UMEM Educational Pearls

Superficial Thermal Burn

Upon further questioning, patient stated that she had been making s'mores by roasting marshmallows over an electric stove 3 days prior. The burns showed up the subsequent morning.

• Thermal injury
  • Types - scald, contact, fire, chemical, electrical, radiation
  • Can still sustain dermal burns from emanating heat without contact
  • Extent of tissue damage based on temperature & duration of exposure

• Non-accidental burns are common in children
  • 10% of physically abused children have intentional burns/scalds
  • Sites: hand, back, wrist, buttock, feet, legs
  • Type: well-define margins of contact/scald burns in unusual places, glove-and-stocking distribution

Take Home Points:

• Take a good history
• Can sustain burns without direct contact (i.e. heat, radiation, etc.)
• Consider non-accidental burns in children

Previous pearls about burns:

Pediatric Burns:

• https://umem.org/educational_pearls/1107/
• https://em.umaryland.edu/educational_pearls/1164/

Monseau AJ, Reed ZM, Langley KJ, Onks C. Sunburn, Thermal, and Chemical Injuries to the Skin. Prim Care. 2015;42(4):591-605.

"Pathophysiology of Thermal Injury." Civic Plus. 2007.

Herpetic whitlow

- It is caused by either HSV 1 or 2.

- Infection is usually transmitted by direct unprotected contact.

- Healthcare workers are at risk of contracting the infection if appropriate preventative measures were not taken when dealing with patients who have the infection.

- Diagnosis is mainly clinical. Tzank smears can be done to confirm the diagnosis if in doubt.

- Treatment with Acyclovir is thought to shorten the duration of the infection and prevent recurrence if started within 72 hours of beginning of symptoms.

- Incision of the vesicular lesion is contraindicated and can cause severe bacterial superinfection.

McDonald, Lucas S., et al. "Hand infections." The Journal of hand surgery36.8 (2011): 1403-1412.

Peritonsillar Abscess

The ultrasound image is a transcutaneous approach with a linear transducer that is placed at the angle of the mandible of the affected side. This is an alternative approach to an intra-oral ultrasound with the endocavitary transducer if the patient has trismus.

• Peritonsillar abscess (PTA) is often taught as a clinical diagnosis; however, 36% are often peritonsillar cellulitis (PTC)
  • Sensitivity and specificity of clinical diagnosis of PTA are 78% and 50%, respectively
• Classically, providers attempt blind needle aspirations (landmark-based)
  • Blind needle aspiration is unreliable for diagnosis of PTA with a false-negative rate of 10-24%
• Intraoral sonography sensitivity: 90-100%
  • Using ultrasound can avoid unnecessary use of CTs and blind needle asprations

Take Home Points:

• Consider intra-oral US for diagnosis of PTA vs. PTC and to reduce unecessary radiation with CT
• Consider transcutaneous US to evaluate for PTA in the setting of trismus
• Consider intra-oral US-guided needle aspiration of PTA vs. blind needle aspiration

How to do an intra-oral US-guided needle aspiration of PTA, check out:

http://www.ultrasoundpodcast.com/2012/01/episode-21-full-peritonsillar-abscess-podcast/

For a brief video on how to perform a transcutaneous US for PTA:

https://www.youtube.com/watch?v=JkIYOhKCweI&t=28s

Halm BM, Ng C, Larrabee YC. Diagnosis of a Peritonsillar Abscess by Transcutaneous Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care. 2016;32(7):489-92.

Rehrer M, Mantuani D, Nagdev A. Identification of peritonsillar abscess by transcutaneous cervical ultrasound. Am J Emerg Med. 2013;31(1):267.e1-3.

This is Herpes Zoster (Shingles).

Presentation:

• Zoster typically appears along a single dermatome, without crossing midline in immunocompetent hosts, but may involve 2-3 adjacent dermatomes.

• In immunocompromised patients, systemic involvement may occur.

• Thoracic and lumbar dermatomes are the most common.

• Lumbar and sacral dermatomes wrap around the lower extremity and may spare the skin between the perineum and the foot.

