SplintER Series: I Declare a Thumb War

Gamekeeper's Thumb

 

A 39-year-old female presents to the emergency department with right thumb pain after falling in a skiing accident. On exam, there is mild swelling and tenderness on the ulnar aspect of the 1st MCP joint. Additionally, there is laxity with valgus stressing of the 1st MCP joint. An x-ray is obtained and shown above (Image 1. Provided by Alex Tomesch, MD).

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SAEM Clinical Image Series: Chronic Back Pain

A 52-year-old male with a past medical history of prostate cancer status post radiation therapy 10 years prior presents to the emergency department (ED) with the chief complaint of low back pain worsening over the past year. He characterizes the pain as a “dull, aching stiffness” associated with decreased motility.

Vitals: BP 128/82; HR 72; RR 18; T 37°C

General: Alert and oriented

MSK: Decreased range of motion of the lumbar spine with flexion; Heberden’s and Bouchard’s nodes on multiple fingers

Neurologic: Within normal limits with no focal motor or sensory deficits appreciated; deep tendon reflexes 2+ throughout

Comprehensive metabolic panel (CMP), complete blood count (CBC), erythrocyte sedimentation rate (ESR), calcium, phosphorous, and urinalysis all within normal limits.

Prostate-specific antigen (PSA): undetectable

HLA-B27: negative

Diffuse Idiopathic Skeletal Hyperostosis (DISH).

The classic clinical presentation is an older male with increasing back pain and stiffness that is worse in the morning, as seen in 80% of affected individuals. Common labs are unremarkable in patients with DISH. Peripheral joint involvement is possible, especially in joints that are not normally affected by primary osteoarthritides, such as the foot and ankle. Heel spurs, Achilles tendinitis, and plantar fasciitis may be seen as well. Differentiating features of DISH compared to ankylosing spondylitis include older age of presentation, preservation of facet joints and disk spaces, and no association with HLA-B27.

This patient has an increased risk of spinal fractures. Thus, if an older patient with known DISH presents with acute back pain following minor trauma, the workup will require a comprehensive neurovascular exam and imaging of the entire spine due to the patient’s disposition to spinal fractures.

Take-Home Points

  • Diffuse idiopathic skeletal hyperostosis (DISH) is an occult noninflammatory disorder of unknown etiology characterized by calcification and ossification of spinal ligaments and entheses on imaging.
  • Diagnostic criteria include linear calcification and ossification along the anterolateral aspect of multiple consecutive vertebral bodies, most often seen in the thoracic spine and less commonly seen in the cervical and lumbar spines.
  • Therapy for patients with DISH is similar to that of chronic lower back pain: physical therapy, exercise, and symptomatic pain management with acetaminophen or NSAIDs.
  • Patients should be educated to monitor acute changes in localized spine pain or neurologic disturbances, as DISH predisposes patients to fractures, even from minor injuries.

  • Cammisa M, De Serio A, Guglielmi G. Diffuse idiopathic skeletal hyperostosis. Eur J Radiol. 1998 May;27 Suppl 1:S7-11. doi: 10.1016/s0720-048x(98)00036-9. PMID: 9652495.

 

By |2021-11-08T10:47:24-08:00Nov 22, 2021|Orthopedic, Radiology, SAEM Clinical Images|

SAEM Clinical Image Series: Pediatric Rash

pediatric rash

A previously healthy 8-year-old female presents to the pediatric emergency department due to a rash. Her symptoms started three days prior to presentation with a painful rash on her lower extremities. The rash subsequently spread to the buttocks and upper extremities, and she developed intermittent diffuse abdominal pain, a nonproductive cough, and pharyngitis. The patient denies subjective fever. Known sick contacts include the patient’s mother, who tested positive for COVID-19 two and a half weeks prior.

 

Vitals: T 98.5°F; HR 93; BP 115/68; RR 16; O2 sat 100% on room air

Constitutional: Well-developed and in no acute distress

HEENT: Normocephalic, atraumatic; moist mucus membranes; no conjunctival injection; posterior pharyngeal erythema without exudates; tonsils are three bilaterally; lips are not cracked; no “strawberry tongue”;

Neck: Normal range of motion; no lymphadenopathy

Cardiovascular: Regular rate and rhythm; normal heart sounds and pulses

Pulmonary: Effort is normal; normal breath sounds; no wheezing

Abdominal: Abdomen is flat; minimal tenderness to palpation without guarding; no organomegaly

