Wednesday Image Review

From the Archives: What’s the Diagnosis? By Dr. Katie Selman

A 76 yo female presents after a fall down several stairs. She is diagnosed with bilateral pubic rami fractures on x-ray. The patient has difficulty with urination. A foley is placed and there is blood return. A CT cystogram is shown below. What’s the diagnosis?

Answer: Bladder injury (extraperitoneal)

  • Occurs with direct blunt trauma to distended bladder
    • 70-97% associated with pelvic fractures
  • Clinically, patient will have gross hematuria, lower abdominal tenderness, perineal or scrotal edema, difficulty voiding
  • Gold standard diagnosis: retrograde cystogram (either x-ray or CT)
    • Can be missed on routine CT or US
  • Intraperitoneal rupture: contrast material leaks into peritoneal cavity
    • Require surgical repair
  • Extraperitoneal rupture: contrast material leaks into retroperitoneum
    • Most common
    • Usually managed conservatively and heal within 2 weeks

References:

Gratton MC, French L. Genitourinary Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016.

Wednesday Image Review

What’s the Diagnosis? By Dr. Erica Westlake

A 33 year old male presents to the ED reporting he was assaulted last night. He is unsure what weapons were used, and is complaining of pain to his head and face. He reports a loss of consciousness during the assault. He denies pain or injuries to his extremities, visual changes, hearing loss, neck pain. His exam is significant for a lacrosse ball sized injury to his left forehead above his eyebrow. Pupils are equal, reactive and circular, EOMs intact, no midline tenderness in the cervical/thoracic/lumbar spine, no hemotympanum, no otorrhea/rhinorrhea, no facial instability, no nasal deformity or dental injury. No signs of injury on chest, back, abdomen or extremities, neurologic exam is unremarkable and intact in all 4 extremities, gait steady. You obtain CT imaging of the facial bones, head and neck, which reveal:  

Diagnosis: isolated anterior table frontal bone fracture 

  • Mechanism: high-energy mechanism required to generate force, ie: unrestrained motor vehicle crashes, assault with blunt objects (bricks, baseball bat)
  • High occurrence for concomitant injuries in facial bones, intracranial injury, cervical spine injury and ocular injuries 
  • Incident of intracranial injury up to 87% and ocular injuries up to 25%
  • If extension into the temporal bones, patients require hearing and facial nerve function evaluation 
  • Important to evaluate the anterior and posterior tables of the frontal sinus as involvement of the posterior table requires surgical repair
    • Dura is attached to the posterior table, surgical repair required to prevent complications such as pneumocephalus, CSF leak or infection 
  • Consider nonaccidental trauma especially in children, elders, pregnant women 
  • Management of isolated anterior table frontal bone fracture: sinus precautions, augmentin course, ENT/plastics follow up 

References:

Hedayati T, Amin DP. Trauma to the Face. 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; 2020.

Gaillard F, Bell D, Frontal sinus fracture. Reference article, Radiopaedia.org 

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 27 year old male presents for a right shoulder injury. He was attempting to break up a fight between his dogs when his right arm was pulled and he felt a “pop” in his right shoulder. He has been unable to move his right shoulder since and there is severe pain that is worse with movement. His vitals are within normal limits. On exam, the right upper extremity is neurovascularly intact. There is an obvious deformity of the right shoulder with severely reduced range of motion. An x-ray is performed and shown below. What’s the diagnosis?

Answer: Anterior shoulder dislocation

  • Anterior dislocations of the shoulder are the most common type, approximating 99%. The mechanism typically occurs from forced abduction and external rotation. 
  • Exam will show a “squared off” appearance of the normal round contour of the shoulder and guarding of the arm in slight abduction and external rotation. The axillary nerve, which provides sensation to the proximal arm and shoulder, is most commonly injured.
  • Diagnosis is obtained with plain radiographs. A scapular “Y” view shown on the right can help confirm anterior vs posterior in unclear cases.
  • Treatment of simple cases involves closed reduction in the ED. There are various methods which can be achieved with or without sedation.
    • Examples that do not require sedation: Cunningham, Davos, Fares,
    • Examples that typically require sedation: Kocher, Traction-Countertraction
    • Complications include recurrent dislocations (most common) and bony injuries such as Hill-Sachs and Bankart lesions

References:

Bjoernsen L, Ebinger A. Shoulder and Humerus 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.

