By Kane McKenzie, DO

HPI: A 55 year old woman presents to the emergency department for back pain. She reports that while walking she suddenly felt a sharp pain in the center of her back. It feels like stabbing, and is worse with a deep breath or movement. She denies recent trauma. She has a history of hypertension for which she does not take medications. ECG shows NSR with new T wave inversions in lateral leads.


Vitals: BP 230/114 HR 80 RR 20 SaO2 97%


PE: Appears uncomfortable. No murmurs, lungs clear but breath sounds diminished. 3+ Radial and Dorsalis Pedis pulses. Mild tenderness to upper thoracic spine. Neurologic exam is nonfocal.


Labs: High sensitivity troponins 24>24, CBC and BMP unremarkable
Imaging: CTA chest shows intramural hemorrhage of the aortic arch and descending thoracic aorta


Diagnosis: Aortic Intramural hemorrhage – Considered an acute aortic disorder but often differentiated from dissection



Management: 
Similar to aortic dissection. Anti-impulse therapy: HR preferred with Esmolol or Labetolol (HR < 80) , BP (systolic < 120) with Nicardipine or nitroprusside + Emergent surgical consultation


Pathophysiology:
-Hematoma within the medial layer of the aorta without a detectable intimal tear
-Can develop into aortic dissection
-Classified using Stanford or Debakey, same as dissections
-Estimated to account for 5-20% of patients with symptoms consistent with an aortic dissection
-Theorized to occur by either rupture of a penetrating atherosclerotic ulcer or spontaneous rupture of the vasa vasorum
-There is debate whether intramural hematoma should be classified as dissection with thrombosis of the false lumen
-Intimal defects are present in 70% of cases initially diagnosed as intramural hematoma
-Often not able to be identified until surgical repair


References:
Black, James H III. Overview of acute aortic dissection and other acute aortic syndromes. In: UptoDate, Connor RF (Ed), Wolters Kluwer. (Accessed August 16, 2024.)
Tintinalli’s Emergency Medicine 
Gaillard F, Hacking C, Jones J, et al. Aortic intramural hematoma. Reference article, Radiopaedia.org (Accessed on 16 Aug 2024) https://doi.org/10.53347/rID-919

By: Dr. Sean Coulson

HPI: Pt is a 38 y/o male with hx of sickle cell (SS) who presents for generalized headache, facial droop and difficulty speaking. Last known normal was 19 hours PTA. No anticoagulation.

Objective: HR 91, BP 155/91, RR 20, Temp 98F, Accu Check 129 NIH 2 – mild left lower facial droop and mild dysarthria. No other neurologic deficits. Stroke alert is called and CT CTA do not show any acute hemorrhagic infarct or large vessel occlusion. Labs and EKG are sent and the only pertinent result includes a Hb of 6.1 (prior baseline 9).

DDX: acute hemorrhagic / ischemic stroke, seizure, dural venous sinus thrombosis, myasthenia gravis, botulism, complex migraine etc.

Management: Given that this patient was outside of the 4.5 hour window and there was a low suspicion for thromboembolic etiology, TNK was held. In discussion with neurology and hemonc, a shiley dialysis catheter was placed and exchange transfusion was initiated.

Exchange transfusion: Goal is to reduce HbS to < 30% preventing further sickling. In hemorrhagic stroke (primary or secondary to an ischemic stroke), exchange transfusion is still indicated however the goal is to prevent secondary vasospasm and recurrent strokes – data is less clear in terms of overall benefit. If exchange transfusion is not possible, simple regular transfusions are indicated immediately and can act as a bridge until exchange transfusion is established. Hb goal determined in discussion w/ Hematology.

Pearls:

~ Sickle cell is a common cause of acute stroke in children and young adults.

~ SS causes increased risk for cerebral aneurysms and other arterial abnormalities (high risk for carotid dissection, subarachnoid, dural venous thrombosis etc)

~ It is still important in acute strokes to apply general sickle cell crisis management (O2, fluids, pain control, transfusion)

~ Exchange transfusions lower risk of recurrent stroke

~ SS is not an absolute contraindication to TPA

*** Thrombolytics can be given in sickle cell patients if there is a high pretest probability for thromboembolic etiologies of the acute stroke (CAD, PVD, Afib etc) and the patient meets typical inclusion/exclusion criteria. However the benefit of thrombolytics in stroke secondary to sickled RBCs is questionable – data is limited.

~ If exchange transfusion is not possible, discussion w/ hematology and neurology about Hb parameters is paramount.

References

Hulbert ML, Scothorn DJ, Panepinto JA, et al. Exchange blood transfusion compared with simple transfusion for first overt stroke is associated with a lower risk of subsequent stroke: a retrospective cohort study of 137 children with sickle cell anemia. J Pediatr. 2006;149(5):710-712. doi:10.1016/j.jpeds.2006.06.037

Alakbarzade V, Maduakor C, Khan U, Khandanpour N, Rhodes E, Pereira AC. Cerebrovascular disease in sickle cell disease. Pract Neurol. 2023;23(2):131-138. doi:10.1136/pn-2022-003440

Tintinalli J. TINTINALLI’S EMERGENCY MEDICINE : A Comprehensive Study Guide. Mcgraw-Hill Education; 2019:1136.

EM:RAP CorePendium. EM:RAP CorePendium. Published 2024. Accessed August 10, 2024. https://www.emrap.org/corependium/chapter/recZWicqx0K20uwsz/Sickle-Cell-Disease#h.1h9pp1rguxde

Sean Coulson D.O.

HPI: Pt is a 24 y/o male who presents for fall, complaining of right lateral anterior palm pain. No medical hx, TDap up to date, no anticoagulation.

Physical Exam: Tender to palpation over the medial right palm on the anterior aspect. Radial pulse 2+, Cap refill intact, Strength and sensation intact, no abrasions / lacerations / skin changes. When the patient closes the right hand and makes a fist, the right 2nd finger angulates and bends overtop the 3rd phalanx (as seen below).

Pertinent Information About 2nd-5th Metacarpal Fractures:

Is it an open vs closed? Does it involve the intra articular space? Cascade of finger placement, malrotation / scissoring (see photo below)?

What are acceptable degrees of angulation based on the digit?

1st metacarpal: < 10 degrees

2nd: <20 degrees

3rd: < 30 degrees

4th: < 40 degrees

If less than the stated degree, may consider reduction, splint and discharge with orthopedic follow up if no other concerning features are present.

Other Indications for operative management and in ED orthopedic consult

Angulation greater than what’s stated above

Shortening > 5mm

Intraarticular or open fracture

Abnormal finger cascade regardless of degree of angulation

Multiple metacarpal fx

Management

+/- Ortho evaluations w/ operative fixation as described above

4th / 5th MCP fx: ulnar gutter splint

2nd / 3rd MCP fx: radial gutter splint

References:

https://jkfs.or.kr/ViewImage.php?Type=F&aid=593409&id=F1&afn=104_JKFS_31_2_61&fn=jkfs-31-61-g001_0104JKFS

https://www.ncbi.nlm.nih.gov/books/NBK551532

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355092

https://www.journal-cot.com/article/S0976-5662(20)30230-7/fulltext

Metacarpal Fractures

https://www.orthobullets.com/hand/6037/metacarpal-fractures