Skin: Diffuse petechial rash and painful, palpable, nonblanching purpura in the dependent regions (most notable on the buttocks and lower extremities)

COVID-19: Detected

Complete blood count (CBC): WBC 10K, hemoglobin 13, platelets 469

Comprehensive metabolic panel (CMP): Na 138, K 4.1, Cl 103, CO2 26, BUN 7, Cr 0.38, Glucose 94, ALT 23, AST 26, Albumin 4.5

Lipase: 10

Urinalysis (UA): Normal

C-reactive protein (CRP): 3.4

Erythrocyte sedimentation rate (ESR): 24

Procalcitonin: 0.03

Fibrinogen: 363

BNP: <10

Troponin: 0.00

Ferritin: 83

Triglycerides: 37

 

  • COVID-19-Associated Multisystem Inflammatory Syndrome in Children (MIS-C): According to CDC criteria, patients must be under 21 years of age, with a fever higher than 38°C/subjective fever for longer than 24 hours, laboratory evidence of inflammation, severe illness requiring hospitalization, and two or more organ systems involved (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic, or neurologic), with no alternative plausible diagnoses and recent COVID-19 infection.
  • Immunoglobulin A Vasculitis (Henoch-Schönlein Purpura): According to the EULAR/PRINTO/PRES criteria, symptoms must include cutaneous findings (palpable purpura or petechiae without the presence of thrombocytopenia), plus at least one of the following: diffuse abdominal pain with acute onset, arthritis/arthralgia, renal involvement in the form of proteinuria or hematuria, or deposition of Immunoglobulin A seen on renal histology.
  • Kawasaki Disease: The diagnostic criteria include fever for five days or longer and four of the following: bilateral conjunctival injection, cervical lymphadenopathy, polymorphous rash, oral mucous membrane changes (including fissured lips, pharyngeal erythema or strawberry tongue), peripheral extremity changes (edema of the hands/feet or desquamation).

Immunoglobulin A (IgA) Vasculitis.

This patient presented with palpable purpura and petechiae without the presence of thrombocytopenia, as well as diffuse abdominal pain. The majority of cases of IgA Vasculitis are preceded by a respiratory pathogen, with the most common being streptococcus, staphylococcus, and parainfluenza virus. Although not well-documented due to its recent conception, COVID-19 is likely to be the cause of this patient’s vasculitis. Usual management of IgA Vasculitis is supportive care, with admission and specialty referral for complications including intussusception and glomerular involvement. Given the severity of the differential diagnoses, this patient was admitted to the hospital for observation and discharged the following day with close follow-up

Take-Home Points

  • COVID-19 can cause a variety of rashes in the pediatric population, and appropriate workup including inflammatory markers, complete blood count, and comprehensive metabolic panel must be initiated to rule out severe disease. Consider obtaining a troponin, EKG, chest x-ray, echocardiogram, ferritin, prothrombin time, partial thromboplastin time, international normalized ratio, fibrinogen, urinalysis and cultures to assess for end-organ damage. If positive, and the patient appears ill, consider Multisystem Inflammatory Syndrome in Children (MIS-C).
  • IgA Vasculitis is usually caused by a respiratory pathogen. Keep it on your differential when assessing children who test positive for Covid-19.
  • Complications of IgA vasculitis include intussusception, heme-positive stool, microscopic hematuria, and periarticular disease.

  • Centers for Disease Control and Prevention, Health Alert Network. (2020). Case Definition for Multisystem Inflammatory Syndrome in Children (MIS-C). [online] Available at: https://emergency.cdc.gov/han/2020/han00432.asp.
  • Trnka P. Henoch-Schönlein purpura in children. J Paediatr Child Health. 2013 Dec;49(12):995-1003. doi: 10.1111/jpc.12403. Epub 2013 Oct 18. PMID: 24134307.
  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Royle J, Burgner D, Curtis N. The diagnosis and management of Kawasaki disease. J Paediatr Child Health. 2005 Mar;41(3):87-93. doi: 10.1111/j.1440-1754.2005.00555.x. PMID: 15790316.

 

SAEM Clinical Image Series: A Young Woman with Chest Pain

ECG

A 35-year-old female with a history of intermittent palpitations who is three months post-partum presented to the emergency department (ED) with three days of sharp, substernal chest pain radiating down her left arm. She reportedly had a normal electrocardiogram (ECG) at an outside hospital on the first day of symptoms. The pain returned and was associated with one episode of vomiting the night prior to presenting to our ED. Initial ECG on arrival is shown.

