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SAEM Clinical Images Series: Hey Doc, Can You Come Look at This Urine?

urine

A 4-year-old male with no significant past medical history presents as a transfer from an outside hospital for suspected inhalation burn secondary to a house fire. The patient was home with his father and sibling when the apartment caught fire from a suspected flame in the kitchen. The patient was evacuated from the building by fire rescue after an unknown period of time. He was intubated at the outside hospital due to concern for inhalation injury. It is unknown if the patient sustained any trauma prior to extraction.

Vitals: T 98.1°F; BP 120/64; P 126; RR 29; O2 Sat 100% on vent

General: Intubated and sedated.

HENT: Singed hair and soot noted to nares, soot in mouth and secretions.

Cardiovascular: Regular rate and rhythm.

Lungs: CTABL, no wheezing or stridor.

GU: Normal appearing genitalia, no blood at meatus or from rectum, dark red urine noted in foley bag.

Skin: 0% TBSA burns, no obvious signs of trauma.

CBC: WNL

ABG at outside hospital: pH 7.0, carboxyhemoglobin 10, methemoglobin 3, lactate 3.7

Repeat ABG after transfer: pH 7.22, carboxyhemoglobin 1.7, methemoglobin 3.7, lactate 2.1

Hydroxocobalamin

Hydroxocobalamin should be given in any case of suspected cyanide toxicity. House fires are the most common cause of cyanide toxicity in industrialized nations. Cyanide toxicity can also occur due to occupational exposures, medications, foods, or intentional ingestion. Cyanide inhibits the electron transport chain thus blocking aerobic metabolism, leading to hypoxia. Patients can present with altered mental status, hemodynamic instability, and dysrhythmias. Labs will be significant for lactic acidosis. Hydroxocobalamin should be given as soon as cyanide toxicity is suspected. Hydroxocobalamin works by chelating cyanide and forming cyanocobalamin which is renally excreted. Hydroxocobalamin is relatively safe and non-toxic but can cause transient hypertension. It also can cause a reddish discoloration of the urine, skin, and mucous membranes that can last up to several days. This is not harmful to the patient but can cause interference in urinalysis results.

Take-Home Points

  • Hydroxocobalamin is the antidote for cyanide toxicity and should be given as soon as possible in suspected cases.
  • Hydroxocobalamin binds cyanide to form cyanocobalamin, which is excreted in the urine.
  • Hydroxocobalamin is relatively safe but can cause transient hypertension and a red urine discoloration that can interfere with urinalysis results.

  • Cescon DW, Juurlink DN. Discoloration of skin and urine after treatment with hydroxocobalamin for cyanide poisoning. CMAJ. 2009 Jan 20;180(2):251. doi: 10.1503/cmaj.080727. PMID: 19153403; PMCID: PMC2621289.
  • Wong SL, Pudek M, Li D. Wine-Colored Plasma and Urine from Hydroxocobalamin Treatment. J Gen Intern Med. 2017 Feb;32(2):225-226. doi: 10.1007/s11606-016-3782-3. Epub 2016 Jun 23. PMID: 27338592; PMCID: PMC5264665.
  • Desai, S. & Su, Mark K. (2021). Cyanide Poisoning. In: UpToDate, Post TW (Ed), UpToDate,Waltham, MA. (Accessed on January 04, 2022.)
  • Lexicomp. (n.d.). Hydroxocobalamin (vitamin B12a supplement and cyanide antidote): Druginformation. UpToDate. Retrieved January 8, 2022,from https://www.uptodate.com/contents/hydroxocobalamin-vitamin-b12a-supplement-and-cyanide-antidote-drug-information

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 |2026-06-16T16:18:15-07:00Feb 13, 2023|SAEM Clinical Images, Tox & Medications|
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Trick of the Trade: Antibiotic ointment for removal of artificial nail glue from eyelids

A bottle of nail glue and timolol eye drops (reproduced with permission from BMJ Publishing Group Ltd [1])

You are working a busy shift in your department’s fast track area and sign up for a patient with a complaint of “eye pain.” The patient is a fan of glue-on nails and mistook her nail glue bottle for her eyedrops. Now she is unable to open her eyelid for the exam and you struggle to open it yourself. You want to avoid cutting the adhered eyelashes and wonder if there’s a better solution.

Background rise of artificial, press-on nails

Artificial acrylic or “press-on” nails were first invented in the 1950s; however, they did not gain in popularity until the 1980s as nail art became a trend [2]. Shortly thereafter, they fell out of style until a resurgence occurred with the COVID pandemic forcing the closure of nail salons. Compared to pre-pandemic values, Google searches for “press on nails” increased 300% [3]. Application of most nails requires nail glue, which often contains a mixture of alcohol, cyanoacrylate (superglue), or photo-bonded methacrylate [4].

