Wednesday Image Review

What’s the Diagnosis? By Dr. Vincent Li

30 year old female is brought by EMS from an outpatient surgery center for evaluation of persistent hypotension and vaginal bleeding after an elective abortion and D&E at approximately 20 weeks gestation. Initial vitals on arrival were T 98.6 F, HR 99, BP 62/palp, RR 21, O2 100%. On exam, patient was pale and lethargic but mentation intact. There is scant vaginal bleeding on pelvic exam. A bedside FAST is performed and shown below. What is the interpretation of the FAST, and which views demonstrate free fluid if present?

Answer: Free Fluid in RUQ, LUQ, and Pelvis

The patient received 2 units of uncrossed pRBCs in addition to 1g TXA IV and was taken emergently to the OR with OBGYN for exploratory laparotomy. She was found to have 1500 ccs of hemoperitoneum from an actively bleeding R uterine artery laceration. She did well post-op and was discharged a few days later!

Focused Assessment with Sonography for Trauma

  • High sensitivity and specificity for detecting intra-abdominal free fluid in hypotensive trauma patients.
  • Four views: RUQ, LUQ, cardiac, and suprapubic
  • Where you’ll find free fluid:
    • RUQ: 1. Subdiaphragmatic space, 2. Hepatorenal space (Morrison’s pouch), and 3. Caudal edge of the liver
      • Most sensitive area for intra-abdominal free fluid is the RUQ – more specifically, the caudal edge of the liver (contiguous with right paracolic gutter)
    • LUQ: 1. Subdiaphragmatic space, 2. Splenorenal space, and 3. Inferior pole of the left kidney
    • Cardiac: 1. pericardial effusion
    • Pelvis: 1. Between the bladder and uterus (in females), 2. Posterior to the uterus (in females), and 3. Posterolateral to the bladder
      • Fluid in the pelvis will first accumulate in the rectouterine pouch of Douglas in females, and the posterior bladder margin in males. Prostate may be confused with free fluid but is generally more hyperechoic and discrete in structure.

Key learning point for this case: clotted blood is more hyperechoic and can start to resemble tissue or other structures. Easy to miss if not looking closely.

References:

  1. Lobo V, Hunter-Behrend M, Cullnan E, Higbee R, Phillips C, Williams S, Perera P, Gharahbaghian L. Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. West J Emerg Med. 2017 Feb;18(2):270-280. doi: 10.5811/westjem.2016.11.30435. Epub 2017 Jan 19. PMID: 28210364; PMCID: PMC5305137.
  2. Ultrasound Guidelines: Emergency, Point-of-Care and Clinical Ultrasound Guidelines in Medicine. Ann Emerg Med ​​. 2017 May;69(5):e27-e54. Doi: 10.1016/j.annemergmed.2016.08.457.
  3. “Fundamentals.” Core Ultrasound Courses, courses.coreultrasound.com/courses/fundamentals. Accessed 2 May 2024.
Tuesday Advanced Cases

Critical Cases – Periodic Paralysis

By Dr. Jacob Martin, MD

HPI:

  • 30 yo healthy male p/w generalized fatigue, b/l UE and LE weakness and pain for several hours
  • Denies strenuous activity, change in diet, falls, trauma, midline back pain, bowel and or bladder incontinence
  • Hospitalized 3 months prior for unexplained hypokalemia (K <2.0) that resolved with IV repletion

PE:

Vitals: BP 182/78 | Pulse 61 | Temp 97.7 °F (Oral) | Resp 22 | SpO2 100% 

  • Awake and alert, appears fatigued
  • Dry MM, cap refill greater than 3 seconds
  • 4/5 strength b/l UE
  • 3/5 strength b/l LE
  • Sensation to light touch intact in bilateral upper and lower extremities
  • 2+ patellar reflexes bilaterally
  • Unable to ambulate due to weakness

Ddx for Generalized Weakness:

  • Hypokalemia/hyperkalemia vs rhabdomyolysis vs periodic paralysis vs spinal cord compression vs Guillain-Barre syndrome

Initial Diagnostics:

