A young man presented after a syncopal episode. He felt fine in the ED. He had no previous cardiac history, but stated that he does have an abnormal baseline ECG.
So this young person with syncope and no other symptoms is having a STEMI?Could it be that this is his abnormal baseline ECG?
NO.
There is no baseline abnormality which looks like this.
There is a condition of baseline inferior ST elevation ("early repolarization" in the limb leads). We have shown that this never has reciprocal ST depression. Here is the reference:
Bischof J. Thompson RP. Tikkanen J. Porthan K. Huikuri H. Salomaa V. Smith SW. ST-segment depression in lead aVL differentiates benign ST elevation from inferior Acute STEMI. ACEP Research Forum 2012. Annals of Emergency Medicine 60(4 Suppl):S8-S9; October 2012.
The patient was taken for PCI of 100% thrombotically occluded RCA. The etiology of the syncope is uncertain, but probably some dysrhythmia related to the inferior STEMI.
Source: DR. SMITH'S ECG BLOG
Radiopaedia by Radiopaedia Pty on iOS
Radiopaedia is a spin-off app from Radiopaedia.org Quiz Module. It allows the user to work through real-life patient cases and interpret their imaging results to come to a diagnosis. There is a mountain of information in the app if the user wants to learn more
Source: LIFEINTHEFASTLANE
Radiopaedia by Radiopaedia Pty on iOS
Radiopaedia is a spin-off app from Radiopaedia.org Quiz Module. It allows the user to work through real-life patient cases and interpret their imaging results to come to a diagnosis. There is a mountain of information in the app if the user wants to learn more
Source: LIFEINTHEFASTLANE
A Mumps Outbreak that shows the Vaccine is Still Working
Recently, New York City suffered flooding, fires, power outages, and many deaths after a superstorm that cycled into the city from the Atlantic. Throughout history, cities particularly suffer from singular natural or man-made events because of their population density. Crowded conditions also make cities rife ground for the transmission of contagious disease – yellow fever, cholera, and influenza swept New York City during the last two centuries. But unlike hurricanes and other natural disasters against which we continue to be largely powerless, medicine has gifted us with the tools to help prevent and contain infectious disease outbreaks. One of the most important public health measures to thwart epidemics has been vaccination. Diseases such as smallpox and polio have become historical footnotes, and illnesses such as pertussis, tetanus, measles, mumps, and rubella are rare in the United States. Still, sometimes these diseases make startling appearances. This week’s NEJM reports on a large outbreak of mumps in New York City between 2009 and 2010. What’s surprising is this outbreak occurred in mostly vaccinated individuals. Is this new fuel for the anti-vaccinationists? After all, people who have received the mumps vaccine were still getting sick. However, as the details of this study reveal, the vaccine continues to limit the spread of mumps ever since it was introduced in 1967.
In the days before the vaccine was widely available, mumps usually struck young children, commonly presenting as swelling of the parotid glands, and frequently causing viral meningitis or leaving the child with permanent unilateral hearing loss. Following the introduction of the mumps vaccine in the 1960s, cases of mumps in the United States dropped a staggering 99%. During the start of the 21st century, a second dose of the vaccine was recommended in children to further increase efficacy. This two-dose vaccination strategy increased the efficacy of the vaccine from 80% to 90%.
The outbreak in New York described by Barskey et al this week, began in 2009 when an eleven year old Orthodox Jewish boy returned to the United States after being exposed to a mumps outbreak in the United Kingdom. He had been appropriately vaccinated with the two-dose regimen. While attending a Orthodox camp in upstate New York, he developed parotitis. Within 2 months, 25 cases of mumps were reported among other boys and adults who attended the same camp. When these participants returned to their homes, the virus subsequently spread throughout Orthodox communities in Brooklyn and surrounding counties. Almost every case occurred and predominated in Orthodox neighborhoods. The majority of affected patients (76%) had received the 2 recommended doses of the vaccine.
