aka Radiological Oddity 020.2

Remember this from last week:

The challenge was to correctly identify:

• the imaging modality,
• the structures shown, and
• the underlying diagnosis

This was the first correct answer:

First across the finish line was our mate in Tasmania, Domhnall Brannigan, who if he wasn’t already a Fellow of the Utopian College of Emergency for Medicine, is now. He was nearly disqualified for wanton use of question marks, but the UCEM adjudicators decided to be lenient as they hadn’t explicitly stated these criteria for disqualification prior to the challenge being issued… However, the promised ‘legend’ status was retracted because, in retrospect, UCEM felt that this one was way too easy.

There were some other great, imaginative answers provided too, that could have been correct in an alternate universe… Thanks to all for the contributions.

As an aside, you may be wondering: why CT a patient with angioedema?

Following awake fiberoptic nasal intubation in ED she was admitted to ICU. Oral intubation with a laryngoscope would have been impossible as her tongue was so swollen nothing could be passed orally. She remained intubated for 3 weeks until the swelling settled. During this time she started spiking temperatures and concerns were raised that there could be an infective component, however no collections were seen on CT. The cause of her angioedema was the good ole ACE inhibitor she had been taking for some time for hypertension. Her fevers were actually due to a ventilator associated pneumonia (she also had trouble handling her secretions and may have aspirated prior, or during, intubation).

The significant findings on CT were:

• extensive opacification of the paranasal sinuses and the ethmoids.
• Endotracheal tube and a nasogastric tube in situ.
• Complete loss of the airway from the post-nasal nasal space caudally to the level of the thyroid.  Diffuse oedema in the soft tissues which envelop the two tubes.

Here are some more images demonstrating the findings -- note the complete lack of air around the ETT above the thyroid:

And finally if you’re not sure what a patient with severe angioedema looks like, here’s a pic from GMEP:

References and Links

Lifeinthefastlane.com

• CCC -- Angioedema

Social Media and Web Resources

• Emedicine -- Angioedema
• PHARM -- Angioedema case presentation by Dr Peter Sherren
• Resus.com.au -- 35y male with difficulty breathing
• Resus.ME -- ACE-inhibitor related angioedema

The post Rorschach Test Revealed appeared first on Life in the Fast Lane medical education blog.

 

Conocí de este caso clínico,que puede generar aprendizaje para todos
Todos conocemos el dicho popular:"Para mentir y comer pescado hay que tener mucho cuidado"
Hoy habra que decir "Para mentir y chupar los huesitos del pollo ,hay que tener mucho cuidado"
Persona de 30 años que consulta en urgencia hospitalaria por que se atragantó al estar comiendo pollo,más chupando los huesos
En la urgencia lo examinan y lo envian a su casa diciendo"ya pasó,solo tiene erosionado el fondo de la faringe  por el hueso del pollo,le dejan antiinflamtorio
Paciente evoluciona en malas condiciones,consulta ahora en Sapu donde tras un examén clinico,derivan a Hospital con sospecha de "Cuerpo extraño esofágico"
Paciente tenía incrustado en esofago,un pequeño hueso de pollo habiendolo perforado,paciente debio ser hospitalizado ,evoluciona con Mediastinitis,felizmente despues de manejo en UTI,fue dado de alta satisfactoriamente.

In this bonus episode, our second instalment of the highlights from the 25th Annual Update in Emergency Medicine from Whistler B.C., we have Dr. David Carr updating us on infectious diseases, Dr. Dennis Scolnick giving us the low down on pediatric urological emergencies, Dr. Anil Chopra reviewing the pearls and pitfalls of managing shock states, [...]

In anticipation of Episode 23 on ‘Vaginal Bleeding in the First Half of Pregnancy’ with Dr. Ross Claybo and Dr. David Dushenski, we have Dr. Claybo’s Best Case Ever. In the upcoming episode we will……. run through the key clinical pearls of the history, the physical, interpretation of the BhCG and the value of serum progesterone [...]

In this episode Dr. David Dushenski & Dr. Ross Claybo discuss the very common presentation of vaginal bleeding in the first half of pregancy. They run through the key clinical pearls of the history, the physical, interpretation of the BhCG and the value of serum progesterone in working up these patients. The newest on bedside [...]

In this episode we have the continuation of our discussion on Respiratory Emergencies with Dr. Anil Chopra and Dr. John Foote. We discuss key clinical decisions in COPD assessment and management – how to assess for impending respiratory failure, how best to oxygenate the COPD patient, medication pearls and how best to approach intubating the COPD [...]

