SAEM Clinical Image Series: Eye Pain

necrotizing

A 59-year-old gentleman experiencing homelessness with a history of hepatocellular carcinoma, hepatitis C, alcohol use disorder, and tobacco dependence presented to the emergency department (ED) with severe, worsening right eye pain, blurry vision, swelling, redness, and purulent discharge after scraping his upper face on concrete during a mechanical fall two weeks prior. Of note, his partner presented to the ED at the same time with a necrotic infection of the breast as well as multiple skin lesions reportedly due to insect bites.

Physical Exam

Vitals: T 102.4°F; HR 108; BP 121/94

Head: Lice nits visible in his hair

Eye: Unable to open right eye without assistance; eyelids crusted and necrotic with underlying orbicularis oculi muscle visible; EOM full but painful in all fields of gaze; visual acuity 20/60 in each eye; pupils 2 mm, equal and minimally reactive.

Laboratory Data

White blood cell (WBC) count: 27,600/μl

Comprehensive metabolic panel (CMP): Na 121; K 2.8; Cl 83; AST 113; ALT 45

Wound culture: Positive for MRSA, Streptococcus pyogenes, Enterobacter cloacae, and Staphyloccocus epidermis

Case Question: What is the diagnosis? What risk factors may have predisposed him to this condition?

This patient’s presentation is consistent with periorbital necrotizing fasciitis complicated by severe sepsis.

This patient had type 1 necrotizing fasciitis given the polymicrobial source of infection with both aerobic and anaerobic organisms growing from his wound culture. Type 2 necrotizing fasciitis is attributable to streptococcal and/or staphylococcal infection alone. Group A strep is the most common organism responsible for necrotizing fasciitis, found in about 50% of cases.

Independent risk factors for necrotizing fasciitis include advanced age, diabetes mellitus, heart disease, liver cirrhosis, alcohol use disorder, and trauma. Furthermore, persons who experience homelessness are at risk of skin lesions due to insect bites, burns, and physical trauma which predispose them to secondary bacterial infections because of inadequate hygiene resources.

A systematic review of periorbital necrotizing fasciitis showed that 35% of cases were triggered by trauma, while 14% were caused by other infections such as acute dacryocystitis, sinus infections, and infections of the parotid glands. Thus, it is likely that the patient’s contact with his partner who had a necrotic soft tissue infection secondary to insect bites, as well as his recent trauma to the eye, predisposed his development of this condition.

Case Question: What is the most appropriate management of this patient?

Initiation of broad-spectrum intravenous (IV) antibiotics with vancomycin, piperacillin/tazobactam, and clindamycin, as well as IV fluids.

In this case, the patient received the above antibiotics, underwent operative debridement, frequent wound care including dilute hypochlorous acid, local vancomycin administered via intra-orbital catheter, as well as lid reconstruction with glabellar flap. He was ultimately discharged on a two-week course of oral moxifloxacin and linezolid, healing well at his one-month follow-up appointment.

Case Discussion

Take-Home Points

Skin problems are a common reason that persons experiencing homelessness seek medical care, given their risk factors for both primary insults and subsequent superinfection.

Common sources of infection for periorbital necrotizing fasciitis include trauma, surgery, and other infections of the upper face.

The standard of care for periorbital necrotizing fasciitis consists of IV and local antibiotics, and operative debridement.

References

Amrith S, Hosdurga Pai V, Ling WW. Periorbital necrotizing fasciitis — a review. Acta Ophthalmol. 2013 Nov;91(7):596-603. doi: 10.1111/j.1755-3768.2012.02420.x. Epub 2012 Apr 20. PMID: 22520175.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By Manasa Bhatta|2022-01-19T13:59:38-08:00Jan 31, 2022|Dermatology, Infectious Disease, Ophthalmology, SAEM Clinical Images|

Human Trafficking in the ED – What you need to know

Human trafficking is a devastating crime, where a human being’s labor is exploited through force, fraud, or coercion, for someone else’s profit (1). For survivors, connecting to support in the community can be incredibly difficult, and may come at the expense of their personal safety (1, 2).

The emergency department (ED) is a rare exception, with some studies estimating that over 60% of trafficked persons will present at some point during their exploitation to the ED (3). Unfortunately, less than 5% of emergency physicians report feeling confident in their ability to identify a trafficked person, citing confusion around patient characteristics and their role as a provider (4).

By learning more about human trafficking, ED providers can better prepare themselves to identify and provide appropriate support to those who experience human trafficking.

What can I do to be ready in the ED?

Understand what human trafficking is and its consequences
Recognize personal bias
Become familiar with how to identify, assess, document, and refer cases of human trafficking
Know your options for survivor advocacy

Click to view full-size image.

Just the Facts – Human Trafficking

What is Human Trafficking?

Human trafficking always involves 3 components –an act, a means, and a purpose.

The “act” refers to the role a trafficker is playing in exploiting the person
The “means” refers to the use of force, fraud, or coercion to exploit a person
The “purpose” is what type of labor they are exploited for (1)

Often human trafficking will overlap with other crimes such as assault, domestic violence, rape, and child abuse (5). Of note, anyone under the age of 18 engaged in commercial sex is considered to be sex trafficked regardless of whether a means is present, as they cannot provide consent.

How many people are affected?

Human trafficking is widespread, but is often undetected, making true estimates of size difficult.

For example, human trafficking prevalence estimates may fail to account for survivors who do not recognize they are being exploited or are afraid to disclose (6, 7).

Who is trafficked?

While no identity is spared, there are certain populations that are at greater risk. These may include:

People of color
Children in welfare and juvenile justice systems
Runaway and homeless youth
Children working in agriculture
Indigenous patients
Migrant laborers
Foreign national domestic workers
Patients with limited English
Patients with disabilities
Members of the LGBTQ community
Patients with limited education
Patients who use substances (6,8)

Why are they targeted?

The only thing all trafficked persons have in common is their vulnerability (1). Trafficking determinants can be conceptualized as “push” and “pull” factors. Push factors lead people to away from their current situation to trafficking (e.g., abuse, poverty, family conflict). Pull factors, drive an individual to something new that increases the risk of trafficking (e.g., income, housing, access to substances) (9, 10).

Who are the traffickers?

In the same way that anyone can be trafficked, anyone can be a trafficker.

Traffickers may be well known in the community, recruiting victims from places of employment or education (1). They may be a family member. They may also lure at-risk individuals by acting as a romantic partner, or by providing emotional affirmation, financial assistance, and material goods (1).

