Skip to main content
Open Access Publications from the University of California


JETem is an online, open access, journal-repository for EM educators in all major topic areas. We focus on active learning and technology. Submissions include team-based learning (modified and classic), small group learning, simulation, podcasts, workshops, lectures, curricula, innovations and submissions to our image and video bank. For our fully searchable site, and details regarding submissions please go to


Acute Hemolytic Transfusion Reaction

ABSTRACT: Audience: This scenario was developed to educate emergency medicine residents on the diagnosis and management of acute hemolytic transfusion reactions in the emergency department. The case is appropriate for senior medical students and advanced practice providers. The principles of crisis resource management, teamwork, and communication are also incorporated into the case.

Introduction: Patients who present with suspected acute hemolytic transfusion reactions require rapid diagnosis and management, as well as a thorough evaluation for other differential diagnoses, such as DIC (disseminated intravascular coagulation), TTP (thrombotic thrombocytopenic purpura), and sepsis. The possibility of acute hemolytic transfusion must be entertained early, as it carries significant morbidity including the risk of developing acute hemolytic anemia, acute renal failure, DIC, shock, and/or death.1 The mortality rate of acute hemolytic transfusion reactions can reach 44%, and it accounts for 20% of all transfusion-related mortalities.2,3 Given this significant morbidity and mortality, early recognition and management are paramount in the emergency department (ED) to avoid clinical deterioration and death.

Objectives: By the end of this simulation session, the learner will be able to: 1) Recognize the clinical signs and symptoms associated with transfusion reactions. 2) Discuss necessary systems-based management of potential transfusion reactions, such as notifying the blood bank and evaluating to see if another patienta accidentally received a wrong unit of blood. 3) Discuss the management of various transfusion reactions. 4) Appropriately disposition the patient to an intensive care unit (ICU) or stepdown unit. 5) Effectively communicate with team members and nursing staff during the resuscitation of a critically ill patient.

Method: This session is conducted using high-fidelity simulation, followed by a debriefing session and lecture on the diagnosis and management of transfusion reactions. Debriefing methods may be left to the discretion of participants, but the authors have utilized advocacy-inquiry techniques.

Topics: Medical simulation, acute hemolytic transfusion reaction, transfusion reactions, hematology, emergency medicine.

In-Flight Emergency: Altered Mental Status Secondary to Hypoglycemia

ABSTRACT: Audience: This simulation is appropriate for all emergency medicine learners from medical students to senior residents.

Introduction: It has been reported that 1 in every 10,000 to 40,000 passengers on board of a commercial airline will have a medical emergency while in- flight.1 That is roughly 1 out of every 600 flights.2 Many healthcare providers are unaware of the available medical equipment, effects of cabin pressure, and resulting opportunities for medical intervention. But physicians on board may be asked to render medical care for passengers experiencing medical emergencies in-flight. It is important for healthcare providers to be familiar with the most common in-flight medical emergencies and how to best address them.

One common emergency that occurs during air travel is hypoglycemia in insulin dependent diabetic patients.3 It has been noted that changes in air and cabin pressures affect the amount of insulin secreted from insulin pumps. One article explains that as the airplane ascends, ambient pressure decreases and air comes out of solution, forming bubbles.3 These bubbles displace insulin in a pump, causing excess delivery.3 Excess insulin delivered during ascent in an airplane may cause hypoglycemia 1-2 hours later while in flight.1,3 The United States Food and Drug Administration states that it addresses such malfunction during the manufacturing of insulin pumps.3,4 However, there have still been reported malfunctions, which occur 40-50 times worldwide per year while in-flight.3

Objectives: By the end of this simulation session, learners will be able to: 1) Discuss the challenges associated with in-flight emergencies. 2) List what is available in United States (US) commercial airline medical kits. 3) Discuss an appropriate differential diagnosis for a patient with altered mental status (AMS). 4) Demonstrate appropriate treatment of hypoglycemia. 5) Describe possible complications in diabetic patients with insulin pumps when flying. 6) Review the legal ramifications of responding to an in-flight emergency.

Method: This case can use a high, medium or low-fidelity simulation mannequin or a standardized patient; alternatively, this case can also be used as an oral boards case.

Topics: Simulation, diabetes, hypoglycemia, altered mental status, seizure, endocrinology.


Novel Emergency Medicine Curriculum Utilizing Self- Directed Learning and the Flipped Classroom Method: Cardiovascular Emergencies Small Group Module

ABSTRACT: Audience: This curriculum, created and implemented at The Ohio State University Wexner Medical Center, was designed to educate our emergency medicine (EM) residents, PGY-1 to PGY-3, as well as medical students and attending physicians.

Introduction: In 2013, chest pain alone was the principal reason for visit for over 6 million Emergency Department visits in the United States. This represents 4.9% of all Emergency Department visits.1 Residents must be proficient in the differential diagnosis and management of the wide variety of cardiovascular emergencies. The flipped classroom curricular model emphasizes self-directed learning activities completed by learners, followed by small group discussions pertaining to the topic reviewed. The active learning fostered by this curriculum increases faculty and learner engagement and interaction time typically absent in traditional lecture-based formats.2-4 Studies have revealed that the application of knowledge through case studies, personal interaction with content experts, and integrated questions are effective learning strategies for emergency medicine residents.4-6 The Ohio State University Wexner Medical Center EM Residency didactic curriculum recently transitioned to a “flipped classroom” approach.7-10 We created this innovative curriculum aimed to improve our residency education program and to share educational resources with other EM residency programs. Our curriculum utilizes an 18-month curricular cycle to cover the defined emergency medicine content. The flipped classroom curriculum maximizes didactic time and resident engagement, fosters intellectual curiosity and active learning, and meets the needs of today’s learners. 3,11,13

Aims/Goals: We aim to teach the presentation and management of cardiovascular emergencies through the creation of a flipped classroom design. This unique, innovative curriculum utilizes resources chosen by education faculty and resident learners, study questions, real-life experiences, and small group discussions in place of traditional lectures. In doing so, a goal of the curriculum is to encourage self-directed learning, improve understanding and knowledge retention, and improve the educational experience of our residents.

