Tuesday Advanced Cases

Critical Cases – The Red Eye!

By Stephanie Smith M.D.

HPI

  • 53 y/o male p/w complaints of L eyelid swelling and redness
  • Started 4 days PTA as small pimple which he popped, and slowly progressed to “softball” sized area of swelling with pus drainage
  • Subjective fevers

Physical Exam

  • BP 153/90, pulse 80, temp 98.6, RR 17
  • PERRL, EOMI
  • Extensive soft tissue erythema and edema of the L upper eyelid, 5×5 area of fluctuance with active pus draining from small laceration
  • Visual acuity: 20/40 R, 20/70 L
  • No corneal abrasions or ulceration on fluorescein staining 
  • IOP 21 bilaterally 

DDx

  • Preseptal / periorbital cellulitis
  • Orbital cellulitis
  • Abscess

Workup 

  • Labs: CBC, BMP, lactate, wound culture
  • Started empirically on broad spectrum abx: 2g vancomycin + 3g unasyn
  • CT orbits w/ contrast: significant soft tissue swelling of the L periorbital region consistent with inflammatory/infectious process, and involvement of the medial orbital wall along the lamina papyracea 

Clinical Course

  • Admission for continued IV antibiotics
  • Repeat CT orbits
  • Consults: OMFS, ophthalmology, ENT, ID 

Take home points

  • MUST differentiate orbital vs preseptal cellulitis given the increased morbidity and mortality a/w orbital (see table)
  • Confirm clinical suspicion with CT imaging
  • Orbital cellulitis complications: subperiosteal abscess, orbital abscess, vision loss, cavernous sinus thrombophlebitis, and/or brain abscess 
Tuesday Advanced Cases

Advanced Cases – Pericardial Tamponade as a Sequelae of Hypothyroidism!

By: Alexander Hilbmann MD

HPI:

52 year old female with pmhx of hypothyroidism who presents to Emergency Department with bilateral leg swelling and SOB with exertion. Reports swelling began one week ago and has progressively worsened. Denies any other symptoms. Patient has not seen a cardiologist/had an echo performed before. Reports she has not taken her prescribed levothyroxine for two years now.  

Physical Exam:

Vitals BP 128/82 HR 80 BPM Temp 92.8F Oral Resp 29 SpO2 99%

Abnormalities on physical Exam:

Periorbital Swelling of bilateral eyes

Rales present in bilateral lower lungs

Distension of abdomen

Bilateral lower extremities with non pitting edema

12 Lead ECG:

Interpretation: Sinus bradycardia, low voltage ECG

Bedside subxiphoid cardiac ultrasound:

Interpretation: Circumferential pericardia effusion, RV collapse consistent with pericardial tamponade physiology

For a FANTASTIC review of ultrasound guided emergency pericardiocentesis, check out the Ultrasound Podcast Youtube video HERE

Case continued:

  • Patient found to be hypoglycemic at 50 mg/dL, D10 administered
  • Patient found to be hyponatremic at 125, likely in setting of fluid overload
  • Cardiology consulted for cardiac tamponade, pericardiocentesis performed with 1.4 L drained. 
  • Ascites drained via paracentesis, other diagnoses ruled out with hypothyroidism most likely cause.
  • Patient restarted on levothyroxine and began liothyronine (T3)in hospital
  • Patient discharged home in stable condition after 10 days in hospital with levothyroxine, has not returned to hospital since

Pearls:

  • Consider hypothyroidism if patient has pmhx or classical physical exam findings: bradycardia, hypothermia, hypotension, lethargy, constipation, hair loss/thinning, facial swelling, coarse skin, pretibial myxedema(thickened, nonpitting edema), menstrual changes, decreased reflexes.
  • Hypothyroidism increases permeability in the blood vessels of the body and decreases drainage of lymphatic system, causing an accumulation of fluid outside of blood vessels and can present as pretibial myxedema, pericardial effusion, or pleural effusion.
  • Precipitating factors of hypothyroidism include medication nonadherence, infection, cold exposure, stroke, autoimmune disorders, thyroid radiation/surgery,  and medications (amiodarone, lithium).
  •  Management of hypothyroidism includes supportive, hydrocortisone(prevents adrenal crisis), levothyroxine (T4) and +/- Liothyronine (T3) supplementation.