How do traffickers coerce survivors?

A number of tactics can be employed by traffickers, each tailored to the individual survivor but can include any combination of the following (1).

Physical violence
Sexual violence
Emotional violence
Withholding basic needs (food, water, shelter)
Intimidation
Coercion and threats
Economic coercion
Social isolation

Specific situations to be wary of:

Runaway or homeless youth – greater incidence of “survival sex,” where sexual acts are exchanged for basic necessities (1, 11)
Recent immigrants – withholding documentation/ fear of deportation are used as powerful coercion tactic (1, 5, 6)

What are some of the health consequences of Human Trafficking (6)?

Physical abuse (traumatic injury, chronic pain)
Sexual abuse (sexually transmitted infections, pregnancy)
Emotional abuse (post-traumatic stress disorder, suicide ideation)
Poor living conditions (malnutrition, dehydration, exposure injuries)
Substance use, overdose
Death

10 Common Misconceptions of Human Trafficking

Click to view full-size images

Guide for Emergency Department Providers

What are the primary goals of an ED visit with a potentially trafficked patient?

Address the acute presenting illness or injury
Establish the ED as a haven from trauma or exploitation
Offer additional resources, if appropriate and available

The goal of the visit is NOT to elicit a disclosure.

Your role as a provider is not to investigate or confirm the presence of trafficking, but to respect the autonomy of the patient in front of you, meet their healthcare needs, and empower them to seek additional support on their terms.

What steps should I take during my encounter?

Capitalize on the same “trauma-informed” principles used to care for survivors of intimate partner violence and child maltreatment.
Encounter tips (1, 6, 12)
- Separate the potential victim from accompanying persons
If difficult, ask the patient to move to another room for an x-ray or routine test.
- Use a trained interpreter when required
- Foster trust and establish rapport
- Use education about rights and resources as an empowerment tool (12)
Providing nonjudgmental education around violence and safety can normalize the sharing of information and open discussion (12)
- Be patient
- Always get consent before proceeding with any next steps (physical exam, diagnostic tests, and involvement of other providers)

Click for full-size images

Red flags For Human Trafficking (1, 13)

Patient Indicators	Companion Indicators
Delayed presentation	Refuses to leave
Discrepancy between history and clinical presentation	Insists on translating or speaking for the patient
Scripted/memorized history	Controlling, interrupting
Hypervigilance, fearful	Has patient’s documents in their possession
Cannot produce identification	Employer demanding access to medical information
Work-related injury with unsafe conditions
Fearful attachment to a cell phone (often used for communication and tracking)

Red flags for pediatric patients (1, 14)

Accompanied by unrelated, non-guardian adults
Material possessions you reasonably doubt they would be able to afford
Truancy or running away
Multiple sexual “partners”

What are the next steps after my assessment?

Any next steps should always be determined by the patient

Referrals (social work, case manager or discharge specialist, local advocacy services) (6, 15)
Human Trafficking Hotline
- USA – National Human Trafficking Hotline at 1-888-373-7888
- Canada – Canadian Human Trafficking Hotline at 1-833-900-1010

Consider offering admission if unsafe to discharge
Clear and accurate documentation (may be relevant to future legal proceedings)
Consider notifying security if appropriate (6)

Unless local criteria for mandatory reporting are met, Police should only be contacted at the explicit instruction of the patient (6, 16).

Interested in advocacy?

Consider implementing an ED and institutional protocol for human trafficking. A complete protocol guide is available through HEAL Trafficking.

References

Alpert EJ, Ahn R, Albright E et al. Human Trafficking: Guidebook on Identification, Assessment, and Response in a Healthcare Setting. Boston, MA: MGH Human Trafficking Initiative, Division of Global Health and Human Rights, Department of Emergency Medicine.
Human Trafficking. Public Safety Canada, Government of Canada. 2019.
Lederer L, Wetzel C. The Health Consequences of Sex Trafficking and Their Implications for Identifying Victims in Healthcare Facilities. Ann Heal Law. 2013;23(1):61–91.
Viergever RF, West H, Borland R, Zimmerman C. Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Front Public Heal. 2015;3:1–9. PMID: 25688343
Canada’s Human Trafficking Laws. British Columbia Public Health Agency. 2014.
Shandro J, Chisolm-Straker M, Duber HC, Findlay SL, Munoz J, Schmitz G, et al. Human Trafficking: A Guide to Identification and Approach for the Emergency Physician. Ann Emerg Med. 2016;68(4):501-508.e1. PMID: 27130802
Global Report on Trafficking in Persons [Internet]. New York; 2014. Available from: https://www.unodc.org/res/cld/bibliography/global-report-on-trafficking-in-persons_html/GLOTIP_2014_full_report.pdf
2021 Trafficking in Persons Report – United States Department of State [Internet]. U.S. Department of State; 2021. Available from: https://www.state.gov/reports/2021-trafficking-in-persons-report/
Macias Konstantopoulos W, Ahn R, Alpert EJ, Cafferty E, McGahan A, Williams TP, et al. An international comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. J Urban Health. 2013. PMID: 24151086
Calhoun C. Push and pull factors. Oxford Dictionary. Soc Sci Oxford Univ Press. 2002;
Walls NE, Bell S. Correlates of engaging in survival sex among homeless youth and young adults. J Sex Res. 2011. PMID: 20799134
PEARR Tool Trauma-Informed Approach to Victim Assistance in Health Care Settings. Dignity Health, in partnership with HEAL Trafficking and Pacific Survivor Center. 2019.
Identifying Victims of Human Trafficking: What to look for in a healthcare setting. National Human Trafficking Resource Center. The Polaris Project.
Tracy EE, Konstantopoulos WMI. Human trafficking: A call for heightened awareness and advocacy by obstetrician-gynecologists. Obstet Gynecol. 2012. PMID: 22525917
Meshkovska B, Siegel M, Stutterheim SE, Bos AER. Female sex trafficking: Conceptual issues, current debates, and future directions. J Sex Res. 2015. PMID: 25897567
Zimmerman C BR. Caring for Trafficked Persons: Guidance for Health Providers. Health Providers. Geneva, Switzerland: International Organization for Migration. 2009.

By Hanni Stoklosa, MD, MPH|2024-04-16T18:33:41-07:00Jan 29, 2022|Emergency Medicine, Expert Peer Review (Non-Clinical), Psychiatry|

Beyond the Abstract: Systematic Online Academic Resource Review #2: Endocrine, Metabolic and Nutritional Disorders

Planning to write the next great FOAM post on hyperkalemia, but not sure what’s already been done? Or maybe a less popular topic, that you hope has minimal coverage? Or are you a resident, medical student, or even a curious attending searching for the latest, best FOAM regarding a specific topic?

