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ALiEM AIR Series | Environmental Module (2025)

Welcome to the AIR Environmental 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 Environmental emergencies in the Emergency Department. 5 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 1 AIR and 4 Honorable Mentions. We recommend programs give 3 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.

 

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Highlighted Quality Posts: Environmental 2025

 

SiteArticleAuthorDateLabel
EM OttawaThe Deep Freeze: A Review of Frostbite ManagementDr. Maria Doubova and Dr. Amanda MatticeNovember 2, 2023AIR
EM OttowaDon’t Sweat It! Heat Related IllnessDr. Steven SandersJuly 6, 2023HM
EMDocsToxCard: Crotalid Envenomation Part 2 – CroFab vs. AnaVip: What’s the Difference?Dr. Sean TrostelAugust 31, 2023HM
Taming the SRUMastering Minor Care: Dog BitesDr. Melanie YatesJuly 12, 2023HM
Kings CountyIt’s Getting Hot in Here: Exertional Heat StrokeDr. Esteban DavilaFebruary 27, 2024HM

 

(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

    1. 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

By |2026-04-29T12:02:21-07:00Apr 23, 2025|Approved Instructional Resources (AIR series), Environmental|
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SAEM Clinical Images Series: I Cannot See My Rashes

A 37-year-old African-American transgender patient presented with progressive, bilateral painful vision loss. The symptoms began acutely in the right eye two weeks prior to presentation, eventually extending to the left eye. Symptoms were worse in the right eye and included headache, blurry vision, photophobia, and pain with eye movement. Additionally, the patient reported the appearance of a diffuse, generalized, non-pruritic, non-tender rash of unknown duration or timeline. The rash was hyperpigmented and located on the trunk, face, genitalia, palms, and soles. The patient denied any recent trauma, using eye drops, wearing glasses, recent new detergents, soaps, illness, nausea, vomiting or sick contacts.

 

rash

Vitals: HR 114; Temp 101.4 °F; BP 120/77; Resp 16; O2 98%

HEENT: Erythematous eyelids, bilateral conjunctival injection with a hazy cornea. Dilated and poorly reactive pupils, and overlying corneal edema without abrasion. Slit-lamp examination showed keratic precipitates in the anterior chamber. Visual acuity RE 20/200, LE 20/70. Intraocular Pressure (IOP) notable for OD 52, LOS 32.

Respiratory: Good bilateral air entry, clear breath sounds.

Cardiovascular: Normal rate, regular rhythm, S1,S2, no added sounds.

Skin/Extremities: Disseminated maculopapular rash all over the body, not itchy/crusty, nontender.

Neuro: At baseline mental status, AO X 3

WBC: 11.6

Hgb: 11.2

Platelets: 507

ALT: 70

AST: 80

ALK PHOS: 1449

HIV: Non-reactive

Hepatitis B: Non-reactive

Orthopoxvirus DNA: Not-detected

If emergency medicine physicians consider glaucoma due to syphilitic uveitis on their differential for patients presenting with skin and ocular symptoms, this can result in more rapid diagnosis and aggressive treatment. The CDC reported 176,713 cases of syphilis in 2021, showing an annual increase and a collective surge of 28.6% from 2020 to 2021. While the frequency of confirmed syphilis cases can vary, the global trend reveals a consistent rise in reported incidences, suggesting continued transmission of the infection. This is especially concerning because some individuals may not exhibit noticeable symptoms due to its challenging diagnosis and presentation. As a result, not all cases of syphilis are diagnosed or confirmed. Prompt recognition and treatment are crucial to save the patient’s vision and quality of life. The patient was empirically started on IOP-reducing medications, intravenous penicillin and admitted with a presumptive diagnosis of ocular syphilis. During admission, both Rapid Plasma Reagin (RPR) and trepanomal tests confirmed the syphilis diagnosis. Subsequently, the patient’s IOP normalized and vision improved to 20/200 in the right eye and 20/70 in the left.

Take-Home Points

  • High suspicion, improved awareness, increased testing, and effective surveillance systems are essential for accurately assessing the prevalence of syphilis in a given population.

  • Beginning treatment early on and before confirmatory testing in the ED will only help improve patient outcomes throughout hospitalization.

  • Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2021 – Syphilis. Centers for Disease Control and Prevention. https://www.cdc.gov/std/statistics/2021/overview.htm#Syphilis. Accessed January 10, 2024.

  • Mathew D, Smit D. Clinical and laboratory characteristics of ocular syphilis andneurosyphilis among individuals with and without HIV infection. Br J Ophthalmol.2021;105:70-74.

