SAEM Clinical Image Series: An Uncommon Cause of Shortness of Breath

shortness of breath

A 102-year-old female presents with intermittent epigastric abdominal pain for the last two days. Episodes have no relieving or exacerbating factors. The pain originates in the epigastrium and radiates diffusely to the abdomen and back, resolving on its own within minutes of onset. She has had one episode of nonbilious, non-bloody emesis. Her last bowel movement was two days prior and she hasn’t been able to pass gas. The pain is associated with mild shortness of breath which has been progressively worsening since the onset of symptoms. Her family was concerned and called EMS because the shortness of breath has worsened and the episodes of pain have been progressively worsening in intensity. The patient denies fever, chills, hematuria, urinary frequency, chest pain, headache, dizziness, syncope, recent traumatic events, and any other associated symptoms.

Additional Images

Physical Exam

General: Well-appearing; no acute distress; awake, alert, and oriented to date, place, and person

Cardiovascular: Regular rate and rhythm; S1/S2 present; 2+ systolic ejection murmur; capillary refill <2 seconds; 2+ pulses in all extremities

Respiratory: Lungs clear to auscultation bilaterally with diminished breath sounds in the left lower lobe; no signs of respiratory distress; no accessory muscle use

Abdomen: Soft; non-tender; non distended; no palpable masses; no guarding or rebound tenderness; no signs of peritonitis

Extremities: Full range of motion of all extremities; nonambulatory at baseline

Laboratory Data

Complete blood count (CBC): WBC 10.8 x 10^3/mcl; Hgb 12 g/dl; Hct 40.1%; Plt 375 x 10^3/mcl

Basic metabolic panel (BMP): Na 139 mmol/L; K 3.7 mmol/L; Cl 97 mmol/L; CO2 31 mmol/L; Glucose 170 mg/dL; BUN 10 mg/dL; Cr 0.58 mg/dL; Ca 10.2 mmol/L

Liver function test: AST 19 U/L; ALT 7 U/L; Alk Phos 144 U/L

Lipase: 11 U/L

Venous blood gas (VBG): pH 7.33; pCO2 61.1 mmHg; pO2 38 mmHg; BE -7 mmol/L

Lactic acid: 1.56 mmol/L

Case Question: What is the diagnosis?

Small bowel obstruction (SBO) secondary to a spigellian hernia with an associated hiatal hernia.

Case Question: What is the cause of this patients gradually progressive shortness of breath?

The CT demonstrates a spigellian hernia causing a small bowel obstruction. Spigellian hernias are hernias in the spigellian fascia which is located between the semilunar line and the lateral edge of the rectus abdominus muscle. These hernias constitute 0.12% of abdominal wall hernias, making them very rare and difficult to diagnose clinically. Spigellian hernias often go unnoticed until they are strangulated and require surgery. This patient not only had a rare spigellian hernia but also had a hiatal hernia causing the stomach to enter the pleural space. It’s possible that the bowel obstruction worsened the hiatal hernia with the backup of gastric contents and gas.

Case Discussion

Take-Home Points

Spigellian hernias are rare abdominal wall hernias with a myriad of potential complications.

Shortness of breath is frequently considered a pathology involving the lungs or pulmonary vasculature, however abdominal complaints, especially in this case, can cause significant respiratory distress.

Elderly patients may have difficulty verbalizing their exact symptoms, and it is good practice to gather collateral information from families to aid in caring for these patients.

References

Spangen L. Spigelian hernia. World J Surg. 1989 Sep-Oct;13(5):573-80. doi: 10.1007/BF01658873. PMID: 2683401.

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 Marimer Rivera-Nieves, MD|2022-02-13T21:38:05-08:00Feb 28, 2022|Gastrointestinal, Geriatrics, Pulmonary, SAEM Clinical Images|

SAEM Clinical Image Series: I Have a Stomachache

stomachache

An 18-year-old male with no significant past medical history presents with diffuse abdominal pain and multiple episodes of non-bloody, non-bilious vomiting for three days. The patient was seen yesterday at another facility and states he was diagnosed with gastritis and discharged with Zofran, which provided no relief. He denies fever, diarrhea, or urinary symptoms and states his last bowel movement was two days ago and was consistent with his usual bowel movements.

