From the Blogosphere
Editor’s note: Emergency Medicine residents and faculty at the University of Louisville have a private blog called Room9ER.com. With permission,
we share four of their posts with Louisville Medicine readers.
Bad news/travel fast!
Amanda Zhang, MD
= BAD BAD BAD
In the setting of Acute Coronary Syndrome,
ST elevation in aVR is a sign for Left Main or
LAD occlusion. Most of us don’t even look at
aVR - it’s the “forgotten lead.” But it should
receive more attention -- ST elevation in aVR
58 yo woman comes in with chest pain. 12-lead ECG shows diffuse ST depression, AND there is ST elevation in lead aVR. A lot
of people would just focus on the ST depression and call this Unstable Angina/NSTEMI. She would get admitted, started on ACS
protocol, but the cath lab would probably not be emergently acti-
vated. But, since she has ST elevation in aVR in the setting of ACS,
this is indicative of a LMCA occlusion, and the cath labs needs
to be activated! Or if you’re in a rural ED, you need to be on the
phone for transfer and consider thrombolytics though they may
be of less value in these patients.
Here’s an article focusing on the importance of a VR, not just in
diagnosing STEMIs but also some other diagnoses, like PEs, pericarditis, etc. www.ncbi.nlm.nih.gov/pmc/articles/PMC2898534/. LM
Note: Dr. Zhang is a second-year resident in Emergency Medicine
at the University of Louisville.
Your Diagnosis is?
Matthew Allinder, MD
P
t. is a 53 yo M who presented intially to
First Care (fast track) for shortness of
breath. Transferred to the main ER for
worsening symptoms. Intial evaluation showed
a patient with labored breathing, stridorous,
and a hoarse muffled voice. Pt. tachycardic, 93% on 2L, 102F. Transferred to room 9 with film above . What are your initial thoughts?
Diagnosis and treatment?
Note: Dr. Allinder is a
second-year resident in
Emergency Medicine at
the University of Louisville.
(Answer in next issue) LM
Summer Penile Syndrome
Megan Bertke, MD
A
5 yo male presented with penile
swelling and irritation for 4 days.
His parents say that he has pain in
the area, but he has not had any fevers or
complained of pain with urination. On exam
he looks well with normal vitals. On GU exam he has mild penile
swelling with some skin breakdown beginning on the anterior
scrotum. He also has multiple erythematous papular lesions in the
inguinal region and at the base of the penis. The rest of his exam
was normal.
When I presented to the attending she asked if I had heard of
summer penile syndrome. Since neither I nor any of the other
residents seemed to know what she was talking about, I thought
this would be a good case to share. Apparently this is a condition
that occurs typically in younger children who play outside a lot in
the summer. It appears to be caused by chigger bites to the inguinal
region. We sent him home with prescriptions for hydrocortisone
cream and benadryl.
(Eewwww poor kid.) LM
Note: Dr. Bertke is a second-year resident in Emergency Medicine
at the University of Louisville
January 2014
33