Volume 32 Number 4 April 2018

Doubling the Stakes

Few emergency clinicians have had significant experience
in the management of trauma in pregnancy. Strong
emotions combined with potentially life-threatening
injuries to more than one patient can create an extremely
stressful and chaotic clinical environment. Unfortunately,
1 in 12 pregnant women will experience significant
trauma. Physicians must be prepared for such cases by
knowing how to manage the physiological challenges
unique to this vulnerable population.

View From the Top

Ultrasound has become ubiquitous in the emergency
department, where rapid diagnoses and continuous
physiological monitoring are essential. One such
approach, transesophageal echocardiography (TEE),
has significant benefits when managing patients in
cardiac arrest. By providing an unobstructed view of
the heart and great vessels, TEE allows clinicians to
accurately evaluate heart function and the quality of
chest compressions, and perform a resuscitation with
the probe still in place.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 7 n Trauma in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Critical Decisions in Emergency Medicine is the official
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 CME publication of the American College of Emergency
Physicians. Additional volumes are available.
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 EDITOR-IN-CHIEF
Michael S. Beeson, MD, MBA, FACEP
Lesson 8 n Transesophageal Echocardiography . . . . . . . . . . . . . . . . . . 19 Northeastern Ohio Universities,
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Rootstown, OH

Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 SECTION EDITORS

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Brigham & Women’s Hospital/Harvard Medical School,
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ISSN2325-0186(Print) ISSN2325-8365(Online)
 Doubling
the Stakes
Trauma in Pregnancy

LESSON 7

By Diann Krywko, MD, FACEP; and Lindsey Jennings, MD, MPH

Dr. Krywko is an associate professor and the director of personal and professional
development and wellness, and Dr. Jennings is an assistant professor and the
assistant residency program director in the Department of Emergency Medicine at
the Medical University of South Carolina in Charleston.

Reviewed by George Sternbach, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Explain the anatomical and physiological changes
that occur during a normal pregnancy.
2. Recognize unique traumatic injuries in pregnant
patients.
3. Explain the initial emergency management of a
pregnant mother and fetus.
4. Describe the ancillary studies necessary for the
management of pregnant trauma patients.
5. Discuss when the perimortem cesarean section is
indicated and how the procedure is performed.
FROM THE EM MODEL
18.0 Traumatic Disorders
18.2 Trauma in Pregnancy
CRITICAL DECISIONS
n What pregnancy-related changes can impede the
diagnosis and treatment of injuries?
n How should placental abruption, uterine rupture,
and amniotic embolus be managed?
n What factors should be considered during the initial
trauma assessment of a pregnant patient?
n Which laboratory studies are most valuable for
assessing obstetrical trauma?
n What are the benefits and risks of radiological
studies in pregnant patients?
n What is the best way to manage a stable patient
with a low-force mechanism of abdominal trauma?
n When should a perimortem cesarean section be
considered?

Few emergency clinicians have had significant experience in the management of trauma in pregnancy.
Strong emotions combined with potentially life-threatening injuries to more than one patient can create an
extremely stressful and chaotic clinical environment. Unfortunately, 1 in 12 women will experience significant
trauma during pregnancy, the leading cause of nonobstetrical maternal death.1,2

April 2018 n Volume 32 Number 4 3

 CASE PRESENTATIONS
■ CASE ONE
A 28-year-old pregnant woman
(G2P1, 33 weeks estimated gestational
age [EGA]) arrives via ambulance after
a motor vehicle collision (MVC). The
patient’s car was going approximately
45 miles per hour when her vehicle was
T-boned on the driver’s side. She is now
complaining of severe posterior neck
pain and diffuse abdominal tenderness.
EMS established an 18-gauge
intravenous (IV) catheter en route, and
administered 1 L of normal saline.
Her vital signs are blood pressure
98/52, heart rate 115, respiratory rate
16, temperature 36.5°C (97.7°F), and
oxygen saturation 95% on room air.
The patient denies any past medical
history, but mentions intermittent
cocaine use. She is alert and oriented
with an intact airway and Glasgow
coma scale (GCS) score of 15. She
has bilateral breath sounds and intact
distal pulses. No vaginal bleeding is
noted, and a focused assessment with
sonography for trauma (FAST) exam-
ination is negative. Bedside laboratory
tests reveal a hemoglobin of 10 and
white blood cell count of 15,000; the
fetal heart rate is 150 beats per minute.
A computed tomography (CT) scan is
initiated to evaluate her cervical spine,
abdomen, and pelvis, and obstetrics is
notified to initiate tocometry.
These injuries, which result in approx­
imate­ly 30,000 acute visits each year,
range from minor to major, blunt
to penetrating, and accidental to
intentional.3,4 Clinicians should be
prepared to manage these vulnerable
patients by gaining a solid understanding
of the physiological changes and unique
challenges inherent in pregnancy.
CRITICAL DECISION
What pregnancy-related changes
can impede the diagnosis and
treatment of injuries?
While the standard principles of
trauma care apply when managing
obstetrical injuries, pregnancy-
4 Critical Decisions in Emergency Medicine
■ CASE TWO
A 21-year-old pregnant woman
(G1P0, EGA 31 weeks) is brought in by
EMS after being physically assaulted
by her boyfriend. Upon arrival, she
complains of severe shortness of breath,
chest pain, and abdominal pain. She
denies drug use and any significant
surgical or medical history, and close
prenatal care has been given by an
obstetrician affiliated with your hospital
system.
The patient’s vital signs are blood
pressure 115/70, heart rate 125,
respiratory rate 32, and oxygen
saturation 89% on room air; her GCS
is 15, and distal pulses are intact. She
is diaphoretic, tachypneic, and unable
to speak in full sentences. A pulmonary
examination reveals crackles bilaterally
with significantly decreased breath
sounds on the right. Her abdomen is
tender with significant ecchymosis noted
over the lower abdominal region.
IV access is obtained, and 2 L of
0.9% normal saline is started. The
decision is made to place a tube in the
right chest at the midaxillary line at
the second intercostal space. Her heart
rate begins to decrease, she remains
tachypneic, and her oxygen saturation
fails to improve. A chest x-ray shows
bilateral pulmonary edema. CT scans
of the head, neck, chest, abdomen, and
related physiological and anatomical
changes may affect the recognition
and management of unique injuries
(Figure 1).
Abdominal Changes
Lower esophageal sphincter tone
decreases as pregnancy progresses,
as does gastric peristalsis. With these
changes, the stomach remains full of
contents and reflux becomes much more
common. Aspiration also becomes a
marked risk.5,6
The peritoneum stretches to
accommodate uterine enlargement,
a process that decreases innervation
in each defined area. As such, the
abdomen is rendered less sensitive,
pelvis do not show any additional
acute findings. Shortly after returning
from CT, the patient’s oxygen
saturation drops precipitously
requiring intubation. She is rushed to
the operating room for an emergent
cesarean section, and is admitted to
the intensive care unit.
■ CASE THREE
A 25-year-old pregnant woman
(G2P1, EGA 35 weeks) presents
with diffuse abdominal pain after a
MVC. She was the restrained driver
of a vehicle that was T-boned on the
driver’s side by a car traveling 50
miles per hour. Her initial vital signs
are blood pressure 90/52, heart rate
137, respiratory rate 18, temperature
36.7°C (98.1°F), and oxygen
saturation 100% on room air. Two
large-bore IV catheters are placed.
Although the fundus cannot be felt
on examination, fetal parts can be
palpated. The patient denies any past
medical history, and her only surgical
history includes one prior cesarean
section. A FAST examination reveals
free fluid in the Morison pouch. A
laboratory panel, including blood
typing and a Kleihauer-Betke test,
are initiated, and she is taken to the
operating room, where she was noted
to have a liver laceration.
and thus less diagnostically reliable.2,7,8
Hemoperitoneum is possible as
pregnancy progresses, even without
tenderness.
In the third trimester, the uterus
becomes large and thin walled, and
blood flow increases tenfold — from
60 mL to 600 mL/minute.9 The uterus
pushes the intestines upward into
the abdomen, displacing the bladder
anteriorly. Due to its sheer size, the
uterus is maternally protective in
penetrating injuries; however, the spleen
remains vulnerable and is the most
commonly injured organ in cases of
blunt trauma.
The uterus itself expands approxi­
mately two fingerbreadths every 2
weeks until the fetus reaches 20 weeks
gestational age. At week 12, the uterus
can be palpated above the symphysis
pubis, at which point it becomes an
intra-abdominal organ. At 20 weeks,
the uterus can be palpated at the
umbilicus. After this, the uterus grows
approximately one fingerbreadth every
2 weeks until birth. Understanding
this will help the clinician determine
the estimated gestational age when the
patient is either unaware of the age or
unable to relay the information. Keep in
mind that this rule varies with multiple
gestations.
Hematological System
Multiple changes also occur in
the hematological system during
pregnancy. Plasma volume expands
out of proportion to the increase in red
cell mass, creating a dilutional anemia.
This deficit results in hematocrit levels
between 32% and 34%, and hemoglobin
levels between 10 and 14 g/dL by
the third trimester. The hemoglobin
reaches nadir between 30 and 34
weeks of pregnancy. A leukocytosis
also develops, predominantly due to an
increase in neutrophils. A white blood
cell count between 12,000 and 18,000
is within normal limits in the third
trimester.10
In addition, two major changes
occur within the coagulation pathway.
Both the intrinsic and the extrinsic
pathways prompt the conversion
of prothrombin to thrombin and
fibrinogen to fibrin, ultimately
resulting in a cross-linked fibrin clot.
Multiple factors need to be present
and activated for these cascades to
occur, and fibrinogen must be present
to form fibrin. During pregnancy,
however, a hypercoagulable state
develops, as fibrinogen nearly doubles
and coagulation factors increase.
As such, caution must be taken
when interpreting a disseminated
intravascular coagulation (DIC) panel.
DIC typically is evidenced by high
fibrinogen levels, prolonged coagulation
times, thrombocytopenia, and elevated
D-dimer levels. In early cases, this
elevated fibrinogen level may decrease
to normal non pregnant levels.
Pulmonary System
During pregnancy, total lung
capacity decreases from 4,200 mL to
4,000 mL. Counterintuitively, tidal
volumes rise by 40% (from 450 mL–
600 mL) as residual volume decreases.
Minute ventilation equals respiratory
rate multiplied by tidal volume. Using
this equation, with the same respiratory
rate and the increase in tidal volume,
the minute ventilation is increased
40%. As such, the partial pressure of
carbon dioxide decreases to 30 mm Hg,
resulting in a chronically compensated
respiratory alkalosis. Caution must be
taken when interpreting the patient’s
arterial blood gas levels.11

FIGURE 1. Management of Trauma in Pregnancy

All patients should receive ATLS plus:

• Determination of gestational number, fetal age, maternal drug use (if possible)
• Assessment of Rh status and consideration of Rho(D) immune globulin administration
• Preparation for precipitous delivery(s) if viable (≥24 weeks EGA as determined by ultrasound, LMP, or
fundal height)
Note: Use caution when measuring fundal height in patients with multiple pregnancies and/or uterine rupture.

MAJOR TRAUMA MINOR TRAUMA

All cases require trauma team activation and laboratory Stable

tests per trauma protocol.
Consider KHB testing, even if Rh positive.
Unstable/Arrest
Unstable
All patients should undergo an ultrasound
assessment for subchorionic hemorrhage.
Stable

Consider x-rays, Viable Previable

Viable Previable
weighing radiation
exposure risks
vs benefits
Obstetrical consultation Obstetrical consultation Obstetrical consultation Education on
X-rays as indicated X-rays as indicated Admit for tocometry signs/symptoms of
Displace uterus laterally if indicated Treatment and disposition obstetrical trauma
Prepare for perimortem section depending on injuries

Continued Viable Previable

ROSC If in DIC,
arrest emergent caesarean
section indicated
Obstetrical consultation Treatment and
Delivery of infant Exploratory laparotomy in Ultrasound disposition dependent
by 5th minute conjunction with cesarean section Admit for traumatic injuries and/or tocometry on concomitant injuries

April 2018 n Volume 32 Number 4 5

 TABLE 1. Anatomical and Physiological Changes of Pregnancy and Their Clinical Effects37
System Alteration
Cardiovascular Increased cardiac output and heart rate
Increased diastolic/systolic blood pressure in
trimesters 1 and 3 only; returns to near normal
by end of 3rd trimester
Decreased peripheral resistance
Caval compression by gravid uterus
Increased blood volume
Respiratory Increased minute ventilation secondary to
increased tidal volume
Increased Mallampati score
Diaphragmatic elevation
Decreased functional residual capacity
Increased oxygen consumption
Hematological Increased plasma volume and red blood cell
production
Increased clotting factors and fibrinogen
Gastrointestinal Smooth muscle relaxation with decreased
esophageal tone and gastric motility
Stretching of abdominal wall
Abdominal contents elevated to upper abdomen
Genitourinary Uterine enlargement and hyperemia
Bladder enlargement and incomplete emptying
Ureteral dilation
Clinical Effect
Heart rate increases 15-20 beats/minute
Maternal hypotension in supine position
Increased circulatory reserve masks hypovolemia and shock
Respiratory alkalosis
Decreased serum bicarbonate with decreased buffering capacity
Difficult intubation
Risk of tension pneumothorax; higher chest tube placement
Increased oxygen requirement and increased respiratory rate
Dilutional anemia
Hypercoagulable state
Increased risk of aspiration with intubation
Increased bowel injury with upper-abdominal trauma
Altered pain localization
Blunted peritoneal irritation masks intra-abdominal hemorrhage
Increased risk of injury and hemorrhage
Increased risk of injury
Abnormal intravenous pyelogram