How could children who are doubly immunized still be developing mumps? The study’s lead author Barskey argues: “Children who contracted the disease participated in intense, close face-to-face contact in the yeshiva,” he says, referring to the practice of “chavrusa” or the close discussion of religious texts across a narrow table. Such high-intensity exposure can allow for the transmission of the mumps virion through respiratory droplets at such high loads that this can overwhelm the capacity of the immune system – even among vaccinated individuals. That the disease did not spread outside of Orthodox circles suggests that routine vaccination contained the disease within this high-exposure community; without immunization, the outbreak would have spread to casual contacts, family members, and the crowded streets of the metropolis. Other outbreaks of mumps reported in the past decade are similar to the New York outbreak, occuring in settings of high exposure with no significant spread to external communities. “That this did not happen underlines the safety and efficacy of the mumps vaccine,” Barskey says.
Like a sudden autumn hurricane, a disease outbreak has a lot of moving parts, making it difficult to predict when it will occur and whom it will affect. What’s clear is that vaccination has been doing its job. The rates of mumps in the United States are at record low levels, with only 370 cases last year. Now, we only notice clusters of disease, and when they do occur, vaccination is an effective barricade that restricts the disease only to populations with intense exposure, preventing wider transmission. Targeted public health measures at such pockets of disease and continued population-based vaccination strategies are imperative to keep the incidence of mumps and other contagious diseases at very low levels. “I’ve never even seen a case of mumps,” I tell Barskey, who knows it wasn’t always so.
Source:THE NEW ENGLAND JOURNAL OF MEDICINE
Trauma and Burns
Trauma and Burns
In the latest Case Record of the Massachusetts General Hospital, a 16-year-old girl was admitted to the hospital because of trauma and extensive burns sustained in a car accident. She had traumatic brain injury, crush injuries to the limbs, and inhalation injury. Management decisions were made.
After primary resuscitation with fluids in a patient with burns and severe trauma, initial care requires clear identification and prioritization of injuries. This is often difficult, since management priorities for the different injuries can conflict with one another. The diagnosis of injuries is also difficult, since the presence of a large burn can obscure deeper injuries and impair the accuracy of serial physical examinations. Management principles include serial examinations, liberal use of imaging, and a high index of suspicion based on the mechanism of injury.
Clinical Pearls
• What is the leading cause of trauma-related deaths in children and adolescents?
Trauma is the leading cause of death in children and adolescents, and most trauma-related deaths are due to traumatic brain injury (TBI) and intracranial hypertension. Severe TBI (score on the Glasgow Coma Scale [GCS], <8; GCS scores range from 3 to 15, with lower scores indicating reduced levels of consciousness) contributes to worse outcome in patients with trauma.
• What are the characteristics of inhalation injury?
The diagnosis of inhalation injury may be confirmed with bronchoscopy, with findings of carbonaceous debris and edema in the major airways. An inhalation injury is a clinical syndrome that usually includes some degree of early airway obstruction and late failure of gas exchange; inhalation injuries are also associated with increases in mortality among patients with a burn of a given size up to 30%. Intubation prevents edema-related upper-airway obstruction and its consequences. Typically, gas exchange is initially normal but deteriorates during the next few days as endobronchial debris accumulates and alveolar edema worsens.
Morning Report Questions
Q: What are risk factors for cerebral edema in a patient with traumatic brain injury?
A: Risk factors for cerebral edema include a high-speed motor-vehicle accident, which can produce subarachnoid and intraparenchymal hemorrhage, young age, the fluid resuscitation required for massive burns, and hypercarbia. Therapy for traumatic brain injury is directed toward controlling intracranial pressure and preventing the secondary insults known to worsen outcome. Surgical management includes evacuation of mass lesions (hematomas and contusions), drainage of cerebrospinal fluid, and monitoring of intracranial pressure.
Q: What are common psychiatric issues in the recovery of a patient after severe trauma?
A: Initial psychiatric goals include mitigating the patient’s acute stress and the effect of gradually dawning traumatic memories when sedation is tapered. Subsequent goals, during the intermediate postinjury period, are to help the patient cope mentally and emotionally with sadness and the symptoms of post-traumatic stress disorder (PTSD), which may include nighttime agitation and sleep disturbance. Management of PTSD during the intermediate period is essential to early restoration of function. Management involves clear explanations of what has transpired, control of pain, and treatment of sleep disturbance, anxious despair, and panic with anxiolytic and antipsychotic agents. Uncontrolled anxiety substantially impairs participation in critical aspects of rehabilitation, especially physical therapy.
Source:NEJM