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Chief complaint: Abdominal pain, nausea, and vomiting

History of present illness: A 46 year-old female with a past history of fibromyalgia, irritable bowel disease, and chronic abdominal pain presented to the emergency department with abdominal pain, nausea, and vomiting. She reported a one-year history of similar symptoms but states that her symptoms are worse today than usual, and not improved by her home hydrocodone, medical marijuana, or heating pad use – all of which she uses daily. She has not been able to tolerate oral intake today, vomiting up her breakfast of plain toast.

The patient was observed using her home heating pad in the emergency department.

---

Physical Exam

General Appearance: A chronically ill-appearing adult female who smelled of marijuana

Abdominal Exam: No focal tenderness and a non-pruritic reticulated rash

Laboratory Data

WBC: 10.6 × 10⁹/L

AST: 21 U/L

ALT: 19 U/L

Lipase: 26 U/L

Pregnancy: Negative

Urine analysis: Non-infected

Case Question: What is the explanation for the patient's abdominal rash?

Erythema ab igne

This rash is also known as “hot water bottle rash” or “toasted skin syndrome.” It results from chronic exposure to low levels of heat or infrared radiation. In our patient’s case, she experienced this rash stemming from her daily heating pad use (i.e. the “toast” in ‘Tea & Toast’, while the tea is old-school slang for the patient’s daily marijuana use).

Other cases have been seen in patients with occupational exposures (such as metal workers) or people who are using their laptop computers on their laps [1].

Case Question: What is the appropriate treatment for her rash?

The treatment involves removal of offending heat source, but may require additional medical treatment if cosmetic lesions persist.

Case Discussion

Take Home Points

• Erythema ab igne is a benign but dramatic appearing rash that is seen with chronic exposure to a low-level heat source.
• The mainstay of treatment involves removal of the heat source.
• Most rashes will fade on their own over time, but may require referral to a dermatologist for cosmetic treatment, if symptoms persist.

Reference

1. Miller K, Hunt R, Chu J, Meehan S, Stein J. Erythema ab igne. Dermatol Online J. 2011 Oct 15;17(10):28. PMID: 22031654.

Author information

The post SAEM Clinical Image Series: Tea & Toast | A Case of an Abdominal Rash appeared first on ALiEM.

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Chief complaint: Eye pain

History of Present Illness: A 41-year-old man presents with pain and a foreign body sensation in the right eye since welding 4 days ago. The patient wore eye protective gear; however, he explains that he only wore sunglasses. A spark flew in from above his glasses and hit him in the right eye. The pain has been steady since. He complains of irritation exacerbated by blinking, but vision has remained unchanged. He has no other injury and no other physical complaint.

---

Physical Exam

General Appearance: Patient is alert, awake, comfortable and in no distress

Vitals: Temp: 98 F; Pulse: 71; BP: 133/72; Pulse ox: 98%

HEENT: No facial swelling, erythema, or facial blisters

Visual Acuity : Left eye: 20/20, right eye: 20/25, both eyes 20/20

Pupils: PERLA, no pain with direct or consensual pupillary light response, no tenderness with EOM

Lid Eversion: No foreign body

 

Slit Lamp Exam:

• Right eye has a corneal foreign body, inferolateral to right pupil, and superficial to the anterior chamber
• Clear cornea with no involvement of the anterior chamber (no hyphema specifically)
• Moderate injection of the right conjunctiva
• Fluorescein exam: No corneal uptake or Seidel’s sign

Imaging Results

CT orbits with contrast: The globes have a normal symmetric contour. Preseptal soft tissues and lacrimal glands appear normal. Retro-orbital fat, optic nerves, and extraocular muscles appear normal. No radiopaque foreign body material is seen. No acute fracture or dislocation is seen. There is minimal ethmoid sinus mucosal thickening present. The visible brain parenchyma appears normal.

IMPRESSION: Unremarkable CT scan of the orbits

Case Question: What complications can occur by delaying treatment?

Rust ring

In the image above, the embedded metal object has already started to develop a rust ring. Seeping rust permanently stains the cornea and has the potential to obstruct vision.

Case Question: How to treat this condition?

Removal of the corneal foreign body

One approach: Apply tetracaine anesthetic to the affected eye. Under the slit lamp 10x view and using a thin 25 gauge needle, remove the embedded foreign body. [Read another ALiEM post featuring a corneal foreign body removal video.]

Case Discussion

Take Home Points

• Foreign bodies from welding embedded in the cornea necessitate prompt intervention.
• Don’t forget the basics:
  • Proper eye exam with fluorescein to rule out globe rupture
  • Tetanus prophylaxis
  • Topical antibiotics (ex: tobramycin + dexamethasone)
• Dislodgment under slit lamp magnified view with prompt ophthalmology follow up

Author information

Hamid Ehsani-Nia, DO

Resident Physician
Robert Wood Johnson Medical School Department of Emergency Medicine
Rutgers University

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After eating the mushroom pictured, a 15-year-old patient arrives to the emergency department agitated, diaphoretic, and hallucinating, and then acutely becomes more somnolent and less responsive. Which neurotransmitter systems are affected by the toxins contained in this mushroom?