Vitals: Tachycardic; afebrile; normotensive; no tachypnea or hypoxemia on room air

General: Mild distress, appears uncomfortable

Cardiovascular: Tachycardic to 100s, regular rhythm, no murmur, normal peripheral perfusion, no edema

Pulmonary: Lungs clear to auscultation, no respiratory distress

Neuro: Alert and oriented, neurologically intact

Complete blood count (CBC) and basic metabolic panel (BMP): unremarkable

Partial thromboplastin time (PTT) and international normalized ratio (INR): normal

Troponin: 42

Spontaneous coronary artery dissection (SCAD).

The patient underwent emergent coronary angiography demonstrating multivessel coronary dissection including a distal left anterior descending (LAD) hematoma with lumen compression as well as obtuse marginal (OM1) and posterior descending artery (PDA) lesions consistent with spontaneous coronary artery dissection (SCAD). She was admitted to the intensive care unit on a heparin drip, had decreasing troponin levels, and ultimately was discharged home on enalapril, metoprolol, aspirin, and clopidogrel.

SCAD is a rare but important diagnosis in the ED as it conveys serious morbidity and mortality risk. Patients present with chest pain, dyspnea, diaphoresis, and potentially signs or symptoms of heart failure from severe ischemia. Most patients are women under the age of 50, and many are pregnant, postpartum, or taking oral contraceptives. This may be mistaken for other diagnoses on presentation, such as ST-segment elevation myocardial infarction (STEMI) or takotsubo cardiomyopathy, which usually presents in post-menopausal patients, but SCAD differs in its typical patient population. Wall motion abnormalities on an echocardiogram are present, but there are not always signs of heart failure as in post-partum cardiomyopathy. Patients are often taken for urgent coronary angioplasty, though in cases with marked ischemia or hemodynamic instability, emergent coronary artery bypass graft (CABG) may be indicated. Recurrence is common; patients should be counseled on mitigating cardiovascular risk factors, particularly smoking and hypertension, and to be cautious with intense exertion and future pregnancies.

Take-Home Points

  • ECG typically shows ST elevation in the leads of the dissecting artery or arteries. Important risk factors include oral contraceptive use, being pregnant or postpartum, and fibromuscular dysplasia.
  • ED management includes aspirin, heparin, and immediate cardiology consultation, as a definitive diagnosis will be made in the cath lab.

  • Yip A, Saw J. Spontaneous coronary artery dissection-A review. Cardiovasc Diagn Ther. 2015 Feb;5(1):37-48. doi: 10.3978/j.issn.2223-3652.2015.01.08. PMID: 25774346; PMCID: PMC4329168.
  • Macaya F, Salinas P, Gonzalo N, Fernández-Ortiz A, Macaya C, Escaned J. Spontaneous coronary artery dissection: contemporary aspects of diagnosis and patient management. Open Heart. 2018 Nov 5;5(2):e000884. doi: 10.1136/openhrt-2018-000884. PMID: 30487978; PMCID: PMC6241978.

 

By |2021-10-26T20:58:04-07:00Nov 1, 2021|Cardiovascular, ECG, SAEM Clinical Images|

Trick of Trade: Large-Bore Endotracheal Tube To Suction the Occluded Airway

vomit suction emesis pumpkin

The paramedics just arrived with a new patient to the resuscitation room. You find an altered patient actively vomiting bloody vomitus and food particles. You prepare for a difficult airway. You prepare 2 Yankauer suction catheters, but you are still worried that the food particles may clog up the catheters. Is there a better alternative?

Background

Up to 44% of emergent intubations are complicated by blood, vomit, or food particles in the airway. It has been shown that contaminated airways may lead to multiple intubation attempts and are associated with poor outcomes, such as peri-intubation cardiac arrest [1, 2].

The Yankauer suction catheter is the most commonly available tool in the Emergency Department to remove foreign particles, but performs poorly when compared to larger-bore catheters [3]. The Yankauer was made initially for surgical field management, with small holes at the tip to gently remove (or become clogged with) debris without damaging tissue. Some standard Yankauer designs have a built-in safety vent hole on the shaft, which if unoccluded, renders the device virtually useless [2]. This protective equipment design does not offer maximum help during emergent large-volume regurgitation dirty airway management.

Alternatively, there is the DuCanto suction catheter. It is a specialized and more expensive large-bore version of the Yankauer; however, it is not as readily available and more expensive [1].

