SAEM Clinical Images Series: A Rash You Don’t Want to Miss

rash

A 54-year-old female with a past medical history of diabetes presented to the Emergency Department (ED) for evaluation of unresponsiveness. The patient was found unresponsive by her spouse, who notes she had missed several doses of insulin over the past few days. EMS notes the glucometer read ‘HIGH’ on fingerstick. The patient remains unresponsive on presentation and is unable to contribute further history.

Vital Signs: BP 148/105; HR 120; RR 24; Pulse Oximetry 98% on room air; Temperature 97.7°F

Constitutional: Patient is morbidly obese, unresponsive, and toxic-appearing.

Cardiovascular: Regular rhythm with tachycardia. No murmur.

Pulmonary: Pulmonary effort is normal. Lungs clear to auscultation bilaterally.

Abdomen: Abdomen is soft and non-distended. Unable to assess for tenderness given unresponsiveness.

Skin: Cool, pale, mottled. Large gangrenous, draining, foul-smelling wound on proximal left thigh. There is necrotic, malodorous, black skin noted over the left lower abdomen and left upper thigh.

Neurological: Unresponsive. GCS 3.

White blood cell (WBC) count: 20.5

Comprehensive metabolic panel (CMP): K 5.8; Cr 2.06; BUN 86; Glucose >600

Venous blood gas (VBG): pH<7; lactate 3.4; bicarbonate 7

These photographs show advanced Fournier’s Gangrene, a form of necrotizing fasciitis located in the genitals, perineum, or perianal region. Rapid involvement of our surgical colleagues is crucial, as these patients will not recover without the debridement of affected tissues. Aggressive fluid resuscitation and broad-spectrum antibiotics can be initiated after a surgical consult is made.

This patient presented with impressive visual evidence of advanced disease including severe ecchymosis, but our clinical suspicion must be high as Fournier’s is rapidly progressing and carries a high mortality rate (may be upwards of 30%). Earlier symptoms are genital or perineal pain which may be associated with itching, lethargy, or fever. The biggest exam finding to keep in mind is ‘pain out of proportion to the exam’ as up to 40% of these patients may present without localized symptoms. Advanced disease, as seen in this patient, can present with crepitus and severe ecchymosis of tissue involved. This patient was also found to be in DKA, as evidenced by her laboratory findings. This case should serve as a reminder that it is vital to perform a proper skin examination in patients presenting with hyperglycemia. Ultimately in this case, the patient was intubated for airway protection and started on vasopressors for cardiovascular support in the setting of septic shock. She went into VTach arrest and was successfully defibrillated before further decompensating and becoming asystolic.

Take-Home Points

  • The first task after suspected diagnosis of Fournier’s Gangrene is a page to your surgery service for evaluation and emergent debridement in the OR (depending on your institution this may be general surgery, urology, or both). After your patient is on the path to definitive management, you can begin aggressive fluid administration and broad-spectrum antibiotics (gram-positive, gram-negative, and anaerobic coverage needed).
  • Fournier’s Gangrene is a clinical diagnosis. Imaging may assist in atypical or borderline cases, but should never result in delay of surgical evaluation and treatment. Crepitus and ecchymotic tissue are very late findings; have high clinical suspicion inpatients with signs of swelling, erythema, and pain.