  • Initial labs notable for K 1.9, Mg 1.5, and Phos 1.1
  • Initial ECG (see below)

Management:

  • Electrolytes repleted as follows…
    • 40 mEq oral K, 20 mEq IV K
    • 2 gm Mg over 2 hours
    • 2 tablets of Neutra-Phos

Case Progression:

  • Ultimately diagnosed with hyperthyroidism, likely secondary to Graves’ disease
    • TSH <0.01
    • Ultrasound thyroid
      • Enlarged heterogeneous thyroid with diffusely increased vascularity
      • Thyroid nodule of the isthmus
  • Started on Methimazole and Propranolol
  • Presenting symptoms and electrolyte abnormalities attributed to thyrotoxic periodic paralysis

Thyrotoxic Periodic Paralysis (TPP)

  • Potentially life-threatening
  • Defined as the triad of
    • Muscle paralysis
    • Acute hypokalemia
    • Hyperthyroidism
  • Less than half of TPP patients exhibit clinical signs of hyperthyroidism
  • Rapid recognition and termination are mandatory to avoid potentially fatal complications of severe hypokalemia
    • Cardiac arrhythmias
    • Respiratory failure
  • Management complicated by the thin line between refractory hypokalemia and rebound hyperkalemia
  • KCl supplementation is essential but often not enough to control TPP
  • IV propranolol has been reported to reverse weakness and hypokalemia in patients unresponsive to KCl administration

References:

Bilha S, Mitu O, Teodoriu L, Haba C, Preda C. Thyrotoxic Periodic Paralysis-A Misleading Challenge in the Emergency Department. Diagnostics (Basel). 2020;10(5):316. Published 2020 May 18. doi:10.3390/diagnostics10050316

Lin SH, Huang CL. Mechanism of thyrotoxic periodic paralysis. J Am Soc Nephrol. 2012;23(6):985-988. doi:10.1681/ASN.2012010046

Friday Board Review

Board Review with Dr. Kat Kaminski

A 4-month old female born at full term otherwise healthy presents to the ED after parents observed her “turning blue” and “breathing funny” for less than a minute that spontaneously self-resolved. Parents report no recent fever or illness and say this has never happened before. Upon arrival to the ED patient appears to be well appearing and in no acute distress, afebrile and with reassuring vital signs and physical exam. Parents ask if they can take her home. What do you do?

A. Tell the parents the baby needs to be admitted to the pediatric floor

B. Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

C. Tell the parents the baby is fine and discharge to home

D. Tell the parents the baby needs to be admitted to the PICU

Answer: Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents

This baby presents with a BRUE, a Brief Resolved Unexplained Event (formerly known as ALTE, Apparent Life-Threatening Event) as defined by:

  • Sudden, brief, and now resolved episode of one or more of the following in an infant < 1 year age:
    • Cyanosis or pallor
    • Absent, decreased, or irregular breathing
    • Marked change in tone (hyper- or hypotonia)
    • Altered responsiveness
    • No explanation for the event after full history and exam

And according to the most recent American Academy of Pediatrics guidelines, this patient is considered low risk according to the following criteria:

  • Age >60 days
  • Born >= 32 weeks’ gestation and corrected gestational age >=45 weeks
  • No CPR by trained medical provider
  • Event lasted <1 minute
  • First event

Therefore, this low risk patient may be safely discharged home with close pediatrician follow up after a period of observation and education provided to the parents about BRUEs. This is different than past practice where nearly all patients with BRUEs (then called ALTEs) were hospitalized. It should be noted that BRUEs can be related to a range of conditions both benign and more concerning. Possible etiologies include GERD, breath-holding spells, non-accidental trauma, and serious bacterial infection. The risk of a serious disorder presenting as a BRUE is unknown, therefore a thorough history and physical exam is essential.