During pregnancy, the diaphragm
is elevated approximately 2 to 4 cm.
Because of this change, chest tubes must
be placed two intercostal spaces higher.12
Hepatic or splenic injury can result if a
tube is placed in the typical anatomical
position.
Upper-airway changes during
pregnancy result in worsened
Mallampati scores. Grade IV scores,
defined as visibility of the hard
palate only and severe difficulty with
intubation, may increase by as much as
34%.13 Although such findings appear
to correlate with body water weight
gain, additional factors may be involved,
including neck extension.14 Studies have
demonstrated similar changes that can
make intubation more difficult. Of note,
failed intubation is a significant source of
maternal mortality.15-17
Cardiovascular System
Pregnancy-related cardiovascular
changes demand the careful
interpretation of vital signs. Although
the pulse rate escalates by 15 to 20 beats
per minute by the third trimester, any
increase beyond a slight tachycardia
warrants further investigation. Both
diastolic and systolic blood pressures
decrease 15 to 20 mm Hg in the first and
second trimesters, but return to normal
near term. Hypotension in a patient at
term should be evaluated expeditiously.
As previously discussed, plasma
volume increases approximately 50%
in pregnancy, resulting in dilutional
anemia. This development, which heralds
maternal hypervolemia by the 34th week,
is the most significant pregnancy-related
cardiovascular change. Patients may
lose up to 30% of blood volume before
showing any signs of shock, a complexity
that can delay recognition.11
CRITICAL DECISION
How should placental abruption,
uterine rupture, and amniotic
embolus be managed?
Placental Abruption
Placental abruption, the result of
shearing forces between the elastic uterus
and the relatively inelastic placenta,
should be considered in all pregnant
patients, even those with minor trauma
(Figure 2). Between 1% and 5% of
patients with minor trauma and 20%
to 50% of those with major trauma
will have placental abruption, the
leading cause of fetal death unrelated
to maternal death.18 If the degree of
placental separation exceeds 50%, the
mortality of the fetus approaches 100%.
Diagnosing this pathology can be
difficult. The classic triad of vaginal
bleeding, abdominal pain, and uterine
irritability may not be present. If the
placental hemorrhage is encapsulated or
away from the cervix, external bleeding
might be absent. Commonly used
ultrasound is only about 50% sensitive
for detecting placental abruption.19
Tocometry, which should begin
immediately following the trauma
assessment, should be performed for a
minimum of 4 hours, as recommended
by the American College of Obstetrics
and Gynecology (ACOG).20 Although
the test has a high rate of sensitivity, it
is not specific for placental abruption.
Uterine irritability typically occurs
within 4 hours, with the vast majority of
cases occurring within 2 hours.
Fetal monitoring may be extended to
24 hours if the patient as more than 4 to
6 contractions per hour, abdominal or
uterine tenderness, significant injuries,
vaginal bleeding, ruptured membranes,
and/or fetal distress. Isolated incidents of
abruption have been reported later than
24 hours after trauma, but this has not
been observed in a large trial.21

6 Critical Decisions in Emergency Medicine

 Ultimate treatment should be dictated
by trauma surgery and obstetrics. If
the fetus is previable and the mother is
stable, supportive maternal monitoring is
appropriate. If the fetus is previable and
the mother is becoming coagulopathic,
an emergent caesarean section is
indicated. Surgical intervention is
necessary if the fetus has reached a viable
age. If the mother is stable, an emergent
cesarean section is indicated; unstable
patients should receive a cesarean section
in conjunction with an exploratory
laparotomy.
Amniotic Fluid Embolus
An amniotic fluid embolus is an
uncommon and catastrophic event.
While the pathophysiology of the disease
is poorly understood, this disorder
appears to be caused by the release of
amniotic fluid into maternal circulation,
precipitating a transient spasm of the
pulmonary artery. This process leads
to hypoxia and subsequent pulmonary
capillary and left ventricular injury;
left ventricular failure ensues, resulting
in adult respiratory distress syndrome.
Ultimately, a coagulopathy develops, and
multisystem organ failure occurs.22
The classic presentation of an
amniotic fluid bolus includes sudden-
onset dyspnea, altered mental status,
cyanosis, and hypotension. These
symptoms may be followed by
cardiopulmonary arrest. This diagnosis
typically is made clinically and
supported with documented hypoxia.
The treatment primarily is supportive
with intubation, vasopressors, and
fluids given as indicated. Coagulation
abnormalities should be corrected with
blood components. Amniotic fluid emboli
in cases of trauma typically result in
poor maternal outcomes and dismal fetal
outcomes.
uterine ruptures occur in the fundus or
through a previous cesarean incision site.
The clinical presentation of rupture
can be dramatic, as evidenced by severe
abdominal pain and distention, palpable
fetal parts, and shock. Some cases,
however, may be much subtler. Due to
the less pronounced peritoneal sensitivity,
abdominal pain is an unreliable indicator.
Multiple diagnostic tools may be
used to detect uterine rupture, including
ultrasound, diagnostic peritoneal
laparotomy, x-ray, CT, and exploratory
laparotomy. Emergency department
management includes fluid resuscitation,
transfusion, and early recognition.
Definitive treatment is exploratory
laparotomy and delivery with repair of
the rupture site.
CRITICAL DECISION
What factors should be consider­
ed during the initial trauma
assessment of a pregnant patient?
It is absolutely essential to remember
that by taking care of the mother, you
are taking care of the fetus. Standard
advanced trauma life support (ATLS)
principles should be employed, keeping
in mind that vital signs are less sensitive
during pregnancy; however, there
are several variations that should be
considered when managing this unique
patient population.
FIGURE 2. Post-Traumatic Placental Abruption
History
The patient’s initial history should
include estimated gestational age and
viability of the fetus, factors that will
help guide treatment decisions. Such
calculations may be done by ultra­
sound, by determining the patient’s
last menstrual period, or by estimating
the date of confinement. The initial
assessment also should include details
about the number of gestations present
and history of maternal drug use,
both of which will be used to prepare
for post-delivery care if necessary.
A secondary history should include
a domestic violence screening and
questions about the presence of
abdominal pain, back pain, vaginal
bleeding, contractions, vaginal leakage,
prior pregnancies, prenatal care, and
obstetrical complications.
Positioning
When in the supine position,
pregnant patients can develop supine
hypotensive syndrome, also known as
aortocaval compression syndrome. This
complication occurs when the heavy
gravid uterus compresses the inferior
vena cava against the lower lumbar
vertebrae, impeding blood flow from the
lower extremities back into the central
circulation. Circulatory compromise may
ensue in cases of traumatic hemorrhage,
when uterine blood flow is at 600 mL/
minute in the third trimester.

Uterine Rupture
Uterine rupture, a rare complication
of trauma (≈0.06% of patients), is
associated with high-energy collisions.23,24
Maternal mortality ranges between 20%
and 65%, and major adverse fetal events,
including death, range between 12%
and 20%.25 Rupture of the uterus occurs
most often in the third trimester and
is associated with pelvic fractures and
bladder injuries. Seventy-five percent of

April 2018 n Volume 32 Number 4 7


FIGURE 3. Sagittal Obstetrical
X-Ray in Frontal View
Aortocaval compression syndrome
can be treated by simply repositioning
the uterus. In a trauma patient that
is on a backboard and in a cervical
collar, this may be done by tilting the
backboard 30 degrees into the left lateral
decubitus position. In addition, premade
elevators or rolled towels should be
placed under the board. Although inline
immobilization may be difficult, it should
remain a priority. If unable to maintain
inline immobilization or if resuscitative
efforts preclude board tilt, the uterus
simply can be moved manually to the
left to alleviate compression of the vena
cava on the vertebrae.
Fetal Assessment
An assessment of the fetus should
coincide with an assessment of the
mother, and should include maternal
vital signs, abdominal examination,
tocometry, and ultrasound. Maternal
vital signs are less sensitive, keeping in
mind that fetal mortality approaches
100% in the presence of maternal shock.
The abdominal examination includes
measurements of fundal tenderness and
height, which may help in determining
gestational age and diagnosing
potential uterine rupture. The absence
of tenderness on palpation does not
exclude injuries or abnormalities, as
the peritoneum is less sensitive and less
reliable due to chronic stretching.
8 Critical Decisions in Emergency Medicine
Tocometry, the most accurate
method of detecting fetal distress,
should be initiated as soon as feasible
in the resuscitation bay. Fetal distress,
as evidenced by decelerations,
indicates maternal blood loss until
proven otherwise. Fetal heart tones
may be obtainable transabdominally
with Doppler ultrasound by 12 to 14
weeks gestation. If possible, a cautious
pelvic speculum examination also
should be done in conjunction with
an obstetrician, who can evaluate
for the presence of amniotic fluid or
blood.20,26,27
CRITICAL DECISION
Which laboratory studies are
most valuable for assessing
obstetrical trauma?
Once the clinical evaluation is
complete, standard trauma panels
should be initiated according to the
individual hospital protocol, and a
rhesus (Rh) factor blood test should
be obtained, even in minor cases of
trauma. In addition, the Kleihauer-
Betke (KHB) test should be considered.
Rho(D) immune globulin should
be given to all Rh-negative patients,
regardless of the extent of injury.
Current recommendations are to treat
all Rh-negative women less than 12
weeks EGA with 50 micrograms of
Rho(D) immune globulin, and all Rh-
negative trauma patients greater than
12 weeks EGA with 300 micrograms.
The dose should be administered
within 72 hours of exposure to avoid
the risk of an immune response to
Rh-positive antigens from the fetus.
This complication can result in fetal
arrhythmias; neonatal anemia; fetal
death from exsanguination; and Rh
sensitization, which may lead to fetal
death in subsequent pregnancies.
The KHB test, an acid elution
assay, can be used to identify a
fetal maternal hemorrhage (FMH)
and guide immunoglobulin dosing.
Trauma-associated FMH, defined as
the transplacental hemorrhage of fetal
blood in the maternal circulation,
occurs in approximately 8% to 30%
of cases. An anterior placental location
increases the risk. Complications
of FMH include fetal arrhythmias,
neonatal anemia, fetal death from
exsanguination, and Rh sensitization of
the mother. This sensitization occurs in
70% of Rh-negative patients with 0.01
to 0.03 mL of Rh-positive blood in fetal
hemorrhage.
The KHB test has a threshold of 5
mL for the detection of maternal fetal
blood. Because isoimmunization may
occur at levels of 0.01 mL to 0.03
mL, this test should guide the amount
of Rho(D) immune globulin given in
cases of massive FMH. Dosing should
be determined based on the following
calculation:
FMH (mL) = fetal cells/maternal
cells % maternal blood volume (mL)
300 micrograms prevents sensitiza­
tion of 15 mL of fetal red blood cells
(30 mL blood). The KHB test should be
reserved for patients with risk factors
for large fetal maternal hemorrhage,
including major injuries, uterine
tenderness, uterine contractions, vaginal
bleeding, and fetal distress.20 Of note,
fewer than 1% to 3% of pregnant
trauma victims will require additional
protection.
CRITICAL DECISION
What are the benefits and
risks of radiological studies in
pregnant patients?
In the appropriate clinical setting,
any radiological study (Figure 3) can be
used in a pregnant patient, when
accompanied by an assessment of the
risk-benefit ratio. Images must be
interpreted in the context of pregnancy-
related changes. For example,
in a radio­graphic analysis of the
chest, increased anterior-posterior
diameter, mild pulmonary vasculature
cephalization, cardiomegaly, and a
slightly widened mediastinum can be
seen in a normal pregnancy. Similarly,
pelvic x-rays will show normal
widening of the sacroiliac joint and
symphysis pubis.
Although the risks associated
with radiation exposure should be
considered, there is very little reliable
information about safe levels in
pregnant patients. Current evidence
supports 5 rads as the cutoff for human
teratogenesis.28 Although plain x-rays
deliver the lowest fetal dosage and
level of radiation, it is important to
remember that radiography also yields
less information than CT. Depending
on the particular machine and study,
CT radiation levels may range from
50 milirads (head CT) to 9 rads
(abdominal/pelvic CT).29
While necessary studies should not
be withheld out of concern for fetal
radiation, imaging should be avoided
if at all possible. The pelvic/fetal
area should be shielded if studies are
obtained, and alternative modalities
(other than a high-radiation CT scan)
should be considered. This will depend
on resources, physician skill and
preference, and the patient's condition.
Gestational age helps dictate the
effects of radiation exposure and
dosage amount. At 2 weeks EGA, the
viability of the conceptus can be lost;
however, no teratogenic effects are
expected if implantation has already
occurred. The greatest demonstrable
effects of radiation exposure occur
between 2 and 7 weeks, during the
period of organogenesis. At this point,
congenital malformations, growth
retardation, and potential childhood
neoplasms (leukemias) can be expected.
Neurological effects are possible at 8
to 17 weeks EGA. Beyond this, there
is little risk of teratogenesis; however,
growth retardation, central nervous
system dysfunction, and childhood
neoplasms remain risks.
CRITICAL DECISION
What is the best way to manage
a stable patient with a low-
force mechanism of abdominal
trauma?
Minor trauma, including a fall
from standing, requires evaluation.
According to one study, 40%
of pregnant patients with minor
abdominal trauma felt preterm
contractions, and 11% experienced
true preterm labor, defined as cervical
changes and significant contractions at
less than 36 weeks gestational age. Of
those, 11% to 25% of patients went on
to deliver prematurely.30
An obstetrical evaluation is
recommended, and tocometry should
be immediately established to evaluate
contractions, even when the fetus
is of previable age; however, this
recommendation is controversial. As
placental abruption is one of the leading
causes of preterm labor in trauma,
evaluation for this entity should be
considered (see section on placental
abruption).31,32 Once life-threatening
injuries have been ruled out, the patient
may be sent to the labor and delivery
unit for monitoring.
Tocolysis is controversial in the
setting of trauma.33 Ninety percent of
contractions resolve spontaneously;
10% to 50% of patients have underlying
abruptions or are near full term.34

