A coin located in the esophagus at the level of the cricopharyneus muscle

Foreign body (FB) pearls

• The cricopharyngeus muscle is the most common site of esophageal obstruction in children
• An "end-on" or a “slit-like" appearance on PA CXR sugggests a foreign body in the trachea
• A “double-ring” sign would identify a button battery rather than a coin
• FBs should generally be removed, or seen to pass into the stomach, before ED discharge. In this case, however, there were signs of obstruction (drooling) so the risk of perforation is high.
• Items in the proximal third of the esophagus should be removed emergently via endoscopy.

Kenton, Foreign Bodies in the Gastrointestinal Tract and Anorectal Emergencies, Emerg Med Clin N Am 29 (2011) 369–400

• 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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Based on the CT scan shown, the differential here includes epidermoid and arachnoid cyst

Arachnoid cysts (AC) occur within the cerebrospinal axis and do not communicate with the ventricular system. Most occur in the middle cranial fossa and are typically benign; continuing cerebrospinal fluid

The majority of AC occurs from abnormalities in development, but a small portion occurs secondary to post-surgical adhesions or in association with cancer.

MRI is the test of choice to help define the extent of the cyst as well as determine alternative diagnoses.

Treatment is variable with some experts stating that only symptomatic ACs should be treated with others recommending removal to avoid future complications. 

The patient in the stem presented with symptoms secondary to complications from the AC.

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Table adapted from Radiology Review Manual, 7th edition, by Wolfgang Dähnert

• This is secondary syphilis
• The preferred treatment is Benzathine Penicillin G
  • 2.4 million units intramuscularly
  • Note: this dose is also the same primary syphilis
• Patients with a true penicillin allergy should receive either:
  • Doxycycline 100mg BID x 14 days
  • Tetracycline 500mg QID x 14 days
• A one-time dose of Azithromycin was previously recommended because of increased patient compliance. Many studies, however, suggest resistant species emerging and subsequent risk of treatment failure.

Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Division of STD Prevention. 2010 Treatment Update.

http://www.cdc.gov/std/syphilis/treatment.htm

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Parasternal short-axis view at the level of the papillary muscles

• A = Anteroseptal wall
• B = Anterior wall
• C = Anterolateral wall
• D = Inferolateral wall
• E = Inferior wall
• F = Inferoseptal wall

Answer: Complex pleural effusion and ascites

The take away point from this case is to always place the diaphragm in the center of the screen in order to distinguish peritoneal from thoracic fluid. Fluid in both compartments will sometimes be present (as in this case).

Complex pleural effusions

• Ultrasound can help differentiate simple versus complex effusions
• Simple effusions tend to be consistent with:
  • Acute volume overload from resuscitation
  • Heart failure
  • Conditions with low oncotic pressure (e.g., nephrotic syndrome)
  • Hepatic hydrothorax
• Complex effusions tend to be consistent with:
  • Hemothorax
  • Empyema
  • Malignancy 

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1. Prednisone
2. Eye drops for lubrication of the affected eye

Bell Palsy

• Etiologies include Lyme disease, Herpes Simplex Virus, Guillain-Barre, Epstein-Barr Virus, etc.
• Critical action is to distinguish Bell palsy from a stroke
  • Bell palsy affects peripheral portion of 7^th cranial nerve (motor and sensory). Inability to wrinkle forehead (shown here), close eyelid, and an asymmetric smile is classic and taste to anterior 2/3 of tongue (sensory) is also affected.
  • Stoke affects the central 7^th cranial nerve causing an asymmetric smile, but the ability to wrinkle the forehead and close eyelid is preserved (due to bilateral cross-over of the peripheral 7^th nerve fibers)
• The two medications that should be given are:
  • Prednisone for 7-14 days
  • Eye drops / ointment to maintain eye moisture and lubrication
• Don’t forget to discharge with instruction to patch their eye during sleep to protect their eye
• About 85% of patients recover within three weeks.