References:

Joel S. Tieder, Joshua L. Bonkowsky, Ruth A. Etzel, Wayne H. Franklin, David A. Gremse, Bruce Herman, Eliot S. Katz, Leonard R. Krilov, J. Lawrence Merritt, Chuck Norlin, Jack Percelay, Robert E. Sapién, Richard N. Shiffman, Michael B.H. Smith, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS, Pediatrics May 2016, 137 (5) e20160590; DOI: 10.1542/peds.2016-0590

Wednesday Image Review

What’s the Diagnosis? By Dr. Chris Smith

A 31 yo male presents with left thumb pain after a dirt bike crash.  Patient is unable to move his left thumb and has tenderness at the base. An x-ray is shown below.  What’s the diagnosis?

Answer: Type I first metacarpal fracture (Bennett fracture)

  • Most commonly occurs in young males from forceful axial load against a fixed object (sports, bicycle accident, punching), presents with pain and swelling at thenar eminence, decreased range of motion at MCP/CMC joints
  • Diagnosis of first metacarpal fractures usually made by plain radiograph
  • Management with reduction (may be accomplished with longitudinal traction, abduction and extension of first MC), thumb spica splint, and prompt orthopedic follow up.  May require percutaneous pin fixation or open reduction and internal fixation.

Classification of first metacarpal base fractures

  1. Type I, Bennett fracture: intra-articular fracture-dislocation/subluxation at the CMC joint
  2. Type II, Rolando fracture: a comminuted Bennett fracture
  3. Type III, (no eponym): extra articular fracture
  4. Type IV, (no eponym): extra-articular pediatric fracture involving the proximal physis

References:

Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.

Wednesday Image Review

What’s the Diagnosis? By Dr. Julie Calabrese

75 y/o M PMHx of ESRD on HD, pulmonary HTN, HLD presents to the ED with 1 week of progressive fatigue and SOB. Pt on 2L NC home O2 but requiring 4L NC in the ED to maintain saturation > 95%. On exam, pt with increased WOB and RR > 20. Lungs are CTA. Cardiac exam shows RRR with mild JVD, abdominal distention and +1 pitting edema B/L. POCUS was performed and is shown below. What is the diagnosis? 

Answer: Right Heart Strain from Pulmonary Hypertension 

  • Signs in POCUS that are indicative of R heart strain:
    • D-sign: septal flattening seen in the parasternal short orientation that is indicative of increased RV pressures 
    • McConnel’s Sign: seen in the apical 4 chamber view. R ventricular free wall akinesis with sparing of the apex (apical hyperkinesis) 
    • Increased RV:LV ratio, typically should be ⅓:⅔ 
    • Decreased TAPSE: measurement of the vertical motion of the tricuspid valve in the apical 4 chamber view (normal > 16 mm)
  • Causes of R- Heart Strain:
    • Pulmonary Embolism
    • Pulmonary hypertension 
    • Biventricular failure
    • R sided heart failure 
    • Valvular dysfunction (Acute TR) 
  • Pulmonary Hypertension:
    • Type 1: primary arterial pulmonary HTN 
    • Type 2: PH due to L heart failure
    • Type 3: PH due to lung disease 
    • Type 4: PH due to chronic thromboembolic disease 
    • Type 5: idiopathic PH 
  • Acute Treatment for PH includes
    • Optimize RV preload- patients typically euvolemic or hypervolemic and do not respond well to rapid shifts in fluid status (usually avoid fluids). If hypovolemia/sepsis consider small 250 ml boluses with frequent reassessments 
    • Improve cardiac output: consider early ionotropes 
    • Reduce RV afterload: avoid hypoxia, acidosis, hypercapnia 
    • Treat arrhythmias: most common is SVT followed by afib/flutter 

Resources: 

https://courses.coreultrasound.com/courses/take/fundamentals/lessons/18316427-right-heart-strain-5minsono

Wednesday Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

A 39 y.o. woman who is G9P1 and currently 6 weeks pregnant presents to the ED with a chief complaint of vaginal bleeding that began in the morning with associated lower abdominal pain and lightheadedness. Physical exam demonstrates lower abdominal tenderness without peritonitis and a small amount of blood in the posterior vaginal fossa with a closed cervical os. You obtain a serum HCG which is 8,960 and perform a transvaginal ultrasound which demonstrates the following. What’s the diagnosis?

