Vasoactive Agents in Septic Shock

Author: Kristin E. Fontes, MD
Academic Fellow/Clinical Instructor, Division of Emergency Medicine
Stanford University

This post was peer reviewed.
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Case: The patient is a 91 y/o female with hypertension, hypothyroidism, and Alzhiemer’s dementia brought in by ambulance from home for fever to 102 F and vomiting. There are no other complaints or symptoms per the caregiver and the patient. In the ED, the patient is alert and oriented to self only (at baseline she is oriented to location as well). Vital signs are as follows: T 102.4 F (oral), HR 120, BP 130/80, RR 20, SpO2 91% RA (95% on 4L nasal cannula). Her exam is otherwise notable for dry mucus membranes, decreased breath sounds at the left lung base, soft and non-tender abdomen, and no rash. Initial studies are notable for an EKG showing sinus tachycardia without signs of ischemia and a lactate of 6.14. Chest x-ray showed an opacity in the left lower lobe, and urinalysis showed evidence of infection.

Foot Pain Out of Proportion to Exam: Lisfranc Injuries

Author: Alexandra Murray, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Originally Published: Modern Resident, February-March 2015

Classic medical conditions that are associated with “pain out of proportion to exam” include compartment syndrome, necrotizing fasciitis and mesenteric ischemia.[1-3] However, another condition that can present with excruciating pain, despite underwhelming exam findings, is a Lisfranc injury.[4-6] Lisfranc injuries encompass a broad spectrum of injuries to the tarsometatarsal (TMT) joints that separate the mid-foot and forefoot. These injuries can be purely ligamentous or involve the osseous and articular structures, resulting in dislocation and/or fracture.[4-6]

Lisfranc injuries comprise only 0.2% of all fractures and can result from direct or indirect trauma. Most cases are associated with high-energy motor vehicle accidents (i.e., ATV accidents) where there is a crush injury to the foot. Indirect trauma from a twisting injury combined with axial loading of the foot can also result in plantar displacement (i.e., sports injury or falling from a step). Most Lisfranc injuries are closed without obvious deformity, making the injury difficult to diagnosis.

EKG Rounds: Trauma Induced EKG Changes

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Author: Meaghan Mercer, DO
Emergency Medicine Resident
University of Nevada School of Medicine
AAEM Resident and Student Association President

A 35 year old male presents to the ED after a motor vehicle collision with ejection. The patient has a Glasgow Coma Scale of 4 on arrival and is immediately intubated. The patient has equal pupils and has facial and chest abrasions. The patient is initially tachycardic with a heart rate of 115. He is normotensive and saturating well on the ventilator. A bedside ultrasound shows no pneumothorax and FAST examination is negative. While waiting for the patient to go to CT an EKG is obtained.

What does the ECG show?

Brugada-type EKG inducers

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Author: Kristin E. Fontes, MD
Academic Fellow/Clinical Instructor, Division of Emergency Medicine
Stanford University

Case
A 6 year old boy is sent to the ED by his outpatient cardiologist for fever. He has a history of an abnormal pattern on EKG when he has a fever. He has an implantable loop recorder. Below is a portion of his EKG obtained on arrival to the ED. His temperature was 101.2. What is the diagnosis?

The patient’s EKG shows a Brugada pattern. Here (cited below) is a small study that looked at 47 patients who presented with Brugada-type EKGs and identified potential inducers. Some patients had the common SCN5A mutation, while some did not. Patients may be asymptomatic or have syncope/sudden cardiac death whether or not they have the mutation.

Reported Brugada-type EKG inducers

• Fever
• Drugs with sodium channel blockade properties (cocaine, TCAs, antidysrrhythmics, anesthetics) 
• Propofol

Management priorities in the emergency department
The most important aspects of treatment are stabilization of malignant arrhythmias as well as fever control and/or removal of the offending agent, if applicable. Cardiology consultation is warranted for consideration of genetic testing, electrophysiologic studies, and potential ICD placement.


References

Junttila MJ, Gonzalez M, Lizotte E, et al. Induced Brugada-type electrocardiogram, a sign for imminent malignant arrhythmias. Circulation. 2008;117(14):1890-3.

Allely, Peter. What is Brugada Syndrome?. Life in the Fastlane Blog, http://lifeinthefastlane.com. http://lifeinthefastlane.com/what-is-brugada-syndrome/. Accessed January 12, 2015.

Cardiology Pearl: Brugada Syndrome

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Author: Puja Gopal, MSIV
Medical Student
University of Illinois School of Medicine

A 41-year-old otherwise healthy male presents to the emergency department after a syncopal episode while standing and waiting for the bus. He states he has been experiencing intermittent episodes of lightheadedness while at rest over the past several weeks. The patient has no other associated symptoms and no significant family history. He has no other complaints and a normal physical exam. His EKG is shown below.

EKG:

Brugada syndrome is a critical diagnosis for an emergency physician because left undiagnosed it may lead to cardiac arrest and death. Brugada syndrome is a disorder related to sodium channel dysfunction in the myocardium. It may be hereditary or due to a spontaneous mutation and occurs in otherwise structurally normal hearts. It most commonly occurs in males, especially those of Asian descent, and tends to present around 40 years of age. Estimated incidence is 0.05–0.60% in adults. Brugada is very rarely diagnosed in children.