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 |2025-04-15T21:32:43-07:00Apr 21, 2025|Infectious Disease, Ophthalmology, SAEM Clinical Images|
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SAEM Clinical Images Series: I’m Plugged Up

foreign body

A 56-year-old male with a history of crack cocaine and opiate drug use presented to the Emergency Department (ED) with concerns about a persistent dry cough for seven days. The cough started after smoking cocaine from a homemade glass pipe. The day before arrival, he developed sharp chest pain with coughing associated with shortness of breath and a sore throat. The patient denied fevers, chills, or shortness of breath. He denied hemoptysis, nausea, vomiting, and diarrhea. A chest x-ray was obtained with the findings seen below.

 

Vitals: Temp: 36.6°C; HR: 78 bpm; RR: 18; BP: 128/85 mmHg; SpO2: 98% RA

General: Disheveled male who is alert in no acute respiratory distress.

Neck: Supple, no crepitus.

Cardiovascular: Regular rate and rhythm, No murmur, gallop, rubs.

Respiratory: Decreased air movement in the right lower lobe without wheezes, rales, rhonchi.

Chest wall: No tenderness.

Gastrointestinal: Soft, Nontender, Non distended, Normal bowel sounds.

WBC: 16.59 x10(3)/mcL

Images 1 and 2 show a radiopaque object in the right bronchus intermedius. By age 15 the aorta makes a prominent indent on the trachea and left mainstem bronchus, increasing the acute angle of the left bronchus compared to the trachea. This results in a relative straightening of the right mainstem bronchus in relation to the trachea and left mainstem bronchus. Thus, foreign bodies are more commonly found in the right bronchial tree of adults and children over 15 years old. In children younger than 15 years of age the angle of the left and right bronchus are symmetrical thus bronchial aspirated foreign bodies are equally likely to be found in either lung. In younger children the relative anatomical narrowing of the tracheobronchial tree results in more proximal airway obstructions at the level of the glottis, larynx, or trachea. (1)

Picture 3 shows a steel wool plug after it was removed from the right bronchus by flexible bronchoscopy. The patient had used the steel wool as a filter for smoking cocaine and accidentally inhaled it during use. Steel wool, like most foreign bodies, causes direct trauma to the tracheobronchial tree as well as post-obstructive pneumonia. Steel wool filters present an added hazard in crack cocaine smoking due to thermal injury to the upper airway (2). Flexible bronchoscopy is the preferred modality for evaluation and treatment of tracheobronchial tree foreign bodies in adults. It has several advantages over rigid bronchoscopy. Flexible bronchoscopy allows better visualization of the distal airways and may be performed using local anesthesia under procedural sedation. (3) In one meta-analysis the procedure had a 90% success rate for foreign body removal. (4) The use of flexible bronchoscopy in children is less clear. A comparison of rigid verses flexible bronchoscopy in children showed a lower rate of respiratory complication in the rigid bronchoscopy group. However, there was no statistically significant overall complication rate for the two modalities. (5)

Take-Home Points

  • Right bronchial foreign bodies are more common after age 15.

  • Steel wool used as a filter in a glass pipe may lead to thermal or mechanical injuries to the upper airway, and post obstructive pneumonia due to aspiration of the entire steel wool plug.

  • Flexible bronchoscopy is the procedure of choice for the removal of bronchial foreign bodies in adults.

  • Cramer N, Jabbour N, Tavarez MM, et al. Foreign Body Aspiration. [Updated 2023 Jul 31]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.Available from: https://www.ncbi.nlm.nih.gov/books/NBK531480/

  • Alda Moettus, Dan Tandberg, Brillo® pad crack screen aspiration and ingestion. The Journal of Emergency Medicine, Volume 16, Issue 6, 1998, Pages 861-863, ISSN 0736-4679, https://doi.org/10.1016/S0736-4679(98)00099-7. (https://www.sciencedirect.com/science/article/pii/S0736467998000997)

  • Bajaj D, Sachdeva A, Deepak D. Foreign body aspiration. J Thorac Dis. 2021 Aug;13(8):5159-5175. doi:10.21037/jtd.2020.03.94. PMID: 34527356; PMCID:PMC8411180.

  • Sehgal IS, Dhooria S, Ram B, Singh N, Aggarwal AN, Gupta D, Behera D, Agarwal R. Foreign Body Inhalation in the Adult Population: Experience of 25,998 Bronchoscopies and Systematic Review of the Literature. Respir Care. 2015 Oct;60(10):1438-48. doi: 10.4187/respcare.03976. Epub 2015 May 12. PMID: 25969517.