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Answer: Non-displaced scapular fracture

Treatment:

• Analgesics (NSAIDs)
• Non-displaced fractures require sling and swath immobilization
• Orthopedic reduction for displaced fractures.
• Early range-of-motion exercises
• Beware post-traumatic arthritis or bursitis as complications

Bonus Pearls: #foam4yrdome

This installment of #foam4yrdome will focus on freeemergencytalks.net which is quite possibly the best Critical Care and Emergency Medicine FREE lecture website.

The website was founded and is maintained by Professor Joe Lex (@joelex5); the website hosts hundreds of free talks.

Check out talks from all the major conferences featuring the best speakers in Emergency and Critical care medicine today.

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Important injuries to consider (image below):

• Tarsal tear
• Laceration of the lacrimal duct
• Corneal abrasion
• Globe rupture.

This patient had only a corneal abrasion on fluorescein exam.

Bonus Pearl: #Foam4yrDome

• Global Medial Educational Project (GMEP.org) is a fantastic resource for anyone interested in medical education, especially Emergency and Critical Care. It's the brainchild of Dr. Mike Cadogan (@sandnsurf).
• After creating your login and profile, you can answer hundreds of clinical questions, browse open-access media, and connect / network with other GMEP members.
• With your account, you also have the ability to upload your own questions and media to share, or you may keep them all private in your own personal cloud-based folder to retrieve anytime.

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Pterygium

• Benign wedge-shaped fibrovascular proliferation extending from sclera to nasal portion of cornea
• Sometimes confused with pinguecula (both are benign)
• Symptoms range from none, to eye irrigation/redness, to visual impairment (if crosses visual field)
• Risk factors (UV-light exposure, male gender, and genetic predisposition)
• Treatment
  • Supportive (artificial tears or short-course topical steroids)
  • Surgical excision, if:
    • discomfort
    • crosses visual-field
    • cosmetic reasons
• Prevent by blocking UV light from eyes (e.g., sunglasses)

Six-word Summary: Cornea, benign, UV, supportive, surgery, and sunglasses  

Bonus Pearl

As a new academic year begins, I will be sharing some amazing free educational online resources/links. These free materials are known as Free Open Access Meducation (or FOAMed) and for those familiar with FOAMed this is an emerging educational revolution. If you don't know what FOAMed is, read about it here and then read this. Updates will happen every Monday and will be known as #FOAM4yourDome  

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Erythema Multiforme

Erythema multiforme (EM) is a pruritic, erythematous, and blanchable maculopapular rash; it is serpiginous or targetoid in shape, with central clearing or pallor.

EM is generally symmetric, appearing on hands, feet, groin, and extensor aspects of legs and forearms.

It is classically associated with upper respiratory infections, medications, connective tissue diseases, and malignancies.

Treatment includes:

• stopping offending agent
• symptomatic treatment (e.g. Benadryl for pruritis)
• local wound care, especially if mucosal involvement

Habif, et al, Skin Disease, 3^rd Ed. 2011

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Adynamic ileus

• Nausea, vomiting, constipation, and obstipation
• Diffuse abdominal swelling
• Diffuse abdominal pain

Risk factors include

• Post-operative state (#1 cause, typically 1-3 days post-op)
• Pharmacological agents (e.g., opioids, anti-cholinergics, antihistamines, etc.)
• Infections (e.g., pneumonia, pancreatitis, etc.)
• Neurological disorders (e.g. diabetic neuropathy)
• Abdominal trauma

Imaging reveals distention of both large and small bowel without a transition zone, which differs from a small or large bowel obstruction. Such cases can be difficult to differentiate clinically from one another, so physicians often rely on imaging, specifically CT scanning to define a discrete obstruction versus an ileus.

References

1. Hayden and Sprouse, Bowel Obstruction and Hernia, Med Clin N Amer 29 (2011) 319-345

2. American College of Radiology, Suspected Small Bowel Obstruction, ACR Appropriateness Guidelines, rev. 2010

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The diagnosis in this case is Non-Hodgkin lymphoma, but read below for more differentials.

Mediastinal Masses

The mediastinum is subdivided into the regions shown below. Here are some differential diagnoses based on region.