Answer: Ectopic Pregnancy

  • When performing a pelvic US in the ED, the focused question is: “Is there an intrauterine pregnancy (IUP) or not?”
  • To diagnose an IUP, one must visualize a gestational sac AND either a yolk sac or fetal pole within the uterus.
  • In this patient, no gestational sac nor yolk sac are visualized within the uterus.
  • The left adnexa demonstrates a tubal ring concerning for an ectopic pregnancy. OBGYN was consulted who took the patient Level 1 to the OR where the ectopic pregnancy was confirmed and removed along with a left salpingectomy.

Resources:

Heaton, Heather. “Chapter 98: Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy.” Tintinalli’s Emergency Medicine A Comprehensive Study GUide, 9th ed., McGraw-Hill, 2020, pp. 615–623.

Pontius E. Ectopic Pregnancy & Heterotopic Pregnancy. In: Johnson W, Nordt S, Mattu A and Swadron S, eds. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/reci4t2X66l3qk1SX/Ectopic-Pregnancy-and-Heterotopic-Pregnancy#h.za15ev4ckcfv. Updated February 2, 2024. Accessed April 17, 2024.

Friday Board Review

Board Review by Dr. Christine Collins

A 60 year old male presents to the hospital in cardiac arrest. After recognition of ventricular fibrillation, you successfully achieve ROSC with early CPR and defibrillation. The patient remains comatose. What is recommended post-resuscitation for this patient?

A: Maintain temperature at 30 degrees Celsius for 24 hours

B: Obtain and electroencephalogram

C: Targeted glucose range 90-130

D: Maintain oxygen saturation at 100%

Answer: Obtain an electroencephalogram

After cardiac arrest, the American Heart Association recommends early coronary artery catheterization (if suspected cardiac etiology), maintenance of hypothermia (between 32 and 36 degrees for 24 hours), controlled reoxygenation >94%, and avoidance of hypotension. For comatose patients, it’s recommended to obtain EEG to assess for subclinical seizure. About 12-22% of patient’s after cardiac arrest that remain comatose have epileptiform activity, and this can lead to worsening neurologic outcomes if not detected.

References: 

Callaway CW, Donnino MW, Fink EL, et al. Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18 Suppl 2):S465–82.

Krumholz A, Stern BJ, Weiss HD. Outcome from coma after cardiopulmonary resuscitation: relation to seizures and myoclonus. Neurology 1988; 38:401.

Wednesday Image Review

What’s the Diagnosis? By Dr. Erica Schramm

25 year-old female presents following a fall from her horse 5 days ago. She complains of severe pain in the radial aspect of her right wrist and has no other injuries.  Plain films at an outside ED immediately following the injury were negative, and repeat plain films are shown here. What’s the diagnosis?

Answer: Non-displaced Scaphoid Waist Fracture

  • The most common carpal bone fracture (60-70% of all carpal fractures). 10-30% of scaphoid fractures are not detected on the first set of plain films, but “scaphoid view” plain films (i.e., AP wrist with ulnar deviation) can improve the view of the scaphoid.
  • If a scaphoid fracture is clinically suspected, the patient should be placed in a thumb spica splint and follow up in 7-10 days for repeat plain films and reexamination
  • The most feared complication of a scaphoid fracture is avascular necrosis (AVN) of the proximal fracture segment. AVN is more likely in unstable scaphoid fractures, for example those that are proximal, oblique, displaced >1 mm, rotated, or comminuted. These require surgical consult and long arm thumb spica splint.
  • Stable fractures can be splinted with a short arm thumb spica splint and patients should be instructed to follow up with orthopedics in 7-10 days

References:

Escarza, Robert et al. “Chapter 266. Wrist Injuries.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 7e.  Eds, Judith E. Tintinalli, et al.  New York, NY: McGraw-Hill, 2011.