Methods: The educational strategies used in this curriculum include small group modules authored by education faculty and content experts based on the core emergency medicine content. This program also includes resident-submitted questions that were developed during review of the content. The question and answer format of the Socratic Method--with a focus on fostering an open learning environment, not negative “pimping”-type questionin--is used during small group sessions to encourage active participation and discussion; small groups also focus on the synthesis and application of knowledge through the discussion of real life experiences. The use of free open access medical education (FOAM) resources allows learners to work at their own pace and maximize autonomy.

Topics: Emergency medicine, flipped classroom, medical education, cardiovascular emergencies, pedagogy, teaching.


The Continuous Residency Improvement Committee (CRIC) – A Novel Twist for Program Evaluation in an Academic Emergency Medicine Residency Program

ABSTRACT: Audience: The continuous residency improvement committee (CRIC) innovation is designed for residency program leadership and residency program coordinators.

Introduction: The Accreditation Council for Graduate Medical Education (ACGME) requires residency- training programs to perform ongoing self-study in order to maintain accreditation status and to engage in continuous program improvement.1 Standard evaluation constructs for self-study often fail to capture input from non-traditional stakeholders and do not always result in actionable recommendations for program improvement. We developed the CRIC process to address the need for a user-friendly evaluation construct that yields actionable recommendations for programmatic improvement from a variety of stakeholders and aligns with the ACGME-prescribed continuous self-study process.

Objectives: The purpose of this innovation was to develop a novel approach to continuous program evaluation and improvement using a multisource feedback design to improve resident satisfaction with the program’s responsiveness to feedback while addressing the ACGME mandate for self-study.

Methods: A committee of rotating reviewers systematically evaluates resident educational rotations over a 12-month period. Reviews focused on obtaining input from both traditional and non-traditional stakeholders in a multisource model in order to document and address deficiencies identified within the rotations.

Topics: ACGME self-study, 360-evaluation, program evaluation, program evaluation committee.

Realistic and Inexpensive Ultrasound Guided Paracentesis Simulator Using Pork Belly with Skin

ABSTRACT: Audience: The pork belly paracentesis simulator is designed to instruct Emergency Medicine (EM) residents and Emergency Medicine-bound students.

Introduction: Abdominal paracentesis is a common procedure done in the Emergency Department (ED) that must be mastered by EM residents and students. The purpose of a paracentesis is to remove accumulating ascites from the peritoneum. Diagnostic paracentesis is indicated with new cases of ascites or to detect the presence of infection in patients with already known or suspected ascites.1 Therapeutic paracentesis is often conducted in the ED setting to relieve any cardiorespiratory and gastrointestinal manifestations of tense ascites.2 While this procedure has been described in modern medical literature for over a hundred years, the addition of ultrasound can enhance the safety of the procedure and can help detect as little as 100 ml of fluid.3

Objectives: By the end of this instructional session learners should be able to: 1) Discuss the indications, contraindications, and complications associated with abdominal paracentesis; and 2) competently perform an ultrasound-guided abdominal paracentesis on a simulator and remove fluid.

Methods: This paracentesis simulator uses a porcine skin with underlying muscle and fascia to replicate the feel of human tissue undergoing this procedure. A gallon water jug is used to simulate the peritoneal cavity filled with ascites. Placing a small hand towel or sterile blue towel in the water jug acts as a wonderful mimic of bowel loops “floating” in the peritoneal fluid when ultrasound is used. A layer of ultrasound gel is placed liberally on one side of the water jug, and then the pork belly is layered on top of that. This tissue is secured to the jug with 3M microfoam surgical tape (or other adhesive-like duct tape). This model has a realistic feel and can be used with ultrasound to replicate intraperitoneal contents. The thickness of the plastic jug will give a realistic “pop” into the peritoneum with the paracentesis needle. Also, this trainer can be used multiple times by different learners before being replaced. This model will allow the learner to conduct a realistic paracentesis procedure while removing actual fluid.

Topics: Paracentesis, ascites, ultrasound-guided procedure, simulation.

Low Cost Task Trainer for Neonatal Umbilical Catheterization

ABSTRACT: Audience: The low cost neonatal umbilical catheterization task trainer is designed to instruct physicians in pediatrics, emergency medicine (EM) and pediatric emergency medicine (PEM).

Introduction: Umbilical catheterization can be a lifesaving technique in the emergent management of a critically ill neonate. Umbilical catheterization remains a common procedure in the neonatal intensive care unit (NICU) setting but is performed less frequently in the emergency department (ED). Given its infrequent nature in the ED, procedural simulation in umbilical catheterization is a necessary component of medical training to gain proficiency and competency in this important technique. Commercially available umbilical catheterization models are available but often represent an expensive investment upwards of a thousand dollars for a single trainer. The expense of these high-fidelity models may be unfortunately cost prohibitive for many departments seeking to offer this simulation training for their physicians. In an effort to diminish the cost associated with these models, a “home built” model was trialed. It was easily constructed with readily available items found in the hospital, the household setting, and the local home improvement and toy store. Each task trainer allows for identification of the umbilical arteries and vein with the ability to catheterize either vessel.