1. Acetylcholine and histamine
2. Dopamine and norepinephrine
3. Gamma-aminobutyric acid (GABA) and N-methyl-D-aspartate (NMDA)
4. Glycine and serotonin

This post was peer reviewed on behalf of ACMT by Bryan Judge, Rob Hendrickson, and Louise Kao.

References

1. 1. Olpe H, Koella W. The action of muscimol on neurons of the substania nigra of the rat. Brain. 1978; 69(1971):2488-2488. PMID: 564284
   2. Johnston GAR. Muscimol as an ionotropic GABA receptor agonist. Neurochem Res. 2014;39(10):1942-1947. doi:10.1007/s11064-014-1245-y. PMID: 24473816
   3. Michelot D, Melendez-Howell LM. Amanita muscaria : chemistry , biology , toxicology , and ethnomycology. 2003;107(February):131-146. doi:10.1017/S0953756203007305. PMID: 12747324
   4. Woodward R, Polenzani L, Miledi R. Characterization of bicuculline/baclofen-insensitive (rho-like)gamma-aminobutyric acid receptors expressed in Xenopus oocytes. II.Pharmacology of gamma-aminobutyric acid A and Gamma-aminobutyric acid B receptor agonsts and antagonsits. Mol Pharmacol. 1993;43(4):609-625. PMID: 8386310
   5. Vendramin A, Brvar M. Amanita muscaria and Amanita pantherina poisoning : Two syndromes. Toxicon. 2014;90:269-272. doi:10.1016/j.toxicon.2014.08.067. PMID:25173077
   6. Koppel C. Clinical symptomatology and management of mushroom poisoning. Toxicon. 1993;31(12):1513-1540. PMID: 8146866
   7. Moss MJ, Hendrickson RG. Toxicity of muscimol and ibotenic acid containing mushrooms reported to a regional poison control center from 2002–2016. Clin Toxicol. 2018;0(0):1-5. doi:10.1080/15563650.2018.1497169. PMID: 30073844
   8. Mikaszewska-sokolewicz MA, Pankowska S, Janiak M, et al. Coma in the course of severe poisoning after consumption of red fly agaric ( Amanita muscaria ). 2016;63(1):2015-2016. doi:10.1016/j.tox. PMID: 26828668
   9. Støíbrný J, Sokol M, Merová B, Ondra P. GC/MS determination of ibotenic acid and muscimol in the urine of patients intoxicated with Amanita pantherina. Int J Legal Med. 2012;126(4):519-524. doi:10.1007/s00414-011-0599-9. PMID: 21751026

Author information

Mary Grady, MD

Pediatric Emergency Medicine Fellow;

Department of Emergency Medicine
Carolinas Medical Center

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The post AMCT Toxicology Visual Pearls: Mushroom Mania appeared first on ALiEM.

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Chief complaint: Left-sided facial swelling

History of Present Illness: A 2-year-old male presents to the emergency department in January after waking up with left-sided facial swelling. Mother states her son has had cough and congestion for the past 4 days for which she has been treating with Tylenol and a children’s cough medication. The patient went to bed, awoke the following morning with facial swelling, and was brought to the emergency department.

He has no allergies, history of trauma to the area, or bug bites. The patient is fully vaccinated including the influenza vaccine.

---

Physical Exam

Vitals: Tachycardic, temperature of 38.2 C.

HEENT: Left sided facial swelling where skin is taught and mildly discolored. Non-tender to touch and no fluctuation is appreciated. Swelling includes left cheek and submandibular region. The rest of the examination is normal.

Upon re-examination 6 hours later, swelling has progressed to include his left peri-orbital region as well as left ear and neck.

Laboratory Data

CBC: WBC of 11.7 bil/L

CRP: Elevated to 24.6 mg/L

ESR: Normal

Rapid flu/RSV swab: Positive for influenza A

Mumps IgM/IgG: Pending

Case Question: What is this patient's diagnosis?

Parotitis secondary to influenza virus

The CT image shows the inflamed parotid gland.

Case Discussion

Take Home Points

• Parotitis is a known complication of influenza virus but the incidence is not well known
• Typically appears in children and more commonly in males
• Influenza should be included in the differential for a pediatric patient presenting with parotitis during the winter months

Author information

The post SAEM Clinical Image Series: Facial Swelling in a 2 Year Old appeared first on ALiEM.

An 82-year-old woman presents with left hip pain after a mechanical fall while cleaning the kitchen floor. When EMS arrived, the left leg was foreshortened and externally rotated. The paramedics administered 10 mg of IV morphine, but she is still writhing in pain on arrival. The AP pelvic x-ray demonstrates a left femoral neck fracture (arrow). You consider performing a fascia iliaca nerve block for better pain control.

Why do a fascia iliaca nerve block? 