In anticipation of Episode 25 on 'Pediatric & Adult Syncope' with Dr. Eric Letovsky and Dr. Anna Jarivs, we have Dr. Jarvis's Best Case Ever. In the upcoming episode we will cover....... - how to differentiate syncope from seizure - key historical and physical exam clues to determine a cause of syncope - ECG pearls of syncope-causing cardiac [...]

In this episode, Dr. Eric Letovksy & Dr. Anna Jarvis run through the key clinical pearls of the history, the physical, interpretation of the ECG and the value of clinical decision rules such as the ROSE rule and the San Franciso Syncope Rule in working up these patients. We discuss how to differentiate syncope from [...]

First week of 6 12 hour shifts under the belt at the new hospital. Well, 5 shifts, as the tradition of getting violently ill every time I start a new hospital and exposed to the local flora of disease held true and I had to call out for one. But holy hell what a different setting that last year. Last year, was a major urban academic hospital in one of the countries biggiest cities. This year it’s a community hospital, with ER and Medicine as the only residencies present, set in a community that doesn’t exactly have health insurance. So gone are the handful of guys every night who were too drunk to get into the homeless shelter who just want a sandwich, replaced with people who haven’t seen a doctor in 10 years and now have some serious pathology going on.  The learning curve has been amazing. I felt like I learned more in this past week then I did in a whole month last year. The best thing? Maybe it’s cause it’s a real hospital, maybe it’s because we’re R2′s now, but we’re treated like colleagues by the attendings and not 4th year med students, which was the case last year.  And it’s a pretty great feeling. I feel like I’m a “working” doctor for the first time, finally getting an idea of how this is going to all work out in the real world.

There are few issues that divide my colleagues more than fish hook removal techniques.

Some like to push, some pull, some use a complex string tension technique.  Then there is the large piece of metal that you yank…. Out it pops.

So I want to know – what is your preferred technique for pulling out barbed hooks?

Let me know on the comments, or link to a video / diagram

Do you have a trick to share?     Casey

 

So, I’m back after 2 1/2 weeks away in the wilds of Yorkshire near the Gothic town of Whitby. It was quite a marvellous holiday with lots of mountain biking, body boarding and walking……but no Internet! This was both a tremendous relief as peace descended in the digital part of my brain, but also an interesting reminder of just how much we rely on digital access to stay in touch and to get things done. No worry though, despite my out of office messages I came back to >1500 emails, roughly 30 would be regarded as important…anyway. I could have written about repetitive strain injury to my delete button finger, but rather I am thinking back to the wonderful mountain biking in Dalby forest and the sort of injuries that I might have sustained whilst attempting the more difficult routes.

So enough of my Jollidays, back to medicine and possibly one of  my favourite diagnoses in the ED, I’m not sure why, possibly because I’ve seen quite a few in cyclists (and ED docs love cycling), but more likely I just like the name. I also think that is an under-diagnosed condition with clinical signs attributed to other conditions such as haematoma.

So what is it? Well, if you don’t know the name you might recognise the condition because I’ll bet you will have seen it at some point if you’ve been around the ED for a few years or so. A Morel-Lavallée lesion occurs when the superfical fat and skin separate from the underlying fascia to produce a potential space which then fills with fluid. These are often initially mistaken for simple haematomas but you can usually clinically distinguish them as they are more mobile, more ‘squishable’ and often demonstrate fluctuating size through the day as activity or posture changes. They are often tricky to spot in the early stages, and they may be missed on first presentation with signs becoming more obvious over days, weeks or sometimes months.

So, in the ED you might see this when a patient first comes to you having sustained a shearing injury with a subcutaneous swelling, but more likley you would suspect this injury in someone who returns days to weeks later with a persistent, fluctuant swelling that does not seem to be going away.

In the literature it is commonly described in relation to severe pelvic injuries, particularly those involving patients being run over where there are severe shear forces applied to the pelvic area and they are of particular concern to pelvic surgeons as they can interfere with operative management. I’m not so concerned with that group in this post as those patients will be heading to theatre under the care of the Orthopaedic surgeons. Rather I’m interested in those lesions that we might see and manage in the ED.

The separation of superficial tissues from fat requires a fairly significant shearing force that drags and tears the skin and fat from the underlying fascia. I guess that’s why we have seen in cyclists as the typical fall at speed, followed by an impact at an angle (as one hits the road or track) lends itself to this sort of injury. Typically they occur around bony protuberances such as the hip and knee as these are areas where the underling tissues are relatively fixed yet the skin is not. The advent of artificial pitches and hard surface playing environments may also be a factor, but that’s just my opinion, no evidence to back that up really…

The sort of crash that might cause this sort of injury is not uncommon in cyclists, particularly track cyclists, and as  Virchester is home to the greatest Velodrome in the world we have seen many riders from first timers right through to Olympic champions over the years. The description attributed to Sir Chris Hoy’s injury back in 2009 is of a Morel-Lavallée lesion and if you look at the footage from the crash you get a real idea of the shear forces involved in the injury mechanism. If you don’t watch the entire Kierin then skip to 2:50 & then slo-mo at 3:45 to see the crash.