If so, then we have great news for these answers are here in the recently published second Systematic Online Academic Resource (SOAR) Topic Review.¹ This series aims to identify and evaluate online education resources by topic. The inaugural entry has already revealed the FOAM landscape related to the renal and genitourinary organ system.² We can now share results for endocrine, metabolic and nutritional disorders.

We developed search terms specific to endocrine, metabolic and nutritional Disorders from the American Board of Emergency Medicine’s Model of the Clinical Practice of Emergency Medicine (MPCEM). We then performed a systematic search of both FOAMSearch as well as each site within the social media index top 50.^3,4 We then assessed the quality of those resources using the revised METRIQ score and designated learner levels for each resource.⁵

The search yielded 36,346 resources, of which 756 met the criteria for quality assessment. Table 1 displays the 121 posts identified as high quality (rMETRIQ ≥ 16). Overall, the most covered subtopic was potassium disorders, representing 15% of all posts. Subtopics that did not have a high-quality resource identified include metabolic alkalosis, respiratory alkalosis, fluid overload, phosphorus metabolism, hyperglycemia, malabsorption, malnutrition and thyroiditis. Table 2 graphically describes the number of high-quality posts by subtopic coverage and recommended target audience. Of note, resources that were better categorized under a different MCPEM category were generally not included. For example, fluid overload content specific to heart failure was not included.

We hope that educators and learners can use this information to find relevant educational resources, and that FOAM content creators can use this information to help identify topics to produce new content.