Anterior / Superior Mediastinum

• Superior vena cava syndrome
• Ascending Aortic aneurysm
• Lymphoma
• Thyroid tumor
• Parathyroid tumor
• Thymic masses / tumors
• Germ-Cell tumor
• Metastatic disease

Middle Mediastinum

• Lymphadenopathy
• Metastatic Disease
• Lymphoma
• Developmental cysts
• Pericardial effusion
• Foregut duplication
• Bronchogenic cyst
• Vascular enlargement
• Aortic aneurysm

Posterior Mediastinum

• Neurogenic tumors
  • Peripheral nerves
  • Sympathetic ganglia
  • Paraganglionic tissue
• Esophageal tumors
• Carcinoma
• Diverticula
• Diaphragmatic (Bochdalek's) hernia

Congratulations to all the graduating residents, especially our own at the University of Maryland. I wish you all the best as you start your phenomenal careers!

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Answer: Tri-plane ankle fracture

Tri-plane Fractures

• Multi-planar ankle fracture in older children and adolescents during an 18 month window prior to distal tibial-physis closure.
• 3 planes (see Xray below): coronal (A: tibal metaphysis), sagital (B: epiphysis), and transverse (C: growth plate)
• Associated fibular spiral fracture (50% cases)
• Commonly due to external rotational or "twisting" forces.
• Xrays are helpfully, but CT scan may be indicated as fractures may be more displaced than radiographs suggest.
• Non-operative treatment for non-displaced fractures:
  • Closed reduction with long-leg splint/cast
  • Reduction may slip once swelling has subsided
• Indications for operative repair:
  • >2mm displacement of fracture segments
  • Intra-articular fracture

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Congenital anterior diaphragmatic defects with herniated bowel.

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Scapholunate dislocation

Scapholunate Dislocation (a.k.a. “Terry Thomas” or “David Letterman” sign)

• Increased distance between the scaphoid and lunate bones on AP wrist X-ray; the distance between the two bones should normally be less than 2mm.
• A widened scapholunate distance suggests ligamentous injury or tear (green arrow below).
• The widened distance resembles the famous dental diastema (i.e., tooth gap) of Terry Thomas (British comedian) and David Letterman

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Answer: Massive subcutaneous emphysema

Click here

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Emphysematous Pyelonephritis (EPN)

EPN is a necrotizing infection of the renal and peri-nephric tissues with accumulation of gas within the tissues and collecting system of the kidney; it is rapidly fatal if not recognized and aggressively treated early.

Risk factors include an immunocompromised host; Diabetics are at particularly increased risk.

The most common etiologic organisms are Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, and Pseudomonas aeruginosa. Infection with anaerobic species is relatively uncommon.

In addition to the classic signs / symptoms of pyelonephritis, (e.g., flank pain, fever, pyuria, etc.), patients presenting with EPN may experience the passage of air in the urine (pneumaturia) or crepitus over their flank.

Abdominal CT scan is the diagnostic test of choice when clinical presentation and laboratory tests are suggestive (see below)

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Answer: Left Ventricular Assist Device (LVAD) 

An LVAD is a mechanical pump that pulls blood from the left ventricle and pumps it to the ascending aorta for systemic delivery; LVADs are increasingly being placed in patients with heart failure so you must be aware of them.

The three indications for an LVAD are:

• Bridge to cardiac transplant
• Temporizing measure when a reversible cardiac disease (e.g., myocarditis) exists
• Destination therapy; patients ineligible for cardiac transplant who would otherwise die from heart failure

There are several models, which have been implanted in people (http://www.mylvad.com/lvad-devices). The main distinction between devices are pulsatile or non-pulsatile (or linear) flow; newer generation devices are non-pulsatile.

Patients with LVAD may develop complications such as infections, arrhythmias, or anemia, but bleeding can be a life-threatening one; bleeding occurs secondary to an acquired von Willebrand factor deficiency, AVMs within the GI tract, or secondary to over anti-coagulation (typically with Warfarin).

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