Objectives: By the end of this instructional session learners should: 1) Discuss the indications, contraindications, and complications associated with umbilical catheterization. 2) Competently perform umbilical catheterization on the task trainer. 3) Demonstrate proper securement of the catheter.

Methods: An umbilical cord was constructed using suction catheters to represent the umbilical arteries and nasal canula oxygen tubing was used to represent the umbilical vein. These tubes were suspended in a silicone base and rolled into a log form to simulate the umbilical cord. A small circular hole was cut into the hollow abdomen of a commercially available plastic toy doll and a section of the umbilical cord was inserted. Once assembled, the task trainer can be used in an instructional procedure session to teach umbilical vessel catheterization. The cord can be tied off and cut, allowing for identification of the umbilical vessels. The vessels (either artery or vein) can be cannulated using a variety of catheter sizes, and ultimately the catheter can be sutured or taped in place. The task trainers can be reused multiple times.

Topics: Neonatal resuscitation, umbilical catheter, umbilical catheterization, umbilical cannulation, instruction, simulation, emergency medicine, pediatrics, neonatal.

A Low Cost Escharotomy Simulation Model for Residency Education

ABSTRACT:Audience: This escharotomy model is designed to instruct emergency medicine residents, medical students, and community physicians.

Introduction: Burns account for over 40,000 hospitalizations and 3,400 deaths in the United States each year.1 Circumferential burns commonly lead to constrictive eschar formation, which may cause underlying tissue ischemia and necrosis.2 Escharotomies are a life or limb saving procedure, and therefore proper technique is essential to the training of emergency medicine residents. However, they are an infrequently encountered procedure and consequently are often performed with inadequate tissue decompression as well as incidental damage to the surrounding nerves and vessels.3 Simulation has been demonstrated to be an effective tool in successfully improving resident procedural skills.4

Objectives: By the end of this educational session, the learner will be able to: 1) Understand the indications for an escharotomy. 2) List equipment needed to perform an escharotomy. 3) Demonstrate how to perform an escharotomy. 4) Perform an escharotomy and experience the sensation of cutting through simulated burned tissue. 5) Understand post-escharotomy management and referral to specialist.

Methods: Attempts have been made previously to build low cost models for teaching escharotomy. We designed a cost-effective model that could be modified to fit any high or low fidelity simulator. A yoga mat is applied to a mannequin torso and extremities to simulate underlying muscle and is then covered with cloth tape and rubber bands. The final stage of building the model includes charring it to simulate the burned tissue. During the simulation session, learners are then able to realistically feel the sensation of incising through the eschar in order to release the compressive effects of the burned tissue. Underlying intravenous tubing provides realistic bleeding from the incised lower tissues.

Topics: Escharotomy, burn, eschar, emergency procedure.

Visual EM

Bedside Ultrasound for the Diagnosis of Retinal Detachment

ABSTRACT: History of present illness: A 19-year-old male with no significant past medical history presented to the Emergency Department with progressively worsening vision loss in his right eye after blunt trauma to the right orbit. The patient endorsed floaters and described his vision as being “cloudy,” but denied any photophobia, foreign body sensation, pain or ocular discharge. He did not use corrective lenses and his visual acuity was 20/100 OD and 20/30 OS. On exam, the patient had non-injected conjunctiva and normal intraocular pressures. Bedside ultrasound was performed and showed evidence of a right-sided retinal detachment and vitreous hemorrhage. Ophthalmology was emergently consulted and took the patient to the operating room for cryopexy.

Significant findings: The ocular point of care ultrasound (POCUS) utilizing a high frequency linear probe shows a retinal detachment (RD) with a thick, hyperechoic undulating membrane in the vitreous humor that is anchored at the ora serrata anteriorly and the optic disc posteriorly. Note that the retina is detached all the way to the optic disc making it "mac off." The macula, and more specifically the fovea, is located in the central retina and contains a high concentration of cone photoreceptors responsible for central, high resolution, color vision. In a "mac on" RD, the retina detaches in the periphery but remains intact centrally. This is an ophthalmologic emergency and timely diagnosis and intervention can be vision saving. This patient also has evidence of a posterior vitreous hemorrhage which has a characteristic swirling appearance with kinetic exam on real-time imaging. The detached vitreous body is not as well defined and is not anchored posteriorly to the optic disc.

Discussion: There are many causes of sudden unilateral vision loss: acute angle closure glaucoma, vitreous hemorrhage, retinal detachment, vitreous detachment, retinal artery occlusion, retinal vein occlusion, optic neuritis, and ischemic optic neuropathy.1 Many of these cases require emergent intervention if the patient’s vision is to be preserved. In this case, the patient’s history of “floaters” is highly suggestive of a retinal etiology. Classically, patients with RD can also present with the perception of a “dark curtain” coming over their field of vision.2 In a review of 78 articles, ocular ultrasound had a sensitivity and specificity that ranged from 97% to 100% and 83% to 100%, respectively, in the diagnosis of RD,3 demonstrating its strength as a rapid diagnostic tool in accurately diagnosing RD.

Topics: Ultrasound, ophthalmology, retina.

