CITW 5: A Close Shave

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 y/o otherwise healthy male presents to the ED with a rash on his neck. He states he woke up with the rash. It burns, but is not pruritic. He’s never had it before. He endorses some chills, but no fevers.  He states these lesions all appeared in areas where he had been shaved yesterday at the Barber Shop.

Vitals: BP 132/76, HR 67, T 98.9 °F, RR 12, SpO2 99 % on RA

Notable exam findings: See below

PF 1

PF 2

What’s the diagnosis?

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‘Let’s talk about N-STEMI, Let’s talk about Cath, baby, Let’s talk about all the good things and the bad things that may be…’

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing: Mehta et al., NEJM 2005. Routine vs. Selective Invasive Strategies in Patients With Acute Coronary Syndromes. A Collaborative Meta-analysis of Randomized Trials PMID: 15956636

Main Points:

  1. This 2005 meta-analysis was devised to answer one of medicine’s most stubborn (but important) questions: Is an ‘early invasive’ strategy for Unstable Angina (UA) and Non-ST-Elevation Myocardial Ischemia (NSTEMI) associated with improved outcomes compared to medical therapy alone?
  2. Yes and no! High-risk patients with positive biomarkers and evidence of ongoing ischemia seem to gain long-term benefit from immediate coronary angiography and revascularization. This benefit appears to outweigh the increased hazard associated with a routine invasive strategy.
  3. Patients with negative biomarkers and lower risk don’t appear to gain long-term benefit from invasive strategy and therefore the increased hazard of a routine invasive strategy is not justified in this group. Patients with negative biomarkers do just as well with medical therapy alone.




Acute Coronary Syndrome (ACS) comprises a spectrum of illness. Presenting signs, symptoms and clinical findings (elevated troponin, EKG changes) are thought to correlate with the degree and the acuity of ischemia. In theory, patients with more severe illness are thought to benefit from more aggressive therapies – i.e. invasive revascularization – while patients with less severe illness have been thought to derive equal benefit medical therapy alone. To an extent, these suppositions have been proven true: There are clear mortality benefits to emergent PCI for patients with STEMI. However, optimal treatment for patients presenting with unstable angina or NSTEMI remains controversial. Importantly, the goal of revascularization in STEMI is different then in NSTEMI/UA. For STEMI, PCI is intended to restore perfusion by eliminating an occlusive thrombus. In NSTEMI, thrombi typically are not occlusive – thus the focus of PCI is to improve long-term outcomes.


The purpose of this study was to determine whether a routine invasive strategy vs. a selective invasive strategy was more effective in the treatment of ACS. The authors devised a meta-analysis of randomized trials to answer this question. Continue reading

ROCKstars – Case 1: US-Guided Central Venous Access (CIV)

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An elderly patient is in the RIH Critical Care bay with severe sepsis and needs central access.  Luckily, Drs. Adam “Hyperechoic” Haag and Eddie “Rule ‘Em Out” Ruhland are on shift.  They settle on the right Internal Jugular vein, but traditional sternocleidomastoid muscle (SCM) and clavicular bone landmarks are not apparent.  So a linear-array probe is correctly placed transversely over the triangle formed by the bifurcation of the SCM, to where the IJ and Carotid are seen in parallel…but there is some sort of hyperechoic, noncompressible mass…

They identify the thrombus, and instead find the Femoral vein, where CIV access is successfully achieved on the first attempt with no immediate complications.  The use of US to guide this procedure changed this patient’s course and potentially saved a complication.  

But exactly how much safer, faster, and more reliable is US-guided CIV placement?


  • Vascular access is critical in emergent situations
  • Body habitus, dehydration, poor perfusion, anatomical abnormalities, or history of IVDU can cause difficulties and delays when using landmark-based techniques
  • Complications of CIV placement include arterial puncture, excessive bleeding, vessel laceration, pneumothorax, hemothorax, and necessitation of multiple attempts
  • US guidance was identified in 2001 by United States Agency for Healthcare Research and Quality as one of the top 11 means of increasing patient safety, but this was based on one study of subclavian lines at one large urban center (1)

The “SOAP-3” Trial (2005)

  • A concealed, randomized, controlled study of 201 patients
  • Studies dating back to the 1990s in EM and Anesthesia (4) had demonstrated the efficacy of ultrasound-guidance, but this was the first study in the ED setting comparing the anatomical landmark method, the static “quick look” US-guided method, and dynamic “real time” US-guided method
  • In the “quick look” group, US was used to identify landmarks, the skin was marked, and the catheter was placed without real-time US guidance
  • EM residents and Attendings passed a 1h training course, then placed 10 CIVs with dynamic US guidance to qualify to participate



US Guidance


US Guidance

Anatomical Landmarks Method
Overall Success 98% 82% 64%
First-Attempt Success

(OR vs LM)

5.8 3.4
Avg # of Attempts 1.7 1.6 3.2
Avg Total Sec 30 20 150
Complications 2 2 8


