Out of Proportion: Acute Leg Pain

October 18, 2021August 25, 2021 ~ J. Austin Lee, USA ~ Leave a comment

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.

Question Of The Day #17

October 16, 2020October 31, 2020 ~ Joseph Ciano, USA ~ Leave a comment

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

Explanation

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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— iem-student (@iem_student) October 16, 2020

References

Smith LM, Mahler SA. Chest Pain. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 18, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2353&sectionid=219641169

Cite this article as: Joseph Ciano, USA, "Question Of The Day #17," in International Emergency Medicine Education Project, October 16, 2020, https://iem-student.org/2020/10/16/question-of-the-day-17/, date accessed: April 26, 2024

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

October 9, 2020October 9, 2020 ~ Joseph Ciano, USA ~ Leave a comment

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

Explanation

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

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

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— iem-student (@iem_student) October 9, 2020

References

McCaslin L, Stearley S. Chest Trauma. In: Stone C, Humphries RL. eds. CURRENT Diagnosis & Treatment: Emergency Medicine, 8e. McGraw-Hill; Accessed August 18, 2020. https://accessmedicine.mhmedical.com/content.aspx?bookid=2172&sectionid=165061181
Nickson, C. (2019). Thoracic Trauma. Life in the Fastlane. Accessed August 18, 2020. https://litfl.com/thoracic-trauma/

Cite this article as: Joseph Ciano, USA, "Question Of The Day #16," in International Emergency Medicine Education Project, October 9, 2020, https://iem-student.org/2020/10/09/question-of-the-day-16/, date accessed: April 26, 2024

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

May 29, 2020June 7, 2020 ~ 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).

Pump

Tank

Pipes

References and Further Reading

By Organ System or Specialty Archives | Page 84 of 123 | ALiEM. https://www.aliem.com/category/emergency-medicine-clinical/system/page/84/
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.
https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/
https://iem-student.org/rush/
https://iem-student.org/efast/

Cite this article as: Murat Yazici, Turkey, "Rapid Ultrasound for Shock and Hypotension (RUSH) Protocol US Imaging – Illustrations," in International Emergency Medicine Education Project, May 29, 2020, https://iem-student.org/2020/05/29/rush-protocol-illustrations/, date accessed: April 26, 2024

19 Questions and Answers on the COVID-19 Pandemic from a Emergency Medicine-based Perspective

covid 19 - from a Emergency Medicine-based Perspective

March 27, 2020June 12, 2020 ~ Francesco Adami, Italy ~ Leave a comment

1) What is COVID-19?

Corona Virus Disease 2019 (COVID-19) is the disease caused by infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

2) What is SARS-CoV-2?

SARS-CoV-2 is a virus belonging to the Coronaviridae family. Spike proteins (S proteins) on the outer surface of SARS-CoV-2 are arranged in a way that resembles the appearance of a crown when viewed under an electron microscope (see Figure 1). S proteins facilitate viral entry into host cells by binding to the angiotensin-converting enzyme 2 (ACE2) host receptor. Several cell types express the ACE2 receptor, including lung alveoli cells. [1].

3) How is SARS-CoV-2 transmitted?

Viral particles can spread from person-to-person through airborne transmission (e.g., large droplets) or direct contact(e.g., touching, shaking hands). We have to remember that large droplets are particles with a diameter > 5 microns and that they can be spread by coughing, sneezing, talking, etc., so do not forget to wear full PPE in the Emergency Department (ED). Other potential routes of transmission are still being investigated.

4) What is the incubation time?

In humans, the incubation period of the SARS-CoV-2 varies from 4 days to 14 days, with a median of about 4 days [2].

5) Can we say the COVID-19 is like the seasonal flu?

No, we can’t say that. COVID-19 differs from the flu in several ways:

First of all, SARS-CoV-2 replicates in the lower respiratory tract at the level of the pulmonary alveoli (terminal alveoli). In contrast, Influenza viruses, the causative agents of the flu, replicate in the mucosa of the upper respiratory tract.
Secondly, SARS-CoV-2 is a new virus that has never met our adaptive immune system.
Thirdly, we do not currently have an approved vaccine to prevent infection by SARS-CoV-2.
Lastly, we do not currently have drugs of proven efficacy for the treatment of disease caused by SARS-CoV-2.

6) Who is at risk of contracting the COVID-19?

