Contributor: Aaron Lessen MD

Educational Pearls:

• Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care

• A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD

• T: Tilt the patient to the left lateral decubitus position

• This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload

• If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side

• O: Administer high-flow adjunctive oxygen 

• L: Lines should be placed above the diaphragm

• Lines below the diaphragm are ineffective due to uterine compression of the IVC

• May consider humeral interosseous line vs. internal jugular or subclavian central line

• D: Dates should be estimated

• > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival

• The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter

• D: Call the labor and delivery unit for additional help

References

1. ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)

2. Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166

3. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300

4. Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22 

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Travis Barlock MD

Educational Pearls:

What is the ST segment?

• The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave). 

• It should appear isoelectric (flat) in a normal ECG.

What if the ST segment is elevated?

• This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural)

• This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis

What if the ST segment is depressed?

• This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic

• This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs

• This is called subendocardial ischemia

What else should you look for in the ECG to identify subendocardial ischemia?

• The ST-depressions should be at least 1 mm

• The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads.

• There is often reciprocal ST elevation in aVR > 1 mm

The most important thing to remember when you see subendocardial ischemia is…history

• Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc.

• Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand.

References

1. Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130

2. Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726

3. Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion.

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Alec Coston MD

Educational Pearls:

• Causes of seizures in a fairly well-appearing child with diarrhea:

• Electrolyte abnormalities: hypocalcemia, hyponatremia

• Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures

• Hypoglycemia

• If the child has diarrhea and appears very sick, differential diagnosis may include:

• Hemolytic uremic syndrome (HUS):

• simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury

• Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli)

• One of the main causes of acute kidney injury in children

• Toxic ingestions such as salicylates, lead, or iron

• In this case, the child had a seizure but appeared well and was afebrile:

• Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG)

• First identified in 1982 in Japan

• Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities

• Uncommon illness caused by rotavirus and norovirus pathogens

• Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home

• This diagnosis does not predispose him to epilepsy later in life

References

1. Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189.

2. Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376

3. ‌Noris, Marina*; Remuzzi, Giuseppe*, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861 

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• Induction agent selection during rapid sequence intubation involves accounting for hemodynamic stability in the post-intubation setting

• Many emergency departments use ketamine or etomidate

• A recent study sought to explore the rates of post-induction hypotension of ketamine compared with propofol

  • Single center retrospective cohort study of patients between 2018-2021

• Ketamine and propofol were both significantly associated with post-induction hypotension

  • Ketamine adjusted odds ratio = 4.50

  • Propofol adjusted odds ratio = 4.88

  • 50% of patients became hypotensive after induction with either propofol or ketamine

• These findings suggest post-induction hypotension is mainly due to sympatholysis rather than the choice of agent itself

References

1. Tamsett Z, Douglas N, King C, et al. Does the choice of induction agent in rapid sequence intubation in the emergency department influence the incidence of post-induction hypotension?. Emerg Med Australas. 2024;36(3):340-347. doi:10.1111/1742-6723.14355

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

Can opioids cause cardiac arrest?

• Opioids can cause respiratory suppression and the subsequent low oxygen levels can lead to arrhythmias and eventually cardiac arrest.

• In 2023, 17% of out-of-hospital cardiac arrests (OHCA) were attributable to opioids.

Given that this is a rising cause of cardiac arrest, should we just treat all cardiac arrest with naloxone (Narcan)?

• Naloxone is correlated with an increased chance of return of spontaneous circulation (ROSC)

• Additionally, a wide variety of individuals can be exposed to opioids and therefore opioid overdose should be considered in all cases of OHCA

But does naloxone improve neurologic outcomes?

• Yes, naloxone, especially when given early on in the resuscitation can improve neuro outcomes

What is the dose?

• 2-4 mg IN/IV depending on access.