Treatment:

• Immunocompromised patients should be treated with IV Acyclovir 10mg/kg q 8hr for 7 days (Use IBW in obese patients)

• In immunocompetent individuals, if identified within 48 hours of rash onset, may receive oral therapy with famciclovir, acyclovir or valcyclovir
• Herpes Zoster alone should not prompt immunosuppression work up
  • However, concerns for underlying immune disorders if:
    • continued development of lesions > 1 week, or
    • involvement of more than 3 dermatomes

Dworkin RH, Johnson RW, Breuer J, et al. Recommendations for the management of herpes zoster. Clin Infect Dis. 2007;44 Suppl 1:S1.

Answer: WES sign

WES sign stands for Wall Echo Shadow sign. It is a triad of:

1- Thick echogenic gall bladder wall (W)

2- Echoes filling the gallbladder (E)

3- A posterior acoustic shadow (S)

• It is suggestive of either one big stone or multiple stones filling the gallbladder.
• This sign can be mistaken for either a bowel loop or an empty and contracted gallbladder.
• To differentiate between WES and a bowel loop, look for visible bowel peristalsis.

Rybicki, F. J. (2000). The WES Sign 1. Radiology, 214(3), 881-882.

Small Bowel Obstruction

• Presentation: abdominal pain, nausea, vomiting, early diarrhea progressing to lack of flatus or bowel movements with complete obstruction. Severe obstruction can result in perforation, unstable vital signs, and physical exam signs of peritonitis.

• Sensitivity and specificity > 90% for diagnosis of SBO with US, with superior test performance compared to X-ray.

• US findings: dilated small bowel loops > 3 cm; no peristalsis, swirling snowstorm appearance of bowel contents

• Treatment: bowel rest, IV fluids, and prompt surgery consultation! Consider NG tube for decompression.

See the corresponding upright abdominal x-ray, showing dilated bowel with air fluid levels.

Kameda T, Taniguchi N. Overview of point-of-care abdominal ultrasound in emergency and critical care. J Intensive Care. 2016 Aug 15;4:53. doi: 10.1186/s40560-016-0175-y. eCollection 2016. Review.

Unl er EE, Yava i O, Ero lu O, Yilmaz C, Akarca FK. Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med. 2010 Oct; 17(5):260-4.

1- Cholecystitis

Ultrasound remains the best modality to test for cholecystitis. However, CT scans can still be obtained for non-classic presentations. The negative predictive value of CT is still relatively high. CT has a negative predictive value of 89%, compared to 97% to that of ultrasound. The absence of cholecysitis on CT will help the argument against the diagnosis, but if the suspicion is high an ultrasound study should still be obtained.

Things to look for on an abdominal CT that are suggestive of cholecysitis:

1. Gallbladder distension ( >5 cm width, >8 cm length).

2. Wall thickening ( >4mm thickness).

3. Pericholecystic fat stranding.

4. Presence of gallstones.

2- An inflated foley catheter in the ureter!

Ureteric insertion of foley catheters is a very rare complication of foley catheterization. There are no clear predisposing factors to this complication. However, it is thought that the presence of an underlying anatomical deformity (e.g. abnormal ureteric insertion site) might put the patient at a higher risk for it. Inflating a balloon in the ureter might result in severe ureteric injury. A suggested method to prevent this kind of injury is to perform bladder aspiration to insure balloon positioning prior to inflation.

References

1- Shakespear, Jonathan S., Akram M. Shaaban, and Maryam Rezvani. "CT findings of acute cholecystitis and its complications." American Journal of Roentgenology 194.6 (2010): 1523-1529.

2- Kim, Myung Ki, and Kwangsung Park. "Unusual complication of urethral catheterization: a case report." Journal of Korean medical science 23.1 (2008): 161.

• Initial Assessment of ABC, ATLS primary survey guidelines.
• Evaluate for tension pneumothorax or cardiac tamponade in all patients presenting with chest trauma and shock.
• Cardiac Box: Surrounded by sternal notch, xiphoid process and nipples.
• Order of injury: Right Ventricle --> Left Ventricle --> Right Atrium --> Left Atrium
• Beck’s Triad: Hypotension, JVD, muffled heart sounds may not be present initially.
• Conduct FAST exam to examine for cardiac tamponade, hemothorax, pneumothorax.
• Cardiac Tamponade more common from stab wounds than from gun shot wounds.
• Hemodynamically unstable patients require immediate operative therapy after quick bedside assessment (physical exam, ultrasound, chest tube as needed)

Differential Diagnosis: Bronchial injury, Diaphragm injury, Hemothorax, Tension Pneumothorax, Aortic Transection, Esophageal injury, Pneumomediastinum

Evaluation: Ultrasound (FAST Exam), CXR, CTA in stable patients, ECG, troponin.

