52 year old female with a history of breast cancer and recent unilateral mastectomy presents to the ED with the complaint of shortness of breath. Symptoms started earlier this evening and is accompanied by pleuritic, diffuse chest pain, dry cough as well as 4 days of left lateral calf pain. Vital signs include HR 112, RR 30, SpO2 89% on room air, BP 85/61, Temp 99.7F. Physical exam is notable for tachypnea, wheezing throughout all lung fields, and a tender, erythematous left calf. EKG demonstrates sinus tachycardia. A point-of-care cardiac ultrasound is shown below. What’s the most likely diagnosis, and what quantitative ultrasonographic measurement can be obtained to increase your post test probability?

Answer: Massive Pulmonary Embolism; Tricuspid Annular Plane Systolic Excursion (TAPSE)

Primary Use: TAPSE should be incorporated with McConnell sign, D Sign, RV Size and wall thickness and as well as with physical exam / HPI and your pretest probability to determine likelihood of PE. It cannot be used alone to diagnose PE due to the issues listed below.

Steps:

1. Obtain a high quality Apical 4 image with clear distinction of the right heart free border 
2. Enable M mode and measure the right heart free border at TV annulus
3. Measure the excursion between nadir and peak of the TV annulus
4. Normal > 1.7cm
   • Abnormal is < 1.7cm. Individuals with elevated RV afterload will have diminished RV TV movement.

Limitations of TAPSE:

• Overall has a limited sensitivity (53%) and specificity (61%) for PE
• A decreased TAPSE is not specific for PE as other causes of RV strain may have similar findings (Pulmonary HTN, pulmonic stenosis, etc)
• Assesses TV motion in one plane, ignoring the 3D motion of the TV which may be abnormal in individuals with prior cardiac wall motion abnormalities
• Numerical value is adversely affected by improper position of the M mode line

References:

https://www.emrap.org/corependium/search?q=TAPSE#h.sb6k765tgtm2

https://www.uptodate.com/contents/clinical-presentation-evaluation-and-diagnosis-of-the-nonpregnant-adult-with-suspected-acute-pulmonary-embolism?sectionName=Echocardiography&search=tapse&topicRef=120068&anchor=H257411441&source=see_link#H257411441

http://www.emdocs.net/tricuspid-annular-plane-systolic-excursion-tapse-for-risk-stratifying-patients-with-pulmonary-embolism/#:~:text=TAPSE%20for%20Evaluation%20of%20Right%20Ventricular%20Dysfunction&text=Approximates%20RV%20ejection%20fraction%20with,75%25%20specificity%20%5B32%5D.

https://www.thepocusatlas.com/right-ventricular-dysfunction/

A 5 year old male with a history of sickle cell disease (SCD) complicated by splenic sequestration presents to the ED with complaints of hip and back pain. He has had the pain for days, but now over the last 24 hour has had decreased PO intake associated with nausea, vomiting, and chest pain.  Mom reports fever at home and that he appears to be having difficulty breathing. Vitals include BP 108/62, HR 152, T 99.2F, RR 40, SpO2 88% on room air. On exam, he appears uncomfortable and has clear lung sounds. A chest x-ray is performed and shown below. What’s the diagnosis?

Answer: Acute Chest Syndrome – note the opacification of the posterior costophrenic sulcus on the lateral film concerning for pneumonia

Definition: New infiltrate on chest x-ray in addition to fever > 101.3F, cough, wheeze, tachypnea, or chest pain

• Clinical features may present before radiographic changes, and patients may develop acute chest during hospitalization for another SCD complication.
• Chest x-ray has an approximately 85% sensitivity, thus obtain a chest CT if chest-x ray is non-diagnostic with high index of suspicion.