Trick of the Trade: Use a large-bore endotracheal tube as a rigid suction catheter

A large-bore, such as a size 10.0, endotracheal tube can serve as a rigid suction catheter. Note the diameter sizes of the Yankauer, DuCanto, and 10.0 endotracheal tube below.

Suction devices (inner diameter):
Yankauer (3.56 mm), DuCanto (6.6 mm), 10.0 endotracheal tube (10 mm)
  • Materials needed
    1. Size 10.0 endotracheal tube (or the largest size you have)
    2. Suction tubing and canister
  • Making the device
    1. Insert the rubber end of the suction tubing over the plastic endotracheal tube adaptor
    2. Attach suction tubing to the canister
    3. Turn suction on

Video Demonstration: Yankauer vs Large-Bore Endotracheal Tube

Editorial Note: If the rigidity of the catheter is less important, you can also insert the soft suction tubing directly into the airway to remove contents.

Read other Tricks of the Trade posts on ALiEM.

References:

  1. Nikolla DA, Heslin A, King B, Carlson JN. Comparison of suction rates between a standard Yankauer and make-shift large bore suction catheters using a meconium aspirator and various sized endotracheal tubes. J Clin Anesth. 2021 Sep;72:110262. doi: 10.1016/j.jclinane.2021.110262. PMID 33839435
  2. Hasegawa K, Shigemitsu K, Hagiwara Y, et al. Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med. 2012;60(6):749-754.e2. doi:10.1016/j.annemergmed.2012.04.005. PMID 22542734
  3. Andreae MC, Cox RD, Shy BD, et al. 319 Yankauer Outperformed by Alternative Suction Devices in Evacuation of Simulated Emesis.” Ann Emerg Med. 68(4), S123 [research abstract] doi: 10.1016/j.annemergmed.2016.08.335
By |2021-10-29T19:15:35-07:00Oct 31, 2021|Critical Care/ Resus, Tricks of the Trade|

Trick of the Trade: Persistent Paracentesis Leakage 2.0

Paracentesis leakage

You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leakage. They’ve tried putting pressure with no success. You tried applying a medical adhesive glue and noticed it was unsuccessful, based on the patient’s gown continuing to get wet with ascites fluid. Now what?

Trick of the Trade: Pressure Gauze and Transparent Film Dressing  

The medical adhesive glue trick was proposed in the Trick of the Trade 1.0 version by Dr. Borloz and Dr. Lin in November 2012. 

Materials Needed

MaterialQuantity
Benzoin tincture1
Gauze 2″ x 2″1-2
Transparent Film Dressing (Tegaderm) 2.5″ x 2.75″3-4

Technique

1. Apply benzoin tincture surrounding the area of the leakage.
gauze ball in hand
2. Use a 2″ x 2″ gauze and roll it into a tight round ball. Hold the gauze with firm pressure over the leak (it is easier if you have the patient or an assistant holding it in place while you move on to the next step).
4. Stretch the transparent film dressing before placing it over the center of the gauze
4. Continue to hold firm pressure on the gauze from over thetransparent film dressing. Note that you are not yet touching the dressing against the skin.
5. Stretch outtransparent film dressing and affix to the patient’s skin.
6. Once you apply the initial transparent film dressing, you can apply 2-3 more over the top, in the same fashion, to increase the pressure on and security of the dressing. Patients may be discharged with this dressing in place for 24-48 hours.

Pro Tip

Consider combining both this trick of the trade and the adhesive glue technique. Hat tip to Dr. Christian Rose [Twitter @RoseLikeTheFlwr] for this idea. 

Interested in other Tricks of the Trade posts?

Read the series of Tricks of the Trade posts.

By |2021-10-15T12:48:11-07:00Oct 20, 2021|Gastrointestinal, Tricks of the Trade|

SAEM Clinical Image Series: A Rapidly Spreading Rash

spreading rash

A 40-year-old male with a past medical history of HIV presented for evaluation of a non-pruritic rash. Six days ago, he suddenly felt a stinging sensation at the back of his head and neck similar to a bug bite. He then noticed bumps were starting to form and developed a shock-like pain in the area. Three days ago, the rash spread from the back of his head towards his chest. Yesterday, the rash spread further and now extends medially and upwards covering most of his left neck and ear. The pain continued to worsen, at which point the patient shaved the left side of his head in an attempt to help the rash. Today, the pain became unbearable, which prompted his visit to the emergency department for further evaluation and management.

Head: Normocephalic, atraumatic; left side of patient’s head is shaved.

