Question Of The Day #90

question of the day
366 - pneumonia-middle lobe

Which of the following is the most likely cause of this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath, productive cough, and fever for 5 days.  On exam, the patient is febrile, tachycardic, and has a low SpO2 on room air.  The lung exam demonstrates focal rhonchi at the right base.  The chest X-ray demonstrates a consolidation at the right middle lobe that obscures the right heart boarder.  The consolidation is highlighted with a red star in the patient’s X-ray below.

Lung consolidations have multiple causes, including pneumonia, malignancy, heart failure, pulmonary emboli, and septic emboli from endocarditis.  Septic pulmonary emboli (Choice A) can present with cough, fever, and difficulty breathing, but often have multiple foci of consolidations on chest X-ray.  This patient has a single area of consolidation.  This patient also lacks the typical risk factors for septic emboli, like IV drug use, recent dental procedures, structural heart disease, or prosthetic heart valves.  An infected pleural effusion (Choice B), also known as an empyema, is shown as a blunted or hazy right costo-diaphragmatic angle.  This patient’s X-ray shows no fluid in both costo-diaphragmatic recesses to indicate the presence of a pleural effusion.  A pulmonary embolism (Choice D) often presents with clear lungs on auscultation and a normal chest X-ray.  However, if the pulmonary embolism progresses to a pulmonary infarct, a wedge-shaped opacity can be seen on the X-ray.  This patient’s X-ray lacks this finding.  The most likely cause for this patient’s symptoms is a right middle lobe pneumonia (Choice C).  She should receive IV fluids, antipyretics, supplemental oxygen, and IV antibiotics.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #90," in International Emergency Medicine Education Project, May 27, 2022, https://iem-student.org/2022/05/27/question-of-the-day-90/, date accessed: October 6, 2022

Question Of The Day #89

question of the day

Which of the following is the most appropriate next step in management?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with acute shortness of breath, an urticarial rash, hypotension, tachycardia, swelling of the lips and tongue, and wheezing on lung exam.  This patient is in anaphylactic shock and requires prompt treatment with epinephrine.  Anaphylaxis is an IgE-mediated life-threatening allergic reaction that by definition affects two or more body systems (i.e., skin/mucosa, pulmonary, cardiovascular, gastrointestinal, etc.).  This patient has involvement of the skin (urticarial rash, mucosal swelling), cardiovascular system (hypotension and tachycardia), and pulmonary system (wheezing).  Symptoms of anaphylaxis may include urticaria, shortness of breath, wheezing, facial or airway swelling, vomiting or diarrhea, and abdominal pain.  Anaphylaxis is a clinical diagnosis and does not require vital signs to be unstable in order to be diagnosed.  Once diagnosed, the most time sensitive and lifesaving treatment is epinephrine.  The recommended initial dose for epinephrine is 0.3-0.5mg intramuscularly in the thigh for adults.  Epinephrine doses can be repeated every 5-15 minutes if there is no improvement after the initial dose. Antihistamines, like Diphenhydramine (Choice D) or famotidine may be helpful as adjunctive treatments, but they are not lifesaving.  Steroids, like Dexamethasone (Choice C), are also routinely given in anaphylaxis with the theory that they can prevent “rebound” allergic reactions.  Again, steroids are not acutely lifesaving and should be given after IM epinephrine.  IV epinephrine can be given in a patient unresponsive to IM epinephrine at a dose of 1-5mcg/min.  A dose of IV Epinephrine 1mg (1000mcg) (Choice A) is the dose of Epinephrine used during cardiac arrest and is too high of a dose to use in anaphylaxis.  The best initial step in management is IM Epinephrine 0.3mg (Choice B).  

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #89," in International Emergency Medicine Education Project, May 20, 2022, https://iem-student.org/2022/05/20/question-of-the-day-89/, date accessed: October 6, 2022

Question Of The Day #88

question of the day
Which of the following is the most appropriate next step in management?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath and abdominal discomfort for 1 day.  On exam, she is hypotensive, tachycardic, and tachypneic.  Her lungs are clear, the abdomen is tender and distended, and the pregnancy test is positive.  This patient has a ruptured ectopic pregnancy until proven otherwise and requires prompt surgical management.  Once diagnosed by the Emergency clinician, ectopic pregnancy can be managed medically or surgically.  See the chart below for more details.

