tag:blogger.com,1999:blog-88137120635054572062024-03-13T17:04:24.866-07:00Emergency Medicine CuriosaBrooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.comBlogger13125tag:blogger.com,1999:blog-8813712063505457206.post-87138037085584025302017-01-10T10:00:00.001-08:002017-01-10T10:05:55.566-08:00A mimic of septal hypertrophy: the false tendon<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A young female came to the ED after having a typical episode of syncope. The intern performed a focused cardiac ultrasound (FoCUS), and was concerned that the septum was thickened, suggesting hypertrophic cardiomyopathy. </span><br />
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The video file, showing the parasternal long axis:</span></div>
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<br /><iframe width="320" height="266" class="YOUTUBE-iframe-video" data-thumbnail-src="https://i.ytimg.com/vi/WZGnFb2ZSEI/0.jpg" src="https://www.youtube.com/embed/WZGnFb2ZSEI?feature=player_embedded" frameborder="0" allowfullscreen></iframe></div>
<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The resident showed me how they had assessed the thickness of the septum (</span><span style="background-color: transparent; color: red; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">red double-arrow line</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">):</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img alt="Screen Shot 2017-01-10 at 11.24.56 AM.png" height="411" src="https://lh3.googleusercontent.com/GAnn50cCbsLNWGW3k_YFY6qJ0jqQup7i2ksbQR0dqMMV8KXA84OPjtxilwRsEPhHvNZksO8uFJUOpMve0ZpxtB-ac21NuIC0BWBYj4a5kclQZeYB9GqmSKaLzfRoQi54kKopbExk" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="624" /></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">I noted that there was an echo-free space within this “septum.” Instead of a thickened septum, there seemed to be normal wall thickness, but with a linear structure attached to the basal ventricular septum (</span><span style="background-color: transparent; color: red; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">red asterisks</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">):</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img alt="Screen Shot 2017-01-10 at 11.25.07 AM.png" height="415" src="https://lh4.googleusercontent.com/VD6qBUUGldxMl5WWbgibBGtzrTULd0wDwBNVVXnN4TXqx28DIO4klHOtyPUQgN8mMQsC3LQcJe-bMBJdBb4vPKoRitNpYF1tYwZpAV36BrfStgCz0vc6whMrMrYPWYWJmQB3q6i_" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="624" /></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This appears to be a left ventricular false tendon. Similar to the moderator band in the right ventricle, the false tendon is a benign structure which may be mistaken for pathology.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">False tendons may be composed of just simple fibrous tissue, but they may also contain myocardial muscle, Purkinje fibers, or even coronary arteries (</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;"> For a </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/23602169" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">clear and concise review</span></a><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, unfortunately paywall access.)</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><br class="kix-line-break" /></span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">False tendons are quite common, seen in about half of autopsies, and are most common seen attached to the basal septum, running to the posteromedial papillary muscle (</span><span style="background-color: transparent; color: red; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">red asterisks</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, as above):</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img alt="Screen Shot 2017-01-10 at 11.43.28 AM.png" height="256" src="https://lh6.googleusercontent.com/9Pyq72vZOHjGTzn70fRKSS_vLNzLsRHiDdF640zd6owtyxqDnrwCl2RNM1woaA7Xu5ZD5ZU6hu4Jw1EWxpDX1EeTp53dCu52MeqN4MFATiN4xUOx8OvQZLLj3flzFjq7sKBc4CZ6" style="-webkit-transform: rotate(0.00rad); border: none; transform: rotate(0.00rad);" width="387" /></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Modified from </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/23602169" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Silber</span></a><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Some case reports have associated false tendons with </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088365/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">early repolarization pattern on the ECG</span></a><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, episodes of ventricular arrhythmias, or with a pseudo-STEMI pattern on the ECG. To these risks of false tendons we can add the potential for incorrectly diagnosing HCM! </span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">This has happened before. A </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714075/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">case report by Ker</span></a><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> described a young adult with a mild murmur who was initially thought to have septal hypertrophy demonstrated on the echocardiogram. Closer evaluation revealed, instead, a false tendon in the same location as our patient!</span><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><br class="kix-line-break" /></span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Modified from </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714075/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Ker</span></a><span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">So, be careful with the FoCUS. Pitfalls abound when considering diagnoses beyond the entities we usually assess (e.g. effusion, aortic root, RV dilation, EF).</span></div>
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<span style="background-color: transparent; color: black; font-family: "arial"; font-size: 16px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Open-access references:</span></div>
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<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714075/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">The subaortic tendon as a mimic of hypertrophic cardiomyopathy</span></a></div>
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<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088365/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-family: "arial"; font-size: 14.666666666666666px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Left ventricular false tendons and electrocardiogram repolarization abnormalities in healthy young subjects</span></a>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-28175754589493679772016-12-14T09:36:00.001-08:002016-12-14T09:36:05.526-08:00Tamponade and Tautologies<div dir="ltr" id="docs-internal-guid-d1e2bd30-fe54-66a7-a6c7-32171f19adc1" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="font-family: Times,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; vertical-align: baseline;">Note: </span></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="font-family: Times,"Times New Roman",serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; vertical-align: baseline;">Our case report </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;"></span><a href="https://www.ncbi.nlm.nih.gov/pubmed/27884577">Low-Pressure Pericardial Tamponade: Case Report and Review of the Literature</a> was just published. I can't really plagarize that text, or use the images from the case, but I had the "good fortune" to see a second case of what I believe was low-pressure tamponade. So, I get to write a #FOAMed version, as well as a conventional publication! Wins all around.</span></span></span></div>
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<span style="font-family: "Trebuchet MS",sans-serif;"><span style="font-size: large;"><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">“Tautology: a statement that is true by virtue of its logical form.”</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Or, as put by <a href="http://xkcd.com/703/"><b>XKCD</b></a>:</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi65FNtBaWHBacQAusW1tMim_8lnnS5slY0GkjZtfPjePjD-Ii-BgQaIpvvQrTTSL7DB0oot_dRJd7cigRRhgpR3E6pv1Ta8BlRBydnknCGSG3DpobLpYyB_VNdt2UcV-uPoTqwny6hmz68/s1600/Screen+Shot+2016-12-14+at+12.15.49+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="137" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi65FNtBaWHBacQAusW1tMim_8lnnS5slY0GkjZtfPjePjD-Ii-BgQaIpvvQrTTSL7DB0oot_dRJd7cigRRhgpR3E6pv1Ta8BlRBydnknCGSG3DpobLpYyB_VNdt2UcV-uPoTqwny6hmz68/s400/Screen+Shot+2016-12-14+at+12.15.49+PM.png" width="400" /></a></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Tamponade, oddly, can be harder to define than tautology!</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Of course, many people say things like “tamponade is defined clinically,” or cite a cut-off level of pulsus paradoxus. But such criteria can be either vague, arbitrary, or poorly supported by good evidence. (For a good review of myriad such issues, check out</span><a href="https://www.ncbi.nlm.nih.gov/pubmed/23891285" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Misconceptions and facts about pericardial effusion and tamponade</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. Paywall – sorry.)</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><span style="font-size: large;"><u><b>A lack of IVC plethora rules out tamponade... right? </b></u></span></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Instead, focus (</span><a href="http://www.sciencedirect.com/science/article/pii/S0894731710008710" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">FoCUS</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">?) on a simpler element of defining tamponade – the IVC. A large number of textbooks and reviews have stated that plethora of the IVC is a very sensitive feature of tamponade. For example, a </span><a href="https://elsevier.ca/product.jsp?isbn=9781455775699" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">beautiful recent handbook</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> of focused ultrasound states that:</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">“If tamponade is a consideration, it may effectively be ruled out by demonstrating of 50% or more with deep inspiration without having to pursue more sophisticated echocardiographic techniques.”</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> A similarly strong statement about the role of the IVC was delivered by</span><a href="http://www.ultrasoundpodcast.com/2013/11/pericardial-tamponade-learn-know-foamed/" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">Ultrasound Podcast: Pericardial Tamponade</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">:</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">“If the IVC is collapsing, you are almost certainly not dealing with tamponade.”