SAEM Clinical Image Series: Man vs Pneumatic Nail Gun

X-ray hand

A 40-year-old male presents with injury to his left hand by a nail gun. While at work, the patient accidentally shot himself with a nail gun. The nail went through pneumatic air hose tubing, his third finger, and his thumb; keeping them all connected. He immediately felt uncomfortable in his left arm, and, upon arrival to the emergency department (ED), complained of swelling in his left arm extending to his neck. He feels shortness of breath and “fullness” in his throat.

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SAEM Clinical Image Series: Worsening Sore Throat

Computed tomography neck

A 40-year-old  male presented to the emergency department (ED) complaining of a sore throat for one week. The patient had presented ten days earlier following a stab wound to the anterior neck that violated the platysma. There was no vascular injury noted on the computed tomography angiography (CTA) but there was extensive soft tissue damage with emphysema extending into the retropharyngeal space. The patient underwent a flexible laryngoscopy by ENT, which showed no airway injury. He was observed in the intensive care unit for two days, then discharged. Following discharge, the patient had progressive sore throat and odynophagia, so he re-presented to the ED.

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SAEM Clinical Image Series: Distended Abdomen after ROSC

distended abdomen

A 64-year-old female presented to the emergency department (ED) in cardiac arrest. Her family members heard her fall in the bathroom and started CPR. EMS intubated the patient and 20 minutes of CPR was done en route. Return of spontaneous circulation (ROSC) was achieved after fifteen minutes of resuscitation in the ED.

At baseline, the patient ambulated with her walker and was conversant. She was having abdominal pain and nausea for the past three days after recently being diagnosed with a urinary tract infection. On arrival to the ED, the patient was pulseless with ventricular fibrillation. The patient received ten doses of epinephrine, two doses of sodium bicarbonate, calcium, amiodarone, magnesium, and one dose of naloxone during the resuscitation. One defibrillatory shock was administered. She was started on a norepinephrine drip and an amiodarone drip.

Computed tomography (CT) of the head was negative. CT of the chest was significant for left pneumothorax and left-sided subcutaneous emphysema. A pigtail chest tube was placed. After a few hours, she developed worsening abdominal distension. An abdominal CT scan revealed the images shown.

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SAEM Clinical Image Series: Atraumatic Proptosis

An 85-year-old female with a past history of hypertension presents with acute right-eye pain, redness, and proptosis/bulging for the past two months that has been worsening over the past two days. She endorses blurry vision that began two days prior. She does not use contacts or glasses. No trauma, headache, or loss of consciousness are reported. She reports a “whooshing” sound in her right ear for two to three months.

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SAEM Clinical Image Series: An Oropharyngeal Mass

oropharyngeal mass

A fifty-year-old male presented to the emergency department (ED) unconscious with CPR in progress. Per EMS report, the patient was found down surrounded by emesis with no pulse or respirations. Fifteen minutes of CPR was performed prior to arrival in the ED with a King Tube in place. The King Tube was filled with emesis and increasingly difficult to bag. The King Tube was removed to attempt intubation and maximize oxygenation and ventilation.

When the Mac 4 blade was placed in the mouth, a large, pink, fleshy, and vascularized structure was seen in the mouth just anterior to where the uvula should have been located.  Attempts were made to compress the mass into the tongue, separate the tongue from the mass, and sweep the mass out of the way. All attempts failed to expose the epiglottis. An attempt was made to remove the mass, but it appeared to be part of the mouth.  The decision was made to proceed with a cricothyrotomy; a 6.0 tube was successfully placed, and the patient was able to be ventilated. Return of spontaneous circulation was never achieved and the patient expired in the ED.

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SAEM Clinical Image Series: The Cocaine Gut

pneumoperitoneum

A sixty-five-year-old male with a medical history of gastroesophageal reflux disease (GERD), hypertension, alcohol dependence, homelessness, and cocaine abuse presents to the emergency department with abdominal pain for three days. The patient describes his abdominal pain as knife-like, 9/10, located diffusely throughout his abdomen, with associated anorexia and nausea. He reports that he had one episode of coffee ground emesis this morning which provoked him to come to the ED. He reports frequent cocaine use with his last use three days ago. He endorses subjective fevers, chills, and no bowel movement for two days. He has had no sick contacts.

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