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Greater Occipital Nerve Block in the Emergency Department

Chief complaints of non-traumatic headaches represent approximately 2% of emergency department (ED) visits in the United States [1]. Headaches are classified as primary (standalone condition) or secondary (a symptom of another medical condition), with primary headaches being the more common type [2].

In the ED, it is critical to rule out life-threatening causes of headaches such as subarachnoid hemorrhages, stroke, or meningitis. Headaches such as migraines, occipital neuralgia, cervicogenic headaches, and cluster headaches while more benign may still be debilitating for patients (Figure 1).

GON headache types

Figure 1. Headaches that may benefit from greater occipital nerve blockade [illustration by Dr. Felipe Ocampo]

Treatment of such headaches includes supportive care, medications, and procedures, including blockade of the greater occipital nerve (GON) [3, 4]. Peripheral nerve blocks such as GON blockade provide pain relief and its effects may outlast the duration of the local anesthetic. The GON block is an efficient, low-cost, and safe intervention for treatment of such headaches in the ED [5, 6]. In this article, we review the GON block, its relevant anatomy, indications, and procedural technique.

Identifying the Greater Occipital Nerve

Anatomy

Bilaterally, the GON originates from the second cervical spinal nerve (C2) and innervates the posterior scalp [7].

After arising from the C2 spinal nerve, the fibers of the GON ascend through the fascial plane between the obliquus capitis inferior and semispinalis capitis muscles. The fibers then pierce the semispinalis capitis and travel deep to the trapezius muscle until exiting the aponeurosis inferior to the superior nuchal line where it lies subcutaneously, medial to the occipital artery (Figure 2). The nerve measures approximately 2.5 to 3.5 mm in diameter [8].

Anatomy of greater occipital nerve for block

Figure 2: Anatomy around the greater occipital nerve (occipital aspect of the skull) [illustration by Dr. Felipe Ocampo]

GON Block: Necessary Equipment

The basic supplies one should collect for the GON block procedure:

  • Chlorhexidine gluconate or isopropyl alcohol applicator
  • 5 mL syringe
  • 18 gauge needle for drawing solution
  • 2 to 4 mL of either: 0.25 – 0.5% bupivacaine or 1 – 2% lidocaine
    • Consider a 1:1 mix in the same syringe for both short and longer lasting relief,
    • Example: 1.5 mL 1% lidocaine + 1.5 mL 0.25% bupivacaine
  • 1.5 inch 25- or 27-gauge needle for injecting solution

Note about inclusion of corticosteroids: The data is weak except in the case of cluster headaches where it is moderate [9].

equipment for greater occipital nerve block

Figure 3. Basic equipment necessary to perform a GON block [illustration by Dr. Felipe Ocampo]

GON Block: Procedural Technique

Procedural Technique #1: Palpation Approach

Traditionally, the GON block can be done by palpating the external occipital protuberance (OP) and the mastoid process (MP). Anesthetic is injected approximately one-third the distance from the OP to the MP (Figure 4) [6]. With this approach, the nerve is targeted more distally from its origin, where it is found more superficially at a median depth of 8 mm [10]. Here, the occipital artery can typically be palpated lateral to the location of the greater occipital nerve but anatomy can vary [11].

surface anatomy injection site for greater occipital nerve block

Figure 4: Injection site for the greater occipital nerve block along the occipital surface of the scalp [illustration by Dr. Felipe Ocampo]

  1. Position patients with their head flexed forward with either technique:
    • Sitting on the edge of the bed with their palms (or a procedure stand with a pillow) supporting their face
    • Prone with a pillow under the chest
  2. Find landmarks by palpating the external OP and MP
  3. Your target will be approximately one-third the distance from the OP to MP
  4. Ensure there is no palpable pulse at your target
  5. After sterilizing the area, insert the needle approaching from an inferior angle.
    • If you hit periosteum/skull, withdraw the needle slightly
    • Aspirate to ensure that you are not in the occipital artery or another vessel
    • Inject the anesthetic solution (typically 1-3 mL per side)
    • Consider slightly withdrawing and advancing while injecting to bathe multiple planes in anesthetic
  6. Assess for numbness along the posterior scalp (within 5 minutes for lidocaine and 10-15 minutes for bupivacaine)

Note: A modified version of this technique is to ask patients to pinpoint the area where pain is maximal or originates and if in general distribution of the GON between the OP and MP, this can be targeted assuming no palpable pulse and/or blood on withdrawal of syringe.

