Category: Clinical Images

Question Of The Day #21

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod21

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Watch the cardiac monitor for a rhythm change
  • B) Continue chest compressions
  • C) Administer intravenous adrenaline
  • D) Check for a pulse

This patient experienced a witnessed cardiac arrest at home, after which pre-hospital providers initiated cardiopulmonary resuscitation (CPR, or “chest compressions”) and Advanced Cardiovascular Life Support (ACLS). ACLS includes the tenets of Basic Life Support (BLS), such as early initiation of high-quality CPR at a rate of 100-120 compressions/minute, compressing the chest to a depth of 5 cm (2 inches), providing 2 rescue breaths after every 30 compressions (30:2 ratio), avoiding interruptions to CPR, and allowing for adequate chest recoil after each compression. In the ACLS algorithm, intravenous epinephrine is administered every 3-5 minutes and a “pulse check” is performed after every 2 minutes of CPR. The patient’s cardiac rhythm, along with the clinical history, helps decide if the patient should receive defibrillation (“electrical shock”) or additional medications. The ACLS algorithm divides management into patients with pulseless ventricular tachycardia (pVT) or ventricular fibrillation (VF) and patients with pulseless electric activity (PEA) or asystole.

The cardiac rhythm seen during the pulse check for this patient is a wide complex tachycardia with a regular rhythm. In the setting of cardiac arrest, chest pain prior to collapse, and a history of acute coronary syndrome, ventricular tachycardia is the most likely cause. The ACLS algorithm advises unsynchronized cardioversion at 150-200 Joules for patients with pVT or VF. Watching the cardiac monitor for a rhythm change (Choice A) or checking for a pulse (Choice D) are not recommended after defibrillation. A major priority of both BLS and ACLS is to avoid interruptions to CPR, so the best next step in management is to continue CPR (Choice B) after defibrillation. Administration of intravenous adrenaline (Choice C) is helpful for cardiac arrests to initiate shockable rhythm and should be repeated every 3-5 minute or every 2 cycle of CPR, particularly valuable in asystole patients. Calcium gluconate is another drug that can be used in patients with hyperkalemia and indicated in a patient with known kidney disease, missed hemodialysis sessions, or a history of usage of medications that can cause hyperkalemia. Magnesium can be used for patients who show polymorphic VT, particularly Torsades de Pointes. The next best step in this scenario is to continue CPR, regardless of the etiology of the cardiac arrest. Correct Answer: B.

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References

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Question Of The Day #20

question of the day
~ Joseph Ciano, USA ~ Leave a comment
cod20
608 - Figure3 - pericardial effusion - ECG

Which of the following is the most appropriate next investigation for this patient’s condition?

  • A) Arterial blood gas
  • B) Bedside cardiac sonogram
  • C) Chest radiography
  • D) CT pulmonary angiography

This patient’s EKG demonstrates alternating amplitudes of QRS complexes, a phenomenon known as electrical alternans. This is caused by the heart swinging back and forth within a large pericardial effusion. The patient is tachycardic and borderline hypotensive, which should raise concern over impending cardiac tamponade. The next best investigation to definitively diagnose a large pericardial effusion with possible tamponade would be a cardiac sonogram (Choice B). This investigation could also guide treatment with pericardiocentesis in the event of hemodynamic decompensation and the development of obstructive shock. Other EKG signs of a large pericardial effusion are diffusely low QRS voltages and sinus tachycardia. Chest radiography (Choice C) may show an enlarged cardiac silhouette in this case and evaluate for alternative diagnoses (i.e. pneumothorax, pleural effusions, pneumonia, atelectasis), however, cardiac echocardiography is the best next investigation. CT pulmonary angiography (Choice D) would demonstrate the presence of a pericardial effusion along with differences in cardiac chamber size indicative of tamponade. Still, bedside cardiac sonogram is a faster test that prevents a delay in diagnosis. Sending a potentially unstable patient for a CT scan may also be dangerous. Arterial blood gas testing (Choice A) has no role in diagnosing pericardial effusion or cardiac tamponade. Correct Answer: B

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References

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Question Of The Day #19

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod19
52 - Perforated Viscus

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

  • A) Pulmonary embolism
  • B) Pancreatitis
  • C) Peptic ulcer disease
  • D) Gastroesophageal Reflux Disorder