</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Let’s see a case, though, to point out the complexities behind such blanket statements.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: large;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Case: Recurrent pericardial effusion s/p pericardial window.</span></u></span></span></h3>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A patient presented to the ED with positional chest pain. However, she also had a recent history of pericardial effusion subsequent to a CABG.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Although she had undergone a pericardial window at that time, and although her vital signs (aside from a modest tachypnea) were normal, the ED physician performed an echo. First, the sagittal and transverse views of the IVC:</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Sagital</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img height="252" src="https://lh4.googleusercontent.com/vqK_hcdpEYTxbalTe241ev89PLgwLp1KPLrOG1nM7OVxYGEFb4c_LUZsjl_iJADwwOpWCtWOozCkOl-0c5KclaaQ8puEmWRLnjc-uMsu8JQxzTox7N1PG9ECSwQZdH26e3ZhIoDq" style="border: medium none; transform: rotate(0rad);" width="624" /></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Transverse</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img height="201" src="https://lh5.googleusercontent.com/CvBehgAjMaiXMwSJmmOFA_d68_XYUbtjgiLAESJAgCjyjnG2-QQ2m0bsZKC9KrqsUCK1UxDZOtYxjEMD_EmWxiR1ZbC_xzA92QpCnfegLvoI3S0wYT4aYko7USBiHcd6YOuCcrsW" style="border: medium none; transform: rotate(0rad);" width="624" /></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;">And the clip:</span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwfRtSrbcvdx0O4tY2faRe-r7kQOvwPNuRmvc6Jtg1W1Kira3Odu__6otK7bhkDHiwP53Srq-DzGOykQzYK7g' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The transverse images show that the IVC diameter is just <b>< 2.1 cm</b>, and collapses just about 50%. The sagittal images, however, demonstrate a much higher degree of collapse in the proximal IVC. Based on these views, could we have ruled-out tamponade?</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Well, here are the rest of the views of the heart.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img alt="Screen Shot 2016-12-13 at 2.29.03 PM.png" height="456" src="https://lh4.googleusercontent.com/-4zWomS--7P8aS0_D0ZFzqdZ6U0PibcZ_ervwD8AU2c5nHsfdO9wGtHEpjJh_DugNQGRygUu24gmdVqy3YGHwFhj4HFpon7q5MiUigraGcpvDf-ErxQCrHoRSRCvSux6sA9kp01W" style="border: medium none; transform: rotate(0rad);" width="624" /></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Significant effusion – </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">check</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">RV collapse in diastole – </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">check</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">.</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">RA collapse in systole – </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">check</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Large respiratory variation in the MV inflow – </span><span style="background-color: transparent; color: black; font-style: italic; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">check!</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">So, is this tamponade? Heck, yes! The next day she had 700 ml worth of effusion aspirated, with an initial intrapericardial pressure of 24 mm Hg. Pretty diagnostic.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: large;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">But isn’t IVC plethora supposed to be almost 100% sensitive for tamponade?</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Technically, 97% sensitive. Almost every textbook or review that gives this figure cites the same <a href="https://www.ncbi.nlm.nih.gov/pubmed/3192844">1988 paper by <b>Himelman et al.</b></a>, and it is imperative to understand the methods of that study before repeating that “almost 100% sensitive” claim.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Himelman <i>et al</i>. defined IVC plethora as <b>< 50% IVC collapse</b> during a deep inspiration, measured 2 cm distal to the RA entrance. So, plethora was not seen in our patient - was this a “miss” for detecting tamponade?</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Well, Himelman had defined tamponade in a pretty narrow sense. They required that either:</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">a) The diastolic filling pressures (i.e. the diastolic pressure in the RA, RV, etc.) had to all be </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">> 12 mm Hg</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">), and be within 5 mm Hg of each other;</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">or</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">b) Hypotension was present, with an </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">initial SBP < 100 mm Hg</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, increasing by ≥ 20 mm Hg immediately after aspiration.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Given this definition, our patient did not have tamponade during the ED evaluation! </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">**</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">First off, the SBP was never below 100 mm Hg.</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Second, the bedside echo showed an IVC diameter < 2.1 cm, with > 50% inspiratory collapse, suggesting a RA pressure of only </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">0 - 5 mm Hg (</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">per</span><a href="https://www.ncbi.nlm.nih.gov/pubmed/23860098" style="text-decoration: none;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">ASE guidelines</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">),</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">There is a circular element to the inclusion criteria and the outcomes here...</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: large;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">The tautologic definition of tamponade is tautological.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Let’s dwell on Himelman’s definition of tamponade a bit more, and implications for the results they found. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">They only included patients with either overt hypotension from their effusion, or patients with RAP ≥ 12 mm Hg. Of the 33 patients found to have tamponade, 20 had a RAP > 12 mm Hg. The ASE guidelines above, then, suggest that most of these patients would be expected to have an IVC that was fat and plethoric. And vice-versa: patients with a plethoric IVC would be predicted to have RA and intrapericardial pressures > 10, and likely > 12 for many of them.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Tautology</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">: If we define tamponade as RA pressure > 12 mm Hg, any sign that </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">defines </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">a high RA pressure (IVC collapse < 50%) will be very common, by definition! </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Put another way, if you say that (based on Himelman) a non-plethoric IVC rules out tamponade, but only if you define tamponade such that the IVC </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">should</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> be plethoric.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><br class="kix-line-break" /></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><br class="kix-line-break" /></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">But isn’t that a common-sense part of defining tamponade; JVD, pulsus, and hypotension? Well, it turns out that tamponade can be defined in many different ways.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: large;"><u><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">There is more to tamponade than the end-stage, “clinical tamponade” presentation.</span></span></u></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Studies of pericardial tamponade have used a variety of definitions of tamponade. And when different definitions of tamponade are used, the utility of IVC plethora (or JVD, which we can use as a clinical surrogate for IVC plethora) will vary as well. For example:</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;"> </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/7756068" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">1995 study</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> defined tamponade as an “</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">effusion causing dyspnea which is relieved by aspiration of the effusion</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">,” and found that 87% of patients who received pericardiocentesis had significant relief of dyspnea.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: super;"></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> But half of the patients who fulfilled their definition of tamponade had no JVD (they did not evaluate IVC plethora).</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A</span><a href="http://circ.ahajournals.org/content/114/9/945" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;"> </span><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">2006 study</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> looked at patients with pericardial effusions, all of whom received both right-heart catheterization and pericardiocentesis.</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: super;"></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Tamponade was defined solely as </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">equalization of RA and IP pressures</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">. They found that 24% of the cases of tamponade showed fairly low RA and IP pressures (< 7 mm Hg) prior to pericardiocentesis. Accordingly, only a fifth of these “low-pressure” cases of tamponade presented with JVD. This suggests that IVC plethora would have been correspondingly low as well, but echo results were not included, sadly.</span></span></span></div>
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<li dir="ltr" style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; list-style-type: disc; text-decoration: none; vertical-align: baseline;"><div dir="ltr" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A </span><a href="https://www.ncbi.nlm.nih.gov/pubmed/20800410" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: underline; vertical-align: baseline;">2012 chart review</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> also used a broader definition of tamponade than had Himelman (any of following echo features: characteristic </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">RA, RV, or LV collapse; characteristic variation in blood flow through the TV or MV, or dilated IVC with lack of inspiratory collapse</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">).</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: super;"></span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Only 13% of these patients had a dilated, plethoric IVC.</span></span></span></div>