We are all susceptible to contracting the COVID-19, so it is essential that everyone respects the biohazard prevention rules developed by national and international health committees. Elderly persons, patients with comorbidities (e.g., diabetics, cancer, COPD, and CVD), and smokers appear to exhibit poor clinical outcome and greater mortality from COVID-19 [3]

7) What are the symptoms of the COVID-19?

There are four primary symptoms of COVID-19: fever; dry cough; fatigue; and shortness of breath (SOB).

Other symptoms are loss of appetite, muscle and joint pain, sore throat, nasal congestion and runny nose, headache, nausea and vomiting, diarrhea, anosmia, and dysgeusia.

8) What is the severity of symptoms from COVID-19?

In most cases, COVID-19 mild or moderate symptoms, so much so it can resolve after two weeks of rest at home. However, onset of severe viral pneumonia requires hospital admission.

9) Which COVID-19 patients we should admit to the hospital?

The onset of severe viral pneumonia requires hospital admission. COVID-19-associated pneumonia can quickly evolve into respiratory failure, resulting in decreased gas exchange and the onset of hypoxia (we can already detect this deterioration in gas exchange with a pulse oximeter at the patient’s home). This clinical picture can rapidly further evolve into ARDS and severe multi-organ failure.

The use of the PSI/PORT score (or even the MuLBSTA score, although this score needs to be validated) can help us in the hospital admission decision-making process.

10) Do patients with COVID-19 exhibit laboratory abnormalities?

Most patients exhibit lymphocytopenia [11], an increase in prothrombin time, procalcitonin (> 0.5 ng/mL), and/or LDH (> 250 U/L).

11) Are there specific tests that allow us to diagnose COVID-19?

RT-PCR is a specific test that currently appears to have high specificity but not very high sensitivity [12]. We can obtain material for this test from nasopharyngeal swabs, tracheal aspirates of intubated patients, sputum, and bronchoalveolar lavages (BAL). However, the latter two procedures increase the risk of contagion.

However, since rapid tests are not yet available, RT-PCR results may take days to obtain, since laboratory activity can quickly saturate during epidemics. Furthermore, poor pharyngeal swabbing technique or sampling that occurs during the early stage of COVID-19 can lead to further decreased testing sensitivity.

Consequently, for the best patient care, we must rely on clinical symptoms, labs, and diagnostic imaging (US, CXR, CT). The use of a diagnostic flowchart can be useful (see Figure 2).

12) Can lung ultrasound help diagnose COVID-19?

Yes, it can help! The use of POCUS lung ultrasound is a useful method both in diagnosis and in real-time monitoring of the COVID-19 patient.

In addition, we could monitor the patient not only in the emergency department (ED) or intensive care unit (ICU), but also in a pre-hospital setting, such as in the home of a patient who is in quarantine.

In fact, POCUS lung ultrasounds not only allows one to anticipate further complications such as lung consolidation from bacterial superinfection or pneumothorax, but it also allows detection of viral pneumonia at the early stages. Furthermore, the use of a high-frequency ultrasound probe, which is an adoption of the 12-lung areas method [4] and the portable ultrasound (they are easily decontaminated), allow this method to be repeatable, inexpensive, easy to transport, and radiation-free.

There are no known pathognomonic patterns of COVID-19.

The early stages COVID-19 pneumonia results in peripheral alveolar damage including alveolar edema and a proteinaceous exudate [5]. This interstitial syndrome can be observed via ultrasound by the presence of scattered B lines in a single intercostal space (see videos below).

Subsequently, COVID-19 pneumonia progression leads to what’s called “white lung”, which ultrasound represents as converging B lines that cover the entire area of the intercostal space; they start from the pleura to end at the bottom of the screen.

Finally, the later stages of this viral pneumonia lead to “dry lung”, which consists of a pattern of small consolidations (< 1 cm) and subpleural nodules. Unlike bacterial foci of infection, these consolidations do not create a Doppler signal within the lesions. We should consider the development from “white lung” to “dry lung” as an unfavorable evolution of the disease.[6]

(the 5 videos above come from the COVID-19 gallery on the Butterflynetwork website)

13) Can CXR/CT help us in the diagnosis of COVID-19?

Yes, it can help! There are essentially three patterns we observed in COVID-19.

In the early stages, the main pattern is ground-glass opacity (GGO)[7]. Ground glass opacity is represented at the lung bases with a peripheral distribution (see videos below) .