Treatment options for ectopic pregnancy

 

Medical Management (Methotrexate) Indicated:

Surgical Management

Indicated:

Patient hemodynamically stable

Patient hemodynamically unstable

HCG <5,000

HCG >5,000

Able to comply with Methotrexate treatment and follow up

Unable to comply with Methotrexate treatment and/or follow up

No fetal cardiac activity on ultrasound

Fetal cardiac activity present on ultrasound

   

This patient has an assumed ectopic pregnancy due to the positive pregnancy test and presence of hemodynamic instability.  A transvaginal ultrasound (Choice C) would help definitively diagnose the patient with a ruptured ectopic pregnancy, but this should not delay consultation with the OBGYN team for definitive surgical management.  Methotrexate (Choice A) is a medical treatment for ectopic pregnancy, but Methotrexate is contraindicated in ruptured ectopic due to the need for surgical treatment and intra-abdominal hemorrhage control.  IV antibiotics (Choice B) are often given preoperatively for infection prophylaxis (prevention), but this is not a crucial next step.  This patient is in shock and needs operative management. The best next step is OBGYN consultation for operative management (Choice D).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #88," in International Emergency Medicine Education Project, May 13, 2022, https://iem-student.org/2022/05/13/question-of-the-day-88/, date accessed: October 6, 2022

Question Of The Day #87

question of the day

 

Test Value

Reference Range

BUN

14

6 – 24 mg/dL

Creatinine

0.87

0.59 – 1.04 mg/dL

Hemoglobin

5.5

12.0 – 15.0 g/dL

WBC count

5.2

4.5 to 11.0 × 109/L

HCG quantitative

0

<5 mIU/mL

Which of the following is the most like cause for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with shortness of breath with deceased exercise tolerance or 5 days.  Her vital signs are normal and lungs are clear, but she appears pale.  The laboratory test provided shows normal kidney function, a negative serum pregnancy test, and a markedly low hemoglobin level.  A ruptured ectopic pregnancy (Choice B) can cause shortness of breath due to anemia and hemorrhagic shock, but this patient has a negative pregnancy test.  Asthma (Choice A) is unlikely given the patient’s normal lung exam without wheezing and no mention of cough.  A pulmonary embolism (Choice D) is possible due to the tachycardia, but the patient lacks other risk factors as stated in the question stem.  A D-Dimer test could help further evaluate if this patient has a pulmonary embolism, but the low hemoglobin likely explains the patient’s symptoms.  The patient’s history of menorrhagia, also known as heavy menses (Choice C), is a common cause of anemia in women of childbearing age.  Even though this patient is not currently menstruating, her heavy menses are the most likely cause for her shortness of breath.  Choice C is the best answer.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #87," in International Emergency Medicine Education Project, May 6, 2022, https://iem-student.org/2022/05/06/question-of-the-day-87/, date accessed: October 6, 2022

Question Of The Day #86

question of the day
420 - right pneumothorax1
Which of the following is the most appropriate next step in management for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient arrives to the Emergency department with acute onset shortness of breath with pleuritic right sided chest pain.  On exam, there is mild tachypnea and a borderline low SpO2 of 95% on room air.  The chest X-ray demonstrates a small right sided pneumothorax (see location of red stars below).

Needle decompression to the right chest (Choice C) would be the right choice if the patient had a right sided tension pneumothorax.  Signs of a tension pneumothorax are hypotension, tachycardia, tracheal deviation, and mediastinal shift on Chest X-ray.  Tension pneumothorax should be diagnosed clinically without a chest X-ray and promptly treated with needle decompression with a 14-16 gauge needle at the 2nd intercostal space in the mid clavicular line.  Needle decompression can also be performed at the 4th or 5th intercostal space in the anterior axillary line. Needle decompression is always followed by placement of a formal chest tube.  This patient does not have the hemodynamic instability or chest X-ray findings of a classic tension pneumothorax. IV Azithromycin (Choice D) would be appropriate for a COPD exacerbation or for community-acquired pneumonia.  This patient does have a cough, but lacks fever, sputum production, and also has a pneumothorax on X-ray that can explain his symptoms.  An IV Heparin bolus and infusion (Choice A) would be the ideal treatment for a pulmonary embolism or acute coronary syndrome.  Again, the Chest X-ray provided shows support for an alternative cause for the patient’s symptoms.  The best next step is supplemental oxygen (Choice B).  100% supplemental oxygen helps decrease the time to lung expansion in patients with pneumothoraces.   A nonrebreather mask at 15L/min is the ideal method to providing this level of oxygen.