Procedural Technique #2: Ultrasound-Guided Approach

For the ultrasound-guided approach, the GON is typically targeted more proximally from its origin, at the level of the C2 vertebra. Here, the GON lies within the fascia above the obliquus capitis inferior (OCI) at a median depth of 1.8 cm [10].

  1. Positioning: same as landmark approach above.
  2. Prep the skin and transducer before insertion of the needle.
  3. Apply a generous amount of ultrasound gel to the lower posterior scalp
  4. A high-frequency linear probe is used with the indicator pointing towards the scanner’s left in the axial view starting at the midline external occipital protuberance (OP). With this view, one can see the semispinalis capitis (SSC) on either side. Note that this view may not be attainable in a patient with longer hair.
  5. Then, the probe can be translated downwards until the bifid C2 spinous process is visualized – here the trapezius, SSC, and obliquus capitis inferior (OCI) are seen on either side.
  6. By rotating the probe obliquely and slightly laterally towards the ear of the affected side, one can visualize the GON lying in the fascia above the OCI. Once this view is achieved, lateral to medial in-plane technique can be used to position the needle (25-27 gauge needle) adjacent to the GON, injecting 1-3 mL of solution to achieve spread around the nerve.
    • Pro Tip: The GON is often not visualized on ultrasound, but as long as your other landmarks are clear (between the OCI and SSC), injecting the solution into the plane is sufficient as long as you visualize your needle tip and confirm you are not intravascular.
  7. As with the palpation method, assess for numbness along the posterior scalp after 5-15 minutes, depending on anesthetic used.

ultrasound GON block

Figure 5: Illustrated sonographic views around the greater occipital nerve (yellow); SSC – semispinalis capitis, OP – occipital protuberance, TM – trapezius muscle, OCI – obliquus capitis inferior, C2 – C2 vertebra [illustration by Dr. Felipe Ocampo]

Greater occipital nerve block GON ultrasound anatomy

Figure 6: Sonographic anatomy of the greater occipital nerve (GON); TM- trapezius muscle, SSC – semispinalis capitis, OCI – obliquus capitis inferior, C2 – C2 vertebra [image from Dr. Felipe Ocampo]

GON Block: Comparing Techniques

Choosing a GON block technique may be up to clinician and/or patient preference or equipment availability.

Studies comparing the 2 approaches seem to favor ultrasound-guided GON blockade at the proximal (C2) site due to:

  • Improved analgesia [10]
  • A theoretical lower risk of damaging the occipital artery because (a) it is further from the GON in the proximal ultrasound-guided approach and (b) the ability to visualize structures [11]
  • Easier skin disinfection as injection site tends to be below the hairline [10, 11]
  • Anatomical variants in GON location making the landmark-based/palpation approach less accurate [14]

GON Block: Contraindications and Adverse Effects

Absolute Contraindications

  • Patient refusal
  • Anesthetic allergy
  • Open skull defect
  • Infection at procedural site

Relative Contraindications

  • Coagulopathy
  • Arnold-Chiari Malformations
  • Inability to lie still

Adverse Effects

  • Hematoma
  • Local infection
  • Lesion to nerve
  • Allergy to local anesthetics
  • Local anesthetic systemic toxicity (LAST)
  • Intradural infiltration
  • Vasovagal syncope
  • Alopecia around injection site

Common Indications for GON Block

1. Occipital Neuralgia

Occipital Neuralgia (ON) is a painful condition characterized by paroxysmal, lancinating, stabbing headaches along the posterior scalp that can last seconds to minutes [2]. The etiology of ON is thought to be due to irritation or compression of the occipital nerves, most commonly the GON. Symptoms are usually unilateral but can be bilateral in a third of cases [15, 16].