  • Wiemers A, Vossen C, Lücke T, Freitag N, Nguyen TMTL, Möllenberg L, Pohunek P, Schramm D. Complication rates in rigid vs. flexible endoscopic foreign body removal in children. Int J Pediatr Otorhinolaryngol. 2023 Mar;166:111474. doi: 10.1016/j.ijporl.2023.111474. Epub 2023 Feb 1. PMID: 36753891.

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 |2025-04-15T21:24:51-07:00Apr 18, 2025|Pulmonary, SAEM Clinical Images|
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ACMT Toxicology Visual Pearl: Turning Blue

What commercially available product can cause blue-grey discoloration of the skin and conjunctiva with long term use?

  1. Benzocaine, 20% oral gel
  2. Colloidal silver, 30 ppm liquid solution
  3. Ferrous sulfate, 325 mg tablet
  4. Methylene blue, 1% oral solution

[Image from Herbert L. Fred, MD and Hendrik A. van Dijk via Wikimedia Commons]

(more…)

By |2025-04-02T16:28:10-07:00Apr 16, 2025|ACMT Visual Pearls, Expert Peer Reviewed (Clinical), Tox & Medications|
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SAEM Clinical Images Series: Weird Flex

tenosynovitis

A 29-year-old female with a history of depression, anxiety, and tobacco use disorder presented with worsening right index finger pain, swelling, and redness for the previous three days. Additionally, she reported that she was unable to further flex or extend her finger. She denied fevers, chills, rashes, or recent illness. There was no history of trauma, aquatic or other environmental exposures, insect bites, or intravenous drug use. She did note that she uses a copper brillo pad to clean her dishes at home which often causes small abrasions to her fingers.

Vitals: BP 160/112; PR 73; Temp 36.4°C; RR 18; SpO2 100% on RA

General: Well-appearing, no acute distress.

Cardiovascular: Right index finger capillary refill <2 sec.

Skin: Right index finger uniformly edematous and erythematous with tenderness to palpation along the tendon sheath; small healed abrasions over distal palmar aspect of the digit; no focal area of fluctuance.

MSK: right index finger held in flexion, pain with passive extension.

WBC: 8.6

ESR: 129

CRP: 105.5

This patient has flexor tenosynovitis, an infection of the synovial sheath surrounding the flexor tendon of the hand. The condition is usually caused by local inoculation from penetrating trauma although can also result from hematogenous spread. Flexor tenosynovitis is considered a surgical emergency, as delayed intervention can lead to significant morbidity including tendon rupture, deep space infection, abscess development, soft tissue necrosis, amputation, and/or chronically compromised hand function. Diagnosis is usually clinical, based on history and physical exam findings; however, laboratory evaluation may reveal leukocytosis and/or elevated inflammatory markers. If there is a history of penetrating trauma, x-rays of the affected digit are recommended to rule out retained foreign body. Management in the ED includes prompt surgical consultation and broad-spectrum antibiotics against common cutaneous pathogens. Antibiotic coverage should be broadened in patients with a history of marine exposure or Pseudomonal risk factors including immunocompromised status.

Flexor tenosynovitis presents with four classic exam findings called “Kanavel Signs.” Kanavel Signs include (1) flexion of the involved digit, (2) tenderness to palpation over the tendon sheath, (3) pain with passive extension, and (4) uniform swelling of the finger. The presence of all four Signs has a sensitivity for flexor tenosynovitis as high as 97.1%, although early in the course of infection, pain with passive extension may be the only finding.

Take-Home Points

  • Flexor tenosynovitis is an infection of the flexor tendon sheath of the hand and a history of trauma or penetrating injury to the area should raise suspicion.

  • Flexor tenosynovitis is a “can’t miss” clinical diagnosis in the ED as there is a risk of significant complications with delayed antibiotics and surgical intervention.

  • Infection can reliably be identified by the presence of the four Kanavel Signs on physical exam.

  • Chan E, Robertson BF, Johnson SM. Kanavel signs of flexor sheath infection: a cautionary tale. Br J Gen Pract. 2019 Jun;69(683):315-316. doi: 10.3399/bjgp19X704081. PMID: 31147342; PMCID: PMC6532803.

  • Chapman T, Ilyas AM. Pyogenic Flexor Tenosynovitis: Evaluation and Treatment Strategies. J Hand Microsurg. 2019 Dec;11(3):121-126. doi: 10.1055/s-0039-1700370. Epub 2019 Nov 2. PMID: 31814662; PMCID: PMC6894957.