Additional Images

Physical Exam

Vitals: T 97.7ºF; HR 138; BP 122/98; RR 18; O2 sat 99% on RA

General: Thin male, appears uncomfortable

Abdominal: Mild distention with diffuse tenderness to palpation; no guarding or rebound tenderness

Laboratory Data

White blood cell (WBC) count: 13k

Complete metabolic panel (CMP): Mild hypokalemia; otherwise unremarkable

Lactate: 4.9

Urinalysis (UA): Mild ketonuria; no hematuria; no evidence of infection

Case Question: What is the diagnosis?

Superior Mesenteric Artery (SMA) syndrome also known as Wilke’s or Cast Syndrome is a condition where the third section of the duodenum gets compressed between the superior mesenteric artery and the aorta leading to a proximal obstruction in the duodenum and stomach. The most common etiology of SMA syndrome is the loss of the mesenteric fat pad surrounding the SMA. This leads to an acute angulation between the SMA and the aorta, thus compressing the duodenum and causing a partial or complete obstruction. While the condition is rare, predisposing factors include sudden weight loss and chronic illnesses such as malabsorption syndromes, AIDS, and malignancy.

Case Question: What is the treatment?

Treatment in the acute stage is conservative management including gastric decompression, IV fluids, correction of electrolyte abnormalities, and nutritional support, which may include temporary gastro-jejunostomy (GJ) tube placement. Severe refractory cases may require surgical intervention. This patient was admitted and treated conservatively, including a temporary GJ tube placement which was removed a few months later.

Case Discussion

Take-Home Points

Consider SMA syndrome in patients with a history of sudden weight loss or chronic illness.
Look for very proximal obstruction on CT with significant gastric distension.
Acute management is conservative treatment.

References

Hamden, A. & Scovell, S. (2020). Superior Mesenteric Artery Syndrome. In K. Collins (Ed.), UpToDate. Retrieved January 4, 2021, from https://www.uptodate.com/contents/superior-mesenteric-artery-syndrome
Niknejad, M. & Ranschaert, E. (2018). Superior Mesenteric Artery Syndrome. Radiopedia.org. Retrieved January 4, 2021, from https://radiopaedia.org/articles/superior-mesenteric-artery-syndrome?lang=us
Karrer FM. (2017). Superior Mesenteric Artery Syndrome. Medscape Reference. Retrieved December 22, 2020, from http://emedicine.medscape.com/article/932220-overview Genetic and Rare Diseases Information Center. (2018). Superior Mesenteric Artery Syndrome. [Online]. Available at: https://rarediseases.info.nih.gov/diseases/7712/superior-mesenteric-artery-syndrome#:~:text=Superior%20mesenteric%20artery%20syndrome%20(SMAS,complete%20blockage%20of%20the%20duodenum

Copyright

By Brett Bartels, MD|2021-12-02T13:55:35-08:00Dec 20, 2021|Gastrointestinal, Pediatrics, SAEM Clinical Images|

SAEM Clinical Image Series: Vomiting in the Pediatric Patient

A 2-year-old boy with a past medical history of Hirschsprung disease presents to the emergency department (ED) with vomiting, abdominal distension, and inability to tolerate PO for one day. His parents had been instructed by their pediatric surgeon to perform rectal irrigations 2-3 times daily for the few days prior to presentation.

Additional Images

Physical Exam

Vital signs within normal limits.

General: Appears lethargic

HEENT: Oral mucosa dry

Abdomen: Moderately distended; decreased bowel sounds

Skin: Normal turgor

Laboratory Data

Non-contributory

Case Question: What is the differential diagnosis for vomiting in the pediatric patient? How does this differential change in the setting of Hirschsprung disease?

The differential diagnosis for pediatric patients presenting with vomiting is broad and includes but is not limited to gastritis, diabetic ketoacidosis, pyloric stenosis, appendicitis, intussusception, urinary tract infection, colic, toxic ingestion, volvulus, incarcerated hernia, and bowel obstruction. However, in a child with Hirschsprung disease who presents with vomiting, an emergency medicine physician must maintain a high degree of suspicion for Hirschsprung-associated enterocolitis (HAEC).

