Answer for Image of the Week 006

Sorry for the delay on this one everyone.  Image of the Week 007 below answers some of my time away.  Anyway, back to the case…

A 32 year old male with a history of HIV, noncompliant with his medications, presents to the ED with a fever, hypoxia, and a cough.  CXR is shown below.  Given his clinical/medical history, what does this most likely represent, and what lab value might help confirm your diagnosis?  What other clinical entity might a CXR like this represent?  What is the first line treatment, and what are the indications for steroid therapy in this patient?

This patient likely has Pneumocystis jirovecii pneumonia (formerly PCP pneumonia).  This is usually noted by diffuse bilateral infiltrates extending from the hilum on CXR.  Having a history of HIV makes this all the more likely.  LDH may be helpful in the diagnosis, as levels are usually elevated (> 250) in patients with this disease process. LDH is relatively sensitive, but somewhat nonspecific.  Highly elevated levels may indicate worse disease and prognosis.  Another prime concern in an immunocompromised patient with a similar CXR would be miliary TB.  

The first line therapy is trimethoprim-sulfamethoxazole (TMP-SMX).  Alternatively, clindamycin + primaquine can be given in patients who have a contraindication to TMP-SMX.  Steroids may be considered as an adjunct therapy that might play a role in decreasing inflammation and respiratory failure.  Indications for steroids include a PaO2 < 70 mmHg or an A-a gradient > 35.  Don’t have an ABG handy?  A pulse ox < 92% generally correlates with a PaO2< 70 mm Hg.  This is a popular test topic in regards to diseases seen in HIV patients.  #EMBoardReview

1. Emergency Medicine: A focused review of the Core Curriculum.  pp 241-242.  


Episode 15: The Seven Deadly Sins – Common US Mistakes and How to Avoid Them

As a graduate of 12 years of Catholic school, I learned about (and committed most of) the 7 deadly sins.  I spend much of my time now teaching residents ultrasound, and reviewing their images.  In the 7 major US categories (AAA, Biliary, Cardiac, FAST, OB, Renal, and Vascular Access), I have noticed there are common mistakes most novices make.  So what are these 7 Deadly US Sins, and how can we avoid them?

  1. AAA:  To find the aorta, do not look for the aorta.  I know…mind blown.  The aorta is anterior/anterolateral to the vertebral column, so setting your depth high initially and finding the hyper echoic vertebral body with posterior shadowing will guide you to the aorta so you do not mistake the SMA for the aorta. 
  2. Biliary: Beware the ultimate SIN - stone in the neck.  Pay special attention to the neck of the gallbladder.  Sometimes, you will not even see the stone itself, so heavy anechoic shadowing behind the neck of the GB should clue you in.  And remember, Hartman pouches can be tricky, so do not miss a stone in the neck of a Hartman’s pouch either.  
  3. Cardiac: Always evaluate the posterior pericardium.  In the subxiphoid view, this means having enough depth and far gain to get there.  In the parasternal long axis, make sure you see the descending thoracic aorta just posterior to the LA/LV.  Pericardial fluid will be anterior to this, and may split between the heart and aorta, while pleural fluid will be lateral/posterior to the aorta.  
  4. FAST: free fluid should have sharp edges and take the shape of its container.  Fluid that is encapsulated, walled off, or rounded in unlikely free fluid.  In the RUQ, the GB sandwiched in between the liver and kidney may be mistaken for free fluid, while a beverage filled stomach may throw you off in the LUQ.  
  5. OB: always find the midline stripe to make sure what you are seeing is truly in the uterus.  A fair number of ectopic pregnancy may have a pseudo gestational sac in the uterus, so remember a yolk sac is the earliest definitive sign of pregnancy.  And size does not matter, you can have a big ectopic.  
  6. Renal: Not all hydronephrosis is ureterolithiasis with obstruction.  A large AAA may compress the ureter, so remember to look for AAA in at risk patients.  Renal colic is possible misdiagnosis of aortic disasters.  
  7. Vascular access: Remember, the point of doing US guided procedures is to always know where your needle tip is.  The US probe can only see what is directly beneath it.  If you are advancing your needle but what you think is the needle is not moving on the screen, you may be looking at the needle shaft.  Stop moving your needle, and move your probe to find it.  TRV vascular access should be a two handed dynamic technique.  

