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] 

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.

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.

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?

Answer: Appendicitis

Appendicitis Ultrasound:

Technique

• 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

Pathologic findings

• 1) Dilation > 6 mm in transverse diameter
• 2) Non-compressible
• 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
  • Appendicitis in a patient >50 yrs of age
  • Chronic symptoms of appendicitis
  • Weight loss and anorexia

References:

https://coreultrasound.com/appendicitis/

Uya, A., & Chaiaza, H. (2021, June 24). Appendicitis. ACEP Symbol. https://www.acep.org/sonoguide/advanced/appendicitis

Osueni A, Chowdhury YS. Appendix Cancer. [Updated 2023 Aug 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK555943/

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
  • Other uncommon causes: adhesions, hernias, IBS, fecal impaction, intraluminal FB, intussusception
• LBO are less common than SBO
• Presenting sypmtoms: abdominal pain/distension, constipation
• CT A/P w/ IV contrast is imaging modality of choice
• Most require surgery
• Ogilvie Syndrome: acute colonic psuedo-obstruction due to loss of sympathetic innervation of colon (no actual mechanical obstruction)
  • Usually seen in severely ill patients with multiple comorbidities
  • CT shows marked dilatation of the large bowel without any evidence of a marked transition point or obstructing lesion

References:
Jaffe T, Thompson WM. Large-Bowel Obstruction in the Adult: Classic radiographic and CT findings, etiology and mimics. Radiology. 2015 June;275(3):651-63.

Price TG, Orthober RJ. Bowel Obstruction. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e Eds. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016, pg 538-41

Case: A 60 year old female with a past medical history of a left hip replacement presents with a chief complaint of left hip pain after a fall. Since the fall she has been unable to move her hip and on exam the left leg is visibly shortened, adducted, and internally rotated, otherwise the patient is neurovascularly intact. X-ray reveals the image below. What’s the diagnosis?

Answer: Posterior Hip Dislocation

Case Continued: Under procedural sedation with keto-fol the hip was reduced successfully using the Captain Morgan technique as demonstrated in post-reduction XRs below. The patient was then placed in a knee immobilizer and discharged with an abduction pillow and orthopedic follow up.

• Over 90% of hip dislocations are posterior
• Up to 10% of prosthetic hips undergo dislocation with the vast majority being posterior
• Native hip dislocations are an orthopedic emergency and should be reduced as soon as possible!
  • The risk of avascular necrosis increases from <10% to about 25%  when reduction is extended from 10 hours to 15 hours
  • Prosthetic hip dislocation is not as time sensitive as there is no blood flow to the joint, thus no risk of avascular necrosis.
  • Sciatic nerve injury can occur in both native and prosthetic posterior hip dislocations
• There are many different reduction techniques including but not limited to:
  • Captain Morgan: https://www.youtube.com/watch?v=lQMWaFX-MeQ 
  • Whistler technique: https://www.youtube.com/watch?v=Fl71ztyFU7I 
  • Allis technique: https://www.youtube.com/watch?v=eMVsjwAukU4 
  • Below is a comprehensive guide to multiple different techniques:
    • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229/ 
• A CT should be obtained post-reduction of native hips to rule out fractures/loose debris

Resources:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations#v35074190

Tintinalli’s Emergency Medicine Cases A comprehensive Study Guide 9th Edition, Judith Tintinalli

A 30 year old female with a history of IV drug use presents with 2 weeks of progressively worsening right sided pleuritic chest pain, productive cough, and shortness of breath.  A chest x-ray is shown below. What’s the diagnosis?

Answer: Cavitary lesion with air-fluid level consistent with abscess from septic emboli secondary to infective endocarditis

Etiology: Bacteria laden clots from right sided bacterial endocarditis, septic thrombophlebitis, periodontal, and central venous catheter infections. In IVDU, the tricuspid valve is most commonly involved with the most common pathogen being Staph aureus

Presentation: Pleuritic chest pain, cough, fever, hemoptysis

Differential for lung abscesses: Septic emboli, Tuberculosis, Aspergillosis, Granulomatosis with Polyangitis, Sarcoidosis, malignancy

Diagnosis: Chest x-ray, CT chest, blood cultures, echocardiogram

Treatment: Typically 2-8 weeks of IV antibiotics with possible abscess drainage +/- heart valve replacement

References:

Stawicki SP, Firstenberg MS, Lyaker MR, et al. Septic embolism in the intensive care unit. Int JCrit Illn Inj Sci. 2013;3(1):58-63. doi:10.4103/2229-5151.109423

Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. J Belg Soc Radiol.2016;100(1):100. Published 2016 Nov 19. doi:10.5334/jbr-btr.1202

A 60 year old woman with a past medical history of HTN, HLD, and recent TIA now on Aspirin and Eliquis presents to the ED with one month of crampy, intermittent abdominal pain. She describes feeling sharp cramps in the epigastric region which typically last a couple of minutes and then resolve on their own. She cannot recall any exacerbating or relieving factors. She does not have any associated nausea, vomiting, diarrhea, or dysuria. She is currently without pain. On exam, her abdomen is non-tender without any rebound or guarding. POCUS findings are as below. What’s the diagnosis?

