Well?

ECG Wave Maven has been my go-to resource for great EKG's. Created by Beth Israel Deaconness Medical Center in 2001, it has an incredible number of fascinating cardiograms, cases, and explanations. It's an unsurpassed repository for learning and education, and I hope you check it out.

This EKG comes from a middle aged man with vague chest pain. Initial troponins are negative.

Challenge: What does the EKG show? (Click for full image)

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What'd I Miss?

Challenge: What kind of highly unstable fracture is shown above?

P.S. Taking a break on cases this weekend, back on Monday.

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Whoops

A 70 year old patient comes in with septic shock. She is febrile, tachycardic, hypotensive, tachypneic, and hypoxemic. Her labs show a leukocytosis, elevated lactate, and elevated procalcitonin. Chest X-ray shows a right lower lung focal opacity. She is fluid resuscitated with 5 liters of crystalloid but still has refractory hypotension. The emergency medicine intern puts in a right internal jugular central venous catheter to start norepinephrine. Later, a KUB is taken which is shown above.

Challenge: What complication happened here?

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Harlequin

An adult patient develops severe hypoxemia from a pneumonia and goes into cardiac arrest. He is successfully resuscitated with the machine shown above. The following day, it is noted that a sat probe on his right forefinger and a sat probe on his ear reads 75% whereas a sat probe on the toe reads 98%. He does have a right femoral arterial cannula and an ABG drawn there reads a PaO2 of 150mmHg. However, when you do a fresh ABG stick from the right radial artery, the PaO2 is 40mmHg.

Challenge: What machine is he on?

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Musculoskeletal II

This happened while blocking a basketball shot. There is loss of sensation in a "shoulder badge" distribution.

Challenge: What's going on here?

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Scandinavia II

A 77 year old woman of Scandinavian descent presents with subacute fever, fatigue, and weight loss. She has been undergoing a workup for fever of unknown origin. She is finally referred to a neurologist because of a new headache. The characteristics of the headache, though, are nonspecific. She also has some jaw claudication with a rapid onset of pain once she starts chewing. Still, no diagnosis is made until she presents to the emergency room with transient monocular visual loss. There was a temporary partial field cut that returned when she was in the ER. The ophthalmologic exam was unremarkable.

Challenge: You better make the diagnosis before she has permanent visual loss; what is this?

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Pace Yourself

This EKG is from a patient with a dual chamber pacemaker that presents to the emergency room with presyncope. The resident says, "It's a paced rhythm, we can't interpret it."

Challenge: But you reply, "The patient's presyncope is from...what?"

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Tick Tock

This rash occurred in an 8 year old child who was traveling around the United States with his family. He presented with fever, headache, malaise, myalgias, and arthralgias. He also complained of abdominal pain, but ultrasound ruled out appendicitis. This rash developed about three days after the onset of the other symptoms. The rash is blanchable and began at the wrists and ankles. You also note some pedal edema. There is no meningismus. The CBC shows a normal white blood cell count, but thrombocytopenia. Sodium is on the low side. Blood cultures are negative.

Challenge: Time's running out...What's your diagnosis?

Atropine

You are an emergency physician attending in a busy ER. A resident comes up to you with this EKG and says it's from a person who was "found down." She administered atropine but there was no increase in heart rate.

Challenge: Why not?

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Refresher II

I'm not sure if this counts as a refresher type case, but it's an important one nonetheless.

The top two panels of the MRI were taken two days after admission. The lower two panels were taken two weeks after admission.

This patient presents with acute onset focal neurologic deficits. He is altered with hemiparesis, dysphagia, aphasia, ataxia, and seizures. He also has been running a high fever.

Challenge: When you perform the lumbar puncture, what diagnostic test should you order?

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A Boo

A 60 year old man with severe COPD on multiple inhalers and home oxygen presents with shortness of breath, productive cough, and increased work of breathing. In the emergency department, he has respiratory distress and is intubated. The resident sets a high minute ventilation in order to "blow off his CO2" since he is worried that the blood gas will be very acidemic. The patient then develops hypotension.

Challenge: Assuming this is not related to the patient's disease process, what is the cause of the hypotension?

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Barium

This barium swallow is in a patient with a history of trauma.

Challenge: What do you see?

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Spire

Challenge: What does this child have?

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Hang Ten

A young otherwise-healthy man is learning to surf for the first time. After his first lesson, he begins to develop progressively worsening low back pain, followed by lower extremity paresthesias. On arrival to urgent care, he has normal vital signs, normal cardiopulmonary exam, no spinal deformity, and a neurologic exam significant for decreased sensation and strength in the lower extremities. Two hours later, he lost complete sensation and motor function of his legs as well as rectal tone. Labs and CSF are unremarkable. Lumbar spine films are unremarkable. CT of the lumbar spine showed no evidence of spondylolysis, spondylisthesis, fracture, or soft tissue abnormalities. Brain MRI is normal. A non-contrast spine MRI (T1w sagittal image) four weeks later shows this:

Challenge: What happened?

Burrito

Challenge: What's being shown here?

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Remember 1897?

You are on a cruise ship well-known for its crazy seafood buffets. When passengers start getting sick, a call for, "Is there a doctor on board?" rouses you. Alas, you seem to be working every vacation. At first, you think this is just a viral GI bug because the passengers complain of diarrhea and abdominal cramps. But what's more remarkable is that this is followed by headache, memory loss, and disorientation. In severe cases, you note diminished reflexes, ophthalmoplegia, coma. One person is sent to shore because he needs an intensive care unit.

Challenge: What's the cause of this?

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Misleading

Challenge: What's the problem here?

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Matchmaker

Challenge: What are we looking at here?

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Dasher, Prancer, Vixen

Sorry about the disorganized cases; I've been traveling in Europe, and internet hasn't been as quick as easy as I hoped.

A basketball player comes in complaining of foot pain that occurred when he landed awkwardly after a jump. A runner has the same complaint when she inverts her ankle running on an uneven surface. Both are worried they sprained their ankle. Their pain is on the lateral edge of their foot. There is focal tenderness, bruising, and swelling at the base of the fifth toe. Both can walk but it's quite painful to do so.

Here is a radiograph:

Challenge: What's the diagnosis?

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Access II

Similar case as the last one. An adult comes in as a major trauma alert. He was involved in a high speed car accident with a prolonged extrication. Unfortunately, all four extremities are mangled, and there is no place to put intravenous access. In addition, all sites for intraosseous access are contraindicated as well; he has tibial plate fractures, sternal fractures, and humeral head fractures.

In your emergency department, he goes into a ventricular fibrillation arrest, potentially from cardiac contusions sustained in the accident. As you start advanced cardiac life support, you wonder how you can give the epinephrine.

Challenge: Any ideas?

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