This patient has a small pneumothorax (<3cm between lung margin and chest wall).  Small primary pneumothoraces have two treatment options.  The first option is to administer 100% oxygen and place a pigtail catheter for rapid lung re-expansion.  The second option is to only administer 100% oxygen administration for a period of 4-6 hours followed by a repeat chest X-ray to evaluate for improvement of the pneumothorax.   If the pneumothorax is improving and symptoms are improving (less shortness of breath and chest pain), the patient can be discharged home with close outpatient follow up and no chest tube placement.  Deciding which treatment option is best should depend on the patient’s ability to follow up with a doctor, patient reliability, and resource availability.  This patient does have a small pneumothorax by measurement, but he likely has a secondary pneumothorax from his COPD.  Secondary pneumothoraces have a higher rate of recurrence and almost always require chest tube placement.  Regardless, the best initial step in treatment is supplemental oxygen (Choice B).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #86," in International Emergency Medicine Education Project, April 29, 2022, https://iem-student.org/2022/04/29/question-of-the-day-86/, date accessed: October 6, 2022

Question Of The Day #85

question of the day
SS Video 3  Pericardial Tamponade
Which of the following is the most likely cause for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient presented to the Emergency department with 2 days of shortness of breath without chest pain, cough, or fevers.  The exam shows tachycardia, hypotension, mild tachypnea, clear lungs, and distant heart sounds.  Tension pneumothorax (Choice B) can cause hypotension and tachycardia and COPD is a risk factor for pulmonary bleb formation and rupture.  However, the lungs are equal and clear bilaterally, so this diagnosis is not likely.  Septic shock due to pneumonia (Choice C) is also less likely as there is no fever, the lungs are clear, and the patient lacks a cough.  The ultrasound image given also provides a clear explanation for the patient’s symptoms.  This patient is at risk for pulmonary embolism (Choice A) given his cancer history which can cause a hypercoagulable state and predispose him to clot formation.  Again, an understanding of the ultrasound image will provide the diagnosis.

The ultrasound image is a subxiphoid view of the heart demonstrating a pericardial effusion (red stars) with compression of the right ventricle (yellow arrow). 

This presentation is consistent with cardiac tamponade (Choice D).  Cardiac tamponade is a condition defined by the accumulation of fluid in the pericardial sac to the point of right ventricular collapse and obstructive shock.  Common presenting symptoms of cardiac tamponade include shortness of breath, chest pain, or nonspecific symptoms.  Risk factors for this diagnosis are penetrating chest trauma (hemopericardium), cancer (malignant effusion), lupus, end stage renal disease, uremia, HIV, Tuberculosis, or history of chest radiation.  The presence of hemodynamic instability (hypotension and tachycardia) is a hallmark of this condition, although early stages of tamponade can be seen on cardiac ultrasound before vital signs decompensate.  The patient may have Beck’s triad of muffled distant heart sounds, jugular venous distension, and hypotension, although the majority of patients with cardiac tamponade do not have all three of these signs together.  Treatment involves IV fluids, bedside pericardiocentesis (ultrasound guided preferred), and surgical pericardiotomy (“pericardial window”).

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #85," in International Emergency Medicine Education Project, April 22, 2022, https://iem-student.org/2022/04/22/question-of-the-day-85/, date accessed: October 6, 2022

Question Of The Day #84

question of the day
475.3 xray abdomen series normal chest
Which of the following is the most appropriate next step in management for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

 

This patient arrives to the Emergency Department with shortness of breath and generalized weakness or 3 days.  On physical exam, there is tachycardia, tachypnea, normal oxygen saturation, and a markedly elevated glucose.  The Chest X-ray provided is normal; there are no lung infiltrates or pleural effusions. 

