ALiEM is back with Trick of the Trade Tuesday: Winging it with External Jugular Cannulation!
Patients with challenging peripheral intravenous access in the extremities may require and benefit from cannulation of the EJ. Often done in the setting of resuscitation, securing these angiocatheters on the neck can be difficult. Tape and dressings may not stick due to sweat and anatomical limitations. Rotation, flexion, and extension of the neck can displace the catheter.
Trick! 💥 If available, modify a winged angiocatheter to allow suturing to the skin of the neck. - Create two small holes, one on each wing of the angiocatheter, using a sharp instrument such as scissors, scalpel, or needle. - Place EJ line and secure to the skin using sutures, similar to stabilization of central or arterial line.
A 78-year-old male with a past medical history of Lewy body dementia, hypertension, hypothyroidism, COPD, and chronic lower extremity edema presented to the emergency department for three days of worsening left-sided neck and facial swelling. Associated symptoms included poor oral intake, a nonproductive cough, and one week of sore throat. What is your suspected diagnosis based on the clinical image? What are the potential feared complications? Scroll down for answer! . . . . Acute suppurative parotitis (ASP) is a serious bacterial infection of the parotid gland that occurs in patients with diminished salivary flow, increased susceptibility to infection, and poor oral hygiene. This patient had multiple risk factors for this which included dehydration, advanced age, sialolithiasis, medications (eg, diuretics, antihistamines, anticholinergics), and certain disorders including diabetes, HIV, hypothyroidism, Sjogren’s syndrome. The most common organisms responsible are Staphylococcus aureus and oral flora anaerobes.
The most feared complications include supraglottitis, cervical necrotizing fasciitis, and other deep neck space infections which can be surgical emergencies and rarely cause impending airway obstruction. Further central and vascular complications include brain abscess, central venous thrombosis, and Lemierre’s syndrome.
Take-Home Points: 💥The role of bedside ultrasound in acute suppurative parotitis can help to rule out a superficial abscess or sialolithiasis. CT scan is beneficial in ruling out deep space infections as a complication from this disease process or other causes of head and neck swelling. 💥ASP-associated complications are rare but can lead to significant morbidity and mortality secondary to the parotid gland’s proximity to vital structures and ability to spread to adjacent deep spaces.
ALiEM is back with another SAEM Clinical Images Series: Breast Swelling
A woman in her 50s with a past medical history of coronary artery disease, pacemaker placement, hypertension, and ESRD presented to the emergency department with the chief complaint of missed dialysis, breast engorgement, and an increase in vascularity in her chest and abdomen. She reported an increase in breast swelling and increased vascularity in her belly over the past 3 months. She also woke up short of breath on the morning of presentation. What is the differential diagnosis for bilateral breast swelling? What does this patient's CTA chest show? Scroll down for diagnosis! . . . . . Superior vena cava (SVC) syndrome results from any condition that leads to obstruction of blood flow through the SVC. Our case was caused by complete occlusion from a thrombus and the patient presented with bilateral breast swelling, skin changes (peau d’orange), and an increase in vascularity in the abdomen and chest (caput medusa). Breast tissue largely drains into the axillary veins, and more proximally into the subclavian veins. Due to occlusion of the SVC, a complete backup of venous flow occurs, resulting in all of the noted collateral hypervascularity. Often SVC occlusion is caused by malignancy obstructing the SVC or invading the vein. The CTA chest demonstrates occlusion of the superior vena cava.
Take-Home Points: 💥Consider superior vena cava occlusion in patients undergoing hemodialysis who present with the above physical exam findings. 💥 Consider occult malignancy as the source or cause of thrombosis. 💥 Be sure to fully expose your patient when appropriate and keep your differential broad.
A 67-year-old man was “found down” in a parking lot. Per EMS, his GCS was 6 with a systolic blood pressure in the 80’s, finger stick glucose of 100, and no response to intranasal naloxone. He was intubated in the field and arrived to the emergency department unresponsive with a BP of 95/60, HR 125, T 38°C, and O2 Sat 100%. Hemodynamic stabilization was achieved with central venous access, and laboratory and imaging studies for the evaluation of altered mental status ensued. What is the potentially life threatening finding on this CT scan? Scroll down for the answer! . . . . . Air embolism to the right ventricle and pulmonary artery! As little as 20 mL or less of air rapidly infused may cause obstruction, ischemia, and hemodynamic collapse. Risk factors include central venous catheterization, lung trauma, ventilator usage, hemodialysis, surgery (esp. coronary, neurosurgery), childbirth, and scuba diving barotrauma.
Take-Home Points: 💥In the appropriate clinical scenario, especially those involving respiratory, cardiac, and neurologic findings where invasive procedures were utilized, the diagnosis of venous air embolism should be entertained. 💥Immediate management of an air embolism involves administration of 100% oxygen by nonrebreather mask (NRM) or ventilator and placement of the patient in the left lateral decubitus (Durant maneuver) and Trendelenburg positions. Hyperbaric oxygen therapy has also been used if there is no clinical improvement. 💥The purpose of the Durant maneuver and Trendelenburg position is to trap air along the lateral right ventricular wall, preventing right ventricular outflow obstruction and embolization into the pulmonary circulation.