FIGURE 4. Process of Rh Incompatibility

! # # # #
# !
! # ## # ## # ##
u # ##
u
## ## ## #u #u
# !
! !!
# #
# ## ##
## # u# #
u
! !! # # # #
#### ## ! # # # ## #u ## #u ##
# # ## ! !! # ## # # ### # ## u ## u
# # ! ! # # # ! # !!!!! u #
#u u #
#u uuu
u
##### !
! ! # # # !!!! # ! ! !! ## # u
# # ! # ! !!!!! # #
u ## uuu
u
## # # # ! !
! ! ### !! ### ###u #u #
# ## #
## # ! !
!
# # ##
## # ### # ###
u
# ###
u
## # # # ! !! ## ### #u#
# #u#
#
## ## ! !!
# # # #
# ## !! ! # # ## ##
u u##
## ## ! !
### ### #u
#
# #u
#
#
## ## #
##
#
# #
#
#
#
# # ! !
## ## ! !! # ## u#
# u#
#
# # # # # # # # # #
# # # #
Rh-negative woman and Rh-negative Cells from Woman be­comes In the next
Rh-positive man conceive a child woman with Rh-positive sensitized – Rh-positive preg-
Rh-positive fetus enter antibodies nancy, maternal
fetus woman’s (u) form to antibodies attack
bloodstream fight Rh-positive fetal red blood
blood cells cells

April 2018 n Volume 32 Number 4 9

 All pregnant patients require blood
typing. If the woman is Rh negative,
Rho(D) immune globulin should
be given for even minor injuries to
the abdomen (Figure 4). If the fetus
is less than 12 weeks, a dose of 50 n Begin tocometry as soon as possible, as it is the most sensitive tool for
micrograms is needed; if greater than measuring uterine contractions, most of which will present within 4 hours.
12 weeks, the full dose (300 micro­ n Repositioning the uterus to prevent and treat supine hypotensive syndrome
grams) should be administered. (aortocaval compression syndrome) may be done by tilting the backboard to
the left and 30° laterally, or by manually shifting the uterus to the left.
CRITICAL DECISION n The KHB test has a laboratory threshold of 5 mL for detecting fetal maternal
When should a perimortem hemorrhage (much greater than the level required for isoimmunization), and
cesarean section be considered? can help guide dosing of Rho(D) immune globulin.
n A perimortem cesarean section necessitates advanced preparation; delivery
While the perimortem cesarean
of the infant should occur on or before minute 5 of maternal arrest.
section is a particularly dramatic
surgical procedure, the method itself is
uncomplicated and rapid. Preferably perform it. At that time, an expert Summary
done by an obstetrician, it also can be consensus recommended considering There are significant anatomical and
performed by a surgeon or emergency a perimortem cesarean section for any physiological changes during pregnancy
physician. The patient is placed in pregnant trauma patient in cardiac that can affect the recognition
left lateral decubitus position, and an arrest with a fetus of greater than or and management of injuries. The
incision is made from the xiphoid to equal to 24 weeks gestation. It was peritoneum becomes very insensitive
the symphysis pubis, through every thought that delivery should occur due to stretching, intubation is more
layer of the abdominal wall. A second within 20 minutes of maternal death, difficult, and patients are at higher
vertical incision — from the upper but ideally within 4 minutes.35 risk of aspiration. Chest tubes must be
uterine fundus toward the bladder At the fifth minute, fetal survival and placed two intercostal spaces higher
— should be made manually, and neurological function plummet. Hence to avoid intra-abdominal injury. In
the uterus should be decompressed the 4-minute rule: maternal CPR for addition, it is important to remember
with a catheter, if possible. The fetus 4 minutes, infant delivery by the fifth that anemia, leukocytosis, and
can be delivered bluntly from the minute. Studies regarding maternal respiratory alkalosis are normal findings
uterus and suctioned, and the cord survival in patients who undergo in pregnancy.
should be clamped and cut. Maternal caesarean section after receiving CPR Injuries unique to this high-risk
resuscitation continues, and neonatal are mixed; survival rates range from population include premature labor,
resuscitation begins. 4.5% to 54.3%, depending on the placental abruption, amniotic fluid
The procedure comes with no study.36 To the authors’ knowledge, no embolus, and uterine rupture. Although
clear guidelines, however. In 2005, health care provider has been found ATLS guidelines still apply, slight
the ACOG stated that there was liable for performing this procedure in tachycardia can be normal near term.
insufficient data to suggest when to the United States. In addition, blood pressure decreases
in the first and second trimesters and
returns to baseline during the third.
The evaluation of the fetus should
include measuring the fundal height,
tocometry, and ultrasonography.
All Rh-negative mothers require Rh
n Relying on abdominal tenderness for the detection of serious injury. It is immunoglobulin, even in cases of minor
important to remember that that peritoneum stretches markedly during trauma. If required, a perimortem
pregnancy, rendering it much less sensitive. Abdominal tenderness may be cesarean section should result in
absent, even in cases of hemoperitoneum. delivery of the fetus within 5 minutes of
n Dismissing hypotension as a sign of serious injury. Low blood pressure is loss of the maternal pulse.
abnormal in the third trimester; pregnant patients may experience a 30% loss
in blood volume prior to showing signs of shock. REFERENCES
n Withholding x-rays for fear of exposing the fetus to radiation. Imaging should 1. Romero VC, Pearlman M. Maternal mortality due to
trauma. Semin Perinatol. 2012;36(1):60-67.
be initiated if medically indicated for the resuscitation of the mother. 2. Fildes J, Reed L, Jones N, et al. Trauma: the leading
n Failing to check the patient’s Rh status or initiate tocometry. These tests cause of maternal death. J Trauma. 1992;32(5):643-
645.
should be administered in any pregnant patient involved in a trauma, 3. Hill CC, Pickinpaugh J. Trauma and surgical
regardless of the mechanism. emergencies in the obstetric patient. Surg Clin North
Am. 2008;88(2):421-440, viii.

10 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
The young car accident victim
underwent CT of her cervical spine
and abdomen. While the test failed
to show any acute spinal injuries,
her cervical collar was left in place
due to persistent tenderness. The
abdominal CT revealed a very small
splenic laceration without active
extravasation, which was managed
nonsurgically.
Tocometry indicated frequent
fetal decelerations, suggesting
distress. Within the context of
trauma and cocaine use, placental
abruption was high on the list of
differential diagnoses. The patient
was taken to the operating room
for immediate cesarean section, and
both the fetus and mother recovered
well.
This case demonstrates the
importance of understanding some
of the physiological changes in
pregnancy. The patient initially was
hypotensive. While mild hypotension
can be normal in the first and second
trimesters, any hypotension close to
term requires a thorough workup;
blood pressure should normalize
by the third trimester. In this case,
4. El Kady D. Perinatal outcomes of traumatic
injuries during pregnancy. Clin Obstet Gynecol.
2007;50(3):582-591.
5. Lim WS, Macfarlane JT, Colthorpe CL. Pneumonia and
pregnancy. Thorax. 2001;56(5):398-405.
6. Goodnight WH, Soper DE. Pneumonia in pregnancy.
Crit Care Med. 2005;33(10 Suppl):S390-S397.
7. Criddle LM. Trauma in pregnancy. Am J Nurs.
2009;109(11):41-47; quiz 48.
8. Rudloff U. Trauma in pregnancy. Arch Gynecol
Obstet. 2007;276(2):101-117.
9. Hill CC, Pickinpaugh J. Physiologic Changes in
Pregnancy. Surg Clin North Am. 2008;88(2):391-401.
10. Gaiser R. Physiologic changes of pregnancy.
Chestnut’s Obstetric Anesthesia: Principles and
Practice. 2009;4:15-36.
11. Burns B. Resuscitation in Pregnancy. In: Tintinalli
JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD,
Cline DM, eds. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide, 8 e. New York, NY:
McGraw-Hill Education; 2016.
12. Raja AS, Zabbo CP. Trauma in pregnancy. Emerg Med
Clin North Am. 2012;30(4):937-948.
13. Pilkington S, Carli F, Dakin MJ, et al. Increase in
Mallampati score during pregnancy. Br J Anaesth.
1995;74(6):638-642.
14. Biro P. Difficult intubation in pregnancy. Curr Opin
Anesthesiol. 2011;24(3):249-254.
15. Elkus R, Popovich J Jr. Respiratory physiology in
pregnancy. Clin Chest Med. 1992;13(4):555-565.
16. Izci B, Vennelle M, Liston WA, et al. Sleep-disordered
breathing and upper airway size in pregnancy and
post-partum. Eur Respira J. 2006;27(2):321-327.
17. Vasdev GM, Harrison BA, Keegan MT, Burkle CM.
Management of the difficult and failed airway in
the patient’s hypotension was fluid
responsive and likely related to her
small splenic laceration.
This case also highlights the
importance of tocometry following
a traumatic event, which should
be used in conjunction with an
obstetrical consultation in any case of
abdominal trauma in pregnancy.
■ CASE TWO
The pregnant assault victim’s
chest x-ray was positive for
pulmonary edema, but negative
for pneumothorax — findings
that suggested an amniotic fluid
embolism. The patient was admitted
to the ICU and eventually started
on extracorporeal membrane
oxygenation (ECMO) for refractory
hypoxia. She developed disseminated
intravascular coagulation and,
despite aggressive blood product
replacement, eventually died.
This case demonstrates the impor­
tance of assessing for an amniotic
fluid embolism when managing
trauma in a pregnant patient. While
rare, the pathology carries a high
risk of morbidity and mortality.
Additionally, the placement of a chest
obstetric anesthesia. J Anesth. 2008;22(1):38-48.
18. Shah KH, Simons RK, Holbrook T, et al. Trauma in
pregnancy: maternal and fetal outcomes. J Trauma.
1998;45(1):83-86.
19. Glantz C, Purnell L. Clinical utility of sonography in
the diagnosis and treatment of placental abruption. J
Ultrasound Med. 2002;21(8):837-840.
20. Mendez-Figueroa H, Dahlke JD, Vrees RA, Rouse DJ.
Trauma in pregnancy: an updated systematic review.
Am J Obstet Gynecol. 2013;209(1):1-10.
21. Brown HL. Trauma in pregnancy. Obstet Gynecol.
2009;114(1):147-160.
22. Clark SL. Amniotic fluid embolism. Obstet Gynecol.
2014;123(2 Pt 1):337-348.
23. Porreco RP, Clark SL, Belfort MA, et al. The changing
specter of uterine rupture. Am J Obstet Gynecol.
2009;200(3):269.e1-e4.
24. Zwart JJ, Richters JM, Ory F, et al. Uterine rupture
in The Netherlands: a nationwide population-
based cohort study. BJOG. 2009;116(8):1069-1078;
discussion 1078-1080.
25. Gibbins KJ, Weber T, Holmgren CM, et al. Maternal
and fetal morbidity associated with uterine rupture
of the unscarred uterus. Am J Obstet Gynecol.
2015;213(3):382.e1-e6.
26. DeIorio NM. Trauma in Pregnancy. In: Tintinalli JE,
Stapczynski JS, Ma OJ, Yealy DM, Meckler GD,
Cline DM, eds. Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide, 8 e. New York, NY:
McGraw-Hill Education; 2016.
27. Barraco RD, Chiu WC, Clancy TV, et al. Practice
management guidelines for the diagnosis and
management of injury in the pregnant patient: the
EAST Practice Management Guidelines Work Group.
J Trauma. 2010;69(1):211-214.
tube must be modified during the
third trimester to avoid splenic or
hepatic injury.
■ CASE THREE
The 25-year-old woman
presenting after an MVC with mild
abdominal pain and palpable fetal
parts experienced uterine rupture.
Such presentations can be seen in
high-speed blunt traumatic injuries
and may be associated with pelvic
fractures. In this case, the fundus
was not palpable.
The patient’s liver laceration was
repaired, and her baby was delivered
via cesarean section. The mother
required postoperative ICU care
for 3 weeks. Her Kleihauer-Betke
test showed 0.2% fetal red blood
cells per the total sample. Using the
equation FMH (mL) = fetal cells/
maternal cells % maternal blood
volume (mL) = 0.002 % 5,000 mL,
the level of fetal whole blood was
calculated to be 10 mL. Since the
300-microgram dose of Rho(D)
immune globulin covers as much
as 30 mL of whole fetal blood, no
additional doses were required.
28. Wang PI, Chong ST, Kielar AZ, et al. Imaging of
pregnant and lactating patients: part 1, evidence-
based review and recommendations. AJR Am J
Roentgenol. 2012;198(4):778-784.
29. Sadro C, Bernstein MP, Kanal KM. Imaging of
trauma: Part 2, Abdominal trauma and pregnancy-
-a radiologist’s guide to doing what is best for
the mother and baby. AJR Am J Roentgenol.
2012;199(6):1207-1219.
30. Pearlman MD, Tintinallli JE, Lorenz RP. A prospective
controlled study of outcome after trauma during
pregnancy. Am J Obstet Gynecol. 1990;162(6):1502-
1507; discussion 1507-1510.
31. Pearlman MD. Motor vehicle crashes, pregnancy
loss and preterm labor. Int J Gynaecol Obstet.
1997;57(2):127-132.
32. Oyelese Y, Ananth CV. Placental abruption. Obstet
Gynecol. 2006;108(4):1005-1016.
33. Pak LL, Reece EA, Chan L. Is adverse pregnancy
outcome predictable after blunt abdominal trauma?
Am J Obstet Gynecol. 1998;179(5):1140-1144.
34. Connolly AM, Katz VL, Bash KL, et al. Trauma and
pregnancy. Am J Perinatol. 1997;14(6):331-336.
35. Katz V, Balderston K, DeFreest M. Perimortem
cesarean delivery: were our assumptions correct? Am
J Obstet Gynecol. 2005;192(6):1916-1920; discussion
1920-1921.
36. Lavecchia M, Abenhaim HA. Cardiopulmonary
resuscitation of pregnant women in the emergency
department. Resuscitation. 2015;91:104-107.
37. Emergencies in the obstetric patient can be double
trouble.” AHC Media - Continuing Medical Education
Publishing. Accessed March 11, 2018. https://www.
ahcmedia.com/articles/29814-emergencies-in-the-
obstetric-patient-can-be-double-trouble.
April 2018 n Volume 32 Number 4 11
 Unhappy with traditional hip-reduction
methods — and the clinical gymnastics required
to perform them — emergency physician Greg
Hendey thought there had to be a better way.
When he caught a TV ad for Captain Morgan
rum, its famous mascot with one foot resting
on a barrel of liquor, he knew immediately
that the iconic pirate was onto something.

