Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 40 year old female presents to the emergency department via EMS for shortness of breath. Prior to arrival to the ED, the patient was hypoxic and in severe respiratory distress with absent left lung sounds prompting needle thoracostomy and rapid sequence intubation by EMS. Vital signs are BP 108/70, HR 102, Temp 98F, RR 16, SpO2 99% on 50% FiO2. A left sided chest tube is placed without complication. Chest x-ray confirms appropriate positioning of the endotracheal tube and chest tube with expansion of the left lung. Four hours later, the ventilator is alarming due to elevated peak and plateau pressures. SpO2 is 90%. There is no change with suctioning. A new chest x-ray is obtained and is shown below. What’s the diagnosis?

Answer: Reexpansion pulmonary edema

  • Reexpansion pulmonary edema is a rare but potentially fatal complication following drainage of a pneumothorax or pleural effusion. The pathophysiology is poorly understood but is thought to involve an inflammatory response leading to increased pulmonary capillary permeability.
  • Risk factors include large size pneumothorax, large volume pleural effusion, rapid reexpansion, and prolonged duration of symptoms (> 72 hours).
    • Prevention includes limiting drainage of pleural effusions to a maximum volume of 1.5 liters in one attempt.
  • Imaging will demonstrate unilateral airspace opacities in portions of the lung that were previously collapsed.
  • Treatment is supportive with supplemental oxygen and observation. Most patients recover without adverse outcomes.

References:

Nicks BA, Manthey DE. Pneumothorax. 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.

Asciak R, Bedawi EO, Bhatnagar R, et al British Thoracic Society Clinical Statement on pleural procedures Thorax 2023;78:s43-s68.

Morioka H, Takada K, Matsumoto S, Kojima E, Iwata S, Okachi S. Re-expansion pulmonary edema: evaluation of risk factors in 173 episodes of spontaneous pneumothorax. Respir Investig. 2013;51(1):35-39. doi:10.1016/j.resinv.2012.09.003

https://radiopaedia.org/articles/re-expansion-pulmonary-oedema

Tuesday Advanced Cases

Hypothermia Arrhythmia by Dr. Edward Guo

Case: A 29 year old male with a past medical history of polysubstance use presents to the ED in December via EMS for a suspected overdose. History is limited due to patient cooperation. EMS states that he was found outside in a puddle, minimally responsive. He was given 2mg IM naloxone by EMS and became acutely agitated and combative afterward, requiring 5mg IM midazolam and 5mg IM haloperidol upon arrival. Fingerstick glucose 226. EKG is obtained and shown below.

Exam: BP 182/84, HR 111, T 86.1F, RR 18, SpO2 100%
Disheveled appearing male in wet clothes, intermittently thrashing. Cold to touch. Pupils 5mm bilaterally. No signs of trauma. GCS E3 V2 M5. Moves all extremities equally. Heart rate is tachycardic and irregular.

EKG interpretation: atrial fibrillation with rapid ventricular response with Osborn waves

Differential diagnosis: polysubstance use, environmental cold exposure, severe sepsis, hypothyroidism

Case continued: Active rewarming is initiated by removing wet clothes, administering warmed IV fluids, and placing a bair hugger. Labs are notable for a creatinine kinase of 3966. The patient’s temperature, heart rate, and mental status significantly improve within 5 hours, and his repeat EKG shows normal sinus rhythm without Osborn waves. He is ultimately admitted to medicine.

Pearls:

  • The cardiovascular response to cold is peripheral vasoconstriction and initial increase in heart rate and blood pressure. As core temperature drops below 32C, there is myocardial irritability and risk of cardiovascular collapse.
    • Atrial fibrillation and flutterare common arrhythmias associated with hypothermia.
    • Rescue collapse is a term to describe cardiac arrest that occurs during extrication or transport of a profoundly hypothermic patient due to profound myocardial irritability.
  • Osborn waves are positive deflections at the end of the QRS complex that are non-specific but may occur in temperatures below 32C.
    • Size of the wave correlates with the degree of hypothermia but has no prognostic value.
  • As temperature continues to drop, EKG changes are variable but classically include bradycardia with prolonged PR, QRS, and QTc. Heart block or ventricular dysrhythmias may be encountered as well. Asystole is the common final dysrhythmia.
  • Rewarming is the treatment of choice.
    • Atrial dysrhythmias such as atrial fibrillation will often resolve with warming.
    • Cardioversion for unstable arrhythmias should be attempted but may be refractory in severe hypothermia.

References:

Brown DA. Hypothermia. 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.

