Answer: Rectus Sheath Hematoma

Rectus Sheath Hematoma (RSH)

Rectus muscle tear causing damage to the superior or inferior epigastric arteries with subsequent bleeding into the rectus sheath; uncommon cause of abdominal pain but mimics almost any abdominal condition.

May occur spontaneously, but suspect with these risk factors:

• Coagulopathy (#1 cause); acquired (e.g., warfarin) or inherited disorder
• Rectus muscle trauma
• Vigorous or sudden contraction of rectus muscle
• Increased intra-abdominal pressure from vigorous coughing
• Pregnancy (gestation, labor, or post-partum)

Typically a self-limiting condition, but hypovolemic shock may result from significant hematoma expansion.

• Hemodynamically stable (non-expanding hematoma): conservative treatment (rest, analgesia, and ice)
• Hemodynamically unstable (expanding hematoma): treat with fluid resuscitation, reversal of coagulopathy, and transfusion of blood products.

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Answer: Retropharyngeal abscess

Retropharyngeal Abscess (RPA)

• Commonly diagnosed in young children because the retropharyngeal space contains lymph nodes that atrophy before puberty; there is an increasing incidence in adults
• Etiologic bacteria: Aerobic (e.g., Beta-hemolytic Strep and Staph), anaerobic (e.g., Bacteroides), or gram-negative species (e.g., Haemophillus); 50% of cases preceded by a URI
• Signs / Symptoms: fever, drooling, sore throat, dysphagia, stiff neck, vocal changes (e.g., "hot-potato" voice), stridor, or respiratory distress.
• Radiologic studies
  • ​Lateral X-ray with soft tissue swelling, gas, or air-fluid levels.
  • Neck CT w/ IV contrast (definitive) defines the presence of an abscess, extent of disease, and presence of cellulitis.
• Treatment: Antibiotics with or without surgical drainage
• Complications: mediastinitis, epidural abscess, sepsis, airway obstruction, and jugular venous thrombosis.

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Answer: Subconjunctival Hemorrhage

Subconjunctival hemorrhage is the accumulation of blood between the conjunctiva and sclera (i.e., subconjunctival space) secondary to bleeding from conjunctival or episcleral blood vessels.

Subconjunctival hemorrhage may be caused by:

• Trauma
• Excessive coughing or valsalva
• High-blood pressure
• Coagulopathy: acquired (e.g., aspirin use) or inherited (e.g., Factor VIII deficiency)
• Post-occular surgery (normal complication)
• Febrile systemic-infections (e.g., meningococcal septicemia)
• Following CPR-associated chest compressions
• Post-cardiac angiography or open-heart surgery

Treatment should be directed towards reversing the underlying cause and providing symptomatic relief (e.g., artificial tears)

Prognosis is typically good. Occasionally the hemorrhage becomes yellowish-green (similar to a bruise) during the healing phase; this eventually resolves.

Bonus Pearl: As July 1rst approaches a new class of doctors will begin their journey to become Emergency Medicine specialists. The EM Basic website, created by Dr. Steve Carroll, was developed as a boot camp guide for Emergency Medicine. At the EM Basic website, you can find podcasts and discussions of must know topics within Emergency Medicine. Check it out today at http://embasic.org or on iTunes

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Diagnosis: Ventriculomegaly secondary to Normal Pressure Hydrocephalus

An approach to ventriculomegaly

Ventriculomegaly is due to cerebral atrophy (e.g., Parkinson disease) or increased cerebrospinal fluid (CSF) within the ventricles. Increased CSF is due to:

• Increased CSF production (e.g., choroid-plexus papilloma), or
• Impaired CSF re-absorption (e.g., subarachnoid-villi inflammation), or
• Obstruction of CSF flow (e.g., non-communicating hydrocephalus)

Congenital causes of ventriculomegaly:

• Neuro-tube defect (e.g, myelomeningocele)
• Aquaductal stenosis
• CNS malformation (e.g., Dandi-Walker syndrome)
• Intrauterine infection (e.g., CMV, rubella, etc.)