All patients who present to the emergency department with chest pain should be evaluated for the top life-threatening conditions causing chest pain. Some of these include myocardial infarction, pulmonary embolism, esophageal rupture, tension pneumothorax, cardiac tamponade, and aortic dissection. Many of these diagnoses can be ruled-out or deemed less likely with a detailed history, physical exam, EKG, and sometimes imaging and blood testing. This patient presents with vague, burning chest pain, nausea, and tachycardia on exam. Pulmonary embolism (Choice A) is hinted by the patient’s tachycardia, but the patient has no tachypnea or risk factors mentioned for PE. Additionally, the chest X-ray findings demonstrate an abnormality that can explain the patient’s symptoms. Pancreatitis (Choice B) and Gastroesophageal reflux disorder (Choice D) are also possible diagnoses, especially with the location and description of the patient’s pain. However, Chest X-ray imaging offers an explanation for the patient’s symptoms. The patient’s Chest X-ray demonstrates the presence of pneumoperitoneum. In the presence of NSAID use, this radiological finding raises concern over a perforated viscus from advanced peptic ulcer disease (Choice C). Peptic ulcer disease (PUD) is most commonly caused by Helicobacter pylori infection, but NSAIDs, iron supplements, alcohol, cocaine, corrosive substance ingestions, and local infections can cause PUD. PUD is a clinical diagnosis which can be confirmed visually via endoscopy. The treatment for PUD includes initiation of a proton pump inhibitor (H2-receptor blockers are 2nd line), avoiding the inciting agent, and H.pylori antibiotic regimens in confirmed H.pylori cases. The treatment for a perforated peptic ulcer with pneumoperitoneum is IV fluids, IV antibiotics, Nasogastric tube placement, and surgical consultation for repair.

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References

[cite]

You may want to read these

Acute Coronary Syndrome – https://iem-student.org/acute-coronary-syndome-acs/ 

Acute Management Of Supraventricular Tachycardias – https://iem-student.org/2020/01/10/acute-management-of-supraventricular-tachycardias/

Deadly ECG Patterns – 5 Can’t Miss ECG Findings – https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/

Cardiac Monitoring – https://iem-student.org/cardiac-monitoring/

Question Of The Day #17

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod17

Which of the following is the most likely cause for the patient’s elevated cardiac troponin level in the emergency department?

  • A) Atrial fibrillation with rapid rate
  • B) Patient age
  • C) Sepsis
  • D) Acute coronary syndrome

Elevated cardiac troponin levels, or troponinemia, are one sign that the myocardium may be infarcting or under some type of stressful condition. Cardiac troponin levels are assessed in conjunction with the clinical history, physical exam, EKG, and another laboratory testing in deciding if troponinemia is due to cardiac ischemia or another condition. Conditions associated with elevated cardiac troponin levels include cardiac ischemia (i.e. STEMI, NSTEMI), cardiac contusion, cardiac procedures, congestive heart failure, renal failure, aortic dissection, tachy- or bradyarrhythmias, rhabdomyolysis with cardiac injury, Takotsubo syndrome, pulmonary embolism, acute stroke, myocarditis, sepsis, severe burns, extreme exertion, and other conditions. It is unlikely that this patient had elevated troponin levels from Acute coronary syndrome (Choice D) as her cardiac catheterization results showed no significant occlusive lesions in the coronary arteries. D-Dimer levels do increase with patient age, but cardiac troponin levels do not increase with patient age (Choice B). Sepsis (Choice C) is a cause for elevated troponin levels, but this patient has no clinical signs or sepsis symptoms. Atrial fibrillation with a rapid rate (Choice A) is the most likely cause of this patient’s elevated troponin level. Correct Answer: A 

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References

[cite]

You may want to read these

Acute Coronary Syndrome – https://iem-student.org/acute-coronary-syndome-acs/ 

Acute Management Of Supraventricular Tachycardias – https://iem-student.org/2020/01/10/acute-management-of-supraventricular-tachycardias/

Deadly ECG Patterns – 5 Can’t Miss ECG Findings – https://iem-student.org/2019/11/22/deadly-ecg-patterns-5-cant-miss-ecg-findings/

Cardiac Monitoring – https://iem-student.org/cardiac-monitoring/

Question Of The Day #16

question of the day
~ Joseph Ciano, USA ~ Leave a comment
qod16

Which of the following is the most appropriate next step in management for this patient’s condition?