References:

Chahine J, Ala CK, Gentry JL, et al Pericardial diseases in patients with hypothyroidism Heart 2019;105:1027-1033.

Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/

Tuesday Advanced Cases

Critical Cases – Fistula Hemorrhage Emergency!

Kane McKenzie M.D.

Dialysis Fistula Bleeding Aneurysm

HPI

69 year-old female with a past medical history of ESRD on HD, HIV, Pulmonary HTN, HFrEF (EF 25%), anemia, thrombocytopenia presents after dialysis with left upper extremity pain and swelling. The dialysis RN reports there was shiny skin present over the LUE AVF and they cannulated to avoid that area, the patient received one hour of treatment that was stopped due to pain. Patient reports the her arm above the AVF has been slowly enlarging

Vitals

BP: 98/54, HR: 78, RR 20, T: 97.6

Exam:

Alert and oriented, no acute distress, chronically-ill appearing

LUE with no external bleeding, fistula has a palpable thrill. Swelling and tenderness are present above the AVF, over the medial upper arm.

Cap refill >2 seconds

Rest of exam unremarkable

Clinical Course

-CTA upper extremity was obtained to assess for active bleeding – showed AV fistula with aneurysmal dilatation, large hematoma with upper arm approximating a volume of 1000cc. No evidence of active hemorrhage

-Direct pressure was held above and below the AVF.

-Repeat BP 58/24

-Central line placed, resuscitated with 2U PRBC, 1 platelets, 1 FFP. Required norepinephrine and vasopressin drip

-Taken level 0 to OR for Brachiocephalic fistula ligation and hematoma evacuation with 500cc hematoma removed

-The patient was stabilized and recovered after being treated for hemorrhagic shock

Pearls

-AVF aneurysms can develop from repeated ruptures, increased venous pressure, and immunosuppression. They are usually asymptomatic, rarely rupture. Aneurysm formation is present in 5-7% of AVF

-Skin changes, pain, high output heart failure, and thrombosis can result from aneurysms and are an indication for operative management.

-AVF pseudoaneurysms can develop from extravasation of blood from cannulation sites, are more prone to rupture, develop more quickly

-Aneurysms/pseudoaneurysms can be identified by their shiny, thin, atrophic skin. In more severe cases can present with necrosis.

-Apply pressure and/or tourniquet above and below the AVF if life threatening hemorrhage is suspected

-Emergent consultation with vascular surgery warranted for operative repair

References:

Pasklinsky G, Meisner RJ, Labropoulos N, Leon L, Gasparis AP, Landau D, Tassiopoulos AK, Pappas PJ. Management of true aneurysms of hemodialysis access fistulas. J Vasc Surg. 2011 May;53(5):1291-7. doi: 10.1016/j.jvs.2010.11.100. Epub 2011 Jan 26. PMID: 21276676.

Lok CE, Huber TS, Lee T, Shenoy S, Yevzlin AS, Abreo K, Allon M, Asif A, Astor BC, Glickman MH, Graham J, Moist LM, Rajan DK, Roberts C, Vachharajani TJ, Valentini RP; National Kidney Foundation. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020 Apr;75(4 Suppl 2):S1-S164. doi: 10.1053/j.ajkd.2019.12.001. Epub 2020 Mar 12. Erratum in: Am J Kidney Dis. 2021 Apr;77(4):551. PMID: 32778223.

Saeed F, Kousar N, Sinnakirouchenan R, Ramalingam VS, Johnson PB, Holley JL. Blood Loss through AV Fistula: A Case Report and Literature Review. Int J Nephrol. 2011;2011:350870. doi: 10.4061/2011/350870. Epub 2011 May 30. PMID: 21716705; PMCID: PMC3118665.

Tuesday Advanced Cases

Advanced Cases – Complications of IBD!

Allison Cash M.D.