Multiple studies have shown decreased in-hospital mortality and complications when regional anesthesia is performed. Specifically for hip fractures, fascia iliaca blocks led to a reduction of postoperative complications from 33% to 20%^​1​ along with decreased mortality, deep vein thromboses, altered mental status, and pulmonary complications.^​2​

Goal of the fascia iliaca nerve block

The goal of this nerve block is to maximize analgesia, while minimizing side effects such as respiratory depression, delirium, hypotension, and nausea/vomiting that may be associated with IV opioid administration. The target of the anesthetic injection is the potential space between the iliacus muscle and the fascia that overlies it (fascia iliaca), within which the femoral nerve and lateral femoral cutaneous nerve (LFCN) course. A large volume injection (40 mL) will lead to appropriate fascial spread and anesthesia of the femoral nerve (88%), LFCN (90%), and sometimes the obturator nerve.^​3​

When should I not perform the fascia iliaca block (contraindications)?

• Any anticoagulation, besides aspirin and NSAIDs 
• Overlying cellulitis at the skin puncture site
• Ipsilateral fractures at high risk of compartment syndrome, such as tibial plateau fractures

Equipment

The necessary equipment for this nerve block includes the following:

Sterile precautions

• Sterile ultrasound probe cover
• Sterile gloves
• ChloraPrep wipe

Identifying the anatomy

• Bedside ultrasound with a linear transducer

Instilling the anesthetic

• Lidocaine 1% (2-5 mL) for local wheal of anesthetic
• Local long-acting anesthetic (e.g., 40 mL of 0.2% ropivacaine) for nerve block
• Sterile saline flush
• 10 mL syringe
• 60 mL syringe
• Extension tubing
• 18-gauge needle
• 25-gauge needle
• 21-gauge nerve block needle

Anesthetic medication options

For a longer period of regional anesthesia, we recommend ropivacaine or bupivacaine. Given the higher cardiac toxicity of bupivacaine due it’s highly lipophilic nature compared to other local anesthetics, we suggest 40 mL of 0.2% ropivacaine as the first-line agent.^​4,5​ Lidocaine is not preferred given it’s shorter duration of action, which is contradictory to the goal of prolonged analgesia.

Figure 4. Local amide-based anesthetic agents and their pharmacokinetic effects, adapted from Goldfrank’s Toxicologic Emergencies^​6​

Technique

Equipment positioning

Start by setting up an equipment stand on the same side of the bed as the patient’s fracture, with the ultrasound machine on the contralateral side of the fracture. You will stand on the side of the fracture facing towards the head of the bed and looking across the patient’s body at the ultrasound machine.  

Sterile preparation

• Wipe the ipsilateral inguinal area with the ChloraPrep and drape the area.
• Fill the 60 mL syringe with 4 mL of 0.2% ropivacaine.
• Attach the syringe to the extension tubing and nerve block needle.
• Remove air from the tubing and “prime it” with the ropivacaine from the syringe. 
• Place the sterile ultrasound probe cover on the probe.

Anatomy identification

• Position the linear, high-frequency ultrasound probe held in horizontal orientation with the probe marker pointed towards the patient’s right side (Figure 5). 

• Locate the femoral vessels ideally at the level of the common femoral artery and vein.
• Slide the probe laterally until you see the iliacus and sartorius muscles (Video 1). The iliacus muscle will be in the same plane as the femoral vessels, and the sartorius will be superior and lateral (Figure 6).

Instillation of anesthetic agent

• Using a 10 mL syringe and 25 gauge needle, deposit a small wheal of local anesthetic (e.g. lidocaine) directly adjacent to the lateral surface of the ultrasound probe. 
• Switch to the longer 21 gauge nerve block needle, which is affixed to an extension tubing and 60 mL ropivacaine-filled syringe (Figure 3). The primary operator should be sterilely gowned and hold the nerve block needle, while a secondary operator should hold the ropivacaine syringe, being in charge of instilling the anesthetic when needed. 
• Primary operator: Insert the nerve block needle at a steep 45-60 degree angle through the wheal and advance in a plane through the subcutaneous tissue until you visualize the tip of the needle underneath the fascia iliaca. You will likely feel pop or change in resistance as you pass through the fascia iliaca.
• Secondary operator: Once the needle is appropriately positioned by the primary operator, inject a micro-aliquot of anesthetic (0.5 to 1 mL) to see if the fascia iliaca appropriately dissects off the iliacus muscle (Video 2). 

• If the needle tip is placed inappropriately above (superficial to) the fascia iliaca in the subcutaneous tissue or within the iliacus muscle, make in-plane adjustments of the needle tip and instill additional micro-aliquots until appropriate localization. 
• Once the needle is appropriately positioned, inject the entire volume of the 40 mL 0.2% ropivacaine. Clear the ropivacaine remaining in the extension tubing with a few mL’s of the sterile saline flush after swapping the 60 mL syringe with a sterile saline flush. 
• Adequate anesthesia can take up to 30-60 minutes as the ropivacaine tracks upwards into the pelvis.