This patient has diabetic ketoacidosis (DKA).  DKA is a serious condition of insulin deficiency characterized by hyperglycemia, metabolic acidosis, and ketosis.  Presenting symptoms include weakness, increased thirst (polydipsia), increased hunger (polyphagia), increased urination (polyuria), abdominal pain, or vomiting.  Shortness of breath can also be seen in DKA as the metabolic ketoacidosis triggers an increased respiratory rate to drive more exhaled carbon dioxide out of the body.  This deep rapid breathing seen in severe DKA is known as Kussmaul breathing.  The treatment of DKA involves IV fluids for hydration, insulin infusion, and close monitoring for electrolyte derangements (potassium abnormalities are common).  DKA patients are severely dehydrated due to osmotic diuresis from their hyperglycemic state.  For this reason, IV fluid resuscitation is the first step to DKA management.  Either normal saline or lactated ringers (Choice B) can be used, although large volumes of normal saline can worsen the acidotic state by causing a hyperchloremic metabolic acidosis.  Intravenous fluids should be started with a 20-30cc/kg bolus.  IV insulin infusion (Choice A) should never be started without a potassium level, and no potassium level is provided in the question stem.  Insulin lowers potassium, and administration of insulin without a potassium level can result in hypokalemia, arrythmia, and death.  Endotracheal intubation (Choice D) should be avoided in DKA whenever possible as the patient’s respiratory status serves as a compensation for the metabolic acidosis.  This patient is tachypneic and mildly confused, but he is not somnolent and does not require immediate intubation.  Intubated DKA patients need carefully monitored ventilator settings in combination with blood gas measurements to avoid worsening acidosis and cardiac arrest.  Nebulized beta-2 agonist (i.e., albuterol, salbutamol) is helpful in asthma, however this patient has DKA and not an asthma exacerbation.  IV lactated ringers solution (Choice B) is the best next step.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #84," in International Emergency Medicine Education Project, April 15, 2022, https://iem-student.org/2022/04/15/question-of-the-day-84/, date accessed: October 6, 2022

Question Of The Day #83

question of the day
infero-lateral MI - 41 yo male - 1 h pain
Which of the following is the most appropriate next step in management for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

 

This patient arrives to the Emergency Department with several hours of shortness of breath, nausea, and generalized weakness.  On physical exam, the vital signs are normal, there is no tachypnea, no hypoxemia, no respiratory distress, and the lungs are clear.  Clear lungs in a patient with respiratory distress should raise concern for acute coronary syndrome, pulmonary embolism, cardiac tamponade, anemia, and metabolic acidosis.    

The 12-lead EKG provided shows an inferior ST-elevation Myocardial Infarction (STEMI).  This is demonstrated through the ST segment elevations in the inferior EKG leads (II, III, AvF) and the reciprocal changes in the lateral leads (most notably in AvL).  The presence or absence of chest pain is not provided in this question, but patients with acute coronary syndromes do not always have chest pain.  Elderly patients and women are more likely to present with non-chest pain anginal equivalents, like shortness of breath, lethargy, or nausea.  Diagnosis of acute coronary syndrome is done through a combination of a 12-lead EKG, blood troponin levels, and history and physical exam.  A STEMI is the most severe of all acute coronary syndromes and requires prompt recognition and treatment with antiplatelets (i.e., aspirin plus clopidogrel or ticagrelor), heparin, pain management (morphine or nitroglycerin), and percutaneous coronary intervention (PCI).  Providing supplemental oxygen (Choice A) is not necessary as the patient has no hypoxemia and a normal lung exam.  Administration of sublingual nitroglycerin (Choice C) can help alleviate ischemic chest pain and other symptoms associated with a STEMI but is contraindicated in inferior STEMIs.  Using nitroglycerin in inferior STEMIs can result in dangerous hypotension due to cardiac preload reduction.  This patient has a STEMI, and a CT head to evaluate weakness (Choice D) will not be helpful.  In general, a detailed neurological exam assessing for motor deficits will be more valuable than a CT head to determine the etiology of a patient’s weakness.  The best next step in this case is to administer 324mg aspirin (Choice B) in this patient with a STEMI.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #83," in International Emergency Medicine Education Project, April 8, 2022, https://iem-student.org/2022/04/08/question-of-the-day-83/, date accessed: October 6, 2022

Question Of The Day #82

question of the day
35.3 - pulmonary congestion

Which of the following is the most likely cause of this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

 

This patient presents to the Emergency department with 1 day of shortness of breath without chest pain, fevers, or a cough.  He has been noncompliant with his home medications for his multiple comorbid conditions.  The exam shows tachypnea, tachycardia, hypertension, a low oxygen level, pulmonary crackles, and peripheral edema.  The chest X-ray shows bilateral pulmonary congestion and infiltrates consistent with pulmonary edema.

Diabetic ketoacidosis (Choice A) can cause shortness of breath, but the severe hypertension, fluid overload on exam, and lack of hyperglycemia make DKA less likely.  Pneumonia (Choice D) can cause shortness of breath, but often has other symptoms like cough, fever, and sometimes chest pain.  It is difficult to rule out an underlying pneumonia in the presence of pulmonary edema by solely looking at the chest X-ray.  The patient’s peripheral edema, severe hypertension, and lack of cough and fever make pneumonia a less likely diagnosis responsible for that patient’s symptoms.  Myocardial infarction (Choice C) often presents with chest pain but can present with only shortness of breath.  A severe myocardial infarction with cardiogenic shock can result in acute fluid overload as seen in this patient, but hypotension would be expected.  A 12-lead EKG is required to more fully evaluate for a myocardial infarction, but the constellation of symptoms this patient has makes congestive heart failure (Choice B) the most likely diagnosis. 