Bullous Emphysema

ABSTRACT: History of present illness: 27-year-old male presented with left chest pain and shortness of breath for 1 month. He reported sharp pain and urge to cough upon taking a deep breath. His lungs were clear bilaterally, without rhonchi, wheezing, rubs or crackles. He denied fevers and never smoked. He had an albuterol inhaler as needed for allergic wheezing.

Significant findings: The upright chest X-ray shows a large lucent area in the left lower lung field without lung markings, with associated curvilinear opacities (yellow arrows) consistent with a large air-filled bulla. The bulla is large enough to compress adjacent lung tissue as shown by the visible pleural line (blue line). The discontinuity of the pleural line and presence of lung markings superiorly makes these findings more consistent with bulla than pneumothorax. The chest computed tomography (CT) confirmed a large left hemithorax bulla.

than 30% of the hemithorax, it is considered a giant bulla.2 The most common causes of bulla formation are smoking, chronic obstructive pulmonary disease (COPD) or idiopathic.1 Damage to the alveoli causing distension may result in the formation of larger air spaces, known as a bulla. Giant bulla are rare occurrences; thus, the epidemiology is not well characterized.3 Patients can present asymptomatically or with obstructive pulmonary symptoms such as productive cough and dyspnea. Chest X-ray is generally sufficient to diagnose a bulla, but may be mistaken as a pneumothorax, which can lead to incorrectly placing a chest tube.3

However, this is not always true, as seen in the chest X-ray above. Mediastinal structures can be deviated to the contralateral side in both a bulla or pneumothorax.4 Thus, any questionable bulla should be confirmed with a chest CT. While comparisons of imaging modalities specifically for giant bullous disease has not been well documented, there is evidence that CT is more sensitive than chest X-ray in detecting emphysematous pulmonary disease.5

For symptomatic patients, treatment of giant bulla is initially managed medically. Surgical bullectomy is considered in refractory and symptomatic idiopathic cases.6 Our patient was treated in the emergency department with ipratropium and albuterol. With treatment, his oxygen saturation improved to greater than 95% on room air. The bulla was discussed with pulmonology, who agreed this could be treated as an outpatient. The patient was discharged home with pulmonology follow-up.

Topics: Bullous emphysema, chest radiograph, pneumothorax, bulla.

The Role of Chest X-Ray and Bedside Ultrasound in Diagnosing Pulmonary Bleb versus Pneumothorax

ABSTRACT: History of present illness: A 48-year-old male with chronic obstructive pulmonary disease (COPD) presented to the emergency department with stabbing chest pain to the right lower rib region along the axillary line. On examination, patient had no visible trauma, but was in mild respiratory distress with absent breath sounds on the right side. The patient's oxygen saturation ranged in the 90s on room air during his encounter, but otherwise had unremarkable vital signs.

Significant findings: The patient was evaluated with bedside ultrasound for concern of possible pneumothorax. Imaging of the left lung with M-mode demonstrated a “sea shore” sign showing a wavy pattern below the pleural line caused by lung sliding as well as “comet tail” artifact caused by from the deep pleura. However, there was no lung sliding on the right shown by a lack of “comet tail” artifact and a “bar code” sign where M-mode shows straight lines throughout the image, this is caused by lack of motion below the pleura. This lack of lung sliding is consistent with possible pneumothorax or bleb.

A two-view chest X-ray (CXR) revealed absent lung parenchyma in the right lung similar to a large pneumothorax (see red outline). Electronic medical record chart review revealed previous CXRs with similar findings. This patient was determined to have an acute COPD exacerbation with chronic blebs, but no pneumothorax.

Discussion: Pulmonary blebs are collections of air in the alveolar layer of the pleura formed by a rupture of the alveolar wall.1 They can leak air into chest cavity leading to a high rate of recurrent spontaneous pneumothorax.2 Chest X-rays (CXR) are the current gold standard in diagnosing pneumothorax. A recent study among 192 critically ill patients showed CXR has high diagnostic accuracy and positive predictive value, at 90.6% and 95.0%, respectively.3 Visible visceral pleural lines on CXR seen without distal lung markings is usually diagnostic of pneumothorax.4 In this case however, the patient’s CXR and lung ultrasound findings were similar to standard pneumothorax findings, however chart review demonstrated the patient had a known large pulmonary bleb.

The treatment for pneumothorax is chest tube insertion. To avoid unnecessary chest tube placement, emergency physicians must consider pulmonary blebs as a diagnosis in patients with mild respiratory distress who have a large area of absent lung parenchyma and visible visceral pleural lines on CXR. If a clinician is unsure and does not have access to previous imaging, a computed tomography scan of the chest can be used to clarify the diagnosis.5

This patient was conservatively managed with oral prednisone, intravenous morphine sulfate, combination albuterol-ipratropium nebulizer treatment, and later discharged for pulmonology follow up.6 The patient did not require any further imaging during this visit. In recurrent disease or severe dyspnea, bullectomy may be indicated.

Topics: Ultrasound, X-ray, pulmonary blebs, pneumothorax.

Fight Bite with Tendon Laceration

ABSTRACT: History of present illness: A 57-year-old male presented 24 hours after punching another individual in the mouth and injuring his right hand. He complained of pain and decreased range of motion in his 4th digit. On exam, the patient had a 1 cm laceration to his right 4th metacarpophalangeal joint with soft tissue swelling and limited extension of the digit against resistance.