Etiology: Pulmonary infection, fat emboli, vaso-occlusion, over aggressive fluid administration

• Most common organisms are Chlamydia pneumoniae and Mycoplasma (other organisms are Staph aureus, Haemophilus influenza, Klebsiella pneumonia, and respiratory viruses)
• Consider Strep pneumoniae in patients with sickle cell disease not taking prophylactic penicillin

Treatment:

• Oxygen for hypoxia
• Pain control
• IV fluids  – correct hypovolemia with isotonic fluid bolus, usually starting with 20 mL/kg if no heart failure; thereafter maintain euvolemia with maintenance oral hydration or IVF (D5NS or D5.45NS)
• Antibiotics to cover atypical organisms and encapsulated organisms
• Beta-2 adrenergic agonists for wheezing
• Exchange transfusion reserved for severe crisis (and PaO2<60 or high hemoglobin)

Pitfall: These patients can decompensate quickly with increasing oxygen requirements and often require critical care!

References:

Long B, Koyfman A. Sickle Cell Disease and Hereditary Hemolytic Anemias. 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

A 3 year old male with a history of severe eczema presents for facial rash and hand pain. Mom has been applying aquaphor and vaseline several times a day. This morning, he woke up with a new rash over his face and hands which prompted ED visit. Vitals include BP 103/61, HR 156, Temp 102.9F, RR 30, SpO2 99%. Exam is notable for diffuse, dry skin throughout and findings as below. Lesions spare mucous membranes and palms/soles. Nikolsky sign negative. What’s the diagnosis?

Answer: Eczema Herpeticum

• Demonstrated by multiple grouped pustules on an erythematous base
• Typically caused by superinfection of HSV due to a diminished skin barrier from atopic dermatitis
• Commonly misdiagnosed as impetigo
• Potentially life-threatening if has multisystem involvement such as HSV keratitis or encephalitis
  • In this case, ophthalmology was consulted to rule out ophthalmologic infection due to extensive rash. Dermatology was consulted for a wound culture which resulted positive for VZV.
• Treatment includes Acyclovir in addition to gram positive coverage such as Bactrim or Cephalexin

References:

American Academy of Pediatrics: Herpes simplex. In: Kimberlin  DW, Brady  MT, Jackson  MA, Long  SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015:432–445.

A 65 year old female with past medical history significant for recently diagnosed COPD presenting with shortness of breath. She has been symptomatic for the past month but has been getting progressively worse over the past couple weeks. She is medically compliant with her prescribed inhalers and is not on supplemental oxygen at home. She also reports worsening bilateral lower extremity edema and fatigue over the past two days.

Patient has an initial pulse oximetry of 65% in triage on room air, placed on non-rebreather and improved to 85%. Other vitals are as follows: BP 122/87, HR 101, Temp 97.4, RR 18. Physical exam significant for tachycardia, respiratory distress with poor air movement bilaterally, and bilateral lower extremity pitting edema from the knees down. A focused cardiopulmonary point-of-care ultrasound is shown below. What’s the likely diagnosis and abnormal ultrasound finding?

Answer: COPD with pulmonary hypertension and right heart strain

• Shown by dilated right ventricular outflow tract (RVOT) on PSLA and D-sign on PSSA.
• Normally in PSLA, the RV outflow tract, aortic outflow tract, and L-atrium should be roughly the same size. Additionally, in PSSA the LV is normally bowing into the RV due to the increased pressures comparatively. When there is right heart strain, the RV dilates from the increased pressure and pushes the interventricular septum back to the midline, creating the “D-sign”.
  • This is most concerning for pulmonary embolism in the acute setting. This patient had a CTA chest performed which was negative for pulmonary embolism.

• Right heart strain is also congruent in the setting of long-standing, untreated COPD leading to pulmonary hypertension causing her shortness of breath and bilateral lower extremity edema without pulmonary edema.
• When seeing an acutely ill patient like this at bedside, it is important to rule out the most life-threatening pathology with the information you have readily available. While the acute-on-chronic nature of her story may support a diagnosis of COPD causing chronic pulmonary hypertension and right heart strain, a pulmonary embolism must be ruled out in the setting of hypoxia and right heart strain on POCUS as it would require more emergent intervention and can also be concurrently present.

References:

https://www.pocus101.com/the-d-sign-right-heart-strain-from-pressure-vs-volume-overload/

Falster C, Egholm G, Wiig R, Poulsen MK, Møller JE, Posth S, Brabrand M, Laursen CB. Diagnostic Accuracy of a Bespoke Multiorgan Ultrasound Approach in Suspected Pulmonary Embolism. Ultrasound Int Open. 2023 Jan 16;8(2):E59-E67. doi: 10.1055/a-1971-7454. PMID: 36726389; PMCID: PMC9886498.