Subtopic	Name of First Author	Name of Blog Post	Level of Trainee Recommendation
Metabolic Acidosis	Farkas, Josh	PulmCrit: pH-guided fluid resuscitation & BICAR-ICU	Intern, Junior, Senior, Attending
Metabolic Acidosis	Farkas, Josh	Is correcting hyperchloremic acidosis beneficial?	Intern, Junior, Senior, Attending
Metabolic Acidosis	Rusyniak, Dan	Tox & Hound – aka AKA	Intern, Junior, Senior, Attending
Metabolic Acidosis	Multiple	Alcoholic ketoacidosis – WikEM	Clerk, Intern, Junior, Senior
Metabolic Acidosis	Spiegel, Rory	CC Nerd-The Case of the Neutral Documents	Clerk, Intern, Junior, Senior, Attending
Respiratory Acidosis	Chan, Wendy	VBG vs ABG in Hypercarbia	Clerk, Intern, Junior, Senior
Acid Base (Mixed)	Farkas, Josh	Fluid selection using pH-guided resuscitation	Intern, Junior, Senior, Attending
Acid Base (Mixed)	Weingart, Scott	Acid Base in the Critically Ill – Part V – Enough with the Bicarb Already	Intern, Junior, Senior, Attending
Corticoadrenal Insufficiency	Long, Brit	Mimics of Sepsis: What do ED Physicians Need to Know?	Intern, Junior, Senior
Corticoadrenal Insufficiency	Farkas, Josh	Adrenal crisis – EMCrit Project	Intern, Junior, Senior, Attending
Corticoadrenal Insufficiency	Gaillard, Frank	Adrenal hemorrhage \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Cushing’s Syndrome	Multiple	Cushing syndrome \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Calcium	Long, Brit	Oncologic Emergencies Part I: Pearls and Pitfalls	Intern, Junior, Senior, Attending
Calcium	Swaminathan, Anand	Hypercalcemia	Intern, Junior, Senior, Attending
Calcium	Multiple	Hypocalcemia – WikEM	Intern, Junior, Senior, Attending
Calcium	Taliaferro, Dustin	EM@3AM: Hyper- and HypoCa	Intern, Junior, Senior, Attending
Hypovolemia	Astin, Matt	The SPLIT Trial: Saline vs Plasma-Lyte Fluid Therapy	Intern, Junior, Senior, Attending
Hypovolemia	Rezaie, Salim	SMART Trial Part 2: Secondary Analysis of Balanced Crystalloids vs Saline in Sepsis	Clerk, Intern, Junior, Senior
Hypovolemia	Rezaie, Salim	Is the Great Debate Between Balanced vs Unbalanced Crystalloids Finally Over?	Clerk, Intern, Junior, Senior
Hypovolemia	Rezaie, Salim	Does Lactated Ringers (LR) Raise Serum Lactate?	Clerk, Intern, Junior, Senior
Hypovolemia	Farkas, Josh	PulmCrit- Get SMART: Nine reasons to quit using normal saline for …	Intern, Junior, Senior, Attending
Hypovolemia	Farkas, Josh	IBCC chapter & cast – Fluid selection & pH-guided fluid resuscitation	Intern, Junior, Senior, Attending
Hypovolemia	Farkas, Josh	The SPLIT trial: Internal vs. external validity	Intern, Junior, Senior, Attending
Hypovolemia	Rezaie, Salim	Balanced vs Unbalanced Fluids in Pediatric Severe Sepsis	Clerk, Intern, Junior, Senior
Hypovolemia	Multiple	Fluid Choice in Sepsis: Does it matter?	Clerk, Intern, Junior, Senior, Attending
Hypovolemia	Kenny, Jon-Emile	Are balanced crystalloids better than saline? SMART Talk with Dr …	Intern, Junior, Senior, Attending
Hypovolemia	Farkas, Josh	PulmCrit- Overcoming occult diuretic resistance: Achieving diuresis …	Attending
Hypovolemia	Multiple	CT hypoperfusion complex \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Hypovolemia	Multiple	Dehydration (peds) – WikEM	Clerk, Intern, Junior, Senior, Attending
Hypovolemia	Rezaie, Salim	The Great Debate Between Balanced and Unbalanced Crystalloids Continues	Junior, Senior, Attending
Hypovolemia	Morgenstern, Justin	IV fluid choice part 1: The SPLIT trial	Clerk, Intern, Junior, Senior, Attending
Hypovolemia	Drenzla, Adam	SALT OF THE EARTH (PART 1)	Clerk, Intern, Junior, Senior
Potassium	Meyers, Pendell	Critical Hyperkalemia by H. Pendell Meyers, EMCrit Intern – EMCrit	Junior, Senior, Attending
Potassium	Farkas, Josh	Hyperkalemia – EMCrit Project	Clerk, Intern, Junior, Senior
Potassium	Farkas, Josh	Management of severe hyperkalemia in the post-Kayexalate era	Intern, Junior, Senior, Attending
Potassium	Swaminathan, Anand	Is Kayexalate Useful in the Treatment of Hyperkalemia in the …	Clerk, Intern, Junior, Senior
Potassium	Singh, Manpreet	Hyperkalemia – The Great Imitator	Clerk, Intern, Junior, Senior
Potassium	Multiple	Tumor Lysis Syndrome – Diagnosis and Treatment	Clerk, Intern, Junior
Potassium	Multiple	Management of the Sick Dialysis/ESRD Patient	clerk, intern, Junior, senior
Potassium	Meyers, Pendell	A young man with back spasms	Intern, Junior, Senior
Potassium	Helman, Anton	Emergency Management of Hyperkalemia \| EM Cases Podcast	Junior, Senior, Attending
Potassium	Long, Brit	Updates in Management of Hyperkalemia	Clerk, Intern, Junior, Senior
Potassium	Weingart, Scott	Treatment of hyperkalemia in the ED	Clerk, Intern, Junior, Senior
Potassium	Farkas, Josh	PulmCrit- BRASH syndrome: Bradycardia, Renal failure, Av blocker …	intern, Junior, senior, attending
Potassium	Farkas, Josh	Myth-busting: Lactated Ringers is safe in hyperkalemia, and is …	Junior, Senior, Attending
Potassium	Multiple	Insulin Dosing in Hyperkalemia	Intern, Junior, Senior, Attending
Potassium	Rezaie, Salim	ECG Changes of Hyperkalemia	Clerk, Intern, Junior, Senior
Potassium	Santistevan, Jamie	emDOCs.net – Emergency Medicine EducationSubtle ECG findings …	Clerk, Intern, Junior, Senior, Attending
Potassium	Morton, A. Ross	Management of Hyperkalemia with ECG Changes	clerk, intern, Junior, senior
Potassium	Awad, Nadia	Thyroid Storm: Treatment Strategies	Intern, Junior, Senior, Attending
Potassium	Grock, Andrew	Bicarbonate: Completely Useless?	Junior, Senior, Attending
Potassium	Hayes, Bryan D	Hyperkalemia Management: Preventing Hypoglycemia From Insulin	Senior, Attending
Sodium	Smarandache, Andrei	When and how to treat hyponatremia in the ED	Intern, Junior, Senior
Sodium	Farkas, Josh	Hypernatremia & dehydration in the ICU – EMCrit Project	Senior, Attending
Sodium	Farkas, Josh	Emergent treatment of hyponatremia or elevated ICP with bicarb …	intern, Junior, senior, attending
Sodium	Farkas, Josh	Taking control of severe hyponatremia with DDAVP	Attending
Sodium	Helman, Anton	Emergency Management of Hyponatremia \| EM Cases	intern, Junior, senior, attending
Sodium	Farkas, Josh	Unconventional therapies for hyponatremia: Thinking outside the …	intern, Junior, senior, attending
Sodium	Farkas, Josh	PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea	Junior, senior, attending
Magnesium	Morgenstern, Justin	Torsades de Pointes: Approach to resuscitation	intern, Junior, senior
Magnesium	Multiple	Hypermagnesemia – WikEM	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Lodeserto, Frank	Pediatric DKA: Do Fluids Really Matter? – REBEL EM – Emergency …	Clerk, Intern, Junior, Senior
Diabetic Ketoacidosis	Morgenstern, Justin	IV fluids do not cause cerebral edema in pediatric DKA – First10EM	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Farkas, Josh	Blood gas measurements in DKA: Are we searching for a unicorn?	Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Farkas, Josh	Anatomy of a DKA resuscitation – EMCrit Project	Clerk, Intern, Junior, Senior
Diabetic Ketoacidosis	Hughes, Darrel	Is There Any Benefit to an Initial Insulin Bolus in Diabetic …	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Abela, Nikki	Fluid Type and Infusion Rate in Paediatric DKA	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Multiple	Cerebral edema in DKA – WikEM	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Lubberdink, Ashley	TREKK Series \| Diabetic Ketoacidosis	Clerk, Intern, Junior
Diabetic Ketoacidosis	Farkas, Josh	PulmCrit- Dominating the acidosis in DKA	Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Farkas, Josh	PulmCrit – Four DKA Pearls	Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Multiple	emDOCs.net – Emergency Medicine Education Diabetic …	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Multiple	Diabetic ketoacidosis \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Diabetic Ketoacidosis	Multiple	PEM Pearls: Treatment of Pediatric Diabetic Ketoacidosis and the Two-Bag Method	Junior, Senior, Attending
Diabetic Ketoacidosis	Monette, Derek	PEM Practice Changing Paper: Clinical Trial of Fluid Infusion Rates for Pediatric DKA	Junior, Senior, Attending
Hyperosmolar Hyperglycemic State	Multiple	Hyperosmolar hyperglycemic state – WikEM	Clerk, Intern, Junior, Senior, Attending
Hyperosmolar Hyperglycemic State	Multiple	Hyperosmolar hyperglycemic state \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Hyperosmolar Hyperglycemic State	Multiple	Non-ketotic hyperglycaemic seizure \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Hypoglycemia	Multiple	Hypoglycemic encephalopathy \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Insulin Pump	Multiple	Insulin Pumps: Complications and Emergency Department Presentations	Intern, Junior, Senior, Attending
Insulin Pump	Weingart, Scott	Podcast 198 – Insulin Pumps and Such with Josh Miller, MD	Clerk, Intern, Junior, Senior, Attending
Insulin Pump	Rezaie, Salim	Diabetic Gastroparesis Needs HUGS	Intern, Junior, Senior, Attending
Nutritional Disorders	Multiple	Osteoporosis \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Nutritional Disorders	Long, Brit	Protein Shakes and Dietary Supplements: What are their ingredients and how much is too much?	Senior, Attending
Vitamin Deficiencies	Multiple	Rickets \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Vitamin Deficiencies	Groth, Meghan	Mythbusting the Banana Bag	Intern, Junior, Senior, Attending
Wernicke-Korsakoff	Multiple	Thiamine Deficiency	Intern, Junior, Senior, Attending
Wernicke-Korsakoff	Pescatore, Rick	Should You Prescribe Oral Thiamine for Chronic Alcoholics …	Senior, Attending
Wernicke-Korsakoff	Multiple	Wernicke-Korsakoff syndrome – WikEM	Clerk, Intern, Junior, Senior, Attending
Wernicke-Korsakoff	Multiple	Wernicke encephalopathy \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Wernicke-Korsakoff	Swaminathan, Anand	Wernicke’s Encephalopathy Archives – REBEL EM – Emergency …	Junior, Senior, Attending
Parathyroid Disease	Multiple	Parathyroid hormone \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Parathyroid Disease	Multiple	Parathyroid glands \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Parathyroid Disease	Newman, Samantha	PTH versus PTHrP — Small Differences, Big Implications – Clinical …	Intern, Junior, Senior
Pituitary Disorders	Multiple	Sheehan syndrome \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Pituitary Disorders	Multiple	emDOCs.net – Emergency Medicine EducationThunderclap …	Intern, Junior, Senior
Pituitary Disorders	Multiple	Pituitary gland \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Pituitary Disorders	Multiple	Optic pathway glioma \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Pituitary Disorders	Multiple	Pituitary apoplexy \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Pituitary Disorders	Multiple	Empty sella \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Pituitary Disorders	Multiple	Elevated prolactin (differential) \| Radiology Reference Article …	Clerk, Intern, Junior, Senior, Attending
Hyperthyroid	Multiple	Thyroid storm – WikEM	Intern, Junior, Senior, Attending
Hyperthyroid	Lipp, Chris	CRACKCast E128 – Thyroid and Adrenal Disorders	Intern, Junior, Senior, Attending
Hyperthyroid	Multiple	Hyperthyroidism – WikEM	Clerk, Intern, Junior, Senior
Hyperthyroid	Multiple	Thyroid Storm and Aortoiliac Occlusive Disease	Intern, Junior, Senior, Attending
Hyperthyroid	Multiple	Bedside Rounds Series: Goiter – Clinical Correlations	Clerk, Intern, Junior, Senior
Hyperthyroid	Lee, Terrance	Diagnosing hyperthyroidism: Answers to 7 common questions	Clerk, Intern, Junior, Senior
Hypothyroid	Fox, Sean	Hypothyroidism and Myxedema Coma — Pediatric EM Morsels	Intern, Junior, Senior, Attending
Hypothyroid	Multiple	Myxedema coma – WikEM	Intern, Junior, Senior, Attending
Hypothyroid	Zhao, Leah	Spot the Diagnosis! The case of the Pale Woman	Intern, Junior, Senior
Tumors Of Endocrine Glands	Multiple	Parathyroid adenoma \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Tumors Of Endocrine Glands	Multiple	Central nervous system germinoma \| Radiology Reference Article …	Intern, Junior, Senior, Attending
Tumors Of Endocrine Glands	Multiple	Craniopharyngioma \| Radiology Reference Article \| Radiopaedia.org	Junior, Senior, Attending
Tumors Of Endocrine Glands	Multiple	Carcinoid tumor \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Adrenal Tumor	Multiple	Pheochromocytoma \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Adrenal Tumor	Multiple	Adrenal adenoma \| Radiology Reference Article \| Radiopaedia.org	Intern, Junior, Senior, Attending
Adrenal Tumor	Multiple	Adrenal cortical carcinoma \| Radiology Reference Article …	Intern, Junior, Senior, Attending
Pituitary Tumor	Multiple	Acromegaly \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Pituitary Tumor	Multiple	Pituitary adenoma \| Radiology Reference Article \| Radiopaedia.org	Clerk, Intern, Junior, Senior, Attending
Thyroid Tumor	Multiple	Medullary thyroid carcinoma \| Radiology Reference Article …	Clerk, Intern, Junior, Senior
Thyroid Tumor	Multiple	Anaplastic thyroid carcinoma \| Radiology Reference Article …	Intern, Junior, Senior, Attending

