Tracings Vol 1.1

A 53-year-old woman presents to the ED resuscitation suite following cardiac arrest. At a local shelter she was reported to have been experiencing “flu-like” symptoms and shortness of breath. On EMS arrival she was hyperventilating; subsequently, she collapsed and was pulseless and apneic. EMS performed ACLS, defibriillating twice. The patient arrived at the ED in cardiac arrest. PMH per EMS: HTN. Meds: nifedipine. Physical exam was consistent with the patient’s arrested state. Monitor rhythm: asytole. Treatment was initiated with ACLS measures resulting in restored circulation followed repeatedly by recurrent cardiac arrest. During one interval while circulation was restored, a 12-lead ECG was obtained (click on to enlarge). No old tracing was available for comparison.

Questions:

1.  What is your ECG interpretation?
2.  What is your disease differential diagnosis?
3.  What would you do?

Tracings is a learning module involving actual cases of patients and their ECGs that present to the Emergency Department.  Topics are derived from the EM Model for Resident Education.

Answer radER Vol 1.4

radER Winners:

Devon Moore

Brian Kern

Brian McMichael

Answer to Case 1.4

A 56-year-old man was brought to your ED after bring involved in a MVC.  He was a restrained driver in a car that was traveling at 40 MPH and slammed into a tree.  The patient denies loss of consciousness.  A radiograph is seen below.

Questions:

1.  What is the abnormality on the radiograph?

2.  Name the nerve(s) that are frequently injured in this type of injury?

3.  What are the motor and sensory physical exam findings corresponding to these nerve(s)?

Answers:

1.  Left acetabular fracture.  A MVC is a very common mechanism that causes acetabular fractures when the knee hits the dashboard causing the flexed hip to move posteriorly into the acetabulum.

2.  The sciatic nerve is the most commonly inured nerve.  Exam findings should be clearly documented on the chart.   The femoral nerve can also be injured with a fracture of the acetabulum.

3. The motor component of the sciatic nerve is checked by testing the strength of the extensor hallucis longus.  This is performed by having the patient resist downward pressure on the great toe while held in extension.  The sensory component is examined by checking sensation over the dorsum of the foot and lateral calf.

The femoral nerve is less commonly injured than the sciatic nerve. The motor component is checked by extension of the knee as well as the patellar reflex.  The sensory component is examined by testing for sensation over the anterior thigh and inner calf.

It looks like an acetabular fracture since it involves the superior pubic ramus at its lateral extent, near the acetabulum.  A second fracture should be present and I believe is seen superior to the acetabulum – a slight break in the iliopubic line (arcuate line).  By the radiograph, the fracture would be classified as an anterior wall fracture.  A CT would show it well.  A superior pubic ramus fracture would generally be in the midportion of the pubic ramus and when it’s this displaced would be associated with an inferior pubic ramus fracture, and, likely as well, a second break in the pelvic ring, e.g., a sacral wing fracture.

The Teardrop Sign

The radigraphic teardrop sign is a landmark present in normal pelvic radiographs and is often disrupted with acetabular fractures.  However, if the patient is rotated, the teardrop sign may not be present.  In addition, the presence of the teardrop sign does not exclude a fracture.  Nonetheless, if the teardrop sign is absent in the right clinical setting, then you should be highly suspicious for an acetabular fracture.

Thank you for everyone who submitted an answer. Please stay tuned for next week’s radER.

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer quizzER 1.4

quizzER Winners:

Sam Lee                Bindu Vanapali         Rob Klever

Marjan Siadat        Devon Moore            Chris Guyer

Brian Kern             Dave Mishkin

Julie Nguyen          Dave Daigle

Last Week’s Question

The answer is D.