The second pattern is constituted by consolidations, which unlike ground-glass opacity, determine a complete “opacification” of the lung parenchyma. The greater the extent of consolidations, the greater the severity and the possibility of admission in ICU.

The third pattern is called crazy paving[8]. It is caused by the thickening of the pulmonary lobular interstitium.

However, we should consider four things when we do a CXR/CT exam. First, many patients, especially in the elderly, exhibit multiple, simultaneously occurring pathologies, so it is possible to clinically observe nodular effusions, lymph node enlargements, and pleural effusions that are not typical of COVID-19 pneumonia. Secondly, we have to be aware that other types of viral pneumonia can also cause GGO, so they cannot be excluded during the diagnostic process. Thirdly, imaging can help evaluate the extent of the disease and alternative diagnoses, but we cannot use it exclusively for diagnosis. Lastly, we should carefully assess the risk of contagion from transporting these patients to the CT room.

Quality CT/XR images on proven COVID-19 provided by Prof. Dr. Filippo Cademartiri, Chairman of Radiology , Marche – Italy. pic.twitter.com/MchsLQMf8z
— Martin Schranz (@martinpschranz) March 5, 2020

14) What is the treatment for this type of patient?

COVID-19 patients quickly become hypoxic without many symptoms (apparently due to “silent” atelectasis). Therapy for these clinical manifestations is resuscitation and support therapy. In patients with mild respiratory insufficiency, oxygen therapy is adopted. In severe patients in which respiratory mechanics are compromised, non-invasive ventilation (NIV) or invasive ventilation should be adopted.

15) How can we non-invasively manage the airways of patients with COVID-19?

In the presence of a virus epidemic, we should remember that all the procedures that generate aerosolization (e.g., NIV, HFNC, BMV, intubation, nebulizers) are high-risk procedures.

Among the non-invasive oxygenation methods, the best-recommended solution is to have patients wear both a high-flow nasal cannula (HFNC) and a surgical mask[9]. Still, we should also consider using CPAP with a helmet interface. Furthermore, we should avoid the administration of medications through nebulization or utilize metered-dose inhalers with spacer (Figure 3).

Figure 3 – General schema for Respiratory Support in Patients with COVID-19 (from PulmCrit Blog)

16) How can we invasively manage the airways of patients with COVID-19?

We should intubate as soon as possible, even in non-critical conditions (Figure 3). Intubation is a high contagion risk procedure. As a result, we should adopt the highest levels of precaution[10]. To be more precise:

As healthcare operator, we should wear full PPE. Only the most skilled person at intubation in the staff should intubate. Furthermore we should consider using a video laryngoscope. Last but not least, we should ensure the correct positioning of the endotracheal tube without a stethoscope (link HERE).
The room where intubation occurs should be a negative pressure room. When that is not feasible, the room should have doors closed during the intubation procedure.
The suction device should have a closed-circuit so as not to generate aerosolization outside.
Preoxygenation should be done using means that do not generate aerosols. Let us remember that HFNC and BVM both can generate aerosolization. So, it is important to remember to turn off the flow of the HFNC before removing it from the patient face to minimize the risk and to use a two-handed grip when using BVM, interposing an antiviral filter between the BVM and resuscitation bag and ventilating gently.
Intubation drugs that do not cause coughing should be used. In addition, we should evaluate the use of Rocuronium in the Rapid Sequence Intubation (RSI) since it has a longer half-life compared to succinylcholine and thus prevents the onset of coughing or vomiting.

In conclusion, let us remember that intubation, extubation, bronchoscopy, NIV, CPR prior to intubation, manual ventilation etc. produce aerosolization of the virus, therefore, it is necessary that we wear full PPE.

17) What is the drug therapy for COVID-19?

Currently, there is no validated drug therapy for COVID-19. Some drugs are currently under study. They include Remdesivir (blocks RNA-dependent RNA polymerase), Chloroquine and Hydroxychloroquine (both block the entry of the virus into the endosome), Tocilizumab and Siltuximab (both block IL-6).

18) Is there a vaccine available for COVID-19?

No, there is still no vaccine currently available to the public.

19) What precautions should we take with COVID-19 infected patients?