  • A) Consult general surgery for exploratory laparotomy
  • B) Apply needle decompression of the chest
  • C) Apply Pericardiocentesis
  • D) Order CT scan of chest, abdomen, and pelvis

This patient sustained a penetrating traumatic injury to the left chest and presented to the emergency department with hemodynamic instability (tachycardic and hypotensive). Some differential diagnoses to consider on arrival include tension pneumothorax, cardiac tamponade, aortic injury, or aero-digestive tract injury. Prior to taking a detailed history on any trauma patient, a primary survey should be performed. The goal of the primary survey in a trauma patient is to identify and treat any life-threatening injuries as soon as possible. The primary survey is also known as the “ABCs.” Sometimes it is referred to as the “ABCDEFs.” This acronym stands for Airway, Breathing, Circulation, Disability, Exposure, and FAST exam (How to learn eFAST exam for free). Each letter is addressed and assessed in the order they exist in the alphabet. This creates a methodical, algorithmic approach to assist the practitioner in assessing the trauma patient for life-threatening injuries. The sonographic view shown in this question is the subxiphoid (cardiac) view and demonstrates the presence of free fluid. Free fluid on ultrasound appears black, or “anechoic” and is assumed to be blood in the setting of trauma. The free fluid is highlighted by red stars in the image below. The collapse of the right ventricle is shown by the yellow arrow in the below image.

cardiac tamponade - explained
SS Video 3 Pericardial Tamponade

In conjunction with hemodynamic instability and a history of penetrating chest trauma, this sonographic view strongly supports the diagnosis of cardiac tamponade. Consulting the general surgery team for exploratory laparotomy (Choice A) would be the correct course of action for a patient with hemodynamic instability and free fluid on the other abdominal views of the FAST exam. Needle decompression of the chest (Choice B) would be the correct initial treatment for a tension pneumothorax. The patient described in the case has clear bilateral lung sounds, no tracheal deviation mentioned, normal O2 saturation on room air, and sonographic demonstration of cardiac tamponade. A CT scan of the chest, abdomen, and pelvis (Choice D) would be indicated in this patient if he had normal vital signs and no free fluid on the FAST exam. A pericardiocentesis (Choice C) is the most appropriate next step in the management of this patient with cardiac tamponade to relieve signs of obstructive shock. It should be noted that this procedure has limitations and is not always effective. Pericardiocentesis is a temporizing treatment with pericardiotomy being the definitive therapy. Blood in an acute hemopericardium may clot and be unable to be aspirated with a large-bore needle. The procedure may injure surrounding organs, such as the liver, intestines, or heart itself. Ultrasound-guidance should be used whenever possible to avoid injury to surrounding organs. Emergent thoracotomy to relieve the cardiac tamponade should be performed on any patient with confirmed cardiac tamponade and cardiac arrest in the Emergency Department. Correct Answer: C

References

[cite]

You may want to read these

Pulmonary Embolism – https://iem-student.org/pulmonary-embolism/

Clinical Decision Rules – https://iem-student.org/clinical-decision-rules/

Question of The Day #6 – https://iem-student.org/2020/07/31/question-of-the-day-6/

Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations

~ Murat Yazici, Turkey ~ Leave a comment

Patients with hypotension or shock have high mortality rates, and traditional physical exam techniques can be misleading. Diagnosis and initial care must be accurate and prompt to optimize patient care. Ultrasound is ideal for evaluating critically ill patients in shock, and ACEP guidelines now delineate a new category of ultrasound (US)– “resuscitative.” Bedside US allows for direct visualization of pathology and differentiation of shock states (1). The RUSH is one of the most commonly used protocols for this purpose.

The RUSH exam involves a 3-part bedside physiologic assessment simplified as “the pump,” “the tank,” and “the pipes” (2).

