VizD Vol 2.1

Case 2.1

A 23-year-old man presents to your ED after being in a bar fight.  The patient states he received multiple punches to his head and face.  You note the following finding on exam.


1. What is the diagnosis?

2. What is the treatment in the ED?

3. What is a complication of this condition?

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.


twiter1A 35-year-old woman presents to the resuscitation room with shortness of breath that began earlier in the afternoon.  The patient has a history of asthma.  On exam, she is in obvious respiratory distress with retractions, accessory muscle use, and faint wheezing on auscultation of her thorax.  She rapidly decompensates and has to be endotrachealy intubated.

Acute asthma exacerbation with respiratory faiulure

  • The most common predictors of fatal asthma seem to be a past medical history of intubation/mechanical ventilation and underuse of steroid therapy
  • Findings suggestive of severe asthma
    • dyspnea so severe the patient is only able to speak a few words at a time
    • poor air movement on auscultation of the lungs
    • use of accessory muscles – reflects diaphragmatic fatigue
    • silent chest – indicates that airflow is dramatically reduced and is no longer adequate to cause wheezing
    • diaphoresis
    • cyanosis – late finding, appearing just prior to respiratory arrest
    • altered mental status – may indicate hypercapnia and often reflects impending respiratory failure
  • Treatment of severe asthma
    • beta2-agonists (onset of action < 5 minutes)
    • anticholinergic agents (onset of action up to 30 minutes)
    • corticosteroids (onset is gradual with initial improvement at 3 hours)
    • heliox
    • magnesium sulfate
    • terbutaline/epinephrine – reserved for patients who are too sick to provide an effective respiratory effort
    • mechanical ventilation – high rate of iatrogenic complications (barotrauma)
      • hypoventilate (8-10 breaths per minute – permissive hypercapnia)
      • I to E ratio increased to at least 1:4

TWITTER notes (This Week In The ER) is an educational resource that presents high-yield, case-based information from actual patient presentations in the Detroit Receving ED.

got public health?

No Love in the Time of Cholera

I was raised on drinking tap water. To this day, I still don’t understand why my California relatives are willing to spend money to drink bottled water. Evidently, they are not alone… stores and filled with complete aisles of multiple brands of bottled water, and now flavored water. However, the current cholera epidemic plaguing Zimbabwe has never made me so appreciative of our easy access to (clean) tap OR bottled water.

At present, there are a greater than 15,000 people affected, with a reported 775 people that have died from cholera. As Zimbabweans are fleeing the country to seek clean water and medical treatment in neighboring countries, the disease has the potential to spread throughout Africa. Due to breaking down of the government and health care system, and lack of access to clean water, Zimbabwe has had multiple outbreaks of cholera throughout the decade, but none this large or devastating.

Caused by the bacteria Vibrio cholerae, disease is transmitted through contaminated food or water, even shellfish. The enterotoxin that is produced invades the mucosal epithelium of thevc small intestine, leading to profound diarrhea. The severe dehydration the develops is considered a medical emergency, and may lead to shock and death in a rapid fashion.

Treatment is simple: aggressive oral rehydration therapy with a prepackaged mixture of sugar and salts which is mixed with water.IV rehydration is also acceptable, yet oral rehydration methods are more readily available, inexpensive and works well (if accesssible). Antibiotics are also available, but the key is rehydration. An oral vaccine has been developed, however it is currently not recommended by the World Health Organization (WHO) or Centers for Disease Control (CDC) once an outbreak has started or to travelers. Also chemoprophylaxis is also discouraged since it may not prevent disease and may facilitate antimicrobial resistance.

Some killer facts (courtesy of CNN):

  • A healthy adult can be killed in hours (unique among diarrheal illnesses)
  • Very short incubation period (2 hours to 5 days)
  • 75% do not exhibit any symptoms (that is, until the runs hit)
  • A total of 236 896 cases were reported in 2006, which is an increase of 79% compared with the number of cases reported in 2005
  • HIV and malnourished individuals are more severely affected and more likely to die—-considering the high prevalence of HIV and malnourishment in Africa, this is a devastating problem.
  • If left untreated, one out of two people may die

For more info:
WHO: World Health Organization
CDC: Centers for Disease Control

Here is an audio clip worth listening to.
It’s hard to write this and not feel helpless….the solution is clear, but what can be done on our end to help? It’s not only the issue of access to clean water and oral rehydration solutions, but getting them to the people who need it most. Can the Gatorade company or the electrolyte/vitamin fortified water manufacturers help out? Surely their products contain most of what is needed, and they have the financial means to do so.

So the next time you see a bag of normal saline or stop by the water machine, be thankful for what we take for granted.

Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.