HPI

  • 42 year old male with history of Crohn’s
  • Presented with 5 days LLQ pain, fevers, chills, diarrhea
  • Denied hematochezia/melena, vomiting

Physical Exam

  • BP 136/82  | Pulse 77  | Temp 98.1 °F (36.7 °C) (Oral)  | Resp 16  | SpO2 98%
  • Exam: patient uncomfortable appearing, LLQ pain with no rebound or guarding

Work-up

  • CBC, BMP unremarkable
  • CT A/P with bowel wall thickening and multiple pericolonic abscesses

Hospital Course

  • Patient admitted to surgery and started on IV Zosyn
  • IR consulted for abscess drainage
  • Transitioned to oral Augmentin, diet advanced, discharge home

IBD complications pearls

References:

  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill.
  2. Maaser C, Sturm, et al. European Crohn’s and Colitis Organisation [ECCO] and the European Society of Gastrointestinal and Abdominal Radiology [ESGAR] ECCO-ESGAR Guideline for Diagnostic Assessment in IBD Part 1: Initial diagnosis, monitoring of known IBD, detection of complications. J Crohns Colitis. 2019 Feb 01;13(2):144-164.
Tuesday Advanced Cases

Critical Cases – TCA Overdose!

by Daniel Petrosky M.D.

HPI

  • 31 y.o. female presents with acute change in mental status
  • Family found unresponsive 
  • EMS trialed one dose of naloxone without effect

PMHX

  • Multiple sclerosis, chronic pain, opioid use disorder, generalized anxiety disorder, and major depressive disorder,

Physical Exam

  • Markedly dry mucous membranes and cracked, dry lips 
  • Pt lethargic, localizes pain, mumbles, and does not follow commands
  • Afebrile

Work-up

  • ECG shows prolonged QT otherwise unremarkable
  • BMP, CBC, LFTs, acetaminophen, salicylate , UA all WNL
  • UDS positive for TCH, benzos, and amphetamines 
  • Bladder scan and subsequent bladder catheterization reveal over 1 L clear urine

Case Conclusion

  • Several hours later the pt was able to state that she overdosed on her amitriptyline and wrote a suicide note
  • Toxicology consulted did not recommend any acute interventions
  •  Psychiatry consulted for suicide attempt. 

TCA Overdose Pearls

  • Toxicity can vary in presentation and thorough review of medications as well as collateral from family can be very important
  • TCA overdose can be tricky as it can affect multiple organ systems and present with anti-cholinergic properties (see below), ECG changes such as QTc prolongation, QRS prolongation, and a “terminal r wave” in lead aVR , and seizures.
  • Symptoms typically occur 6 hours after ingestion and can be worse with con-ingestion of sedatives
  • Those with ECG changes should be monitored for 36-48 hrs
  • Treatment is aimed at overcoming cardiac sodium channel blockade with sodium bicarbonate or hypertonic saline, and is reserved for those patients with ECG changes
Classic Symptom DescriptionPhysical Exam Manifestation
“Mad as a Hatter”Acute encephalopathy
“Red as a Beet”Erythroderma (in fair skinned patients)
“Blind as a Bat”Dilated and unresponsive pupils
“Dry as a Bone”Dry, cracked mucous membranes, no sweating
“Tachy as a Leisure Suit”Sinus tachycardia
“Hot as Hell”Hyperthermia

References:

In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e. McGraw Hill; 2016, 1194-1199.

Tuesday Advanced Cases

Critical Cases – Acute HA in the ED and the SNOOP Mnemonic!

Author: Dan Harwood M.D.

HPI:

A 63 y.o. female with PMH of migraines and chiari malformation presents with headache. Patient reports that for the past 10 days, she has had a right-sided migraine that she describes as similar in quality to her prior migraines but longer-lasting. However, at 2 PM yesterday, she experienced an acute worsening of the severity of her headache – additionally, the pain became bilateral and occipital at this time. The patient reports dizziness, nausea, and photophobia, and her husband states that the patient has been slower to respond to questions for the past day. Denies vomiting, visual changes, or fever.

Vitals: BP: 133/90 | Pulse: 71 | Temp: 98.1F | Respiratory Rate: 18 | SpO2: 99%

Neuro exam is non-focal. Patient appears tired, but responds to questions appropriately. 

Clinical Course:

Patient given Tylenol, 10 mg IV Compazine, and 1 L lactated ringers with significant improvement in symptoms. Given change in headache quality from prior migraines and acute worsening of headache, CT Head wo contrast ordered. 

CT revealed a large hemorrhagic neoplasm in the right frontal region with associated mass effect and 1.2 cm leftward midline shift resulting in obstructive hydrocephalus. Patient subsequently noted to be increasingly somnolent compared to initial presentation. Neurosurgery was emergently consulted who recommended decadron, Keppra for seizure prophylaxis, and admission to the Neuro ICU.

