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SAEM Clinical Images Series: When Needles Go Beyond Sewing and Acupuncture

needles

A 64-year-old male with a history of bipolar 1 disorder, PTSD, anxiety, depression, obsessive-compulsive disorder, GERD, and HTN presented to the ED with the chief complaint of foreign body and self-injury. He reported years of sticking sewing needles into his right arm, most recently yesterday. He explained that inserting needles makes him feel better with mild associated pain. He endorsed suicidal ideas, elaborating that he did not want to stop injuring himself. He also reported depression and wished that he was not alive. He stated that he had told his therapist that he didn’t want to present to the ED today and added that he wanted to leave the ED and did not want to be seen by the psych team. He denied homicidal ideation.

 

Extremities: When palpating the right forearm, multiple linear hard objects are felt in the subcutaneous tissue. The patient can flex/extend the wrist, supinate and pronate, and flex/extend the elbow without issue. No erythema or fluctuance. No obvious insertion site noted.

None

Numerous linear metallic foreign bodies are present throughout the right forearm; several new foreign bodies are noted. Bony exam is significantly limited due to the presence of numerous (greater than 50) linear metallic densities throughout the forearm. Mild to moderate degenerative changes of the wrist and elbow are noted.

Take-Home Points

  • Removal of metallic foreign bodies is an individualized risk vs benefit decision based on the following: signs of infection, suspected level of contamination, type of metal, cooperativeness of the patient, location nearby vital structures, cosmetic deformity, and pain. When the risk of removal outweighs the benefits or if the patient does not desire removal, foreign body removal is not always needed.
  • Regarding prophylaxis, antibiotics need not be routinely administered if the wound is clean. Tetanus vaccination status should be reviewed, and the vaccine (Tdap) and/or potentially tetanus immune globulin should be administered if indicated.

  • Rupert J, Honeycutt JD, Odom MR. Foreign Bodies in the Skin: Evaluation and Management. Am Fam Physician. 2020 Jun 15;101(12):740-747. PMID: 32538598.
  • Lane JC, Mabvuure NT, Hindocha S, Khan W. Current concepts of prophylactic antibiotics in trauma: a review. Open Orthop J. 2012;6:511-7. doi: 10.2174/1874325001206010511. Epub 2012 Nov 30. PMID: 23248721; PMCID: PMC3522105.

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 |2024-10-15T10:59:39-07:00Oct 25, 2024|Psychiatry, Radiology, SAEM Clinical Images|
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Trick of the Trade: Cut IV extension tubing for 2-person ultrasound guided nerve block

illustration nerve block ultrasound guided needle

Ultrasound-guided procedures are difficult enough just identifying the anatomy. Performing a nerve block with the ultrasound in one hand and the needle in the other hand adds extra challenges. The simplest 1-person approach involves attaching a syringe with local anesthetic directly to the end of the procedural needle. A 2-person approach involves attach the syringe to a custom tubing-needle setup such as below. However, this custom setup may not be readily available.

IV and extension tubing attached to needle

Trick of Trade: Cut Standard IV Extension Tubing

Required equipment:

  • Ultrasound linear probe
  • 10 cc syringe
  • IV tubing
  • Procedural needle
  • Shears

IV extension injection port

Almost all standard IV extension tubing that connects IV fluid bags to a peripheral IV have an injection port near the downstream end.

  1. Clamp the IV tubing just upstream from the injection port and cut off all the unused upstream IV tubing.
  2. Attach a 10 cc syringe with local anesthetic to the injection port.
  3. Attach the other end of this IV tubing (Luer lock attachment) to the procedural needle.
  4. Prime the IV line with the anesthetic.
  5. Perform the nerve block with one person advancing the needle under ultrasound guidance, while the other person aspirates and injects the anesthetic when needed.

Video: 2-person ultrasound-guided nerve block with cut IV tubing

Bonus Tip: This approach is applicable to many procedures requiring aspiration or instillation of anesthetic, such as peritonsillar abscess aspiration.