  • Shyam DC, Rapsang AG. Fournier’s gangrene. Surgeon. 2013 Aug;11(4):222-32. doi: 10.1016/j.surge.2013.02.001. Epub 2013 Apr 8. PMID: 23578806.
  • Ustin JS, Malangoni MA. Necrotizing soft-tissue infections. Crit Care Med. 2011 Sep;39(9):2156-62. doi: 10.1097/CCM.0b013e31821cb246. Erratum in: Crit Care Med. 2011 Nov;39(11):2592. Dosage error in article text. PMID: 21532474.
  • Harbrecht BG, Nash NA. Necrotizing Soft Tissue Infections: A Review. Surg Infect (Larchmt). 2016 Oct;17(5):503-9. doi: 10.1089/sur.2016.049. Epub 2016 Aug 2. PMID: 27483003.
  • Singh A, Ahmed K, Aydin A, Khan MS, Dasgupta P. Fournier’s gangrene. A clinical review. Arch Ital Urol Androl. 2016 Oct 5;88(3):157-164. doi: 10.4081/aiua.2016.3.157. PMID: 27711086.
  • Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. doi: 10.1016/j.jamcollsurg.2008.10.032. Epub 2008 Dec 12. PMID: 19228540.
  • 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; 2020. p.592- 593.

SAEM Clinical Images Series: ‘Tis Not the Season to be Wheezing

wheezing

A 2-year-old male with a history of solitary kidney presented with greater than one month of daily coughing, wheezing, and decreased appetite. The patient was previously seen by his primary care physician after three weeks of symptoms where he was prescribed albuterol as needed for viral bronchospasm. The patient’s wheezing did not improve after two weeks of albuterol treatment so a chest x-ray was ordered. The patient’s mother denied any fevers, vomiting, diarrhea, weight changes, or night sweats.

Vitals: BP 131/60; Pulse 148; Temp 36.7 °C (98.1 °F) (Axillary); Resp 28; Wt 15.7 kg (34 lb 9.8 oz); SpO2 95%

General: Alert; well appearing

HEENT: Pupils equally reactive to light; moist mucous membranes; nares with normal mucosa without discharge

Cardiovascular: Regular rate; regular rhythm; normal S1, S2; no murmur noted; distal pulses 2+

Pulmonary: Good aeration throughout all lung fields; clear breath sounds bilaterally; prolonged expiratory phase; stridor with agitation

Abdomen: Soft; non-tender; non-distended

White blood cell (WBC) count: 56.1/uL (Blasts 58%)

Platelets: 288/uL

Uric acid: 8.3 mg/dL

LDH: 2231 iU/LD

D-Dimer: 3.22 ug/mL

Fibrinogen: 463 mg/dL

Bronchospasm, bronchiolitis, viral infection, pneumonia, foreign body aspiration, space-occupying lesion, vocal cord dysfunction, cardiac dysfunction, and acute chest in patients with sickle cell disease.

The radiograph shown demonstrates a mediastinal mass. This patient was ultimately diagnosed with T-cell acute lymphoblastic leukemia. T-ALL can present with fatigue, fevers, weight loss, easy bleeding/bruising, paleness, or a mediastinal mass. Mediastinal masses found on chest x-ray require further evaluation to determine the diagnosis, location, and treatment. If malignancy is suspected, an oncology referral and bone marrow sample will be necessary.

Take-Home Points

  • In patients with first-time wheezing that does not improve with bronchodilator therapy, consider alternative diagnoses and further evaluation.
  • A mediastinal mass is found at the time of diagnosis in 10% to 15% of children with acute lymphoblastic leukemia.

  • Steuber, P (2021). Overview of common presenting signs and symptoms of childhood cancer.UpToDate. Retrieved January 2, 2021.2.
  • Juanpere, S., Cañete, N., Ortuño, P., Martínez, S., Sanchez, G., & Bernado, L. (2013). A diagnostic approach to the mediastinal masses. Insights into imaging, 4(1), 29–52.https://doi.org/10.1007/s13244-012-0201-0

Trick of the Trade: Managing Epistaxis with Merocel Nasal Packing and an Angiocatheter


There are many ways to manage epistaxis. Once nasal clamping and cauterization fail, the next step is to consider using tranexamic acid (TXA) and performing nasal packing. Inflatable packing devices such as a Rhinorocket are painful to insert and do not conform well to the shape of the naris. The expandable Merocel nasal packing, a compressed, dehydrated sponge, provides a softer, alternative option, although the insertion process can be painful given its initial rigid, edged structure. We propose 2 strategic tricks to optimize your nasal packing technique using the Merocel sponge.