Immediate initial actions for this patient should include placing the patient on a cardiac monitor, obtaining a 12-lead EKG, sitting the patient upright to assist with breathing, and providing supplemental oxygen.  Acute decompensated heart failure should be aggressively treated with Nitroglycerin to lower the blood pressure and stress on the heart (preload).  Noninvasive positive pressure ventilation (NIPPV), such as BIPAP or CPAP, is another crucial initial step to help provide oxygenation, lower the preload, and push the fluid out from the lungs.  IV diuresis to remove fluid from the body and evaluating for the underlying cause are other important steps in acute CHF management. 

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #82," in International Emergency Medicine Education Project, April 1, 2022, https://iem-student.org/2022/04/01/question-of-the-day-82/, date accessed: October 6, 2022

Question Of The Day #81

question of the day
475.3 xray abdomen series normal chest
Which of the following is the most likely diagnosis for this patient’s condition?

Shortness of breath, also known as dyspnea, is a common reason for patients to visit the Emergency Department.  Dyspnea is often caused by a pulmonary or cardiovascular condition, but it is important to remember that dyspnea can be due to endocrine conditions, toxicologic conditions, neurologic conditions, hematologic conditions, musculoskeletal conditions, and psychiatric conditions. 

The initial approach to all patients with shortness of breath involves the primary survey, or “ABCs” (Airway, Breathing, Circulation).  This first involves checking the patient for a patent airway.  A simple method to assess the airway is to ask the patient to speak and listen for the voice.  A muffled voice, the presence of stridor, hematemesis, or a lethargic patient are clues that a patent airway may not be present.  Problems with the airway, such as an obstructing foreign body, inflammation (i.e., epiglottitis, anaphylactic shock), or vocal cord dysfunction can certainly cause shortness of breath.  Endotracheal intubation may need to be performed before moving forward.  Breathing is assessed by evaluating the function of the lungs.  Steps include looking at how the patient is breathing (fast or slow), measurement of an SpO2 level, and auscultation of both lungs for wheezing, crackles, rhonchi, or distant or absent sounds.  A low oxygen level should be immediately addressed with supplemental oxygen before moving forward.  The patient’s breathing rate and lung sounds can be very helpful in discovering the diagnosis and guiding treatment.  Lastly, circulation should be assessed.  Check the heart rate, blood pressure, peripheral pulses, skin color and temperature, and evaluate for any sites of hemorrhage.  The presence of hypotension or tachycardia should be addressed appropriately based on the presumed cause.  After the primary assessment (“ABCs”) and initial treatment actions, a more detailed history and physical exam should be conducted. 

Pertinent causes of shortness of breath for the emergency practitioner to know are outlined in the chart below. 

 

 

Select Causes of Shortness of Breath (Dyspnea)

Pulmonary

 

Tension pneumothorax, pneumonia, empyema, pleural effusion, pulmonary edema, asthma, COPD

Cardiovascular

 

Acute coronary syndrome (i.e., STEMI), pulmonary embolism, cardiac tamponade, Decompensated Congestive Heart Failure (acute pulmonary edema)

Endocrine

 

Diabetic ketoacidosis (Kussmaul breathing)

Toxicologic

 

Salicylate overdose, or any ingestion that causes a severe metabolic acidosis

Neurologic

 

Intracranial hemorrhage, Stroke, Spinal cord injury, Guillain-Barre syndrome, Myasthenia Gravis crisis (myasthenic crisis)

Hematologic

 

Severe anemia (i.e., GI bleeding, trauma, miscarriage, post-partum hemorrhage, ruptured ectopic pregnancy)

Musculoskeletal

 

Rib fracture, flail chest

Psychiatric

 

Anxiety, Panic attack

Airway Problem

Foreign body, epiglottitis, anaphylactic shock (laryngeal swelling), expanding neck hematoma