Significant findings: The video shows a water bath ultrasound of the right 4th digit, demonstrating soft tissue swelling with a hypoechoic region along the tendon consistent with edema and tendon disruption (see video and annotated still image).

Discussion: Hand extensor tendon injuries can be caused by laceration, trauma, or overuse.1 Extensor tendon injuries are classified into eight zones.2 This patient suffered a Zone V partial tendon injury, commonly termed a “fight bite.” Management of tendon injuries is dependent on: partial vs full, closed vs open, and injury location.3,4 Closed tendon injuries require a volar extension splint with hand surgery follow-up within one week. Open tendon injuries involving >50% tendon width can be repaired in the emergency department, though some will require delayed repair.4 Ruptures involving <50% of tendon width should be placed in a volar extension splint, whereas ruptures involving >50% of tendon width should be sutured.3 Injuries to Zones II-IV and Zone VI may be repaired in the emergency department.4 However, injuries to other zones, the thumb, open fractures, neurovascular compromise, grossly contaminated wounds, or immunocompromised patients should be referred to a hand surgeon.5 “Fight bite” injuries should be treated with antibiotics and hand surgery consult for possible operative intervention.6

After a normal X-ray, a bedside water-bath ultrasound was performed, revealing a Zone V extensor tendon rupture. The patient received tetanus prophylaxis, IV antibiotics, was splinted and admitted to the hand surgery service for operative washout of the wound and delayed tendon repair.

Topics: Water bath ultrasound, tendon laceration, extensor tendon injury, fight bite, hand injury, orthopedics.

Recurrent Sigmoid Volvulus in a Young Female

ABSTRACT: History of present illness: A 31-year-old female with history of sigmoid volvulus status post sigmoidectomy 2 years prior presented to the emergency department with 1-week history of diffuse, crampy abdominal pain. In the 24 hours prior to her arrival, patient stated that her abdominal pain acutely worsened and was accompanied with decreased stool output and non-bloody, non-bilious emesis. She denied any fever, chills, weight loss, chest pain, or shortness of breath.

Significant findings: Computed tomography (CT) of the abdomen and pelvis was obtained revealing a colonic volvulus in the left mid to upper abdomen (blue arrow) involving the distal transverse colon and descending colon, with gaseous colonic distention to 8.5 cm (red arrow). The characteristic “whirl pattern” is also present (yellow arrow). These findings are suggestive of a high-grade colonic obstruction. It was without evidence of pneumoperitoneum, pneumatosis, or drainable collection. Of note, a 3.6 cm dermoid tumor is also observable in the left adnexa (green arrow).

Discussion: A colonic volvulus refers to the twisting of a portion of the colon, most often the sigmoid, in a manner leading to obstruction and potential ischemia and gangrene.1 Colonic volvulus is responsible for approximately 15% of all large bowel obstructions in the United States.1 The mortality associated with this condition is less than 10% in patients who have not developed gangrene, but can be as high as 60% if gangrene is present.2 A sigmoid volvulus occurs when the sigmoid colon is elongated, leading to a redundant loop which rotates around its mesocolon.3 This condition is most common in the elderly with a mean age of 70 years at presentation.4 Institutionalized patients with neuropsychiatric disorders and patients in nursing homes are at the highest risk as these populations experience prolonged recumbency and chronic constipation, which are both highly associated with sigmoid volvulus development.1

Patients with sigmoid volvulus present with slow onset and progressive abdominal pain, nausea, abdominal distention, and constipation. Vomiting is also common but normally occurs several days after the initial onset of pain.5 Computed tomography is the preferred method of diagnosis with a sensitivity of 71%.6 Diagnostic findings include a "whirl pattern," which is caused by the twisting of the sigmoid colon around its mesocolon, and a "bird-beak" appearance of the afferent and efferent colonic segments.7 Treatment of a sigmoid volvulus begins with a flexible sigmoidoscopy for decompression and detorsion, followed by definitive surgery to prevent recurrence.4 Without definitive surgery, recurrence rates of sigmoid volvulus has been reported as high as 90%.1 In this case, gastroenterology was consulted and patient was taken to the endoscopy suite for decompression and detorsion.

Topics: Sigmoid volvulus, large bowel obstruction, colonic volvulus.

Bilateral Tibia/Fibula Fractures in Automobile versus Pedestrian Accident

ABSTRACT: History of present illness: A 25-year-old female presented to the emergency department (ED) with bilateral lower extremity deformities after being struck by a car while riding a skateboard. The patient was not wearing a helmet but did not report a loss of consciousness. She endorses using methamphetamine and crack cocaine on the day of the accident. Examination of the right lower extremity revealed a 10cm x 7cm soft tissue injury with a 5cm segment of exposed tibia on the anteromedial aspect and a deep abrasion on the lateral aspect of the leg just superior to the patella. Examination of the left leg revealed a small 0.5cm x 0.5cm open wound on the anteromedial aspect of the tibia with oozing blood containing fat droplets and superficial abrasions over the knee. Dorsalis pedis and posterior tibial pulses were 2+ bilaterally. There was low suspicion of compartment syndrome, and there was no neurological deficit noted in the lower extremities.

Significant findings: Plain film shows severely comminuted and displaced mid tibia/fibula fractures of bilateral lower extremities (red arrows) and comminuted right fibular head (blue arrow) and proximal shaft fracture (yellow arrow).