Trick of the Trade: Strategic expansion of the Merocel sponge

The common approach for Merocel packing involves inserting the unexpanded sponge into the nose, tilting the patient’s head back, and dripping in TXA solution to expand the sponge to tamponade the bleeding.

Trick #1: Wet the tip of the Merocel’s sharp edge to allow for a softer cushion to slide the packing more comfortably and deeper into the naris.

Trick #2: Use an angiocatheter to deliver the TXA solution directly onto the mid-portion of the packing. Commonly, the TXA solution is dripped onto the outer end, which may cause an uneven and inadequate expansion at the site where the bleeding may be occurring. Because blood also can react with the packing, it is likely the blood will expand the packing before TXA reaches the center by osmosis. Another benefit of Merocel expansion starting at the center is that it will help anchor the sponge in place. In contrast, TXA administration at the outer tip first may pull the sponge out of the naris a few millimeters.

Equipment

  • 20g or 22g angiocatheter (closed IV catheter system)
  • Tranexamic acid solution
  • A syringe
  • Merocel nasal dressing

Technique

merocel sponge nasal packing trick setup

1. Insert the angiocatheter needle into the Merocel packing about ⅓ the distance from the external end of the packing. Remove the needle, leaving the plastic angiocatheter in place.

merocel tip moisten txa trick

2. Soak the insertion tip of the nasal packing with a drop of TXA to soften it. Or apply a light coat of an antibiotic ointment or petroleum jelly to the insertion tip for lubrication. This will make it easier to advance the packing and also less painful for patients. Advance the Merocel into the affected naris just as you would a nasogastric tube. Some additional tips are in the ALiEM article about nasogastric and nasopharyngeal tube insertion.

3. Once the nasal packing is fully inserted, expand the sponge by administering TXA via the attached angiocatheter. The mid-portion of the sponge should expand first, thus preventing outward slippage of packing. Also TXA more quickly reaches the area of bleeding rather than from a more gradual osmotic effect when dripped in from the external tip.

SplintER: Pop, Lock & Drop It

Shoulder

A 38-year-old female presents to the ED with right shoulder pain after a fall directly onto that shoulder. She noticed immediate pain and difficulty moving the arm associated with mild tingling in her right fingers. The radiographs above were obtained in the ED (Image 1. AP and lateral radiographs of the right shoulder, author’s own images).

 

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SAEM Clinical Images Series: An Enlarging Scalp Mass

scalp mass

A 27-day-old female infant born at 34 weeks 4 days with a prenatal history of maternal syphilis treated with penicillin presented with an enlarging scalp mass since birth. Since birth, the patient has had a 1 cm erythematous and flat lesion on her scalp. Since that time, the lesion has continued to grow and develop scales. On the day of presentation, the lesion was noted to be 7-8cm in diameter with multiple surrounding smaller lesions. There is some clear to bloody drainage coming from the main lesion. The patient has otherwise been growing and developing normally. No fevers or other sick symptoms. Feeding well. Mom has no concerns with bowel movements or voiding habits.

General: She is active. She is not in acute distress. She is well-developed.

HEENT: No congestion or rhinorrhea. Mucous membranes are moist. No posterior oropharyngeal erythema.

Cardiovascular: Normal rate and regular rhythm. Normal pulses. No murmur heard.

Pulmonary: Respiratory effort is normal. No retractions. Normal breath sounds. No wheezing.

Skin: Skin is warm. Capillary refill takes less than 2 seconds. On the left side of the scalp, there is a large raised keratinized plaque with a stuck-on appearance. Some red blood is noted when tapped with a white sheet. The plaque is firm and non-tender. On the rest of the scalp, there are several peeling flat lesions with hair attached, and intermittent alopecia.

Neurological: No focal deficit present. She is alert. Suck is normal.