References:

Special thanks to SOAR co-authors Ryan Pedigo, Lisa Zhao, JooYeon Jung, Shirley W Bae, Teresa Chan, and Andrew Grock.

Hsiao, JJ, Pedigo, R, Bae, SW, et al. Systematic online academic resource (SOAR) review: Endocrine, metabolic, and nutritional disorders. AEM Educ Train. 2021; 5:e10716. doi:1002/aet2.10716
Grock A, Bhalerao A, Chan T, Thoma B, Wescott A, Trueger N. Systematic Online Academic Resource (SOAR) Review: Renal and Genitourinary. AEM Educ Train. 2019;3(4):375-386. doi:10.1002/aet2.10351
Raine T, Thoma B, Chan T, Lin M. FOAMSearch.net: A custom search engine for emergency medicine and critical care. Emerg Med Australas. 2015;27(4):363-365. doi:10.1111/1742-6723.12404
Thoma B, Sanders J, Lin M, Paterson Q, Steeg J, Chan T. The social media index: measuring the impact of emergency medicine and critical care websites. West J Emerg Med. 2015;16(2):242-249. doi:10.5811/westjem.2015.1.24860
Colmers-Gray I, Krishnan K, Chan T, et al. The Revised METRIQ Score: A Quality Evaluation Tool for Online Educational Resources. AEM Educ Train. 2019;3(4):387-392. doi:10.1002/aet2.10376

By Jonie Hsiao, MD|2022-01-29T06:11:54-08:00Jan 28, 2022|Emergency Medicine|

Nasal congestion is a common symptom of upper respiratory tract infections, such as bronchiolitis, in newborns and infants. Because newborns are obligate nose breathers, any congestion presents a challenge during feeding and sleeping. These infants become frustrated when they cannot breathe while feeding and tend to have disturbed sleep when their nasal passages are occluded. This often leads to dehydration and irritability. Although the infant bulb syringe (above) can often alleviate the congestion, other commercial products may be able to more forcefully clean out the nasal mucus (e.g., NoseFrida, Bubzi Nasal Aspirator).

Trick of the Trade: DIY Nasal Snot Aspirator

In the Emergency Department, you may encounter families who may not have the resources to purchase or be aware of commercial aspiration devices for children. The concept behind our DIY Nasal Snot Aspirator is to allow the caregiver to suction the child’s nose using the negative pressure generated from the caregiver’s own mouth. The left video demonstrates how the NoseFrida works, and the right video demonstrates our DIY Nasal Snot Aspirator. Note that the specimen trap serves as the protective “filter”, or barrier, between the child’s suctioned mucus and the caregiver’s mouth. Thanks to Stephany Landry, RN, BSN for sharing this trick of the trade.