Captain Morgan Technique

for Closed Reduction of Hip Dislocation

The Critical Procedure

Hip dislocation may be encountered as the result of high-energy trauma, or
postoperatively after total hip arthroplasty. The Captain Morgan technique, one
of many reduction methods that can be used in the emergency department, can
help reduce stress on both the patient’s knee and the physician’s back.

By Jen Chapman, MD
Dr. Chapman is the associate director of the emergency
medicine residency program at Orange Park Medical
Center in Orange Park, Florida.
Reviewed by Steven Warrington, MD, MEd, FACEP
Contraindications
n Open hip dislocation
n Multiple (2-3) failed closed reduction attempts
n Prolonged dislocation
n Persistent instability after reduction
n Fracture dislocation*
n Neurological deficit or vascular compromise*
*Dislocation associated with any of these complications requires
emergent orthopedic operative management. If unavailable, closed
reduction should be attempted in the emergency department.

12 Critical Decisions in Emergency Medicine

Risks and Benefits
The benefits of closed
TECHNIQUE
hip reduction include a 1. Place the supine patient on a backboard.
decreased risk of femoral 2. Attach a strap over the patient’s pelvis, which should be affixed to the board.
and sciatic nerve injury,
3. Stand on the side of the affected knee.
femoral head osteonecrosis,
4. Place your foot on top of the board and closest to the affected hip.
and post-traumatic arthritis.
Common techniques involve 5. Place the patient’s flexed knee (popliteal fossa) over your thigh.
the physician standing or 6. Grasp the patient’s ankle with one hand, and slide your other hand underneath
crouching on the stretcher, the knee. The second hand should lie on top of your thigh and under the patient’s
while using significant popliteal fossa.
force to gain traction and 7. Plantar flex your foot on top of the board, while applying upward traction with
countertraction. The Captain the hand that is underneath the patient’s knee. Use slow, firm pressure and avoid
Morgan technique not only sudden movements.
can reduce strain placed on the 8. Repeat the procedure if initially unsuccessful. Adduct and abduct the hip by
patient’s knee, the procedure rocking and rotating the patient’s lower leg until reduction is achieved.
allows safer positioning for the
physician by reducing pressure Closed Hip Reduction Aftercare
on the lumbar region and 1. Obtain confirmatory imaging.
decreasing the amount of force
2. Obtain an orthopedic consultation.
needed for reduction.
Risks associated with the 3. Apply an abduction pillow, brace, hip binder, or knee immobilizer.
procedure are the same as 4. Limit weight-bearing for 4 to 6 weeks.
those associated with other
closed hip reduction methods:
missed occult fracture, fracture
caused by reduction, loosening
or disruption of prosthetic
Hand B
hardware, damage to the
sciatic and femoral nerves, and
vascular damage.

Alternatives
There are many well-
Hand A
described alternative hip
reduction techniques, including
the Allis and the Bigelow
maneuvers. Closed reduction
may be performed by an
orthopedist in the operating
room. Dislocations may
require open reduction.

Special Considerations
Closed hip reduction of
the conscious patient requires
adequate sedation and pain
control. This typically is
achieved with conscious
sedation using agents such as
ketamine, propofol, etomidate,
etc. Inadequate sedation may
Hand A should be positioned under the patient’s knee, and used to lift
prevent successful reduction.
up on the femur. Hand B, which should be placed over the patient's
Additional causes of procedure
ankle, can be used to leverage down against the tibia/fibula.
failure include occult fracture
or an incarcerated tendon or Adapted from Tintinalli JE, Stapczynski JS, Ma OJ, et al. Tintinalli’s Emergency Medicine: A Comprehensive
capsule. Study Guide.

April 2018 n Volume 32 Number 4 13

 The LLSA Literature Review
Spontaneous Intracerebral
Hemorrhage
By Rachel Harper, MD; and Laura Welsh, MD
University of Washington School of Medicine, Department of
Emergency Medicine, Seattle, WA
Reviewed by Andrew J. Eyre, MD, MHPEd
Hemphill JC, Greenberg SM, Anderson CS, et al. Guidelines for the management of spontaneous
intracerebral hemorrhage. Stroke. 2015;46(7):2032-2060.
In the past several years, consider­
able research advancements have
been made in the management
of patients with intracerebral
hemorrhage (ICH). Importantly,
improvements in care can directly
impact morbidity and mortality. The
2015 American Heart Association
(AHA)/American Stroke Association
(ASA) guidelines for the management
of spontaneous ICH, an update to
the 2010 recommendations, provide
evidence-based guidance for treating
these critically ill patients.
Upon presentation to an appropriate
stroke center, a rapid noncontrast
computed tomography (CT) scan
should be obtained in any patient
for whom ICH is considered (level A
recommendation). Other imaging studies
such as CT angiography and magnetic
resonance imaging can be used to
detect the patient’s risk for hematoma
expansion or evaluate for underlying
vascular lesions. Because many patients
experience neurological decompensation
in the first few hours, a baseline severity
score, calculated using diagnostic tools
such as the National Institutes of Health
Stroke Scale or ICH score also should be
obtained early.
No predictive model is recommended
for use in the emergency department
to forecast an ICH patient’s clinical
prognosis or help families make care
decisions. Instead, early aggressive
14 Critical Decisions in Emergency Medicine
treatment always should be initiated,
and any decisions about withdrawal of
care should be put off until the second
full day of hospitalization (level B
recommendations).
The acute medical treatment of ICH
focuses on the correction of hemostatic
abnormalities and blood pressure control.
In patients taking vitamin K antagonists,
prothrombin complex concentrates
(PCC) can reverse coagulopathy within
minutes and may have fewer side effects
than fresh frozen plasma (FFP), which
requires higher transfusion volumes
and has a longer time of action (level
B recommendation). Intravenous
vitamin K also should be administered;
however, due to its slow peak of action,
this supplement alone is insufficient for
primary coagulopathy reversal.
While recombinant factor VIIa
(rFVIIa) can rapidly normalize the
international normalized ratio, it does not
replace all necessary factors and is not
recommended (level B recommendation).
There is limited data on the reversal
of newer anticoagulants, including
dabigatran, rivaroxivan, and apixaban;
however, PCC and rFVIIa can play roles
in the reversal of these agents. Dabigitran
alone may respond to dialysis (level C
recommendation).
Elevated blood pressures are common
in such cases and are associated with
worse outcomes. For patients with an
initial blood pressure between 150 mm Hg
and 220 mm Hg, a rapid reduction in
blood pressure to a goal of 140 mm Hg
is safe (level A recommendation) and
can improve functional outcomes (level
B recommendation). Starting blood
pressures above 220 mm Hg should
be lowered, but data regarding targets
and safety are not available (level C
recommendation).
KEY POINTS
n Although a baseline severity
score should be calculated for any
patient with ICH, no predictive
model is recommended for
forecasting a clinical prognosis
or helping families make care
decisions in the emergency
department.
n Patients taking vitamin K antagon­
ists should receive intravenous
vitamin K supple­mentation and
replacement of vitamin K-
dependent factors. PCCs can
reverse anticoagulation quickly and
with fewer side effects.
n Correcting hypertension to a
systolic blood pressure goal of 140
mm Hg can help prevent recurrent
ICH and is associated with
improved functional outcomes.
n Surgical evacuation is
recommended for patients with
cerebellar hemorrhage, but its
utility in supratentorial hemorrhage
is not well established.
 Intracranial pressure (ICP) monitoring
is recommended for any patient with a low
Glasgow coma scale (GCS) score (level B
recommendation). In addition,
anyone with a GCS below 8, signs of
herniation, or a large ICH should be
treated with a goal coronary perfusion
pressure of 50 mm Hg to 70 mm Hg (level
C recommendation). Although cortico­
steroids are not recommended for the
treatment of elevated ICP, ventricular
drainage may be indicated (level B
recommendation).
There currently is insufficient evidence
to support minimally invasive clot removal,
aspiration, or the use of intraventricular
thrombolytics (level B recommendation).
For surgical evacu­­ation, guidelines are
driven by the location of the hemorrhage
and the patient’s condition. Those with
cerebellar hemorrhage accompanied
by clinical deterioration or evidence of
hydrocephalus should undergo emergent
surgical removal of the hemorrhage (level
C recommendation). The benefits of
surgical evacuation are not well established
in cases of supra­tentorial ICH (level A
recommendation).
After the initial resuscitation, care
should focus on the prevention of secondary
brain injury. As many as 16% of patients
with ICH show signs of clinical seizure
activity; this complication should be
treated with antiseizure medication (level A
recommendation). However, prophylactic
antiseizure therapy has not demonstrated
a benefit and may be associated with
increased death and disability (level B
recommenda­tion). Fever should be treated,
and both hyper- or hypoglycemia should be
avoided (level C recommendation).
Additional treatments should focus on
reducing the medical complications of ICH.
Comprehensive stroke care should include
a screening for myocardial ischemia with
cardiac enzymes and an electrocardiogram
(ECG); as many as 20% of these patients
will have elevated cardiac enzymes within
24 hours of presentation. To reduce the
risk of aspiration pneumonia, all patients
should undergo a formal screening for
dysphagia prior to any oral intake (level B
recommendations). Finally, these patients
necessitate admission to an inpatient unit
with neuroscience acute care expertise.
Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2018 Lifelong Learning
and Self-Assessment Reading List. Available online at acep.org/llsa and on the ABEM website.
TABLE 1. Integral Components of the History, Physical Examination,
and Workup of the Patient with ICH
History Comments
Time of symptom onset
(or time the patient was last normal)
Initial symptoms and progression of
symptoms
Vascular risk factors History of stroke or ICH, hypertension,
diabetes mellitus, and smoking
Medications Anticoagulant drugs, antiplatelet agents,
antihypertensive medications, stimulants
(including diet pills), sympathomimetic
drugs
Recent trauma or surgery Carotid endarterectomy or carotid stenting
(ICH may be related to hyperperfusion after
such procedures.)
Dementia Associated with amyloid angiopathy
Alcohol or illicit drug use Cocaine and other sympathomimetic drugs
are associated with ICH, stimulants
Seizures
Liver disease May be associated with coagulopathy
Cancer and hematological disorders May be associated with coagulopathy
Physical Examination
Vital signs
A general physical examination
focusing on the head, heart, lungs,
abdomen, and extremities
A focused neurological examination A structured examination such as the
National Institutes of Health Stroke
Scale can be completed in minutes and
provides a quantification that allows easy
communication of the severity of the event
to other caregivers. GCS score is similarly
well known and easily computed.
Serum and Urine Tests
Complete blood count, electrolytes, Higher serum glucose is associated with
blood urea nitrogen and creatinine, worse outcomes.
and glucose
Prothrombin time (with international Warfarin-related hemorrhages are
normalized ratio) and an activated associated with an increased hematoma
partial thromboplastin time volume, greater risk of expansion, and
increased morbidity and mortality.
Cardiac-specific troponin Elevated troponin levels are associated
with worse outcomes.
Toxicology screen to detect Cocaine and other sympathomimetic drugs
cocaine and other are associated with ICH.
sympathomimetic drugs of abuse
Urinalysis and urine culture, as
well as a pregnancy test in
women of childbearing age
Other Routine Tests
Neuroimaging CT or MRI; consider contrast-enhanced or
vascular imaging.
ECG To assess for active coronary ischemia or
prior cardiac injury; ECG abnormalities can
mark concomitant myocardial injury.
Adapted from AHA/AHS Guidelines for the Management of Spontaneous Intracerebral Hemorrhage.
April 2018 n Volume 32 Number 4 15
 The Critical Image
A 47-year-old man presents with severe epigastric and right upper- By Joshua S. Broder, MD, FACEP
quadrant pain. His symptoms began approximately 8 hours earlier, but Dr. Broder is an associate professor and the
residency program director in the Division
have nearly resolved by the time he is seen in the emergency department. of Emergency Medicine at Duke University
For the past month, he has been experiencing pain after meals; the Medical Center in Durham, North Carolina.
episodes usually last about 1 hour. He denies fever, nausea, vomiting, or
diarrhea, and reports no chest pain or dyspnea. The patient has no prior
surgical history and denies alcohol, tobacco, or drug use.
His vital signs are blood pressure 143/89, heart rate 76, respiratory rate 18, temperature 36.1°C (97°F), and oxygen saturation
99% on room air. The patient appears to be in no distress. Palpation of the right upper quadrant elicits mild tenderness without
rebound or guarding. He has a negative Murphy sign and no jaundice, and the remainder of his examination is normal.