There is also an absolutely fantastic personal account of a bicycle sustained M-L lesion on this blog by Fatheral, plus the blog has a great series of personal photos of what an M-L lesion looks like – although their lesion ended up with surgery (not always needed  – see below).

Although MR is advocated by radiologists as an optimal way of looking for these lesions I have found USS to be an excellent tool to define the nature and extent of these lesions. There are a few nice examples of what you see on USS in this paper from the Journal of Ultrasound Medicine, but you should be able to predict what you would see. A fluid collection superficial to the fascia that is easily compressible. Some good pics here as well. The one thing to think about when you are attempting ultrasound is that these are very ‘squishable’ so you can miss them if you are heavy handed. A very light touch may be needed to avoid ‘squashing’ the fluid away from your field of view.

So what to do about it? I have not found definitive advice on treatment but there appear to be a number of options.

• 1. Simple compression – reported as successful in some case series.
• 2. Serial aspiration under USS (done this several times and works well – but time consuming as daily repeats with compression bandaging between times).
• 3. Insertion of surgical vacuum drain.
• 4. Sclerodesis with something a tetracycline/doxycycline

So my personal plan with these lesions is, as always, dependent on the patient characteristics and size of the lesion. In patients with very small lesions then I would go for compression, particularly around the knee where compression is easy to achieve. For lesion around the hip it’s pretty difficult to get a compression bandage on in any effective manner so I tend to go straight for aspiration in those lesions, repeating on a daily or bi-daily manner under USS guidance. USS also gives you a really good idea of whether you are winning and if not then it’s a referral over to the surgeons for a vacuum drain.

So, a favourite diagnosis and although not common it is one that we can do something about and it’s got a great name….what more do you want

….well, to be honest I’d like to see someone do a proper review of this lesion for the FCEM exam. I think it would make a great CTR.

vb

Simon Carley

 

Further reading.

• Nice review on the radiological features on MR here
• Bio of Morel-Lavallée here
• Paper on sports related knee M-L injuries here
• Sclerodesis therapy here

…and thanks to Nat for sorting my accents out

 

Unbelievable.

FORT WORTH CBSDFW.COM - With hundreds of human cases of the West Nile Virus being reported across Texas and more than a dozen related deaths in North Texas it seems some people are overreacting and calling 911 when they're bitten by a mosquito.In short, health officials say a mosquito is not a health emergency."We understand peoples concerns regarding the West Nile Virus, but in the absence of any symptoms of West Nile then a simple mosquito bite is really not a reason for someone to call 911," said Matt Zavadsky, public affairs director for MedStar Emergency Medical Services.One woman called Fort Worth 911 requesting assistance because her young nephew had a bump on his arm.

via Health Officials: No Need To Call 911 For Mosquito Bites « CBS Dallas / Fort Worth.

We’re seeing some of this in the ED, people with bug bites coming straight in ‘to get checked out’.

Sad.

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3 out of 5 stars
A Fatal Case of Thallium Toxicity: Challenges in Management. Riyaz R et al. J Med Toxicol 2012 Aug 4 [Epub ahead of print]

Abstract

This case report emphasizes an important clinical point. The case describes a 36-year-old man who presented to hospital with vomiting and abdominal pain 45 minutes after ingesting an unknown amount of thallium rodenticide.

Treatment included supportive care, Prussian blue, and multidose activated charcoal. Despite this therapy, he developed increasing renal insufficiency on day 3, and then shock and acidosis on day 5. At that time continuous renal replacement therapy. Two hours after CRRT was started, the patient suffered a ventricular fibrillation arrest from which he could not be resuscitated.

Thallium is an extremely toxic heavy metal. Although its marketing as a rat poison has been banned in the U.S. since 1965, the patient apparently had access to an old container.

Aside from supportive care, there are three possible specific treatments for thallium toxicity. Since thallium undergoes enterohepatic and enteroenteric circulation, and binds readily to charcoal, multidose activated charcoal offers theoretic benefit and has been proved effective in animal models. Prussian blue can trap thallium in exchange for potassium; oral doses will maintain a concentration gradient and promote diffusion of thallium into the gut.