Alternative Technique

A suprainguinal approach may lead to more proximal spread of anesthetic and more successful pain control; however, the approach relies on adequate visualization of the patient’s internal oblique muscle, which is often tiny and hard to see in the elderly. The suprainguinal approach mirrors the above approach to identify the iliacus muscle. Then slide the probe superiorly along the iliacus muscle until the probe is above the inguinal canal. Then rotate the probe marker 90 degrees so that it points towards the umbilicus. The sartorius and internal oblique muscles will form a “bowtie” shape with the iliacus muscle below them. Inject the anesthetic in between the bowtie, aiming just below the fascia iliaca as described in the traditional approach (Figure 8).

Want to learn more?
Join Dr. Shyy and other UCSF expert ultrasound educators at the High Risk Hawaii Conference in Maui April 14-18, 2019, where they will teach hands-on ultrasound-guided nerve blocks, vascular access, and orthopaedic procedures. Dr. Amal Mattu will also be there to lecture and teach an Advanced EKG Bootcamp!

Author information

William Shyy, MD

Director of Emergency Ultrasound, Parnassus Heights
Co-Director of Emergency Ultrasound Fellowship
Co-Chair High Risk Hawaii Conference
Assistant Clinical Professor
Department of Emergency Medicine
University of California, San Francisco

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Amoxicillin is a penicillin derivative antibiotic against susceptible gram positive and gram negative bacteria. It has reasonable coverage for most upper respiratory infections and is used as prophylaxis for asplenia and bacterial endocarditis. This post aims to demystify amoxicillin treatment for common pediatric infections.

Susceptible Bacteria

Amoxicillin dosing recommendations and tips

1. Indications for high dose amoxicillin

S. pneumoniae have intermediate to high resistance to penicillin antibiotics. “High”-dose amoxicillin helps overcome this resistance, and should be used in infections commonly seen with S. pneumoniae including the 3 following conditions:

• Recommended max dose for suspension: 1000 mg/dose twice daily (max 2000 mg/day)
• Recommended max dose for tablet: 875 or 1000 mg/dose
• Liquid amoxicillin is available in many concentrations. Prescribe higher concentrations to minimize volumes. A common concentration is 400 mg/5 mL.

For more information on recommendations regarding observation, surveillance, and safety-net antibiotic prescription: American Academy of Pediatrics’ AOM management guidelines

2. Indications to prescribe amoxicillin-clavulanate instead of amoxicillin alone

Amoxicillin-clavulanate (Augmentin) is the antibiotic of choice when AOM treatment fails or recurs despite amoxicillin. The clavulanate irreversibly inhibits bacterial beta-lactamase, increasing the effectiveness of amoxicillin. The amoxicillin component remains “high”-dose (80-90 mg/kg/day).^​2​

Indications for prescribing amoxicillin-clavulanate include:

1. AOM treated with amoxicillin within the last 30 days: The risk of beta-lactamase resistance or of AOM due to non-typeable Haemophilus influenza and Moraxella catarrhalis (which produce beta-lactamase) increases.
2. Recurrent AOM: This is defined as having ≥3 episodes of AOM in a period of 6 months, or ≥4 episodes in 12 months.^​3​ Non-typeable Haemophilus influenza is common in recurrent episodes.
3. AOM with concomitant purulent conjunctivitis: Typically seen with non-typeable Haemophilus influenza

Amoxicillin-clavulanate prescribing:

• Amoxicillin-clavulanate dose: 80-90 mg/kg/day, divided into 2 doses daily
• Duration:
  • < 2 years of age = 10 days
  • ≥ 2 years of age = 5-7 days

3. Treatment for strep pharyngitis

A serious sequelae of strep pharyngitis is rheumatic heart disease. Children diagnosed or suspected of strep pharyngitis are treated with amoxicillin to prevent such a complication.

Traditionally, amoxicillin dosing for group A strep pharyngitis was twice daily dosing. However, recent evidence favors once daily amoxicillin in patients aged 3 years and older.^​​1​

• Amoxicillin dose: 50 mg/kg once daily (max 1000 mg/dose/day) for age ≥3 years
• Duration: 10 days

4. Treatment for pediatric community-acquired pneumonia

The etiology of pediatric community-acquired pneumonia (CAP) varies depending on age group.

The first line treatment is with high-dose amoxicillin for 7 days. If the patient does not improve 48 hours after initiating amoxicillin, consider broadening coverage to include atypical pneumonia, penicillin-resistant S. pneumo, or S. aureus. Replace amoxicillin with a macrolide, such as azithromycin.

• Azithromycin dosing: 10 mg/kg/dose PO on day 1 (max 500 mg/dose), then 5 mg/kg/dose PO daily on days 2-5 (max 250 mg/dose)
• Duration: 5 days

Also consider other etiologies, such as:

• Viral pneumonia
• Aspiration pneumonia
• Asthma
• Foreign body aspiration
• Complications of pneumonia (pleural effusion, empyema, and necrotizing pneumonia)

5. Prophylaxis treatment for bacterial infections

Amoxicillin is used as prophylaxis against bacterial infections in higher risk children. Examples include:

• Cardiac prophylaxis for a child with prosthetic heart valves, congenital heart disease, or history of previous infective endocarditis
• Urinary tract infection prophylaxis for children >2 months of age with hydronephrosis or vesiculoureteral reflux
• Prophylaxis for children with functional (e.g. secondary to sickle cell disease) or anatomic (e.g. spleen removal) asplenia

Consult a specialist for dosing and duration as needed.