Read more from the Tricks of the Trade series.

By |2024-10-23T07:23:46-07:00Oct 23, 2024|Neurology, Tricks of the Trade, Ultrasound|
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SAEM Clinical Images Series: Not Your Average Ear Infection

ear infection

A 5-year-old generally healthy fully immunized boy presented to the ED with worsening left ear redness, swelling, and tenderness that his family noticed the day before presentation. His family had also recently noticed an abrasion over that ear. The patient was on amoxicillin for strep throat, which was diagnosed a week before the onset of his symptoms and was improving.

Vitals: BP 130/68; HR 105; Temp 98.9°F; RR 22; O2 Sat 100% RA

General: Alert, interactive, well-appearing

HEENT: Left ear with moderate redness, swelling, warmth, and tenderness of the auricle sparing the lobule. Superficial lineal abrasion over concha, hemostatic. Ear canal and tympanic membrane normal.

Neck: Shotty left posterior cervical lymphadenopathy

Cardiovascular: Regular rate and rhythm, brisk capillary refill

Pulm: Clear to auscultation bilaterally

Abdomen: Soft, non-tender, non-distended

MSK/extremities: No edema

Skin: No rash except as noted

None

This is a case of perichondritis of the auricle, or a bacterial infection of the ear’s cartilage. It often occurs in the setting of trauma, which may be occult. Findings suggestive of perichondritis (versus cellulitis) include sparing of the ear’s lobule. It is most commonly caused by p. aeruginosa and requires treatment with antibiotics providing anti-pseudomonal coverage to prevent permanent ear deformity.

Take-Home Points

  • Consider the diagnosis of perichondritis when evaluating skin and soft tissue infections of the auricle.
  • Treat this condition with anti-pseudomonal antibiotics.

  • Davidi E, Paz A, Duchman H, Luntz M, Potasman I. Perichondritis of the auricle: analysis of 114 cases. Isr Med Assoc J. 2011 Jan;13(1):21-4. PMID: 21446231.
  • Klug TE, Holm N, Greve T, Ovesen T. Perichondritis of the auricle: bacterial findings and clinical evaluation of different antibiotic regimens. Eur Arch Otorhinolaryngol. 2019 Aug;276(8):2199-2203. doi: 10.1007/s00405-019-05463-z. Epub 2019 May 11. PMID: 31079204.

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 |2024-10-15T10:24:35-07:00Oct 21, 2024|HEENT, SAEM Clinical Images|
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SAEM Clinical Images Series: A Blistery Mystery

blister

A 76-year-old female presented with a lingering cough and an oral lesion to the left lower cheek. She reported ten days of improving flu-like symptoms but had a persistent cough and nasal congestion. On the day of presentation, she developed a painful, intermittently bleeding “blood blister” to the left lower cheek that had increased in size, as well as new red spots on her arms and legs. She reported no recent trauma or history of similar lesions in the past.

Vitals: 98.3°F; HR 85; BP 178/89; RR 16; SpO2 98% on RA

HENT: Blood-filled pocket to the left lower vestibule

Skin: Diffuse petechial rash to extremities

CBC: Hb 13.6, Plt 6, WBC 10.3

PT: 12.2

INR: 1.05

PTT: 33

Immune thrombocytopenia (ITP) is an acquired autoimmune disorder caused by autoantibodies against platelet antigens. It is thought to be due to IgG directed against platelet membrane glycoprotein GPIIb/IIIa, leading to platelet destruction. Common inciting events include viral infections, autoimmune diseases, or immunodeficiency syndromes [1]. Patients typically present with bleeding or nonspecific symptoms such as fatigue or generalized weakness. The severity of bleeding can range from petechiae, purpura, and epistaxis, to (very rarely) life-threatening hemorrhage. It is important to perform a thorough skin and oral exam to evaluate for petechial rashes or mucosal bleeding. Initial diagnostics include a CBC which will show isolated thrombocytopenia, as well as hemolysis labs to exclude alternative etiologies.