• High suspicion for opioid overdose consider going with an even higher dose such as 4-8 mg IN/IV

References

1. Orkin, A. M., & Dezfulian, C. (2024). Recognizing the fastest growing cause of out-of-hospital cardiac arrest. Resuscitation, 198, 110206. https://doi.org/10.1016/j.resuscitation.2024.110206

2. Quinn, E., & Du Pont, D. (2024). Naloxone administration in out-of-hospital cardiac arrest: What's next?. Resuscitation, 201, 110307. https://doi.org/10.1016/j.resuscitation.2024.110307

3. Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2010). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 81(1), 42–46. https://doi.org/10.1016/j.resuscitation.2009.09.016

4. Wampler D. A. (2024). Naloxone in Out-of-Hospital Cardiac Arrest-More Than Just Opioid Reversal. JAMA network open, 7(8), e2429131. https://doi.org/10.1001/jamanetworkopen.2024.29131

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce MS1 & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• A study evaluated the patient-care impact and financial costs of holding patients in the ED, a nationwide issue

• Prospective, observational study of acute stroke management

• Conducted at a large urban, comprehensive stroke center

• The study evaluated patients in multiple categories: 

1. admitted to med/surg

2. admitted to med/surg but held in the ED

3. admitted to the ICU

4. Admitted to ICU but held in the ED

• Examined the amount of time nurses and providers spent with each patient

• This was analyzed in conjunction with the knowledge of each providers’ salaries and the overhead costs of the med/surg unit, ICU, and ED 

• Conclusions:

• Patients who required med/surg inpatient care but who were held in the ED resulted in a doubled daily cost

• $1856 for med/surg inpatient boarding vs $993 for med/surg inpatient care

• Patients who required ICU care but who were held in the ED also resulted in an increased daily cost, but this difference was not as large

• $2267 for ICU inpatient boarding vs $2165 for ICU care

• Holding in the ED negatively impacts patients since they receive less time from providers

• Holding also results in increased financial costs

References

1. Canellas MM, Jewell M, Edwards JL, Olivier D, Jun-O’Connell AH, Reznek MA. Measurement of Cost of Boarding in the Emergency Department Using Time-Driven Activity-Based Costing. Annals of emergency medicine. Published online May 1, 2024. doi:https://doi.org/10.1016/j.annemergmed.2024.04.012

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma

• Majority are caused by automobile collisions or motorcycle accidents

• Due to sudden deceleration mechanism accidents

• Clinical manifestations

• Signs of hypovolemic shock including tachycardia and hypotension, though not always present

• Patients may have altered mental status

• Imaging

• Widened mediastinum on chest x-ray, though not highly sensitive

• CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities

• In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used

• Four types of aortic injury (in order of ascending severity)

• I: Intimal tear or flap

• II: Intramural hematoma

• III: Pseudoaneurysm

• IV: Rupture

• Management

• Hemodynamically unstable: immediate OR for exploratory laparotomy and repair

• Hemodynamically stable: heart rate and blood pressure control with beta-blockers

• Minor injuries are treated with observation and hemodynamic control

• Severe injuries may receive surgical management

• Some patients benefit from delayed repair

• An endovascular aortic graft is a surgical option

• Mortality

• 80-85% of patients die before hospital arrival

• 50% of patients that make it to the hospital do not survive

References

1. Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470

2. Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027

3. Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007

4. Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003

5. Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416

Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit

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Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley

Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3

Show Pearls

Map of South Africa Referenced

South Africa Geography Lesson

• There is a big disparity between Cape Town and its neighbor Khayelitsha.

• Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas.

• Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing.

• This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid.

• Apartheid was a policy of segregation that lasted from 1948 to 1994.

How does medical education work in South Africa?

• Medical education in South Africa typically follows a 6-year undergraduate program directly after high school

• Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists.

Pearls from the case and the discussion afterward

• Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious.

• Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise.

• Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix.

• Fever is common in appendicitis (~40%) and becomes less common with older patients.

• Don’t be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood.

• Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies.

• Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization.

• Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient.

Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health.

References

1. Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678.

2. Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40.

3. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776.

4. Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502

5. Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696.

Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII

Contributor: Taylor Lynch, MD

Educational Pearls:

What is neutropenic fever?