Hoek T. 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010. 122:5829-5861

Wednesday Image Review

What’s the Diagnosis? By Dr. Edward Guo

A 50 year old male with a past medical history of Crohn disease with ileocolectomy presents via EMS for shortness of breath. Prior to arrival to ED, patient was found to be hypoxic and in acute respiratory distress prompting rapid sequence intubation by EMS. Vital signs are notable for hypotension and tachycardia. On exam, there are equal breath sounds bilaterally. His abdomen is distended with bruising on the left flank. GCS is 3T. A portable chest x-ray is obtained to confirm endotracheal tube placement and is shown below. What’s the diagnosis?

Answer: Pneumoperitoneum

  • Most commonly caused by gastrointestinal perforation from etiologies such as peptic ulcer disease, traumatic injury, bowel obstruction, or infection.
  • While CT is the gold standard for diagnosis, a chest x-ray may be utilized to quickly assess for presence of subdiaphragmatic air.
    • Sensitivity of upright chest x-ray to detect pneumoperitoenum varies across studies but is up to 80%.
    • Upright positioning for 10 minutes prior to radiograph or lateral upright positioning may increase sensitivity to over 90%.
    • Specificity is approximately 90%.
  • Management includes emergent surgical consultation, broad spectrum antibiotics with anaerobic coverage, and gastric decompression.

References:

Bogle AM, Gratton MC. Peptic Ulcer Disease and Gastritis. 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.

Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16:713–16.

Woodring JH, Heiser MJ. Detection of pneumoperitoneum on chest radiographs: comparison of upright lateral and posteroanterior projections. Am J Roentgenol 1995;165:45–7.

Wednesday Image Review

What’s the Diagnosis? By Dr. Katie Selman

A 63 year old female is brought in by EMS after being found down. She has multiple ecchymoses on her chest and bilateral flanks. GCS is 6. After intubation, she is taken for CT head/cervical spine and a CT chest/abdomen/pelvis with contrast. Upon return from CT, x-rays are done (shown below) to further evaluate bruising and a laceration to her L elbow. What’s the diagnosis?

Answer: Contrast extravasation

  • Predisposing factors for contrast extravasation
    • Small IV gauge (22G or less)
    • More distal access (hand)
    • Rapid injection of contrast
  • Incidence: up to 1% of patient receiving IV contrast through peripheral IV
  • Most common symptoms: local pain, swelling
  • Complications occur in < 1 %  (more common with large volume and in patients with atherosclerosis, venous insufficiency, or impaired lymphatic drainage)
    • Compartment syndrome
    • Tissue necrosis
  • Close monitoring required following extravasation
    • Compartment checks, vascular checks, and monitoring of overlying skin
    • Surgery consult for any signs of compartment syndrome or tissue injury
    • Elevate limb, warm compresses may be used
    • Patients rarely require more than conservative supportive treatment

References:

Sbitany, H., Koltz, P. F., Mays, C., Girotto, J. A., & Langstein, H. N. (2010). CT contrast extravasation in the upper extremity: Strategies for management. International Journal of Surgery, 8(5), 384-386. doi:10.1016/j.ijsu.2010.06.002

Sonis, J. D., et al (2018). Implications of iodinated contrast media extravasation in the emergency department. The American Journal of Emergency Medicine, 36(2), 294-296. doi:http://dx.doi.org/10.1016/j.ajem.2017.11.012

Wednesday Image Review

What’s the Diagnosis? By Dr. Daniel Petrosky

50-year-old with a history of T2DM, hypertension, hyperlipidemia, substance use, and asthma who presents with 4 weeks of progressive left index finger pain. The patient had some swelling from the fall, but now has had one week of swelling worsening, pain, redness. Physical exam reveals digit red, swollen, fusiform, very tender, and unable to flex or extend DIP and PIP. A POCUS is obtained and shown below. What’s the diagnosis?

Answer: Necrotizing Fasciitis

POCUS is very quick to evaluate for many of differentials but would be painful to press directly on the digit with gel. There is an excellent alternative here: waterbath technique.

Water is an excellent medium for ultrasound. In this instance, we submerged the patient’s hand in water, and we are able to submerge the probe and hover above the affect area without concern for the amount of gel we displace in assessing the area or the pressure we apply to get clear images. Also, the high transmissibility of ultrasound through water allows for excellent visibility of superficial structures of body parts like fingers when direct contouring with gel would be virtually impossible. With this technique, we can look for fractures, abscesses, air, and cobble-stoning quickly, easily and with a high degree of accuracy.

So, in this patient as it turns out, air and cellulitis are visible, likely being a necrotizing infection. POCUS with a waterbath was the quickest way to establish this diagnosis. This is extremely important because even with advances in antibiotics, time to surgical intervention is most important in decreasing morbidity and mortality in these patients.

Resources:

Blaivas M, Lyon M, Brannam L, Duggal S, Sierzenski P. Water bath evaluation technique for emergency ultrasound of painful superficial structures. Am J Emerg Med. 2004 Nov;22(7):589-93. doi: 10.1016/j.ajem.2004.09.009. PMID: 15666267.