Equipment Needed: DIY nasal snot aspirator

Left: Little Sucker Aspirator [Amazon]
Middle: Short suction tubing
Right: Mucous specimen trap, 40 cc [Amazon]

Description of the Trick

Suction tubing: Attach one end to the Little Sucker Aspirator and the other end to the short connector port on the specimen trap.
Instill some saline drops into the child’s nose.
Insert the aspirator tip of your contraption into the child’s nostril.
Have the caregiver suck out through the “straw” attached on top of the specimen trap.

trick DIY nasal snot aspirator — DIY Nasal Snot Aspirator, demonstrated by Stephany Landry, RN, BSN

Disclosures

The authors and ALiEM do not have any affiliation with any of these device companies.

By Shyam Sivasankar, MD|2022-01-21T01:18:17-08:00Jan 26, 2022|HEENT, Pediatrics, Tricks of the Trade|

SAEM Clinical Image Series: Pediatric Rash

pediatric rash

A 17-month-old girl with a history of eczema presents to the pediatric emergency department for evaluation of a rash. The rash is different from her usual eczema, developed three days prior to presentation, and is described as red with yellow crusting. Her mother also noticed blistering in her groin and under her axilla. She has associated fussiness and decreased feeding, but no fever.

Additional Images

Physical Exam

Vitals: T 37.7°C; HR 161; BP 115/75; RR 24; O2 sat 100% on room air

General: Fussy but consolable

Eyes: No conjunctival erythema or discharge

Mouth: Yellow crusting and fissuring surrounding mouth; no intra-oral lesions

Neck: No nuchal rigidity

Cardiovascular: Tachycardic with regular rhythm; no murmurs

Respiratory: Normal rate; normal breath sounds

Abdomen: Non-tender to palpation; non-distended; normal bowel sounds

Neurologic: Alert

Skin: Diffusely erythematous; scaling rash over the face with areas of yellow crusting; erythematous areas with blistering/desquamation to the anterior trunk, axilla, and inguinal regions

Laboratory Data

Complete blood count (CBC) and comprehensive metabolic panel (CMP) unremarkable.

Case Question: What is the diagnosis in this patient and what is likely the trigger in this case?

Staphylococcal scalded skin syndrome caused by impetigo.

This case describes a patient with a rash, blistering/desquamation of axilla and groin, and systemic symptoms consistent with staphylococcal scalded skin syndrome (SSSS). Clinical features of SSSS include erythema to intertriginous areas, rapid progression of erythema, and systemic symptoms such as fever, irritability, and poor oral intake. Mucous membranes are not typically involved. Physical exam findings include perioral crusting and fissuring (seen in photo), blanching erythema, desquamation, shallow skin erosions, and a positive Nikolsky sign. SSSS is caused by exfoliative toxin A (ETA) and exfoliative toxin B (ETB), two exotoxins produced by certain strains of S. aureus. ETA and ETB cause the breakdown of keratinocyte adhesions within the epidermis, leading to desquamation. Infection with S. aureus at any site can cause SSSS, including bacterial conjunctivitis, wound/skin infection, staphylococcal pneumonia, pyomyositis, septic arthritis, and endocarditis. SSSS is more common in children, a phenomenon thought to be due to a lack of protective antibodies against staphylococcal antigens. The diagnosis of SSSS is clinical but can be confirmed with histopathology. In this case, the extensive yellow, crusting lesions of the face suggest impetigo, a superficial skin infection predominantly caused by S. aureus, as the etiology of SSSS. Children with eczema are at increased risk of impetigo due to disruption of the normal skin barrier. Complications of SSSS include fluid losses due to extensive skin breakdown, electrolyte abnormalities, sepsis, and death.

Case Question: What are the best initial therapies for this condition and what specific therapy should be avoided?

Penicillinase-resistant penicillins (oxacillin, nafcillin) or first- or second-generation cephalosporins. Clindamycin monotherapy should be avoided due to high rates of resistance. Management of SSSS in most cases also includes hospitalization for IV antibiotics and supportive care. In patients with significant skin involvement, admission to either an ICU or burn unit is warranted for close monitoring and wound care.

Case Discussion

Take-Home Points

Staphylococcal scalded skin syndrome (SSSS) is caused by the release of S. aureus exfoliative toxins A and B into the bloodstream, thus SSSS can be caused by any infection caused by S. aureus.
Penicillinase-resistant penicillins are the first-line therapy in patients with SSSS. First- and second-generation cephalosporins, as well as vancomycin, can also be considered.
Treatment with clindamycin monotherapy should be avoided in patients with SSSS due to high levels of resistance among strains of S. aureus which cause SSSS.

References

Mishra AK, Yadav P, Mishra A. A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates. Open Microbiol J. 2016 Aug 31;10:150-9. doi: 10.2174/1874285801610010150. PMID: 27651848; PMCID: PMC5012080.
Paller A, Mancini, A. Hurwitz Clinical Pediatric Dermatology: A Textbook of Skin Disorders of Childhood and Adolescence. Edinburgh, Scotland: Elsevier; 2015.
Handler MZ, Schwartz RA. Staphylococcal scalded skin syndrome: diagnosis and management in children and adults. J Eur Acad Dermatol Venereol. 2014 Nov;28(11):1418-23. doi: 10.1111/jdv.12541. Epub 2014 May 20. PMID: 24841497.
Braunstein I, Wanat KA, Abuabara K, McGowan KL, Yan AC, Treat JR. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8. doi: 10.1111/pde.12195. Epub 2013 Aug 23. PMID: 24033633; PMCID: PMC4349361.
Neubauer HC, Hall M, Wallace SS, Cruz AT, Queen MA, Foradori DM, Aronson PL, Markham JL, Nead JA, Hester GZ, McCulloh RJ, Lopez MA. Variation in Diagnostic Test Use and Associated Outcomes in Staphylococcal Scalded Skin Syndrome at Children’s Hospitals. Hosp Pediatr. 2018 Sep;8(9):530-537. doi: 10.1542/hpeds.2018-0032. PMID: 30139766; PMCID: PMC6317540.

Copyright

By Drew Birrenkott, Ph.D.|2022-01-15T22:47:28-08:00Jan 24, 2022|Dermatology, Pediatrics, SAEM Clinical Images|

Background

Two new oral agents were given Emergency Use Authorization to be used in patients with mild-moderate COVID-19 at high risk of progression to severe infection, molnupiravir and nirmatrelvir/ritonavir (Paxlovid) [1,2]. Prior to this authorization, most evidence-based COVID therapies were parenteral and required significant healthcare resources to coordinate and administer.