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<span style="font-size: large;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><b><u><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline;">Well, those studies didn’t look at “real” tamponade.</span></u></b></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Because of studies like those just summarized, a subset of tamponade, know as “low pressure” tamponade, has been more widely recognized. Often seen when a patient with a pericardial effusion is also hypovolemic (e.g. from diuretics or illness), a low-pressure tamponade nonetheless manifests with the symptoms and hemodynamic characteristics of “real” tamponade. JVD, pulsus, or overt hypotension, however, may be initially absent.</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><img alt="Screen Shot 2016-12-14 at 11.33.50 AM.png" height="200" src="https://lh5.googleusercontent.com/4zd3KzmYss-v3BV5CuxWsrnTzsdCadWGEXVGHAnLWbh0ejrdKJqJSTrFvERzjBqQ2bIEmbaZpYGAjju-sWaDIgL4G1L0d1q3TviPrMksc3jzW802Wj7kAhjMdAPvfdEV9sI2w-UO" style="border: medium none; transform: rotate(0rad);" width="267" /></span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">In fact, </span><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110902/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">many experts</span></a><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> have tried to push the view of tamponade as a spectrum, with broader inclusion criteria. Instead of a binary diagnosis of tamponade, we ought, they argue, to be evaluating where the patient is on the spectrum, as well as their potential to move “up” that spectrum; i.e deteriorate. </span></span></span></div>
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<span style="font-size: large;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><u><b><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; text-decoration: none; vertical-align: baseline;">The IVC is but a single data point</span></b></u></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">In our patient, a modest degree of tachypnea, as well as a classic echo profile suggested that this patient was in echocardiographic tamponade, and at risk of deteriorating. If the non-plethoric IVC had been used to classify our patient simply as “not </span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">real</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> tamponade,” the patient could have received less scrutiny, delayed evaluation, and perhaps a poorer outcome. </span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><br /></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">But this is nothing surprising, really. Almost every disease comes on a spectrum, and tamponade is no different. Accordingly, it isn’t useful, and may indeed be harmful, to teach that the IVC can “rule out tamponade.”</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">__________________________________________</span></span></span></div>
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<span style="font-size: small;"><span style="font-family: "Helvetica Neue",Arial,Helvetica,sans-serif;"><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">**</span><span style="background-color: transparent; color: black; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> Yes, the intrapericardial/RA pressure was higher the next day, when directly measured during aspiration. However, the procedure was about 1 day after the echo. In that interval probably more fluid had accumulated in the pericardium. The patient had also received > 2 liters of IV fluids before the procedure. IV fluids have frequently been shown to worsen a “low-pressure” tamponade, sometimes converting into the more conventional, hypotensive sort!</span></span></span></div>
Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-74872832441162885412016-07-07T10:16:00.000-07:002016-07-07T10:22:18.134-07:00Sinus bradycardia and lithium: Toxicity at "non-toxic" level?<div dir="ltr" id="docs-internal-guid-d768ea71-c652-170f-e2ed-1d0f73611ff9" style="line-height: 1.38; margin-bottom: 0pt; margin-top: 0pt;">
<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A woman taking lithium for bipolar depression for years came to the ED “abnormal labs.” </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">She had recently been ill, and had profuse diarrhea after taking a series of antibiotics. She was sent to the ED when outpatient labs showed her to be in marked acute renal failure. </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">She was not taking any beta-blockers, calcium-channel blockers, or any other nodal blocking medications. Aside from marked bradycardia, her vital signs were normal. The patient was unconcerned, though, saying “My heart rate has been that slow for years!”</span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSZVRCoyDVvP6FfFNSajctZombwiCot1_Cs0e-vB_HLWRg4j-pNDF46cg6DdcSATXSTH3jWHc0hRP6hUtrOi1K-CJnINRjQze-IdsIj12ZNzoyaLoVoftI9ZRv7o7YyiPJEGMN79hS8abK/s1600/screenshot1811.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="184" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgSZVRCoyDVvP6FfFNSajctZombwiCot1_Cs0e-vB_HLWRg4j-pNDF46cg6DdcSATXSTH3jWHc0hRP6hUtrOi1K-CJnINRjQze-IdsIj12ZNzoyaLoVoftI9ZRv7o7YyiPJEGMN79hS8abK/s640/screenshot1811.jpg" width="640" /></a></div>
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<span style="font-family: "times" , "times new roman" , serif;"><i><b><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Sinus bradycardia, without signs of AV block or QRS/QT prolongation. </span></b></i></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Labs were repeated, showing a prerenal AKI, with normal potassium, troponin, and TSH. Her lithium, however, was </span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">1.9</span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> mEq/L (0.6-1.2 mEq/L). </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Why so brady?</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Bradycardia has a few common causes: hyperkalemia, cardiac ischemia (especially of the RCA territory), and, of course, high doses of nodal blockers. But she wasn’t taking any such medications, and her ECG and labs did not suggest problems with ischemia or potassium. </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Lithium toxicity, however, has been reported to cause sinus bradycardia and even sinus arrest, and so it was expected that the heart rate would increase as the lithium level fell.</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">Course</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">IV fluids were started, and repeat labs showed her AKI to be resolving, and the lithium level decreasing: at 36 hours after ED arrival, level had fallen to </span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">1.6 </span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">mEq/L. But despite the chemical improvement, her ECG did not show improvement of the sinus bradycardia.</span></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPsYRFc3t_QCCN59CN2kDfKy4ph1OKmg490k8BfVM8ZWbw7ifY0jME1YwyM7teEW_AsC20CBex5MExNk2OAPr5FrDTZINu5fAEwZkhFf_eD-glbT2czAN9guhcw7w3QxBwcW6xnU_Qr9HM/s1600/screenshot1810.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPsYRFc3t_QCCN59CN2kDfKy4ph1OKmg490k8BfVM8ZWbw7ifY0jME1YwyM7teEW_AsC20CBex5MExNk2OAPr5FrDTZINu5fAEwZkhFf_eD-glbT2czAN9guhcw7w3QxBwcW6xnU_Qr9HM/s640/screenshot1810.jpg" width="640" /></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Not much difference from the first. </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">In fact, her heart rate continued to hover in the 30s - 40s during the rest of her admission, even as the lithium level dropped to</span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;"> 1</span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><b> mEq/L</b>, squarely in the therapeutic range. </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 700; text-decoration: none; vertical-align: baseline;">So, is lithium off the hook? </span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Maybe not. Turns out this old drug has some weird toxic properties.</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Lithium can produce bradycardia at therapeutic levels</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">A drug doesn’t have to be at “toxic” levels to be toxic. This has been known about lithium </span><a href="http://onlinelibrary.wiley.com/doi/10.1002/clc.4960071113/abstract" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">since at least 1984,</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> with </span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603999/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">numerous case reports</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> since. Even at “safe” levels, </span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1025335/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">bradycardia and prolonged sinus pauses</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> are more common with lithium, even if it’s</span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647873/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;"> still uncommon overall.</span></a></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: italic; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">The cardiac effects of lithium take a while to wear off</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">Perhaps we just didn’t wait long enough! The case reports of bradycardia at therapeutic levels show that, even after immediate cessation, a heart rate above 60 bpm took </span><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603999/" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">over 5 days</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> or </span><a href="http://onlinelibrary.wiley.com/doi/10.1002/clc.4960071113/abstract" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">over 8 days</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"> to resolve (our patient was admitted for about half that time). In one case of a deliberate lithium overdose, the bradycardia only manifested </span><a href="http://www.ncbi.nlm.nih.gov/pubmed/17448123" style="text-decoration: none;"><span style="background-color: transparent; color: #1155cc; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: underline; vertical-align: baseline;">as the levels were decreasing</span></a><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">, approaching the therapeutic range. It appears that lithium requires time to build up in cardiac myocytes, causing a delayed “local” toxicity, even as serum levels are low or “therapeutic.”</span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"></span><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;"><b>What to do?</b></span></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="background-color: transparent; color: black; font-size: 14.6667px; font-style: normal; font-variant: normal; font-weight: 400; text-decoration: none; vertical-align: baseline;">In many similar cases, the value of lithium in controlling the mania has outweighed the threat of the bradycardia. Even in cases of outright hemodyamically significant bradycardia many patients have opted to have a pacemaker implanted rather than tamper with a med that keeps their lives together. And without such hemodynamic compromise, it would be hard to argue that stopping lithium would improve their quality of life.</span></span></div>