Rush steps and probs
Rush pump
Rush Tank
Rush pipes

Pump

Rush pump
RUSH parasternal long axis
RUSH parasternal long axis
RUSH parasternal long axis
RUSH parasternal short axis
RUSH parasternal short axis
RUSH subcostal
RUSH apical

Tank

Rush Tank
Rush IVC
Rush intraperitoneal fluid
Rush intraperitoneal fluid
Rush intraperitoneal fluid
Rush lung
Rush lung

Pipes

Rush pipes
Rush pipes
Rush pipes
Rush pipes

References and Further Reading

  1. By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
  2. Seif D1, Perera P, Mailhot T, Riley D, Mandavia D. “Bedside ultrasound in resuscitation and the rapid ultrasound in shock protocol” Crit Care Res Pract. 2012;2012:503254.
  3. https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
  4. https://iem-student.org/rush/
  5. https://iem-student.org/efast/
[cite]

Lower Extremity Deep Venous US Imaging – Illustrations

lower extremity us illustrations
~ Murat Yazici, Turkey ~ Leave a comment

Ultrasound evaluation for deep venous thrombosis (DVT) is one of the 11 core ultrasound applications for emergency physicians as listed in the 2008 American College of Emergency Physicians guidelines (1). Because ultrasound applications started to be implemented into medical school curriculum in many countries, learning basic ultrasound applications as early as possible will benefit medical students and junior residents. In this post, I will share lower extremity venous ultrasound illustrations with you. 

Indications

The clinical indications for performing a lower venous ultrasound examination is the suspicion of a lower extremity DVT in a swollen or discoloured leg. 

Transducer

Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.

lower extremity venous ultrasound - linear transducer

Remember Risk Factors of DVT

  • Age > 60
  • Cancer
  • Central venous catheter/insertion
  • Genetic causes of hypercoagulopaty
  • History of DVT
  • Immobilization
  • Obesity
  • Pregnancy
  • Smoking
  • Trauma or recent surgery
  • Use of birth control pills or hormone replacement therapy

Wells Score for Deep Vein Thrombosis

CriteriaScore
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)
1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia1
Localized tenderness along the distribution of the deep venous system1
Entire leg swollen1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)1
Pitting edema confined to the symptomatic leg1
Non varicose collateral superficial veins1
Previously documented DVT1
Alternative diagnosis at least as likely as DVT1
DVT evaluation algorithm
Select a high-frequency linear transducer, (5-10) MHz transducer since it provides optimal venous copmression and image resolution.
sectional anatomy of lower extremity veins

Normal DVT Ultrasound Findings

normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings
normaL DVT ULTRASOUND findings

Reference and Further Reading

  1. American College of Emergency Physicians. Emergency ultrasound guidelines 2008. http://www.acep.org/WorkArea/DownloadAsset.aspx?ID=32878. February 2012.

Note: Visual drawings are inspired by the Point-of-Care ULTRASOUND Book.

[cite]

You may like to view these resources too

A simple cellulitis of the foot?

a simple cellulitis of the foot?
~ Anthony Rodigin, USA ~ Leave a comment

Case Introduction

A 47 year old woman comes to a community ED complaining of pain and redness in her right foot developing quickly over two days. She denies any trauma and otherwise feels well. She is not sure, but may have had a “sore” near her toes that has already healed. Patient has diabetes but is normoglycemic. She has no prior history of cellulitis, joint infections or gout. There is no history of immunocompromise, including steroids, or any IV drug use. All vitals are within normal limits and review of systems is negative for fever, chills, respiratory or gastrointestinal symptoms.

On exam, there is generalized edema, erythema and tenderness, but no tenderness out of proportion, and no open sores or ulcerations. A sub-acute appearing callus is apparent on the plantar surface opposite fifth and fourth distal metatarsals. The ankle joint is tender but less so than the foot, and ranging it does not elicit more pain than at baseline. Distal sensation, pulses and toe motion are intact, though capillary refill is slightly delayed.

cellulitis - foot
cellulitis - foot 2

Initial Questions

  • What would be your plan?  And when and how would you present this case to an attending?
  • Are labs indicated, which ones, and what are they expected to show?  Will that change your plan?
  • Any imaging? Your choices range from nothing, to bedside US to look for an abscess, to XR, CT scan or even an MRI, if available.
  • Is she a candidate for oral antibiotics and discharge? If so, what sort of follow up does she need?
  • Is there any benefit of IV antibiotics if the patient is going to go home?
  • What is the worst case scenario here that may not be apparent? Is there any threat to life, limb or both?

Basic labs obtained are unremarkable and patient is receiving IV broad spectrum antibiotics, including MRSA coverage. Plain films are obtained, and there is some concern for small air pockets in the soft tissues.

cellulitis - xray 2
cellulitis - xray

A phone consultation with podiatry is obtained. A decision is made to take the patient to the OR on the same evening. No further imaging or diagnostic studies are advised.