Comparison

	Nirmatrelvir/ritonavir [3]	Molnupiravir [4]
Mechanism	Protease inhibitor leadings to interruption of viral replication Ritonavir has no role in treating COVID-19, it is only included to boost levels of nirmatrelvir via CYP3A4 inhibition	Increased frequency of RNA mutations and impaired replication [5]
Efficacy vs Placebo (Hospitalization or Death)	0.8% vs 6.3% (CI -7.21 to -4.03)	6.8% vs 9.7% (CI -5.9 to -0.1)
Drug Interactions	CYP3A4 inducers, inhibitors, and substrates May decrease efficacy of hormonal contraceptives, non-hormonal contraceptives should be considered Contraindicated medications include: amiodarone, carbamazepine, clozapine, colchicine, dihydroergotamine, dronedarone, flecainide, lovastatin, ranolazine, sildenafil, simvastatin Many other important interactions exist so care should be taken to assess all medication interactions	N/A
Cost*	Patient: $0 US government: $530 [6]	Patient: $0 US Government: $700 [7]
Dose	300 mg/100 mg BID for 5 days Must be started within 5 days of symptom onset	800 mg BID for 5 days Must be started within 5 days of symptom onset
Notes	Approved for patients ≥ 12 years old AND ≥ 40 kg Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis	Approved for patients ≥ 18 years Not approved for inpatient initiation If patient is hospitalized, continuation is up to the discretion of the provider Not used as pre-/post-exposure prophylaxis
Renal/Hepatic Dose Adjustments	eGFR ≥30 to <60 mL/min: 150 mg/100 mg BID eGFR <30 mL/min: Not recommended Child-Pugh class C: Not recommended	None

*Note: The US federal government has purchased 10 million doses of nirmatrelvir/ritonavir and 3 million doses of molnupiravir [8,9]. These supplies will be allocated to states and territories as needed and will be available to patients at no charge.

Evidence:

Nirmatrelvir/ritonavir (Paxlovid)

Paxlovid was evaluated in the EPIC-HR trial, which is not fully published at this time [3]. This was a phase 2/3, double-blinded, randomized placebo controlled trial including nonhospitalized, unvaccinated patients adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor† for development of severe illness from COVID-19. Exclusion criteria included patients with a history of COVID-19 infection or COVID vaccination. Patients were given Paxlovid 300 mg/100 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at day 28. The modified intention-to-treat1 (mITT1) group excluded patients who did not receive nor were expected to receive COVID-19 mAb treatment. In the mITT1 group, the primary outcome occurred in 0.8% of patients receiving Paxlovid vs 6.3% of patients in the placebo group (8/1039 vs 66/1046, CI -7.21 to -4.03).

These results appear quite robust with a fragility index of 37. Additionally, in patients with detectable COVID antibodies there was less of an impact of the study medication. However, these patients still appeared to have some benefit (0.2% vs 1.5%, CI -2.45 to -0.23) which suggests that vaccinated patients may still benefit from Paxlovid.

†Risk factors for progression to severe disease: BMI >25, chronic lung disease, asthma, chronic kidney disease, current smoker, immunosuppressive disease or immunosuppressive treatment, cardiovascular disease, hypertension, sickle cell disease, neurodevelopmental disorders, active cancer, medically-related technological dependence, or age >60 years

Molnupiravir

Molnupiravir was evaluated in the MOVe-OUT trial [10]. This was a phase 3, double-blinded, randomized, placebo controlled trial including nonhospitalized, unvaccinated adults with mild-moderate COVID-19 within 5 days of symptom onset with at least 1 risk factor‡ for development of severe illness from COVID-19. Exclusion criteria included anticipated hospitalization within 48 hours, eGFR <30 or dialysis dependent, pregnancy, and COVID vaccination. Patients were able to receive steroids but not monoclonal antibodies (mAbs) nor remdesivir. Patients were given molnupiravir 800 mg or placebo BID for 5 days. The primary outcome was hospitalization or death at 29 days. In the mITT population, the primary outcome occurred in 6.8% of patients in the study group vs 9.7% in the placebo group (48/709 vs 68/699, CI -5.9 to -0.1). Death occurred in 1 patient on molnupiravir and in 9 patients on placebo (0.1% vs 1.3%, RRR 89%, CI 14 to 99).

Despite the above results, this may not be the positive trial it initially appears. First of all, for the primary outcome, the fragility index is 0, meaning that if 1 more patient in the study group experienced the primary outcome then it would have changed the statistical significance. Additionally, when the mITT analysis was adjusted for sex, the absolute risk reduction remained 2.8% but the confidence interval was not significant (-5.7 to 0.1). Lastly, in the subgroup analysis, there was no benefit in patients that had positive COVID antibody tests and there was a slight preference towards placebo over molnupiravir (3.7% vs 1.4%, ARR 2.3, CI -1.7 to 7.1). This suggests that vaccinated patients may not benefit from this therapy as much (or at all) as compared to unvaccinated patients.

‡Risk factors for progression to severe disease: age >60 years, active cancer, chronic kidney disease, COPD, BMI ≥30, heart failure, coronary artery disease, cardiomyopathy, or diabetes mellitus

Note: Both the EPIC-HR and MOVe-OUT studies were funded by their respective pharmaceutical company.

Bottom Line:

Nirmatrelvir/ritonavir (Paxlovid) and molnupiravir are approved under FDA EUAs for patients with mild-moderate COVID infection at high risk of severe disease within 5 days of symptom onset
Both medications appear to reduce death or hospitalization within a month, with most benefit likely to be experienced by unvaccinated patients
Nirmatrelvir/ritonavir (Paxlovid) appears to be more effective but also has many more drug interactions and contraindications

Want to learn more about EM Pharmacology?

Read other articles in the EM Pharm Pearls Series and find previous pearls on the PharmERToxguy site.