  • Hermena S, Tiwari V. Pyogenic Flexor Tenosynovitis. In: StatPearls. StatPearls Publishing; 2022.

  • Kennedy CD, Huang JI, Hanel DP. In Brief: Kanavel’s Signs and Pyogenic Flexor Tenosynovitis. Clin Orthop Relat Res. 2016 Jan;474(1):280-4. doi: 10.1007/s11999-015-4367-x. Epub 2015 May 29. PMID: 26022113; PMCID: PMC4686527.

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 |2025-03-30T20:30:57-07:00Apr 7, 2025|Orthopedic, SAEM Clinical Images|
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SAEM Clinical Images Series: Ptosis? A Don’t Miss Diagnosis!

ptosis

A 50-year-old female with no past medical history presented to the emergency department for a headache. She developed progressive dull, left-sided head pain with sinus pressure one week prior, associated with sleep disturbance. In addition, she described two days of left eyelid drooping. She had no fever, chills, cough, difficulty breathing, neck pain, jaw claudication, vision changes, dizziness, numbness, or recent weight loss. She also denied any recent trauma to the head or neck.

 

Vitals: BP 119/59; PR 92; Temp 37°C; RR 16; SpO2 100% on RA

General: Well-appearing, no acute distress.

HEENT: EOMI, left eyelid ptosis with miosis of left pupil.

Cardiovascular: RRR, normal S1/S2, no murmur.

Neurologic: Alert and oriented x 3, normal strength and sensation bilateral upper and lower extremities, left ptosis and miosis, otherwise cranial nerves II-XII unremarkable.

WBC: 8.9

INR: 0.9

This patient presented with Horner Syndrome, a triad of ipsilateral anhidrosis, miosis, and ptosis, the latter two of which are evident in this clinical image. Horner Syndrome presents when a lesion or insult disturbs the three-order sympathetic pathway that innervates the head, neck, and ipsilateral eye. Physical examination findings may be variable and/or subtle in patients with carotid dissection. Interestingly, isolated Horner Syndrome is the only abnormal physical finding in up to 50% of patients with carotid dissection. Further, patients with carotid dissection may present with only a partial Horner’s, with anhidrosis limited to the ipsilateral eyebrow, which can be difficult to identify. Evaluation of a patient with a new Horner Syndrome in the emergency department should include CT brain, CXR, and, if there is concern for carotid artery dissection, CTA or MRA head/neck. Carotid artery dissection is a neurologic emergency with significant morbidity and mortality ranging between 25-46% if left untreated. Management requires emergent neurology consultation with activation of the stroke team, as the treatment may require systemic thrombolytics and/or mechanical thrombectomy. Patients who present outside the time-window for stroke care, or who demonstrate resolving symptoms should be treated with antiplatelet or anticoagulant therapy. Notably, for patients with intracranial dissection or dissection involving the aorta, the preferred treatment is antiplatelet therapy in conjunction with neurology consultation.

Horner syndrome has a broad differential diagnosis including stroke, neoplastic disease (brain, neck or lung), vascular injury, demyelinating disease, lymphoma, and iatrogenic injuries. This patient’s Horner syndrome was attributable to a carotid artery dissection (the most common vascular cause of Horner’s). Carotid dissection may occur after blunt trauma to the neck, but also as a result of seemingly innocuous movements of the neck. For example, evidence suggests that yoga, massage, and roller coaster rides each may increase risk for carotid dissection.

Take-Home Points

  • Horner syndrome is the triad of ipsilateral anhidrosis, miosis, and ptosis, although physical exam findings may be subtle.

  • The differential for Horner Syndrome includes several urgent and emergent underlying etiologies.

  • Carotid artery dissection is an important cause of Horner Syndrome to consider in the appropriate clinical context.

  • Hakimi R, Sivakumar S. Imaging of Carotid Dissection. Curr Pain Headache Rep. 2019 Jan 19;23(1):2. doi: 10.1007/s11916-019-0741-9. PMID: 30661121.

  • Keser Z, Chiang CC, Benson JC, Pezzini A, Lanzino G. Cervical Artery Dissections: Etiopathogenesis and Management. Vasc Health Risk Manag. 2022 Sep 2;18:685-700. doi: 10.2147/VHRM.S362844. PMID: 36082197; PMCID: PMC9447449.

  • Flaherty PM, Flynn JM. Horner syndrome due to carotid dissection. J Emerg Med. 2011 Jul;41(1):43-6. doi: 10.1016/j.jemermed.2008.01.017. Epub 2008 Sep 14. PMID: 18790590.