Nail glue complications

Use of nail glue at home can result in adverse exposures with the most common location being the eye [5]. Because nail glue is often packaged in small containers identical to eye drop bottles, patients can mistake the nail glue for ophthalmic drops — especially those with visual impairment [6]. This exposure was first described in the medical literature in 1982 and has been described many times since despite repeated calls for manufacturers to modify the bottles to be safer [1].

In the presence of water, cyanoacrylate rapidly polymerizes, leading to the bonding effect [5]. If the glue gets into a person’s eye, reflexive blinking pushes the glue to the eyelid margins resulting in the eyelashes or eyelid margins sticking together [5], also known as inadvertent tarsorrhaphy. Methods to open the eyelids include removal of glue with forceps, removal or cutting of the eyelashes, or soaking the eye for hours to days with a moist gauze [1, 6, 7].

Although the most successful solvent to dissolve dried glue is acetone, this can cause corneal and conjunctival injuries [8]. The effectiveness of other solvents has been debated in the literature with mixed reports of efficacy [9].

Trick of the Trade: Apply petroleum-based topical antibiotic ointment

Our personal experience managing several of these cases suggests that a petroleum-based topical antibiotic ointment, such as Bacitracin, can help loosen the glue bond. It is an inexpensive option with minimal harm to fix inadvertent eyelid adhesion from nail glue (or other superglue). It is worth trying before attempting more aggressive techniques.

eyelid nail glue adhesion inadvertent tarsorrhaphy ointment

Before and after application of topical antibiotic ointment to remove inadvertent nail glue causing eyelid adhesion

Materials Needed

  • Bacitracin ointment (1-2 tubes)
  • Cotton-tipped applicatiors (Q-tips)

Technique

  1. Apply the topical ointment liberally to the affected eye.
  2. Let rest undisturbed for 15-20 minutes.
  3. Gently pull the eyelids and eyelashes apart.
    • Be careful not to massage the area too vigorously onto the eye itself, as any residual local glue can result in corneal trauma.
    • You can use cotton-tipped applicators to help gently tease the lid margins apart.
  4. Copiously irrigate the eye.
  5. Perform an eye exam to assess for ocular injury.
  6. Consider obtaining an ophthalmology consult.

References

  1. Yusuf IH, Patel CK. A sticky sight: cyanoacrylate “superglue” injuries of the eye. BMJ Case Rep. 2010;2010:bcr11.2009.2435. doi:10.1136/bcr.11.2009.2435
  2. Quinn J. Not Your ’80s Press-Ons: Why the Press-On Manicure Trend Is a Must-Try. Sunday Edit. Published June 10, 2022. Accessed October 26, 2022.
  3. Google Trends on “press on nails”. Google Trends. Accessed October 26, 2022.
  4. Brambilla E, Crevani M, Petrolini VM, et al. Exposure to Nail and False Eyelash Glue: A Case Series Study. Int J Environ Res Public Health. 2020;17(12):E4283. doi:10.3390/ijerph17124283
  5. Forrester MB. Characteristics of ocular nail glue exposures reported to the National Electronic Injury Surveillance System during 2000-2019. Clin Toxicol Phila Pa. 2021;59(7):633-638. doi:10.1080/15563650.2020.1834115
  6. Samet A, Li DQ, Al-Qahtani A, Arthurs B, El-Hadad C. Nail glue injuries to the eye: assessment of two cases. Can J Ophthalmol. 2022;57(1):e11-e13. doi:10.1016/j.jcjo.2021.04.026
  7. Cohen J. Super Glued Shut. Brown Emergency Medicine. Published Apr 12, 2017. Accessed February 5, 2023.
  8. Reddy SC. Superglue injuries of the eye. Int J Ophthalmol. 2012;5(5):634-637. doi:10.3980/j.issn.2222-3959.2012.05.18
  9. Prouty H, Adams DS, Heard K. Evaluation of Treatments for Cyanoacrylate Eyelash Adhesion Using an In-Vitro Model. Cutan Ocul Toxicol. 2008;27(1):11-14. doi:10.1080/15569520701856732
By |2023-02-06T13:59:27-08:00Feb 8, 2023|Ophthalmology, Tricks of the Trade|
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SAEM Clinical Images Series: An Adult with a Lower Extremity Rash

vasculitis

A 37-year-old male with a past medical history of type 2 diabetes presents to the Emergency Department (ED) with a rash. Initial symptoms began one week prior with small spots on the right leg with associated itching and burning. He initially presented to an outside facility where he was diagnosed with an allergic reaction versus scabies and was given a short course of oral steroids and topical permethrin that provided some relief. The rash progressed to bilateral lower extremities prompting re-presentation to the ED. He also reports associated dark urine and nausea.