Adverse Effects with Rashes

Amoxicillin is notorious for causing rashes. Amoxicillin can be continued to be used in patients with low-risk reactions, such as a rash caused by concurrent infectious mononucleosis, or by delayed-hypersensitivity reactions without features of immediate allergy. If the rash is caused by an immediate IgE-mediated reaction, penicillins should be avoided. If there is any question about whether the history or exam have features of an immediate allergy, it is recommended that the family avoid penicillins until they can be seen by an allergy specialist.

Low-risk factors that are reassuring against immediate hypersensitivity response are:

• Skin-only manifestations (without mucous membrane or systemic symptoms)
• Maculopapular rash rather than urticarial rash
• A rash that occurred days into antibiotic course
• Did not require systemic steroids to control symptoms

1. Concurrent infectious mononucleosis infection

Patients with infectious mononucleosis secondary to Epstein-Barr virus who take amoxicillin frequently develop an itchy, erythematous rash on extensor surfaces and pressure points. The rash usually resolves in 1-2 weeks after discontinuation of amoxicillin. This amoxicillin-associated rash in infectious mononucleosis is NOT thought to be a true drug allergy although its mechanism is not well understood.

2. Delayed hypersensitivity reaction

Patients may develop a rash after more than one dose of amoxicillin, or even several hours after the last dose. Patients with a “delayed” hypersensitivity reaction do NOT carry the risk of life-threatening anaphylaxis (not IgE-mediated). However, If there is a question of a severe penicillin allergy, referral to an allergy specialist for supervised re-exposure is the best course of action.

For non-severe allergy (i.e. non-anaphylactic) to penicillins, cefdinir is recommended for AOM and CAP.

• Cefdinir dose: 7 mg/kg/dose PO BID (max 600 mg/day)
• Duration: Same as for amoxicillin

3. Immediate IgE-mediated reaction

Patients with an “immediate” IgE-mediated hypersensitivity reaction to amoxicillin are at risk of developing life-threatening anaphylaxis with re-exposure. Patients may not develop symptoms with the first dose (as allergic sensitization develops), but may show symptoms within an hour of the last dose.

If the patient had a severe allergy concerning for anaphylaxis, azithromycin is recommended over a beta-lactam antibiotic for both AOM and CAP.

• Azithromycin dose: 10 mg/kg/dose PO on day 1 (max 500 mg/dose), then 5 mg/kg/dose PO daily on days 2-5 (max 250 mg/dose)
• Duration: 5 days

Take-Home Points

Amoxicillin is used to treat a variety of conditions in pediatrics, most commonly community-acquired pneumonia, acute otitis media, and streptococcal pharyngitis.

• CAP and AOM: High-dose amoxicillin (to overcome bacterial resistance) is prescribed 80-90 mg/kg/day divided into 2 doses
• Group A Strep pharyngitis: 50 mg/kg/day, once a day (to prevent rheumatic fever)
• Amoxicillin-clavulanate: Use if AOM treated in last 30 days, AOM with purulent conjunctivitis, 3+ episodes of AOM in 6 months, or 4+ episodes of AOM in 12 months
• Counseling: Educate parents/guardians on potential adverse effects with amoxicillin:
  • Rashes (due to IgE-mediated or delayed hypersensitivity reactions or to Ebstein-Barr virus co-infection)
  • If any signs of anaphylaxis, take to an ED immediately.

Thumbnail Image: © Nicholas Larento, #19510647

References

Author information

Rosy Hao, MD

Pediatric Emergency Medicine Fellow
SUNY Downstate and Kings County Medical Center

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Welcome to another ultrasound-based case, part of the “Ultrasound For The Win!” (#US4TW) Case Series. In this case series, we focus on a real clinical case where bedside ultrasound changed the management or aided in the diagnosis. In this case, an 18-year-old man presents with a sore throat.

Learning Objectives:

1. Review the differential for a patient presenting to the ED with throat pain/voice change
2. Value of POCUS in evaluating patients with possible peritonsillar abscess (PTA)
3. Review advantages and anatomy of ‘telescopic’ view as a potential approach to ultrasound-guided PTA drainage

Case Presentation:

An 18-year-old male with no significant past medical history presents to the emergency department with throat pain for two weeks. He was seen by his primary doctor one week ago with negative strep and monospot testing. He was diagnosed with viral pharyngitis and sent home with instructions for symptomatic care. His symptoms became worse over the last few days with difficulty swallowing, decreased oral intake and fever. He noted the pain was worse on the left side of his throat and that his voice ‘sounded different.’ He denied any drooling, neck stiffness or shortness of breath.

Vitals:

BP: 127/69
HR: 90
RR: 16
O2 sat: 98% RA
Temp: 100.1°F

Differential Diagnosis

• Peritonsillar abscess (PTA)
• Peritonsillar cellulitis (Quinsy)
• Retropharyngeal abscess
• Epiglottitis
• Uvulitis
• Ludwig’s angina
• Tonsillitis/pharyngitis
  • Strep, Coxsackie, Adenovirus, EBV, CMV, gonococcal, Candida, primary HIV

Physical Examination:

Physical examination revealed a non-toxic appearing man with no signs of respiratory distress. He had no appreciable facial swelling. His neck was supple with no meningeal signs.  