A 34 year old male presenting to the emergency department for left shoulder pain. The pain is constant and worse with movement. He frequently has been feeling similar pain but was in a motor vehicle accident yesterday that exacerbated the pain. He was noted to have a left shoulder deformity with intact range of motion at the shoulder. What’s the diagnosis and treatment?

Answer: Grade III acromioclavicular joint separation; immobilize with a sling for 6-12 weeks and follow up with orthopedic surgery.

Grade	Ligament involvement	X-ray Findings and Exam	Treatment
I	– AC ligament sprain – No instability of clavicle	Exam: Tenderness over AC joint     X-ray: Normal imaging	Ice, rest, analgesics, immobilization Early range of motion 1-2 weeks
II	– AC ligament rupture – Sprain of coracoclavicular ligament	Exam: Tenderness and mild step off of AC joint X-ray: Clavicle elevated 25-50% above acromion, widening of the AC joint	Ice, rest, analgesics, immobilization Early range of motion 1-2 weeks
III	– AC ligament rupture – Coracoclavicular ligaments partially ruptured – Deltoid and trapezius muscles detached	Exam: Shoulder droops, prominent distal clavicle X-ray: Clavicle elevated 100% above acromion, widening of coracoclavicular space	Conservative with sling immobilization Some cases may be operative
IV	– AC joint dislocation with AC ligament rupture – Complete or partial rupture of coracoclavicular ligament – Clavicle displaced posteriorly	Exam: Posterior displacement of clavicle X-ray: Axillary radiograph required to see posterior dislocation	Surgical repair
V	– AC joint dislocation with AC ligament rupture – Complete rupture of coracoclavicular ligament	Exam: Gross clavicular deformity X-ray: AC joint dislocated, coracoclavicular interspace with 200-300% disparity	Surgical repair
VI	– AC joint dislocation with AC ligament rupture – Intact coracoclavicular ligament – Clavicle displaced inferiorly – Intact, partial or complete deltoid and trapezius detachment	Exam: Severe swelling   X-ray: AC joint dislocated, clavicle displaced inferiorly	Surgical repair

References:

Gorbaty JD, Hsu JE, Gee AO. Classifications in Brief: Rockwood Classification of Acromioclavicular Joint Separations. Clin Orthop Relat Res. 2017 Jan;475(1):283-287. doi: 10.1007/s11999-016-5079-6. Epub 2016 Sep 16. PMID: 27637619; PMCID: PMC5174051.

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Bjoerson, L. Ebinger, A. Chapter 271. Page 1824-1826. McGraw Hill Professional, 22 Oct. 2019.

A 27 year old male with a history of osteosarcoma with numerous lung metastases s/p left upper lobe wedge resection 1 year ago presents with dyspnea on exertion and “abnormal findings on outpatient CT scan”. Vitals include HR 135, RR 18, SpO2 93% on room air. On exam, he has diminished but present breath sounds bilaterally. A chest x-ray is obtained and shown below. What’s the diagnosis?

Answer: Hydropneumothorax (see pleural line in periphery of left lung and pleural effusion)

• Defined as the presence of both air and fluid in the pleural space
• Can be either atraumatic or traumatic (hemopneumothorax)
• Underlying etiologies can include: COPD (due to presence of blebs), pneumonia, TB, malignancy, prior lung instrumentation
• Most common presenting symptoms are SOB and cough
• Diagnosis can be made on CXR, US, or CT
• In the event of tension physiology, treat as tension PTX with needle decompression, tube thoracostomy
• For more stable cases, treatment is supplemental O2 to help with lung re-expansion, tube thoracostomy, and pulmonology consultation
• Ultimately, requires admission for further workup, treatment of underlying condition
• The etiology of this patient’s hydropneumothorax was unknown, but possibly related to underlying malignancy

References:

Kasargod V, Awad NT. Clinical profile, etiology, and management of hydropneumothorax: An Indian experience. Lung India. 2016;33(3):278-280. 