GI: Abdomen soft, non-tender, non-distended.

MSK: No joint swelling, tenderness, erythema or warmth.

Skin: Numerous scattered bright red palpable purpuric papules and plaques, most concentrated on bilateral lower extremities extending to lower abdomen at the level of the umbilicus.

White blood cell (WBC) count: 14.5 k

Creatinine: 1.1 mg/dL on day of presentation, peaked at 2.2 mg/dL approximately 10 days later.

C-reactive protein (CRP): 32.7 mg/L

Erythrocyte sedimentation rate (ESR): 34 mm/hr

Urinalysis: 3+ protein, 2+ blood, 11-20 RBC, 26-50 WBC, rare bacteria

This is a case of IgA vasculitis, formerly called Henoch-Schonlein purpura or HSP. This diagnosis is suspected when a patient has purpuric skin lesions predominantly on the lower limbs as well as at least one of the following: abdominal pain, joint involvement, renal involvement (proteinuria/hematuria), and biopsy demonstrating IgA deposition. This vasculitis is more commonly seen in children and has a male predominance.

Similar to children with IgA vasculitis, adults presenting with this palpable purpuric rash can have associated joint involvement and GI involvement, though intussusception is less common in the adult population. Renal manifestations are more common in adults with this diagnosis and range from proteinuria and hematuria to renal failure. Our patient initially presented with hematuria/proteinuria and less than two weeks later had a doubled his creatinine. A renal biopsy later confirmed IgA nephropathy.

Take-Home Points

  • Consider IgA vasculitis in patients with lower extremity purpuric skin lesions with associated abdominal pain/GI bleed, arthralgia, renal involvement, and/or biopsy confirming IgA deposition.
  • In adults with IgA vasculitis, renal involvement is more common and often more severe.

  • Ozen S, Pistorio A, Iusan SM, Bakkaloglu A, Herlin T, Brik R, Buoncompagni A, Lazar C, Bilge I, Uziel Y, Rigante D, Cantarini L, Hilario MO, Silva CA, Alegria M, Norambuena X, Belot A, Berkun Y, Estrella AI, Olivieri AN, Alpigiani MG, Rumba I, Sztajnbok F, Tambic-Bukovac L, Breda L, Al-Mayouf S, Mihaylova D, Chasnyk V, Sengler C, Klein-Gitelman M, Djeddi D, Nuno L, Pruunsild C, Brunner J, Kondi A, Pagava K, Pederzoli S, Martini A, Ruperto N; Paediatric Rheumatology International Trials Organisation (PRINTO). EULAR/PRINTO/PRES criteria for Henoch-Schönlein purpura, childhood polyarteritis nodosa, childhood Wegener granulomatosis and childhood Takayasu arteritis: Ankara 2008. Part II: Final classification criteria. Ann Rheum Dis. 2010 May;69(5):798-806. doi: 10.1136/ard.2009.116657. PMID: 20413568.
  • Yaseen K, Herlitz LC, Villa-Forte A. IgA Vasculitis in Adults: a Rare yet Challenging Disease. Curr Rheumatol Rep. 2021 Jul 1;23(7):50. doi: 10.1007/s11926-021-01013-x. PMID: 34196893.

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 |2023-01-20T15:48:31-08:00Jan 30, 2023|Dermatology, Renal, SAEM Clinical Images|
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SplintER Series: Patellar Tendon Rupture

A 46-year-old female with a history of diabetes and morbid obesity presents to the emergency department (ED) with difficulty walking after she tripped on a curb and fell onto her right knee. You obtain X-rays (Figure 1). What is your suspected diagnosis? What is your initial workup in the ED? What is your management and disposition?

Figure 1. AP/lateral x-ray of the right knee. Author’s own images.

(more…)

By |2022-12-23T09:52:15-08:00Jan 25, 2023|Expert Peer Reviewed (Clinical), Orthopedic, SplintER|
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SAEM Clinical Images Series: Spicy Gum Leads to Spicy Gums

gums

A 32-year-old male with a past medical history of asthma presents with a two-day history of cracked lips and progressively worsening oral pain, associated with white discharge, foul smell, and a metallic taste. The patient presented to urgent care and was sent to the Emergency Department (ED) for a sepsis workup. The worsening sores caused him to eat and drink less, including the gum he normally chews. He endorses oral sex with one female partner one week ago. No recent dental work. He recently completed a prednisone course for the same issue. Denies fevers, tooth pain, tongue pain, dysphagia, odynophagia, chest pain, difficulty breathing, abdominal pain, genitourinary discharge or lesions, sick contacts, trismus, facial swelling, or voice changes.