Wednesday Image Review

What’s the Diagnosis? By Jake Barr, MS3

The patient is a 40-year-old male with no past medical history who presents with concerns of a rash on his hands. He states that the lesions appeared two days ago, but had a fever, muscle aches, and pruritis two days before that. He does not have a history of hives or contact dermatitis. He does not take any medications, but states he recently developed “cold sores.” His temperature is 100.6oF, but his other vitals are within normal limits. The cutaneous rash is demonstrated below. When looking in his mouth, blistering lesions are also present. What the diagnosis and management?

Answer: Erythema Multiforme

  • Erythema multiforme is the result of a T-cell mediated hypersensitivity reaction resulting in a characteristic pruritic, targetoid papules, with a hazy-center, and surrounding erythematous rings.
  • 90% of cases are associated with infectious etiologies, with HSV-1 being most common in adults and Mycoplasma pneumonia in children.
    • Remaining 10% are due to drugs (NSAIDs, antiepileptics, antibiotics), malignancy, and autoimmune diseases. Their mechanism of rash formation is unknown.
  • There are two specific subtypes:
    • Erythema multiforme minor: rash without mucosal involvement or constitutional symptoms
    • Erythema multiforme major: rash with mucous membrane involvement and constitutional symptoms (fever, malaise, myalgias etc.)
  • Diagnosis is often clinical, but immunofluorescence can be helpful if uncertain.
    • PCR testing for both HSV and Mycoplasma pneumoniae should be done if suspected.
  • Treatment is mostly symptomatic, and the rash is usually self-limited.
    • Antihistamines are useful for pruritis.
    • Systemic steroids maybe be used, but the impact on long-term outcomes and symptom duration is unclear.
    • Acyclovir may be used to prevent recurrent HSV infections.
    • Macrolides may be used in Mycoplasma pneumoniae is suspected.

References:

  1. Baluzy Matthew, Karaze Tallib. Maculopapular Rashes. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recvFPlc0BmXxYuzp/Maculopapular-Rashes#h.til8vwjxmfh6. Updated June 21, 2023. Accessed January 24, 2024.
  2. Sokumbi O, Wetter DA. Clinical features, diagnosis, and treatment of erythema multiforme: a review for the practicing dermatologist. Int J Dermatol. 2012;51(8):889-902. doi:10.1111/j.1365-4632.2011.05348.x
  3. Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019;100(2):82-88.
  4. J. Brady W, Pandit A, R. Sochor M. Generalized Skin Disorders. 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. Accessed January 24, 2024. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=221180403
  5. DermNet. https://dermnetnz.org/topics/erythema-multiforme-images
Wednesday Image Review

From the Archives: What’s the Diagnosis? By Dr. Alyse Volino

A 24 year old female with a history of gallstones presents to the ED with 2 hours of severe, aching right upper quadrant abdominal pain that woke her from sleep associated with nausea and vomiting. Patient has had similar episodes of pain in the past, often after eating fatty foods. On exam, she is tender in RUQ of the abdomen and is actively vomiting. A right upper quadrant abdominal ultrasound is performed and shown below. What’s the diagnosis?

Answer: Symptomatic Cholelithiasis

  • Characterized by episodes of RUQ pain that are brought on by obstructing gallstone and relieved when gallstone moves from that position
  • Can progress to cholecystitis if gallstone remains in obstructing position and gallbladder subsequently becomes inflamed or infected.
  • Differential: cholecystitis, choledocholithiasis, cholangitis.
  • If simple symptomatic cholelithiasis (no signs of infection or other biliary obstruction) and pain is controlled, patient can often be discharged from ED with outpatient surgical follow-up.

