Wednesday Image Review

From the Archives: What is the diagnosis? By Dr. Guo

A 2 year old with no past medical history presents with severe left leg pain after falling off a trampoline. He is crying and refusing to bear weight or straighten his left leg. The extremity is otherwise neurovascularly intact. An XR of his left lower leg is shown below. What’s the diagnosis and specifically what type of fracture is it?

Answer: Salter-Harris type II fracture of the proximal left tibia

  • Salter-Harris fractures are fractures of the growth plate, and there are 5 types which are commonly learned with the mnemonic SALTER
Salter Harris TypeLocationManagement
1 (Slipped)Epiphysis separated from metaphysisBrace, follow up with pediatrician
2 (Above)Extends though physis and into metaphysisSplint, NWB, ortho follow up
3 (Lower)Extends into intra-articular spaceSplint, ED ortho consult
4 (Through)Extends through metaphysis, physis, and epiphysisSplint, ED ortho consult
5 (ERased)Physis compression Splint, ED ortho consult

References:

Mayersak R.J. (2020). Initial evaluation and management of orthopedic injuries. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Wednesday Image Review

What is the Diagnosis? By Dr. Cevallos

A 68 year old male with a history of DM, HTN, and breast cancer presents to the ED with progressively worsening dyspnea over the past three to four days. On exam she is tachycardic to 120, appears tachypneic with accessory muscle usage and pulse ox is 88% on room air. You perform a lung ultrasound which reveals the following:

What is the diagnosis?

Pleural Effusion.

Ultrasonographic findings of pleural effusion:

  • Fluid appears dark (anechoic) cephalad to the diaphragm and may be homogeneous or heterogeneous depending on the etiology of the fluid.
  • Lung may be seen as a triangle-like structure floating in the pleural fluid
  • Thoracic spine sign: the spine is able to be visualized due to loss of mirror artifact as a hyperechoic area posterior to the fluid as the fluid acts a medium through which the ultrasound waves can be transmitted

Case continued:

A pigtail was placed to remove the fluid with the patient experiencing improvement in respiratory status status post drainage of approximately 800mL of fluid.

Resources:

Deschamps, Jade, and Vi Dinh. “Lung Ultrasound Made Easy: Step-By-Step Guide.” Pocus 101, 2023, www.pocus101.com/lung-ultrasound-made-easy-step-by-step-guide/. Accessed 6 Nov. 2024. Co-authors: Jessica Ahn, Satchel Genobaga, Annalise Lang, Victor Lee, Reed Krause, Devin Tooma, and Seth White. Oversight, review, and final edits by Vi Dinh.

Huang, Calvin, Andrew S. Liteplo, and Vicki E. Noble. “Lung and Thorax.” Practical Guide to Emergency Ultrasound, edited by Vicki E. Noble and Bret P. Nelson, 2nd ed., Cambridge University Press, 2011, pp. [specific page numbers if available].

Wednesday Image Review

From the Archives: What is the Diagnosis? By Dr. Selman

A 51-year-old male with past medical history of HTN, DM presents with right shoulder pain. He states he tripped off the curb and landed on his right shoulder. On exam, there are no palpable deformities, but patient has limited abduction of shoulder and tenderness on palpation of anterior shoulder. An X-ray is obtained and shown below. What’s the diagnosis?

Answer: Acromioclavicular (AC) joint separation

  • AC joint is composed of the acromion process and clavicle and supported by AC ligament, coracoclavicular ligament
  • Mechanism of injury is fall directly on shoulder or FOOSH
  • AC joint injuries range from sprain of ligaments to complete rupture of all supporting ligaments and complete separation of clavicle and acromion
    • Type I: normal X-ray, due to sprain of ligaments
    • Type II (X-ray above): widened AC joint, clavicle is displaced <50%, due to rupture of AC ligaments
    • Type III: clavicle displaced >50%, due to rupture of AC ligaments and coracoclavicular ligaments
    • Type IV: clavicle is dislocated posteriorly
    • Type V: clavicle displaced >200% superiorly
    • Type VI: clavicle dislocated inferiorly
  • Treatment
    • Sling immobilization and physical therapy for types I – III
    • Surgical repair for types IV – VI