You take a look in his oropharynx and see this –

Inspection of his oropharynx revealed left greater than right tonsillar enlargement with erythema and mild uvular deviation to the right concerning for a peritonsillar abscess. The ED team performed a point-of-care ultrasound to evaluate for a drainable collection.

Ultrasound Image Quality Assurance (QA): 

The role of ultrasound in identification and drainage of PTA has been previously established in EM literature.^​1,2​ Ultrasound can differentiate true abscess from cellulitis/phlegmon and help guide your bedside drainage procedure – whether just to identify anatomical landmarks and gauge a safe target for needle insertion or with dynamic guidance through the procedure.^​3,4​ This is generally described using the endocavitary probe. The probe is placed into the mouth against the affected tonsil to visualize any adjacent collection. However, not all EM providers have access to an endocavitary probe. The patient may also have trismus or difficulty opening their mouth wide enough to accommodate the endocavitary probe. Some patients simply cannot tolerate the oral ultrasound. A ‘telescopic’ submandibular ultrasound approach has been described as an alternative to endocavitary views in these patients. The curvilinear probe is positioned medial to the angle of the mandible on the side of the affected tonsil and the probe fanned to localize any collection as well as visualizing the internal carotid artery. This method is dubbed a telescopic approach as the tonsil is being visualized remotely.  See figures 3A,B below.

Ultrasound-Guided Needle Aspiration of Peritonsillar Abscess:

A point-of-care ultrasound was performed to look for a drainable peritonsillar collection.  No endocavitary probe was available in the ED at the time and we decided to try the telescopic submandibular approach.

Let’s break down the steps:

• The curvilinear probe was placed under the patient’s mandible and the probe fanned to locate the tonsil.
• A hypoechoic collection was visualized adjacent to the left palatine tonsil with positive squish sign consistent with a peritonsillar abscess. Color doppler was utilized to isolate the carotid vessels on the screen and exclude a vascular component to the collection.
• The estimated distance of the drainable collection to the carotid was measured on the screen as well as the estimated size of the abscess cavity. An 18G spinal needle was obtained and the cap cut to act as a needle guard (see Figure 3).
• The area was anesthetized, and needle cap was first used to indent to tonsil in the projected site/plane of needle entry to make adjustments via ultrasound prior to sticking the patient. A partner held the probe in place while the patient held a laryngoscope to comfortably depress the tongue and light the field, leaving the performing physician free to perform the needle aspiration with two hands.  Figures 5&6 detail needle insertion/abscess drainage in real time.

Disposition and Case Conclusion:

A needle aspiration procedure yielded 4 cc of purulent material. The patient tolerated the procedure well with no complications.  He felt some immediate improvement in his throat pain and dysphagia post-procedure and noted his voice “already sounded more normal.”

Using this submandibular approach we were able to capture real time images of the procedure (Fig. 5, 6). This approach allows constant visualization of the needle tip, the abscess cavity and the carotid throughout the procedure adding an extra layer of patient safety, as well as reassurance for the performing provider.

Take Home Points:

• Point-of-care ultrasound can improve your success in identifying and draining peritonsillar abscess
• The telescopic submandibular approach with the curvilinear probe can be a useful alternative to the endocavitary probe
• As with any procedure, set-up is key – optimizing patient positioning, pain control, equipment/personnel before you start improves your chances of a fast, successful drainage procedure

Read more on ALiEM about how to drain a peritonsillar abscess.

References:

Author information

Kelly Goodsell, MD

Director UME POC US Education
Department of Emergency Medicine

Thomas Jefferson University
Sidney Kimmel Medical College

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Tamponade physiology, in which a pericardial effusion impedes cardiac output, is a medical emergency and requires prompt diagnosis and intervention before cardiovascular collapse ensues. However, not every fluid collection in the pericardial sac results in tamponade physiology. A clinical diagnosis of tamponade (Beck’s triad) has poor sensitivity and will occur only in the late stages of tamponade.^​1​ In order to know whether or not an intervention is necessary for the setting of pericardial effusion, ultrasound diagnosis of tamponade is paramount. 

What is pericardial tamponade?

The pericardial sac is made of a tough membrane that does not stretch rapidly. When there is a rapid accumulation of fluid in the pericardial sac, that tough membrane has no time to stretch and accommodate, thereby exerting pressure on the right side of the heart and decreasing cardiac output.^​2​ In contrast, if that filling is slow and gradual, the tough membranous sac will stretch and accommodate fluid without exerting too much pressure on the heart. Cardiovascular compromise ultimately depends on how fast fluid accumulates, rather than how much.

What ultrasound views do you need?

You can see pericardial effusion in any view, depending on its size. The subxiphoid view and the apical 4-chamber views will give you more information on the right side of the heart. Start with the parasternal long (PSL) view; this will help determine if the fluid resides in the pericardial versus pleural space.