ALiEM is back with another SAEM Clinical Image Series: Localized Weakness
A 69-year-old woman with a past medical history of seizures, cerebral vascular accident, and Parkinson’s disease presents by EMS for evaluation of a 30-minute episode of left upper and lower extremity weakness and left facial drooping. The patient also has a right-sided “migraine-type” headache. Exam is notable for the skin finding above, left-sided facial droop, sluggish speech, mild left-sided upper and lower extremity weakness, and Parkinson's associated tremor. What is the cutaneous finding called? What medical conditions are associated with this finding? Scroll down for the answer! . . . . . .
Port-wine stain birthmark! When located around the eye, they are associated with an increased risk of glaucoma. Large port wine stains on the arm or leg are associated with extra growth in that limb known as Klippel-Trenaunay syndrome. Port wine staining of the face, forehead, and scalp, when associated with cerebral leptomeningeal angiomas that elicit migraine headaches, seizures, strokes, and intellectual impairment as in this patient, are the classic findings of Sturge-Weber syndrome.
Take-Home Points: 💥Sturge-Weber syndrome is the 3rd most prevalent neurocutaneous disorder impacting 1 in 20,000 live births. It is a sporadic congenital neurocutaneous disorder that involves the GNAQ gene. 💥Sturge-Weber syndrome is characterized by a facial port-wine stain, leptomeningeal angiomatosis, and glaucoma. Brain involvement can begin early in infancy, and manifests as seizures, strokes, stroke-like episodes, and a variety of neurological impairments. 💥Anticonvulsants, low-dose aspirin, and glaucoma medications are often employed in the management of Sturge-Weber syndrome as well as skin pulse dye laser therapy as desired for cosmesis. The prognosis of this condition depends on the extent of leptomeningeal involvement and the severity of glaucoma.
Remember to click the link in bio for full article! 📲
ALiEM is back with another Trick of the Trade Tuesday! 💥
It’s a busy shift and you need to perform a bedside ultrasound when you realize that the ultrasound gel bottle is nearly empty. Try this!
✔️Turn the bottle upside down so the cap is facing the ground. ✔️Place the bottle into a (fresh) patient’s sock or transducer cover. Alternatively, you can use a plastic bag or ortho tubular stockinette. ✔️Firmly holding the bag, and spin the bag for a few seconds in a circular motion, almost like you were throwing a grappling hook. ✔️The centrifugal motion will generate an outward force pushing all of the viscous gel to the bottle cap! ✔️Once you’ve used the gel, store the bottle cap-side down so you don’t have to do this again. This trick is useful in a pinch, because it makes use of the entire gel bottle and promotes an eco-friendly use of ED resources.
A 33-year-old female presented with a progressively worsening rash for 1 week after hiking the John Muir Trail, a backpacking trip that encompassed 3 weeks and over 240 miles. On the last days of the trip, she developed a severely itchy, red rash on both feet. She now has swelling and difficulty walking. The rash does not involve the hands or other parts of the body, and she has no other symptoms. Exam shows diffuse edema and erythematous maculopapular rash to both feet, with vesicles and bullae overlying the dorsal and plantar surfaces of toes and feet. What is your suspected diagnosis? What is your management?
Scroll down for the answer and click the link in bio for full explanation! 📲 . . . . Allergic contact dermatitis due to colophony allergy. Colophony was found in the sports tape she used to tape her feet which caused a severe allergic contact dermatitis. This is a T-cell-mediated reaction caused by repeated exposure to an allergen on the skin.
Take Home Points: 💥The presence of both vesicles and bullae narrow the differential to contact dermatitis or dyshidrotic eczema. Both of these should respond to topical and/or oral steroids. 💥Look for patterns on the highest concentrated area of the rash to suggest allergic contact dermatitis. 💥Repeated lengthy exposure over a short course of time can cause allergic contact dermatitis to develop.
A common question is how much should we expect the blood glucose concentration to increase after dextrose 50% (D50) administration. Fortunately, we have an answer from 3 studies.
Take Home Points: 💥 Glucose concentrations increase 4-6 mg/dL per gm of dextrose administered 50 mL of D50 = 25 gm = expected 100-150 mg/dL glucose rise 💥 D50 rescue glucose is short-lived (30 minutes) 💥 If the blood glucose does not respond as anticipated, investigate further (e.g., IV decannulation)
Remember to click the link in bio for full article! 📲
Trick of the Trade Tuesday: Use a "Fiberbougie" through a supraglottic King tube when exchanging for an endotracheal tube!
Once a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide and could potentially be safer and more effective.