Case Question: Why is it important to rapidly diagnose Hirschsprung-associated enterocolitis?

Hirschsprung disease is a rare congenital condition affecting approximately 1-in-5,000 births that refers to a functional intestinal obstruction due to the absence of ganglionic cells in the myenteric plexus of the distal colon. Life-threatening complications of Hirschsprung disease include bowel obstruction, Hirschsprung-associated enterocolitis (HAEC), and toxic megacolon. HAEC is the leading cause of morbidity and mortality in these patients. HAEC can present with vague symptoms such as fever, diarrhea, vomiting, rectal bleeding, constipation, and lethargy. Due to these nonspecific symptoms, it is necessary for emergency medicine physicians to maintain a high index of suspicion for HAEC. Once diagnosed, immediate resuscitation should begin with the placement of a rectal tube for decompression, initiation of broad-spectrum antibiotics and fluids, as well as urgent pediatric surgery consultation.

Case Discussion

Take-Home Points

HAEC can present with nonspecific symptoms of diarrhea, vomiting, fever, lethargy, abdominal distension, and obstipation.
HAEC must be quickly identified in patients with Hirschsprung disease due to the risk of rapid decompensation from hypovolemic shock secondary to dehydration, septic shock from HAEC, and the development of toxic megacolon.
HAEC is the leading cause of morbidity and mortality in pediatric patients with Hirschsprung disease.

References

Guillaume AWD, Miller AC, Nguyen MC. Enterocolitis in a Child With Hirschsprung Disease. Pediatr Emerg Care. 2019 Jul;35(7):e131-e132. doi: 10.1097/PEC.0000000000001108. PMID: 28328696.
Demehri FR, Halaweish IF, Coran AG, Teitelbaum DH. Hirschsprung-associated enterocolitis: pathogenesis, treatment and prevention. Pediatr Surg Int. 2013 Sep;29(9):873-81. doi: 10.1007/s00383-013-3353-1. PMID: 23913261.
Gosain A. Established and emerging concepts in Hirschsprung’s-associated enterocolitis. Pediatr Surg Int. 2016 Apr;32(4):313-20. doi: 10.1007/s00383-016-3862-9. Epub 2016 Jan 19. PMID: 26783087; PMCID: PMC5321668.
Maloney, Patrick J. “Gastrointestinal Disorders.” Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th Edition. Chapter 171. Page 2126-2144. 2018.

Copyright

By Emily Wynia, MD|2021-12-02T13:34:44-08:00Dec 13, 2021|Gastrointestinal, Pediatrics, SAEM Clinical Images|

You’re seeing a patient returning to the ED after a recent diagnostic paracentesis. The patient is complaining of persistent peritoneal fluid leakage. They’ve tried putting pressure with no success. You tried applying a medical adhesive glue and noticed it was unsuccessful, based on the patient’s gown continuing to get wet with ascites fluid. Now what?

Trick of the Trade: Pressure Gauze and Transparent Film Dressing

The medical adhesive glue trick was proposed in the Trick of the Trade 1.0 version by Dr. Borloz and Dr. Lin in November 2012.

Materials Needed

Material	Quantity
Benzoin tincture	1
Gauze 2″ x 2″	1-2
Transparent Film Dressing (Tegaderm) 2.5″ x 2.75″	3-4

Technique

1. Apply benzoin tincture surrounding the area of the leakage.

gauze ball in hand — 2. Use a 2″ x 2″ gauze and roll it into a tight round ball. Hold the gauze with firm pressure over the leak (it is easier if you have the patient or an assistant holding it in place while you move on to the next step).

4. Stretch the transparent film dressing before placing it over the center of the gauze

4. Continue to hold firm pressure on the gauze from over thetransparent film dressing. Note that you are not yet touching the dressing against the skin.

5. Stretch outtransparent film dressing and affix to the patient’s skin.

6. Once you apply the initial transparent film dressing, you can apply 2-3 more over the top, in the same fashion, to increase the pressure on and security of the dressing. Patients may be discharged with this dressing in place for 24-48 hours.

