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ALiEM AIR Series | Respiratory 2023 Module

ALiEM AIR- respiratory module 2023

Welcome to the AIR Respiratory 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 respiratory diseases in the Emergency Department. 6 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 3 AIR and 3 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.

Take the AIR Respiratory Module at ALiEMU

Interested in taking the AIR quiz for fun or asynchronous (Individualized Interactive Instruction) credit? Please go to the above link. You will need to create a free, 1-time login account.

Highlighted Quality Posts: Respiratory

SiteArticleAuthorDateLabel
EMCritIBCC: Asthma Josh Farkas, MDApril 12, 2023AIR
EMCritIBCC: Severe Community Acquired PneumoniaJosh Farkas, MDOctober 11, 2022AIR
EM DocsEmpyema: ED Presentation, Evaluation, and ManagementHeath Garner, MDApril 11, 2022AIR
Rebel EMPigtail Catheter vs Large Bore Chest Tube for PneumothoraxJessica DiPeri, MDDecember 1, 2022HM
The Skeptics Guide to EMHey Ho! High Flow vs Standard O2 therapy for hospitalized children with respiratory failureDennis Ren, MDApril 22, 2023HM
PEM BlogWhy we do what we do: Treatments for severe asthmaBrad Sobolewski, MDAugust 23, 2022HM

(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

 

 

Sponsors

Thank you to the Society of Academic Emergency Medicine (SAEM) and the Council of EM Residency Directors (CORD) for jointly sponsoring the AIR Series! We are thrilled to partner with both on shaping the future of medical education.

By |2023-10-13T14:22:22-07:00Oct 14, 2023|ALiEMU, Approved Instructional Resources (AIR series), Pulmonary|
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SAEM Clinical Images Series: A Rare Cause of Recurrent UTI

bulge

A 52-year-old male presents to the Emergency Department with a chief complaint of right lower abdominal pain with urinary frequency and urgency over the past week. The pain radiates from his right groin with 10/10 severity at times. He reports multiple diagnoses of urinary tract infections over the last year requiring oral antibiotics. He claims intermittent constipation, denies any trauma, and is a truck driver by trade.

Vitals: T 97.7 °C; BP 138/75; HR 75; RR 16; O2 sat 96%

General: WDWN obese male, A/O x4, in mild distress

Abdomen: Soft, nondistended, normoactive bowel sounds, no organomegaly. A 5 cm moderately tender soft tissue bulge suggestive of a direct hernia is palpated in the right inguinal area and is reduceable.

Complete blood count (CBC): Within normal limits

Complete metabolic panel (CMP): Within normal limits

Urinalysis (UA):

  • Color: Cloudy, yellow
  • Blood: Trace
  • Leukocyte esterase: Positive
  • Nitrite: Positive
  • WBCs: 15-30 hpf
  • RBCs: 3-5 hpf
  • Bacteria: Moderate

This patient’s CT scans demonstrate an inguinal herniation of the urinary bladder, which occurs in less than 4% of all inguinal hernias. The clinical finding of a soft tissue mass in the groin in the setting of recurrent urinary tract infections should include urinary bladder herniation in the differential diagnosis.

Oral or parenteral antibiotics based on clinical presentation and prevalent sensitivities should be given to address urinary tract infections. Emergent or non-emergent (if reduceable) surgical consultation, usually by a urologist, is standard. Surgical reduction and repair techniques that utilize mesh versus non-mesh have been associated with a better prognosis with less recurrence.

Take-Home Points

  • Although rare, an inguinal herniation of the urinary bladder should be considered in males over 50 years old who have a herniation on physical exam and urinary complaints.
  • Risk factors include obesity, BPH, and male sex. This condition is diagnosed in very few women.
  • Computerized tomography is the usual imaging modality to diagnose a urinary bladder herniation.
  • Patients may be asymptomatic or have symptoms that may include inguinal pain or swelling, urinary retention, and acute renal failure.
  • Manual compression of hernia to void is pathognomonic for a urinary bladder herniation.

  • Branchu B, Renard Y, Larre S, Leon P. Diagnosis and treatment of inguinal hernia of the bladder: a systematic review of the past 10 years. Turk J Urol. 2018 Sep;44(5):384-388. doi: 10.5152/tud.2018.46417. Epub 2018 Sep 1. PMID: 30487042; PMCID: PMC6134980.
  • Papatheofani V, Beaumont K, Nuessler NC. Inguinal hernia with complete urinary bladder herniation: a case report and review of the literature. J Surg Case Rep. 2020 Jan 2;2020(1):rjz321. doi: 10.1093/jscr/rjz321. PMID: 31911827; PMCID: PMC6939942.