Vitals: T 102°F; HR 125; BP 114/81; RR 19; SPO2 94%

General: No distress. Alert and oriented.

Skin: Warm and dry, no rash.

Ears: Hearing grossly intact.

Nose: Bilateral nares patent, no bleeding.

Neck: Soft, symmetric, no adenopathy, non-tender.

Extraoral: Ulcerations on upper and lower lips.

Intraoral: 1 small ulcer on tip of the tongue on the right. Inflamed, erythematous and bleeding gingiva and interdental papilla. Uvula midline. Maximal interincisal opening ~ 40 mm. Teeth intact.

Heart: Regular rate and rhythm, no murmur.

Lungs: Clear to auscultation, air entry to bases.

Abdomen: Soft, non-tender, no guarding.

GU: Patient denied symptoms and declined exam.

White blood cell (WBC) count: 11.4

pH: 7.386

Lactic Acid: 1.7

Urinalysis (UA): Negative Blood. Culture sent.

STI workup including HSV titers and HIV testing obtained and pending.

The differential is broad, including ANUG (acute necrotizing ulcerative gingivitis) also known as “trench-mouth” and, more commonly, primary herpes gingivostomatitis and candidal infection. Consideration of periodontitis and dental abscess/pulpitis is necessary. The spectrum of erythema multiforme, Stevens-Johnson syndrome, and toxic epidermal necrolysis is important to include, as well as autoimmune disorders which commonly have mucosal involvement such as systemic lupus erythematosus (SLE), Behcet’s, and Crohn’s disease. Scurvy, although uncommon, can also present with gingival erythema and pain.

Consider the presence of a known autoimmune disorder, chronic systemic disease, or an immunocompromised state. History should include new sexual partners, dietary changes, and changes in dental hygiene. We were concerned given this patient’s vital signs on presentation, and alongside a sepsis workup, called dental to the bedside. They immediately asked the patient about the recent use of chewing gum and its flavor, and the patient described a recent preference for cinnamon gum, which he had been using for about 1-2 weeks. The dental consultant came to the diagnosis immediately. A literature search reveals a phenomenon called “cinnamon-contact stomatitis” which is believed to be caused by a delayed T-cell-mediated hypersensitivity reaction. It is characterized by white patches on the mucosa with erythema and erosions on the buccal mucosa and lateral tongue. Treatment consists of discontinuation of the offending agent, and corticosteroids in patients with severe symptoms. Lesions can take up to two weeks to heal, and appropriate follow-up with dental is needed to monitor for resolution.

Take-Home Points

  • The differential for ulcerated, painful gums is broad, and one must consider any history of systemic disease or an immunocompromised state.
  • Consider cinnamon-contact stomatitis in patients that present with extensive oral ulcerations in the absence of other risk factors.

  • Georgakopoulou EA. Cinnamon contact stomatitis. J Dermatol Case Rep. 2010 Nov 19;4(2):28-9. doi: 10.3315/jdcr.2010.1047. PMID: 21886744; PMCID: PMC3157809.
  • Vivas AP, Migliari DA. Cinnamon-induced Oral Mucosal Contact Reaction. Open Dent J. 2015 Jul 31;9:257-9. doi: 10.2174/1874210601509010257. PMID: 26312097; PMCID: PMC4541332.

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 |2023-01-20T15:34:14-08:00Jan 23, 2023|Allergy-Immunology, Dental, SAEM Clinical Images|
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ALiEM AIR Series | Neurology 2022 Module

air series

Welcome to the AIR Neurology 2022 Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Social Media Index, the ALiEM AIR Team is proud to present the highest quality online content related to related to neurologic 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 2 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 Neurology 2022 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: Neurologic Emergencies

Site Article Author(s) Date Label
EMDocs Cauda Equina Syndrome: Why do we miss it? How to improve? John H. Priester, MD; Mark Bisanzo, MD 13 Jun 2021 AIR
EMCrit Spinal Epidural Abscess Josh Farkas, MD 25 Feb 2022 AIR
Clinical Monster Must Be Blood on the Brain Molly Piccione, DO 3 June 2021 HM
EMCrit Neuro emergencies in pregnancy Josh Farkas, MD 23 Feb 2022 HM
EMCrit Neuro-onc emergencies Josh Farkas, MD 2 June 2022 HM

(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! More in-depth information regarding the Social Media Index.

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 |2026-06-16T16:18:13-07:00Jan 15, 2023|ALiEMU, Approved Instructional Resources (AIR series), Neurology|
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