Pro Tip

Consider combining both this trick of the trade and the adhesive glue technique. Hat tip to Dr. Christian Rose [Twitter @RoseLikeTheFlwr] for this idea.

Interested in other Tricks of the Trade posts?

Read the series of Tricks of the Trade posts.

By Carmen Estrada|2021-10-15T12:48:11-07:00Oct 20, 2021|Gastrointestinal, Tricks of the Trade|

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric intussusception. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Take the ALiEMU PEM POCUS: Intussusception Quiz – test your skills

PATIENT CASE

Johnny is a 2-year-old boy who comes into the emergency department for abdominal pain for the last day. His parents are concerned that he has been having intermittent abdominal pain and has seemed very tired all day. Parents deny bloody stool.

On arrival, his vital signs are:

Vital Sign	Finding
Temperature	36.9C
Heart rate	110 bpm
Blood pressure	97/50
Respiratory rate	22
Oxygen saturation (room air)	99%

He is tired appearing, and his abdominal exam is soft but diffusely tender. Given his intermittent abdominal pain, you decide to perform an intussusception point of care ultrasound (POCUS) exam.

ULTRASOUND TECHNIQUE

Intussusception is when one part of the bowel telescopes, or gets stuck, in another part of the bowel. Typically intussusception refers to ileocolic intussusception where the ileum becomes stuck in the colon. To perform the ultrasound, start in the right lower quadrant and trace the colon. See below for a step-by-step technique.

Technique

The patient should be positioned supine.
To aid in comforting the child, the child can be positioned supine in the parent’s lap while undergoing the scan. Having the parent or another provider offer a toy, book, or phone/tablet to distract the child during the scan can also help ease anxiety.
Begin in the right lower quadrant (RLQ), using a high frequency linear probe with the probe marker to patient’s right.
First, identify the anatomical landmarks in the RLQ (see ultrasound images below):
- Psoas muscle (green) laterally
- Right iliac vessels (blue)
- Abdominal muscles (red)
- Bladder (yellow) medially

Ultrasound image: Anterior Abdomen (RLQ) View

Ultrasound Image: Anterior Abdomen RLQ (More Medial) View

PEM POCUS intussusception RLQ More Medial

Perform graded compression, with slow steady pressure to displace bowel gas
Follow the colon from the RLQ to right upper quadrant (RUQ) until the liver (purple) and gallbladder are identified

Ultrasound Image: Anterior Abdomen (RUQ) View

Rotate the probe marker to patient’s head and scan the entire length of the transverse colon.
Rotate the probe marker back to patient’s right and scan the entire length of the descending colon, making sure to scan all four quadrants.
Save representative video clips and still images of each quadrant.
If an intussusception is found, measure its diameter in transverse view and note in which quadrant(s) it is found.
At the end of scan, if you have found an intussusception, re-image the abdomen to make sure it was not transient.
The provider should maintain awareness of the patient’s comfort throughout the scan.

INTUSSUSCEPTION CLASSIC FINDINGS

Normal (no intussusception)

Normal: There is no target or sandwich sign, but rather just folded normal bowel. (To replay, press circular arrow in bottom left corner)

Abnormal findings

Look for findings of a sandwich sign (or pseudo-kidney sign) in the longitudinal view and target sign (or donut sign) in the transverse view.
If visualized, measure the diameter of the intussusception in short axis (transverse) and note which in which quadrant(s) it is located.

Sandwich

Anterior abdomen ultrasound: Intussusception – Presence of a sandwich sign (long axis view) and target sign (short axis view)

Target Sign

Intussusception diameter ultrasound — **Measurement:** The diameter of an intussusception (i.e., target sign) in transverse view involves measuring the distance from outer wall to outer wall.

Additional Anterior Abdominal Ultrasound Videos

Pro Tip
It can be difficult to distinguish intussusception of the small bowel-small bowel (i.e., when the ileum or part of the small bowel telescopes into itself) versus ileocolic (i.e., when the ileum becomes telescopes into the colon). The former often does not require a procedure for reduction, while the latter typically does. If the target sign diameter is <2 cm and transient, a small bowel-small bowel intussusception should be suspected. The length of the intussusception, or how many quadrants are involved, can also be measured for an idea of how much bowel is involved.