  • Dynamic guidance is superior but requires the most training
  • Static guidance is vastly superior to Landmark, and while slightly inferior to Dynamic, it requires less training
  • 10% of the study patients had “extremely narrow” (<5mm) IJs bilaterally, which could explain the inferior performance of the LM technique, even with experienced practitioners
  • All the complications were arterial punctures, and these were not statistically significant


  1. Agency for Health Care Research and Quality (AHRQ). Evidence Report/Technology Assessment: Number 43. Making Health Care Safer. A Critical Analysis of Patient Safety Practices: Summary 2001. 2007.
  1. Milling, et al. Randomized, controlled clinical trial of point-of-care limited ultrasonography assistance of central venous cannulation: The Third Sonography Outcomes Assessment Program (SOAP-3) Trial.  Critical Care Medicine, 2005, Aug;33(8); 1764-9.
  1. Sulek et al.  A Randomized Study of Left versus Right Internal Jugular Vein Cannulation in Adults.  J Clin Anesth, 2000, Mar; 12(2): 142-5

Slow, big breaths ain’t what the doctor’s ordering

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing:  The Acute Respiratory Distress Syndrome Network. “Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome” N Eng J Med, May 2000; 342(18): 1301-08

Main Points

This landmark study was stopped early! It determined that in patients with acute respiratory distress syndrome (ARDS) who are treated with lower tidal volumes than those treated with traditional volumes:

  1. Mortality is decreased by 31.0% vs 39.8% (P = 0.007)
  2. Breathing without assistance increases by the 28th day by 65.7% vs 55.0%
  3. The number of ventilator free days increases by 12 ± 11 vs 10 ± 11. days (P = 0.007)

ARDS is a life-threatening condition for which the mortality was quoted in this study to be approximately 40 to 50 percent.  (To be blunt, any study that uses death as its primary outcome is looking at a very ill cohort.) 

Much has been learned about the pathophysiology of ARDS, but very little headway has been made in the treatment of it. The authors of this study looked at adjusting ventilatory tidal volume and plateau pressures for treatment for ARDS.  The authors also measured plasma interleukin-6 in the first 204 of 234 patients as a measure of lung inflammation. The results were significantly in favor of the lower tidal volume group.  


This was a prospective, randomized controlled study that assorted 861 patients into two groups.  Patients were randomly selected to be treated with tradition ventilation treatments, initial tidal volumes of 12 ml per kilogram of predicted body weight and a plateau pressure of 50 cm of water or less, versus lower tidal volumes of 6 ml per kilogram of predicted body weight and a plateau pressure of 30 cm of water or less.

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CITW 4: Abdominal Pain and a Curious Rash

Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!

HPI: 20 year old female with no significant past medical history who presents to the ED with one week of severe, diffuse abdominal pain. She’s never had this pain before. It waxes and wanes. Nothing makes it better or worse. It is associated with nausea, intermittent joint pain and swelling, and a non-pruritic rash on her lower extremities. She states she had a head cold about three weeks ago, but has been otherwise well. She denies fevers, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, or urinary symptoms. Of note, she was seen at an urgent care when her symptoms started and put on doxycycline for presumed Lyme, although she denies any tick bites.

Vitals: BP 126/81, HR 73, T 98.7 °F, RR 18, SpO2 100 % on RA

Notable physical exam findings: Mild, diffuse abdominal tenderness, but no rebound or guarding. She has scattered, raised, purpuric lesions on her bilateral lower extremities. They are non-painful and non-blanchable (see below).

Notable laboratory workup: Trace, microscopic hematuria and a mildly elevated creatinine (1.24).


What’s the diagnosis?

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EUS for Increased ICP & Proximal Lower Extremity DVT

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Brown Ultrasound Tape Review  –  9:3:2015


Article #1:  Increased ICP via Optic Nerve Sheath Diameter (ONSD)

Amini, et al. (2013). Use of the Sonographic Diameter of Optic Nerve Sheath to Estimate Intracranial Pressure. American Journal of Emergency Medicine 2013; 31: 236–239.

In this 2013 study, Amini et al measured the ONSD of 50 non-traumatized patients undergoing LP and found that an ONSD >5.5mm correlated with an ICP >20mm Hg with a sensitivity and specificity of 100%.  While this sounds great, we discussed well known concerns regarding inter-operator reliability and the technical aspects of accurately measuring the ONSD; measuring Optic Disc elevation is an alternative strategy.

The bottom line:   while normal ONSD measurements cannot rule out increased ICP, it may be a useful adjunct in patients with low pre-test probability.


Article #2:  Proximal Lower Extremity DVT

Crisp, et al. (2010).  Compression Ultrasonography of the Lower Extremity with Portable Vascular Ultrasonography Can Accurately Detect Deep Vein Thrombosis in the Emergency Department.  Annals of Emergency Medicine 2010; 56 (6): 601-611.