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 |2023-10-06T13:25:23-07:00Oct 6, 2023|Genitourinary, SAEM Clinical Images|
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SAEM Clinical Images Series: Unusual Scalp Lesions

scalp

A 6-year-old male presented to the pediatric emergency department (PED) for scalp lesions. He was seen by his pediatrician 2 weeks prior and prescribed antibiotics and a delousing shampoo for suspected cellulitis versus lice infestation. Symptoms did not improve despite completion of treatment. An outpatient ultrasound was performed showing “multiple scalp echogenic nodular lesions measuring from 0.5 cm to 1.2 cm in the long axis diameter.” The following differential diagnosis was entertained: lymphadenitis, benign avascular mass, epidermal inclusion cyst, or pilomatricoma, and the patient was started on clindamycin. Due to concern for an oncologic process, a surgery consultation was placed to arrange for a biopsy. Four days after the ultrasound and before the biopsy could be performed, the patient and his mother presented to the PED due to worsening symptoms. Multiple new lesions developed across the patient’s scalp which bled when pressure was applied. The patient denied fever and reported intermittent pruritus and pain over the lesion sites. The mother reported a history of travel to Ecuador one month prior to symptom onset.

Vitals: BP 98/61; Pulse 73; Temp 36.3°C (97.3°F) temporal; Resp 18; SpO2 99%, RA

Skin: Large, 3 x 3cm indurated, erythematous lesion located over the patient’s right temporal scalp (Image 1). Five additional lesions noted across the entirety of the scalp. No lesions identified below the neck. Lesions are mildly tender to palpation; no fluid able to be expressed. A small centrally located pore is noted on each lesion with appearance of pulsatile fluid level. No associated lymphadenopathy. A point-of-care ultrasound (POCUS) using a high-frequency, linear transducer was performed during the PED visit (Image 2).

Non-contributory

In short axis, there is an echogenic lesion with surrounding fluid (halo sign) suggesting a foreign body that also exhibits posterior acoustic shadowing. With the transducer held still, independent movement is visualized within the center of the lesion (Image 3).

Cutaneous furuncular myiasis due to Dermatobia hominis (botfly infestation).

Take-Home Points

  • Native to Central and South America, botfly infestation is facilitated through an infected female mosquito which deposits its eggs on the skin of a mammal on which it feeds.
  • Cutaneous furuncular myiasis is important to consider for unexplained head, neck, and extremity lesions when there is suspected travel to endemic areas and is unlikely to be recognized in the continental United States due to low prevalence.
  • Consider pertinent physical exam findings and utility of POCUS in confirming the diagnosis.

  • Harris AT, Bhatti I, Bajaj Y, Smelt GJ. An unusual cause of pre-auricular swelling. J Laryngol Otol. 2010 Mar;124(3):339-40. doi: 10.1017/S002221510999082X. Epub 2009 Aug 11. PMID: 19664319.
  • Minakova E, Doniger SJ. Botfly larva masquerading as periorbital cellulitis: identification by point-of-care ultrasonography. Pediatr Emerg Care. 2014 Jun;30(6):437-9. doi: 10.1097/PEC.0000000000000156. PMID: 24892687.

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 |2023-09-27T08:23:43-07:00Oct 2, 2023|Dermatology, Pediatrics, PEM POCUS, SAEM Clinical Images|
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SAEM Clinical Images Series: Only a Flesh Wound

flesh

A 49-year-old male was triaged to the Fast Track area with complaints of an abrasion to the neck following an assault. The patient was attending a party with his family when “someone started shooting.” The patient believes some stucco or stone fragment from a brick wall struck him in the neck during the initial incident, but his primary concern was for his more seriously wounded family members. He now presents requesting “Neosporin.” His tetanus status is out of date.

General: Well-appearing male in no distress

Neck: Hemostatic wound to his left neck. No significant pain, no hematoma, no bruits.

Neuro: Exam is non-focal

Non-contributory

This is a zone 2 injury to the neck. Despite the small size of the wound, a piece of metallic shrapnel from the splintered bullet is noted adjacent to the carotid on CT imaging. Penetrating wounds can be deceptively innocuous, and a high index of suspicion is required. In cases where the nature of the missile is known, plain films or POCUS may be a reasonable first step, but CT imaging would be definitive.

Development of hoarseness or a Horner syndrome on the affected side may indicate involvement of the carotid sheath, and an angiogram may be considered, though CTA compares favorably to angiography in penetrating as opposed to blunt arterial trauma.

Take-Home Points

  • “Superficial” wounds must be evaluated diligently for any signs of deeper extension, and advanced imaging obtained for any suspicious findings or concerning mechanism of injury.
  • CTA is likely to be adequate in most cases of penetrating trauma, but a role may still exist for angiography in the presence of compelling clinical findings.

  • Goodwin RB, Beery PR 2nd, Dorbish RJ, et al. Computed tomographic angiography versus conventional angiography for the diagnosis of blunt cerebrovascular injury in trauma patients. The Journal of Trauma. 2009 Nov;67(5):1046-1050. DOI: 10.1097/ta.0b013e3181b83b63. PMID: 19901666.
  • Múnera F, Soto JA, Palacio D, Velez SM, Medina E. Diagnosis of arterial injuries caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology. 2000 Aug;216(2):356-62. doi: 10.1148/radiology.216.2.r00jl25356. PMID: 10924553.

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 |2023-09-14T13:12:37-07:00Sep 29, 2023|SAEM Clinical Images, Trauma|
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