Stroke/TIA Mimics .... US Better Than Cardiologists

Two great articles from ACEP news. Well worth the read, especially in this day and age where we all fear the infamous "Stroke Code," a great discussion on mimickers of Stroke/TIA - most commonly being Complicated Migraine and Partial Seizure. I assure you after the article you will be more confident differentiating the bogus neuro symptoms and complaints we see ALL THE TIME, versus serious stuff we need to work up.

Stroke Mimic Article 


The next article is a summary of a cool study showing the uselessness of cardiologists -- haha just kidding. But seriously, a simple and quick bedside US Echo outperformed the cardiologists physical exam:  "Ultrasound had a far higher correct-diagnosis rate than did cardiologists’ physical exam for nearly all of the heart conditions the cardiologists encountered."

Check out the report here:

US vs Cardiologist Physical Exam Article

WINNERS: Ultrasound Competition MARCH 2013

Thanks to all who submitted.  The winner is:

MAYA LIN    -->  Maya's images below

Submission: DVT/PE  with Right Ventricular strain and classic D sign. This is a sign of Acute PE. You must however in the acute setting have some evidence differentiating RV strain of a chronic etiology to the acute etiology (PE or other mechanical RV outflow tract obstruction).

D Sign: This is a sign in which the LV appears like the letter D due to paradoxical leftward movement of the interventricular septum during LV relaxation.

Taken from an excellent article on Ultrasound of the Right Ventricle in Critical Illness

There are other ways to assess for acute PE in the setting of cardio-respiratory arrest including the McConnell sign , or apical RV contraction with a kinesis of RV free wall, plump IVC with no respiratory variation, RV/LV size ratio >1:1.

More Resources:

http://www.slideshare.net/basselericsoussi/thoracic-ultrasound-for-diagnosing-pulmonary-embolism

http://emoryeus.blogspot.com/2012/04/mcconnells-sign-and-acute-pe.html

Transvenous Pacer Placement

Thanks to a scary, but interesting recent case in our ED. The following is a helpful video to remind us all how to place this a temporary transvenous pacer.

Either here, in a formal dictated video:
http://www.youtube.com/watch?v=5BiQQYjw6no

Or here, in an actual clinical scenario:

Empathy

Ultrasound Competition Winners: February

Congratulations to the winners of February's Ultrasound Competition. This was the first month ever of the competition and was a very successful one. We had many very interesting ultrasounds from the department. After review by Dr. Chiricolo and the fellows, the following were selected as winner and runner up:

FIRST PLACE PRIZE WILL RECIEVE A $10 CRESPELLA GIFT CERTIFICATE, 2ND PLACE GETS A $5 GIFT CERTIFICATE.

1st Place
Submitted by Bethany Byrd (Images also obtained with Jaja Almasi)

These images were taken from a 70 year old male with a prior CVA who presented with several hours of right hand paresthesias and pain. The patient was found to have a clear axillary artery thrombus confirmed by this excellent bedside ED ultrasound. The patient subsequently underwent an embolectomy via the brachial artery. There is no question that this ultrasound image led to faster diagnosis and treatment. GREAT JOB!

2nd Place

Submitted by Laura Prendergast

The second place prize goes to an excellent image of a hepatic abscess in a patient hydatid cyst. Great images!

Methodist ECG Lesson: with a little help from Amal Mattu

So... here is a real case from Methodist. Try to figure out what is wrong...

The case is a young (40's) male with a history of pulmonary sarcoid and diabetes presenting with chest pain.

Trouble finding the abnormality? So did I. Thats why I emailed Dr. Amal Mattu, the EM ECG guru.  Luckily enough, he graciously wrote back with his own interpretation:

Jordan,
Here are some thoughts.
The tall R wave in aVR is a bit unusual, so the first thing I'd do is to recheck to make sure the leads were placed correctly. Assuming the leads are placed properly, I'd interpret as follows.
Normal sinus rhythm, left anterior fascicular block. There are Qs in V1-V2 and poor R wave progression so there's evidence of an anteroseptal MI of uncertain age. There's also loss of tall Rs in the lateral V leads (V4-6 normally have taller R waves than S waves), and that could also indicate evidence of anterior MI of uncertain age. 

There are concerns for acute ongoing ischemia: 
1. The initial portions of the T waves in V2-4 are very straight, and although this could possibly be normal for this patient, I'd want to get an old ECG to see if that's old; or I'd like to get some serial ECGs to see if anything evolves.
2. There's slight STE in V2, and maybe in I + aVL (with T wave inversions in those leads, which could be ischemia). I'm a bit more worried about the STE in V2, given that there's a Q wave and also straightening of the initial portion of the T wave.

We must bear in mind that the ECG must be interpreted in the context of the patient's symptoms. I have seen ECGs showing many of these findings in asymptomatic patients and it's just the patient's baseline. On the other hand, if this patient is acutely having some concerning cardiac symptoms, I would call this ECG an acute STEMI.

So......what's the answer?

Thanks for sharing the case. 
Amal

 

Here is the conclusion: 

This patient spit out a troponin in the ED of 53. He was actively having chest pain and was brought to the cath lab. These are the cath results: 

IMPRESSIONS: -- Significant two vessel coronary artery disease with 99%

proximal LAD and 90% OM2 stenoses with left to left and right to left

collaterals.

-- Status post successful mechanical thrombectomy and PCI of the proximal LAD

with a 3.0 mm x 15 mm Integrity bare metal stent. The first diagonal branch

acutely closed post stent delivery and was unable to be reopened.

-- Status post successful PCI of OM2 with a 3.0 mm x 26 mm and a 3.0 mm x 9 mm

Integrity bare metal stents.

Landmark Trials on Stroke Management: Is tPA Just As Good?

This could set off an interesting conversation with our neurosurgical and neurointerventional colleagues.  Check out this site (with links to all trials at the bottom).