As healthcare professionals, we should wear full personal protective equipment (PPE) and know how to wear them (“DONning”) and how to remove them properly (“DOFFing”) (see video below). Furthermore, we should wear full PPE for the entire shift and when in contact with patients with respiratory problems.

Resources on COVID-19

Cite this article as: Francesco Adami, Italy, "19 Questions and Answers on the COVID-19 Pandemic from a Emergency Medicine-based Perspective," in International Emergency Medicine Education Project, March 27, 2020, https://iem-student.org/2020/03/27/19-questions-and-answers-on-the-covid-19/, date accessed: April 26, 2024

References

[1] Zheng YY, Ma YT, Zhang JY, Xie X. COVID-19 and the cardiovascular system. NatRev Cardiol. 2020 Mar 5.

[2] del Rio C, Malani PN. COVID-19—New Insights on a Rapidly Changing Epidemic. JAMA. Published online February 28, 2020. doi:10.1001/jama.2020.3072

[3] Yee J et al. Novel coronavirus 2019 (COVID-19): Emergence and Implications for Emergency Care. Infectious Disease 2020. https://doi.org/10.1002/emp2.12034

[4] Belaïd Bouhemad, Silvia Mongodi, Gabriele Via, Isabelle Rouquette; Ultrasound for “Lung Monitoring” of Ventilated Patients. Anesthesiology 2015;122(2):437-447. doi: https://doi.org/10.1097/ALN.0000000000000558.

[5] Qian-Yi Peng, Xiao-Ting Wang, Li-Na Zhang & Chinese Critical Care Ultrasound Study Group (CCUSG). Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. 12 March 2020 Intensive Care Medicine.

[6] Chan JF, Yuan S, Kok KH, et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet 2020.

[7] Chest CT Findings in Cases from the Cruise Ship “Diamond Princess” with Coronavirus Disease 2019 (COVID-19)

[8] Radiographic and CT Features of Viral Pneumonia Hyun Jung Koo, Soyeoun Lim, Jooae Choe, Sang-Ho Choi, Heungsup Sung, and Kyung-Hyun Do RadioGraphics 2018 38:3, 719-739 doi: https://doi.org/10.1148/rg.2018170048

[9] WHO – Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected.

[10] Safe Airway Society. Consensus Statement: Safe Airway Society Principles of Airway management and Tracheal Intubation Specific to the COVID-19 Adult Patient Group. MJA 2020.

[11] GUAN WJ, Ni ZY, Hu Y, Liang WH, et al Clinical Characteristics of Coronavirus Disease 2019 in China. N Engl J Med. 2020 Feb 28. doi: 10.1056/NEJMoa2002032

[12] Tao Ai et al. Correlation of Chest CT and RT-PCR Testing in Coronavirus Disease 2019 (COVID-19) in China: A Report of 1014 Cases. Radiology, published online February 26, 2020; doi: 10.1148/radiol.2020200642

Lower Extremity Deep Venous US Imaging – Illustrations

February 14, 2020February 8, 2020 ~ 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.

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

Criteria	Score
Active cancer(treatment ongoing or within previous 6 months or palliative treatment)	1
Paralysis, paresis, or recent plaster immobilization or of the lower extremities	1
Recently bedridden for 3 days or more or major surgery within the previous 12 weeks requiring general or regional anesthesia	1
Localized tenderness along the distribution of the deep venous system	1
Entire leg swollen	1
Calf swelling > 3cm compared to asymptomatic leg (measuring 10 cm below tibial tuberosity)	1
Pitting edema confined to the symptomatic leg	1
Non varicose collateral superficial veins	1
Previously documented DVT	1
Alternative diagnosis at least as likely as DVT	1

Normal DVT Ultrasound Findings

Reference and Further Reading

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 this article as: Murat Yazici, Turkey, "Lower Extremity Deep Venous US Imaging – Illustrations," in International Emergency Medicine Education Project, February 14, 2020, https://iem-student.org/2020/02/14/lower-extremity-deep-venous-us-imaging-illustrations/, date accessed: April 26, 2024

Cellulitis – Clinical Image and Ultrasound

December 2, 2019November 26, 2019 ~ 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.

What are the differential diagnoses?

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.

Which bedside test/imaging can be helpful for diagnosis and what is the typical finding for soft tissue infections?

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

What are the treatment options?

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.

Which patients should be admitted?

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.