  • Maloney WF, Younge BR, Moyer NJ. Evaluation of the causes and accuracy of pharmacologic localization in Horner’s syndrome. Am J Ophthalmol. 1980 Sep;90(3):394-402. doi: 10.1016/s0002-9394(14)74924-4. PMID: 7425056.

  • Stein DM, Boswell S, Sliker CW, Lui FY, Scalea TM. Blunt cerebrovascular injuries: does treatment always matter? J Trauma. 2009 Jan;66(1):132-43; discussion 143-4. doi: 10.1097/ TA.0b013e318142d146. PMID: 19131816.

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 |2025-04-03T09:22:20-07:00Apr 4, 2025|Neurology, SAEM Clinical Images|
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SAEM Clinical Images Series: Case of Painless Vision Changes

lens

A 62-year-old female presented to the emergency room with a chief complaint of atraumatic painless blurry vision. She reported a medical history of bilateral lens replacements in 1999 and a prior history of bilateral retinal detachments and expressed concern that she may have detached her retina again. The patient first noted floaters starting 3 days ago, that progressed yesterday to sudden onset blurry vision of her right eye. She denied any sensation of “a curtain falling. The patient clarified that this presentation is different in nature to her prior bilateral retinal detachments.

 

vision loss

Vitals: BP 115/70; Pulse 98; Temp 98.7°F, Resp 22, SpO2 100%

Constitutional: Patient is well-appearing, alert, oriented x 3 in no acute distress.

HEENT:

Visual acuities: Left eye: 20/ 30 ; Right eye: 20/ 200 . Bilateral: 20/25.

Lids & Lashes: Normal, no erythema or swelling.

Pupils: Equal and reactive to light and accommodation, 3 mm bilaterally reactive.

EOM’s: Intact. Nonpainful. Horizontal beating nystagmus noted of the right eye.

Conjunctivae: No injection noted Cornea: No corneal abrasion visualized.

Anterior chamber: Fluttering of iris during EOM right eye IOP in right eye 18 mmHg; left eye 20 mmHg

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

Neurological: She is alert. She exhibits normal muscle tone. NIH 0.

None

Image 2 is a great image demonstrating the anterior chamber, iris and ciliary body, posterior chamber, and the lens floating.

This case highlights the importance of recognizing iridodonesis as a clinical sign for possible lens subluxation and partial dislocation. Iridodonesis is a clinical sign commonly seen in lens partial dislocation/subluxation. It can indicate weakness or laxity in the zonular fibers that support the lens within the eye. This is particularly relevant in cases of trauma, advanced age, or surgical complications. This case emphasizes the importance in performing a thorough history and physical exam. In particular, the history of cataract surgery in the right eye raises suspicion for zonular weakness as a potential cause of iridodonesis. Lastly, point-of-care ocular ultrasound is an essential diagnostic modality in the emergency department for ophthalmologic presentations.

Image 1 demonstrates subluxation of the right lens. Image 3 is a freeze frame of the iridodonesis movement.

Take-Home Points

  • In patients who have undergone cataract surgery, the presence of lens subluxation and iridodonesis likely suggest compromised zonular integrity.

  • Iridodonesis is commonly associated with pseudoexfoliation syndrome, a condition characterized by the accumulation of abnormal extracellular material in various ocular tissues.

  • Oustoglou, Eirini, et al. “Prime Pubmed: Reoperations after Cataract Surgery: Is the Incidence Predictable through a Risk Factor Stratification System?” PRIME PubMed | Reoperations After Cataract Surgery: Is the Incidence Predictable Through a Risk Factor Stratification System?, 3 Nov. 2020, www.unboundmedicine.com/medline/citation/33133858/ Reoperations_After_Cataract_Surgery:_Is_the_Incidence_Predictable_Through_a_Risk_Factor_Stratification_System. Pieklarz B;Grochowski ET;Saeed E;Sidorczuk P;Mariak Z;Dmuchowska DA; “IRIDOSCHISIS-A Systematic Review.” Journal of Clinical Medicine, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/33081187/. Accessed 9 Jan. 2024.

  • RH;, Marques DM;Marques FF;Osher. “Subtle Signs of Zonular Damage.” Journal of Cataract and Refractive Surgery, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/15177607/. Accessed 9 Jan. 2024.

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 |2025-03-30T20:20:14-07:00Mar 31, 2025|Ophthalmology, SAEM Clinical Images|
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