DeAngelis, Michael A and David A Wald. “Wrist.” Simon’s Emergency Orthopedics, 7e.  Ed. Scott C Sherman.  New York, NY: McGraw-Hill, 2014

Jordanov, Martin I and Robert Warne Fitch. “Chapter 9 Upper Extremity.” The Atlas of Emergency Radiology. Eds. Jake Block et al.  New York, NY: McGraw-Hill, 2013

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 20 year old male presents to the emergency department via EMS for left knee pain. He was playing basketball when he jumped and felt a “pop” in his left knee and has been unable to walk on his left leg since. He denies falling. On exam, the left lower extremity is distally neurovascularly intact with normal strength, sensation, and a palpable pulse. There is slight bogginess and swelling with tenderness to palpation to the inferior knee. He is unable to extend at the knee. A point of care ultrasound of the bilateral knees is performed and shown below. What’s the diagnosis?

Answer: Left patellar tendon rupture

  • Commonly occurs from forced quadriceps contraction or falling on a flexed knee.
  • Associated with a high-riding patella also known as patella alta which can be appreciated on physical exam and lateral radiographs of the knee.
  • There is emerging data demonstrating point of care ultrasound as a quick and effective method to diagnose tendon injuries in the emergency department compared to physical exam, x-ray imaging, and MRI.
  • Treatment:
    • Incomplete tears with intact extensor mechanism can be immobilized and followed up outpatient with orthopedics.
    • Complete tears or loss of extensor mechanism should prompt orthopedic consultation in the ED as expedited surgical repair is often indicated.

References:

Bengtzen R. Knee Injuries. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill Education; 2020.

Berg, K., Peck, J., Boulger, C., & Bahner, D. P. (2013). Patellar tendon rupture: an ultrasound case report. BMJ case reports2013, bcr2012008189. https://doi.org/10.1136/bcr-2012-008189

Wu TS, Roque PJ, Green J, et al. Bedside ultrasound evaluation of tendon injuries. Am J Emerg Med. 2012;30(8):1617-1621. doi:10.1016/j.ajem.2011.11.004

Tuesday Advanced Cases

Alcohol Withdrawal By Dr. Sandhya Ashokkumar

HPI

  • A 53-year-old male with a history of chronic daily alcohol use presents to the ED via EMS after a witnessed seizure at home
  • The medics say he drinks every day, but his last drink was 3 days ago because he was not able to go to the store (history obtained from the sister who witnessed the seizure)

Physical Examination

T 98.3F, BP 177/106, HR 191, RR 22, Sat 93% 

  • Patient appears anxious, uncomfortable, and is actively vomiting blood tinged sputum
  • He appears confused and is not answering questions appropriately
  • He is tachycardic and his lungs are clear to auscultation bilaterally
  • Abd: soft NTND

Differential 

  • Alcohol withdrawal/ Delirium Tremens
  • Thyrotoxicosis
  • Sepsis
  • Pulmonary embolism
  • Heart failure

Workup and Management

  • The nurse informs you that the patient is seizing
  • This patient is exhibiting evidence of delirium tremens (psychomotor agitation and autonomic instability) and alcohol withdrawal seizure
  • The patient is no longer tolerating his secretions, he is confused, gurgling, and requires a definitive airway
  • After intubation, you bolus the patient with propofol and start him a propofol infusion
  • The patient is admitted to the ICU for further management

Teaching Points

  • ETOH withdrawal begins 6-8 hours after last intake and peaks in 72 hours 
  • Symptom based treatment via the CIWA score can help stratify patients, scores >15 indicate severe withdrawal
  • Start with IV diazepam at 10mg or lorazepam at 4mg and repeat them in doubling doses
  • Consider adding phenobarbital for refractory cases (i.e. after 200 mg of diazepam)
  • Consider propofol as the induction agent and sedative post-intubation as propofol potentiates GABA receptor activity and inhibits NMDA receptors Summary 
  • Delerium tremens can result in death from hyperthermia, arrhythmia and seizures

Sources:

Long D, Long B, Koyfman A. The emergency medicine management of severe alcohol withdrawal. The American Journal of Emergency Medicine. 2017;35(7):1005-1011. doi:10.1016/j.ajem.2017.02.002

Schuckit MA, Author Affiliations From the Department of Psychiatry. Recognition and Management of Withdrawal Delirium (Delirium Tremens): NEJM. New England Journal of Medicine. https://www.nejm.org/doi/10.1056/NEJMra1407298. Published February 5, 2015. Accessed December 9, 2020.