On exam, there may be dysesthesia (abnormal perceptions of touch) or allodynia (pain to typically non-painful stimuli) of the posterior scalp. There may also be a positive Tinel’s sign along the course of the GON.

A GON block can be both diagnostic and therapeutic by providing immediate relief and can provide up to 2 months of symptom relief [12].

2. Migraine

A migraine is a complex disorder that can be divided into two major subtypes: without aura (75%) and with aura. The etiology of migraines is unclear but some theories describe involvement of the peripheral and central nervous system, the former of which may involve sensory input from nerves including the GON [17].

Migraine characteristics:

  • Migraine without aura involves recurrent episodes of headache lasting 4-72 hours with at least two of the following characteristics: unilateral, pulsatile, moderate to severe in intensity, aggravated by or causing avoidance of physical activity. A migraine headache occurs with at least one of the following symptoms: nausea and/or vomiting, photophobia, phonophobia.
  • Migraine with aura is characterized by transient neurological symptoms that precede or accompany the headache described above. Auras involve at least one unilateral disturbance of: visual, sensory, speech and language, motor, brainstem.
  • A diagnosis is made with at least 5 attacks meeting the above criteria.
  • Chronic migraines are diagnosed when episodes occur 15 or more days per month for 3 months or longer [2].

GON blockade may be helpful for the immediate treatment of migraine episodes or as an alternative treatment in refractory episodes [12]. It has been shown to be as effective as a regimen of intravenous NSAIDs and metoclopramide in patients with acute migraine headaches in the ED [18]. In a case series of patients in the ED with migraine headaches, there were improved symptoms on 2-week call backs of patients who had received a GON block [19]. For chronic migraines, GON block may be as effective as current prophylactic treatments [12].

3. Cervicogenic Headache

Cervicogenic headaches are thought to be due to referred pain from disorders or lesions of the cervical spine or soft tissues of the neck. These headaches tend to be unilateral, moderate to severe in intensity, and may localize to the occipital, frontotemporal, and periorbital regions [2, 20]. Etiology is thought to be due to nociceptive signals from injury of structures in the neck innervated by C1-3 converging into the trigeminal cervical complex [12]. There may be clinical or imaging evidence of cervical lesions.

On exam, there may be decreased cervical range of motion and worsening of the headache with provoking maneuvers.

GON blockade may support diagnosis of cervicogenic headaches by rapidly relieving symptoms and may provide prolonged remission of headaches [12]. One study showed reduced analgesic medication consumption for months in patients with refractory cervicogenic headaches who had received GON blockade [21].

4. Cluster Headache

Cluster headaches are excruciating unilateral headaches that typically localize to the orbit with attacks lasting 15 minutes to 3 hours in duration [2]. This condition is rare, affecting approximately 0.1% of the population, most commonly males in their thirties. The etiology of cluster headaches is unclear but theories describe an association with the trigeminovascular system, parasympathetic nerve fibers, and the hypothalamus [22].

Cluster headache characteristics:

  • Severe, unilateral, orbital or supraorbital and/or temporal in location
  • Attacks occur with at least one ipsilateral autonomic symptom of:
    • Conjunctival injection or lacrimation
    • Nasal congestion or rhinorrhea
    • Eyelid edema or forehead or facial sweating
    • Miosis or ptosis
    • Unilateral photophobia or phonophobia
  • May involve agitation or restlessness
  • Occur with a frequency of once every other day to 8 times per day

GON blocks have been shown to be effective in both the acute and prophylactic treatment of cluster headaches [13, 23, 24]. The data for using corticosteroids in GON blocks is strongest for cluster headaches [12].