💥💥Description of the Trick: 1. Insert a disposable bronchoscope through the airway port of the King airway 2. Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina 3. Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina 4. Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway 5. Insert the endotracheal tube over the “fiberbougie” 6. Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords 7. Confirm placement with capnography and/or with direct visualization and x-ray
For more information, full article and video demonstration, click the link in bio! 📲
ALiEM is back with another case from the SplintER Series: Stop! 🛑 Hammer Time
A 54-year-old female presents to the emergency department with 3rd and 4th right finger pain after “jamming” them a week ago. She was reaching to tap someone on the shoulder and they backed into her hand forcing her fingers into flexion. She has swelling and pain at the distal interphalangeal (DIP) joint of her 3rd and 4th digits on the right and cannot extend the digits at the DIP joint. An x-ray of the right hand is shown above. What is your suspected diagnosis? What is your management and disposition?
Scroll down for answer and click link in bio for full explanation! 📲
A distal phalanx avulsion fracture causing a mallet finger, or a terminal extensor mechanism injury. It is typically caused by forced flexion at the DIP joint against resistance. The distal phalanx will typically be flexed with the patient unable to actively extend at the DIP joint. The affected digit should be splinted in extension at the DIP joint, ideally with a stack splint or figure of 8 splint, AT ALL TIMES for 6-8 weeks. If the finger is allowed to flex at the DIP joint even briefly, the clock is reset and an additional 6-8 weeks of extension will be required. Orthopedics does not need to be consulted in the ED but urgent follow-up should be arranged, especially if there are bony avulsions, to evaluate the need for surgical repair.
Trick of the Trade: ALiEM is back with another #TrickofTheTradeTuesday: Don't Fight the Ultrasound Cord for PIV Access
Ultrasound-guided IVs require hand-eye coordination and fine movements of probe in Goldilocks fashion. Apply too much pressure, and the vein in question is compressed. Slide a little to the right, and now it’s out of the window. Something that practitioners don’t think about is the tension from the cord. If left to its own devices, the cord will tug on the probe, making the probe harder to steer and handle, especially for those tiny veins.
💥💥Reduce cord tension
Have the patient grasp the cord!
This makes them an active participant. Usually, if they are awake and good-humored, tell them “audience participation is required.” Doing so will give you enough slack to effectively visualize and troubleshoot the ultrasound-guided IV.💥💥
ALiEM is back with another case from the SplintER Series: Point Tender! 👈
A 42-year-old female presents to the emergency department with complaints of worsening finger pain. She reports the pain started 2 days ago with redness at the tip of the finger. Over the past 24 hours, her redness has spread and the finger has become more painful. On arrival, she is afebrile and hemodynamically stable. She has the above exam findings with tenderness along the volar aspect of the finger and pain with passive extension. What is your suspected diagnosis? What is your initial workup? What is your management and disposition?
Scroll down for answer and click link in bio for full explanation! 📲 . . . . Pyogenic flexor tenosynovitis - a bacterial infection of the flexor tendon sheath as a result of hematogenous spread or local inoculation. Most commonly it is caused by trauma or injury to the hand. Kanavel’s cardinal signs can be pathognomonic- fusiform digital swelling, finger held in slight flexion, pain with passive extension, and tenderness to palpation over the flexor tendon sheath.
ALiEM is back with another case from the SplintER Series: Between a Rock and a Hard Place ⠀ BlurbA 17-year-old male basketball player presents with right lateral thigh pain for the past 3 weeks. He had a collision with another player 5 weeks ago that resulted in a bruise that has since resolved. He is mildly tender over the lateral mid-thigh in the soft tissues and has a decreased knee flexion. You obtain X-rays (Figure 1). What is your suspected diagnosis? What is your initial workup in the ED? What imaging confirms the diagnosis? What is your management and disposition?
Scroll down for answer and click link in bio for full explanation!📲 . . . . .
Myositis ossificans, which in this case is acquired from a traumatic injury. This is identified by the radiopaque mass within the muscle body on the AP and lateral views of the femur representing the calcifications
ALiEM is back with another #ACMT from #ToxicologyPearl: Substance-Induced Crystalluria: All That Glitters Is Not Gold
Which of the substance causes crystalluria with hexagonal crystals that shimmer on macroscopic urine examination? . . . . . .
Primidone, a medication used to treat epilepsy and essential tremor, has been associated with hexagonal crystals in the urine, typically when levels are very high such as following an overdose.
💎Used rarely for the treatment of essential tremors or seizure disorders 💎Decreases central nervous system excitation Metabolized to 2 active metabolites: phenobarbital and phenylethylmalonamide (PEMA) 💎Phenobarbital results in decreased CNS excitation by GABA receptor agonism 💎PEMA enhances phenobarbital activity at the receptor 💎Common symptoms after exposure include crystalluria, sedation, ataxia, nystagmus, decreased deep tendon reflexes, hypotension, and coma
Remember to click the link in bio for full article! 📲