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Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com2tag:blogger.com,1999:blog-8813712063505457206.post-41846317086490862002016-06-12T12:16:00.000-07:002016-06-12T12:16:15.131-07:00Tombstone STEMI (but echo llooks great!)<span style="font-family: "trebuchet ms" , sans-serif;">A middle-aged male presented to the ED with typical cardiac ischemic symptoms. The onset had been somewhere in the range of 3-24 hours ago (depending on who took the history).</span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhl5vCDeOTEKsKy0ILsNuybvnCFF6YnOIv9XZzU7GdUIKdFq9lhe4RMBSTRie3ZGQEaFiIiGePh403rhyF95cqNBzyJPGNcceIXDQhTK0jFm2GhPj29G6RZOBI096pbXu0mPbGYPVNiEIXZ/s1600/screenshot1730.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="110" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhl5vCDeOTEKsKy0ILsNuybvnCFF6YnOIv9XZzU7GdUIKdFq9lhe4RMBSTRie3ZGQEaFiIiGePh403rhyF95cqNBzyJPGNcceIXDQhTK0jFm2GhPj29G6RZOBI096pbXu0mPbGYPVNiEIXZ/s400/screenshot1730.jpg" width="400" /></a></span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><br />Not a mystery - this is an inferior STEMI, resulting from a total occlusion of the mid-RCA. And it looks like a nasty one<span style="font-family: "trebuchet ms" , sans-serif;">. Firs<span style="font-family: "trebuchet ms" , sans-serif;">t of all, the infa<span style="font-family: "trebuchet ms" , sans-serif;">rct apparent<span style="font-family: "trebuchet ms" , sans-serif;">ly covers a good deal of myocard<span style="font-family: "trebuchet ms" , sans-serif;">ium, since we see:</span></span></span></span></span></span><br />
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<li><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">Marked eleva<span style="font-family: "trebuchet ms" , sans-serif;">tion in leads II, <span style="font-family: "trebuchet ms" , sans-serif;">III and aVF (inferior wall)<span style="font-family: "trebuchet ms" , sans-serif;"> </span></span></span></span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">Subtle ST elevations in V5 and V6<span style="font-family: "trebuchet ms" , sans-serif;"> (<span style="font-family: "trebuchet ms" , sans-serif;">lateral wall)</span></span></span></span></span></span></span></li>
<li><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">ST<span style="font-family: "trebuchet ms" , sans-serif;"> depression in leads V2 and V3 out of proportion <span style="font-family: "trebuchet ms" , sans-serif;">for a RBBB ("posterior<span style="font-family: "trebuchet ms" , sans-serif;">" wall)</span></span></span> </span></span></span></span></span></span></span></li>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">B<span style="font-family: "trebuchet ms" , sans-serif;">ut also note the char<span style="font-family: "trebuchet ms" , sans-serif;">acter of t<span style="font-family: "trebuchet ms" , sans-serif;">he</span></span></span></span> ST segment<span style="font-family: "trebuchet ms" , sans-serif;"> morph<span style="font-family: "trebuchet ms" , sans-serif;">ology</span></span> in III and aVF <span style="font-family: "trebuchet ms" , sans-serif;">- it's the classic</span></span> "tombstone" <span style="font-family: "trebuchet ms" , sans-serif;">appearance! </span></span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><u><b>What's the medical term for "tombstone elevations?" </b></u></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;">Besides having an ominously picturesque name, does the morphology of the STEMI here contain prognostic information? Actually, this phenomenon has been well studied.</span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">"<span style="font-family: "trebuchet ms" , sans-serif;">Tombstone"</span></span> ST segment elevation <span style="font-family: "trebuchet ms" , sans-serif;">is more accu<span style="font-family: "trebuchet ms" , sans-serif;">rately de<span style="font-family: "trebuchet ms" , sans-serif;">scribed as a</span></span></span> STEMI with either "<b>grade 3 ischemia</b>" or "<b>terminal QRS distortion</b> (<b>TQRSD</b>)<span style="font-family: "trebuchet ms" , sans-serif;">."</span> It's defined in the inferior leads as a J point that is higher than half-way up the R wave. </span></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbKEg_DZanezkkNEsmJIaKkM4RxVTot195-8T74Uvys1tLxwFgqkTNdE8c62D1bruFVpq4F0mUOdwKnn1dQo8Hng8d7b-MmNLIbI93cyVMenxZI6Abk5shOSOHCCYqrWYmdK3Rumc2Z4U5/s1600/screenshot1734.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="275" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhbKEg_DZanezkkNEsmJIaKkM4RxVTot195-8T74Uvys1tLxwFgqkTNdE8c62D1bruFVpq4F0mUOdwKnn1dQo8Hng8d7b-MmNLIbI93cyVMenxZI6Abk5shOSOHCCYqrWYmdK3Rumc2Z4U5/s400/screenshot1734.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "trebuchet ms" , sans-serif;">Examples a-d <b>do</b> <b>not</b> show TQRSD, <br />examples e-f <b>do</b> show TQRSD.</span></td><td class="tr-caption" style="text-align: center;"><br /></td><td class="tr-caption" style="text-align: center;"><br /></td></tr>
</tbody></table>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span><br /><span style="font-family: "trebuchet ms" , sans-serif;">It turns out that (on average) a STEMI with TQRSD has a significantly worse prognosis than those without TQRSD. More troponin release, <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3905251/">bigger infarcts</a>, poorer response to reperfusion therapy, and <a href="http://www.ncbi.nlm.nih.gov/pubmed/8609331">worse in-hospital mortality.</a></span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">After seeing the ECG,<span style="font-family: "trebuchet ms" , sans-serif;"> the ED team performed a focused echo, expecting to find <span style="font-family: "trebuchet ms" , sans-serif;">significant systolic dysfunctio<span style="font-family: "trebuchet ms" , sans-serif;">n<span style="font-family: "trebuchet ms" , sans-serif;">.</span></span></span></span> </span><br />
<br />
<u><b><span style="font-family: "trebuchet ms" , sans-serif;">So<span style="font-family: "trebuchet ms" , sans-serif;"> <span style="font-family: "trebuchet ms" , sans-serif;">how terrible was the ejection fraction</span></span>?</span></b></u><br />
<span style="font-family: "trebuchet ms" , sans-serif;">Actually.... not too bad. Pretty <span style="font-family: "trebuchet ms" , sans-serif;">good</span>, in fact.</span><br />
<br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">Sometimes our patients don't read the textbooks, and their hearts don't keep up with the electrocardiography literature!<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span></span> </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">The post-PCI formal echo did not reveal any significant wall motion abnormalities. Aside from a bout of VF during stent placement, the patient did great!</span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"> </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;"><u><b>Open-access references:</b></u></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/8609331"><b>Prognostic significance of the admission electrocardiogram in acute myocardial infarction.</b></a></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3905251/"><b>Prognostic significance of the <span class="highlight">distortion</span> of <span class="highlight">terminal</span> portion of <span class="highlight">QRS</span> <span class="highlight">complex</span> on admission electrocardiogram in ST segment elevation myocardial infarction.</b></a></span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;"></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com2tag:blogger.com,1999:blog-8813712063505457206.post-76239067705634516332016-05-26T11:39:00.002-07:002016-05-26T11:39:19.628-07:00Septic hip or synovitis? Use ultrasound!<br />
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>The presentation</b></u></span><span style="font-family: "Trebuchet MS",sans-serif;"> </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">The
parents said their 5 year-old boy was limping on his right leg for the
past day. The don't think he had hurt himself, and my exam confirmed
that his foot, ankle, leg, and knee were atraumatic, but his hip was
painful to range. He could still eke out an antalgic gait on the right leg, though. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">He had a slight temperature elevation of <b>100.2</b> F (37.9
C), and labs showed a WBC of <b>11.8</b>, and an ESR of<b> 28</b>.<br /><br />Was this a septic hip? What was the next test?</span><span style="font-family: "Trebuchet MS",sans-serif;"></span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8anEhyuKKiMQt03NSi_3tORHlDEIZFw2kIqTcOJ7qseBgPWN0s9ULnLAWZsCjQuX0Y-c1tUi3aI7dnRk4L7GK8dMk00B4lZhkuH_0Hx1sEYlyO04Cdv3JEjnNoSPzOC8Ul4P4VvbGULbs/s1600/Kocher+sux_MIM.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8anEhyuKKiMQt03NSi_3tORHlDEIZFw2kIqTcOJ7qseBgPWN0s9ULnLAWZsCjQuX0Y-c1tUi3aI7dnRk4L7GK8dMk00B4lZhkuH_0Hx1sEYlyO04Cdv3JEjnNoSPzOC8Ul4P4VvbGULbs/s320/Kocher+sux_MIM.jpg" width="256" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Hint.</td></tr>
</tbody></table>
<span style="font-family: "Trebuchet MS",sans-serif;"><u><strong><span style="font-size: 12pt;">"The best decision rule is Kocher’s criteria."</span></strong></u></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Some folks <a href="http://www.annemergmed.com/article/S0196-0644%2815%2901609-1/pdf">still recommend using <b>Kocher's criteria</b></a> to rule-out septic arthritis in the limping child. If the child is able to weight bear, has no fever, and WBC <b>< 12,</b> and ESR <b>< 40</b>, then the risk of septic arthritis was only <b>0.2%</b> in Kocher's original study.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Problem is, these sorts of results are all tied up with the population being studied and the prevalence of septic hip. Subsequent studies have found that kids with Kocher score of 0 can still have a risk of septic arthritis that ranges from < 0.2% to <i><b>17</b></i>%.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiex6IpD_WKZVw_0Qjk8UtfhjFVPEdS5zUABy1_LrCNdVjX8kZQDw8NvD0hgr1NJQ9YYULUpCXC0YmyTRjuPk31uHKGpj1dkwBEZrVQDZ1ZuY8Q6D3s6fR3nCtCMvueMuMl_K5OtdwusJ-D/s1600/Kocher+sux_table+from+Sultan.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="124" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiex6IpD_WKZVw_0Qjk8UtfhjFVPEdS5zUABy1_LrCNdVjX8kZQDw8NvD0hgr1NJQ9YYULUpCXC0YmyTRjuPk31uHKGpj1dkwBEZrVQDZ1ZuY8Q6D3s6fR3nCtCMvueMuMl_K5OtdwusJ-D/s400/Kocher+sux_table+from+Sultan.jpg" width="400" /></a></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://www.bjj.boneandjoint.org.uk/content/92-B/9/1289.long"><b>Sultan & Hughes</b></a></span></td></tr>