Small bowel-small bowel intussusception

Small bowel-small bowel intussusception – Note the small size of the target lesion. Because the ultrasound video scans to a depth of 3.3 cm (see bottom right side of the screen), the target sign appears to be approximately only 1 cm in diameter.

Small bowel-small bowel intussusception – There is a target sign, but it is small (<2 cm) with a small fat (white) core.

Ileo-colic intussusception

Ileo-colic intussusception with classic target sign – Note the lymph nodes (black) inside the mesenteric fat (white) in the center of the target.

FACTS and LITERATURE REVIEW

Mimickers of Intussusception

There are additional pathologies that can be mistaken for intussusception such as an intussuscepted appendix, appendicitis surrounded by abscess, and Meckel’s diverticulum, which are beyond the scope of this course. Any concerning finding for intussusception should be followed by a confirmatory study by the radiology department.

Benefits of intussusception POCUS scans

Although few studies have looked at point of care ultrasonography (POCUS) for intussusception, the existing studies have shown excellent test characteristics and a decreased length of stay with using POCUS.

Two studies assessed the test characteristics of the intussusception POCUS.

Publication	Study Methodology	Sensitivity	Specificity
Riera et al. (2012)¹	This journal publication was a prospective study of 82 patients who underwent POCUS by pediatric emergency medicine (PEM) providers. The gold standard was a comprehensive radiology ultrasound.	85%	97%
Trigylidas et al. (2017) ²	This abstract reported a retrospective study of 105 intussusception POCUS scans by PEM providers. The gold standard was either a direct radiology over-read of the POCUS scans or a radiology department ultrasound.	96.2%	92.6%
Lin-Martore et al. (2020)⁶	This systematic review and meta analysis included 1,303 patients and 6 studies.	94.9%	99.1%
Bergmann et al. (2021)⁷	This prospective study of 256 children across 17 sites (35 sonologists) compared POCUS and radiology performed ultrasound using a gold standard of clinically important intussusception which was defined as an intussusception that required radiographic or surgical reduction during or within 7 days of the incident ED visit.	96.6%	98%

In terms of ED length of stay (LOS), Kim et al. (2017) reported that after the introduction of an intussusception POCUS scanning protocol, the LOS decreased by >200 minutes.³

Differentiating small bowel-small bowel from ileocolic intussusception

In general, true ileocolic intussusceptions are:

Found on the right side of the abdomen
>2 cm in diameter
Have mesenteric fat (which is white) and lymph nodes in the center
Do not self resolve

There have been studies looking at distinguishing small bowel-small bowel from ileocolic intussusception. These, however, have been radiology-based and not POCUS studies, making generalizability to the ED setting challenging. Thus, if there is a concern for an intussusception, a radiology ultrasound should be ordered.

One small study with 27 patients by Wiersma et al. (2006) found that small bowel-small bowel intussusceptions had a smaller mean diameter and length compared to ileocolic intussusceptions.⁴

Type of intussusception	# of patients and scans	Mean diameter (range)	Mean length (range)	Location
Small bowel-small bowel	10 patients, 11 scans	1.5 cm (1.1-2.5 cm)	2.5 cm (1.5-6 cm)	Distributed throughout the abdomen (6 paraumbilical, 2 RUQ, 2 RLQ, 1 LLQ)
Ileocolic	14 patients, 16 scans	3.7 cm (3-5.5 cm)	8.2 cm (5-12.5 cm)	All on right side of abdomen

Lioubashevsky et al 2013⁵ had a larger sample size (174 patients) with similar findings. The authors also measured the ratio of the inner fat core to the intussusception outer wall and identified the presence or absence of lymph nodes within the lesion.