Patients with life-threatening bleeding should be treated emergently with platelet transfusions, IVIG, and steroids. In all other cases, management decisions should be made in conjunction with Hematology. In general, those with mild/moderate bleeding and platelets <20,000/μL should be treated with a steroid course, with IVIG or platelet transfusions in special circumstances only [3]. Patients who receive any treatment or have diagnostic uncertainty should be admitted.

Take-Home Points

  • Immune thrombocytopenia is an acquired isolated thrombocytopenia that can be a primary disorder or secondary to viral illness, autoimmune syndrome, or immunodeficiency disease.
  • Patients typically present with minor bleeding and nonspecific symptoms such as fatigue, or, rarely, severe hemorrhage. Perform a thorough skin and oral exam to evaluate for petechial rashes or mucosal bleeds.
  • Life-threatening bleeding should be treated immediately with platelet transfusions, IVIG, and steroids. Treatment for mild/moderate bleeding is more nuanced. Consult Hematology early to guide management.

  • Cines DB, Bussel JB, Liebman HA, Luning Prak ET. The ITP syndrome: pathogenic and clinical diversity. Blood. 2009 Jun 25;113(26):6511-21. doi: 10.1182/blood-2009-01-129155. Epub 2009 Apr 24. PMID: 19395674; PMCID: PMC2710913.
  • Neunert C, Terrell DR, Arnold DM, Buchanan G, Cines DB, Cooper N, Cuker A, Despotovic JM, George JN, Grace RF, Kühne T, Kuter DJ, Lim W, McCrae KR, Pruitt B, Shimanek H, Vesely SK. American Society of Hematology 2019 guidelines for immune thrombocytopenia. Blood Adv. 2019 Dec 10;3(23):3829-3866. doi: 10.1182/bloodadvances.2019000966. Erratum in: Blood Adv. 2020 Jan 28;4(2):252. PMID: 31794604; PMCID: PMC6963252.
  • Provan D, Arnold DM, Bussel JB, et al. Updated international consensus report on the investigation and management of primary immune thrombocytopenia. Blood Adv. 2019;3(22):3780-3817. doi:10.1182/bloodadvances.2019000812

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 |2024-09-28T21:40:15-07:00Oct 11, 2024|Heme-Oncology, SAEM Clinical Images|
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SAEM Clinical Images Series: Doubly Double Vision

palsy

A 52-year-old female with a past medical history of hypertension and prediabetes presented to the emergency department with double vision that started one day prior to arrival. She stated that her double vision improved when she closed one eye. She denied trauma, headache, neck pain, dizziness, dysphagia, numbness, tingling, weakness, or gait instability.

 

Vitals: BP 181/119; HR 76; RR 18; T 98.4°F; O2 saturation 96% on room air

General: No acute distress, well-appearing

Neurologic: AOx3; Following commands. Speech without dysarthria. PERRLA. EOM: incomplete abduction of the L and R eye. No facial asymmetry. Tongue protrudes midline. No pronator drift. 5/5 strength in all extremities. Sensation is intact throughout. Finger to nose is normal. Gait is narrow and steady.

None

Cranial nerve 6 (CN VI), also known as the abducens nerve, is responsible for ipsilateral eye movement. CN VI palsy presents clinically with the inability to abduct the eye resulting in horizontal diplopia. Patients often present complaining of double vision that is worse with lateral gaze. Other symptoms on presentation may include headache, nausea, vomiting, hearing loss, and recent viral symptoms. CN VI is typically diagnosed clinically by an inability to abduct the eye. It is the most common oculomotor palsy in adults and can be caused by damage anywhere along the course of the abducens nerve. Etiologies in adults include ischemia, trauma, neoplasm, demyelinating lesions, increased intracranial pressure, and infection. Risk factors include microvascular disease such as hypertension and inflammatory conditions. Bilateral CN VI nerve palsy without associated intracranial abnormalities is rare. Importantly, abducens nerve palsy is the second most common oculomotor palsy in children and a frequent presenting sign of an intracranial tumor. Children with CN VI palsy should be evaluated for ataxia and other gait disturbances which may indicate a brainstem glioma.

