Friday Board Review

Board Review by Dr. Edward Guo (Edited by Dr. Parikh)

Vidhi ParikhLeave a comment

A 30 year old male presents with a displaced right ankle bimalleolar fracture. He is undergoing procedural sedation in the emergency department using midazolam and fentanyl for fracture-dislocation reduction. During the procedure, he becomes apneic and hypoxic. The hypoxia improves with bag valve ventilation, but he becomes progressively more difficult to ventilate. There is absence of chest rise despite increasing positive pressure. What is the likely cause of this patient’s presentation?

A: Laryngospasm

B: Musculoskeletal stiffness

B: Opioid induced hypoventilation

C: Pneumothorax

Answer: Musculoskeletal stiffness

This patient is likely experiencing Rigid Chest Syndrome, a rare but potentially fatal side effect of synthetic opioids causing skeletal muscle rigidity. The exact mechanism is unknown but is related to the dose and administration. It is commonly seen at high doses (> 3 mcg/kg of fentanyl) and with rapid IV push but has been reported with low doses as well. Treatment includes use of propofol for muscle relaxation or naloxone for reversal of opioid agonism. Neuromuscular paralysis and intubation may be required in refractory cases.

Laryngospasm is a known adverse reaction of ketamine administration which usually responds to first-line maneuvers such as jaw thrust or bag valve ventilation. Hypoventilation is a common side effect of opioids but should not cause chest wall rigidity. While uncommon, a pneumothorax may be caused by excessive positive pressure, but at least unilateral chest rise should be visualized with ventilation.

References:

Myers JG, Sutherland J. Procedural Sedation and Analgesia in Adults. 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.

Çoruh  B, Tonelli  MR, Park  DR: Fentanyl-induced chest wall rigidity case report. Chest 143: 1145, 2013. [PubMed: 23546488.

Patel, Nishika. “Wooden Chest Syndrome.” CriticalCareNow, 5 Aug. 2021, criticalcarenow.com/wooden-chest-syndrome/. Accessed 22 Mar. 2024.

Wednesday Image Review

What’s the Diagnosis? By Dr. Daniel Petrosky

Edward GuoLeave a comment

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

Edward GuoLeave a comment

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]  

Monday Back to Basics

Bradycardia, Part 2 with Dr. Allison Cash

Erica WestlakeLeave a comment
  1. Treat possible underlying cause if known 
  1. Atropine
    •  Class 2a treatment
    • Dose 0.5 mg IV every 3-5 minutes, up to total dose 3 mg 
    • Can produce paradoxical worsening bradycardia 
    • Less effective in patients with cardiac transplant 
    • Skip if unstable, move directly to pacing 
  1. Transcutaneous pacing  
    • Class 1a recommendation
    • Place pads in anterior lateral or anterior posterior position 
    • Consider sedation or pain control  
    • Set monitor to “Pacer” 
    • Set rate, usually around 60 bpm 
    • Start current at 0 mA and slowly increase until capture is obtained. Consider different placement of pads if capture not achieved by 130 mA 
    • Confirm capture by feeling pulse or cardiac ultrasound 
    • Transcutaneous pacing is ultimately a bridge to transvenous pacing or permanent pacemaker – discuss with cardiology or transfer to center with these capabilities  
    • Capture (pictured below) shows pacer spike followed by a wide QRS and then ST and/or T wave  

References: 

  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 
  1. Doukky R, Bargout R, Kelly RF, Calvin JE. Using transcutaneous cardiac pacing to best advantage: How to ensure successful capture and avoid complications. J Crit Illn. 2003 May;18(5):219-225. PMID: 30774278; PMCID: PMC6376978. 
  1. Holger J S, Lamon R P, and Minnigan H J et al.: Use of ultrasound to determine ventricular capture in transcutaneous pacing. Am J Emerg Med.  2003; 21: 227 
Friday Board Review

Board Review by Dr. Alex Hilbmann (Edited by Dr. Parikh)

Vidhi ParikhLeave a comment

A 66 year old female reports to the emergency department with right arm pain after slipping on ice and trying to catch herself while falling forward. The patient is in incredible pain and has an obvious deformity of the right forearm upon presentation. An x-ray of the right forearm is shown below. What injury does the patient have?

A. Colles Fracture

B. Monteggia Fracture

C. Galeazzi Fracture

D. Smith Fracture

Answer is C. The x-ray shows a distal third radial fracture with disruption of the distal radioulnar joint space, which is a Galeazzi fracture. A Colles Fracture (A) is a distal radius fracture with dorsal displacement whereas a Smith Fracture (D) is a distal radius fracture with volar displacement. Both fractures frequently do not involve significant disruption of the radioulnar joint. A Monteggia fracture (B) is a fracture of the proximal ulna which results in radial head dislocation. For a Galeazzi fracture, the anterior osseous nerve (a branch of the median nerve) is often affected and function should be assessed by asking the patient to perform an “Okay” sign with first and second digit of affected arm.  Orthopedic Surgery consultation is necessary in adults as treatment is an open reduction and internal fixation (ORIF). If open fracture is present Cefazolin should be administered and if the wound is > 10 cm, appears contaminated, or involves seawater/freshwater/farming equipment Gentamicin should also be administered.

Picture from:

https://www.orthobullets.com/trauma/1029/galeazzi-fractures

Resources:

Atesok KI, Jupiter JB, Weiss AP. Galeazzi fracture. J Am Acad Orthop Surg. 2011 Oct;19(10):623-33. doi: 10.5435/00124635-201110000-00006. PMID: 21980027.

Garg R, Mudgal C. Galeazzi Injuries. Hand Clin. 2020 Nov;36(4):455-462. doi: 10.1016/j.hcl.2020.07.006. PMID: 33040957.

Mills, Trevor J.. “Forearm Fractures.” (2013). https://www.semanticscholar.org/paper/Forearm-Fractures-Mills/dead0398468fc50a88349251a8cb8a49b88f838f

Wednesday Image Review

What’s the Diagnosis? By Dr. Katie Selman

Edward GuoLeave a comment

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.

Critical Cases – The Red Eye!
Tuesday Advanced Cases

Critical Cases – The Red Eye!

Richard ByrneLeave a comment

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 
Monday Back to Basics

Bradycardia, Part 1 with Dr. Allison Cash

Erica WestlakeLeave a comment
A ACS Myocardial infarction, also consider cardiomyopathies, myocarditis 
T Thyroid Hypothyroidism 
R Rhythms  Second degree AV block (type I & II), complete AV block 
O Overdose Digoxin, beta blockers, calcium channel blockers, amiodarone, clonidine, organophosphates, naturally occurring cardiac glycosides (e.g. foxglove), opioids 
P Pressure Increased intracranial pressure (Cushing’s response) 
I Infection Lyme disease, diphtheria, typhoid fever, aortic root abscess 
N Nippy  Hypothermia  
E Electrolytes Glucose, potassium, calcium, and magnesium 

Other Considerations:

  • Hypoxia
  • Infiltrative Disorders (Amyloidosis, Sarcoidosis, Hemochromatosis)
  • Autoimmune disorders (SLE)

References: 

  1. Judith E. Tintinall, et al. (2020). Tintinalli’s Emergency Medicine : A Comprehensive Study Guide (Ninth Edition). New York: McGraw-Hill. 
  1. Briggs, Blake & Husain, Iltifat. (2024, Jan 16) Bradycardia: “But my Apple Watch…?” (208). Emergency Medicine Board Bombs.