Laboratory tests reveal a white

blood cell count of 7.1, and his A
alkaline phosphatase, aspartate
aminotransferase, and alanine
transaminase levels are slightly above
normal limits. The patient’s lipase Hyperechoic
gallstones

}
and bilirubin tests are normal. An
ultrasound scan of the right upper Gallbladder
quadrant is performed. wall
Region
of dense
Thin
acoustic
hypoechoic
shadowing
à bile stripe
hides
A. Wall-echo-shadow sign. remainder
The gallbladder wall, a thin stripe of
of bile, echoes from gallstones, gallbladder
and then a region of dense
acoustic shadowing form the
wall-echo-shadow (WES) complex.

B
ß
B. The transducer has been turned
approximately 90 degrees, and
the curve of the gallbladder wall is
Hyperechoic accentuated.

}
gallstones
Gallbladder
wall
Region
of dense
Thin acoustic
hypoechoic shadowing
bile stripe hides
remainder CASE RESOLUTION
of The patient had recurrent pain
gallbladder and underwent a cholecystectomy,
which confirmed the diagnosis.

16 Critical Decisions in Emergency Medicine

KEY POINTS
n A normal gallbladder can be
visualized as a teardrop-shaped,
anechoic structure just deep to the
liver; its sonographic appearance
is caused by liquid bile, a good
acoustic transmission medium that
does not generate internal echoes.
The gallbladder wall, best measured
anteriorly, is normally <3 mm in
thickness.1
n Acoustic enhancement normally
is visible deep to the normal
gallbladder, and makes wall
measurements inaccurate along
the posterior wall. Acoustic
enhancement is an artifactual
increase in echogenicity (brightness)
caused by the low attenuation of
the acoustic signal by bile or other
materials that are good transmitters
of sound. The computer algorithm
used to generate ultrasound
images assumes a uniform loss
of signal with depth, and boosts
the brightness proportionally to
account for the expected loss, called
“time gain compensation.” This
normally prevents the ultrasound
image from appearing darker with
increasing depth. When less than
the anticipated signal loss occurs
(because the material through
which the signal passes transmits
sound well), the image brightness is
increased excessively.
n When present, gallstones usually
layer in the dependent portions of
the gallbladder and are visible as
hyperechoic (bright) curves, which
are caused by the reflection of
the acoustic beam from the dense
stones. The gallstones usually are
surrounded more superficially by
hypoechoic bile. Acoustic shadowing
occurs deep to the stones, which
obstruct the penetration of sound.1
n The WES sign occurs when
gallstones completely fill the
gallbladder, with little or no bile
between the anterior wall and the
layered gallstones.1-3 Classically,
this results in two parallel, curved
1. Ratanaprasatporn L, Uyeda JW, Wortman JR, et al. Multimodality imaging, including dual-energy CT, in the evaluation of gallbladder disease. Radiographics. 2018;38:75-89.
2. MacDonald FR, Cooperberg PL, Cohen MM. The WES triad — a specific sonographic sign of gallstones in the contracted gallbladder. Gastrointest Radiol. 1981;6:39-41.
3. Rybicki FJ. The WES sign. Radiology. 2000;214:881-882
echogenic lines (the gallbladder wall
and echogenic stones), separated
by a thin, hypoechoic space (residual
bile) and marked by significant
acoustic shadowing deep. While this
finding implies a large stone burden,
it is accentuated in the setting of
a contracted gallbladder, which
empties of liquid bile, leaving behind
the solid stones.
n When the WES sign is present,
the gallbladder can be difficult
to identify and can be mistaken
for an air-filled loop of bowel (the
normal bowel creates a hyperechoic
acoustic reflection from air and
generates acoustic shadowing deep
to air collections). The right upper
quadrant commonly demonstrates
air in the hepatic flexure of the
colon or adjacent small bowel, so
the wall-echo-shadow sign of the
gallbladder can be misinterpreted
as this common bowel finding.
The differential diagnosis for the
WES sign also includes porcelain
gallbladder.
n Because the expected appearance
of the gallbladder is not seen,
the clinician may even wonder
if the patient has undergone a
C
Anechoic bile
in gallbladder
}
Hyperechoic
gallstones
Region of
acoustic
enhance-
ment
Acoustic shadow
from gallstone
C. Ultrasound image from another patient, demonstrating the more common
appearance of the gallbladder with anechoic bile, echogenic gallstones, acoustic
enhancement, acoustic shadowing, and bowel gas.
cholecystectomy. In addition,
the gallbladder is incompletely
visualized in the presence of
the WES sign; consequently,
findings of acute cholecystitis
(eg, pericholecystic fluid) may be
hidden. In a suggestive clinical
setting, symptomatic biliary disease
requiring a cholecystectomy may
still be recognized.
n When the gallbladder cannot be
well seen with ultrasound and more
information is needed, CT can be
helpful, as neither gas nor dense
stones impede the transmission of
x-rays used to generate the image.
Gallstones can be difficult to detect
with traditional single x-ray-source
CT scanners. In one study, CT was
only 39% sensitive for acute biliary
disease, compared with 83% for
ultrasound; specificity was similar
at 93% (CT) and 95% (ultrasound).
However, newer dual-energy CT
scanners using two different x-ray
spectra may improve detection.1
Hepatobiliary nuclear scintigraphy
and magnetic resonance cholangio­­
pancreatography can also be helpful
in uncertain cases, particularly when
bile duct obstruction is suspected.1
Echo from
bowel gas
}
Acoustic
shadow
from
bowel gas
April 2018 n Volume 32 Number 4 17
 A 93-year-old woman presents after a syncopal episode.

The Critical ECG

Sinus rhythm with second-degree atrioventricular (AV) block type 1 By Amal Mattu, MD, FACEP
(Wenckebach, Mobitz I), rate 50, left bundle branch block (LBBB). Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
The atrial rate is approximately 60, although the approximate ventricular rate is 50.
Fellowship in the Department of
Nonconducted P waves are present, and a constant P-P interval persists, indicating Emergency Medicine at the University
the presence of an AV block. For those P waves that are conducted, the PR interval of Maryland School of Medicine in
Baltimore.
appears to gradually increase preceding the nonconducted P waves. The increasing
PR interval defines Mobitz I AV conduction. The novice interpreter may miss the nonconducted P waves because both of the
nonconducted P waves on the rhythm strip are “buried” within the T waves. A LBBB is also present with expected ST-segment
discordance — ST segments are normally deviated opposite to the terminal deflection of the QRS complex when a LBBB is
present (ie, when the terminal portion of the QRS complex points primarily upward, ST-segment depression is expected; when
the terminal portion of the QRS complex points downward, ST-segment elevation is expected).

à The P waves are

partially obscured
by the T wave in (a)
and (c); the P wave is
entirely obscured
by the T wave in this
beat (b).

From Mattu A, Brady W, ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008:11,23. Reprinted with permission.

18 Critical Decisions in Emergency Medicine

 View From
the Top
Transesophageal
Echocardiography
LESSON 8

By Maria O’Rourke, MD; David Denson, MD;

Byron R. Mendenhall, MD; and J. Christian Fox, MD
Dr. O’Rourke is the director of ultrasound in the GME Emergency Medicine Program,
and Dr. Denson is an attending physician in the Department of Emergency Medicine
at St. Joseph’s Medical Center in Stockton, California. Dr. Mendenhall is the chief
of cardiovascular anesthesia in the Department of Anesthesiology at Kaweah Delta
Health Care District in Visalia, California. Dr. Fox is a professor of emergency medicine
at the University of California, Irvine.
Reviewed by Walter L. Green, MD, FACEP
Contributors: Vicken Totten, MD, MS, FACEP, FAAFP; Christopher
Christiansen, MD; and Michael B. Pesce, MD, JD

OBJECTIVES
On completion of this lesson, you should be able to:
CRITICAL DECISIONS
1. Describe common applications of emergency ultrasound.
2. Discuss the goal-directed transesophageal n What role can ultrasound play in the
echocardiography (TEE) examination of a patient in management and resuscitation of patients in
cardiac arrest. cardiac arrest?
3. Explain the ways in which TEE is superior to other imaging
modalities for the acute management of cardiac arrest. n How is TEE superior to traditional TTE for the
4. Describe how to obtain each of the four modified TEE management of patients in cardiac arrest?
views.
5. Identify the visible anatomical landmarks in each of the n What TEE views are most useful for determining
four views. the etiology of cardiac arrest?
FROM THE EM MODEL n What risks should be considered when
19.0 Procedures and Skills Integral to the Practice
performing TEE in a patient in cardiac arrest?
of Emergency Medicine
19.5 Ultrasound

Much like dolphins, which use echolocation to navigate the underwater world, physicians can use ultrasound
to “see” inside the human body with high-pitched pulses of sound that register well above the range of
human hearing.1 Ultrasound has become ubiquitous in the emergency department, where rapid diagnoses and
continuous physiological monitoring are essential. The modality not only can image the structure of organs (much
like radiography), it also enables clinicians to observe the organ and its blood flow in motion and assess the effects
of interventions in real time.