Depending on the presenting symptoms and medical history, the workup should include an MRI/MRA brain to evaluate for microvascular ischemia and cerebrovascular accident. Treatment of CN VI palsy should be targeted at the underlying cause. In cases of CN VI palsy due to microvascular ischemia, symptoms often self-resolve. In children, treatment includes alternating patching of the eyes, but this has not been shown to be effective in adults.

Take-Home Points

  • CN VI palsy is the most common oculomotor palsy in adults and presents with an inability to abduct the eye.
  • Treatment of CN VI palsy should target the underlying pathology which may include infection, trauma, neoplasm, or increased intracranial pressure.
  • CN VI palsy in children may indicate an intracranial tumor and workup should include a full neurologic examination and intracranial imaging when appropriate.

  • Graham C, Gurnani B, Mohseni M. Abducens Nerve Palsy. 2023 Aug 24. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29489275.

    Merino P, Gómez de Liaño P, Villalobo JM, Franco G, Gómez de Liaño R. Etiology and treatment of pediatric sixth nerve palsy. J AAPOS. 2010 Dec;14(6):502-5. doi: 10.1016/j.jaapos.2010.09.009. PMID: 21168073.

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 |2024-09-28T21:34:14-07:00Oct 7, 2024|Neurology, SAEM Clinical Images|
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SAEM Clinical Images Series: Unidentified Intrauterine Object

IUP

A 31-year-old female G3P2 presented to the emergency department with vaginal spotting for one week and worsening lower abdominal cramping. She tested positive on a home pregnancy test one day prior to presentation. On the day of presentation, she passed a small blood clot and bled through one pad. She had not yet seen an OB for this pregnancy. Her last menstrual period was one month and three days prior. The current pregnancy is undesired. She denied fevers, chills, urinary symptoms, lightheadedness, palpitations, shortness of breath, nausea, or vomiting.

 

gestational sac

Vitals: BP 95/55; HR 75; Temp 98.4°F; Resp 16; SpO2 100% on room air

Abdomen: Soft; tender to palpation in the suprapubic region, no guarding or rebound tenderness

GU: Scant blood in the vaginal canal, no clots or tissue; os closed, no adnexal tenderness, no cervical motion tenderness

bHCG: 36,966

Rh Factor: Positive

Hgb: 9.2

Ectopic pregnancy needs to be ruled out. This patient has vaginal bleeding, a positive pregnancy test, and abdominal pain. She has not established care with an OB provider and has not had a confirmed intrauterine pregnancy. Specific ultrasound findings for an ectopic pregnancy include a gestational sac with a yolk sac outside of the uterus. Findings suggestive of an ectopic pregnancy include complex adnexal masses, free fluid with debris (suggestive of rupture), and an empty gestational sac within an adnexal mass.

Yes, this is a viable intrauterine pregnancy (IUP). Confirmation can be done with transabdominal ultrasound but in very early pregnancy may require a transvaginal ultrasound. Findings needed to confirm an IUP include a gestational sac containing a yolk sac within a thickened myometrium. The hyperechoic structure seen on transabdominal and transvaginal ultrasounds for this patient is an intra-uterine device (IUD) that is in place. The risk of pregnancy with an IUD in place is <1%; according to a database of 18 million hospital deliveries, the reports of retained IUD at birth was 12 per 100,000 births. For pregnancies with an IUD in place, the rate of ectopic pregnancy is higher. There is also a higher risk of maternal infection, miscarriage, preterm premature rupture of membranes, preterm birth, and intrauterine fetal demise. For desired pregnancies, if the strings are visible, the IUD is removed as soon as possible and a single dose of azithromycin is given due to increased risk of infection during pregnancy. There is limited evidence to guide management for desired pregnancies when strings are not visible. One option is hysteroscopic removal, although this increases the risk of pregnancy loss. More than 50% of pregnancies with in situ IUDs were found to end in spontaneous abortion.