This is a case of erythema infectiosum or Fifth’s Disease. Infection by Parvovirus B19 produces this pattern of a “slapped cheek” appearance. It is characterized by an eruption that presents initially as an erythematous malar blush followed by an erythematous maculopapular eruption on the extensor surfaces of extremities that evolves into a reticulated, lacy, mottled appearance. Fever and other symptoms may be present but are uncommon. In patients with chronic hemolytic anemias like sickle cell disease, aplastic anemia is a serious complication.  Pregnant women should avoid exposure to this virus, since it may cause fetal hydrops in 10% of cases.
The article by Kellermayer, R. “Clinical presentation of parvovirus B19 infection in children with aplastic crisis”. The Pediatric infectious disease journal. 22 (12), p. 1100.
_________________
Sickle cell patients can develop osteomyelitis (a), however, the clinical presentation is inconsistent. Patients with osteomyelitis caused by Salmonella species are generally those with sickle cell disease.  However, the most common organism that causes osteomyelitis in patients with sickle cell disease is Staphylococcus aureus.  Encephalitis (b) is an inflammation of the brain parenchyma and is not commonly caused by Parvovirus. Common etiologic agents include herpes simplex, herpes zoster, varicella-zoster, West Nile virus, and toxoplasmosis. Pneumonia (c) is a common diagnosis in patients of all ages. In children, the most common causative agents are viral. The most commonly found bacterial agent is S. pneumonia. Meningitis (e) is an infection of the meninges that surround the brain. It is caused by viral and bacterial entities. The most common bacterial agents include: E. coli, Group B streptococcus, and L. monocytogenes in very young infants and S pneumonia, N meningitides, and H influenza in older children.

Thank you for everyone who submitted an answer.  Please stay tuned for next week’s quizzER.

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

Answer VizD 1.4

Case 1.4

A 35-year-old woman presents to your ED with pain to her right leg.  The patient states that she was swimming in the ocean approximately one hour ago and felt a sharp pain around her knee.  She thought her pain was due to the paddle ball game she was playing earlier in the day.  What do you think?

Questions:

1. What is the diagnosis?

2. What is the most effective treatment?

3. Name one complication of this patient’s presentation?

Answers:

1. Jellyfish sting – envenomation occurs through nematocysts, which are sharp stinging cells.  Nematocysts are enclosed in venom sacs and present in tentacles.

2. On scene, vinegar is ideal.  Sea water is acceptable.  Tap water should be avoided as it may lead to a worsening of the envenomation.  Patients should receive tetanus toxoid if mandated.

3. Anaphylactoid reaction, leading to hypotension, dysrhythmias. bronchospasm, and cardiovascular collapse.

Here is an article from the Australian experts on Marine Envenomations

Thank you to everyone who submitted their answer.  Stay tuned for next week’s VizD

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.

radER vol 1.4

Case 1.4

A 56-year-old man was brought to your ED after bring involved in a MVC.  He was a restrained driver in a car that was traveling at 40 MPH and slammed into a tree.  The patient denies loss of consciousness.  A radiograph is seen below.

Questions:

1.  What is the abnormality on the radiograph?

2.  Name the nerve(s) that are frequently injured in this type of injury?

3.  What are the motor and sensory physical exam findings corresponding to these nerve(s)?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

radER is a weekly contest, hosted by Dr. Kerin Jones’ “Fracture”,  consisting of a radiograph selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

quizzER 1.4

Pediatrics

A 3-year-old African American boy with a history of sickle cell disease presents to the ED after he developed a low-grade fever, runny nose, and an erythematous discoloration of both cheeks. His vital signs are heart rate 110 beats per minute, respiratory rate of 24 breaths per minute, and pulse oximetry of 98% on room air. The patient looks well and is in no acute distress. You note a macular lesion on both cheeks. The rash is not pruritic and there is no associated cellulitis or suppuration. What is the most serious complication to consider in this patient?
a.    Osteomyelitis
b.    Viral encephalitis
c.    Pneumonia
d.    Aplastic anemia
e.    Meningitis

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

quizzER is a weekly contest consisting of a question selected from various areas of emergency medicine that are central to the education of medical students and residents in training.

VizD Vol 1.4

Case 1.4

A 35-year-old woman presents to your ED with pain to her right leg.  The patient states that she was swimming in the ocean approximately one hour ago and felt a sharp pain around her knee.  She thought her pain was due to the paddle ball game she was playing earlier in the day.  What do you think?

Questions:

1. What is the diagnosis?

2. What is the most effective treatment?

3. Name one complication of this patient’s presentation?

Please post your answer in the “reply box” or click on the “comments” link  You will not see your answer post until next week when all of the submitted answers will be posted.  Good luck!

VizD is a weekly contest of an interesting or pathognomonic image from emergency medicine. Its goal is to integrate learning into a fun and relaxed environment. All images are original and are posted with the consent of the patient.