Acquired causes of ventriculomegaly:

• Paget's disease (obstruction of CSF flow)
• Bacterial or viral meningitis (impaired CSF absorption)
• Tumor (obstruction of CSF flow)
• Post-hemorrhagic (e.g., trauma, aneurysmal rupture, AVM, coagulopathy) impaired absorption and/or obstruction of flow

Sub-talar dislocation

• Dislocation of distal talar articulation at talocalcaneal and talonavicular joints (ankle joint is undisturbed)
• Also known as "basketball foot"; a common mechanism of injury
• Medial dislocation is more common than lateral (85% vs 15%) and it is usually caused by injury while foot is in inversion
• Closed reduction is facilitated with knee in flexion to relax the gastrocnemius
• Approximately 20% of lateral dislocations require open reduction
• CT scan is recommended following closed reduction to rule out osteochondral lesions and better assess the reduction

Wheeless' Textbook of Orthopedics

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Chou, H. et al. Tracheal rapid ultrasound exam (T.R.U.E.) for confirming endotracheal tube placement during emergency intubation. Resuscitation. Jun 2011

Werner SL,et al. Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement. Ann Emerg Med 2007;49:75–80.

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Lung abcess

case compliments of our very own Zac Dezman

Cerebral Ring-Enhancing Lesions

Neoplasm

• Primary brain tumor
• Primary CNS lymphoma
• Metastatic disease

Infectious

• Pyogenic abscess
• Tuberculoma
• Syphilis
• Neurocysticercosis  
• Toxoplasmosis
• Nocardiosis
• Cryptococcosis
• Aspergillosis

Neurologic

• Multiple sclerosis (lesions within the white matter)
• Sacroidosis
• Vasculitis
• Aneurysm
• Resolving hematoma
• Cerebral infarct
• Postoperative change

Bonus pearl: Do you like Emergency Ultrasound and want a quick review before you scan your next patient? Well, check out the "One-minute Ultrasound App". It's provides a quick review for many essential ultrasound studies...and yes, it's FREE for both iphone and android.

Iphone: http://itunes.apple.com/us/app/one-minute-ultrasound/id512301845?mt=8&ls=1

Adroid: https://play.google.com/store/apps/details?id=com.v1_4.oneminuteus.com&feature=search_result#?t=W251bGwsMSwxLDEsImNvbS52MV80Lm9uZW1pbnV0ZXVzLmNvbSJd

Garg, R., Sinha, M. Multiple ring-enhancing lesions of the brain. J Postgrad Med. 2010 Oct-Dec; 56(4):307-16

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Answer: Hiatal hernia

• Hiatal hernias are commonly retrosternal and present with GERD-like symptoms
• A barium swallow is the diagnostic test of choice.

The differential diagnosis for circumscribed air-fluid levels on chest X-ray includes:

• Hiatal hernia
• Cavitary disease (e.g., tuberculosis)
• Empyema
• Lung abscess

Bonus Pearl

Do you like listening to pre-recorded lectures, especially when they’re free? Then check out Free Emergency Medicine Talks (http://freeemergencytalks.net) where you can listen to millions (ok, more like 1,384) of free lectures recorded at major conferences around the world.

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Answer: Infectious Flexor Tenosynovitis

Infectious Flexor Tenosynovitis

- Closed space infection of the flexor tendon sheath; an orthopedic emergency

- Typically an infection with skin flora secondary to penetrating trauma

- Diagnosed by Kanavel's Signs:

           - Finger held in slight flexion
           - Fusiform swelling
           - Pain on passive extension
           - Pain while palpating the tendon sheath

- If early and not severe a course of IV antibiotics (covering skin flora) may be tried, however, surgical intervention is often necessary; early consultation with a hand surgeon is highly recommended

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Answer: Testicular torsion

• Most common pediatric cause of testicular pain; Occurs in 1 in 4,000 males less than 25 years-old
• Sudden and severe pain with diffuse testicular swelling and tenderness; right side is affected more than the left.
• Most sensitive sign (90-100%) is absent or decreased cremaster reflex.
• Diagnosis is made by ultrasound demonstrating an enlarged testicle, increased echogenicity, and little to no Doppler flow (as seen above) compared to a testicle with normal flow (see below)
• Requires emergent urology consult for surgical detorsion and fixation of testis to prevent recurrence; testicular salvage rate is 90% within 6 hours of presentation as compared to 20% at 24-48 hours
• Manual detorsion should be attempted if urology consult is delayed.