</tbody></table>
<span style="font-family: "Trebuchet MS",sans-serif;">In my patient's case, the kid's "Kocher score" was <b>zero</b>. And if we had trusted in this score we might have missed a septic hip! </span><br />
<br /><span style="font-family: "Trebuchet MS",sans-serif;"><u><b>Don't guess with Kocher - just look at the joint with ultrasound!</b></u></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">First, we looked at the left (contralateral) hip, seeing what normal should look like. Then we looked at the painful right hip. It wasn't subtle!</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4GR64p0TJErOXueUnoXFnW4U40iUF1K4GZZgKgGgK_O9AMPbdqnsPndrPNNs3ddzDFdGQe7eUT7NrSgz2gkjCvILkSQZJotBTS5NWQSck2MWCDse7W0hAbCFBUW1-Ebc-YwYwdh1X6Pai/s1600/Kocher+Sux_compare.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="218" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh4GR64p0TJErOXueUnoXFnW4U40iUF1K4GZZgKgGgK_O9AMPbdqnsPndrPNNs3ddzDFdGQe7eUT7NrSgz2gkjCvILkSQZJotBTS5NWQSck2MWCDse7W0hAbCFBUW1-Ebc-YwYwdh1X6Pai/s400/Kocher+Sux_compare.jpg" width="400" /></a></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">An anechoic space space in the hip joint > 5 mm is generally considered positive for effusion. <br /><br />The live clips were even clearer:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">IR was contacted, and we performed sedation for the aspiration. The aspirate from his hip was wildly positive; grossly purulent, with <b>> 100,000 WBC/mL</b>. The child was admitted, and did well.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<u><b><span style="font-family: "Trebuchet MS",sans-serif;">Note: Case was modified slightly for teaching purposes.</span></b></u><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Only in 2 respects: His WBC was actually trivially higher, at <b>12.2</b>, and he couldn't bear any weight at all on the right leg. These are small differences, and further highlight the potential pitfalls in using indirect criteria like Kocher's. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>Open-Access References</b></u>:</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://www.annemergmed.com/article/S0196-0644%2815%2901609-1/pdf"><b>Limping Child? Think LIMPSS.</b></a></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://www.bjj.boneandjoint.org.uk/content/92-B/9/1289.long"><b>Septic arthritis or transient synovitis of the hip in children: The value of clinical prediction algorithms</b></a></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-82159299177853740302016-05-17T11:01:00.000-07:002016-05-17T11:01:02.684-07:00Bugs in the B-hive: Read the lung ultrasound in context!<span style="font-family: "Trebuchet MS",sans-serif;">Lung ultrasound is a great tool, as well as cheap and fast. Heck, the ease of grabbing a quick look at the anterior apices makes the "STAT portable chest X-ray!" seem downright disappointing.</span><br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcFs133it7slSIy8cvy62qe-8kMPS7whP4DOlEwfR-QnEg_9RWzbnd1XOjh5oYpG4mZL-lVC250tHa4TjXUBgyl38bJjw0IxpKx-kir_qUqaIxz1MMbZJWTf7bxnTtBg7m9sLrpY35QpE8/s1600/screenshot1691.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="298" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcFs133it7slSIy8cvy62qe-8kMPS7whP4DOlEwfR-QnEg_9RWzbnd1XOjh5oYpG4mZL-lVC250tHa4TjXUBgyl38bJjw0IxpKx-kir_qUqaIxz1MMbZJWTf7bxnTtBg7m9sLrpY35QpE8/s400/screenshot1691.jpg" width="400" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;">Although not as disappointing as blowing $1 of your allowance on these.</span></td></tr>
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<span style="font-family: "Trebuchet MS",sans-serif;">A great use of lung ultrasound is to help suggest the etiology of acute dyspnea, mainly to distinguish acute pulmonary edema from other causes. The "<a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734893/"><b>BLUE protocol</b></a>" of Lichtenstein has shown that certain lung ultrasound findings can be very accurate for acute edema.</span><br />
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<tr><td style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQRRtSdrzR9t02J2WcbxE7UnrRMmOHsvR_owTXvl-OoG1cgQxA5vMYkTBretSz8yn_riZhSRZjNCjMQHcQRPuAa7AsxL8hFPL7v4mMGU4rZGAWqaZlzAc8IiSw70Jnl1niSjkFZXNW0o9I/s1600/screenshot1689.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="242" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQRRtSdrzR9t02J2WcbxE7UnrRMmOHsvR_owTXvl-OoG1cgQxA5vMYkTBretSz8yn_riZhSRZjNCjMQHcQRPuAa7AsxL8hFPL7v4mMGU4rZGAWqaZlzAc8IiSw70Jnl1niSjkFZXNW0o9I/s400/screenshot1689.jpg" width="400" /></a></span></td></tr>
<tr align="right"><td class="tr-caption"><span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/18403664">CHEST</a></span></td></tr>
</tbody></table>
<span style="font-family: "Trebuchet MS",sans-serif;"><br />Specifically, Lichtenstein found that "<i>diffuse anterior B-lines with lung sliding</i>" was <b>97% sensitive</b>, and <b>95% specific</b>, for cardiogenic pulmonary edema. So, if you have bilateral "B-hives," maybe we don't even need chest X-rays or BNPs!</span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>Let's apply this to a case.</b></u></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">An elderly female was brought to the ED with apparently acute onset shortness of breath. The history was sketchy, owing to the patient's dementia, but EMS reported a room-air sat in the 80's, improved with oxygen. In the ED she was tachycardic, hypoxic, and (initially) afebrile. No JVD or pedal edema. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">Ultrasound scans of the bilateral thoracic apices and bases was performed immediately.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">However, her heart appeared to be squeezing quite well...</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">... and her IVC did not appear particularly plethoric either:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">This seemed highly atypical for systolic or diastolic heart failure, and so we started antibiotics, and deferred nitro or diuretics. She later developed a fever in the ED, vindicating our decision.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Interestingly, the ED CXR showed only a left-sided infiltrate:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnsGP4kKIOEuOeXBJ2iaIAoSHeSICoYfMq-L-s-V1CfJysL6cthWjF6guqkgokZ_WPM5cF-_I3IRAzSTt2bhf2xvuSwdVcVwhyphenhyphenTKQG5FwU8tsHLqwsoTavG-PxrJyjII5_3HPeJqr3U6A_/s1600/screenshot1692.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="268" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgnsGP4kKIOEuOeXBJ2iaIAoSHeSICoYfMq-L-s-V1CfJysL6cthWjF6guqkgokZ_WPM5cF-_I3IRAzSTt2bhf2xvuSwdVcVwhyphenhyphenTKQG5FwU8tsHLqwsoTavG-PxrJyjII5_3HPeJqr3U6A_/s320/screenshot1692.jpg" width="320" /></a></span></div>
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">After the resident intubated the persistently-hypoxic patient, I predicted that, based on the lung ultrasound, that this was actually a bilateral pneumonia, and that she would deteriorate dramatically in the next few days. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">And indeed, 2 days later, her status was worsening, and a CXR showed progressive infiltrates bilaterally:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIyRdxYQMHs9DFw2FxbMn4Nto7iH1Nnsqip6X5es46TEQjwLKpk9F7_szHjctpD34fQ55EzQWAUARTx65R9NkILr8pAVzd7QWPOQhYFP5QzQOE3Otm20UrourTIi9N6LFTiZKbzs4_gEHf/s1600/screenshot1693.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="285" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIyRdxYQMHs9DFw2FxbMn4Nto7iH1Nnsqip6X5es46TEQjwLKpk9F7_szHjctpD34fQ55EzQWAUARTx65R9NkILr8pAVzd7QWPOQhYFP5QzQOE3Otm20UrourTIi9N6LFTiZKbzs4_gEHf/s320/screenshot1693.jpg" width="320" /></a></span></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>What happened to "<i>95% specific</i>?"</b></u></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">I can't dive into the weeds of Lichtenstein's methods or results, but there were numbers in his article that suggested caution in adopting his BLUE protocol. Of the <b>68</b> patients with diffuse anterior B-lines, <b>6</b> were ultimately diagnosed with pneumonia. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">I'm not sure how this squares with the "95% specific" figure, with 9% of patients being incorrectly predicted as cardiogenic pulmonary edema. Nonetheless, don't get carried away with lung ultrasound, without taking account of the clinical context!</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><b>Open-Access Reference:</b></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3734893/"><b>Relevance of lung ultrasound in the diagnosis of acute respiratory failure: the BLUE protocol.</b></a></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-30516902323786011272016-05-13T20:06:00.000-07:002016-05-13T20:06:24.783-07:00PE with a negative CT: Basic & Bonus lessons.<style>
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<span style="font-family: "trebuchet ms" , sans-serif;"></span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"> </span><span style="font-family: "trebuchet ms" , sans-serif;">A healthy male came to the ED complaining of chest pain and
exertional dyspnea, worsening over the past few days. He mentioned that it felt
like “<i>the time I had a PE.</i>” <span style="font-family: "trebuchet ms" , sans-serif;">(Th<span style="font-family: "trebuchet ms" , sans-serif;">at PE had been</span></span> provoked by a
lower-extremity fracture, and he had completed 6 months of anticoagulation
without problems.)</span><span style="font-family: "trebuchet ms" , sans-serif;"> </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">While the vitals and exam were unremarkable, the
ECG suggested RV strain: </span></div>
<span style="font-family: "trebuchet ms" , sans-serif;">
</span><br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQeLXJ62xCzPcYuyD78kEtrtcoCbSKFBk2FY-sdRiA1ZAMbKqT2dYZNt4H-XBnJENdlYGCEvL1zVTbflzuqtmXjcNTwdUQNEH3dV2THCfNBVmf0eqSMe2vxXYXvsi2GbUW54XhBmTN4Vv2/s1600/screenshot1685.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="127" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjQeLXJ62xCzPcYuyD78kEtrtcoCbSKFBk2FY-sdRiA1ZAMbKqT2dYZNt4H-XBnJENdlYGCEvL1zVTbflzuqtmXjcNTwdUQNEH3dV2THCfNBVmf0eqSMe2vxXYXvsi2GbUW54XhBmTN4Vv2/s400/screenshot1685.jpg" width="400" /></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">A bedside echo also supported RV strain,with the apical 4-chamber showing</span><span style="font-family: "trebuchet ms" , sans-serif;"> notable RV
dilation and septal bowing.</span></div>