2008 ACEP US Guidelines

Thank you to everyone for reading and listening.  2013 was fun, and I have some great content planned for you coming up.  As always, let me know if you have any questions/concerns/feedback.  If you like what you hear, please go to iTunes to rate and review me.  Know residents that aren’t listening?  Let them know about the blog and podcast.  If you are using a reader, I do have an RSS feed here

Also, for US residents, the In Service exam is coming up in February.  Be sure to check out, @EMBoardReview on Twitter.  Hoping to get most of the content there finished in the next few months, and have a ton there already.  Jon Schonert (@emchatter) has done a great job with this.  

Listen to the podcast:

Answer for Image of the Week 005 and Image 006

This patient unfortunately has suffered a comminuted, displaced fractured clavicle, a fractured scapula, and there is a fracture fragment inferior to the humeral head (red arrows).  When you get the lateral view (see blow), you also note a posterior dislocation with humeral head fracture.  The posterior dislocation is suggested on the AP view by the “lightbulb sign” (blue arrow), and by the “rim sign” (green line, medial border of the humeral head is > 6 mm from the anterior glenoid rim).  

Remember, a fracture of the scapula is a significant injury and can portend serious intrathoracic and other concomitant traumatic injuries.  CT imaging of the thorax is recommended to evaluate for further injury.  

For more information on radiographic findings of the shoulder, check this out.  

Image 006

A 32 year old male with a history of HIV, noncompliant with his medications, presents to the ED with a fever, hypoxia, and a cough.  CXR is shown below.  Given his clinical/medical history, what does this most likely represent, and what lab value might help confirm your diagnosis?  What other clinical entity might a CXR like this represent?  What is the first line treatment, and what are the indications for steroid therapy in this patient?

Answer for Image of the Week 004 and Image 005

This patient appears to have an abrasion in the RUQ, likely sustained when the handlebars made a direct impact.  On further questioning, the family saw the handlebars hit directly in the RUQ, with one end hitting her belly and the other hitting the ground.  The next step in management is to evaluate for internal injuries.  A CBC would provide baseline hemoglobin and hematocrit (H/H) levels, although remember even if there is acute bleeding, the H/H will likely be normal.  You should also obtain a liver panel and lipase.  While normal values here do not rule out liver or pancreatic injuries, they may be helpful in tracking injury progression with serial levels.  In any trauma patient in whom you suspect there may be internal bleeding, consider a blood bank tube to hold or type and screen.  UA may be obtained to evaluate for hematuria.  

The next question is imaging.  The role of the FAST exam is not well defined in children, and in the otherwise stable child may not yield information, although there have been studies investigating serial FAST exams along with serial evaluation with some promise.  Ultimately, given the location and mechanism of injury with abdominal pain and an overlying abrasion, a CT scan with IV contrast to evaluate for solid organ injury would be advisable.  The most common/classic injuries seen with handlebar injuries include liver and splenic lacerations, pancreatic injuries, duodenal hematoma, and hollow viscous injuries.  

Even if the initial imaging and workup is negative, serial abdominal exams over the next twenty four hours would be advisable as trauma protocol CT scanning has poor sensitivity for hollow viscous injuries, and patients should be watched for delayed onset of peritonitis.  Your patient had a positive FAST exam, and CT showed a low grade liver laceration with elevated AST/ALT.  They did not require operative intervention and were managed conservatively.  

Beware the handlebar injury! (see reference 2).  

1. Pediatric Blunt Abdominal Trauma

2. The High Morbidity of Handlebar Injuries

Image 005

A 29 year old male arrives after falling off of an ATV.  He is complaining of left shoulder pain, and appears in moderate distress.  The following image was obtained of the shoulder.  What injuries are noted (hint: there are at least two)?  What  else should you be worried about based on the injuries/findings in this XR?  What is the next step in the management of this patient?