Additional Questions

  • What if there is no podiatry, and your general or orthopedic surgeon does not handle foot cases? What if there is no surgical coverage at all?
  • Would there be a role for a limited ED I&D or needle aspiration in this case?
  • Would you transfer this case? How do you justify it, if all the labs and vitals are normal?

After the callus is taken off in the OR, large amount of frank pus is obtained that tracks all the way to the third metatarsal. A debridement is performed, and long term antibiotics with close follow up are needed. Overall impression was that while no necrotizing infection was found, any further delay would have risked a trans-metatarsal amputation (at the least).

Key Points

While we do not have room for a lengthy discussion on differentiating plain cellulitis from “other”, it is worthwhile to note several things:

  • Do not get locked in onto cellulitis as the diagnosis. Abscesses, necrotizing infections and septic joints need to be considered and ruled out at all times.
  • Susceptible populations such as diabetics and IV drug users are easy.  But the rapidity of symptom development is just as important in any population.
  • Beware even chronic appearing calluses as masking places for pus and as barriers to its natural drainage.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • More advanced imaging is not always the answer. Careful exam, plain films and the OR is often the right answer too. Labs are overrated. Period.
  • To I&D or not to I&D is often the question. Good news is that more often than not I&D is the right answer. There is a reason you have already thought of it. You are in the ED - the last line of defense for many patients. Pus needs to come out. The surgeons are not the only guys with knives. Don’t let yourself or anyone talk you out of it. For the tremulous patients (and providers), there is ketamine.
[cite]

Further Reading

Salter-Harris Fractures

salter harris
~ Mohammad Anzal Rehman, UAE ~ Leave a comment

Case Presentation

You are a medical student doing your first clinical shift as part of your Emergency Medicine rotation. A 9-year-old boy is brought in by his father after an injury to his left hand approximately 1 hour back. As explained by the father, the child was playing at home with his elder brother when his left index finger became caught in between a door that had quickly slammed shut. Following the injury, the child was reported to be crying due to severe pain, but had no lacerations or other associated injuries. He was rushed to the hospital and presented in the ED as an anxious, weeping boy who held out his left index finger and pointed to the tip as the region of maximal pain. Mild swelling was noted at the distal interphalangeal joint as well as at the tip of the affected finger. After appropriate analgesia was initiated, the child was sent to the Radiology department for X-ray imaging. The images obtained by the department are shown below in Figures 1.1 and 1.2.

Figure 1.1
Figure 1.1
Figure 1.2
Figure 1.2

Findings

Due to the lack of ideal positioning and suboptimal cooperation from the child and his parent, the radiology technician reports back to you stating that the best images they could obtain were the ones displayed above. Although unclear, you can confidently identify a small break in the bone at the base of the distal phalanx. You mention to the father that you see a fracture on the X-ray and report back to your Attending Physician. 

The Attending Physician decides to take a break from his morning coffee and utters the dreaded question: “What kind of fracture is this?” You try to recall a lecture you had about Salter-Harris fractures but cannot recall the classification of these fractures. As if on cue, the father of the patient finds you shuffling your weight in front of the Attending Physician and asks: “You said he has a fracture, will he have to get surgery for his finger?”

“What kind of fracture is this?”

Salter-Harris Fractures

Salter-Harris Fractures refer to fractures that involve the growth plate (physis). Therefore, these fractures are applicable specifically to the pediatric population, occurring most often during periods of rapid growth (growth spurts) when the growth plate is at its weakest, close to age ranges where children tend to participate in high-risk activities (11-12 in girls and 12-14 in boys) [1].

Originally described in 1963 by Dr Robert Salter and Dr Robert Harris [2], the now infamous Salter-Harris fractures are classified by the region of bone that is affected. Figure 2 displays the gross anatomy of a normal distal phalanx similar to the picture we examined in the X-ray, labelled to reflect the different areas of the bone relative to each other. The types of fractures that can occur are outlined below.

SALTER HARRIS ANATOMY
Figure 2

  • Type I Salter-Harris Fractures (Slipped)

    Type I fractures occur when a longitudinal force is applied across the physis, resulting in a displacement (“slip”) of the epiphysis from the metaphysis. Though relatively infrequent (5%), suspicion of this fracture is raised when the epiphysis is seen to either be displaced to the side of its original position relative to the metaphysis or when the gap between the two segments is widened.