Answer: Abdominal Aortic Aneurysm with impending rupture

• The aorta can be visualized with the curvilinear probe and is found lying just anterior to the spine. AAA is defined as an aorta >3cm in diameter; repair is considered with diameter >5cm or in symptomatic patients. Smoking is the greatest risk factor, increasing chances 4x compared to lifetime non-smokers. Other risk factors include family member with AAA, male sex, and age >60¹.
• Physical exam is only 29% sensitive for aortic diameter 3.0 – 3.9cm, 50% for 4.0 – 4.9cm, and 76% for greater than 5.0cm². This patient did have a palpable abdominal pulsation with deep pressure. Tenderness is associated with unstable AAA, though lack of pain does not rule this out.
• Bedside US dramatically increases sensitivity to >90% for diagnosing and measuring AAAs of all sizes³. Measurements should be taken from the outside wall to outside wall in transverse and longitudinal views. This patient’s aorta was measured to be >5cm and had concerning signs of thickened walls.
• CTA is the gold standard for diagnosis and measurement in stable patients. This patient had findings of extension of luminal contrast beyond the expected aortic wall and calcifications, which was concerning for impending rupture⁴. The patient was evaluated by vascular surgery and taken Level 1 to the OR for emergent open aortic repair.

References:

1. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Prince, L. Johnson, G. Chapter 60. Page 416. McGraw Hill Professional, 15 Nov. 2023.
2. Lederle FA, Simel DL: The rational clinical examination. Does this patient have abdominal aortic aneurysm? JAMA 281: 77, 1999. [PMID: 9892455]
3. American College of Emergency Physicians: Emergency ultrasound imaging criteria compendium. Ann Emerg Med 48: 487, 2006. [PMID: 16997700]
4. Vu KN, Kaitoukov Y, Morin-Roy F, Kauffmann C, Giroux MF, Thérasse E, Soulez G, Tang A. Rupture signs on computed tomography, treatment, and outcome of abdominal aortic aneurysms. Insights Imaging. 2014 Jun;5(3):281-93. doi: 10.1007/s13244-014-0327-3. Epub 2014 May 1. PMID: 24789068; PMCID: PMC4035490.

A 19 year old female with a past medical history of autism and anxiety presents with right lower extremity swelling and pain. Two weeks ago, she developed right lower back pain with radiation into her right hip and leg which she describes as sore. She is sexually active and was started on hormonal contraception 2-3 months ago. Vital signs include BP 117/75, HR 108, RR 18, SpO2 99% RA, T 97.5F. The patient’s right lower extremity is neurovascularly intact with tenderness to palpation and swelling without color change. A right lower extremity ultrasound is shown below. What’s the diagnosis? How is this ultrasound performed?

Answer: Right Common Femoral and Popliteal DVT

DVT Ultrasound Evaluation: must evaluate at least 2 regions, typically femoral and popliteal veins

Femoral Vein

1. Most often performed using the linear probe (curvilinear probe may provide greater penetration for larger body habitus)
2. Start just distal to the groin where the iliac vein becomes the common femoral vein
3. Follow common femoral vein down to where the common femoral splits off into greater saphenous, femoral, and the deep femoral vein (approximately mid-thigh) and continue to follow the femoral vein until at least the mid-thigh, compressing in 1 cm increments to ensure compressibility of veins throughout

Popliteal Vein

1. Place probe on posterior aspect of the knee and look for popliteal vein (superficial to popliteal artery)
2. Follow popliteal vein and compress in 1 cm increments to ensure compressibility until the vein divides into the fibular, posterior tibial and anterior tibial veins

DVT Ultrasound Pearls:

• A vein is compressible if the walls touch with compression – if you are pushing hard enough to compress the artery but not the vein, there is likely a DVT!
• Evaluation of femoral and popliteal regions is crucial because a DVT within either of these veins is considered “proximal” and requires medical management with anticoagulants and further evaluation for iliac/IVC involvement or pulmonary embolism.
• Clinical diagnosis of DVT is typically unreliable due to the infrequency of classic findings (edema, warmth, erythema, pain, and tenderness) which are only present in 23 to 50 percent of patients
• Venogram remains the “gold standard” for the diagnosis of deep venous thrombosis. However, ultrasound is the most accurate non-invasive test to diagnose deep venous thrombosis.

This patient received prompt anticoagulation in the ED and after being admitted, received a CT venogram revealing acute deep vein thrombosis in the infrahepatic inferior vena cava, bilateral common iliac, bilateral external iliac, bilateral internal iliac and bilateral common femoral veins requiring percutaneous mechanical thrombectomy!

References:

Baker M, Anjum F, dela Cruz J. Deep Venous Thrombosis Ultrasound Evaluation. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

https://sso.uptodate.com/contents/overview-of-the-treatment-of-proximal-and-distal-lower-extremity-deep-vein-thrombosis-dvt?search=dvt%20management&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H5

https://coreultrasound.com/dvt/

A 62 year old male with a history of coronary artery disease s/p recent cardiac stents, atrial fibrillation on Plavix and Eliquis presents to the ED with sudden onset headache, aphasia, and right sided facial deficits. A stroke alert is immediately activated, and non-contrast head CT imaging reveals the image below. What’s the diagnosis?

Answer: Subdural Hematoma

The patient’s anticoagulation was reversed with andexanet alfa. He additionally was provided with one unit of platelets and Keppra for seizure prophylaxis. Ultimately, the patient underwent embolization of the middle meningeal artery with significant clinical improvement of symptoms and was able to be discharged several days later.

Subdural Hematoma Pearls:

• Crescent shaped hematoma on CT
• Elderly and alcoholic patients at much higher risk due to brain atrophy
• Most commonly caused due to acceleration-deceleration injuries with tearing of the bridging veins

Eliquis reversal pearls:

• Traditionally 4-factor prothrombin complex concentrate (4Factor-PCC) has been used
  • Contains Factors II, VII, IX, and X
• More recently, andexanet alfa has been developed which functions by binding and inhibiting factor Xa inhibitors

References:

Cline, David, et al. “Head Trauma.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, McGraw-Hill Education, New York, 2020.