history of Parkinson's disease, s/p fall with injury to the chest. Pt states that he was walking in the street, when he tripped, fell and hit his chest. No LOC. Not on AC. Patient is complaining of pain in his chest, increased stiffness and  swelling over R clavicle and R arm,  difficulty breathing. Denies any palpitations, sob, cp before falling. Denies headache, n/v, other extremity pain, back pain, neck pain.

ROS
Eyes:  No visual changes, eye pain or discharge.
ENMT:  No hearing changes, pain, discharge or infections. No neck pain or stiffness.
Cardiac: Pain over R distal clavicle and midsternal.  No edema.
Respiratory:  +SOB. No cough or respiratory distress.
GI:   No nausea, vomiting, diarrhea
GU:  No dysuria, frequency or burning.
MS:  R arm and clavicle pain and swelling. No myalgia, muscle weakness, back pain.
Neuro:  No headache or weakness.  No LOC.
Skin:  No skin rash, abrasion, laceration.

PE
GCS: 15
GENERAL: in distress due to pain
HEAD:  Atraumatic, Normocephalic
EYES: EOMI, PERRL, conjunctiva and sclera clear
NECK: No Tracheal Deviation. No Mid-line tenderness C-spine. Supple. No JVD.
CHEST/LUNG: R sided chest tenderness. 5 x5 cm  hematoma, lungs clear to auscultation bilaterally;
HEART: Regular rate and rhythm; No murmurs, rubs, or gallops
ABDOMEN: Soft, Nontender, Nondistended; Bowel sounds present
EXTREMITIES:  2+ Peripheral Pulses,
NEUROLOGY: non-focal deficits

Labs, Radiology, Cardiology, and Other Results: FAST exam negative

 CXR

CXR

 CT Scan

CT Scan

QUESTIONS

  1. What is most concerning in blunt trauma to the chest as demonstrated by the images above?

  2. What tests/imaging modalities would you perform?

  3. What findings might you see on bedside echo?

  4. What do you see on this lung ultrasound?

  5. How would you manage this patient?

ANSWERS

  1. Cardiac and lung contusion. This patient has a pulmonary hematoma secondary to sternal fracture.
  2. EKG, ECHO, cardiac enzymes, CXR, and lung ultrasound.
  3. Wall motion abnormality, usually of the right ventricle. The right heart is most commonly injured due to its position closest to the anterior chest wall. 
  4. You will see B-lines in various lung fields, which in the setting of blunt force trauma would represent pulmonary contusion. You may also see hypoechoic/anechoic sharply demarcated fluid in various lung fields with a swirling pattern, strongly indicative of a hemothorax.  Other major pulmonary injuries that should definitely be considered on ultrasound would be pneumothorax, which can be identified by absence of lung sliding, otherwise known as a “barcode sign.”
  5. Observe all patients with cardiac monitoring, interval assessment of cardiac markers, SpO2 monitoring, chest tube placement as needed, and pulmonary physical therapy.