<span style="font-family: "trebuchet ms" , sans-serif;">
</span><br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dzWAc4XYmAO93R4tgD-zQ_X1x1TbNF_KWZ5U-6NI2R0NRiz3WmBKQrEVzC333h8cqiGwUmMPvhNJdZr9D8ZUQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<span style="font-family: "trebuchet ms" , sans-serif;">
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<span style="font-family: "trebuchet ms" , sans-serif;">A CT for PE was
ordered. Even before he had left for the CT suite, however, enoxaparin was
ordered. The patient, who had been reading quite a bit about diagnosing and
treating PEs in the past few days (quite educated!), reasonably asked why
treatment was being ordered prior to the test.</span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><b>The Basic Lesson:</b> </span></div>
<span style="font-family: "trebuchet ms" , sans-serif;">
</span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">If the patient has a<b> high probability</b> of having a PE, t</span>here is still a <a href="http://pubs.rsna.org/doi/full/10.1148/radiol.2421060971"><b>40%</b> chance of PE if the CTA is negative</a>.</span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvn7ONsZgCHREoBN-HHZ9YQ77eQynkcvjelqdlNMyOswqUhPIwq5TNmNB-6LkCPM7p8QweFZQ7u4gy1hPKBEZmpeA_OUMn67d-RVU6afU_7nUTPMUz5_QD7k8LVsv4-Cr9paLyA40XFAyq/s1600/screenshot1687.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="179" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgvn7ONsZgCHREoBN-HHZ9YQ77eQynkcvjelqdlNMyOswqUhPIwq5TNmNB-6LkCPM7p8QweFZQ7u4gy1hPKBEZmpeA_OUMn67d-RVU6afU_7nUTPMUz5_QD7k8LVsv4-Cr9paLyA40XFAyq/s320/screenshot1687.jpg" width="320" /></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">
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<span style="font-family: "trebuchet ms" , sans-serif;">In this case, the ED
echo, along with the clinical and ECG data, assuredly defined this patient as
very high risk for PE. </span><span style="font-family: "trebuchet ms" , sans-serif;"> </span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">Des<span style="font-family: "trebuchet ms" , sans-serif;">pite the high probability,</span></span> the CTA <i>was</i> <span style="mso-bidi-font-weight: normal;">negative</span>. However, a V/Q done the next day was
interpreted as <b style="mso-bidi-font-weight: normal;">high probability</b> for
PE, with multiple areas of mismatch.</span><span style="font-family: "trebuchet ms" , sans-serif;"> </span><span style="font-family: "trebuchet ms" , sans-serif;"> </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">So, the CTA is <b>not</b> the gold standard we often take it to be<span style="font-family: "trebuchet ms" , sans-serif;">, and we need to be careful <span style="font-family: "trebuchet ms" , sans-serif;">to avoid ruling-out VTE prematurely. Of course, <span style="font-family: "trebuchet ms" , sans-serif;">patients who are <b>truly</b> high probability for PE are infrequently seen<span style="font-family: "trebuchet ms" , sans-serif;"> <span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">(</span>only</span> <b>6%</b> of <span style="font-family: "trebuchet ms" , sans-serif;">subjects in <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa052367">PIOPED II</a>)<span style="font-family: "trebuchet ms" , sans-serif;">.</span></span></span></span></span></span></span></div>
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<b><span style="font-family: "trebuchet ms" , sans-serif;">The <span style="font-family: "trebuchet ms" , sans-serif;">Bonus</span> Lesson:</span></b></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"> </span></div>
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<div class="MsoNormal">
<span style="font-family: "trebuchet ms" , sans-serif;">Why the discrepancy? The answer was likely on the ED echo as
well.</span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">Color <span style="font-family: "trebuchet ms" , sans-serif;">and</span> continuous wave Doppler, were used to interrogate the tricuspid valve.<span style="font-family: "trebuchet ms" , sans-serif;"> <span style="font-family: "trebuchet ms" , sans-serif;">Only a moderate degree of regurgitation was seen, but with impres<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">s</span>ive velocities<span style="font-family: "trebuchet ms" , sans-serif;">. The RV inflow view is sho<span style="font-family: "trebuchet ms" , sans-serif;">wn here<span style="font-family: "trebuchet ms" , sans-serif;">:</span></span></span></span></span></span></span></div>
</div>
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<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dzYct26YLNX6ki_ghiHGK8Hd-kb0v-KmJJGFX3sRuyWVJ4CR9IyP4zGYyTtmTklHimMijRC_MsnhEDegPTI5g' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">The maximum vel<span style="font-family: "trebuchet ms" , sans-serif;">ocity of the TR jet exceeded <b>4 m/s</b>, <span style="font-family: "trebuchet ms" , sans-serif;">suggesting a RV systolic pressure over <b>70 mm Hg</b>. This is a <a href="http://www.ncbi.nlm.nih.gov/pubmed/12208411">bit high for a</a><span style="font-family: "trebuchet ms" , sans-serif;"><a href="http://www.ncbi.nlm.nih.gov/pubmed/12208411">n acute PE</a>, and suggests <span style="font-family: "trebuchet ms" , sans-serif;">instead that a chronic process is involved. And indeed, chronic PE is known to be poorly visualized by CTA, but wel<span style="font-family: "trebuchet ms" , sans-serif;">l demonstrated on V/<span style="font-family: "trebuchet ms" , sans-serif;">Q s<span style="font-family: "trebuchet ms" , sans-serif;">cans.</span></span></span></span></span></span></span></span>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
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Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com3tag:blogger.com,1999:blog-8813712063505457206.post-24095584876655867602016-04-08T10:05:00.001-07:002016-04-08T10:05:30.486-07:00Big bad bladder? <span style="font-family: "Trebuchet MS",sans-serif;"></span><span style="font-family: "Trebuchet MS",sans-serif;">Little old lady sent in from nursing home. </span><span style="font-family: "Trebuchet MS",sans-serif;"></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">She had been noted to be anuric, but also had a distended abdomen. A bladder scan had been done, and was markedly positive, reading about a liter. Placement of a Foley catheter, however, had returned only a minimal amount of urine, and so she was sent to the ED for her "difficult catheterization."</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Oddly, placement of the urinary catheter did <i>not</i> seem difficult to the emergency nurses, but even though the Foley flushed well, and the flush could be aspirated, only trivial amounts of urine were obtained, </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">A bedside ultrasound easily identified a gigantic "bladder", but the balloon and tip of the Foley could not be located.</span><br />
<div class="separator" style="clear: both; text-align: center;">
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dxTr5dq1RAFCEgCSehwptfXz9L1DoYvsbaJNpbTTTe9b5GiwKw5EaMVqWRgv6oVKIuoQDMtlLxT2iYrrJYTmQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><br />Despite numerous tricks of Foley placement, and extensive US investigation, no urine could be obtained, and a CT scan was ordered to check for abnormal anatomy.</span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0GDkmi9EM4Q-43Lo5CXY6lGEMeI-I4I8IYGJ_D2Wr1lE1KekfJenGS19KYT2X7IQyetirm2GN34ARH-8nCRhcTb03UP9cL_Ei8pk5UbT-NW3iuGh4vbrg2bVDixTdcCxaJJ5NW3qVsvTz/s1600/Rebal_cyst_CT_2.PNG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="304" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg0GDkmi9EM4Q-43Lo5CXY6lGEMeI-I4I8IYGJ_D2Wr1lE1KekfJenGS19KYT2X7IQyetirm2GN34ARH-8nCRhcTb03UP9cL_Ei8pk5UbT-NW3iuGh4vbrg2bVDixTdcCxaJJ5NW3qVsvTz/s320/Rebal_cyst_CT_2.PNG" width="320" /></a></span></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;">Bingo!</span></td></tr>
</tbody></table>
<span style="font-family: "Trebuchet MS",sans-serif;">Turns out that <i>wasn't </i>a bladder, but instead a <a href="http://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-7-39#CR13"><b>giant renal cyst</b></a>. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Repeat bedside ultrasound demonstrated that the clues had been there, but that they were subtle (in the sagittal suprapubic view) or quite difficult to obtain (right coronal view of the kidney).</span><br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwGFVCOr3dM2RyQG9blrybhnHkxg2Y3MgRgINIzDzbOuc9Y4bAx3B7dg4MX-OfRU-Ne8mMoZt0hZ0Zkjq4Rww' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Renal cysts of this size are fairly rare, and so this scenario, where urinary catheterization is pursued fruitlessly, is unlikely to be encountered often. But the signs of a misplaced balloon, as well as cystic structure in the kidney, could have been appreciated without the aid of CT imaging. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Open-Access References:</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><b><a href="http://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-7-39#CR13">A huge renal cyst mimicking ascites: a case report</a></b></span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;"><b><a href="http://medind.nic.in/jac/t06/i3/jact06i3p252.pdf">An Unusual Cause of Giant Renal Mass </a></b></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-65781284354698502272016-03-30T11:22:00.000-07:002016-03-30T18:00:23.120-07:00Yin and Yang in the groin.<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyBJC8_aEuhBy4F4xy2E3oOPoyZnhdcP4Cl6zytxrnURdKaWiOv8lpZB8dQ5q4y16ISj7zeFzuaTCBnZ7rJVnywxGTbgUoqGeUAXI7I7MJ6nxd_GNPj5gYBTENMLbdxbmGpyXPf36Wi0eT/s1600/screenshot1648.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="142" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgyBJC8_aEuhBy4F4xy2E3oOPoyZnhdcP4Cl6zytxrnURdKaWiOv8lpZB8dQ5q4y16ISj7zeFzuaTCBnZ7rJVnywxGTbgUoqGeUAXI7I7MJ6nxd_GNPj5gYBTENMLbdxbmGpyXPf36Wi0eT/s320/screenshot1648.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS", sans-serif;">True, this <i>is</i> a Yin & Yang on the groin, <br />but not quite what we're aiming for...</span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS", sans-serif;"> </span></td><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS", sans-serif;"> </span></td><td class="tr-caption" style="text-align: center;"><br /></td></tr>
</tbody></table>
<span style="font-family: "trebuchet ms" , sans-serif;"><u><b>The case</b></u></span><span style="font-family: "trebuchet ms" , sans-serif;"> </span><br />
<span style="font-family: "trebuchet ms" , sans-serif;">The patient had undergone emergent angiography and PCI for a STEMI. Access for the PCI was gained through the radial artery, which is associated with fewer complications than femoral artery access. Unfortunately, they also required placement of an intra-aortic balloon pump, which was placed through the right femoral artery.</span><br />