References:

O’Shaughenessy J. Food and Drug Administration. Molnupiravir Emergency Use Authorization 108. December 23, 2021. https://www.fda.gov/media/155053/download
O’Shaughenessy J. Food and Drug Administration. Nirmatrelvir/ritonavir Emergency Use Authorization 105. December 22, 2021. https://www.fda.gov/media/155049/download
Nirmatrelvir/ritonavir. Package insert. Pfizer, Inc. 2021. https://www.fda.gov/media/155050/download
Molnupiravir. Package insert. Merck Sharp & Dohme Corp. 2021. https://www.merck.com/eua/molnupiravir-hcp-fact-sheet.pdf
Kabinger F, Stiller C, Schmitzová J, et al. Mechanism of molnupiravir-induced SARS-CoV-2 mutagenesis. Nat Struct Mol Biol. 2021;28(9):740-746. doi: 10.1038/s41594-021-00651-0. PMID: 34381216.
Mishra M. U.S. to buy 10 mln courses of Pfizer’s COVID-19 pill for $5.3 bln. Reuters. Accessed January 12, 2022. https://www.reuters.com/business/healthcare-pharmaceuticals/us-govt-buy-10-mln-courses-pfizers-covid-19-pill-529-bln-2021-11-18/
Willyard C. How antiviral pill molnupiravir shot ahead in the COVID drug hunt. Nature. Published online October 8, 2021. doi: 10.1038/d41586-021-02783-1. PMID: 34625735.
Paxlovid (nirmatrelvir/PF-07321332 and ritonavir). U.S. Department of Health & Human Services: Office of the Assistant Secretary of Preparedness and Response. Updated: January 12, 2022. Accessed January 12, 2022. https://www.phe.gov/emergency/events/COVID19/investigation-MCM/Paxlovid/Pages/default.aspx
Molnupiravir (MK-4482). U.S. Department of Health & Human Services: Office of the Assistant Secretary of Preparedness and Response. Updated: January 12, 2022. Accessed January 12, 2022. https://www.phe.gov/emergency/events/COVID19/investigation-MCM/molnupiravir/Pages/default.aspx
Jayk Bernal A, Gomes da Silva MM, Musungaie DB, et al. Molnupiravir for oral treatment of covid-19 in nonhospitalized patients. N Engl J Med. Published online December 16, 2021. doi: 10.1056/NEJMoa2116044. PMID: 34914868.

By Mike O'Brien, PharmD|2022-01-15T19:00:38-08:00Jan 15, 2022|EM Pharmacy Pearls, Infectious Disease, Tox & Medications|

SAEM Clinical Image Series: Painful Blue Arm

arm swelling

A 68-year-old male with a past medical history of hypertension, hyperlipidemia, and recent ileostomy secondary to small bowel obstruction presented for acute left arm swelling, discoloration, and numbness since last night. He endorses sudden onset of painful edema with the development of purple discoloration. He denies trauma, history of similar problems, chest pain, or shortness of breath. He endorses difficulty flexing at the elbow secondary to the amount of swelling, pain, and numbness to the arm. The patient had a peripherally inserted central catheter (PICC) line placed in the left upper extremity two weeks ago.

Additional Images

Physical Exam

Vitals: T 37.1°C; HR 80; BP 154/82; RR 18; O2 sat 100% on RA

General: Moderate distress secondary to pain but non-toxic appearing

Cardiovascular: Regular rate and rhythm; no murmurs; left ulnar artery 2+; left radial artery 1+ to palpation; bedside doppler—triphasic left ulnar artery and biphasic left radial artery; capillary refill three seconds

Respiratory: Lungs clear to auscultation bilaterally; no adventitious breath sounds

Musculoskeletal: Left upper extremity with global nonpitting edema from fingers to shoulder; skin with purple cyanotic discoloration; moderately tender to palpation throughout the entire limb; no crepitus or bullae; pain is not out of proportion; soft compartments throughout the left upper extremity

Neurologic: Alert and oriented to person, time, and place; Glasgow Coma Scale 15; cranial nerves II-XII grossly intact; sensation decreased in left upper extremity; all other extremities intact

Laboratory Data

Complete blood count (CBC): Unremarkable

Partial thromboplastin time (PTT) and International normalized ratio (INR): Unremarkable

Case Question: What is the diagnosis?

Phlegmasia cerulea dolens (PCD) of the Upper Extremity. It’s just a deep venous thrombosis (DVT) right?

PCD is not just another DVT, it’s a severe limb-threatening (12-25% amputation rate) and life-threatening (25-40% mortality rate) disease that presents with marked swelling in the extremity, pain, and cyanosis.

The pathophysiology of PCD involves complete obstruction of both superficial and deep venous return, resulting in increased interstitial tissue pressure, arrest of capillary flow, tissue ischemia, and ultimately, gangrene. Upper extremity involvement is rare and only occurs in approximately 2-5% of all phlegmasia cases. PCD presents with key characteristics: marked edema, severe pain, pathognomonic blue discoloration/cyanosis, and eventually ischemia.

Ultrasound is the best initial modality for suspected PCD and bedside ultrasound with two-point compression can be quickly performed by the emergency physician.

Management should include fluid resuscitation, systemic anticoagulation, and emergent vascular surgery or interventional radiology consult for possible thrombectomy or catheter-directed thrombolysis.

Case Discussion

Take-Home Points

PCD is a rare, life-and-limb-threatening disease that can rapidly progress to gangrene and tissue death.
Phlegmasia cerulea dolens literally translates to “painful blue inflammation.” Large clot burden causes severe pain, cyanosis, and marked edema.
Prompt evaluation with ultrasound, treatment with anticoagulation, and emergent vascular surgery or interventional radiology consultation are essential.

References

Chaochankit W, Akaraborworn O. Phlegmasia Cerulea Dolens with Compartment Syndrome. Ann Vasc Dis. 2018 Sep 25;11(3):355-357. doi: 10.3400/avd.cr.18-00030. PMID: 30402189; PMCID: PMC6200621.
Kommalapati A, Kallam A, Krishnamurthy J, Tella SH, Koppala J, Tandra PK. Upper Limb Phlegmasia Cerulea Dolens Secondary to Heparin-induced Thrombocytopenia Leading to Gangrene. Cureus. 2018 Jun 21;10(6):e2853. doi: 10.7759/cureus.2853. PMID: 30148006; PMCID: PMC6104908.
Kou CJ, Batzlaff C, Bezzant ML, Sjulin T. Phlegmasia Cerulea Dolens: A Life-Threatening Manifestation of Deep Vein Thrombosis. Cureus. 2020 Jun 12;12(6):e8587. doi: 10.7759/cureus.8587. PMID: 32670722; PMCID: PMC7358928.
Onuoha CU. Phlegmasia Cerulea Dolens: A Rare Clinical Presentation. Am J Med. 2015 Sep;128(9):e27-8. doi: 10.1016/j.amjmed.2015.04.009. Epub 2015 Apr 22. PMID: 25910785.

Copyright

By Roger Farney, DO|2022-01-04T11:48:50-08:00Jan 10, 2022|Cardiovascular, SAEM Clinical Images|

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