Symptomatic Cholelithiasis vs Cholecystitis on Ultrasound

Cholecystitis may have the following:

  1. Gallstones present in gallbadder
  2. Sonographic Murphy’s sign
    • Maximal tenderness over the most anterior portion of GB as defined with US imaging
  3. Wall thickness of gallbladder over 3 mm
    • Be sure to measure GB wall thickness at anterior aspect to avoid false positive increased secondary to posterior acoustic enhancement!
  4. Pericholecystic fluid

These findings should be used in conjunction with lab results to help identify diagnosis on spectrum of biliary disease.

References:

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Edition. Ch 79: Pancreatitis and Cholecystitis. Judith E. Tintinalli

Soni, Nilam, et. al. Point of Care Ultrasound, 2nd Edition. Ch 27: Gallbladder 

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 2 year old female with no past medical history presents for a nasal foreign body. The patient’s mother states that the child approached her earlier this evening while pointing at her nose. When the mother looked into the child’s right nostril, she noticed something metal. Vital signs are normal for age. On exam, the patient is in no acute distress with mucus coming from the right nostril and a silver metallic object lodged in the nare. A skull x-ray is obtained and shown below. The area of interest is included and zoomed in. What’s the diagnosis and what’s the appropriate management?

Answer: Nasal button battery – emergent removal in ED

  • Button batteries are distinguished on plain films most commonly by the “double ring sign” in AP view which is best shown in the lateral film above. Lateral views of a button battery may also show a step-off which is also evident in the AP x-ray.
  • Management of a nasal button battery differs from many other foreign bodies due to the risk of rapid necrosis and septal perforation in as little as 7 hours.
  • ED methods for removal of nasal foreign bodies include the “parent kiss” technique or bag valve mask to expel the foreign body, forcep or suction catheter removal, or use of a foley balloon.
  • In this case, the object was ultimately removed by ENT with procedural sedation in the ED.

References:

Cohen JS, Agrawal D. Nose and Sinus Disorders in Infants and Children. 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; 2020.Loh  WS, Leong  J, Tan  HK: Hazardous foreign bodies: complications and management of button batteries in the nose. Ann Otol Rhinol Laryngol 112: 379, 2003. [PubMed: 12731636] 

Friday Board Review

Infectious Disease Board Review with Dr. Edward Guo

A 65 year old male with no past medical history presents to the emergency department with a painful rash on his neck and left shoulder for 2 days. Vitals are within normal limits. Exam is notable for the skin findings shown below with no other abnormal skin findings elsewhere. He is currently being examined in a hallway stretcher. What is the appropriate level of infection control precaution for this patient?

A: airborne

B: contact

C: droplet

D: standard

Answer: standard

This patient is presenting with a vesicular rash on an erythematous base in a dermatomal distribution characteristic of herpes zoster (shingles). Immunocompetent hosts with no signs of disseminated herpes zoster infection should have their skin lesions covered and only require standard infection precautions which is the same for all patients. Immunocompromised patients with localized infection or any patient with signs of disseminated infection should initially be placed on airborne and contact precautions which involves a negative pressure room, gown, and respirator such as N95 mask.

References:

Takhar SS, Moran GJ. Serious Viral Infections. 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; 2020.

https://www.cdc.gov/shingles/hcp/hc-settings.html

Wednesday Image Review

From the Archives: What’s the Diagnosis? By Dr. Katie Selman

A healthy 22 yo female presents to the ED with left thumb pain.  She was jogging and tripped and used her left hand to break her fall.  An x-ray is shown.  What’s the diagnosis?