Type of Intussusception	# of patients	Mean diameter (range)	Mean length (range)	Ratio of fat core to the intussusception outer wall	% of patients with lymph nodes in the lesion
Small bowel-small bowel	57 patients	1.4 cm (1.1-2.5 cm)	2.5 cm (1.5-6 cm)	<1	14%
Ileocolic	143 patients	2.6 cm (1.3-4 cm)	8.2 cm (5-12.5 cm)	>1	89.5%

References [click to expand] +

Riera A, Hsiao A, Langhan M, Goodman T, Chen L. Diagnosis of intussusception by physician novice sonographers in the emergency department. Ann Emerg Med. 2012;60(3):264-268. PMID 22424652
Trigylidas TE, Kelly JC, Hegenbarth MA, Kennedy C, Patel L, O’Rourke K. 395 Pediatric Emergency Medicine-Performed Point-of-Care Ultrasound (POCUS) for the Diagnosis of Intussusception. Annals of Emergency Medicine. October 2017:S155. DOI
Kim J, Lee J, Kwon J, Cho H, Lee J, Ryu J. Point-of-Care Ultrasound Could Streamline the Emergency Department Workflow of Clinically Nonspecific Intussusception. Pediatr Emerg Care. September 2017. PMID 28926507
Wiersma F, Allema J, Holscher H. Ileoileal intussusception in children: ultrasonographic differentiation from ileocolic intussusception. Pediatr Radiol. 2006;36(11):1177-1181. PMID 17019589
Lioubashevsky N, Hiller N, Rozovsky K, Segev L, Simanovsky N. Ileocolic versus small-bowel intussusception in children: can US enable reliable differentiation? Radiology. 2013;269(1):266-271. PMID 23801771
Lin-Martore M, Kornblith AE, Kohn MA, Gottlieb M. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception in Children Presenting to the Emergency Department: A Systematic Review and Meta-analysis. West J Emerg Med. 2020 Jul 2;21(4):1008-1016. doi: 10.5811/westjem.2020.4.46241. PMID: 32726276.
Bergmann KR, Arroyo AC, Tessaro MO, et al; P2Network. Diagnostic Accuracy of Point-of-Care Ultrasound for Intussusception: A Multicenter, Noninferiority Study of Paired Diagnostic Tests. Ann Emerg Med. 2021 Jul 2:S0196-0644(21)00340-1. doi: 10.1016/j.annemergmed.2021.04.033. Epub ahead of print. PMID: 34226072.

Case Resolution

You place a linear, high-frequency probe on the right side of the patient’s abdomen. You perform a bedside ultrasound scan, viewing transversely and longitudinally through the upper and lower abdomen. You observe the following:

What is the diagnosis?

This is an intussusception!

The intussusceptum (red) is the part of the bowel that has telescoped into the intussuscipiens (blue). When ileum becomes trapped in the colon, this can lead to ischemia and necrosis over time. This is what causes the classic “currant jelly stools”, which are bloody stools.

Tip: The classic triad of colicky abdominal pain, palpable mass and bloody stool are present in less than 50% of patients, and intussusception should be suspected for patients with vomiting, abdominal pain, and/or lethargy.¹

Hospital course

Johnny underwent an air enema reduction in the Radiology department, which successfully reduced the ileocolic intussusception.

Reference

Daneman A, Alton D. Intussusception. Issues and controversies related to diagnosis and reduction. Radiol Clin North Am. 1996;34(4):743-756. PMID 8677307.

Take the ALiEMU PEM POCUS: Intussusception Quiz – test your skills

The PEM POCUS series was created by the UCSF Division of Pediatric Emergency Medicine to help advance pediatric care by the thoughtful use of bedside ultrasonography.

Learn more about bedside ultrasonography on the ALiEM Ultrasound for the Win series

By Margaret Lin-Martore, MD|2021-10-21T16:59:09-07:00May 10, 2021|Gastrointestinal, PEM POCUS, Ultrasound|

SAEM Clinical Image Series: Distended Abdomen after ROSC

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.

(more…)

By Sheri-Ann Olivia Kaltiso, MD|2020-09-18T20:43:44-07:00Sep 21, 2020|Critical Care/ Resus, Gastrointestinal, SAEM Clinical Images, Uncategorized|

SAEM Clinical Image Series: An 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.

(more…)

By Matthew Sherman, MD|2020-08-25T17:47:32-07:00Aug 31, 2020|Emergency Medicine, ENT, Gastrointestinal, SAEM Clinical Images|

Previous 123 4 5 6 7 8 Next