Conclusions

In the emergency department, it is critical to evaluate for life-threatening headaches. However, when indicated for patients presenting with specific headaches, the GON block may be an effective and efficient tool in providing analgesia.

References

  1. Goldstein JN, Camargo CA Jr, Pelletier AJ, Edlow JA. Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses. Cephalalgia. 2006;26(6):684-690. doi:10.1111/j.1468-2982.2006.01093.x PMID 16686907
  2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. doi:10.1177/0333102413485658. PMID 23771276
  3. Austin M, Hinson MR. Occipital Nerve Block. [Updated 2023 Apr 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  4. Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes–prolonged effects from a single injection. Pain. 2006;122(1-2):126-129. doi:10.1016/j.pain.2006.01.016. PMID 16527404
  5. Guner D, Bilgin S. Efficacy of Adding a Distal Level Block to a C2 Level Greater Occipital Nerve Block under Ultrasound Guidance in Chronic Migraine. Ann Indian Acad Neurol. 2023;26(4):513-519. doi:10.4103/aian.aian_169_23. PMID 37970254
  6. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7(2):197-203. doi:10.1016/j.nurt.2010.03.001. PMID 20430319
  7. Yu M, Wang SM. Anatomy, Head and Neck, Occipital Nerves. [Updated 2022 Oct 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  8. Güvençer M, Akyer P, Sayhan S, Tetik S. The importance of the greater occipital nerve in the occipital and the suboccipital region for nerve blockade and surgical approaches–an anatomic study on cadavers. Clin Neurol Neurosurg. 2011;113(4):289-294. doi:10.1016/j.clineuro.2010.11.021. PMID 21208741
  9. Benzon HT, Elmofty D, Shankar H, et al. Use of corticosteroids for adult chronic pain interventions: sympathetic and peripheral nerve blocks, trigger point injections – guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, the International Pain and Spine Intervention Society, and the North American Spine Society. Reg Anesth Pain Med. Published online August 7, 2024. doi:10.1136/rapm-2024-105593. PMID 39019502
  10. Greher M, Moriggl B, Curatolo M, Kirchmair L, Eichenberger U. Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br J Anaesth. 2010;104(5):637-642. doi:10.1093/bja/aeq052. PMID 20299347
  11. Gürsoy G, Tuna HA. Comparison of two methods of greater occipital nerve block in patients with chronic migraine: ultrasound-guided and landmark-based techniques. BMC Neurol. 2024;24(1):311. Published 2024 Sep 4. doi:10.1186/s12883-024-03816-8. PMID 39232647
  12. Santos Lasaosa S, Cuadrado Pérez ML, Guerrero Peral AL, et al. Consensus recommendations for anaesthetic peripheral nerve block. Guía consenso sobre técnicas de infiltración anestésica de nervios pericraneales. Neurologia. 2017;32(5):316-330. doi:10.1016/j.nrl.2016.04.017. PMID 27342391
  13. Blumenfeld A, Ashkenazi A, Napchan U, et al. Expert consensus recommendations for the performance of peripheral nerve blocks for headaches–a narrative review. Headache. 2013;53(3):437-446. doi:10.1111/head.12053. PMID 23406160
  14. Shim JH, Ko SY, Bang MR, et al. Ultrasound-guided greater occipital nerve block for patients with occipital headache and short term follow up. Korean J Anesthesiol. 2011;61(1):50-54. doi:10.4097/kjae.2011.61.1.50. PMID 21860751
  15. Djavaherian DM, Guthmiller KB. Occipital Neuralgia. [Updated 2023 Mar 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  16. Choi I, Jeon SR. Neuralgias of the Head: Occipital Neuralgia. J Korean Med Sci. 2016 Apr;31(4):479-488. https://doi.org/10.3346/jkms.2016.31.4.479. PMID 27051229
  17. Pescador Ruschel MA, De Jesus O. Migraine Headache. [Updated 2024 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  18. Korucu O, Dagar S, Çorbacioglu ŞK, Emektar E, Cevik Y. The effectiveness of greater occipital nerve blockade in treating acute migraine-related headaches in emergency departments. Acta Neurol Scand. 2018;138(3):212-218. doi:10.1111/ane.12952. PMID 29744871
  19. Yanuck J, Shah S, Jen M, Dayal R. Occipital Nerve Blocks in the Emergency Department for Initial Medication-Refractory Acute Occipital Migraines. Clin Pract Cases Emerg Med. 2019;3(1):6-10. Published 2019 Jan 22. doi:10.5811/cpcem.2019.1.39910. PMID 30775654
  20. Al Khalili Y, Ly N, Murphy PB. Cervicogenic Headache. [Updated 2022 Oct 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  21. Gabrhelík T, Michálek P, Adamus M. Pulsed radiofrequency therapy versus greater occipital nerve block in the management of refractory cervicogenic headache – a pilot study. Prague Med Rep. 2011;112(4):279-287. PMID 22142523
  22. Kandel SA, Mandiga P. Cluster Headache. [Updated 2023 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.
  23. Gönen M, Balgetir F, Aytaç E, Taşcı İ, Demir CF, Müngen B. Suboccipital steroid injection alone as a preventive treatment for cluster headache. J Clin Neurosci. 2019;68:140-145. doi:10.1016/j.jocn.2019.07.009. PMID 31326284
  24. Gordon A, Roe T, Villar-Martínez MD, Moreno-Ajona D, Goadsby PJ, Hoffmann J. Effectiveness and safety profile of greater occipital nerve blockade in cluster headache: a systematic review. J Neurol Neurosurg Psychiatry. 2023;95(1):73-85. Published 2023 Dec 14. doi:10.1136/jnnp-2023-331066. PMID 36948579
By |2025-03-26T14:01:20-07:00Mar 28, 2025|Expert Peer Reviewed (Clinical), Neurology|
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SAEM Clinical Images Series: Infantile Enigma