Discussion: Limb trauma is one of the most common injuries seen in emergency medicine and is the most common reason for hospitalization in nonfatal traumas. Approximately 25% of tibial fractures are open, making the tibia the most common long-bone in which an open fracture occurs.1 The largest threat of limb loss is vascular injury. Bleeding can be controlled with direct pressure,2 a tourniquet,3,4 or clamping of the vessel. One should not attempt to clamp a vessel if it cannot be visualized.

If there are no signs of vascular injury requiring immediate surgery, nerves, bones, and soft tissues should be assessed. Sensation and strength should be evaluated to assess the integrity of the femoral, sciatic, deep fibular, and tibial nerves. Skin should be evaluated for lacerations, avulsions, penetrating injury, contamination, and open fractures.5 If there is extensive muscle damage, one must also monitor for signs of rhabdomyolysis.6

Extremity radiography is indicated if there is presence of deformity. Assessment should include the joint above and below the site of injury. Comminuted fractures increase the risk of arterial damage and such an injury should lead to a full vascular assessment.5 If the fracture is open, prophylactic antibiotic treatment should be started as the patient is at risk for osteomyelitis.7 Surgery is required for comminuted or open fractures. With casting only, comminuted fractures have an increased risk of nonunion, malunion, or shortening of the limb.8 Furthermore, by stabilizing the fracture, the soft tissues are stabilized, decreasing bacterial spread and inflammatory responses. Debridement of an open fracture is necessary to remove debris and unhealthy tissue from the wound.9

The patient in this case was given intravenous cefazolin and was taken to the operating room the same day by orthopedic surgery for bilateral lower extremity tibia and fibula open reduction and internal fixation.

Topics: Tibia/fibula fracture, pedestrian vs. automobile, trauma.

A Rare Cause of Pelvic Pain in a Teenage Girl

ABSTRACT: History of present illness: A 14-year-old female presented with rectal pain, pelvic pressure, urinary hesitancy and difficulty defecating despite daily laxative use. She had a history of irregular periods and was currently menstruating. Her vital signs were normal. Her abdominal exam was unremarkable and the external genitourinary exam showed a visible vaginal introitus and no masses.

Significant findings: Due to pain out of proportion to her exam, an ultrasound of her pelvis was obtained and showed a blood-filled distended uterus, or hematometrocolpos (white arrow), with a 4.9 cm right ovarian cyst (blue arrow). A pelvic magnetic resonance imaging (MRI) then revealed an obstructed right hemi-vagina, normal left uterus and vagina and ipsilateral renal agenesis (red arrow) with normal left kidney (double arrow) consistent with obstructed hemivagina, ipsilateral renal agenesis (OHVIRA) syndrome. The patient underwent surgical repair with complete resolution of symptoms.

Discussion: OHVIRA is rare syndrome that occurs due to a failure of lateral fusion of the Mullerian ducts.1 It affects an estimated 0.1%-3.8% of the population.2 The majority of these cases are associated with ipsilateral renal anomalies, but up to half can have contralateral anomalies.1,2 The most common presenting symptom is pelvic pain.1 On physical exam, patients may have a bulge in the vaginal wall which represents hematometrocolpos due to obstruction of outflow of menstrual blood. Transabdominal pelvic ultrasound or MRI are helpful modalities for diagnosis in adolescents.1,3 In one pediatric case series of OHVIRA, all 8 patients had a history of normal menses and presented with acute or chronic pelvic pain that began after menarche.2 All patients in this case series were initially misdiagnosed, due to the rarity of the disorder and the fact that most patients have a history of regular menses despite progressive pelvic pain. Definitive treatment requires surgical excision of the vaginal septum. Post-surgical prognosis is typically good;4-6 potential complications include endometriosis and increased risk for preterm labor or malpresentation.7

Topics: Pelvic pain, obstructed hemivagina, renal agenesis, rectal pain, hematometrocolpos, hematocolpos.

Acute Dysphagia in a 25-Year-Old Male

ABSTRACT: History of present illness: A 25-year-old male with a history of asthma presented to the emergency department (ED) with the sensation of food impaction in the mid-thoracic region and inability to swallow that began twenty minutes prior to arrival after eating chicken. Careful history revealed that the patient had several ED visits for similar episodes during his early childhood. Physical examination was benign with stable vitals. He had a clear oropharynx and normal breath sounds bilaterally. On cardiac auscultation, there was a regular rate and rhythm without appreciable murmur.

Significant findings: After an unremarkable chest radiograph was obtained, a computed tomography (CT) scan of the chest was obtained due to possible co-ingestion of bones to rule out perforation. The CT scan demonstrated focal distention of the mid-esophagus due to an impacted food bolus (white arrow). An aberrant right subclavian artery (yellow arrow) was located just distal to the impaction site with partial compression of the esophagus (red arrow).

Discussion: Arteria lusoria is an aberrant right subclavian artery. It is the most common embryologic abnormality of the aortic arch, occurring in 0.5% to 1.8% of the population.1 In this condition, the right subclavian artery arises directly off of the aorta, distal to the left subclavian artery, as opposed to the normal branching off the right brachiocephalic artery. While the majority of cases are asymptomatic, occasionally the artery will compress adjacent structures including the trachea and esophagus.2 This phenomenon was first described in 1794 by a London physician who remarked on a fatal case of "obstructed deglutition.”3 When the aberrant right subclavian artery causes compression and trachea-esophageal symptoms such as dysphagia, it is termed dysphagia lusoria.