Cite this article as: Arif Alper Cevik, "Cellulitis – Clinical Image and Ultrasound," in International Emergency Medicine Education Project, December 2, 2019, https://iem-student.org/2019/12/02/cellulitis-clinical-image-and-ultrasound/, date accessed: April 26, 2024

Hepatobiliary US Imaging – Illustrations

November 27, 2019November 25, 2019 ~ Murat Yazici, Turkey ~ Leave a comment

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.

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

Patient Position and Transducer Position

Normal Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings

Cite this article as: Murat Yazici, Turkey, "Hepatobiliary US Imaging – Illustrations," in International Emergency Medicine Education Project, November 27, 2019, https://iem-student.org/2019/11/27/hepatobiliary-us-imaging-illustrations/, date accessed: April 26, 2024

Massive Pneumothorax Without A Tension

November 25, 2019November 22, 2019 ~ Arif Alper Cevik ~ Leave a comment

Case Presentation

A 24-years-old male with shortness of breath and chest pain presented to the emergency department. He was alert and oriented. Vitals were as follows; BP: 127/65 mmHg, HR: 101 beats per min, RR: 24 breaths per min, T: 37-degree celsius, SatO2: 94%. Physical examination revealed that normal breathing sounds on the left side, but decreased breath sounds on the right side of the chest. No JVD noted. Other examination findings were unremarkable.

Shortness of breath and chest pain started suddenly while he was playing soccer about 30 minutes ago. Since then, shortness of breath and chest pain increased. He has no known medical disease, allergy.

Bedside ultrasound revealed pneumothorax on the right.

Bedside Ultrasound Examination

Above video shows left side B mode ultrasound examination. Investigation was done in lung settings by using Butterfly iQ portable ultrasound. Lung sliding and comet tail artefacts are seen on examination which is normal findings.

Above video shows right side B mode and M-mode ultrasound examination. There is no lung sliding or comet tail artefacts in B mode, and M-mode revealed “barcode sign” which is seen in pneumothorax.

Image shows “barcode sign” in M-mode examination.

Bedside Portable Chest X-ray

Bedside portable anteroposterior chest x-ray shows right sided large pneumothorax.

More pneumothorax images

Home Made IV Access Ultrasound Phantoms

November 18, 2019November 16, 2019 ~ Masuma Ali Gulamhussein ~ Leave a comment

We recently had the 3rd Tanzanian Conference on Emergency Medicine. Point of Care Ultrasound (PoCUS) training was one of the pre-conference workshops. Ultrasound-guided intravenous cannulation can be very challenging for many doctors in the emergency department.

Therefore, we had a station providing a real-time opportunity to practice IV access using our homemade ultrasound phantoms. And I shall share with you how we came up with this solution.

Ingredients

A plastic container (dimensions used here 8 x 5.5 x 5inches)
Long balloons
Assorted food colors
Gelatin
Metamucil (psyllium)
Powdered household detergent
Spoon, sieve, hand mixer, measuring cup, cooking pot and cooker
Filler syringes
Gloves

How to make your mixture

Take a cooking pot and fill it with 1200 mls of water (we used this as our molding device could accommodate this amount of mls) bring it to a boil (just as it begins to form tiny bubbles on the base add gelatin powder 8 tablespoons and stir with a hand mixer until it completely dissolves. Thereby add 2 tablespoons of Metamucil and 1 tablespoon of detergent and continue stirring with low flame until the mixture begins to thicken. At this point, you will also see foam that sits on top of the mix. Use a sieve to get the foam out. You can, at this point, add any colors that you would want. Let the mixture cool a little before pouring it into the container. As it cools, you will notice it becoming thicker.

How to set-up your mold/containers

You will need to make a hole on both ends on the container using a hand drill or a hot pointed knife. For this case, since we didn’t have a drill, we used a knife with a pointed tip – heated it up in a burner until it was hot enough and used it to make holes through the plastic container using a circular motion. It is important for the holes not to be too big but estimated to the caliber/ diameter of the long balloons since we need just enough space to pass the balloons across.

For our case, we made 4 holes, 2 on each end. But you can do more if you want. You can arrange balloons in superficial or deeper locations.

To setup the vessels using the long balloons, you will need half cup of water and red color dye. Mix just enough to make a mixture that looks like blood. This can be filled in the balloons with a syringe. Since the color dye can stain your fingers, it is important to use gloves just to prevent your fingers from staining.

