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What Do You Mean You Don’t Have Your Icd Card?!

Post by @FTeranmd

Screen Shot 2014-10-30 at 8.48.45 Pm

Image from Jacob et al. Heart Rhythm. 2011 Jun;8(6):915-22

We’ve all had a patient who shows up at the ED with a pacemaker or implantable cardioverter-defibrillator (ICD) that may be malfunctioning.  The patient didn’t bring the manufacturer ID card and isn’t sure about the make or model. So there you are, looking at the CXR, trying to identify the type — or at least the manufacturer. Is there anything we can actually look for to reliably identify these devices?

Continue reading “What Do You Mean You Don’t Have Your Icd Card?!” »

Approach to the Bleeding Tracheostomy in the Ed

 Approach to the Bleeding Tracheostomy in the ED 

By @FTeranmd

Photo (2)


Clinical scenario: 72 yo F with history of lung carcinoma with permanent trachestomy placed four  months prior presentation, brought by EMS with profuse, active bleeding from the stoma site. Patient is ventilator dependent and is being assisted with BVM at arrival. Per nursing home staff bleeding was noted an hour prior presentation and there was no history of unusual manipulation or trauma. Previous management had included aspiration and local pressure with dressings. Patient’s O2 Saturation is 97% at arrival on 40% FIO2.  BP is 102/60 and HR 100. Mental status is normal.

What the next step in management of this patient?

Continue reading “Approach to the Bleeding Tracheostomy in the Ed” »

Intermittent Visual Symptoms

57 yo M with PMHx of uncontrolled DM and HTN who presents with 3 weeks of intermittent  visual problems. Patient reports he sees flashes on both left sides of visual fields in both eyes. He is also unable to process 3D spacing and has trouble walking and reading due to vision problems. Episodes of symptoms tend to last 3-4 hours. Additionally patient complaints of mild R parietal headache that usually coincides with visual symptoms. Denies weakness or sensation deficits, dizziness, seizures or fever.

Physical examination in the ED is remarkable for absent vision on both left sides of his visual fields. Detailed eye and neurological exam reveal no additional abnormalities

Labs are only remarkable for hyperglycemia of 600 mg/dl, with no ketones or acidemia.







Management of hyperglycemia did not improve symptoms.

Brain CT and MRI were performed showing no abnormalities that could explain clinical picture.

What is the name of this patient’s deficit and where is anatomically located ?

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Sepsis and Ppm Failure

85 yo M with PMHx of CHF, paroxysmal atrial fibrillation and dual chamber PPM placed for sick sinus syndrome, who presents with lightheadedness, confusion and progressive lethargy x 1 day. At arrival to the ED patient hypotensive 70/30, bradycardic 46 x min, febrile 102 F.

EKG is obtained






Initial labs are remarkable for pH 7,10 HCO3 10 and Lactate of 5, with normal electrolytes

Patient’s pacemaker is set at a rate of 60 and recent interrogation showed no abnormalities.

What is the diagnosis and most likely explanation for this problem?  Continue reading “Sepsis and Ppm Failure” »

Twisted Ankle

A 32 yo M presents with ankle pain and swelling after forcefully externally rotating it while playing soccer. He is unable to ambulate.  Ankle x ray is shown below.

What other joint should you image?

Continue reading “Twisted Ankle” »

Chris Hansen