The third possible treatment is hemodialysis. Although thallium is not protein bound, it has a relatively high final volume of distribution of 3.6 L/kg, suggesting limited benefit from hemodialysis. However, it is important to realize that thallium has complex kinetics, and during the first hours after ingestion much of the poison will be in the central compartment where it could be susceptible to hemodialysis. The use of hemodialysis was not considered in this case until the patient became too unstable to tolerate it. The authors conclude that although the efficacy of dialysis in thallium toxicity has not been established, “[i]f hemodialysis is to make a difference, then logic would dictate that it be started as early as possible”.

Came across this unique application of ocular ultrasound while doing some web browsing.  Wild… LINK TO ARTICLE: Optic Disc Edema, ...
Continue reading

Needles, one of the tools of our trade.
We use them every day. But have you ever wondered how they are made?
How exactly do they get that teeny tiny hole in a 25G needle?

Well hang on to your sharps bin, ’cause I am about to get straight to the point and tell you everything you have never wanted to know about hypodermic needles.

Interestingly, in order to manufacture the those tiny tubes of steel needed for most medical needles, the process begins with a big thick tube.
To begin with, a large piece of sheet metal is fed into a series of rollers that bend it over and around into a tube. The tube then passes through a welder to seal the seam.

Alternatively, 'seamless' tubing is produced by taking a chunk of metal known as a 'billet', heating it and boring a hole through the center. In some instances this is done with a with a laser.
You would think that laser technology would be quicker and more accurate, but apparently the gold standard for producing these incredibly high tolerances and precise measurements remains the welding method.
Old school rules.

Tubular:

Where were we? Oh yes, the tube. This large tube is then heated to soften it (a process known as annealing), after which it is drawn by significant forces through a tool (or die) that has a much smaller diameter hole in it.
Think of those Play-Doh toys that squeeze out spaghetti worms of various shapes and diameters.
It wasn’t until I was 5 or 6 that I realised Play-Doh wasn’t one of the 5 food groups.

The tube is then extruded through smaller and smaller dies right down to the final diameter. Sometimes a rigid length of wire known as a mandrel is placed inside the tube to maintain its integrity during the process.

The final die pass is often done without any heat. This cold working of the tube increases its strength and rigidity.
The metal of choice used for needles, of course, is surgical steel, which is a type of stainless steel.
During the manufacturing of surgical steel, alloying elements of chromium, nickel and molybdenum are added to the mix. It is the molybdenum that gives the finished needle greater strength and a sharper cutting edge.

Molybdenum. Anyone about to have a baby girl and looking for a unique name?
Move over Shaniqwa and Shumonte there is a new girl in the class....

BD needles:

OK. I’m sure you have all seen BD syringes and needles, but did you know what the BD sands for?

Becton Dickinson is one of the largest manufacturers of medical devices and instrument systems in the world. But it all began back in 1897 developing syringes and needles (in fact it was BD that patented the luer lock connection).

BD use a 3/4 inch stainless steel tubing that is rolled and welded, heated, and drawn down to the required size with a final cold-draw.
This tubing is cut into the correct lengths and then the bevel is sliced across the end.

The very tip of the needle is known as the lancet and various shapes are used depending on the application.
From the lancet, the cutting edge sweeps elegantly back across the bevel to form the shoulder.

The actual shape of the bevel is also a highly specialized bit of kit. Check out the A-bevel, B-bevel, C-bevel, Bias, Chiba, Crawford, Deflected Tip, Francine, Hustead, Huber, Trocar, and Tuohey. Collect the whole set.

Finally, the hub is attached. These can be made from metal or plastic and are bonded to the needle by a crimping process or using an epoxy.

The final product is sometimes coated with a low-friction lubricant to create a smoother penetration that is less painful.

Gauge:

The diameter of the needle is referred to as its Gauge and is based on the 'Stubs Needle Gauge'.
Smaller gauge numbers indicate a larger outer diameter. The Stubs Iron Wire Gauge system (also known as the Birmingham Wire Gauge or BWG) was adopted in Britain in 1884 to specify the thickness of metal wires. Although it was not used much anywhere else in the world, an Act of Congress in the US made it the only wire gauge system used there (and so here).

The other scale used to measure gauge is the French scale often written as FR or Fg.This is usually used to measure the external diameter of catheters.

• 1 French = diameter of 1/3mm. Therefore you can impress your colleagues by quoting the diameter of any catheter in millimeters by dividing the Fr guage by 3.

So now you are a bit of an expert on the old hypodermic.
Perhaps you can meducate your patients all about them to help pass the time as you are digging around looking for that recalcitrant vein.

Me comentaba un colega: – tienes abandonado el Blog.

Yo le respondía: – lo tengo en barbecho.