Salter-Harris Type I
Salter-Harris Type I

  • Type II Salter-Harris Fractures (Above)

    Type II fractures are the most common (75%) of the Salter-Harris fractures. As with our patient above, this fracture only involves structures “Above” the epiphysis (Metaphysis + Physis/growth plate) with virtually no fracture or displacement of the epiphysis itself. Fortunately, type I and most type II fractures can be managed conservatively with cast immobilization and splinting.

Salter-Harris Type II
Salter-Harris Type II

  • Type III Salter-Harris Fractures (Lower)

    Type III fractures involve both the physis and the epiphysis. Although relatively uncommon (10%), the involvement of the epiphysis and consequent disruption of the growth plate makes this an intra-articular fracture that usually requires surgical fixation.

Salter-Harris Type III
Salter-Harris Type III

  • Type IV Salter-Harris Fractures (Through)

    Continuing the trend of worse outcomes with higher classification types, Type IV fractures involve all three layers (metaphysis, physis and epiphysis) and thus harbor more adverse outcomes and risks, with management primarily consisting of operative internal fixation. Similar to Type III fractures, this is an intra-articular fracture and also occurs at a similar rate of 10%.

Salter-Harris Type IV
Salter-Harris Type IV

  • Type V Salter-Harris Fractures (Rammed/Crushed)

    The rarest of all the Salter-Harris fractures, type V fractures occur due to high impact compression of the growth plate. Potential disruption of the germinal matrix and compromised vascular supply to the growth plate can lead to growth arrest.

Salter-Harris Type V
Salter-Harris Type V

A convenient method to recall the Salter-Harris classifications is outlined below using the mnemonic “SALTR”

Salter-Harris Classification
Salter-Harris Classification

Case Resolution

You ascertain the patient’s fracture to be a type II Salter-Harris fracture, justifying your answer to the Attending Physician by pointing out that the affected region in the X-ray is limited to the metaphysis and physis with no epiphyseal involvement. Recognizing the potential for parental misconceptions surrounding the diagnosis of fractures in pediatric patients [3], you approach the father and explain that, though there is a fracture present, there is likely no need for any surgical intervention. You advise that the left index finger will be immobilized using a splint and further elaborate on the unlikelihood of this injury to manifest any long-term developmental or growth arrest in the affected region.

References and Further Reading

  1. Levine RH, Foris LA, Nezwek TA, et al. Salter Harris Fractures. [Updated 2019 Aug 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan
  2. Salter, Robert B.; Harris, W. Robert: Injuries Involving the Epiphyseal Plate, The Journal of Bone and Joint Surgery (JBJS): April 1963 – Volume 45 – Issue 3 – p 587-622
  3. Sofu H, Gursu S, Kockara N, Issin A, Oner A, Camurcu Y. Pediatric fractures through the eyes of parents: an observational study. Medicine (Baltimore). 2015;94(2):e407. doi:10.1097/MD.0000000000000407
[cite]

I woke up like that! – Bilateral Shoulder Pain

bilateral shoulder pain
~ Shaza Karrar, UAE ~ Leave a comment

Case Presentation

A 35-year-old male presented to fast track complaining of bilateral severe shoulder pain for one-day duration. He reports waking up like that, and not being able to move his shoulders much due to the pain.

He denied any recent falls, injuries, or direct trauma to his shoulders. He also denied any fever, rashes, skin changes, headaches, numbness or weakness. No further findings found upon review of systems. Past medical history revealed a history of epilepsy. Otherwise, he’s not on any medications and denies any known allergies.

Physical examination showed slim male, with flattened anterior shoulders and normal inspection of the skin overlying his shoulders. He had internally rotated upper extremities, flexed elbows, and arms held in adduction. Upon attempts on any passive or active test of the range of motion, he experienced reluctance and pain on external rotation or abduction of his shoulders. Bilateral Shoulder X-rays were obtained.

shoulder dislocation and fracture 1
shoulder dislocation and fracture 2

This patient had bilateral posterior shoulder dislocation, with associated fractures.