Scalp ultrasound: Posteriorly exophytic left parietal lesion is peripherally echogenic, possibly representing a calcified lesion or cephalohematoma. CT or MRI may be useful for further evaluation, as clinically indicated.

a. Seborrheic Dermatitis: A common, self-limiting eruption consisting of erythematous plaques with greasy, yellow-colored scales that distribute to the areas of the body with sebaceous glands.

b. Atopic Dermatitis: Erythematous, scaly, crusted lesions that are poorly demarcated. It is pruritic and commonly involves the cheeks, scalp, and extensor surfaces.

c. Psoriasis: Uncommon in infants, but can mimic seborrheic dermatitis with sharply demarcated, shiny, erythematous plaques with fine silvery scales in non-intertriginous regions.

d. Tinea Capitis: While rare, tinea can present with a scaly scalp rash in infants. There may be a mild to moderate inflammatory reaction associated as well as hair loss.

e. Langerhans Cell Histiocytosis (LCH): LCH can present as refractory seborrheic dermatitis. There may also be papules or reddish-brown nodules that appear with the rash.

Pityriasis Amiantacea secondary to Seborrheic Dermatitis with a significant build-up of crust and scale. Pityriasis amiantacea is an exaggerated inflammatory response to regional dermatitis, most often seborrheic dermatitis. Treatment consists of a keratinolytic and antibacterial ointment. In this patient, 1:4 part vinegar and water soaks were recommended twice daily, followed by mupirocin ointment until the resolution of the lesions.

Take-Home Points

  • Seborrheic dermatitis is a commonly presenting rash in infancy.
  • When rashes are refractory to conservative management, additional diagnoses and sequelae need to be considered.

  • Amorim GM, Fernandes NC. Pityriasis amiantacea: a study of seven cases. An Bras Dermatol. 2016 Sep-Oct;91(5):694-696. doi: 10.1590/abd1806-4841.20164951. PMID: 27828657; PMCID: PMC5087242.
  • Olanrewaju O. Falusi; Seborrhea. Pediatr Rev February 2019; 40 (2): 93–95. https://doi.org/10.1542/pir.2017-0215. PMID: 30709979.

SplintER Series: Let the Feet Drop

A 20-year-old male distance runner who was jogging and happened to be running past the emergency department presented with severe bilateral leg pain, foot pain, and foot numbness that had resolved by the time he was evaluated in the ED. The x-ray above was obtained (Image 1. X-ray of the leg. Case courtesy of Andrew Murphy, Radiopaedia.org, rID: 41408).

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The Fall of FOAM

Fork in Road Disappearance of FOAM blog podcast

The landscape of emergency medicine and critical care (EM/CC) blogs and podcasts has changed dramatically over the past 20 years. The number of free, open-access EM/CC blogs and podcasts has plummeted. As reported by Lin and colleagues in JMIR Education (2022), these sites decreased in number from 183 in 2014 to just 109 this year– a drop of 40.1% [1].

via GIPHY

This comes after a period of rapid growth of these educational resources in the late 2000’s [2], with expectations that new sites would continue to come online. It is unclear when the combined number of EM/CC blogs and podcasts peaked, or how recently it declined.

Why do we care in these declining numbers?

The FOAM (free open-access medical education) movement has become an important component of EM curricula at many training programs. Online learning resources such as medical blogs and podcasts have all but replaced traditional textbooks, and research suggests that some trainees use these products as their primary study materials [3]. Therefore, the observed decrease in FOAM sites is alarming, as training programs and trainees have come to rely on their availability.

Featured paper

In our JMIR Medical Education paper, Lin et al. sought to identify active EM/CC blogs and podcasts during a 2-week period in May 2022. The authors found a total of 50 blogs, 25 podcasts, and 34 blogs + podcasts (n=109). The age of these FOAM sites ranged from 1-18 years and most were physician-led. Just over half had leadership teams of 5 or more individuals. Support was identified for approximately 75% of the sites and included advertisements, institutional sponsorship, or the sale of goods and services (though site access remained free).