April 2018 n Volume 32 Number 4 19

 CASE PRESENTATIONS
■ CASE ONE
A 40-year-old man presents with a
nonproductive cough and runny nose;
he claims that when lying flat, he
coughs to the point of choking. The
patient, who is visiting from Germany
while on holiday, says he has not slept
for 4 days, but denies fever or chest
pain. He is otherwise healthy, does
not smoke, and has no family history
of coronary artery disease.
His vital signs are blood pressure
112/75, pulse 127, respiratory rate
20, oxygen saturation 97% on room
air, and temperature 36.7°C (98°F).
His physical examination reveals
mild expiratory wheezes, tachycardia
without murmurs, and no extremity
edema. A nebulizer treatment is
adminis­tered. A chest x-ray reveals
left parahilar patchy pneumonia, and
both lungs also show a pattern of
diffuse interstitial pneumonia with
central peribronchial thickening.
When the patient returns from
the radiology suite, he becomes
Ultrasound can be a critically important
tool for resuscitating a patient whose heart
has stopped. Although the modality has
long been used to help diagnose valvular
heart disease, wall-motion abnormalities,
strain, regurgitation, and cardiac outflow,
one particular approach has significant
benefits when managing patients in cardiac
arrest. By providing an unobstructed
view of the heart and great vessels,
transesophageal echocardiography (TEE)
allows clinicians to accurately evaluate
heart function and the quality of chest
compressions, and perform resuscitative
measures with the probe still in place.
CRITICAL DECISION
What role can ultrasound play in
the management and resuscitation
of patients in cardiac arrest?
Bedside or pocket ultrasound can help
clinicians evaluate a variety of important
cardiac parameters as often as necessary.2
Even in patients without trauma, the
modality has become the standard of care
20 Critical Decisions in Emergency Medicine
hypoxic to 91% on room air. He also
is diaphoretic and complaining of
pain with deep inspiration. Suspecting
a pulmonary embolism (PE), the
emergency physician orders a computed
tomographic (CT) angiography scan,
which is negative for PE.
A bedside cardiac point-of-care
ultrasound (POCUS) is limited because
the patient is unable to lie in the left
lateral position. However, in the
parasternal long-axis view, the clinician
can see a very enlarged left ventricle
and dilated aortic root (4.2 cm). An
electrocardiogram (ECG) reveals sinus
tachycardia with lateral wall depressions
and ST elevations in the anterior leads.
A cardiac consultation is requested,
and the cardiologist requests that the
patient be intubated prior to going to the
catheterization laboratory.
■ CASE TWO
An obese 54-year-old man in cardiac
arrest arrives via ambulance. The event
was witnessed by his wife, who started
cardiopulmonary resuscitation (CPR)
for detecting emergent pathologies in
the aorta.3,4
Although leg raising may be a simple
bedside technique for evaluating fluid
responsiveness, ultrasound observation
of the diameter and fluid responsiveness
of the inferior vena cava (IVC) may
be superior.5,6 Transthoracic chest
ultrasound can detect congestive heart
failure and most lung pathologies,
including pneumonia, acute respiratory
distress syndrome, and pneumothorax
— and often earlier and with better
accuracy than plain radiographs.7-11
Point-of-care cardiac ultrasound
also can reveal the right heart strain of
acute, significant pulmonary embolism
(PE), right heart diastolic collapse in
pericardial tamponade, and even the de-
pressed ejection fraction of cardiogenic
shock.12 Some of the modality's many
indications that are specific to critical
care include the evaluation of cardiac
arrest, hypotension, and undifferenti-
ated shock.12-14
Direct observation of heart function
immediately. Upon arrival, the patient
is intubated and resuscitative efforts
are continued; return of circulation
(ROSC) is achieved. The patient’s
vital signs are blood pressure 80/60,
and heart rate 130 with sinus
tachycardia.
An initial ECG shows ST
elevations in leads AVR V1 and V2 .
ST depressions are noted in leads I,
II, III, and aortic valve flow is seen in
leads V3 through V6 . The cardiologist
is paged to take the patient to the
catheterization laboratory; however,
both rooms already are occupied by
other cases.
The emergency physician attempts
to perform a subxiphoid transthoracic
echocardiogram, but visualization is
difficult because the patient is obese
and has a stomach full of air. The
clinician next attempts a parasternal
long-axis approach, but is unable
to evaluate the myocardial walls,
endocardial excursion, or right heart.
The clinician decides to attempt
transesophageal echocardiography.
is most critical during resuscitation,
when efforts can be guided in real
time.15,16 This is especially true when
managing a pulseless patient.17
The first resuscitative protocol
was published in the Emergency
Medicine Journal in 2009.18 The
Abdominal and Cardiac Evaluation
with Sonography in Shock (ACES)
guidelines recommended imaging the
heart, pleural and peritoneal cavities,
IVC, and aorta for the early diagnosis
of shock and to guide goal-directed
therapy in patients with nontraumatic,
undifferentiated hypotension. By 2014, a
number of other resuscitative protocols
had been published (Table 1), all of
which recommend an ultrasonographic
evaluation of the heart, aorta, and IVC
at minimum.
Current Advanced Cardiac Life
Support (ACLS) guidelines emphasize
that chest compressions should continue
with as few interruptions as possible,
with adequate depth and rate. (CPR
succeeds by optimizing forward blood
flow, which is diminished by the number
and duration of interruptions.)19
Although outcomes for patients
who present in cardiac arrest with
demonstrated cardiac standstill are
very poor, early cardiac ultrasound can
decrease futile resuscitative efforts and
potentially reduce resource utilization.15,20
In addition, cardiac ultrasound can
help pinpoint disorganized movement.
There are reports of apparently asystolic
patients whose underlying fine ventricular
fibrillation, detected by ultrasound,
responded to electric shock with a return
of spontaneous circulation.21
With only limited training, emergency
physicians can learn to evaluate the
adequacy of the left ventricular ejection
fraction (LVEF) with an accuracy
that rivals that of fellowship-trained
cardiologists.22 While a severely
depressed LVEF requires inotropic
support, a hyperdynamic, coordinated
myocardium with little forward flow
demands aggressive fluid administration.
A heart beating faster than its fill time
requires rate control.
Electrical activity without a palpable
pulse might stem from either a pumping
heart or a heart at standstill. Only
the ultrasound probe can differentiate
between complete cardiac standstill with
electrical activity (true pulseless electrical
activity [PEA]) and organized cardiac
motion without forward blood flow.
True PEA has a dismal prognosis, but the
faster the culprit is found, the more likely
the cause can be treated.
For example, ultrasound can diagnose
tamponade by revealing a pericardial
effusion associated with diastolic
right heart collapse.23,24 Alternatively,
a right ventricle that is enlarged more
than the left ventricle suggests the
right ventricular strain of pulmonary
embolism.16 Hemodynamically significant
PE is an important early indicator of a
poor outcome and higher in-hospital
mortality.25 Ultrasound, which can help
clinicians identify blood clots early,
enables timely intervention with lytic
infusions or thoracic surgery.
Another potential cause of poor
forward flow (which is not mentioned
in classic ACLS scenarios) is vascular
rupture. Aortic root regurgitation or
dissection can be suspected when the
diameter of the aortic root is wider than
4 cm.23,26 The prompt recognition of
vascular rupture should expedite definitive
surgical repair; such cases never should be
treated with lytic therapy.

FIGURE 1. Recommended Sequence of TEE Examination, Cross-Sectional Views

ME four chamber ME AV SAX TG basal SAX TG RV inflow ME asc aortic LAX

ME mitral commissural ME RV inflow-outflow TG mid SAX deep TG LAX ME asc aortic SAX

ME two chamber ME AV LAX TG two chamber desc aortic SAX UE aortic arch LAX

ME LAX ME bicaval TG LAX desc aortic LAX UE aortic arch SAX

Approx. multiplane angle indicated by the icon adjacent to each view. ME = mid-esophageal, LAX = long axis, TG = transgastric,
SAX = short axis, AV = aortic valve, RV = right ventricle, ASC = ascending, DESC = descending, UE = upper esophagea
Adapted from the American Society of Echocardiography/Society of Cardiovascular Anesthesiologists guidelines.

April 2018 n Volume 32 Number 4 21


TABLE 1. Resuscitation Protocols Using Ultrasound
Year Protocol
1989 FATE: Focus Assessed
Transthoracic Echocardiography
2001 UHP: Undifferentiated
Hypotensive Patient
2007 FEER: Focused Echocardiographic
Evaluation Resuscitation
2008 BLUE: Bedside Lung Ultrasound
in Emergency
2008 CAUSE: Cardiac Arrest
Ultrasound Exam
2009 RUSH: Rapid Ultrasound for
Shock and Hypotension
2009 ACES: Abdominal and Cardiac
Evaluation with Sonography
in Shock
2010 FOCUS: Focused Cardiac
Ultrasound
2010 RUSH Protocol/RUSH HiMAP
2010 FEEL: Focused Echocardiographic Cardiac
Evaluation in Life Support
2011 EGLS: Echo-Guided Life Lungs for pneumothorax, cardiac, IVC, lungs
Support for edema
2014 CORE: Concentrated Overview
of Resuscitative Efforts
2015 “5Es”: Effusion, Ejection,
Equality, Exit, and Entrance
2017 SHoC: Sonography in
Hypotension and Cardiac Arrest
CRITICAL DECISION
How is TEE superior to traditional
TTE for the management of
patients in cardiac arrest?
Traditional transthoracic
echocardiography (TTE) is no more
than a chest ultrasound performed by a
technician following a predefined protocol
and capturing static and video images for
physician interpretation.3 While the test
can be extremely helpful for answering
specific clinical questions, it has its
limitations.
First, it is difficult to visualize the
heart during chest compressions; the gel
can cause the rescuer’s hands to slide
around on the patient’s chest, and ribs
can get in the way. Obesity, which has
become increasingly common, can make
it particularly difficult to obtain good
transthoracic images.22 Hyperinflated
lungs in patients with chronic
obstructive pulmonary disease (COPD)
22 Critical Decisions in Emergency Medicine
Purpose
Aorta, cardiac
FAST, aorta, cardiac
Cardiac
Pneumothorax, pulmonary edema,
pulmonary consolidation, and effusions
Cardiac arrest ultrasound exam
The mnemonic of the RUSH protocol —
pump, tank, and pipes — was created as a
physiological roadmap for clinicians to easily
remember in emergent resuscitation.
Cardiac, lung, effusion
Cardiac ultrasound in shock
Cardiac, IVC, FAST, aorta, pneumothorax
Cardiac, IVC, aorta, FAST, lungs
Cardiac, effusion
Cardiac arrest
or on mechanical ventilation also can
interfere.22
During TEE, on the other hand, the
probe lies right beside the heart and does
not impede chest compressions.27 Of
note, this approach is more sensitive than
TTE for detecting left atrial thrombus,
small vegetations, and aortic dissection,
and isn’t hindered by endotracheal
intubation.28 In the emergency
department, TEE also can assess cardiac
rhythm and continuously monitor
cardiac function and output, much in the
way it is used during heart surgery.12,25
TEE can provide a wealth of valuable
diagnostic information about an
intubated patient — quickly and with
very limited risk. The test (Figure 1) can
reveal the patient’s volume status, left
and right ventricular function, and the
effectiveness of CPR, and it often can
detect previously unknown pathologies
such as tamponade, pulmonary
embolism, and aortic dissection or
rupture.28 This valuable information can
aid resuscitation and guide the placement
of an intra-arterial balloon pump
(IABP).29 The TEE probe is relatively easy
to maneuver and, importantly, does not
interfere with CPR.26
In cases of acute myocardial infarction
(AMI), TEE can be used to visualize
the hypokinetic area of the myocardium
prior to sending the patient to the
catheterization laboratory. Imaging can
help confirm which vessel is the likely
culprit and enable the cardiologist to
evaluate the left ventricular function.
Such findings may eliminate the need for
an intracatheterization ventriculogram,
thereby reducing the amount of dye that a
patient receives.
The test is particularly safe and
effective for the management of patients in
cardiac arrest.15,24,30 Most complications
have been documented in awake patients,
who complain of discomfort with
insertion and manipulation of the probe.28
Clearly, such concerns do not pertain to
patients in cardiac arrest.
A potential barrier to getting started
with TEE may be training; however, there
is evidence to suggest that emergency
physicians can successfully perform a
limited, four-view procedure with as
few as 4 hours of instruction.31 TEE is
better able to visualize cardiac motion
and structures than TTE, and also is
better at illuminating etiologies of cardiac
compromise, including fine ventricular
fibrillation.28,31 It is ideal for identifying
proximal aortic dissections in unstable
patients, in whom early diagnosis can help
direct care to the underlying cause.16,31
CRITICAL DECISION
What TEE views are most useful
for determining the etiology of
cardiac arrest?
When initiating a TEE examination,
the tip of the scope can be angled upward
or downward by a lever, much like a
bronchoscope or flexible laryngoscope.
In addition, the scope has a flat head that
resembles a miniature brick, which houses
a movable transducer or “multiplane.” The
multiplane is steered by a button that can
be reached with the thumb of the hand
holding the handle. The clinician’s other
hand may be positioned at the patient’s
mouth, where it should be used to prevent
the scope from turning or inadvertently
sliding in and out. The different views
(Figures 2 and 3) are obtained by rotating
the multiplane and directing the tip of the
scope. The emergency physician should
concentrate on mastery of the first two
views outlined below, which are the most
valuable in cases of cardiac arrest.
Mid-Esophageal
Four-Chamber View
The most diagnostically valuable view
(and the one that is easiest to obtain)
is the mid-esophageal four-chamber
(MEFC) view. The windows can be
seen when the probe is first inserted
and the multiplane is set at zero degrees
(ie, not rotated). With minimal to no
manipulation, the clinician can see all
chambers of the heart, the mitral and
tricuspid valves, septal and lateral walls
of the left ventricle (LV), free wall of the
right ventricle (RV), and pericardium.
This view also can reveal the effectiveness
of chest compressions, degree of forward
blood flow, fluid status, ventricular
function, presence or absence of fine
ventricular fibrillation, and the presence
or absence of a significant pericardial
effusion or possible tamponade.
An extremely dilated RV with
FIGURE 2. The Four Views Comprising the Focused TEE Protocol
n TEE is more sensitive than TTE for detecting left atrial thrombus, small
vegetations, and aortic dissection, and isn’t hindered by endotracheal intubation.
n Emergency physicians should concentrate on mastering the MEFC and TGMPSA
views, which are the most valuable in cases of cardiac arrest.
n Absolute contraindications to TEE are severe esophageal stenosis or a
tracheoesophageal fistula, which might be suspected in any patient with a
gastrostomy feeding tube.
free-wall akinesis and normal apical the beginning emergency physician, the
contractions (ie, McConnell sign) is TGMPSA approach is ideal; in this view,
highly diagnostic for an acute, massive the distribution of all three coronary
PE. If a thrombus is visualized in the arteries can be seen.
RA or RV, a PE may be to blame for The tip of the probe should be
the patient’s cardiac arrest. Although anteflexed, since the heart is superior
TEE is not the preferred imaging study to and slightly anterior to the cardio-
for diagnosing PE, it does offer useful esophageal junction. After anteflexion, the
information in patients who are too probe is withdrawn and the LV will come
unstable to undergo CT or magnetic into view in its short axis. Ideally, the
resonance imaging. LV will look like a doughnut, with both
papillary muscles appearing inside the
Transgastric Mid-Papillary “doughnut” on the screen. With the proper
Short-Axis View depth of view, the papillary muscles should
As one would guess from its name, appear equal in size. This view also may
the transgastric mid-papillary short-axis be obtained with the multiplane at zero
(TGMPSA) view requires the scope to degrees, as with the MEFC view; however,
be pushed into the patient’s stomach and a slight rotation of the scope or multiplane
the tip turned to look back on itself. For may be needed to facilitate an optimal
view of the LV.
The TGMPSA view allows the clinician
to assess LV function and detect wall-
motion abnormalities, which can indicate
occlusion of the coronary artery or
arteries. Critical minutes are saved when
the cardiologist knows which vessel to
catheterize first. Confirming the location
of the infarct may obviate the need for
an LV angiogram, thereby reducing
the burden on the patient’s already
compromised kidneys. This also is an ideal
view for assessing the effectiveness and
depth of chest compressions during CPR.
This approach also allows the clinician
to see the pericardium and evaluate for
(and measure) pericardial fluid. In cases
of tamponade, this view can be used to
guide the placement of a drainage needle
or catheter. Although technically more
difficult, this view provides much of the
same information as the MEFC view.
However, the TGMPSA approach provides
two important benefits: It can confirm
whether the distribution of the coronary
April 2018 n Volume 32 Number 4 23