Answer: Dislocation of the first metacarpophalangeal joint

  • Occurs with hyperextension injuries, most dislocations occur dorsally
  • Most commonly involves the index finger
  • Simple dislocation
    • More apparent clinical appearance – the MCP joint is in 60-90 degrees of hyperextension
  • Complex dislocation
    • More subtle appearance – the phalanx is almost parallel to the metacarpal
    • Almost impossible to reduce
  • Reduction technique: further hyperextension with pressure at the base of the phalanx
  • After successful reduction immobilize with MCP flexed at 60 degrees
  • Higher incidence of irreducible dislocations (compared to PIP or DIP joint dislocations)
    • consult hand surgery if unable to reduce

Reference:

Manthey DE, Askew K. Hand. In: Sherman SC. eds. Simon’s Emergency Orthopedics, 7e New York, NY: McGraw-Hill; 2014.

Friday Board Review

Cardiology Board Review with Dr. Edward Guo

A 34 year old female with no past medical history that is 2 weeks post-partum from an uncomplicated vaginal delivery presents for acute chest pain that started while she was exercising. Vital signs are within normal limits. On exam, she appears uncomfortable but in no respiratory distress. There is no lower extremity edema. Her EKG demonstrates ST segment elevations in contiguous leads with reciprocal depressions. Based on the leading diagnosis, which coronary artery is most commonly involved?

A: left anterior descending (LAD)

B: left circumflex (LCx)

C: posterior descending (PDA)

D: right coronary (RCA)

Answer: left anterior descending (LAD)

This patient presentation is typical for spontaneous coronary artery dissection (SCAD) which predominantly affects young to middle aged females. Risk factors include pregnancy, postpartum period, and hormonal therapy. Physical stressors such as exercise or emotional stress are classically involved. Unlike acute coronary syndrome, the pathophysiology involves a dissection tear in the coronary artery wall, not an atherosclerotic plaque or embolization. The LAD is most commonly involved in about 32 to 46% of cases. It is diagnosed by coronary angiography. Management varies but is typically conservative with medical therapy. Invasive measures such as coronary stenting is considered in cases with ongoing ischemia or hemodynamic instability.

References:

Hayes SN, Kim ESH, Saw J, et al. Spontaneous Coronary Artery Dissection: Current State of the Science: A Scientific Statement From the American Heart Association. Circulation. 2018;137(19):e523-e557. doi:10.1161/CIR.0000000000000564

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 24 year old female with no past medical history presents for right eye pain. She does not wear glasses or contacts. About 1 week ago, she was at a beach when she felt like she got sand into her right eye. She has been rubbing that eye often and has been developing worsening pain with gradual loss of vision. Her vital signs are within normal limits. Visual acuity is 20/400 OD and 20/20 OS. Exam demonstrates a 3 x 3 mm pale grey lesion with irregular borders over the right cornea. Fluorescein stain results are shown below. Intraocular pressure is normal. What’s the diagnosis?

Answer: Corneal ulcer

  • Corneal ulcers are a vision-threatening emergency that develops due to a disruption in the corneal epithelial barrier that evolves into more extensive involvement.
    • The ulcer typically develops days after the initial injury which is an important distinguishing history from a corneal abrasion which has instantaneous symptoms after injury. A corneal abrasion may develop into an ulcer.
  • Worrisome complications of corneal ulcers include permanent loss of vision, globe perforation, or endophthalmitis which is an infection of the posterior chamber of the eye.
  • Management includes ophthalmology consult for a corneal ulcer wound culture and antibiotic eyedrops. Contact lens wearers should receive coverage for Pseudomonas. Do not patch the eye due to possibility of worsening infection. Other etiologies include Staphylococcus, Herpes, Gonococcal, and less commonly Aspergillus. Eyedrops should be administered every hour and close outpatient follow up with ophthalmology in 24-48 hours should be arranged.

References:

Ahmed F, House RJ, Feldman BH. Corneal Abrasions and Corneal Foreign Bodies. Prim Care. 2015;42(3):363-375. doi:10.1016/j.pop.2015.05.004

Walker RA, Adhikari S. Eye Emergencies. 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; 2020.