References

Shan Yin, MD, MPH, Jennifer L. Trainor, MD, Diagnosis and Management of Testicular Torsion, Torsion of the Appendix Testis, and Epididymitis, Clin Ped Emerg Med, 10:38-44, 2009

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Answer: Perilunate dislocation

Perilunate dislocations usually occur following high-energy trauma (e.g., fall from a height); the mechanism is usually wrist hyperextension, ulnar deviation, and carpal supination.

Tenderness is palpated along the dorsum of the wrist; specifically distal to the lister tubercle along the scapholunate ligament; injuries may be associated with scaphoid fracture

Paresthesias may also occur along the median nerve distribution with up to 25% of cases developing carpal tunnel syndrome.

Treatment options include closed reduction and casting or open reduction and ligamentous repair with internal fixation.

The figure below illustrates the differences between lunate and perilunate dislocations.

References

Lunate and Perilunate Dislocations. Kannikeswaran, N & Sethuraman, U.

http://www.radiologyassistant.nl/en/42a29ec06b9e8 (diagram)

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Answer: Pneumoperitoneum

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Answer: Patella Alta secondary to Patellar tendon rupture

• Mechanism is knee flexion combined with forceful contraction of the quadriceps
• Swelling, patellar tenderness, and limited extension of knee
• Radiographs are helpful in diagnosis when using the Insall-Salvatti ratio (see below)
  • This ratio is the patellar length (PL) (in cm) divided by the distance between inferior pole of the patella and tibial tuberosity (PT)
  • Insall-Salvatti ratio PL/PT =1 is normal; <0.8 is predictive of tendon rupture

References

• Insall J, Salvati E. Patella position in the normal knee joint. Radiology 1971;101:101
• Sibley T, Algren D, Ellison S. Bilateral patellar tendon ruptures without predisposing systemic disease or steroid use: a case report and review of the literature. American Journal of Emergency Medicine 2012; 30: 261.e3-261.e

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Answer: Secondary syphilis

• The differential diagnosis for rash on the palms and soles is small and should always include syphilis.
• The rash may be maculopapular, papular, annular, or pustular.
• Syphilis easily crosses the placenta and fetal damage can occur; the extent of the damage depends upon its stage of development at the time of infection and the duration of untreated infection.
• Without therapy, fetal infections  may result in miscarriage, stillbirth, growth restriction, hydrops fetalis, premature delivery, and neonatal death.
• "The physician who knows syphilis knows medicine." -Sir William Osler

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Answer: Frontal sinus fracture (inner and outer table) with pneumocephalus.

A few quick pearls when managing skull fractures:

Medical management:

• Little evidence for prophylactic antibiotics; even with a laceration over fracture (i.e., an open fracture)
• Little evidence for prophylactic anti-convulsants

Surgical management, if:

• Skull depression >5mm relative to adjacent segment(s)
• Dural tear; suggested by CSF or pneumocephalus
• Debridement and washout for suspected or confirmed wound contamination

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Answer: Pneumothorax (left chest) and bullous disease (right chest).

In questionable cases like this, bedside ultrasound can help distinguish between bullae and pneumothorax. Bullae should have a positive lung sliding sign whereas pneumothorax does not.

See the referenced case report for more information:

Simon, B. et al. Two cases where bedside ultrasound was able to distinguish pulmonary bleb from pneumothorax. J Emerg Med. 2005 Aug;29(2):201-5.

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Answer: Partial obstruction of the Superior vena cava (SVC)

SVC Syndrome

SVC syndrome is caused by compression or obstruction of the superior vena cava blocking anterograde flow.

Most cases are secondary to extrinsic compression by malignancy. Other causes are secondary to thrombosis and internal obstruction (e.g., central venous catheter placement).

Symptoms present sub-acutely, worsen with bending over, and are secondary to increased venous pressure in the head and neck (e.g., epistaxis, headache, tinnitus, conjunctival injection, neck swelling, etc.).

Treatment focuses on reversing the underlying cause (e.g., radiation or chemotherapy if due a sensitive tumor) and treatment of symptoms:

• Steroids, diuretics, and hyperosmolar agents to reduce edema
• Elevate the head of bed to reduce brain edema
• Anti-emetics to prevent vomiting-associated increases in intracranial pressure

Rice TW, Rodriguez RM, Light RW. The superior vena cava syndrome: clinical characteristics and evolving etiology. Medicine (Baltimore). Jan 2006;85(1):37-42.

Nunnelee JD. Superior vena cava syndrome. J Vasc Nurs. Mar 2007;25(1):2-5; quiz 6.

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