FIGURE 3. Effect of Changes in TEE Probe Position
Effect of flexion or withdrawal and retroflexion or advancement of the transesophageal probe tip on the
imaging plane in relation to the mitral valve at a transducer rotational angle of zero degrees. A1, A2, A3 =
interior leaflet sections; Ao = aorta; LAA = left atrial appendage; P1, P2, P3 = posterior leaflet sections.
Adapted from Foster GP, Isselbacher EM, Rose GA, et al. Accurate localization of mitral regurgitant defects using
multiplane transesophageal echocardiography. Ann Thorac Surg. 1998;65:1025–1031.
artery is hypokinetic, and help estimate
the patient’s LV function.
For further aortic evaluation, the
probe should be rotated to the patient’s
left. The aorta in short axis (cross
section) comes into view, where it can
be assessed for dissection or aneurysm.
Caution should be used, however. Before
pulling the probe back, the flexion
should be reset to “neutral,” and the
multiplane reset to zero degrees. The
probe should be pulled out slowly until
it is in the upper-esophageal position.
From there, the descending aorta and
distal aortic arch may be visualized.
Mid-Esophageal Long-Axis
View
The mid-esophageal long-axis
(MELA) view is obtained by placing
the probe at the mid-esophageal depth
and rotating the multiplane angle to
approximately 120 degrees, or to the
point at which the LV outflow tract
is seen. This position enables the
evaluation of the LV inflow and outflow
tracts and the mitral and aortic valves;
dissection or dilatation of the proximal
ascending aorta also can be seen. In
24 Critical Decisions in Emergency Medicine
this view, the clinician can visualize any
LV anteroseptal and inferolateral wall-
motion abnormalities.
Mid-Esophageal Bicaval View
When using the mid-esophageal
bicaval (MEBC) approach, the scope
should be rotated toward the patient’s
right (clockwise from the head to the feet
of a supine patient). This will bring the
left and right atria into view; however,
the angle of the multiplane may need to
be decreased by 5 to 15 degrees. The left
atrium (LA) can be seen at the top of the
screen, and the right atrium (RA) can
be seen in the middle. The inferior and
superior vena cava, interatrial septum,
and RA appendage also can be visualized.
MEBC is a good screening view for
assessing RA size or searching for a clot in
the IVC or RA in cases of suspected PE.
CRITICAL DECISION
What risks should be considered
when performing TEE in a patient
in cardiac arrest?
A TEE examination in an intubated
patient in cardiac arrest is a low-risk,
high-reward endeavor. Although the
patient’s medical history is unlikely
to be forthcoming, the test’s absolute
contraindications — tracheoesophageal
fistula or severe esophageal stenosis —
might be suspected in any patient with a
gastrostomy feeding tube. Furthermore,
common sense dictates that if insertion
is difficult or there is marked resistance
when trying to advance or rotate
the probe, the procedure should be
reconsidered. On the other hand,
patients in cardiac arrest are destined to
suffer complications if they survive.
Another potential pitfall of TEE
is test misinterpretation, which
can lead to unnecessary, possibly
harmful treatments. In the emergency
department, resuscitation is the goal.
Once ROSC has been achieved, findings
should be confirmed before launching
into more invasive procedures. Since
experience is the best teacher, the most
senior echocardiographer available
should be present. Such expertise can
help reduce the risk of injury, image
misinterpretation, misdiagnosis, and
inappropriate treatment.
Contrast-induced nephropathy (CIN),
a potentially dangerous complication of
angiography, occurs in about 12% of
patients and is the third most common
cause of hospital-acquired acute renal
injury. Patients with congestive heart
failure, diabetes mellitus, or baseline
renal insufficiency are at higher risk.
Fortunately, CIN is generally transient
and reversible. 32
Summary
Ultrasound has become the
stethoscope of the 21st century, especially
in acute settings, where rapid diagnosis
and continuous physiological monitoring
are essential. The benefits of TEE in the
management of patients in cardiac arrest
far outweigh the risks. The procedure
provides an unobstructed view of
the heart and great vessels, provides
more information than transthoracic
ultrasonography, and does not interfere
with CPR.
REFERENCES
1. Nicholson M and Fleming JEE. Imaging and Imagining
the Fetus: The Development of Obstetric Ultrasound.
The Johns Hopkins University Press, 2013.
2. Stock KF, Klein B, Steubl D, et al. Comparison of
a pocket-size ultrasound device with a premium
ultrasound machine: diagnostic value and time
required in bedside ultrasound examination. Abdom
Imaging. 2015 Oct;40(7):2861-2866.
 CASE RESOLUTIONS
■ CASE ONE
The young tourist’s coronary
arteries were normal, but cardiac
catheterization revealed congenital
bicuspid aortic stenosis. The patient
was in heart failure. He was treated
with diuretics and admitted to the
intensive care unit, where he was
stabilized with inotropic medications.
He insisted that he wanted to be
treated at home in Germany and did
not want to be in a foreign country
during his postoperative recovery.
Since the patient was in extremis
and unable to lie down, his TTE
3. Rubano E, Mehta N, Caputo W, et al. Systematic
review: emergency department bedside ultrasono­
graphy for diagnosing suspected abdominal aortic
aneurysm. Acad Emerg Med. 2013 Feb;20(2):128-138.
4. Kuhn M, Bonnin RL, Davey MJ, et al. Emergency
department ultrasound scanning for abdominal aortic
aneurysm: accessible, accurate, and advantageous.
Ann Emerg Med. 2000 Sep;36(3):219-223.
5. Marik PE, Levitov A, Young A, Andrews L. The use
of bioreactance and carotid Doppler to determine
volume responsiveness and blood flow redistribution
following passive leg raising in hemodynamically
unstable patients. Chest. 2013 Feb 1;143(2):364-370.
6. Lee CW, Kory PD, Arntfield RT. Development of a fluid
resuscitation protocol using inferior vena cava and
lung ultrasound. J Crit Care. 2016 Feb;31(1):96-100.
7. Cortellaro F, Colombo S, Coen D, Duca PG. Lung
ultrasound is an accurate diagnostic tool for
the diagnosis of pneumonia in the emergency
department. Emerg Med J. 2012 Jan; 29(1):19-23.
8. Bass CM, Sajed DR, Adedipe AA, West TE. Pulmonary
ultrasound and pulse oximetry versus chest
radiography and arterial blood gas analysis for the
diagnosis of acute respiratory distress syndrome: a
pilot study. Crit Care. 2015 Jul 21; 19:282.
9. Cardinale L, Priola AM, Moretti F, Volpicelli G.
Effectiveness of chest radiography, lung ultrasound
and thoracic computed tomography in the diagnosis
of congestive heart failure. World J Radiol. 2014 Jun
28; 6(6):230-237.
10. Saqib A, Pandya B, Siddiqui F, Chalhoub M. 1032: Role
of ultrasonography in diagnosing pneumothorax:
meta-analysis of current evidence. Crit Care Med. 2016
Dec;44(12 Suppl 1):334.
n Misinterpreting a TEE examination, a mistake that can lead to unnecessary,
possibly harmful treatments. Once ROSC has been achieved, findings should be
confirmed before launching into more invasive procedures.
n Pausing chest compressions to perform ultrasound. It is important to remember
that CPR succeeds by optimizing forward blood flow, which is diminished by the
number and duration of interruptions.
n Neglecting to take advantage of TEE training opportunities.
examination was limited to a single
parasternal long-axis view. While
this isolated glimpse revealed a
dilated aortic root, visualizing the
aortic outflow tract is essential to
the diagnosis and management of an
acute valvular disorder.
Had a TEE probe been placed, it
would have revealed bicuspid valve
disease and eliminated the need
for cardiac catheterization. If TEE
had been initiated even earlier, the
patient also might have avoided the
CT angiogram to rule out pulmonary
embolism.
11. Inglis AJ, Nalos M, Sue KH, et al. Bedside lung
ultrasound, mobile radiography and physical
examination: a comparative analysis of diagnostic tools
in the critically ill. Crit Care Resusc. 2016 Jun;18(2):124.
12. Arntfield RT, Millington SJ. Point of care cardiac
ultrasound applications in the emergency department
and intensive care unit--a review. Curr Cardiol Rev. 2012
May; 8(2):98-108.
13. Jones AE, Tayal VS, Sullivan DM, Kline JA. Randomized,
controlled trial of immediate versus delayed
goal-directed ultrasound to identify the cause of
non-traumatic hypotension in emergency department
patients. Crit Care Med. 2004 Aug;32(8):1703-1708.
14. Jones AE, Craddock PA, Tayal VS, Kline JA. Diagnostic
accuracy of left ventricular function for identifying
sepsis among emergency department patients
with non-traumatic symptomatic undifferentiated
hypotension. Shock. 2005 Dec;24(6):513-517.
15. Blaivas M, Fox JC. Outcome in cardiac arrest patients
found to have cardiac standstill on the bedside
emergency department echocardiogram. Acad Emerg
Med. 2001; 8(6), 616-621.
16. Comess KA, DeRook FA, Russell ML, et al. The
incidence of pulmonary embolism in unexplained
sudden cardiac arrest with pulseless electrical activity.
Am J Med. 2000; 109(5):351–356.
17. Zengin S, Yavuz E, Al B, Cindoruk Ş, et al. Benefits
of cardiac sonography performed by a non-expert
sonographer in patients with non-traumatic
cardiopulmonary arrest. Resuscitation. 2016
May;102:105-109.
18. Atkinson PR, McAuley DJ, Kendall RJ, et al. Abdominal
and cardiac evaluation with sonography in shock
(ACES): an approach by emergency physicians for the
use of ultrasound in patients with undifferentiated
hypotension. Emerg Med J. 2009 Feb; 26(2):87-91.
■ CASE TWO
The TEE examination revealed that the
obese, middle-aged man had an ejection
fraction of less than 20% with marked
global hypokinesis. Using a TGMPSA
approach, the emergency physician
detected no movement on the posterior
and anterior walls of the patient’s heart.
The cardiologist was consulted.
In the catherization laboratory, the
left main coronary artery was confirmed
to be 100% occluded and stented. A
ventriculogram was avoided, and the
patient did not require a dye load. His
further recovery was uneventful.
19. http://cpr.heart.org/AHAECC/CPRAndECC/Programs/
HandsOnlyCPR/UCM_475604_CPR-Learn-More.jsp
20. Salen P, Melniker L, Chooljian C, et al. Does the
presence or absence of sonographically identified
cardiac activity predict resuscitation outcomes of
cardiac arrest patients? Am J Emerg Med. 2005
Jul;23(4):459-462.
21. M. Blaivas. Transesophageal echocardiography during
cardiopulmonary arrest in the emergency department.
Resuscitation. 2008;78;135-140.
22. Moore CL, Rose GA, Tayal VS, et al. Determination
of left ventricular function by emergency physician
echocardiography of hypotensive patients. Acad
Emerg Med. 2002; 9(3):186-193.
23. Labovitz AJ1, Noble VE, Bierig M, et al. Focused
cardiac ultrasound in the emergent setting: a
consen­sus statement of the American Society
of Echocardiography and American College of
Emergency Physicians. J Am Soc Echocardiogr.
2010 Dec;23(12):1225-1230.
24. Ramarapu S. Complete Neurological Recovery
After Transesophageal Echocardiography-
Guided Diagnosis and Management of Prolonged
Cardiopulmonary Resuscitation. A Case Rep. 2015 Dec
1;5(11):192-4. doi: 10.1213/XAA.0000000000000210.
PMID: 26588031
25. Stein PD, Matta F, Janjua M, et al. Outcome in stable
patients with acute pulmonary embolism who had
right ventricular enlargement and/or elevated levels
of troponin I. Am J Cardiol. 2010 Aug 15;106(4):558-63.
26. Keisler B, Carter C. Abdominal aortic aneurysm.
Am Fam Physician. 2015 Apr 15;91(8):538-543.
27. van der Wouw PA, Koster RW, Delemarre BJ, et al.
Diagnostic accuracy of transesophageal echocardio­
graphy during cardiopulmonary resuscitation.
J Am Coll Cardiol. 1997 Sep;30(3):780-783.
28. Vignon P, Mentec H, Terré S, et al. Diagnostic
accuracy and therapeutic impact of transthoracic
and transesophageal echocardiography in
mechanically ventilated patientsin the ICU. Chest.
1994 Dec;106(6):1829-1834.
29. Blaivas M. Bedside emergency department
ultrasonography in the evaluation of ocular pathology.
Acad Emerg Med. 2000 Aug;7(8):947-950.
30. Daniel WG, Erbel R, Kasper W, et al. Safety of
transesophageal echocardiography. A multicenter
survey of 10,419 examinations. Circulation.
1991 Mar; 83(3):817-821.
31. Arntfield R, Pace J, McLeod S, et al. Focused
transesophageal echocardiography for emergency
physicians-description and results from simulation
training of a structured four-view examination. Crit
Ultrasound J. 2015 Dec; 7(1):27.
32. Malaisrie SC, McDonald E, Kruse J, et al. Mortality
while waiting for aortic valve replacement. Ann Thorac
Surg. 2014 Nov;98(5):1564-1570; discussion 1570-1571.
April 2018 n Volume 32 Number 4 25
 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its entirety.