Eye: Pupils equal, round, reactive to light; extraocular movements intact; no corneal ulcers or dendritic lesions with fluorescein staining.

Visual acuities: Right 20/25, left 20/25, baseline 20/25

Ear, nose, throat: Mucous membranes are dry; oral thrush and tonsillar erythema appreciated; localized erythema, crusting and blistering rash of varying sizes and ages along with the outer ear including the tragus, antihelix, and antitragus; helix mildly swollen. On otoscopy, the tympanic membranes appear pearly grey, shiny, translucent with no bulging, and without cerumen impaction.

Neck: Full range of motion appreciated but both horizontal and vertical movement is slow secondary to pain; no lymphadenopathy.

Neurological: Awake, alert, and oriented to date, place, and person; moves all extremities; cranial nerves II through XII grossly intact; strength 5/5 in all extremities; gait steady; no ataxia, dysmetria, or dysarthria.

Skin: Erythematous, localized, crusted, blistering vesicular rash of various sizes and ages appreciated along the left V3 distribution, C3 to T3 dermatomes anteriorly, and C2 to C6 dermatomes posteriorly.

HIV-1 antibody: positive

CD4 helper t-cells: 48 (L)

HIV-1 RNA PCR: 36,490

The lesions can be characterized as vesicles in various stages of healing. Some lesions are crusted, others are bullous, and a few are pustular. The C2-C6 dermatomes are affected posteriorly, and the C2-T3 dermatomes are involved anteriorly.

The diagnosis is Disseminated Herpes Zoster. The rash in reactivation varicella zoster virus (VZV) is preceded by tingling, itching, or pain, and begins as maculopapular then progresses to vesicles, pustules, and bullae. The rash typically involves a single dermatome and does not cross the midline. Rash present in multiple dermatomes (>3) or a rash that crosses the midline signifies disseminated disease. Hutchinson’s sign is a lesion on the lateral dorsum and tip of the nose indicating the involvement of the nasociliary branch of the ophthalmic division of the trigeminal nerve. The nasociliary branch innervates the eye, thus these lesions are highly suspicious for herpes zoster ophthalmicus. Herpes zoster ophthalmicus on fluorescein examination appears as pseuododendritic lesions with no terminal bulbs (not to be confused with herpes simplex virus (HSV) keratitis, which has dendritic lesions with terminal bulbs). Vesicles in the auditory canal (herpes zoster oticus) may be a part of Ramsay Hunt syndrome with ear pain and paralysis of the facial nerve.

The patient is immunocompromised and requires hospitalization for intravenous (IV) antiviral therapy and pain management. VZV primary infection results in viremia, diffuse rash, and seeding of sensory ganglia where the virus establishes latency. Herpes zoster is the result of viral reactivation with spread along the sensory nerve in that dermatome. Antiviral therapy aids in the resolution of lesions, reduces the formation of new lesions, reduces viral shedding, and decreases the severity of acute pain, but does not affect the development of post-herpetic neuralgia.

Immunocompetent patients may receive Valacyclovir 1 g PO q8hrs (preferred) or Acyclovir 800 mg PO 5x/day x 7d if the onset of rash is <3 days or >3 days with the appearance of new lesions.

Immunocompromised, transplant, and cancer patients are all at high risk for dissemination, chronic skin lesions, acyclovir-resistant VZV, and multi-organ involvement. Immunocompromised patients and patients with disseminated zoster require aggressive multimodal treatment, admission to the hospital, and IV antiviral therapy regardless of the time of onset of rash. Recommended therapy is Acyclovir 10 mg/kg IV q8h or Foscarnet 40 mg/kg IV q8h for acyclovir-resistant VZV. All patients require adequate analgesia, typically with non-steroidal anti-inflammatory drugs, opioids, Gabapentin, Nortriptyline, and Lidocaine patches on intact skin.

Take-Home Points

  • Disseminated herpes zoster is defined as reactivation of VZV in three or more dermatomes. It requires admission, IV antiviral therapy, and pain control.
  • If VZV reactivation involves the face, one must evaluate for herpes zoster ophthalmicus and oticus.
  • Perform a thorough neuro exam including evaluation of cranial nerves V, VII, and VIII.
  • VZV requires airborne precautions.
  1. Cohen JI. Clinical practice: Herpes zoster. N Engl J Med. 2013 Jul 18;369(3):255-63. doi: 10.1056/NEJMcp1302674. PMID: 23863052; PMCID: PMC4789101.

 

 

 

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