rash

A previously healthy 4-week-old born full-term presented to the emergency department with possible umbilical drainage and a new onset rash in the left lower abdominal region. The patient had an uncomplicated newborn stay with a mother with negative maternal serologies other than GBS positive, which was appropriately treated intrapartum. The patient had been gaining weight well without fevers or sick symptoms. Parents reported that their pediatrician had seen the patient earlier in the day for a routine check-up. Notably, a “cream” was applied to a small remnant of the umbilical cord that was still present. The parents noted that this abdominal rash was not present and only discovered during this evening’s diaper change. Parents had potentially accounted for this rash as a seat belt that may have been placed too tight.

General: Well-appearing neonate in no acute distress.

HEENT: Atraumatic, appropriate fontanelle. No abnormal bruising. No frenulum tears. No scalp hematomas.

Cardiac: Regular rate and rhythm. No auscultated murmur.

Pulmonary: Clear lung sounds bilaterally.

Abdomen: Soft, non-tender, non-distended. Umbilicus has homogenous darkening without evidence of fluctuance, erythema, or drainage. The left lower abdomen has a linear homogenously darkened macular rash without vesicular lesions, minimally erythematous, and no fluctuance.

Genitourinary: Phenotypic external male genitalia without rash.

Integumentary: Otherwise, no abnormal bruising or rash was noted.

None

To our knowledge, the “cream” that was applied to the umbilicus was silver nitrate, a joint compound used to cauterize umbilical granulomas. This compound is made of silver and potassium nitrate, activated when mixed with moisture. Its application may have unfavorable events if misapplied, and if applied to healthy skin, it may result in burns. We suspect this linear rash to be an accidental contact swipe of a silver nitrate stick. This patient was treated as a mild chemical burn – bacitracin applied along with a non-stick dressing and bandages with outpatient follow-up. In our evaluation of this patient, we considered early infection source or non-accidental trauma but did not pursue additional workup given this clinical history and presentation.

Take-Home Points

  • Silver nitrate sticks can be used to stop localized bleeding in the emergency department setting. It is important to be cautious when handling and applying as it may cause unwanted burns.