QUESTIONS Submit your answers online at acep.org/newcriticaldecisionstesting; a score of 75%

or better is required. You may receive credit for completing the CME activity any time
within three years of its publication date. Answers to this month’s questions will be
published in next month’s issue.

1 What is the leading cause of fetal death unrelated

to maternal death? 7 A 26-year-old woman presents after sustaining a
mechanical fall from standing. She is 8 months pregnant
A. Amniotic fluid embolism and landed on her abdomen, but presents without
B. Direct fetal injuries complaints and has no abdominal pain. What is the
C. Fetal maternal hemorrhage appropriate next step?
D. Placental abruption A. Monitor the patient with tocometry for a minimum

2
Which of the following is a frequent and early
indicator of inadequate maternal resuscitation?
of 4 hours
B. No acute intervention is necessary
A. Abnormal fetal heart rate C. Perform a vaginal examination and discharge if
B. Maternal hypotension negative for bleeding
C. Maternal hypoxia D. Perform an ultrasound examination and discharge if
D. Maternal tachycardia negative for acute abnormalities

3
Which of the following cardiovascular-related change
can be expected in pregnancy?
8 Which of the following ancillary tests exposes a fetus to
the greatest level of radiation?
A. Blood pressure drops, reaching its lowest level by
A. Computed tomography (CT) of the abdomen and
the end of the third trimester
pelvis
B. Cardiac output remains steady in all trimesters
B. CT scan of the head
C. Plasma volume increases by approximately
10% to 15% C. Plain radiographs of the lumbar region
D. Pulse rate increases 15 to 20 beats/min by term D. Ultrasound

4 What is the most important factor for predicting fetal

outcome when performing a perimortem cesarean
section?
A. Extent of maternal injuries
B. Gestational age of fetus
C. Presence of neonatal team upon delivery of infant
D. Time to delivery from maternal cardiac arrest
9 A young pregnant woman (G4P3, 37 weeks EGA)
presents after a moderate-speed MVC. She has stable,
normal vital signs and no evidence of external trauma;
however, she soon develops sudden-onset chest pain,
shortness of breath, and hypotension. Which diagnosis
is most likely?
A. Amniotic fluid embolus

5
When managing a pregnant trauma patient, how B. Placental abruption
should the Kleihauer-Betke test be used? C. Supine hypotensive syndrome
A. To determine the mother’s Rh status D. Thrombotic embolus
B. To evaluate for uterine rupture
C. To identify fetal maternal hemorrhage and
guide Rho(D) immune globulin dosing

10 What is the leading cause of trauma-associated preterm
labor?
A. Hypovolemia
D. To measure fetal distress
B. Hypoxia

6 Which of the following findings can be expected in

the third trimester?
A. Decreased fibrinogen and anticoagulation factor
levels
B. Elevation of diaphragm by 4 to 6 cm
C. Respiratory alkalosis from increased tidal volume
and a resultant decrease in partial pressure of
carbon dioxide to 30 mm Hg
D. Uterine blood flow of 60 mL/minute
C. Intra-abdominal hemorrhage
D. Placental abruption
11 Which of the following views would best demonstrate
the McConnell sign?
A. Mid-esophageal bicaval (MEBC)
B. Mid-esophageal long-axis (MELA)
C. Mid-esophageal four-chamber (MEFC)
D. Transgastric mid-papillary short-axis (TGMPSA)

26 Critical Decisions in Emergency Medicine

12 An obese 55-year-old woman presents in cardiac
arrest; the family witnessed the event and
performed good CPR. Downtime before arrival is
16
an estimated 3 minutes. The patient has a history
of diabetes mellitus, congestive heart failure, and
chronic obstructive pulmonary disease (COPD). EMS
found the patient in asystole and administered a
single dose of epinephrine. The patient is intubated.
A transthoracic echocardiogram (TTE) is initiated,
but the image quality is poor and no cardiac
motion is seen. What potential advantage might
transesophageal echocardiography (TEE) offer?
A. TEE can reveal a normal pericardium, even without
signs of pericardial effusion
B. TEE can reveal complete cardiac standstill,
allowing the clinician to terminate the “code”
C. TEE can reveal fine ventricular fibrillation that
17
may be amenable to cardiac defibrillation or
antiarrythmic medications
D. TEE can show right mainstem intubation
Which of the four recommended views is most critical
when managing a patient in cardiac arrest?
A. The deep TGMPSA view, which can help identify
RV-to-LV enlargement when the probe is positioned
at 120 degrees
B. The deep TGMPSA view, which monitors LV function
and volume status, and aids identification of the left
anterior descending, circumflex, and right coronary
arteries
C. The MEFC view, which allows an evaluation of the
aortic valve leaflets
D. The MEFC view, which provides the best view of the
ventricles
When acquiring the TGMPSA or "doughnut" view, how
should the TEE scope be positioned to obtain the best
image of the LV?
A. In anteflexion
B. In retroflexion

13
C. Rotated to the patient’s left
A 45-year-old man with a history of myocardial
infarction (MI), COPD, and coronary artery disease D. Rotated to the patient’s right

18
presents with crushing chest pain. His blood
pressure begins to drop, and he becomes confused.
His ECG shows ST elevations in the precordial leads,
and you suspect a significant MI. Which finding
would change this patient’s disposition?
A. TEE can reveal a 4.5-cm ascending aorta with an
intimal flap
B. TEE can reveal a globally decreased left ventricle
ejection fraction (LVEF)
C. TEE can show a regional wall-motion abnormality
over the lateral myocardium, suspicious for the
19
left anterior descending coronary artery
D. TEE can show mild mitral regurgitation
When using the TGMPSA view, what finding confirms
that the TEE scope has reached the correct depth?
A. Both papillary muscles are seen and are equal in size
B. The aortic valve can be visualized as a “Mercedes
emblem”
C. The intra-atrial septum is easily seen
D. The mitral valve is seen
Which of the following should be considered when
manipulating the TEE probe?
A. “Retroflexing” involves flexing the tip of the probe
anteriorly
B. The heart structure most anterior and closest to the

14 Which of the following is an absolute
contraindication to TEE?
TEE probe is the right ventricle
C. When advancing or pulling on the probe, it is best to
A. COPD have it in full flexion or retroflexion
B. Endotracheal intubation D. With reference to the heart, the “superior” position
C. Morbid obesity
points toward the head, and “inferior” points toward
D. Tracheoesophageal fistula
the feet

15 Which of the following is concerning for a
massive PE on the MEFC view?
20
Which of the following is a relative contraindication to
TEE in the emergency department?
A. An extremely dilated LV with free-wall akinesis
and normal apical contractions A. Active gastrointestinal bleeding
B. An extremely dilated RV with free-wall akinesis B. Esophageal tumor
and normal apical contractions C. Perforated viscous
C. Global hypokinesis with right atrial dilation D. Recent upper-gastrointestinal bleed
D. Thrombus within the right ventricle

ANSWER KEY FOR MARCH 2018, VOLUME 32, NUMBER 3

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
D B B A B C B C A B B D A D D C B C D B

April 2018 n Volume 32 Number 4 27

 Drug Box
MEROPENEM/VABORBACTAM COMBO
By Frank Lovecchio, DO, MPH, FACEP, Maricopa Medical
Center/Banner Poison and Drug Center, Phoenix, AZ
Although multidrug-resistant urinary tract infections (UTIs) are
becoming increasingly common, treatment options for complex
organisms are limited. Meropenem/vaborbactam is used for the
managment of complicated adult patients caused by susceptible
Escherichia coli, Klebsiella pneumoniae, and Enterobacter
cloacae species in adult patients.
Mechanism of Action
Meropenem inhibits bacterial cell wall synthesis by binding to
penicillin-binding proteins, which in turn inhibit peptidoglycan
synthesis. Bacteria eventually lyse due to the ongoing
activity of cell wall autolytic enzymes (autolysins and murein
hydrolases), and cell wall assembly is arrested.
Vaborbactam is a beta-lactamase inhibitor that protects
meropenem from degradation by certain serine beta-
lactamases (eg, K. pneumoniae carbapenemase [KPC]).
Dosing
cUTI (eg, pyelonephritis): (IV) 4 g every 8 hours for ≤14 days
eGFR ≥50 mL/minute/1.73 m2: No dosage adjustment needed
eGFR 30 to 49 mL/minute/1.73 m2: 2 g every 8 hours
eGFR 15 to 29 mL/minute/1.73 m2: 2 g every 12 hours
eGFR <15 mL/minute/1.73 m2: 1 g every 12 hours
Renal impairment: Use with caution; dosage adjustment is
required in patients with creatinine clearance <50 mL/min.
Hemodialysis patients: Dialyzable (meropenem [38%],
vaborbactam [53%]); adjust dose based on degree of renal
impairment; administer after hemodialysis on dialysis days.
Precautions
Increased seizure risk and thrombocytopenia have been
reported in patients with renal impairment. Adverse reactions
include phlebitis (≤4%), headache (9%), hypokalemia (1%),
diarrhea (3%), nausea (2%), increased serum ALT (2%),
increased serum AST (2%), hypersensitivity (2%), infusion site
reaction (≤4%), and fever (2%).
Meropenem is excreted in breastmilk; excretion of vabor­
bactam is not known. The drugs’ effects in pregnancy have
not been well studied.
Tox Box
LAUNDRY DETERGENT PODS
By Christie Sun, MD, and Christian A. Tomaszewski, MD, MS,
MBA, FACEP, University of California, San Diego
Pods containing concentrated laundry detergent were introduced
to the North American market in 2011. These capsules release their
contents on contact with moisture. Numerous reports of toxicity
have prompted increasing public health awareness. Most exposures
involve ingestions in children <5 years of age, but some adolescents
are deliberately biting into them (eg, “the laundry pod challenge”).
Pharmacology
The pods include a mixture of anionic and non-ionic surfactants,
propylene glycol, and ethanol pH 7-9.
Mechanism of Toxicity
Surfactants may have a caustic effect that compromises the
upper airway. Propylene glycol and ethanol may contribute to
central nervous system (CNS) depression and hypoventilation.
Clinical Presentation
CNS: drowsiness, lethargy
Gastrointestinal: nausea, vomiting, foaming at the mouth
Pulmonary: coughing, stridor, respiratory distress, aspiration
Ocular: conjunctivitis, corneal ulceration
Dermal: erythema, rash, burns, blistering, irritation
Diagnostic Evaluation
Consider chest radiography if there is concern for aspiration.
Baseline blood counts, and renal and liver function tests are
recommended in severe cases.
Management
• Airway management and supportive care are mainstays of
treatment, with intubation in severe cases.
• External or ocular decontamination with irrigation may be
warranted.
• Consider a gastroenterology consult in cases of caustic injury
with ingestion.
• Consider an ophthalmology consult for patients with ocular
injuries.
• Discharge if the airway is clear and the patient is tolerating
fluids; otherwise, observe for airway or neurological
compromise.