A 52 year old female presents via EMS after being found down outside. Medical history is notable for reported insulin-dependent diabetes. The patient is found to have altered mental status on presentation, and is unable to provide further history. Vitals are notable for heart rate of 138, blood pressure 92/50, and temperature of 102.1F; POC blood glucose shows blood sugar over 600. On physical exam, patient is found to have hemorrhagic bullae of her left lower extremity with palpable crepitus. Labs in the emergency department are notable for WBC of 36k, anion gap of 30, and lactate of 2.5.

Point-of-care ultrasound of the left lower extremity is shown below. What is the most likely diagnosis, and what findings on the ultrasound imaging support this?

Answer: Necrotizing Fasciitis; “dirty shadowing”

• Subcutaneous air results will appear as hyperechoic lines on soft tissue ultrasound, with “dirty shadowing” of tissue/structures deep to the air.
• These hyperechoic lines are seen at the borders between air and soft-tissue, due to a scattering of ultrasound waves that occurs at these boundaries.
• Additional findings of necrotizing fasciitis on ultrasound include a “cobblestone” appearance of the subcutaneous tissue with abnormal fluid collections. These findings are not specific to necrotizing fasciitis, however.

References:

Tso DK, Singh AK. Necrotizing fasciitis of the lower extremity: imaging pearls and pitfalls. Br J Radiol. 2018 Jul;91(1088):20180093. doi: 10.1259/bjr.20180093. Epub 2018 Mar 28. PMID: 29537292; PMCID: PMC6209465.

Buttar S, Cooper D Jr, Olivieri P, Barca M, Drake AB, Ku M, Rose G, Siadecki SD, Saul T. Air and its Sonographic Appearance: Understanding the Artifacts. J Emerg Med. 2017 Aug;53(2):241-247. doi: 10.1016/j.jemermed.2017.01.054. Epub 2017 Mar 31. PMID: 28372830.

A 55 year old male with a past medical history of colon cancer on chemotherapy presents with a chief complaint of right lower extremity pain/discoloration to his calf and thigh as well shortness of breath that has developed over the past 48 hours. A physical exam reveals dopplerable DP and PT pulses. The right calf and thigh is visualized as in the image below. What’s the diagnosis?

Answer: Phlegmasia Cerulea Dolens (PCD) – a near-total occlusion of the major deep venous system of an extremity as well as the majority of microvascular collateral veins of the extremity. 

PCD occurs on a spectrum with phlegmasia albans dolens (PAD): thrombosis of the deep venous system with patency of the collateral veins and venous gangrene: when there is complete obstruction of venous outflow with irreversible capillary involvement and muscle infarction. It is differentiated from PAD by a pale/white limb versus a dusky/cyanotic limb in PCD. 

Clinical Features: Triad of swelling, pain, cyanosis. Limb can develop firmness and there is a risk for arterial compromise and compartment syndrome. Thrombosis can extend into the IVC and it is often accompanied by pulmonary embolism with the incidence reported to vary from 12-40%.  

Diagnosis: Clinical history/exam in conjunction with imaging. Gold standard diagnosis is contrast venography, however often due to difficulty and length of time to attain this ultrasound venography is often preferred. CT-venogram is useful for visualization of extension of thrombus in the IVC. 

Management: Immediate elevation of affected extremity above the level of the heart to encourage return of circulation. Anticoagulation with unfractionated IV heparin bolus at 10-15 units/kg followed by an infusion titrated to an aPTT of 1.5-2 times the lab control value. Immediate vascular/interventional radiology consultation for possibly thrombectomy versus catheter-directed thrombolysis. If no service is available and transfer is unable to be arranged within 6 hours then consider systemic fibrinolytics if no contraindications are present. 

Case Continued: Duplex ultrasound, CT-venogram, and CTA Chest on our patient revealed DVT of the major deep veins of the right lower extremity that extended into the IVC as well as bilateral pulmonary embolisms. He was started on heparin and had a mechanical thrombectomy of the right iliofemoral/IVC DVT. He was able to be discharged on apixaban several days later. 