This patient presents to the Emergency Department with 1 day of acute onset shortness of breath with pleuritic chest pain. Her exam shows tachycardia, tachypnea, a normal glucose level, and clear lungs bilaterally.  The chest X-ray provided shows no acute abnormalities.  Pneumothorax (Choice A) can present as acute onset shortness of breath with pleuritic chest pain, but the chest X-ray shows no signs of pneumothorax.  Diabetic Ketoacidosis (Choice B) can cause shortness of breath, and this patient has a history of diabetes.  However, the patient lacks other symptoms of this condition such as hyperglycemia (often glucose >250mg/dL (13.8mmol/L)), polydipsia, polyphagia, polyuria, or vomiting.  This makes DKA an unlikely diagnosis. Pneumonia (Choice D) is also unlikely as there is no fever, no cough, and no infiltrate seen on the chest X-ray provided.  Pulmonary Embolism (Choice C) is the most likely diagnosis and the correct answer.

The most common presenting symptom in pulmonary embolism (PE) is shortness of breath.  Other symptoms seen in PE include chest pain worsened by deep inspiration, unilateral leg swelling, hemoptysis, and fever.  Risk factors for PE include immobility, recent surgery or hospitalization, trauma, or hypercoagulable states (malignancy, estrogen use, Factor V Leiden mutation, antiphospholipid syndrome).  Common signs of PE on physical examination include tachycardia (common), fever (less common), and sometimes hypotension in a massive PE causing obstructive shock.  The gold standard for PE diagnosis is CT pulmonary angiography, but D-dimer blood testing, bedside ultrasound, and other tests can be useful in PE diagnosis.  The mainstay of treatment in PE is anticoagulation.  Unfractionated heparin and low molecular weight heparin are equally effective in PE.  Surgical treatment (embolectomy) and thrombolysis (alteplase) are other treatment options fo larger PEs.

References

Cite this article as: Joseph Ciano, USA, "Question Of The Day #81," in International Emergency Medicine Education Project, March 25, 2022, https://iem-student.org/2022/03/25/question-of-the-day-81/, date accessed: October 6, 2022

Seizure: Lethal Dissection

Lethal Dissection Seizure

Case Presentation

A 49-year old female without any co-morbidities presented to the emergency department (ED) with seizures. On arrival, she was in a postictal state.

She had recently visited a local hospital with complaints of severe dysmenorrhea and low back pain. The attenders informed us that she was very sleepy and weak at that time, was treated for pain and given tranexamic acid, and sent home. The next day, she had one episode of Generalized Tonic-Clonic Seizure, and she arrived in our ED in a postictal phase. She vomited twice in the ED.

Her vitals were as follows: 

  • Blood pressure (BP): 160/100 mmHg.
  • Heart rate (HR): 22/min
  • Peripheral capillary oxygen saturation (SPO2): 98% on room air
  • General Random Blood Sugar (GRBS): 233 mg/dl
  • Glasgow Coma Scale (GCS): E2V5M6

Her examination was as follows:

  • The patient was drowsy but arousable. 
  • Pupils bilateral reacting to light. No anisocoria.
  • CNS examination could not be completed as the patient was drowsy.
  • A normal pattern of breathing. The respiratory examination was normal.
  • The abdomen was soft, symmetric, and non-tender without distention.

Point-of-care ultrasound (POCUS) showed a flap in the abdominal aorta. (See Figure 1 and 2 for transverse and longitudinal views of the aorta, respectively) Upon this finding, cardiac surgery and neurology consultations were sought.

Transverse section of the abdominal aorta showing a flap.
https://ibb.co/N6VyMD8

Image shows transverse section of the abdominal aorta showing a flap.

Abdominal aorta showing a flap
https://ibb.co/wwkYHJY

Image shows abdominal aorta showing a flap.

The laboratory results were as follows:

  • D-dimer: 1192 ng/ml
  • Haemoglobin (Hb): 10 g/dl
  • The international normalized ratio (INR): 1.25
  • Platelets: 260000 per mcL
  • Total leucocyte count (TLC): 22000 cells/mm3
  • Creatinine :1.6 mg/dl.

Meanwhile, the patient was suffering multiple seizure-like episodes, characterized by staring, deviation of the mouth, and irregular limb movements, but these episodes lasted for few minutes and ended without the postictal phase. The patient was drowsy but obeyed commands and did not have any recollection of those few minutes.

Head computed tomography (CT) showed no infarct or bleeding. It was normal.

CT angiogram and aortogram revealed that the patient had Stanford Type A aortic dissection with the flap extending to the entire left subclavian artery, with severely occluding filling defects and thrombosis of the false lumen into bilateral common carotid arteries (See Figure 3, 4 and 5). On the other end, the dissection extended to the common iliac arteries (See Figure 6).

