ACMT Toxicology Visual Pearl: A Toxic Tuber
Improper preparation of this food causes poisoning from which toxic compound?
- Atropine
- Cicutoxin
- Cyanide
- Oxalic acid
Image from Wikimedia Commons [1]
SAEM Clinical Images Series: Infantile Enigma
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.
SAEM Clinical Images Series: What is in my Child’s Mouth?
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
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Eruption cysts can be managed conservatively with pain control and anticipatory guidance.
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If symptomatic, patients with eruption cysts should be referred to a dental provider for further evaluation and possible surgical excision.
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If the eruption cyst does not resolve within two weeks, the patient should be evaluated for other causes.
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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.
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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.
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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.
SAEM Clinical Images Series: A Rare Cause of Dyspnea
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
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Pneumopericarditis requires early, aggressive operative intervention and intensive care management.
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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.
SAEM Clinical Images Series: An Unusual Arm Conundrum
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.
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
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Patients with inferior shoulder dislocations often present holding their arm above their head. Often, patients cannot adduct their arm.
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Axillary nerve injuries occur in about 60% of inferior dislocations. Compared to other dislocations, inferior dislocations have the highest incidence of axillary nerve injuries.
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Patients with inferior dislocations often present with neurovascular compromise of the affected arm, so be sure to do a thorough exam after reduction.
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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.
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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.
ACMT Visual Pearl: If the Glove Fits
What medication given intravenously can cause the pictured finding?
- Carbamazepine
- Levetiracetam
- Phenytoin
- Valproic Acid
Image from Dr. Fabio Corsi, MD [1]
ALiEM AIR Series | HEENT Module (2025)
Welcome to the AIR HEENT Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to related to HEENT emergencies in the Emergency Department. 4 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 2 AIR and 2 Honorable Mentions. We recommend programs give 2 hours of III credit for this module.
AIR Stamp of Approval and Honorable Mentions
In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.
Want asynchronous Individualized Interactive Instruction (III) credit?
Take the AIR quiz at ALiEMU. Free, 1-time login required.
Highlighted Quality Posts: HEENT 2025
| Site | Article | Author | Date | Label |
| EMCrit | Epiglottitis | Dr. Josh Farkas | July 22, 2024 | AIR |
| EMDocs | Auricular Hematoma | Dr. Jacob Tauferner, Dr. Mihir Patel | April 13, 2024 | AIR |
| EMDocs | Malignant/Necrotizing Otitis Externa | Dr. Russ Burgin, Dr. Rachel Bridwell | April 27, 2024 | HM |
| Taming the SRU | Diagnostics and Therapeutics: Ear Emergencies in the Department | Dr. Nicole Lewis | November 14, 2023 | HM |
(AIR = Approved Instructional Resource; HM = Honorable Mention)
If you have any questions or comments on the AIR series, or this AIR module, please contact us!
Reference
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- Lin M, Phipps M, Chan TM, et al. Digital Impact Factor: A Quality Index for Educational Blogs and Podcasts in Emergency Medicine and Critical Care. Ann Emerg Med. 2023;82(1):55-65. doi:10.1016/j.annemergmed.2023.02.011, PMID 36967275