Podcast production and sound design by Anton Helman, voice editing by Sheza Qayyum
Podcast content, written summary & blog post by Graham Mazereeuw, edited by Anton Helman
Cite this podcast as: Helman, A. Swaminathan, A. Long, B. Gottlieb, M. Foohey, S. Koblic, P. Mohindra, R. Stoklosa, H. Simard, R. Morgenstern J. EM Quick Hits 20 – Imaging in Renal Colic, Human Trafficking, Atrial Fibrillation in COVID-19, Transvenous Pacemaker Placement, COVID-19 Lung POCUS, COVID-19 Dermatology, Virtual Simulation. Emergency Medicine Cases. June, 2020. https://emergencymedicinecases.com/em-quick-hits-20-june-2020/. Accessed [date].
Imaging in renal colic
Most cases do not require imaging
Clear-cut indications for imaging:
Worried about alternative diagnosis
Febrile or septic
Uncontrolled pain or urgent surgical intervention anticipated
CT renal colic is the gold standard. However, less than 5% detect a clinically important alternative diagnosis and most CT scans do not change management
POCUS is helpful: sensitivity is only 70%, specificity is 75% for all stones but POCUS is unlikely to miss large stones requiring surgical management
Moore CL, Carpenter CR, Heilbrun ME, et al. Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus. Ann Emerg Med. 2019;74(3):391-399.
Smith-Bindman R, Aubin C, Bailitz J, et al. Ultrasonography versus computed tomography for suspected nephrolithiasis. N Engl J Med. 2014;371(12):1100-10.
The ED is the front line for human trafficking: most trafficked persons access healthcare while being trafficked and they most commonly present to the ED
Definition: a crime involving the recruitment, transportation, harbouring and/ or exercising control, direction or influence over the movements of a person in order to exploit that person, typically through sexual exploitation or forced labour
Means of control can be force, fraud and/or coercion (psychological, financial, threats to person or family)
Trafficked persons present with a variety of chief complaints: suicidal ideation, substance use, and illnesses of poor living conditions are common
You have the skills to suspect that a person may be trafficked
Under-regulated, underpaid industries
Substance use/addiction (particularly opioids)
Individuals experiencing homelessness
Individuals supported through child welfare system
Clues in the assessment
History inconsistent with physical exam
Patient is more fearful than expected
Delayed presentation of common conditions
Use the PEARR tool to foster safety and permit disclosure in your conversation
Privacy: ensure patient privacy unless unsafe to do so
Educate: educate patient about abuse and violence, available resources
Ask: ask patient about their experiences
Respect: respect patient wishes to disclose/not disclose
Respond: as appropriate, provide resources
Law enforcement: work with your patient to determine whether to involve law enforcement and which service to involve; Acting without their consent may harm them more than it helps
Sedation for electrical cardioversion may necessitate aerosol-generating procedures, increasing the risk of SARS-CoV-2 transmission
Consider cardioversion with procainamide 1 g IV over 1 hour (monitor for hypotension and QRS widening)
Rate control: metoprolol 2.5-10 mg IV, repeated q15mins to a maximum of 15 mg plus metoprolol 25-50 mg PO loading dose if successful OR diltiazem 0.25 mg/kg IV plus a follow up dose of 0.15 mg/kg (caution is warranted if left ventricular function is unknown)
Andrade JG, Verma A, Mitchell LB, et al. 2018 Focused Update of the Canadian Cardiovascular Society Guidelines for the Management of Atrial Fibrillation. Can J Cardiol. 2018;34(11):1371-1392.
Simplified Transvenous Pacemaker Placement
Monitor heart rate using the O2 saturation monitor, instead of the ECG
Line placement in the right internal jugular or the left subclavian vein provides the easiest approach to right side of heart
Use a 5.5 Fr or 6 Fr catheter, bundled with your pacer line, as the standard 8 Fr introducer is too large
Target a heart rate of 80 bpm – or at least 30 bpm faster than their present heart rate; turn the output all the way (~ 25 mA), with the sensitivity off (optimizing these settings allows wire placement to be the only variable in achieving capture)
Advance the wire to 20 cm, then inflate the wire balloon to float it
Three key lung POCUS findings among patients with COVID-19
Numerous B lines emanating from “lumpy, bumpy”, irregular pleura. This is consistent with non-cardiogenic pulmonary edema
Sub-pleural consolidations, often bilateral, with a liver-like appearance (“hepatisation”) of the lungs (representing lobar pneumonia)
Absence of pleural effusions
Use dedicated COVID-19 POCUS machines; protect them and clean them as per local/national protocols.
CXR may be more helpful/practical than POCUS in the diagnosis of COVID-19 pneumonia as x-ray has the advantage of not requiring patient contact
Lung POCUS for COVID-19 pneumonia is unlikely to significantly aid in disposition decisions as disposition is based on vital sign abnormalities, work of breathing and social situation regardless of imaging findings
Figure 1. A) “lumpy, bumpy”, irregular pleura associated with non-cardiogenic pulmonary edema and COVID-19. B) Smooth, normal pleural line
Figure 2. A) Subpleural consolidations consistent with pneumonia and COVID-19. B) Normal lung appearance
Recalcati S. Cutaneous manifestations in COVID-19: a first perspective [published online ahead of print, 2020 Mar 26]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16387. doi:10.1111/jdv.16387.
Galván Casas C, Català A, Carretero Hernández G, et al. Classification of the cutaneous manifestations of COVID-19: a rapid prospective nationwide consensus study in Spain with 375 cases [published online ahead of print, 2020 Apr 29]. Br J Dermatol. 2020;10.1111/bjd.19163. doi:10.1111/bjd.19163
Hedou M, Carsuzaa F, Chary E, Hainaut E, Cazenave-Roblot F, Masson Regnault M. Comment on “Cutaneous manifestations in COVID-19: a first perspective ” by Recalcati S [published online ahead of print, 2020 Apr 21]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16519. doi:10.1111/jdv.16519
Tammaro A, Adebanjo GAR, Parisella FR, Pezzuto A, Rello J. Cutaneous manifestations in COVID-19: the experiences of Barcelona and Rome [published online ahead of print, 2020 Apr 24]. J Eur Acad Dermatol Venereol. 2020;10.1111/jdv.16530. doi:10.1111/jdv.16530
Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.