<span style="font-family: "trebuchet ms" , sans-serif;">At a follow-up appointment soon after discharge, examination revealed swelling in the right inguinal crease</span><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">.</span> The swelling was both pulsatile and had a sharp systolic bruit.</span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;">Point-of-care ultrasound (POCUS) of the area of pulsatility was conducted with both B-mode and color Doppler.</span><br />
<div class="separator" style="clear: both; text-align: center;">
<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dw9jRvoaoZ8QOozmZB5A_mjcN_jWuku04HPtjce2iYj8Ixf8Q61oawlSdix05W8DqZGx1T9AwAVkAS4Ui7I0g' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
<br />
<span style="font-family: "trebuchet ms" , sans-serif;"></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"></span>
<span style="font-family: "trebuchet ms" , sans-serif;">The physical exam, of course, <span style="font-family: "trebuchet ms" , sans-serif;">h<span style="font-family: "trebuchet ms" , sans-serif;">ad been</span></span> strongly suggestive of a </span><span style="font-family: "trebuchet ms" , sans-serif;"><b>pseudoaneurysm</b> of the femoral artery<span style="font-family: "trebuchet ms" , sans-serif;">. T</span>he POCUS is diagnostic<span style="font-family: "trebuchet ms" , sans-serif;">!</span></span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjR97Ik0_3qm6HPSRcHZalQeLDVjY8-Wg0aHMUN_5iW7Q9DJjvrs-BXvcU_4WUkTSPMVCA03lVez-N4u9HFWfhV4KUh2_womzjtLMHmdFBYQ04iqoGVh5W2NEJf8rdW_Bdvghujjy8y7p22/s1600/screenshot1650.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="287" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjR97Ik0_3qm6HPSRcHZalQeLDVjY8-Wg0aHMUN_5iW7Q9DJjvrs-BXvcU_4WUkTSPMVCA03lVez-N4u9HFWfhV4KUh2_womzjtLMHmdFBYQ04iqoGVh5W2NEJf8rdW_Bdvghujjy8y7p22/s320/screenshot1650.jpg" width="320" /></a></div>
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<span style="font-family: "trebuchet ms" , sans-serif;">The<b> B-mode image</b> shows a large pulsatile hypoechic structure, but a post-operative hematoma might have the same appearance (e.g. if an adjacent artery was causing pseudo-pulsation). </span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><b>Color Doppler</b> is required to exclude hematoma by demonstrating pulsatile flow <i>within</i> the structure. Such flow may appear as a "swirling" or "to and fro" pattern.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzZinphhqfZ7jJxkCL8CWxLdym6u9Q4x_goYpwmUdUP5wWYWoU6EQmsZXACM_FBaIW57IXqVkiggQrg7W6XKhvMjNK9qxXizz4I8KcxbkVBPFadhWzgzzm6xeGyLPiPNu3k2PErBRBvSCg/s1600/screenshot1652.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhzZinphhqfZ7jJxkCL8CWxLdym6u9Q4x_goYpwmUdUP5wWYWoU6EQmsZXACM_FBaIW57IXqVkiggQrg7W6XKhvMjNK9qxXizz4I8KcxbkVBPFadhWzgzzm6xeGyLPiPNu3k2PErBRBvSCg/s320/screenshot1652.jpg" width="274" /></a></div>
<span style="font-family: "trebuchet ms" , sans-serif;">Even more "colorfully" (pun intended), the pattern has been described as the <a href="http://www.jultrasoundmed.org/content/27/1/95.full.pdf"><b>Yin-Yang sign</b></a>.</span><br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguG13SXWFQLH_xNGnrFEVINh02dpsXU76zZRpvNHweAV5NcvxflPXT_6wut32sepEat0EQgYeEyo0iS6SMF5SYd6nFhL-r8O7wDlXtXSU2_Sh9V7llHl-a8pgoRPgfTe56BOSvIQlniKe7/s1600/screenshot1651.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="283" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEguG13SXWFQLH_xNGnrFEVINh02dpsXU76zZRpvNHweAV5NcvxflPXT_6wut32sepEat0EQgYeEyo0iS6SMF5SYd6nFhL-r8O7wDlXtXSU2_Sh9V7llHl-a8pgoRPgfTe56BOSvIQlniKe7/s320/screenshot1651.jpg" width="320" /></a></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><b>Treatment</b> </span><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">can be as simple as ultrasound-directed compression of </span></span><span style="font-family: "trebuchet ms" , sans-serif;">the </span><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">pseudoaneurysm sac, or as invasive as surgical management. The majority of post-cathetererization </span></span><span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;">pseudoaneurysms, however, are managed with <a href="http://circ.ahajournals.org/content/115/20/2666.full"><b>injection of thrombin into the sac</b></a>. This is almost always successful.</span></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">And lastly, speaking of things that required fixing...</span><br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy-9d_ionExqcgJlY2qhkUHi9bLpGSPyPDkjFWnc9YK50TqD5tdz00OngfJ4ztGK8HIy2wSKWLDG6vIgODzcNEBVPvECR1RBvV1vmeDTnBIubMEO_EYi2bELCeLYOWYo9xWE070mfSzp1P/s1600/screenshot1653.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="165" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjy-9d_ionExqcgJlY2qhkUHi9bLpGSPyPDkjFWnc9YK50TqD5tdz00OngfJ4ztGK8HIy2wSKWLDG6vIgODzcNEBVPvECR1RBvV1vmeDTnBIubMEO_EYi2bELCeLYOWYo9xWE070mfSzp1P/s320/screenshot1653.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: "Trebuchet MS",sans-serif;">Perfect</span>!</td></tr>
</tbody></table>
<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><span style="font-family: "trebuchet ms" , sans-serif;"></span></span>
<span style="font-family: "trebuchet ms" , sans-serif;"><u><b>Open-access references:</b></u><br /><a href="http://circ.ahajournals.org/content/115/20/2666.full"><b>Contemporary Management of Postcatheterization Pseudoaneurysms</b></a></span><br />
<a href="http://www.jultrasoundmed.org/content/27/1/95.long"><b><span style="font-family: "trebuchet ms" , sans-serif;">Sonographic Evaluation of Vascular Injuries</span></b></a>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com1tag:blogger.com,1999:blog-8813712063505457206.post-74008473717268302532016-03-25T10:26:00.002-07:002016-03-28T19:18:32.247-07:00Gusano de la muerte<span style="font-family: "trebuchet ms" , sans-serif;">A young adult presented to the emergency department with chest pain and shortness of breath.<br /><br />They had had an ICD placed years ago, but this had been removed a month ago after they had been developed bacteremia. A large vegetation had been found on the right ventricular ICD lead, and the post-removal echo had been normal. A PICC in the right arm was delivering antibiotics.</span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
<span style="font-family: "trebuchet ms" , sans-serif;">The chest discomfort was modestly pleuritic, and they endorsed recent development of a cough and chills. A chest X-ray was interpreted as showing an infiltrate, so antibiotics for health-care associated pneumonia were started.<br /><br />A bedside echo was performed, and the following clips were obtained from the <a href="http://www.wikiecho.org/wiki/Transducer_positions_and_views#RV_inflow_view">RV inflow view</a> (N.B. the probe orientation here is "flipped" from the cardiologists' convention):</span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwj-xmIYQjZbk16AsXNfEgZ1ZhST7O-h1EBo4I_-Gr5SKJFaSL3_Li8G1P8EbjZWglMHT13ztwWvxTOABrbTQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div>
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<span style="font-family: "trebuchet ms" , sans-serif;"><b>What two findings suggest further imaging?</b></span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcpBsPQEtl3bA6ouvYXwWJrZP9Y5h5KdRW4_xsyJof5hMnDpAttCEzoiTkfaHnvd0C4dugormS_43lVKrNJbRWi1-p9mljJA9IkAUlQnX_Nx8O-4tpBWs20fkj8uOCS9eDuWR0lmLsmjMA/s1600/screenshot1637.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="284" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcpBsPQEtl3bA6ouvYXwWJrZP9Y5h5KdRW4_xsyJof5hMnDpAttCEzoiTkfaHnvd0C4dugormS_43lVKrNJbRWi1-p9mljJA9IkAUlQnX_Nx8O-4tpBWs20fkj8uOCS9eDuWR0lmLsmjMA/s320/screenshot1637.jpg" width="320" /></a></span></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
<span style="font-family: "trebuchet ms" , sans-serif;">First, the dramatic, circus-like <b>tricuspid regurgitation</b> suggests either a new problem with the valve, or new pulmonary hypertension. Comprehensive echocardiography is indicated to investigate the valve and assess for pulmonary hypertension. </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">But <i>why</i> is there TR? </span><br />
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhTguh2zuJyKyfo3wtj2DL6wr4Zq2tv7z7IiACKl3TF22WdXndTH6nKTbffKjRnAIJitQhiyENLAcVid4ZXGQKoZHydmfXli7ngytOdBKJD1oGdo8On70Onl78G6fjv5MKCC1CQo82Hgs7/s1600/screenshot1645.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="222" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhTguh2zuJyKyfo3wtj2DL6wr4Zq2tv7z7IiACKl3TF22WdXndTH6nKTbffKjRnAIJitQhiyENLAcVid4ZXGQKoZHydmfXli7ngytOdBKJD1oGdo8On70Onl78G6fjv5MKCC1CQo82Hgs7/s320/screenshot1645.jpg" width="320" /></a></div>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
<span style="font-family: "trebuchet ms" , sans-serif;">Probably because of the little <a href="https://es.wikipedia.org/wiki/Aka_Allghoi_Khorhoi"><b><i>gusano</i></b></a> in the RA that the red arrows are pointing at. Although RA masses have a broad differential, the history (a recent normal echo, PICC, recent hospitalization) obligated consideration of a pulmonary embolism. Which the the patient had: A CT scan revealed that the "infiltrate" was hiding a PE. <br /><br />Venous emboli in transit through the heart are often described as "worm-like" or serpiginous in appearance, although other morphologies are described. Other signs of venous thrombolic embolic disease are typically present, and a <a href="http://circ.ahajournals.org/content/99/21/2779.full">PE is diagnosed through complementary imaging</a>, as was the case with this patient. </span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;">It is crucial to highlight, however, that a point-of-care ultrasound may be the sole test that suggests VTE. A <a href="http://www.jultrasoundmed.org/content/34/4/727.full">recent case report by Minardi <i>et al</i>.</a> described a patient with a history strongly suggestive of PE, and a right atrial mass but a negative CTA for PE.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><b><u>UPDATE</u></b></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;">Although
the RA clot seemed obvious on the screen of my US machine, it has been
pointed out that my clips above are not unambiguous. <br /><br />Well, it
doesn't help to simply sputter "It was there, I tell you!" Instead, let
me offer a clip from the formal echo that was obtained soon after my
focused ED echo. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">WARNING: While it demonstrates more clearly the mass in the RA, the quality of the clip here is, quite frankly, horrid.</span><br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwWbzg1OhK_yCe4ywCgSEvSmParEF9oYeTno1QIkGZJhhNmnmkQII0KxT8V_zzx0i-Ixl4ol-qy6m_6SYPHMw' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
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<span style="font-family: "trebuchet ms" , sans-serif;"><u><b>References</b></u>:<br /><a href="http://circ.ahajournals.org/content/99/21/2779.full"><b>Free-Floating Thrombi in the Right Heart </b></a></span><br />
<br />
