CITW 6: A Clumsy Foot

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

HPI: 74 y/o male with multiple medical problems who presents to the ED with four days of left leg pain, left foot numbness, and a new left foot drop. Additionally, his wife points out that she has noticed a new rash extending up his left foot and leg. He denies any fevers, chills, recent infections or trauma to the leg.

Vitals: BP 157/72, HR 77, T 98.8 °F, RR 16, SpO2 97 % on RA

Notable PE: Numbness and rash (see below) noted on the dorsal aspect of the left foot, extending up the lateral aspect of the left leg to the knee. 3/5 strength with dorsiflexion of the left foot.

Rash 1
Rash 2
What’s the diagnosis?

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Passed out…Peace out. Who can go home after syncope?

Discussing: Quinn et al. Annals of Emergency Medicine. Prospective Validation of the San Francisco Syncope Rule to Predict Patients With Serious Outcomes

Main Points:
1. This 2006 prospective cohort trial aimed to validate a clinical rule to help risk stratify patients presenting to the ER with syncope in relation to short term outcomes. The rule was validated to have a sensitivity of 98% in preventing serious outcomes after syncope within 30 days.

2. The San Francisco Syncope rule is positive if the patient has a chief complaint of “shortness of breath”, a medical history of CHF, a presenting SBP <90mm Hg, a hematocrit <30%, or an abnormal ECG result (any non-sinus rhythm or new changes).


Approximately 25% of the general population will have an episode of syncope in their lifetime. Patients with syncope account for 1-2% of all Emergency Department visits and hospital admissions. Patients admitted for syncope, however, have been shown to receive little to no further diagnostic care, nor do they often receive a firm diagnosis concerning the cause of their syncope. Given this, the authors’ purpose was to validate the decision rule in a prospective cohort of consecutive ED patients by determining whether it can predict short-term serious outcomes.

Syncope was defined as “transient loss of consciousness with return to baseline neurologic function,” and patients presenting with acute syncope or pre-syncope were screened for the study. When a clinician had finished working up the selected patient, a short Web-based questionnaire was completed to evaluate for aspects of the history, ECG, vitals or lab results that pertain to the decision rule. In this trial, the decision rule was 98% sensitive and 56% specific to predict a serious outcome within 30 days. If applied in the study cohort, this clinical rule may have decreased syncope admissions by 24%.

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Vancomycin 1g for Everyone, Right?

From our very own ED pharmacist, Natalija Farrell:


The Issue

  • Methicillin-resistant Staphylococcus aureus (MRSA) infections and MRSA-related hospitalizations continue to increase.1
  • Vancomycin remains the cornerstone for the treatment of suspected or confirmed MRSA infections.
  • Its efficacy is measured by troughs (goal 10-20 mg/L) and troughs <10 mg/L foster vancomycin resistance.2
  • Due to the increased mortality in patients with vancomycin susceptible aureus with higher minimum inhibitory concentrations (“MIC creep”) and emergence of vancomycin intermediate or resistant S. aureus (VISA, VRSA),3-5 it is even more paramount to dose vancomycin correctly and target troughs 15-20 mg/L.
  • Emergency Departments are underdosing vancomycin in >70% of patients (especially in obese patients).
    • Most patients received vancomycin 1 g IV. 6-7

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Emergent Umbilical Venous Catheter (UVC) Placement

In a sick neonate where peripheral venous access is not possible, placement of an umbilical venous catheter (UVC) may be lifesaving!
The umbilical vein may remain patent for up to 10 days after birth.

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  • Emergency resuscitation and stabilization of neonates (to give volume or medications, such as epinephrine


  • Abdomen doesn’t look normal (omphalocele, gastroschisis, omphalitis, peritonitis, necrotizing enterocolitis)
  • Vascular compromise of the lower limbs


Umbilical Vessel Anatomy:

Neonatal Anatomy

From Robert and Hedge’s Clinical Procedures in Emergency Medicine

  • Umbilical cord has 2 arteries and 1 vein
    • Vein is thin-walled, usually at 12 o’clock
    • Arteries are smaller and thick-walled
  • Neonatal blood flow:
    • Umbilical vein –> ductus venosus –> IVC –> RA –> PA –> ductus arteriosus –> aortic arch
    • Umbilical arteries –> internal iliac arteries


Finding your Materials:

  • In Hasbro ED:
    • Locate UVC Tray and UVC lines in Hasbro Trauma Bay
    • Other materials not in kit:
      • 3-0 silk suture on a curved needle
      • Infusion solution (usually NS or D10W)
      • Three-way stopcock
      • Tegaderm and tape

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EUS: Comprehensive LE DVT studies & LP Guidance

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Brown Ultrasound Tape Review – 9:17:15


ARTICLE #1  –  If “2-Point Compression” is Good, Would “5-Point Compression” Be More Good?

Srikar et al.  Isolated Deep Venous Thrombosis: Implications for 2-Point Compression Ultrasonography of the Lower Extremity. Annals of Emergency Medicine 2015; 66: 262-267

For the evaluation of DVT, the American Institute of Ultrasound in Medicine recommends compressibility and spectral Doppler waveforms of the Common Femoral, proximal Deep Femoral, Femoral, Popliteal, and proximal Great Saphenous veins.  But ever since Bernardi et al found equivalence with “2-Point Compression” plus D-Dimer, many ER physicians have been employing this faster technique at the bedside, which uses compressibility and direct visualization of the Common Femoral and Popliteal veins only.  This study questioned whether we should consider assessing more veins by investigating the prevalence of thrombi elsewhere in symptomatic patients.  This was a 6 year retrospective study of 2451 symptomatic patients who received “comprehensive” studies of the Common Femoral, Deep Femoral, Femoral, Popliteal, and Calf veins, which were interpreted by vascular surgeons. Continue reading