CT Aortogram showing bilateral common carotid artery filling defects
https://ibb.co/M6TMqpq

Image shows CT Aortogram showing bilateral common carotid artery filling defects

And on the other loose of the string the dissection was extending till the common iliac arteries.
Ascending and descending aortic dissection
https://ibb.co/n8Rbdvm

Image shows ascending and descending aortic dissection

Dissection of the common iliac artery before bifurcation
https://ibb.co/jVjL0qJ

Image shows dissection of the common iliac artery before bifurcation.

 

Management

Initially, the patient was treated symptomatically by anti-epileptics and analgesics. After the cardio-thoracic and vascular surgeon consultations, we decided to airlift the patient to a higher centre as our hospital was tertiary care and there were no grafts for the urgent repair of the extensive aortic dissection. We intubated the patient for secure transportation. However, we learned that the patient expired in the higher centre before reaching the operating room.

Discussion

Before I shed light on the important part of this discussion, I know that the outcome of this case was unfortunately grave. However, I chose this case because of it.

In this case, the patient had low back pain in her previous hospital visit. However, she was sent home with symptomatic management, implying that it could have been addressed more carefully. She visited our ED one day later, and POCUS let us diagnose the dissection in 15 minutes, which was confirmed by a CT aortogram within 40 minutes. After consultations and finding the available facility, we airlifted the patient to a higher centre for urgent repair, but the patient could not make it to the operating room.     

We all know acute aortic dissection is the most common life-threatening disorder affecting the aorta. Over the first several hours, the mortality rate increase up to 1% per hour; therefore, early intervention is critical (1). In our case, the involvement of bilateral carotid arteries caused seizure-like episodes and altered mental status. Also, studies show that patients with similarly located dissections may experience neck pain, transient ischemic attacks (TIA), cerebral ischemia, transient monocular blindness and subarachnoid haemorrhage (SAH) but not seizure(2). In our case, the global hypo-perfusion caused recurrent TIAs, which resembled seizure-like clinical episodes. That’s why emergency physicians should be vigilant about the underlying causes of seizure-like activities, even if altered mental status similar to postictal state is present, especially if the patient does not have a history of seizures and the complaints are unclear. Keep the aortic dissection in mind as a differential. Also, I cannot stress the use of POCUS in the ED enough. It is a game-changer, and in our case, it detected a lethal disease successfully.

Learning Points

  1. Never ignore back pain that does not subside after adequate pain management.
  2. POCUS is always a game-changer. It saves a lot of time and lives, as in my case.
  3. Seizures or not, you must keep a high suspicion for lethal vascular diseases. Remember the basics: If unclear, go back to history.
  4. Once you confirm an aortic dissection, never delay treatment because time = life.
  5. Never ever send a patient back home unless you are completely sure about the cause of the presenting symptom. Over investigating is ok when compared to under investigating, when it might cost a life.

References and Further Reading

  1. Braverman AC. Acute aortic dissection: clinician update. Circulation. 2010;122(2):184-188. doi:10.1161/CIRCULATIONAHA.110.958975
  2. Debette S, Grond-Ginsbach C, Bodenant M, et al. Differential features of carotid and vertebral artery dissections: the CADISP study. Neurology. 2011;77(12):1174-1181. doi:10.1212/WNL.0b013e31822f03fc
Cite this article as: Naveen Paila, India, "Seizure: Lethal Dissection," in International Emergency Medicine Education Project, November 15, 2021, https://iem-student.org/2021/11/15/seizure-lethal-dissection/, date accessed: October 6, 2022

Out of Proportion: Acute Leg Pain

Case Presentation

A 48-year-old male, with history of hypertension and diabetes and prior intravenous drug use (now on methadone) presents with acute onset right leg pain from his calf to the ankle, that woke him from sleep overnight. The pain has been constant, with no modifying or relieving factors. He hasn’t taken anything other than his daily dose of methadone. He hasn’t had any fevers or chills and denies any recent trauma or injuries.

Any thoughts on what else you might want to ask or know?

  • Any recent travel or prolonged immobilization?
  • Have you ever had a blood clot?
  • Are you on any blood thinners?
  • Have you used IV drugs recently?
  • Any numbness or weakness in your leg?
  • Any associated rash or color change?
  • Any back pain or abdominal pain? Any bowel or bladder incontinence?
  • Any recent antibiotics (or other medication changes)?
  • Have you ever had anything like this before?
[all of these are negative/normal]

Pause here -- what is your initial differential diagnosis looking like?

