AAEM 22nd Annual Scientific Assembly
AAEM 22nd Annual Scientific Assembly

American Academy of Emergency Medicine (AAEM)

22nd Annual Scientific Assembly

Photo Competition

Submissions are now closed

Photographs of patients, pathology specimens, Gram stains, EKGs, and radiographic studies or other visual data may be submitted. Your submission should depict clear examples of findings that are relevant to the practice of emergency medicine or findings of unusual interest that have educational value. If your submission is accepted, you must mount it for viewing.

No more than three different photos may be submitted for any one case. Submissions are now closed.

Photo submissions must be accompanied by a brief case history written as an “unknown” in the following format: 1) chief complaint, 2) history of present illness, 3) pertinent physical exam (other than what is depicted in the photo), 4) pertinent laboratory data, 5) one or two questions asking the viewer to identify the diagnosis or pertinent finding. In a separate MS Word document, please list the following information: 6) answer(s) and brief discussion of the case, including an explanation of the findings in the photo, and 7) one to three bulleted take home points or “pearls.” Please submit only blind copies, omitting your name, institution, city, state, or any other identifier.

The case history is limited to no more than 250 words. If accepted for display, AAEM reserves the right to edit the submitted case history. Submissions are selected based on educational merit, relevance to emergency medicine, quality of the photograph, the case history, and appropriateness for public display. If your photograph is accepted, you will be notified and informed of set-up and dismantle times. Patients and patient identifiers must be appropriately masked. Additionally, you must attest that written consent and release of responsibility have been obtained for all photos EXCEPT for isolated diagnostic studies such as EKGs, radiographs, Gram stains, etc.

Responsibility for bringing photo and case submission(s) to the Scientific Assembly rests with the submitter. A 4´ x 8´ vertical area will be available for each submission. Photo competition participants who submit by November 15, 2015, will receive notification of acceptance or rejection by January 13, 2016.

 

Sample Photo Submission

Joseph J. Bove, DO

Chief Complaint:
104 Fever and Chest Pain: Not Just Pneumonia

History of Present Illness:
57-year-old Lebanese female with past medical history significant for recurrent bronchitis presents to the ED complaining of fevers chills and chest pain for two days duration. She states her chest pain is intermittent, sharp and located sub-sternal. It radiates to the back and there are no alleviating or aggravating factors. She admits to being short of breath, but denies any cough, abdominal pain, nausea, vomiting, sick contacts, or recent travel.

Physical Exam:
VITALS: BP: 117/71, Pulse: 100, Temp: 104.0, RR: 16, Sp02: 100% on room air
GENERAL: Mild distress, uncomfortable
NEURO: AAOX3 without gross deficits
HEENT: NCAT, PERRLA, oropharynx clear, TM intact B/L
CHEST: No crepitus. Partially reproducible chest wall pain
RESPIRATORY: Equal breath sounds and clear bilaterally
CV: Normal S1 S2, regular rhythm, tachycardia, no murmurs rubs or gallops
BACK: No midline tenderness, deformity, or swelling
ABDOMEN: Soft non-tender non-distended
SKIN: warm, dry with no evident rash

Questions:

  1. What pattern is noted on the EKG?
  2. What are the common presentations of this disease?

Answers:

  1. Brugada pattern
  2. Asymptomatic, syncope, sudden cardiac arrest, nocturnal agonal respirations, and fever

Case Discussion:
Upon review of the EKG, a STEMI code was activated for concern of anterior MI verses Brugada. The patient was brought to the cardiac cath lab where no lesions were found. Her lab work showed a white count of 23.9, hb of 13.7, hct 39.2, platelets 281 with segs of 89 and bands of 3. Electrolytes were within normal limits. Troponin was 0.02. X-ray showed left lower lobe pneumonia. The second EKG taken after cath shows resolved Brugada (Figure 2). Electrophysiology was consulted and further history revealed four siblings who died of sudden death before the age of three with no known etiology and no autopsies done. The patient was brought to the EP lab and an AICD was placed. The patient did well with no complications. The patient was treated for left lower lobe pneumonia and discharged on hospital day three.

Brugada is an autosomal dominant genetic disorder with variable expression characterized by abnormal findings on electrocardiogram together with an increased risk of ventricular tachyarrhythmias and sudden cardiac arrest. Brugada type one pattern as may be seen in Figure 1 is
described as an elevated ST segment that descends with an upward convexity to an inverted T wave. Brugada type two pattern is known as the “saddle back” and has an elevated ST segment that descends toward the baseline and then rises again to an upright biphasic T wave. It is unclear why it is up to nine times more common in males than females. Presentation can be at any time but is largely in adulthood and in the fourth decade of life. It may present in asymptomatic individuals or in those with syncope, sudden cardiac arrest, or nocturnal agonal respirations. Central to the workup is excluding drug induced cases found with verapamil, flecainide, amitriptyline, nitrates, cocaine and many others.

Although AICD is not indicated in particular low risk scenarios, Brugada is still a cause of sudden death. In 2010, Probst, et. al., followed Brugada patients for 32 months and reported that the cardiac arrest event rate per year may range from 7.7% to 1.9% to 0.5%, depending on the initial Brugada presentation of sudden cardiac arrest, syncope, or asymptomatic respectively. Risk stratification and the need for AICD placement largely depends on symptoms, EKG, family history, and EPS. For AICD placement, one must demonstrate a Brugada type 1 pattern plus any of the following: 1) aborted sudden cardiac death, 2) syncope seizure or nocturnal agonal respirations, 3) family history of sudden cardiac death (likely Brugada) AND a positive EPS study, or 4) a positive EPS study. Therefore, those with type two patterns, type three patterns, or an asymptomatic type 1 pattern that has a negative EPS study may fall in to the low risk cohort that would not benefit from AICD placement.

There have been many reports of the increased prevalence of Brugada in the setting of fever. A recent study in 2013 by Adler, et al., showed
Brugada to be almost 20 times more common in the setting of fever when compared to afebrile individuals (2% vs 0.1%). Interestingly, all but one did not show a Brugada type pattern on follow up EKG. This highlights the importance of recognizing this potentially transient fever induced Brugada to help risk stratify the patient for AICD placement or conservative management.

To help increase the sensitivity of discovering a Brugada EKG, some have suggested elevating the electrodes one to two intercostal spaces. Although literature is limited to small studies, one such study of 340 individuals failed to show any type 1 EKG pattern with manipulating the electrodes in this manner. On the contrary, R wave suggesting incomplete right bundle branch block was uncovered quite commonly by raising the leads. This study and others led authors to suggest that incomplete right bundle branch block may not have a true association with conduction abnormalities. Therefore, until more evidence exists, obtaining multiple EKG’s with elevated electrodes is probably not indicated.

Pearls:

  • A Brugada EKG alone does not indicate the need for AICD.
  • Recognize fever induced Brugada as a known entity that is often transient.


Figure 1


Figure 2

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