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
Usually managed conservatively and heal within 2 weeks
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.
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
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
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.
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.
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.
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.
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
Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019;100(2):82-88.
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.
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.
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]
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.
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.
A 76-year-old male with a history of coronary artery disease presents with 3 months of abdominal pain. Patient first experienced nausea, vomiting, diarrhea, chills, and severe right lower quadrant abdominal pain approximately 3 months ago. Patient states the pain improved after several days of rest, a bland diet, and hydration. However, patient reported continued decreased appetite and weight loss of 15-20 pounds over the intervening months. The pain recurred approximately one month ago and did not improve with rest prompting patient to see his primary care physician. Patient was placed on oral amoxicillin–clavulanate and instructed to get a CT scan of the abdomen and pelvis. Patient presented to the emergency department following the CT. Vitals include BP 122/69, HR 60, SpO2 98% on RA, T 97.8F. Patient is well appearing with mild tenderness to palpation in the right lower quadrant.
An ultrasound is performed and shown below. What’s the diagnosis? How is the ultrasound performed? What else should you be considering given this patient’s history?
Probe – Linear probe often works best. Can consider curvilinear probe in those with larger body habitus.
1) Ask patient to point area of maximal tenderness and place linear probe on this area
2) Apply steady but gradually increasing pressure in this area to displace bowel gas and enable visualization
3) Appendix is typically anterior to psoas and iliac vessels and is a blind tubular structure that has no peristalsis
4) If not visualized over area of maximal tenderness can track up and down along iliac vessels to look for appendix
1) Dilation > 6 mm in transverse diameter
3) May have surrounding edema and fecalith within the appendix
Appendicitis Ultrasound Pearls:
Appendix can be hard to visualize due to body habitus, bowel gas, or because it is retrocecal. Tips to improve visualization:
Have patient place right leg crossed over left
Roll patient into left lateral decubitus
Appendix can be hard to differentiate from terminal ileum
Terminal ileum does not have a blind ending
Terminal ileum will show peristalsis
Always make sure to visualize the blind ending of the appendix
Ultrasound “Rules In” appendicitis!
Patient ultimately taken to OR by surgery where appendix was removed and sent to pathology. Given patients presentation of chronic appendicitis couple with weight loss there was concern for appendiceal cancer. Pathology has not returned at this time.
Appendiceal Cancer Facts:
Cancer of the appendix is observed in <2% of appendiceal specimens
Most patients are asymptomatic but in those who experience symptoms 30% present with acute appendicitis
History that should raise suspicion for appendiceal cancer include
A 62 year old male presents to the ED with 1 week of abdominal distension with associated nausea and vomiting. He has had only 2 small bowel movements in the last week. He denies abdominal pain. On exam, his abdomen is distended and rigid. An obstruction series is obtained and shown below. What’s the diagnosis?
Answer: multiple air-fluid levels concerning for obstruction
CT A/P obtained (shown below) – diagnosis of Large bowel obstruction
Most common cause of large bowel obstruction = neoplasm/mass
Other causes: diverticulitis, sigmoid or cecal volvulus