Realmente pensaba: si no tienes nada que decir no digas nada.

Estamos en VERANO: época de vacaciones.

Yo ya me he fundido las mías, disculpadme que no os las cuente.

Ahora de vuelta al cole/curro, conectado a la WEB, me he encontrado con un video en Qué se cuece? que me ha encantado (real como la vida misma):

The current issue of The New Yorker magazine carries an amazing piece (subscription required) by author and neurologist Oliver Sacks detailing his extensive drug use while a neurology resident at UCLA and a young attending physician in New York.

Sacks -- who meticulously describes the drug effects he observed in himself --started with marijuana, but soon escalated to taking 20 pills at a time of the antimuscarinic drug Artane. This caused dry mouth, mydriasis, and anticholinergic delirium, as he found himself having absolutely realistic encounters with friends who weren’t there, as well as a conversation with a spider who inquired if he thought that the philosopher Bertrand Russell had disproved Frege’s paradox.

Early on, Sacks took drugs only on weekends. “During the week, I would avoid drugs, working as a resident at U.C.L.A.’s neurology department.” Some of these weekend episodes involved cocktails of LSD, amphetamine, and hashish. When LSD was not available, Sacks substituted morning-glory seeds, which contain lysergic acid amide, causing drug-induced Capgras Syndrome. (Sacks points out that today these seeds are commonly coated with a pesticide to discourage ingestion.) Injecting intravenously a “large syringe” of morphine produced a 12-hour hallucination of the Battle of Agincourt acted out on the sleeve of his dressing gown. (I did  wonder at points -- as I have reading some of Sacks’ books such as The Man Who Mistook His Wife for a Hat -- if he was indulging in some literary embellishment.)

When Sacks withdraws from massive doses of chloral hydrate he develops delirium tremens. Finally, after taking a huge dose of amphetamines (causing “a sustained pulse rate close to two hundred and a blood pressure of I-know-not-what”) while reading a 19th-century treatise on migraines, he decides on his life’s work (physician/author) and “never took amphetamines again” -- although he doesn’t say if he continued taking other drugs.

A very strange article, but worth reading.

[Photograph of Oliver Sacks from wikipedia.org]

Aussi appelé fulguration, lightning strike en anglais (coup d'éclair), c'est un accident rare rentrant dans le cadre des électrisations (électrocutions désigne un accident électrique létal). L'incidence exacte des coups de foudre n'est pas connue, on l'estime à 50 à 100 cas par an en France. Ces accidents occasionnent aussi des dégradations de bâtiments, de compteurs électriques, [...]

This is a really slick website and mobile app I found called Docphin. This is a huge help in staying up with the latest EM literature (...except a certain podcast you know and love!).

{enclose keeping_up_update_v45.mp4}

One of the things people who work in ER always wonder about is: WHY IN THE HELL DOES EVERYONE DECIDE TO COME AT ONCE??!!! Why is it that certain days, the teeming masses present at the triage desk?

Some theories:

1) Change in barometric pressure
2) Full moon
3) Nothing on TV
4) Get it over with before the big game
5) Nothing else to do
6) A voice told them to come
7) Out of crack, meth, heroin
8) Solar storms

After about 2 weeks working in ER you give up ever trying to make sense of it. Its random, there's no rhyme or reason.

So why, pray tell, do I bring this up? Because it has been so damn busy in the last couple of weeks. We're not talking regular busy, we're talking
****BUSY!!!!!!!****. Most people ever seen on one day in ER history this past week. 30% more than budgeted daily census. People waiting hours.

Did something happen that I don't know about? Was there some shift in the universe? A change in gravity? What in THE HELL is going on? I don't like it. I don't like it at all...

Are you busier?

2012-08-21 07h55 Twitter and International EM Editor, Emergency Physician International

2012-08-21 08h00 International EM Education Efforts & E-Learning   Joe’s slides from this talk can be downloaded from http://download.yousendit.com/WUJZZUNqb0JZY1JjR01UQw 

2012-08-21 08h30 Selecting and Preparing for an International EM Rotation

2012-08-21 08h45 The Role of IFEM in Global Health Professor, Emergency Medicine, University of Texas Southwestern Past President, International Federation for Emergency Medicine Past President, American College of Emergency Physicians

2012-08-21 09h00 Humanitarian Assistance and Refugee Health

2012-08-21 10h00 Emergency Medicine and Global Health Vice President, RAND Corporation Director, RAND Health Member, IOM Committee on the Future of Emergency Health Care in the US Health System

2012-08-21 10h45 EM Rotations in Tanzania

2012-08-21 10h55 EM Rotations in Viet Nam