In this 2010 study by Crisp et al, 47 ED physicians performed “2 Point Compression” on the Common Femoral and Popliteal veins in 199 patients, and their results were compared to the “comprehensive” results from the Department of Radiology studies that each patient also received.  The physicians took a 10 minutes training session, and the test was “positive” if a thrombus was visualized, or if the vein was non-compressible.  When compared to the Radiology results, the ED docs were 100% sensitive and specific for DVTs in these locations.  Our discussion centered around whether calf veins (which 2 Point Compression does not search for) are worth searching for (no one knows).

The bottom line:  2-point compression with a D-Dimer (and follow up comprehensive study if positive) may be an acceptable strategy for the management of DVT in the ED.


Special thanks and credit to Jon Thorndike

Double-Line Sign? It’s benign.

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To truly understand the FAST exam, you need to be familiar with the common structures and well-known findings, but you also have to know the FAST “fake-outs”.  This post will discuss one common fake-out, the “Double-Line Sign,” and after reading it, you’ll be better armed to avoid a false positive study.

Think FAST, what do you need for a complete study?

Quick review: the FAST is comprised of a series of 4 “views”, each requiring visualization of key structures to be considered complete.

  • Hepatorenal – Look at 5 locations:
    1. Pleural space – Watch for anechoic fluid with lung floating in it and a visible spine (aka “spine sign” indicating supra-diaphragmatic fluid).  Lung tissue which appears to be liver is actually normal; this is called “multi-path reflection”, “duplication” or “mirror” artifact, and it’s due to magic/wave reflection).
    2. Sub-diaphragmatic space
    3. Morison’s Pouch (between liver and kidney)
    4. Tip of Liver – Easy to miss a positive FAST if you don’t check here
    5. Inferior pole of Kidney
    6. Splenorenal –Similar to the 5 locations in the RUQ, but substituting the spleen for the liver The most dependent position is peri-splenic recess, so don’t just stop at the kidney.  (Below, #1: Free fluid in the Pleural Space.  Below, #2: Normal RUQ – note the lack of anechoic fluid above the diaphragm, no visible spine, and the appearance of liver above the diaphragm due to artifact).                                                   Freefluid1
  • Pelvic – Both axial and longitudinal views are needed, as well as a full bladder for a complete scan. Watch for sharp areas of anechoic fluid.  (Below: Positive FAST, showing pelvic free fluid)                                                                                                                                             
  • Pericardial – Subxiphoid views for pericardial effusion.  (Below: Pericardial effusion as seen from subxiphoid view)

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Stop Mucking Around and Throw the End Tidal On: A Safer Way to Perform Procedural Sedation and Analgesia!

This is part of a recurring series examining landmark articles in Emergency Medicine, in the style of ALiEM’s 52 Articles.

Discussing: “Does End-tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices?” Burton, J. Harrah, J. Germann, C. Et al. Acad Emerg Med, May 2006, 13(5): 500-4


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Main Points:

  1. This trial was stopped early after an interim safety analysis demonstrated that standard care was potentially placing patients at higher risk for delayed recognition of acute respiratory events. 17 out of 20 acute respiratory events recorded in the dataset demonstrated changes in the end tidal carbon dioxide (ETCO2) level indicative of hypoventilation or apnea.
  2. Twenty acute respiratory events were recorded in the study cohort of 60 procedural sedation and analgesia (PSA) encounters. In 14 of these episodes, the ETCO2 demonstrated changes prior to SpO2 change or clinically observed hypoventilation.


PSA is a routine practice that is critical to many tasks in the emergency department. There are many guidelines from various professional societies that discuss the components of PSA and associated requirements for safe patient monitoring. Many clinicians use a wide array of pharmacologic options based on patient characteristics when performing PSA, yet it is always challenging to predict how each individual will respond to the drugs used. Therefore, having an extra tool for patient monitoring that will improve safety is a great aid for quality patient care.

ACEP has issued multiple guidelines over the past decade to keep up with the evolution of clinical practice as well as technologic changes such as capnography. Currently ACEP has a level B recommendation for the use capnography as part of the PSA monitoring tools. The article by Burton and his colleagues is one of many studies that helped change practice patterns over the past ten years. The authors collected a prospective convenience sample of two 30 patient blocks undergoing PSA at a single tertiary ED. There was an attending and 3 residents collecting ETCO2 data during PSA events and the clinical team was blinded to this information. The purpose was to identify the ability of ETCO2 to detect acute respiratory events before conventional strategies. Continue reading

Nerve Blocks Rule

Jon and I did this awesome ultrasound-guided superficial cervical plexus nerve block the other day for a R IJ central line placement– taught to us by none other than the amazing Dr. Otto Liebmann.

It was so neat we made a video about it. Check it out!


CITW: Case 3

A 15 y/o male with a history of  diabetes mellitus and hypothyroidism presents to the ED with a diffuse rash. It is not painful or pruritic. Of note, he was seen at the at his primary care doctors office earlier that week and found to have hyperglycemia (400’s) and hypertriglyceridemia (>10,000 mg/dL):




What’s the diagnosis?

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