  • In the evaluation of the newborn rash, underlying severe infection or non-accidental trauma must be considered in the differential.

  • Sanyaolu L N, Javed M, Wilson-Jones N. A baby with a discharging umbilical lesion BMJ 2016; 355:i5587 doi:10.1136/bmj.i5587

  • Majjiga VS, Kumaresan P, Glass EJ. Silver nitrate burns following umbilical granuloma treatment. Arch Dis Child. 2005 Jul;90(7):674. doi: 10.1136/ adc.2004.067918. PMID: 15970607; PMCID: PMC1720504

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T22:13:27-07:00Mar 21, 2025|Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: What is in my Child’s Mouth?

cyst

A 16-month-old male with no significant past medical history presented with a chief complaint of bleeding from the mouth. The patient’s mother looked inside his mouth and described a “black ball of flesh” near the right side of his lower gum. The mother noted that he had been more fussy than usual and appeared to have a decreased appetite over the past few days. The mother was unsure how long the lesion had been present. The mother denied any recent witnessed falls, trauma, or injury. The mother denied any recent fever, emesis, skin rashes, or lesions. She reported that the patient is an otherwise healthy child without any drug allergies or daily medications.

 

General: He is not in acute distress. He is well-developed.

HEENT: Head: Normocephalic and atraumatic. Nose: Nose normal. No congestion or rhinorrhea. Mouth: Mucous membranes are moist. Purple-colored flesh- appearing nodule erupting from right lower gum. Dentition is intact and well-appearing.

Pharynx: Oropharynx is clear.

Skin: Warm and dry. No other skin rashes, lesions, or abrasions.

None

An eruption cyst (EC) is a dome-shaped soft tissue lesion associated with the eruption of primary or permanent teeth. An eruption hematoma forms when the cyst fluid contains blood, often appearing blue or black.

Differential diagnosis:

  • Retrocuspid papillae are small, firm, round, pink to red papules on the posterior surface of the gums, typically behind the lower canine teeth in most children. They are often bilateral.
  • Parulis or “gum boil” is a soft, solitary, red papule on the gums above or below a necrotic tooth, typically forming over a fistulous tract between the abscess and gums.
  • Dentigerous cyst (DC) is a well-defined area of radio-opacity that is characterized by permanent teeth that are incapable of eruption.
  • Neonatal alveolar lymphangioma (NAL) is a rare, benign condition that presents with a bluish-black fluid-filled dome on the alveolar ridge surface. This condition is most often seen in black neonates.
  • Oral hemangiomas are benign tumors that develop due to endothelial cell proliferation. The majority of these tumors will resolve over time and do not require treatment.
  • Amalgam tattoo is a localized area of blue, gray, or black pigmentation that is caused by excess amalgam inadvertently embedded during a dental procedure.

Eruption cysts are typically asymptomatic and will not require active treatment. The majority of ECs burst spontaneously with the passage of the tooth. If the cyst is symptomatic, simple surgical excision by a dental profressional is recommended, as well as pain control with acetaminophen and ibuprofen. This procedure consists of incising the cyst roof to allow drainage of fluid and descent of the tooth.

Take-Home Points

  • Eruption cysts can be managed conservatively with pain control and anticipatory guidance.

  • If symptomatic, patients with eruption cysts should be referred to a dental provider for further evaluation and possible surgical excision.

  • If the eruption cyst does not resolve within two weeks, the patient should be evaluated for other causes.

  • Dhawan, Preeti, et al. “Eruption cysts: A series of two cases.” Dental Research Journal, vol. 9, no. 5, 2012, p. 647, https://doi.org/10.4103/1735-3327.104889.

  • Keels, Martha Ann. “Soft Tissue Lesions of the Oral Cavity in Children.” UpToDate, www.uptodate.com/contents/soft-tissue-lesions-of-the-oral-cavity-in-children/print. Accessed 28 Dec. 2023.