    • Posterior shoulder dislocations make up 2-4% of shoulder dislocations.
    • May go undiagnosed and often missed on physical exam and imaging
    • Epileptic seizures or electrical shocks, sports injuries are the most common causes.
    • Subtle signs on AP X-Ray include:
        • Light Bulb Sign: Fixed internal rotation of the humeral head, makes the greater tuberosity anterior, giving a symmetrical appearance of the humeral head, that looks like a light bulb.
        • Empty Glenoid Sign: Humeral Head and Glenoid fossa widened articular space
        • Trough Sign: Vertical Line on AP, can indicate compression fracture of the humeral head medially.
    • In suspected Posterior Shoulder Dislocations, you should always get multiple views, including Anterior-Posterior (AP), scapular (Y), and Axillary Views.
    • Rounded posterior shoulder.
    • Prominent coracoid and acromion.
    • Palpable posterior humeral head.
    • Flattened anterior shoulder contour.
    • Neurovascular injuries
    • Rotator cuff tears
    • Osteonecrosis of the humeral head
    • Recurrent posterior shoulder instability or re-dislocation
    • Joint stiffness and post-traumatic osteoarthritis
    • You need to evaluate each case separately. The cases like this patient, with associated fractures, can complicate your management, and hence consulting orthopedic services would be advised, as surgical interventions should be evaluated.
    • If closed reduction fails, usually open reduction is pondered by subspecialty, especially in cases with extensive damage to the humeral head.
    • In cases with no associated fractures, the approach is the reduction of the dislocation. Most of them would require procedural sedation and analgesia.
    • Consider discussing options of procedural sedation and analgesia, with or without intraarticular blocks with your attending, for better and successful procedures, and minimal pain for your patient. The most convenient procedure options should also be discussed with patients, and consent should be taken. 
    • Patients would require pre and post-reduction neurovascular examination and X-rays.
    • Make sure your patient is examined again after the procedure, assessing the stability of the joint for regained full range of motion. 
    • Shoulder immobilization and follow up care plans with orthopedics services should be arranged.
    • Don’t forget, patients with known epilepsy, non-adherence or uncontrolled seizures have to be evaluated as well, and referred to appropriate neurology evaluation.

Case Reflections

  • Bilateral shoulder dislocations are rare and of these, bilateral posterior shoulder dislocations are more prevalent than bilateral anterior shoulder dislocations.
  • Bilateral fracture-dislocation is even rarer, with a few cases reported in the literature.
  • In the rare case of an asymmetrical bilateral dislocation, attention may be distracted to the more evident lesion, which is the anterior dislocation. This may lead to delayed diagnosis, especially in an unconscious patient in a post-ictal state.
  • In the present case, open reduction and internal fixation was performed.

References and Further Reading

  1. Roberts & Hedges Clinical Procedures in Emergency Medicine (6th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 49
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (7th ed) 2011. New York. McGraw Hill Companies Inc. – Chapter 268
  3. Rosen’s Emergency Medicine: Concepts and Clinical Practice (8th ed) 2014. Philadelphia. Elsevier Saunders Inc. – Chapter 53
  4. Wikem – Posterior Shoulder dislocation: https://www.wikem.org/wiki/Posterior_shoulder_dislocation
  5. Canadiem – Posterior Shoulder Dislocation: Radiographic Evidence : https://canadiem.org/posterior-shoulder-dislocation-radiographic-evidence/ 
  6. Meena S, Saini P, Singh V, Kumar R, Trikha V. Bilateral anterior shoulder dislocation. J Nat Sci Biol Med. 2013;4(2):499–501. doi:10.4103/0976-9668.117003S – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783813/
  7. Sharma A, Jindal S, Narula MS, Garg S, Sethi A. Bilateral Asymmetrical Fracture Dislocation of Shoulder with Rare Combination of Injuries after Epileptic Seizure: A Case Report. Malays Orthop J. 2017;11(1):74–76. doi:10.5704/MOJ.1703.011 – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393121/

Acknowledgement

Credit and acknowledgment for Dr. Eelaf Elhassan for sharing the case.

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Cellulitis – Clinical Image and Ultrasound

cellulitis
~ Arif Alper Cevik ~ Leave a comment

Case Presentation

A 45-years-old male with a week history of right leg swelling and redness presented to the ED. He has type II DM and hypertension. He denies fever; however, complaints about burning pain over the skin. Vitals were 156/98 mmHg blood pressure, 98 beats per minute heart rate, 16 respiration per minute, 36.7 degrees Celsius temperature and 98% oxygen saturation in room air. Physical exam revealed erythema over the right medial lower leg and calf area (images). Minimally painful with palpation. The area was hot compared to the left leg. Other examination findings were unremarkable.