The patient was diagnosed with dysphagia lusoria and given an intravenous bolus of glucagon with resolution of symptoms in one hour. He was able to tolerate liquids and solids without difficulty upon discharge. Management of dysphagia varies based on presentation and ability to tolerate oral intake. CT imaging may be useful in cases of recurrent food bolus impactions or high clinical suspicion for aerodigestive injury. Patients unable to swallow may require emergent subspecialist evaluation with additional imaging and endoscopic evaluation. Structural abnormalities such as dysphagia lusoria may ultimately require surgical intervention for definitive resolution of symptoms.

Topics: Arteria lusoria, dysphagia, aberrant right subclavian artery.

Dorsally-Displaced Metacarpal Dislocation-Fracture

ABSTRACT: History of present illness: A 19-year-old male presents to the emergency department with an injury to his right hand that he sustained after punching a tree while intoxicated. The patient had his fingers flexed and wrist extended while he punched the tree. He was able to move his fingers after the event but was complaining of severe pain over the ulnar aspect of the wrist. The patient denies punching someone in the mouth, obviating concern for a “fight bite.” On exam, the ulnar aspect of the dorsum of the right hand appeared grossly deformed and edematous. There were two abrasions over the dorsum of the hand, without exposed bone, lacerations, ecchymosis, or active bleeding. Capillary refill, strength, and sensation were present in all parts of the hand, including radial, ulnar, and median nerve distribution.

Significant findings: A two-view radiograph of the right hand was obtained which revealed a dorsal dislocation of the distal fourth and fifth metacarpals (see red and blue outline, respectively) with a concomitant fracture of the distal fifth metacarpal (see yellow line) and avulsion fracture of the lateral aspect of the hamate (see green line). After reduction the fourth and fifth metacarpal dislocations are resolved; however, the distal fifth metacarpal fracture (yellow line) and avulsion fracture of the lateral aspect of the hamate (green line) are still visible.

Discussion: In a case series including 21 patients, dorsal dislocation of carpometacarpal joints was initially missed in 15 of these cases.1 This is often due to the overall swelling that may mask the ulnar deformity as well as failure to obtain a true lateral X-ray. This is a rare injury because there are many strong supporting ligaments.2 The dislocation requires closed reduction, with application of ventral longitudinal pressure and traction of fourth and fifth digit. 3 There is debate amongst hand surgeons if closed reduction followed by casting or open reduction is superior, but there have been no large-scale studies comparing treatment options.4 Post-reduction films were obtained and an ulnar gutter splint was placed. The patient was instructed to follow up with hand surgery in the next week.

Topics: Dorsal dislocation of carpometacarpal joints, orthopedics, hand fracture, metacarpal fracture.

Woman Swallows a “Handful of Pills”

ABSTRACT: History of present illness: A 64-year-old female presented to the emergency department feeling like she had “pills stuck in [her] throat,” specifically calcium and a multivitamin, which she tried to relieve with drinking, eating and sticking two fingers down her throat. She was sitting upright, speaking in full sentences but had a hoarse voice. She was tolerating her secretions but had frothy sputum in the posterior oropharynx.

Significant findings: Soft tissue lateral X-ray of neck was performed. The lateral soft tissue X-ray of the neck showed a metallic foreign body at the level cricoid.

Discussion: Most swallowed foreign bodies enter the esophagus. Larger foreign bodies tend to obstruct proximally and may cause airway compromise in addition to esophageal trauma.1 Foreign bodies tend to lodge at areas of anatomic narrowing, most commonly the upper and lower esophageal sphincters, physiologic angulation, and areas of pathologic stricture.2,3 Ensuring airway patency and ability to manage secretions is paramount and any concern for compromise should prompt emergent consultation with otolaryngology and/or gastrointestinal. Determination of which service to consult should be made based on the suspected location of obstruction and associated symptoms. In addition to obtaining a complete history of the ingestion including type of foreign body, size, and shape, it is prudent to ask what measures, if any, the patient has already taken to remove the object.

In this case, flexible fiberoptic laryngoscopy revealed swollen arytenoids and some small abrasions proximal to the vocal cords, which themselves appeared normal. She had copious secretions with no foreign bodies seen. On endoscopy, a metallic finger ring was found at the cricopharyngeus muscle along with non- obstructing laryngeal edema. The ring was removed with rat-toothed forceps. No pills were found. The patient had no recollection of swallowing the ring, but presumably, it slipped off her finger in the process of attempting to make herself vomit. After brief observation, she passed a bedside swallow assessment and was discharged in good condition. Repeat upper endoscopy 8 days later revealed a tortuous esophagus but was otherwise unremarkable.

Topics: Foreign body, laryngoscopy, endoscopy, airway management.

Lisfranc Injury

ABSTRACT: History of present illness: A 21-year-old male was brought in by ambulance to the emergency department status post motor vehicle accident. The patient was the restrained driver of a vehicle that struck a wall head- on at an unknown speed. His vitals were stable. The patient’s only complaint was severe pain to his right foot. On exam, the patient’s right foot was swollen and tender with deformity and was neurovascularly intact. Due to the unstable nature of the traumatic injury, the patient underwent urgent midfoot stabilization in the operating room.

Significant findings: The frontal view of the right foot showed divergent dislocation of the second through fifth metatarsal bones (red outlines) consistent with Lisfranc injury. Though the Lisfranc ligament is not visualized by radiograph, the yellow markings represent the location of the Lisfranc ligament between the medial cuneiform (blue dot) and the base of the second metatarsal bone. The first metatarsal and the medial cuneiform remain congruent. The lateral view shows dorsal dislocation of the midfoot (pink circle) consistent with instability. There is associated extensive midfoot soft tissue swelling.