Question: Is the fluid pericardial or pleural on the PSL view?

• On your PSL view, identify the descending aorta (DA)
• If fluid tracks anterior to the DA, then it is in the pericardial space
• If fluid tracks posterior to the DA, then it is in the pleural space

How does ultrasound diagnose tamponade? 

The right side of the heart is a low pressure system. If the pericardial fluid exerts enough pressure to impede filling of the right side of the heart, tamponade physiology exists.

The right atrium (RA) usually fills with blood in systole, whereas the right ventricle (RV) fills in diastole. Any signs of RA collapse during systole or RV collapse in diastole is concerning for tamponade. Another worrisome finding for tamponade is a non-collapsible, plump inferior vena cava (IVC), because if the RA is under pressure from tamponade, there will be impaired filling of the RA, leading to a dilated IVC. 

Ultrasound tips

• Use the tricuspid valve position to identify systole and diastole.
  • Closed valve: systole
  • Open valve: diastole
• If triscuspid identification is difficult, the mitral valve can be used a surrogate.
• If you have difficulty examining these valves in real-time, use M-mode or freeze your ultrasound image and scroll back until you can identify the closure and opening of the valves.^​2​
• If RA is collapsed in systole or RV is collapsed in diastole, tamponade physiology is likely present.

Take-home points

Look for tamponade physiology using ultrasonography. Worrisome findings include:

• Right atrial collapse in systole
• Right ventricular collapse in diastole
• Plump inferior vena cava

Read more on ALiEM about how to perform an ultrasound-guided pericardiocentesis.

References

Author information

Leen Alblaihed, MBBS, MHA

Clinical Assistant Professor
University of Maryland Upper Chesapeake Medical Center

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Figure 1: Terminal extensor tendon avulsion at distal interphalangeal joint of 5th digit

A 17-year-old baseball player presents complaining of finger pain and difficulty straightening his finger after a baseball game. You obtain x-rays and see the following fracture (photo credit).

What is your diagnosis and emergency department management?

Author information

Sergio Alvarez, MD

Senior Resident, Class of 2020
UCSF-ZSFGH Emergency Medicine Residency
Department of Emergency Medicine
University of California, San Francisco

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The post SplintER Series: Funny Looking Finger appeared first on ALiEM.

[Click for larger view]

Chief complaint: Headaches for 1 year

History of Present Illness: A 31-year-old woman with no significant past history presents with a dull headache.

She notes the headache is generalized, has been almost daily for a year and is worsened by bending over. She denies nausea, vomiting, photophobia, trauma, seizures, focal weakness, numbness, or vision change. Acetaminophen and ibuprofen provide only mild, short-acting relief. She takes oral birth control and her periods have been normal.

---

Physical Exam

Vitals: Height 5’ 7”, Weight is 223 lbs (101 kg), otherwise unremarkable.

Eyes:

• Pupils are 3 mm and reactive, extraocular movements are normal and there is no injection.
• Visual fields are intact to finger counting and visual acuity is 20/30 bilaterally.
• Examination of the fundus is revealed in the photo.

Neurologic: Gait is normal and there are no focal deficits.

Laboratory Data

CBC: Normal

BMP: Normal

D-Dimer: Negative

Case Question: How would you describe the fundoscopic examination?

Papilledema

Case Question: What is the most likely diagnosis?

Idiopathic intracranial hypertension

Case Discussion

This is a classic presentation of idiopathic intracranial hypertension (IIH).

It is mainly diagnosed in young obese women; predisposing factors include oral contraceptives, anabolic steroids, tetracycline, and vitamin A. The pathophysiology is not known, but may be due to an imbalance of CSF production and absorption. CSF pressure is greater than 200 – 250 mm H20.

Papilledema is present and visual field defects and blindness can occur with progression of the disease. Neuroimaging is required to rule out other causes of intracranial hypertension including intracranial masses, obstruction of CSF flow, and venous sinus thrombosis. A negative D-Dimer can help evaluate for venous sinus thrombosis in low-risk patients, although venous phase imaging with MRI is more sensitive and specific. Evidence-based treatment of IIH is lacking. Acetazolamide has been used to decrease CSF production, but emergent referral for ventricular shunting or optic nerve sheath fenestration is indicated if visual loss is present. The retinal image was taken at the bedside using a Panoptic attached to a smartphone camera.

Take Home Points

• Papilledema is a sign of intracranial hypertension and may be caused by intracranial masses, obstruction of CSF flow, or idiopathic intracranial hypertension.
• Idiopathic intracranial hypertension is typically seen in young, obese women.
• Predisposing factors include oral contraceptives, anabolic steroids, tetracycline and vitamin A.

Author information

Walter L Green, MD

Assistant Program Director; Chief, Billing & Coding
Associate Professor, Dept of Emergency Medicine
University of Texas Southwestern/Parkland Hospital, Dallas, Texas

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The post SAEM Clinical Image Series: Young Woman with a Headache appeared first on ALiEM.