Management: Penetrating cardiac trauma require emergent thoracotomy, pericardial window.

Clancy K, Velopulos C, Bilaniuk JW, et al. Screening for blunt cardiac injury: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73(5 Suppl 4):S301-6.

El-menyar A, Al thani H, Zarour A, Latifi R. Understanding traumatic blunt cardiac injury. Ann Card Anaesth. 2012;15(4):287-95.

Tintinalli's 7th Edition. Emergency Medicine Manual. Chapter 164: Cardiothoracic Trauma.

Myositis of the deltoid muscle

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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.

Diagnose with CT, but try using ultrasound (thanks Dr. Joseph Minardi)

May occur spontaneously, but suspect with the following 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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Pneumobilia (air in the biliary tree). Be careful, this must be distinguished from portal venous gas.

Diagnoses to consider when pneumobilia is present:

• Infection
  • Cholangitis
  • Liver abscess communicating with biliary tree
  • Emphysematous cholecystitis
• Biliary instrumentation (e.g., recent ERCP)
• Incompetent sphincter or Oddi
  • passage of a gallstone
  • sphincterotomy
  • certain medications
• Biliary-enteric fistula (e.g., Peptic ulcer disease, gallstone ileus, trauma,, etc.)

http://radiopaedia.org/articles/pneumobilia

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Lung point indicating pneumothorax (PTX)....see below for the false positives

What's the (Lung) Point

• Separation of the visceral and parietal pleural secondary to a PTX leads to well recognized loss of lung sliding on ultrasound. 
• Lung point (LP) on ultrasound is where the transition between pleural sliding and the loss of this sliding is demonstrated. Previous studies have reported that the LP has 100% specificity for a PTX.
• Although this is a great sign to demonstrate PTX, be aware that there are several LP mimics:
  • lung-heart interface
  • lung-diaphragm interface (lower thorax laterally)
  • pleural effusion
  • blebs
• Check out these great #FOAM posts by @ultrasoundjelly & @ultrasoundMD for more on the LP (and their mimics). Check them out here & here

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Ruptured gastric ulcer with pneumoperitoneum (CT scan below)

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Lens disclocation

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Displaced fracture of the proximal ulna.

Pearls

• Always look for injury at the radial head when the proximal ulna is fractured, specifically looking for a radial head dislocation; this pattern is known as a Monteggia fracture.
• Remember the mnemonic MUGR (MU-GR)
  • Monteggia fracture-dislocation = Ulnar fracture with a proximal radial dislocation
  • Galeazzi fracture-dislocation = Radial fracture with a distal radioulnar dislocation

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• Massive retroperitoneal and peritoneal free-air from ascending colon rupture
• Colon cancer was eventually diagnosed in the operating room.
• Notice that the kidney and psoas muscle outlined by the free-air below.

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Subcutaneous emphysema

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Orbital floor fracture with entrapment of the inferior rectus muscle.

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Coin lodged in the esophagus

Coin ingestions

• More than 100,000 foreign body ingestions are reported in children each year; coins are #1 cause
• Although not always 100% true, coins typically appear circular on an AP Xray of the neck when in the esophagus and linear when in the trachea
• Coins usually pass without issue, but warning signs are drooling, dysphagia, hoarse voice, wheezing, or stridor
• 10-20% require endoscopy for removal and 1% require surgery
• Objects lodged in the middle esophagus should raise concern for underlying pathology such as strictures, masses, or webs

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Waltzman ML, Baskin M, Wypij D, Mooney D, Jones D, Fleisher G. A randomized clinical trial of the management of esophageal coins in children. Pediatrics. 2005;116(3):614.

Cevik M, Gókdemir MT, Boleken ME, Sogut O, Kurkcuoglu C. The characteristics and outcomes of foreign body ingestion and aspiration in children due to lodged foreign body in the aerodigestive tract. Pediatr Emerg Care. 2013;29(1):53.