Cellulitis 2

Cellulitis 1

Patients with red, swollen, painful leg may have very severe problems such as necrotizing fasciitis (infection involving muscular fascia) or infections involving muscles with or without gangrene. The patients having these infections are generally ill-looking, severely painful, and may have subcutaneous crepitations. Therefore, we should be aware of these red flags. This patient has no sign of crepitations, systemic illness, or severe pain.

Lipodermatosclerosis is chronic erythema. Patients show exacerbations because of vascular insufficiency (venous). It can be bilateral or unilateral. One of the discriminative findings from cellulitis is temperature over the lesion. Lipodermatosclerosis is not hot. In the case, the palpation showed warm skin compared to the left side.

Erysipelas is superficial and its’ borders are very sharp. The lesion is fluffy compared to the skin around the lesion. In the case, some areas of the skin were found a little bit raised compared to surrounding structures. However, its’ borders were not well-demarcated.

Other differentials are burns, contact dermatitis, urticaria, etc.

Bedside ultrasound imaging can help to identify cellulitis, abscess, foreign body, fracture, etc. Cobblestone finding is a typical finding for cellulitis.

Bedside ultrasound imaging was performed with Butterfly iQ with soft tissue settings. Cobblestone finding was found in the erythematous areas. This is a nonspecific finding and can be seen many different soft tissue infections. There were no gas/air artifacts (necrotizing fasciitis) or obvious abscess formation. However, there was a minimal fluid accumulation, which creates a suspicion of an abscess. In the case, there was no air artifact. However, x-rays can also help to show air accumulation in soft tissues.

An Example for Necrotizing Fasciitis

The ultrasound investigation in this video shows the air (white) artifacts in the soft tissue.

X-ray Image Showing Subcutaneous Air in Necrotizing Fasciitis

Case courtesy of Dr Matt Skalski, Radiopaedia.org. From the case rID: 25026

For mild uncomplicated patients – dicloxacillin, amoxicillin, and cephalexin are common choices.

If the patient has a penicillin allergy – clindamycin or a macrolide (clarithromycin or azithromycin) can be used.

Fluoroquinolones should be reserved for gram-negative organisms’ sensitivity defined by culture results because of their additional toxicity risks.

For more antibiotic options and explanations, please visit – here. 

The patients with co-morbidities compromising immune response, periorbital or perianal locations, unable to tolerate oral medication, deep infections should be admitted.

References and Further Reading

  • Loyer EM, DuBrow RA, David CL, Coan JD, Eftekhari F. Imaging of superficial soft-tissue infections: sonographic findings in cases of cellulitis and abscess. AJR Am J Roentgenol. 1996 Jan;166(1):149-52. PubMed PMID: 8571865.
  • Shyy W, Knight RS, Goldstein R, Isaacs ED, Teismann NA. Sonographic Findings in Necrotizing Fasciitis: Two Ends of the Spectrum. J Ultrasound Med. 2016 Oct;35(10):2273-7. doi: 10.7863/ultra.15.12068. Epub 2016 Aug 31. PubMed PMID: 27582527.
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Hepatobiliary US Imaging – Illustrations

hepatobiliary ultrasound
~ Murat Yazici, Turkey ~ Leave a comment

Anatomy Of The Hepatobiliary System

Anatomy of the hepatobiliary system

Indications

Indications for clinicians to perform point-of-care hepatobiliary ultrasound include the evaluation of; abdominal pain, jaundice, sepsis and ascites.

Transducer

The most commonly used positions include; left lateral decubitus and supine position. A low-to medium-frequency (2–5 MHz) curvilinear ultrasound transducer will suffice for most ultrasound examinations of the gallbladder.

curvilinear transducer

Patient positioning

Patient positioning plays a vital role in the hepatobiliary ultrasound examination. Transducer position according to gallbladder; longitudinal and transverse.

Focus Points on Hepatobilary Ultrasound

focus points hepatobilary ultrasound

Patient Position and Transducer Position

Patient Position and Transducer Position​
Patient Position and Transducer Position​

Normal Hepatobiliary Ultrasound Findings

Normal Hepatobiliary Ultrasound Findings​

Pathological Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
Pathological Hepatobiliary Ultrasound Findings
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