Tip: To make an artery, you can fill the balloon much more so that there is minimal compressibility and for the vein, you can fill just enough and have room for compressibility. Don’t fill the balloons before passing it through the container; if you do this, the filled balloon won’t manage to fit into the holes. Once fixed, tie both ends to make knots that are big enough to cover the seal the holes made.
Before pouring the mixture into the container, spray it with some oil, or you can use a cloth dip it in oil and apply it on the inside of the container.

After that, pour your mixture in the container and let it cool. You can place it in the refrigerator and use it the next day. We left ours for 24 hrs prior use.

You can use silicone seals at the holes if you notice to have any leaks. Otherwise, if you don’t have this, you can use plastic food wrap to create a seal between the balloon knots and the container just so the mixture does not leak out until it has set.

And finally, the images that you will have on ultrasound.

Cite this article as: Masuma Ali Gulamhussein, "Home Made IV Access Ultrasound Phantoms," in International Emergency Medicine Education Project, November 18, 2019, https://iem-student.org/2019/11/18/home-made-iv-access-ultrasound-phantoms/, date accessed: April 26, 2024

Basic Transthoracic Echocardiographic Imaging

June 12, 2019September 4, 2019 ~ Murat Yazici, Turkey ~ Leave a comment

In the adult transthoracic echocardiographic (TTE) imaging, a standard series of cross-sectional anatomical views are recommended by the American Society of Echocardiography (ASE).

There are two major obstacles for ultrasound beam transmission: 1) bony chest wall, 2) air-filled lungs. Specific ultrasound transducer positions on the chest wall are required in order to perform optimal examination.

Four primary transducer positions or “windows” are recommended. For patients with normal levocardia, the examination begins at (1) the left parasternal window, followed by the apical window, (3) the subcostal or subxiphoid window, and (4) the suprasternal notch window

In this blog post, I will try to explain the “windows” of the echocardiographic imaging through drawings

Cite this article as: Murat Yazici, Turkey, "Basic Transthoracic Echocardiographic Imaging," in International Emergency Medicine Education Project, June 12, 2019, https://iem-student.org/2019/06/12/basic-transthoracic-echocardiographic-imaging/, date accessed: April 26, 2024

Bat Sign

February 18, 2019February 11, 2019 ~ iEM Education Project Team ~ Leave a comment

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.

The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).

Case Presentation

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

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

What are some key parts of your targeted physical exam?

What diagnostic studies would you like to send?

What treatments would you like to provide?

Remember

Further Reading

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References

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Pump

Tank

Pipes

References and Further Reading

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1) What is COVID-19?

2) What is SARS-CoV-2?

3) How is SARS-CoV-2 transmitted?

4) What is the incubation time?

5) Can we say the COVID-19 is like the seasonal flu?

6) Who is at risk of contracting the COVID-19?

7) What are the symptoms of the COVID-19?

8) What is the severity of symptoms from COVID-19?

9) Which COVID-19 patients we should admit to the hospital?

10) Do patients with COVID-19 exhibit laboratory abnormalities?

11) Are there specific tests that allow us to diagnose COVID-19?

12) Can lung ultrasound help diagnose COVID-19?

13) Can CXR/CT help us in the diagnosis of COVID-19?

14) What is the treatment for this type of patient?

15) How can we non-invasively manage the airways of patients with COVID-19?

16) How can we invasively manage the airways of patients with COVID-19?

17) What is the drug therapy for COVID-19?

18) Is there a vaccine available for COVID-19?

19) What precautions should we take with COVID-19 infected patients?

Resources on COVID-19

References

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Indications

Transducer

Remember Risk Factors of DVT

Wells Score for Deep Vein Thrombosis

Normal DVT Ultrasound Findings

Reference and Further Reading

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Case Presentation

An Example for Necrotizing Fasciitis

X-ray Image Showing Subcutaneous Air in Necrotizing Fasciitis

References and Further Reading

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Anatomy Of The Hepatobiliary System

Indications

Transducer

Patient positioning

Focus Points on Hepatobilary Ultrasound

Patient Position and Transducer Position

Normal Hepatobiliary Ultrasound Findings

Pathological Hepatobiliary Ultrasound Findings

Sharing is caring

Like this:

Case Presentation

Bedside Ultrasound Examination

Bedside Portable Chest X-ray

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Ingredients

How to make your mixture

How to set-up your mold/containers