Shelhoss S C, Burgin C M (November 16, 2022) Maximizing Foreign Body Detection by Ultrasound With the Water Bath Technique Coupled With the Focal Zone Advantage: A Technical Report. Cureus 14(11): e31577. doi:10.7759/cureus.31577

Shrimal P, Bhoi S, Sinha TP, Murmu LR, Nayer J, Ekka M, Mishra P, Kumar A, Trikha V, Aggarwal P. Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures. Am J Emerg Med. 2022 Mar;53:118-121. doi: 10.1016/j.ajem.2021.12.067. Epub 2022 Jan 2. PMID: 35016093.

Bonne SL, Kadri SS. Evaluation and Management of Necrotizing Soft Tissue Infections. Infect Dis Clin North Am. 2017 Sep;31(3):497-511. doi: 10.1016/j.idc.2017.05.011. PMID: 28779832; PMCID: PMC5656282.

Tuesday Advanced Cases

Neonatal Tachycardia by Dr. Edward Guo

Case: A 4 day old female born at 36w1d via C-section presents for tachycardia. Father at bedside states that he placed a heart monitor on the patient and it read over 200 bpm. Patient was seen at urgent care and transferred to ED via ambulance. Baby has otherwise acting normally, eating frequently, making 6+ wet diapers per day. No prior medical history. No family history of abnormal heart rhythms. Vitals include BP 85/53, HR 300, Temp 97.5F, RR 50, SpO2 100%. Exam shows a well appearing, interactive neonate with tachycardia on auscultation. 

Differential diagnosis: Arrhythmia, dehydration, anemia, infection, hyperthyroidism

EKG is obtained and shown below:

EKG interpretation: Supraventricular tachycardia at rate of 300

Case continued: Patient is placed on continuous cardiac monitoring. Vagal maneuvers are attempted including rectal temperature without success in terminating SVT. An IV is placed and adenosine is administered. Repeat EKG following adenosine is shown below. Pediatric cardiology is consulted and recommends administration of digoxin and transfer for further evaluation. Patient is then transferred to a pediatric center in stable condition.

Learning points:

  • A heart rate > 220 bpm in an infant or > 180 bpm in a child with rate out of proportion to clinical status is likely supraventricular tachycardia.2
  • Vagal maneuvers should be attempted initially for patients who are stable.
    • Maneuvers that can be attempted in infants include obtaining a rectal temperature or applying a cold ice pack to the face to activate the mammalian diving reflex.
  • If vagal maneuvers fail, rapid push of IV adenosine at a dose of 0.1 mg/kg is recommended.
  • If the patient is unstable or adenosine fails to terminate the rhythm, perform synchronized cardioversion at a dose of 0.5-1 J/kg.
    • Subsequent synchronized cardioversion attempts should be dosed at 2 J/kg.

References:

Hauda, II WE. Resuscitation of 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 Education; 2020. 

Kleinman  ME, Chameides  L, Schexnayder  SM,  et al: Part 14: pediatric advanced life support. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 122(18 suppl 3): S876, 2010. [PubMed: 20956230]  

Wednesday Image Review

What’s the Diagnosis? By Dr. Katie Selman

A 2 year old female presents to the ED with fever and difficulty swallowing. Mom reports she has been fussy with intermittent fever and rhinorrhea for 4 days but today did not want to eat or drink much, talking in a whisper and complaining of pain when eating. On exam, the patient is febrile, drooling, and has a swollen posterior oropharynx. A soft tissue neck x-ray is shown below. What’s the diagnosis?

Answer: Retropharyngeal Abscess

  • Most common in children under 5 years
  • May be preceded by URI symptoms or trauma to posterior pharynx
  • Xray finding = widened prevertebral space
    • In children, consider abscess when the prevertebral space is >6mm at C2 or >22mm at C6
    • Accurate assessment requires neck extension during x-ray
  • Common organisms involved – often polymicrobial, Staph aureus, Strep pyrogens, Strep viridans, Fusobacterium, Haemophilus specieas or other respiratory anaerobes
  • Management:
    • Admission 
    • IV antibiotics
    • Consult ENT for possible I&D
    • Definitive airway if any respiratory compromise
  • Complications include airway obstruction and mediastinitis

References:

Jain H, Knorr TL, Sinha V. Retropharyngeal Abscess. [Updated 2019 Oct 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:https://www.ncbi.nlm.nih.gov/books/NBK441873/

Mapelli E, Sabhaney V. Stridor and Drooling in Infants and Children. 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. Dan Fullerton

A 45 year old woman with past medical history of DM and nephrolithiasis s/p ureteral stent placement presents with right flank pain. Pain is progressive and associated with nausea and vomiting. She has had subjective fevers at home and dysuria. She denies polyuria or increased urinary frequency. Physical exam is significant for right CVA tenderness and right-sided abdominal pain radiating to the groin. Point of care bilateral renal ultrasound demonstrates the findings below. What’s the diagnosis?