The Christensen Theory of Disruptive Innovation may explain the recent decline in EM/CC blogs and podcasts. Using this lens, FOAM sites are considered ‘disruptors’ in medical education that quickly gained market share previously dominated by ‘incumbents’ such as medical textbooks, journals, and in-person conferences. Rather than cede their influence, incumbent organizations co-opted the disruptive innovation itself, in this case leveraging their assets to create their own online learning resources, blogs, and podcasts. As these incumbent offerings grew, there was less need for new, independent FOAM sites. Concurrently, FOAM sites continue to generate little-to-no revenue and academic value for the creators, making it difficult for the disruptors to challenge the market dominance of incumbents or to create its own unique, sustainable market space. We theorize that older sites likely succumbed to these financial and academic opportunity costs as well as high user expectations for design and functionality.

What is the future of FOAM?

Though EM/CC blogs and podcasts changed the landscape of medical education in fundamental ways, they will likely not endure as independent entities without new business models for sustainability. A recent study suggests that the costs of FOAM might be offset by advertising or other revenues [4]. Based on our observations of current practices on existing FOAM sites, this might include at least incorporating any/all of the following:

  1. Inserting advertisements
  2. Creating products for sale such as books, courses, swag, or consulting services
  3. Developing partnerships
  4. Soliciting for donations

In the meantime, we posit one of 3 potential futures of new and existing blogs and podcasts: hybridization, disappearance, and new-market independence.

future of foam christensen

  1. Hybridization strategy: Incumbents partner with or create their own blogs/podcasts. This loss of independence, which was part of the initial appeal of FOAM grassroots efforts, is traded for more stability and infrastructure. Already 44% of EM blogs are officially affiliated with a sponsoring institution.
  2. Continued disappearance of sites: Progressively fewer independent, free blogs/podcasts because of site demise, merging of sites, or conversion to paid subscription model
  3. Independent sustainability: Growth of independent, free blogs/podcasts as its own new-market endeavor, separate from the incumbent market space, only achievable with better return on investments (academically and financially) for bloggers/podcasters. Once FOAM efforts are no longer a major opportunity cost, educators may even be able to pivot their careers towards this primarily, rather than as a side project.

It remains to be seen whether FOAM can withstand market and academic pressures or whether it is destined to be assimilated by better-resourced incumbent organizations.

What is the future of ALiEM?

We hope to stick around and hope the rest of the FOAM community will evolve with us.

Comments?

Join the interesting discussion on Twitter. We are thrilled to bring this conversation to the forefront.

https://twitter.com/M_Lin/status/1582021848958500864?s=20&t=nBcJtrRvgML2QMRNnZkwwA

References

  1. Lin M, Phipps M, Yilmaz Y, Nash CJ, Gisondi MA, Chan TM. A Fork in the Road: Mapping the Paths of Emergency Medicine and Critical Care Blogs and Podcasts. JMIR Medical Education. 2022 (preprint available: https://doi.org/10.2196/39946)
  2. Cadogan M, Thoma B, Chan TM, Lin M. Free Open Access Meducation (FOAM): The rise of emergency medicine and critical care blogs and podcasts (2002-2013). Emerg Med J. 2014;31(e1):e76-e77. doi:10.1136/emermed-2013-203502
  3. Branzetti J, Commissaris C, Croteau C, et al. The Best Laid Plans? A Qualitative Investigation of How Resident Physicians Plan Their Learning [published online ahead of print, 2022 May 24]. Acad Med. 2022; doi:10.1097/ACM.0000000000004751
  4. Lee M, Hamilton D, Chan TM. Cost of free open-access medical education (FOAM): An economic analysis of the top 20 FOAM sites. AEM Educ Train. 2022;6(5):e10795. Published 2022 Sep 9. doi:10.1002/aet2.10795

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