References:

Bjoernsen, Lars Petter, and Alexander Ebinger.. “Shoulder and Humerus Injuries.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016

Monday Back to Basics & Pharmacology · Wednesday Image Review

What is the Diagnosis? By Dr. Cevallos

A 5 week old male with no significant PMH and an uncomplicated gestational/birth history presents to the ED after multiple episodes of projectile non-bilious vomiting. Vital signs include a HR of 165, Temp of 98.5F, RR 35, SpO2 100%. Exam is notable for a dry mucous membranes but otherwise is unremarkable. You perform an abdominal ultrasound and find the image below. What is the diagnosis?

Pyloric Stenosis:
– It is caused by hypertrophy of the pylorus leading to gastric outlet obstruction
– Presents with non-bilious projectile vomiting
– Can lead to hyperchloremic, hypokalemic, metabolic alkalosis
– Most commonly presents between 3-6 weeks of age
– Physical exam may reveal an “olive” sized mass in the epigastric region
– Patients may appear dehydrated with protracted disease but generally patients appear well without any signs of peritonitis or even abdominal tenderness

Diagnosis: Ultrasound is the test of choice (97-100% sensitivity and specificity of 99-100%)
– Think Pi: 3.14!
– In the longitudinal view: Length greater than 14mm and pyloric muscle wall thickness greater than 3mm is abnormal.

This patient underwent a pylorotomy without any complications and was successfully discharged.

Resources:
https://www.acep.org/sonoguide/advanced/pediatric-pyloric-stenosis#:~:text=Hypertrophic%20pyloric%20stenosis%20is%20an,2%2D12%20weeks%20of%20age.&text=Classic%20findings%20include%20projectile%20non,%25%20of%20the%20time%2C%20respectively.

https://www.emrap.org/corependium/chapter/recZCk7ICgxcy7hbM/Infantile-Hypertrophic-Pyloric-Stenosis#h.whcpdchy1ovf

Friday Board Review

Friday Board Review with Dr. Ethan Anderson

A 55-year-old man with end-stage renal disease (ESRD) on hemodialysis presents to the emergency department with complaints of shortness of breath, chest pain, and confusion. His vital signs are as follows: BP 170/100 mm Hg, HR 105 bpm, RR 26 breaths/min, SpO2 88% on room air. His physical exam reveals jugular venous distension, diffuse crackles on lung auscultation, and pitting edema in his lower extremities. A chest X-ray shows bilateral pulmonary edema. His most recent dialysis session was 4 days ago.

Which of the following is the most appropriate initial management for this patient?

A) Administer intravenous nitroglycerin
B) Initiate noninvasive positive pressure ventilation (NIPPV)
C) Administer intravenous furosemide
D) Perform emergent hemodialysis
E) Administer intravenous morphine

Answer: D) Perform emergent hemodialysis

Explanation: This patient is presenting with symptoms of acute volume overload and pulmonary edema, a life-threatening complication in patients with ESRD on dialysis who miss or delay dialysis sessions. His history of missed dialysis, elevated blood pressure, jugular venous distension, pulmonary crackles, and pitting edema all point toward hypervolemia. Additionally, his symptoms of confusion and shortness of breath raise concern for uremic encephalopathy and pulmonary edema.

Emergent hemodialysis is the most definitive treatment in this case, as it addresses both fluid overload and potential uremia by rapidly removing excess fluid and toxins. Other options may provide temporary relief and may be initiated in the ED while awaiting initiation of hemodialysis, but do not address the underlying cause.

  • Option A (IV nitroglycerin) may reduce preload and afterload, providing some symptomatic relief, but it does not directly treat the excess fluid or uremia
  • Option B (NIPPV) can help improve oxygenation in acute pulmonary edema but is an adjunct and not a definitive therapy for fluid overload in ESRD
  • Option C (IV furosemide) is ineffective in patients with ESRD as their kidneys cannot produce urine, making diuresis impossible
  • Option E (IV morphine) may reduce dyspnea but is rarely used due to potential side effects like respiratory depression and worsening hypercapnia

References:

  • Tintinalli’s Emergency Medicine Manual, 9th Edition