[Click for larger view]

Chief complaint: Foreign Body Ingestion

History of Present Illness:

A 4-year-old male presents to the Pediatric ED for evaluation of swallowed foreign body.

The mother reports the patient was at his grandmother’s house playing near a cabinet when they witnessed him put a small unknown object in his mouth and swallow. Family denies vomiting, difficulty breathing, change in behavior, abdominal pain, or any additional symptoms at this time.

---

Physical Exam

Vitals: BP 102/65; Pulse 95; Temp 98.2 °F (36.8 °C);  Resp 22;  SpO2 100%

Constitutional: No distress

HENT:

• Right Ear: Tympanic membrane normal, no foreign bodies
• Left Ear: Tympanic membrane normal, no foreign bodies
• Nose: No foreign bodies
• Mouth/Throat: Oropharynx is clear and moist and mucous membranes are normal
• Neck: Normal range of motion

Cardiovascular: Normal rate, regular rhythm and normal heart sounds.

Pulmonary: Breath sounds normal, no stridor, no respiratory distress, no decreased breath sounds, and no wheezes.

Abdominal: Soft. He exhibits no distension. There is no tenderness. There is no guarding.

Neurological: He is alert. He exhibits normal muscle tone.

Laboratory Data

No labs drawn

Case Question: Can you identify the foreign body?

Button battery

When foreign body ingestion is suspected, a radiograph is often the first diagnostic modality following physical exam [1]. On radiograph, the classic “double ring” sign on PA films and “step off” sign on lateral films can be used to identify a button battery.

Ingestion is a true emergency given the risk of esophageal injury and perforation into mediastinal structures including the airway and aorta.

Case Question: Based on location, what is the recommended management?

If the battery is in the esophagus, the close contact between the battery and the moist mucosal surfaces in the esophagus creates a complete circuit. This can cause the button battery to discharge an electric current, potentially causing esophageal necrosis [2]. This current continues until the battery is removed.

The subsequent clinical management of button battery ingestion varies depending on size of the battery, location, and the child’s age.

All button batteries in the esophagus must be removed endoscopically.

If the button battery is in the stomach, management is controversial:

• Immediate removal should occur for symptomatic patients.
• If the patient is asymptomatic, large batteries (> 20 mm) can be given up to 48 hours to pass the pylorus before removal is indicated.
• Asymptomatic smaller batteries can be given 10-14 days to allow for passage with strict return precautions, stool inspection and radiographs at the end of this time period if the battery has not passed.

If the button battery is in the intestines:

• Immediate removal should occur for symptomatic patients.
• Asymptomatic batteries can be given 10-14 days to allow for passage with strict return precautions, stool inspection and radiographs at the end of this time period if the battery has not passed.

Magnet co-ingestion is an indication for button battery removal regardless of location.

In this case, immediate removal was not indicated given the patient was asymptomatic, the button battery was located in the stomach and was under 20 mm.

For 24/7 guidance with button battery management, the National Capital Poison Center has a 24 hour hotline and an algorithm posted on their website [3].

Case Discussion

Button battery ingestion is a true emergency. Esophageal button batteries must be immediately removed. Button batteries in the stomach and intestine warrant GI consult and close follow-up if immediate removal is not indicated.

Author information

Brett Berliner, MD

Emergency Medicine Resident
Hackensack University Medical Center

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The post SAEM Clinical Image Series: Foreign Body Ingestion appeared first on ALiEM.

Author information

William Denq, MD

Sports Medicine Fellow
Department of Emergency Medicine
University of Utah

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The post SplintER Series: Ankle and Foot Pain in a Child appeared first on ALiEM.

Welcome to the AIR Procedures Module! After carefully reviewing all relevant posts 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  emergency procedures. 10 blog posts within the past 12 months (as of April 2019) met our standard of online excellence and were curated and approved for residency training by the AIR Series Board. We identified 1 AIR and 9 Honorable Mentions. We recommend programs give 5 hours (about 30 minutes per article) of III credit for this module.

AIR Series 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 quiz at ALiEMU: ALiEMU AIR Procedures Quiz

Interested in taking the 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 on Emergency Procedure

(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!

Thank you to the Society of Academic Emergency Medicine (SAEM), our exclusive multi-year sponsor of the AIR Series! We are thrilled to partner with you on shaping the future of medical education.

From the ALiEM AIR Executive Board and ALiEMU Team

• Farhad Aziz
• Jeremy Branzetti
• Hari Bhatt
• Chris Belcher
• Adam Evans
• Sean Fox
• Chris Gaafary
• Andrew Grock
• Jacob Hennings
• Jaime Jordan
• Nikita Joshi
• Jay Khadpe
• Michelle Lin
• Allie Min
• Eric Morley
• Salim Rezaie
• Lynn Roppolo
• Matthew Rosen
• Kaushal Shah
• Derek Sifford
• Anand Swaminathan
• Wes Trueblood
• Natasha Wheaton
• David Yang

Author information

Chris Belcher, MD

Co-Editor, ALiEM AIR Series
Assistant Professor and Staff Physician
Department of Emergency Medicine
San Antonio Uniformed Services Health Education Consortium

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