Take-Home Points

  • A definite IUP requires an intrauterine gestational sac with yolk sac and/or embryo (with or without cardiac activity).
  • Pregnancy with an IUD is extremely rare and increases the risk of ectopic pregnancy, maternal infection, miscarriage, PPROM, preterm birth, and fetal demise.
  • Management for desired pregnancies with IUDs in place when IUD strings are visible consists of early IUD removal with a single dose of prophylactic antibiotics.

  • ACOG Practice Bulletin No. 121: Long-acting reversible contraception: Implants and intrauterine devices. Obstet Gynecol. 2011 Jul;118(1):184-196. doi: 10.1097/ AOG.0b013e318227f05e. PMID: 21691183.
  • Ganer H, Levy A, Ohel I, Sheiner E. Pregnancy outcome in women with an intrauterine contraceptive device. Am J Obstet Gynecol. 2009 Oct;201(4):381.e1-5. doi: 10.1016/j.ajog.2009.06.031. Epub 2009 Aug 29. PMID: 19716537.
  • Roline, C.E., Heegaard, W.G. & Anderson, K.S. Early pregnancy with an intrauterine device in place. Crit Ultrasound J 3, 91–92 (2011). https://doi.org/10.1007/s13089-011-0068-1

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 |2024-09-28T21:27:46-07:00Oct 4, 2024|Ob/Gyn, SAEM Clinical Images, Ultrasound|
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SAEM Clinical Images Series: Didn’t See That Coming

hyphema

A 23-year-old healthy male presented to the emergency department with left eye pain, soreness, and blurry vision after being hit in the left eye with a Nerf gun bullet two days prior. He had no prior ophthalmologic history and does not wear corrective lenses.

Left eye: Visual acuity 20/30. Intraocular Pressure 17. Pupil 3mm, irregular, minimally reactive. Slit lamp exam revealing 3+ RBCs, vertical layering of blood along the nasal aspect.

None

Vertical hyphema

Blunt trauma induces shearing forces upon the vasculature of the ciliary body and iris, resulting in the accumulation of red blood cells (RBCs) in the anterior chamber. This space normally contains only clear, aqueous humor. RBCs slowly settle to the bottom of the anterior chamber in a gravity-dependent manner. Classically this develops in a horizontal pattern, but patients who subsequently sleep on their side may experience vertical hyphema formation. Although trauma is the most common etiology, hyphema can occur due to any hematologic abnormality. It is a frequent complication of sickle cell disease. As in all cases of ocular trauma, globe rupture must be immediately ruled out before proceeding with a comprehensive ophthalmologic examination.

The patient had a Grade I hyphema.

Grade 0: No visible layering, but red blood cells within the anterior chamber (microhyphema)

Grade I: Layered blood occupying less than one-third of the anterior chamber

Grade II: Blood filling one-third to one-half of the anterior chamber

Grade III: Layered blood filling one-half to less than total of the anterior chamber

Grade IV: Total filling of the anterior chamber with blood (also known as 8-ball hyphema)

Take-Home Points

  • A hyphema is a collection of blood in the anterior chamber of the eye.
  • Before measuring intraocular pressure, remember to inspect the anterior ocular anatomy with consideration for globe rupture. If this is not excluded, avoid tonometry as it can cause extrusion of aqueous humor and further damage to the globe.
  • Blunt trauma is the most common cause of hyphema. However, non-traumatic hyphema should prompt investigation for hematologic disorders such as Sickle cell disease.

  • Brandt MT, Haug RH. Traumatic hyphema: a comprehensive review. J Oral Maxillofac Surg. 2001 Dec;59(12):1462-70. doi: 10.1053/joms.2001.28284. PMID: 11732035.
  • Gragg J, Blair K, Baker MB. Hyphema. 2022 Dec 26. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan–. PMID: 29939579.

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 |2024-09-28T21:19:11-07:00Sep 30, 2024|Ophthalmology, SAEM Clinical Images|
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