<span style="font-family: "trebuchet ms" , sans-serif;"><a href="http://www.jultrasoundmed.org/content/34/4/727.full"><b>Focused Cardiac Ultrasound: Uncommon but Critical Diagnoses Made at the Point of Care</b></a></span><br />
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<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>
<span style="font-family: "trebuchet ms" , sans-serif;"><br /></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-80051460065844420812016-03-07T13:22:00.004-08:002016-03-07T13:22:57.325-08:00"Atrial belly-dance," aka Atrial Septal Aneurysm<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">A woman with sickle cell disease, CAD, and pulmonary hypertension came to the ED with dyspnea, and a focused cardiac ultrasound (<b>FoCUS</b>) was performed. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">Ventricular function and dimensions were unremarkable, but a good view of the atria revealed an odd finding:</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
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<span style="font-family: "Trebuchet MS",sans-serif;"><iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dzsoQ7wOu8hwS96Lij26MC1Red4gWuIS-OZKw8EYNrc51xHn0yUS0g47UHLvgIdZkhn8qPEVuAcLQrbP5NYiQ' class='b-hbp-video b-uploaded' frameborder='0'></iframe></span></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>What the heck is that?</b></u></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">An atrial septal aneurysm (ASA). This is infrequently seen, and has been described as a benign congenital abnormality in the past. However, much like a PFO, there appears to be an <a href="http://circ.ahajournals.org/content/91/11/2785.long">association with cerebral emboli</a>. </span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;">Criteria for ASA aren't completely clear, but a common definition requires ≥ 10 mm of atrial septal excursion. In the picture below(from an <a href="http://circ.ahajournals.org/content/91/11/2785.long">open-access article</a>), the total excursion = a + b.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
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<span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHhkzTsDd59m4LdH_20zGdUtItPOx9JjiNQMqqAVzAqoyvgIKxPKCjMCsuBYIcu2yE-bWvIjgQ6Nq9_ctSQAiat-YIjybxCFvcfp5e8EQqtycg7aBPqFjeFhlXqn0iwDvjUqcX9EcaFc2S/s1600/screenshot1618.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHhkzTsDd59m4LdH_20zGdUtItPOx9JjiNQMqqAVzAqoyvgIKxPKCjMCsuBYIcu2yE-bWvIjgQ6Nq9_ctSQAiat-YIjybxCFvcfp5e8EQqtycg7aBPqFjeFhlXqn0iwDvjUqcX9EcaFc2S/s400/screenshot1618.jpg" width="300" /></a></span></div>
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">Emergency physicians have learned to recognize a number of cardiac conditions besides the 4 or 5 problems usually sought on a FoCUS. With increasing utilization, however, rare abnormalities will be <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4162738/">increasingly identified in the ED</a>. </span><br />
<br />
<span style="font-family: "Trebuchet MS",sans-serif;">An ASA found on FoCUS does not require urgent therapy, and outpatient referral to cardiology would most likely be appropriate. On the other hand, if an ASA is found in a patient being investigated for a suspected acute stroke, this finding should be discussed with cardiology, since specific echocardiographic testing (e.g. bubble test for PFO, a TEE for atrial thrombi) may be pursued.</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><br /></span>
<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>Open-Access references:</b></u></span><br />
<div class="csl-bib-body" style="line-height: 1.35; padding-left: 2em; text-indent: -2em;">
<div class="csl-entry">
<span style="font-family: "Trebuchet MS",sans-serif;">Butterfield, Michael, Christine Riguzzi, Oron Frenkel, and Arun Nagdev. “From the Heart: Interatrial Septal Aneurysm Identified on Bedside Ultrasound.” <i>Western Journal of Emergency Medicine</i> 15, no. 6 (September 2014): 719–20. doi:10.5811/westjem.2014.7.22972.</span></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><span class="Z3988" title="url_ver=Z39.88-2004&ctx_ver=Z39.88-2004&rfr_id=info%3Asid%2Fzotero.org%3A2&rft_id=info%3Adoi%2F10.5811%2Fwestjem.2014.7.22972&rft_id=info%3Apmid%2F25247052&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=From%20the%20Heart%3A%20Interatrial%20Septal%20Aneurysm%20Identified%20on%20Bedside%20Ultrasound&rft.jtitle=Western%20Journal%20of%20Emergency%20Medicine&rft.stitle=West%20J%20Emerg%20Med&rft.volume=15&rft.issue=6&rft.aufirst=Michael&rft.aulast=Butterfield&rft.au=Michael%20Butterfield&rft.au=Christine%20Riguzzi&rft.au=Oron%20Frenkel&rft.au=Arun%20Nagdev&rft.date=2014-09&rft.pages=719-720&rft.spage=719&rft.epage=720&rft.issn=1936-900X"></span></span>
</div>
<div class="csl-bib-body" style="line-height: 1.35; padding-left: 2em; text-indent: -2em;">
<div class="csl-entry">
<span style="font-family: "Trebuchet MS",sans-serif;">Mügge, Andreas, Werner G. Daniel, Christiane Angermann, Christoph Spes, Bijoy K. Khandheria, Itzhak Kronzon, Robin S. Freedberg, et al. “Atrial Septal Aneurysm in Adult Patients A Multicenter Study Using Transthoracic and Transesophageal Echocardiography.” <i>Circulation</i> 91, no. 11 (June 1, 1995): 2785–92. doi:10.1161/01.CIR.91.11.2785.</span></div>
<span style="font-family: "Trebuchet MS",sans-serif;"><span class="Z3988" title="url_ver=Z39.88-2004&ctx_ver=Z39.88-2004&rfr_id=info%3Asid%2Fzotero.org%3A2&rft_id=info%3Adoi%2F10.1161%2F01.CIR.91.11.2785&rft_id=info%3Apmid%2F7758185&rft_val_fmt=info%3Aofi%2Ffmt%3Akev%3Amtx%3Ajournal&rft.genre=article&rft.atitle=Atrial%20Septal%20Aneurysm%20in%20Adult%20Patients%20A%20Multicenter%20Study%20Using%20Transthoracic%20and%20Transesophageal%20Echocardiography&rft.jtitle=Circulation&rft.stitle=Circulation&rft.volume=91&rft.issue=11&rft.aufirst=Andreas&rft.aulast=M%C3%BCgge&rft.au=Andreas%20M%C3%BCgge&rft.au=Werner%20G.%20Daniel&rft.au=Christiane%20Angermann&rft.au=Christoph%20Spes&rft.au=Bijoy%20K.%20Khandheria&rft.au=Itzhak%20Kronzon&rft.au=Robin%20S.%20Freedberg&rft.au=Andre%20Keren&rft.au=Karl%20Dennig&rft.au=Rolf%20Engberding&rft.au=George%20R.%20Sutherland&rft.au=Zvi%20Vered&rft.au=Raimund%20Erbel&rft.au=Cees%20A.%20Visser&rft.au=Oliver%20Lindert&rft.au=Dirk%20Hausmann&rft.au=Paul%20Wenzlaff&rft.date=1995-06-01&rft.pages=2785-2792&rft.spage=2785&rft.epage=2792&rft.issn=0009-7322%2C%201524-4539&rft.language=en"></span></span>
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Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-38643412436416583902016-03-03T11:14:00.002-08:002016-03-03T11:14:38.484-08:00What changed in the second echo clip?<span style="font-family: "Trebuchet MS",sans-serif;">A young adult was brought to the ED with seizure versus syncope, and an echocardiogram was performed. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">These two clips were obtained within seconds of each other, and I've combined them in sequence here. Of course, color Doppler is being employed in the second clip, but there is a subtle abnormality. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Perhaps it would be helpful to see the cardiac rhythms. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">During the first clip, the monitor showed:</span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmtEOHAHa8Z0vZ-xueUDhN77cW2cemQWsT7PBjEivKSL2nU8Qf9tvTdifa8deMhtYzXwAZsiDtUTe6O4npMKYKJgNr6NdBbUb3LIt8ValtxA4Wkg1svWi8XnDHL9jXjp4gPufYXAjK868H/s1600/screenshot1616.jpg" imageanchor="1"><img border="0" height="100" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmtEOHAHa8Z0vZ-xueUDhN77cW2cemQWsT7PBjEivKSL2nU8Qf9tvTdifa8deMhtYzXwAZsiDtUTe6O4npMKYKJgNr6NdBbUb3LIt8ValtxA4Wkg1svWi8XnDHL9jXjp4gPufYXAjK868H/s640/screenshot1616.jpg" width="640" /></a></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">During the second clip, however, the monitor showed:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaw2mU7Jcp7j88Y-72BqiW6a6q66XnnBh9zmzjd2xkf2ec-9j0eemYJKesPOCotbZGF8urQarts7cCcyf5OfjdUkWvPk5kPCaknnp-uCKNkEmbU6p0R2gDIFp8u3daj-5WRC-NdYy6dSYO/s1600/screenshot1617.jpg" imageanchor="1"><img border="0" height="130" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaw2mU7Jcp7j88Y-72BqiW6a6q66XnnBh9zmzjd2xkf2ec-9j0eemYJKesPOCotbZGF8urQarts7cCcyf5OfjdUkWvPk5kPCaknnp-uCKNkEmbU6p0R2gDIFp8u3daj-5WRC-NdYy6dSYO/s640/screenshot1617.jpg" width="640" /></a></span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">These show, respectively, a <b>long QTc</b> and <b>Torsades de Pointes</b>. The patient had no pulse during the second recording.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">Looking back at the second clip, the septal and lateral walls can be seen oscillating at a rate far faster than the opening and closing of the aortic and mitral valves. Here is a slowed-down version:</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"> </span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0tag:blogger.com,1999:blog-8813712063505457206.post-32478424656851453562016-03-01T10:13:00.003-08:002016-03-01T10:13:58.412-08:00Thick apex on FoCUS<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: "Trebuchet MS",sans-serif;">A middle-aged male presented to the ED with dyspnea. He had a history of both severe ischemic cardiomyopathy, as well as poor adherence to outpatient care. He had not seen a physician in 2 years.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">He was mildly hypoxic, and had clinical signs suggestive of heart failure. Point-of-care thoracic ultrasound demonstrated US B-lines. A focused cardiac ultrasound was performed, and apical 4-chamber view obtained.</span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;"><u><b>What does the echo show?</b></u><br />There is marked systolic dysfunction, which is not significantly different than his prior echo report suggested. However, in contrast to the thin septal wall, the apex appears thick, but akinetic. It also seems oddly trabeculated. <br /><br />Sometimes, an obliquely directed A4C view can produce a foreshortened and thick "apex," but that isn't the case here. This is instead a <b>left ventricular thrombus</b>. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">LV thrombi can form in the LV, especially following a large anterior MI that produces a large region (especially the apex) of akinesis. </span><span style="font-family: "Trebuchet MS",sans-serif;">These used to be more common in the past, but are only infrequently seen now in the days of lytics and PCI. </span><br />
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<span style="font-family: "Trebuchet MS",sans-serif;">The rate of embolic complications appears to have decreased in the reperfusion era. Treatment with lytics, heparin, or oral anticoagulants haven't shown an unequivocal benefit. Given this patient's problems with adherence, anticoagulation was defered.<br /><br /><u><b>Reference</b></u></span><br />
<span style="font-family: "Trebuchet MS",sans-serif;"><a href="http://heart.bmj.com/content/98/23/1743.full"><b> Left ventricular thrombus formation after acute myocardial infarction</b></a></span>Brooks Walshhttp://www.blogger.com/profile/16108633682893762401noreply@blogger.com0