• Specific type of fever that is seen in cancer patients and other patients with impaired immune systems

• These patients are highly susceptible to infection

• Typically occurs 7-10 days after the last chemotherapy dose, this is when the immune system is the weakest

• It is useful to know the specific type of malignancy. For example, heme malignancies (ALL, AML, etc.) have more intense chemo and are at higher risk of neutropenic fever

• To qualify as a neutropenic fever, a patient must have one recorded temperature greater than 38.3 degrees C or be over 38 degrees C for one hour.

• The severity of the neutropenic fever is established by the absolute neutrophil count. Abs neutrophil count under 1500 is mild, less than 1000 is moderate, less than 500 is severe.

• Also look at monocytes (cell that becomes a macrophage). Less than 200 is very concerning

What is the workup and treatment?

• Obtain a panculture (culture blood from both arms and all indwelling lines), obtain urine culture, and get a chest x-ray.

• Do not preform a rectal exam or obtain a rectal core temperature. This could cause bacteremia.

• Treat with Cefepime (broad range and includes pseudomonas but not MRSA). If there is concern for MRSA add vancomycin.

• Admit with Neutropenic precautions (gowns, gloves, mask, positive pressure room)

References

1. Peseski, A. M., McClean, M., Green, S. D., Beeler, C., & Konig, H. (2021). Management of fever and neutropenia in the adult patient with acute myeloid leukemia. Expert review of anti-infective therapy, 19(3), 359–378. https://doi.org/10.1080/14787210.2020.1820863

2. Zimmer, A. J., & Freifeld, A. G. (2019). Optimal Management of Neutropenic Fever in Patients With Cancer. Journal of oncology practice, 15(1), 19–24. https://doi.org/10.1200/JOP.18.00269

Summarized by Jeffrey Olson, MS3 | Edited by Meg Joyce & Jorge Chalit, OMS3

Contributor: Jorge Chalit-Hernandez, OMS3

• Typically presents with biliary colic

• Right upper quadrant abdominal pain lasting more than 30 minutes and subsiding over several hours

• Often associated with fatty meals but not always

• Must rule out other causes of pain

• Peptic ulcer disease - typically presents with epigastric pain

• Pancreatitis - pain that radiates to the back or family history of pancreatitis

• Laboratory workup 

• LFTs including ALT, AST, and alkaline phosphatase are within the reference range

• Lipase and amylase within the reference range

• Imaging workup

• RUQ ultrasound is unremarkable

• Upper endoscopy with ultrasound can help rule out peptic ulcer disease and small stones

• HIDA scan may show a reduced gallbladder ejection fraction below 30-35% or it may be normal 

• Opiates may give false-positive results

• Opiates can sometimes make biliary colic worse due to their contractile effect on the sphincter of Oddi

• Some patients may benefit from surgical intervention i.e. cholecystectomy

• Classic biliary-type pain (best predictor of response to cholecystectomy)

• Pain for > 3 months duration

• Positive HIDA scan

References

1. Alhayo S, Eslick GD, Cox MR. Cholescintigraphy may have a role in selecting patients with biliary dyskinesia for cholecystectomy: a systematic review. ANZ J Surg. 2020;90(9):1647-1652. doi:10.1111/ans.16003

2. Arshi J, Layfield LJ, Esebua M. Mast cell infiltration and activation in the gallbladder wall: Implications for the pathogenesis of functional gallbladder disorder in adult patients. Ann Diagn Pathol. 2021;54:151798. doi:10.1016/j.anndiagpath.2021.151798

3. Carr JA, Walls J, Bryan LJ, Snider DL. The treatment of gallbladder dyskinesia based upon symptoms: results of a 2-year, prospective, nonrandomized, concurrent cohort study. Surg Laparosc Endosc Percutan Tech. 2009;19(3):222-226. doi:10.1097/SLE.0b013e3181a74690

4. Joehl RJ, Koch KL, Nahrwold DL. Opioid drugs cause bile duct obstruction during hepatobiliary scans. Am J Surg. 1984;147(1):134-138. doi:10.1016/0002-9610(84)90047-3

5. Mahid SS, Jafri NS, Brangers BC, Minor KS, Hornung CA, Galandiuk S. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187. doi:10.1001/archsurg.2008.543

Summarized & Edited by Jorge Chalit, OMS3

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