  • Sen-Tunc, E, et al. “Eruption cysts: A series of 66 cases with clinical features.” Medicina Oral Patología Oral y Cirugia Bucal, 2017, pp. 0–0, https://doi.org/10.4317/medoral.21499.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T22:05:32-07:00Mar 17, 2025|Dental, SAEM Clinical Images|
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SAEM Clinical Images Series: A Rare Cause of Dyspnea

pneumopericarditis

A 73-year-old female with past medical history significant for Roux-en-Y gastric bypass 14 years prior complicated by gastro-jejunal ulcers, rheumatoid arthritis on daily prednisone for six months, coronary artery disease, history of remote pulmonary embolism no longer on anticoagulation, GERD, non-insulin dependent type 2 diabetes, morbid obesity, and chronic obstructive pulmonary disease, presented with two-week progression of dyspnea after a ground level fall. She endorsed pain to her neck, back, and stomach. She denied any chest pain, cough, hemoptysis, fevers, chills, leg pain, leg swelling, wheezing, recent surgeries or hospitalizations, recent travel, or history of tobacco use.

 

Vitals: Temp 98.4°F; HR 81; BP 61/46; RR 19; O2 sat 96% on 6L nasal cannula

General: Not in acute respiratory distress. Appears ill.

Neurologic: A&OX4. Face is symmetrical. Following commands. Moves all four limbs spontaneously.

Cardiovascular: Normal rate and rhythm without murmurs, gallops, or rubs. Heart sounds are muffled. Unable to assess for JVD due to body habitus.

Pulmonary: Lungs clear to auscultation bilaterally. No wheezing, rhonchi, rales. No accessory muscle use. Speaking in full sentences.

Abdominal: Diffusely tender to deep palpation. No rebounding, guarding, or tenderness.

Extremities: DPs 2+ and radials 2+. No asymmetric leg swelling. Legs non-tender.

CBC: WBC 12.5 k/µL, hemoglobin 10.3 g/dL

Lactate: 5.0 mmol/L

ABG: pH 7.34, PaCO2 28.3 mmHg, PaO2 78.5 mmHg, O2 sat 94.5%, bicarb 14.8 mmol/L

Blood glucose: 125 mg/dL

Troponin: 132, 133 ng/L.

EKG: Normal sinus rhythm with low voltage and ST-segment elevations in lead II, V3-V6

The diagnosis is pyopneumopericarditis from a pericardial-jejunal fistula. The differential diagnosis for pneumopericarditis includes a history of blunt or penetrating trauma, thoracic surgery or pericardial fluid drainage, positive pressure ventilation, and infectious pericarditis. In this case, the cause was a fistula likely as a side effect of chronic steroid use, which increases the risk of peptic ulcer disease.

Definitive management requires operative intervention with thoracic surgery. Pneumopericarditis carries a high mortality risk and a high risk for tamponade or cardiogenic shock from myopericarditis, as well as septic shock if infection is also present. Therefore, disposition for these patients usually requires surgical intensive care for close hemodynamic and respiratory monitoring and support. It is prudent to start broad-spectrum antibiotics and obtain blood cultures, as well as intraoperative pericardial fluid cultures to narrow antibiotic selection. CT esophagram and/or endoscopy is often indicated to rule out a pericardial-enteric fistula if there are no other immediate causes unveiled on history and examination. The patient should also receive aspirin and colchicine if concomitant myopericarditis is present.

Take-Home Points

  • Pneumopericarditis requires early, aggressive operative intervention and intensive care management.

  • Use steroids judiciously in patients with known gastritis or peptic ulcer disease.