Headache Pearls:

The majority of headaches are due to primary headaches such as tension headache, migraine, or cluster headache. However, as 18% of patients with chief complaint of headache may be experiencing a secondary headache disorder. Many of these secondary headaches represent life-threatening emergencies such as intracranial bleeding or CNS infection. The SNOOP mnemonic is a helpful tool for remembering “red flag” headache symptoms to identify headache patients who warrant further imaging/laboratory work-up in the ED. Additionally, improvement in symptoms with medication does not decrease the likelihood of a secondary headache disorder.

Systemic: Systemic signs or conditions such as fever, weight loss, immunocompromise, HIV, cancer

Neuro: Neurologic findings including mental status changes, vision changes, seizure, confusion, or focal neuro findings on exam

Onset: Onset that is acute with progression to worst severity within minutes

Older: Older patient (50 y.o. or older) with new headache or a progressive headache

Previous: No history of previous headaches, or in a patient with history of headaches, a change in severity/symptoms/location from prior headaches

Pregnancy: Headache in pregnant or post-partum patient

References:

Ashenburg Nick, Marcolini Evadne, Hine Jason. Approach to Headache. In: Mattu A and Swadron S, ed. CorePendium. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/rec8eRzSrPsVUiMuV/Approach-to-Headache#h.pq7xksb5a2qy. Updated October 8, 2022. Accessed December 22, 2023.

Dodick DW. Clinical clues and clinical rules: primary vs secondary headache. Adv Stud Med 2003;3:87–92.

Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134-144. doi:10.1212/WNL.0000000000006697

Tuesday Advanced Cases

Critical Cases – Submassive Pulmonary Embolism!

Author: Vincent Li M.D.

HPI

  • 68 year old female with PMHx HTN, HLD, breast cancer in remission who  presents after near syncopal event
  • Similar episodes this week that occurred with rising from seated position
  • No chest pain, SOB, palpitations, numbness, weakness, vision or gait changes, tongue biting, urinary  incontinence
  • Denied unilateral leg pain or swelling, prolonged immobilization, active cancer, prior VTE
  • Pulse ox noted at 92% on RA in ED, requiring 2L to maintain O2 sat > 96%
  • Physical exam is unremarkable, lungs clear

Vitals

T 98.4F, HR 99, BP 112/55, RR 18, O2 97% on 2L NC

Clinical Course

  • ECG showed NSR @ 98 BPM, no ischemic ST or T changes
  • Labs unremarkable except for D-dimer, which  was elevated at 5.4.
  • CXR showed non-specific RLL opacity
  • Bedside cardiac ultrasound showed  increased RV:LV > 1
  • CTA chest showed right pulmonary artery embolism extending into lobar and  segmental branches, minimal RV dilatation, patchy R lung consolidation suggestive of infarcts vs  pneumonia, moderate R pleural effusion, and diffuse osseous metastases
  • Heparin gtt started and critical care was consulted; patient ultimately admitted to the INCU for submassive PE
  •  Ultimately transitioned to Eliquis and discharged on HD5 with outpatient heme/onc followup for new metastatic breast cancer

Pulmonary embolism pearls

  • PE categorized as massive, submassive, and low-risk
  • Massive PE: hemodynamic instability (systolic BP < 90 mmHg for > 15  minutes or SBP > 40 mmHg from baseline, or clear evidence of shock /  vasopressor requirement – treatment is intravenous thrombolytics
  • Submassive PE: evidence of R heart strain (by imaging or biomarkers such as troponin, pro-bnp) without hemodynamic instability   – treatment is systemic anticoagulation with heparin or low molecular weight heparin, consider catheter based thrombolysis or clot extraction (no mortality benefit)
  • Non-massive or submassive PE – oral anticoagulant, consider discharge if low risk by evidence based scoring system (such as sPESI)

References

1. Garrett, John S., and Anant Patel. “Pulmonary Embolism.” Edited by Jeremy Berberian.  Corependium, 2023, Accessed 26 Dec. 2023. 

2. Tintinalli, Judith E., et al. “Venous Thromboembolism Including Pulmonary Embolism.”  Tintinalli’s Emergency Medicine, Ninth ed., McGraw Hill, New York, 2020, pp. 389–399.