Resources:

Cline, D., Ma, O. J., Meckler, G. D., Stapczynski, J. S., Thomas, S. H., Tintinalli, J. E., Yealy, D. M., & Kline, J. A. (2020). Venous Thromboembolism Including Pulmonary Embolism. In Tintinalli’s emergency medicine: A comprehensive study guide (pp. 389–398). essay, McGraw-Hill Education. 

Gardnella, L., & Falk, J. (n.d.). Phlegmasia Alba and cerulea Dolens – StatPearls – NCBI Bookshelf. Phlegmasia Alba and Cerulea Dolens. https://www.ncbi.nlm.nih.gov/books/NBK563137/ 

Perkins, J. M., Magee, T. R., & Galland, R. B. (1996). Phlegmasia caerulea dolens and venous gangrene. British Journal of Surgery, 83(1), 19–23. https://doi.org/10.1002/bjs.1800830106 

A 44 year old male presents for left foot and ankle pain. He was running and stepped into a hole, stating he heard a “crack”. He has been unable to bear weight since the injury. On exam, his left lower extremity is neurovascularly intact. He has swelling and marked bony tenderness of both the lateral and medial malleoli and heel. X-rays of the left foot is obtained and shown below. What’s the diagnosis?

Answer: Comminuted Calcaneal Fracture

Etiology

• Most commonly due to high axial load injuries such as fall from height or MVC
• Most common tarsal fracture

Presentation

• Diffuse pain, swelling, and ecchymosis after trauma
• Often unable to bear weight
• Deformity of heel or plantar arch on exam
• Mondor’s sign – ecchymosis/hematoma that tracks along sole of foot
  • Pathognomonic for calcaneal fracture

Diagnosis

• Plain radiographs of ankle/foot
• Harris view: calcaneus in axial view
• Non-contrast CT of foot/ankle is gold standard and assists with surgical planning
• Sander’s Classification (based on CT)
  • Type I: All intra-articular fractures that have < 2 mm displacement, regardless of number of fracture lines or fragments
  • Type II: Two bony fragments involving posterior facet
  • Type III: Three bony fragments including depressed middle fragment
  • Type IV: Four comminuted bony fragments

ED Treatment

• Analgesia, ice, elevation
• Splinting, often with bulky Jones dressing
• Orthopedics consultation
  • Most intra-articular fractures require surgical repair
  • Most extra-articular fractures can be managed conservatively with 10-12 weeks of casting and non-weight bearing

References:

Jiménez-Almonte JH, King JD, Luo TD, Aneja A, Moghadamian E. Classifications in Brief: Sanders Classification of Intraarticular Fractures of the Calcaneus. Clin. Orthop. Relat. Res. 2019 Feb;477(2):467-471

A 78 year old female presents to the ED from a cardiac rehabilitation facility with increasing shortness of breath and a productive cough. She was discharged from the hospital two weeks ago after having a coronary stent placed which was complicated by pneumonia and developing heart failure. She was discharged on PO amoxicillin-clavulanate. Vitals are notable for a heart rate of 101 and are otherwise within normal limits. 

Labs are remarkable for an elevated WBC of 18.55 and elevated NT-ProBNP of 2155. Point-of-care cardiac ultrasound shows a normal ejection fraction. Right sided point-of-care lung ultrasound findings are shown below. What’s the most likely diagnosis, and what pathognomonic ultrasound “sign” is seen?

Answer: Pneumonia; Hepatization of the lung

• Normally, lung is not well visualized on ultrasound because the alveoli are filled with air which does not transmit ultrasound beams well to produce an image.
  • Aerated lung will produce horizontal “A lines”, a reverberation artifact from the result of sound waves bouncing between the skin and pleural line.
• With consolidation of the lung or pneumonia, ultrasound beams are able to travel through the purulent or fluid filled alveoli.
  • The lung will appear hypoechoic and heterogeneous, resembling the liver, hence the term “hepatization of the lung.”

References:

Dawson M, Mallin M. Introduction to Bedside Ultrasound: Volume 1. Emergency Ultrasound Solutions; 2013. 

Durant A, Nagdev A. Ultrasound detection of lung hepatization. West J Emerg Med. 2010;11(4):322-323

https://litfl.com/lung-ultrasound-pneumonia/