Answer: Bilateral Staghorn Calculi

Patient had a hospital admission 2 weeks prior to this presentation and underwent cystoscopy and right retrograde pyelogram with ureteral stent placement. Urine cultures grew gram-negative rods, she was treated with ceftriaxone.

Learning Points
Staghorn calculi
– Large, complex stones filling the majority of the renal pelvis and calyces.
– Increased rates of infection, urosepsis, and kidney injury leading to increased morbidity and mortailty.
– Often struvite in composition and associated with Proteus mirabilis; a gram-negative rod. Other urease-producing bacteria are potential sources.
– Treatment can be conservative with antibiotics and percutaneous procedures. More often surgical intervention is necessary to prevent complications and mortality.

POCUS – is there hydronephrosis?
– Bedside ultrasound is useful in identifying and grading severity of hydronephrosis.
– Studies have demonstrated a sensitivity of 77-90% and specificity of 71-96% for detecting hydronephrosis for emergency physicians

Retrieved from: https://www.pocus101.com/renal-ultrasound-made-easy-step-by-step-guide/

References:

  1. Sharbaugh A, Morgan Nikonow T, Kunkel G, Semins MJ. Contemporary best practice in the management of staghorn calculi. Ther Adv Urol. 2019;11:1756287219847099. Published 2019 May 9. doi:10.1177/1756287219847099
  2. 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.
  3. Sibley S, Roth N, Scott C, et al. Point-of-care ultrasound for the detection of hydronephrosis in emergency department patients with suspected renal colic. Ultrasound J 2020; 12(1):31.
  4. Riddell J, Case A, Wopat R, Beckham S, et al. Sensitivity of emergency bedside ultrasound to detect hydronephrosis in patients with computed tomography-proven stones. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health 2014; 15(1).
  5. Watkins S, Bowra J, Sharma P, et al. Validation of emergency physician ultrasound in diagnosing hydronephrosis in ureteric colic. Emerg Med Australasia 2007;19(3):188-95.
  6. Nixon G, Blattner K, Muirhead J & Kerse N. Rural point-of-care ultrasound of the kidney and bladder: quality and effect on patient management. Journal of primary health care 2018; 10(4), 324–330.
Wednesday Image Review

What’s the Diagnosis? By Dr. Shivani Talwar

3 y/o male presenting with significant left arm pain and swelling. He was jumping on the bed when he fell off and landed on his left arm. There were no open wounds or lacerations of the arm. He cried immediately and was brought directly to the emergency department. He was noted to have significant swelling and tenderness of the left elbow and was neurovascularly intact. What’s the diagnosis?

Answer: Monteggia fracture 

  • This patient has a proximal ulnar fracture with radial head dislocation. This fracture can be distinguished from a Galeazzi’s fracture as this fracture involves a radial shaft fracture with distal radioulnar joint dislocation. 
  • In Monteggia’s fracture, the radiocapitellar line is disrupted, the apex of the ulnar fracture points in the direction of the radial head dislocation.
  • This fracture can frequently be missed in the emergency department if the joint alignment is not carefully examined.
  • Mechanism: fall on outstretched and or direct blow to the forearm with the elbow extended and forearm in hyperpronation
  • Radiocapitellar joint disruption occurs from the energy from the ulnar fracture that transmits along the interosseous membrane leading to rupture of the proximal quadrate and annular ligaments
  • Exam: significant swelling and pain of the elbow, may palpate the radial head
  • Diagnosis: anterior posterior and lateral elbow x-rays to assess for the radiocapitellar line 
  • 4 different types based on the Bado classification
Bado TypeFractureRadial head dislocation direction
IUlnar shaftAnterior
IIUlnaPosterior
IIIUlnaLateral
IVRadius and ulnaAnterior
  • Treatment of Monteggia fracture involves reduction with long arm splint in the arm in 110 degrees. It is typically recommended to consult Orthopaedic surgery as these fractures can be unstable and occasionally require open reduction and internal fixation 
  • Complications: radial nerve injury, posterior interosseous nerve injury, nonunion, recurrent dislocation  

References:

Johnson NP, Silberman M. Monteggia Fractures. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470575/

Mathur N, Lau KK. Monteggia fracture: an easy fracture to miss. Emerg Radiol. 2020 Aug;27(4):377-381. doi: 10.1007/s10140-020-01763-8. Epub 2020 Feb 21. PMID: 32086608.

The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. (n.d.). https://www.rch.org.au/clinicalguide/guideline_index/fractures/monteggia_fracturedislocations_emergency_department_setting/#ED_management 

Tintinalli’s Emergency Medicine (9th ed). Chow, Y. Lee, S. McGraw Hill, 2018. Chapter 270 and Page 1820-1821. 

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.