  • Deep vein thrombosis
  • Superficial vein thrombosis
  • Pyomyositis
  • Necrotizing fasciitis
  • Muscle sprain or tear
  • Arterial thromboembolism
  • Bakers cyst
  • Achilles tendonitis, Achilles tendon rupture

What are some key parts of your targeted physical exam?

  • VITAL SIGNS! [BP was slightly hypertensive, and he is slightly tachycardic, normothermic]
  • Neurologic exam of the affected extremity (motor and sensory)
  • Vascular exam of the affected extremity (femoral/popliteal/posterior tibialis/dorsalis pedis)
  • Musculoskeletal exam including ranging the hip, knee, ankle and palpating throughout the entire leg
  • Skin exam for signs of injury or rashes etc.
  • Consider a cardiopulmonary and abdominal exam, particularly the lower abdomen

On this patient’s exam, he was overall uncomfortable appearing and had slight tachycardia (110s, EKG shows normal sinus rhythm), normal cardiopulmonary exam, normal abdominal exam. He had a 2+ right femoral pulse and faintly palpable DP pulse that had a good biphasic waveform on doppler. His hip/knee/ankle all have painless range of motion. The compartments are soft in the upper and lower leg. He does have some diffuse calf tenderness and the medial aspect feels slightly cool compared to the contralateral side, but his foot is warm and well perfused. There isn’t any spot that is most tender. There is no rash, no crepitus, no bullae or bruising or other evidence of injury.

What diagnostic studies would you like to send?

  • CBC, BMP
  • CPK, lactate
  • DVT ultrasound?
  • Anything else?

What treatments would you like to provide?

  • Analgesia (mutli-modal)?
  • Maybe a bolus of IV fluids to help with the tachycardia?

The patient is having a lot of pain despite already getting NSAIDs, acetaminophen, and a dose of morphine. You decide to re-medicate the patient with more morphine and send him for DVT ultrasound. As soon as he gets back, he’s frustrated that you still haven’t treated his pain “at all” and he really does look uncomfortable and in a lot of pain.  You start to wonder if he’s faking it giving his history of IV drug use.

His DVT ultrasound comes back as normal. The lab work is also coming back and unrevealing. A normal CBC, metabolic panel, normal CPK, normal lactate. His pain is not really improving. You reexamine the leg, and the exam is unchanged. It really seems like his pain is out of proportion to the exam.

Pain is out of proportion to the exam should catch your attention every time. While we always need to keep malingering and less emergent causes for pain that seems to be more than expected in the back of our minds. But! Several emergent diagnoses have patients presenting in pain in a way that doesn’t fit what you can objectively identify as a cause. Diagnoses like compartment syndrome and mesenteric ischemia can be erroneously dismissed by emergency providers, and it is crucial you don’t just stop looking for the cause of pain out of proportion. In fact, it’s important you dig in deeper and rule out all potentially life and limb threatening causes.

In this case, the pain was recalcitrant to multiple doses of IV opiates and several other modes of treatment. The patient was getting so frustrated that he pulled out his IV and threatened to leave the ED. After talking with him further, he agreed to stay and a new IV was placed, more pain medication given, and a CTA with lower extremity run-off was performed, which showed the acute thrombus of the proximal popliteal artery, just below the level of the knee.

He was started on a heparin infusion and vascular surgery was consulted; the patient was admitted from the ED and taken for thrombectomy. No source of embolism was identified, and his occlusion was presumed to be thrombotic (most commonly from a ruptured atheromatous plaque leading to activation of the coagulation cascade), with particular attention to his history of diabetes and hypertension raising his risk for this. He had a fair amount of collateralization from other arteries around the occlusion, such that his foot wasn’t cold, and he had a doppler-able DP pulse. 

Remember

Go with your gut and don’t minimize pain that is out of proportion to the exam. Keep hunting for a reasonable explanation or you may miss a life or limb threatening cause of an atypical emergency presentation.

Further Reading

Deep Vein Thrombosis (DVT)

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

Read More »

Acute Mesenteric Ischemia

by Rabind Antony Charles Case Presentation A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with

Read More »

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Read More »
Cite this article as: J. Austin Lee, USA, "Out of Proportion: Acute Leg Pain," in International Emergency Medicine Education Project, October 18, 2021, https://iem-student.org/2021/10/18/acute-leg-pain/, date accessed: October 6, 2022