  • Azzu V. Gastropericardial fistula: getting to the heart of the matter. BMC Gastroenterol. 2016 Aug 19;16(1):96. doi: 10.1186/s12876-016-0510-8. PMID: 27542946; PMCID: PMC4992300.
  • Davidson JP, Connelly TM, Libove E, Tappouni R. Gastropericardial fistula: radiologic findings and literature review. J Surg Res. 2016 Jun 1;203(1):174-82. doi: 10.1016/j.jss.2016.03.015. Epub 2016 Mar 15. PMID: 27338548.
  • Murthy S, Looney J, Jaklitsch MT. Gastropericardial fistula after laparoscopic surgery for reflux disease. N Engl J Med. 2002 Jan 31;346(5):328-32. doi: 10.1056/NEJMoa010259. PMID: 11821509.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T21:57:21-07:00Mar 14, 2025|Cardiovascular, Gastrointestinal, SAEM Clinical Images|
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SAEM Clinical Images Series: An Unusual Arm Conundrum

shoulder

A 58-year-old female with a past medical history significant for osteoporosis presented with right shoulder pain after a witnessed mechanical fall down two stairs. She sustained no headstrike or loss of consciousness. She endorses severe right shoulder pain without numbness/tingling over any part of her arm. Since the fall, she has been unable to move her arm, which remains abducted overhead.

 

dislocation

General: Right arm fixed, abducted position and elevated over her head.

Vascular: 2-second capillary refill in all nail beds, strong palpable radial pulse.

Neuro: Sensation intact to light touch on medial and lateral aspects of all distal digits, and throughout entire axillary, radial, ulnar and median nerve distribution.

Motor: Flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) intact in digits 2 through 5. Extensor digitorum communis (EDC) and extensor indicis proprius (EIP) intact. Normal finger abduction and adduction. Normal thumb opposition. Normal OK sign. Wrist flexors and extensors intact.

None

Luxatio erecta (inferior shoulder dislocation) is a rare type of shoulder dislocation. The majority of shoulder dislocations are anterior (over 95%), with a smaller number being posterior (2-4%). Inferior dislocations are the least common injury pattern (0.5%), but prompt identification and treatment are crucial due to the high risk of neurovascular damage.  Radiographs will typically demonstrate the humeral head lying inferior to the glenoid fossa, with the humeral shaft parallel to the spine of the scapula. Classically, the entire arm is held in abduction.

Inferior shoulder dislocation most commonly occurs either due to hyperabduction of the shoulder (such as when grasping at a tree branch above while falling) or through an axial load from above on a hyperabducted arm (as seen in falls or motor vehicle accidents). Patients presenting with inferior shoulder dislocation are at substantial risk for neurovascular compromise, particularly of the axillary nerve, leading to impaired upper extremity movement and sensation. Due to the substantial injury mechanism, patients with inferior shoulder dislocations are also at increased risk for rotator cuff pathology. Treatment of inferior shoulder dislocation is immediate closed reduction to reduce the risk of neurovascular complications. Once reduced, the arm should be placed in an immobilizer to prevent recurrent dislocation.

Take-Home Points

  • Patients with inferior shoulder dislocations often present holding their arm above their head. Often, patients cannot adduct their arm.

  • Axillary nerve injuries occur in about 60% of inferior dislocations. Compared to other dislocations, inferior dislocations have the highest incidence of axillary nerve injuries.

  • Patients with inferior dislocations often present with neurovascular compromise of the affected arm, so be sure to do a thorough exam after reduction.

  • Grate I Jr. Luxatio erecta: a rarely seen, but often missed shoulder dislocation. Am J Emerg Med. 2000 May;18(3):317-21. doi: 10.1016/s0735-6757(00)90127-x. PMID: 10830689.

  • Nambiar M, Owen D, Moore P, Carr A, Thomas M. Traumatic inferior shoulder dislocation: a review of management and outcome. Eur J Trauma Emerg Surg. 2018 Feb;44(1):45-51. doi: 10.1007/s00068-017-0854-y. Epub 2017 Oct 3. Erratum in: Eur J Trauma Emerg Surg. 2018 Feb;44(1):53. doi: 10.1007/s00068-017-0878-3. PMID: 28975397.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2025-03-09T21:48:15-07:00Mar 10, 2025|Orthopedic, SAEM Clinical Images|
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