Discussion: Lisfranc injury refers to damage of the tarsometatarsal joint.1 It comprises up to 0.4% of all fractures and dislocations and typically co-exists with tarsal or metatarsal fractures.2 Anytime the foot gets forced into a hyperplantarflexion position, the joint may be subject to a Lisfranc injury.1 Motor vehicle collisions and sports injuries are among the most common causes.1 High velocity injuries typically cause obvious evidence of injury on exam, such as bony deformity and plantar ecchymosis.2 In comparison, low velocity injuries may only result in pain with a relatively benign exam. The estimated annual incidence is 1 in 55,000, but up to one third of injuries are initially missed due to unremarkable exam and radiographs, as further detailed below.2

The diagnosis can be made clinically and confirmed with radiographs of the foot with frontal, lateral, and oblique views (sensitivity 84.4%, specificity 53.3%).3 For high clinical suspicion of a radiographically occult Lisfranc injury with negative non-weight bearing foot radiographs, further evaluation with weight bearing radiograph and/or foot MRI should be considered.

Patients with stable fractures, defined as <2mm of diastasis between the base of the first and second metatarsals, may be treated with a non-weight bearing splint and should visit an outpatient orthopedic surgeon within two weeks for repeat radiographs.4 If repeat images show no progression of the injury and the patient’s pain has resolved, he or she may return to weight-bearing activities as tolerated. If the patient continues to be symptomatic, he or she will need additional non-weight-bearing immobilization for four weeks.1 Those with unstable fractures, either immediately after the injury or upon repeat films, or evidence of an open fracture, should be immediately referred for possible surgical reduction and stabilization.1 A Lisfranc injury that is inappropriately managed may result in midfoot instability, traumatic osteoarthritis and long-term disability.4

Topics: Lisfranc injury, tarsometatarsal joint, orthopedic trauma.

Incidental Hiatal Hernia on Chest X-ray

ABSTRACT: History of present illness: A 58-year-old male with history of smoking presented to the emergency department for productive cough, subjective fevers, shortness of breath, and pleuritic chest pain. Patient was discharged three days prior from another hospital where he was admitted for pneumonia and chronic obstructive pulmonary disease (COPD) exacerbation. He was discharged with prescriptions for antibiotics and steroids, which he did not fill. On exam, patient was afebrile and hemodynamically stable. Labs including respiratory syncytial virus and influenza panel were negative.

Significant findings: The two-view chest X-ray shows mild opacification of the bilateral lower lobes concerning for pneumonia (red arrows). Incidental retrocardiac opacity with air-fluid level consistent with large hiatal hernia is also observed (green arrow).

Discussion: A hiatal hernia (HH) is defined as a protrusion of abdominal contents into the thoracic cavity through the diaphragmatic esophageal hiatus.1 HHs can be congenital (1/3000 live births) or, more commonly, acquired.2 HHs are more common in women than in men, and their frequency increases with age, from 10% in patients younger than 40 to 70% in patients over 70 years old.1,3 Acquired HHs can be classified as sliding, paraesophageal, or mixed. Sliding hernias make up greater than 90% of all HHs and occur when the abdominal portion of the esophagus and the cardia & fundus of the stomach slide superiorly through the esophageal hiatus.1 Sliding hernias are clinically significant due to their association with reflux disease.1 Paraesophageal hernias make up less than 10% of all HHs and only involve the stomach fundus passing superiorly into the thoracic cavity.1 Paraesophageal hernias tend to enlarge over time potentially leading to incarceration and subsequent strangulation or perforation.4

Patients with HHs can be asymptomatic or have symptoms such as epigastric fullness, postprandial distress, regurgitation, nausea, chest pain, or cough.4,5 Radiography studies, especially an upper GI barium series, are the preferred examination method to diagnosing HHs with a sensitivity of 77%.6 The primary diagnostic finding is a retrocardiac air-fluid level located within a paraesophageal hernia or intrathoracic stomach.1 Asymptomatic hernias may not require treatment. HH with reflux disease can be managed medically. Symptomatic HHs and paraesophageal hernias might require surgical intervention; thus surgical consultation is recommended.4

In this case, the chest X-ray was concerning for pneumonia, and a large, incidental hiatal hernia was also appreciated. Patient was started on antibiotics for the pneumonia and admitted to internal medicine. The hiatal hernia was not operated on because the patient was asymptomatic.

Topics: Hiatal hernia, sliding hernia, paraesophageal hernia, retrocardiac air bubble.

Button Battery in Esophagus

ABSTRACT: History of present illness: A 2-year-old male was brought to the emergency department by his parents after a brief choking episode at home and the inability to tolerate oral liquids afterwards. The patient’s mother noticed she was missing a button battery on the counter and suspected her child had swallowed it. On exam, patient had no active drooling or vomiting. His airway was patent with no respiratory distress or stridor. No foreign body was visualized in the oropharynx. Abdominal exam was unremarkable.

Significant findings: Chest radiograph showed the presence of a round radiopaque foreign body in the mid- chest. It was suspected to be in the esophagus rather than in the trachea due to the en-face positioning of the foreign body. The foreign body demonstrated two concentric ring circles concerning for a “double ring” or “halo" sign, which was suggestive of the presence of a button battery rather than a coin.

Discussion: Button battery (BB) ingestion is a potentially very dangerous condition. Over 3,300 exposures are reported annually to the American Poison Control Centers.1 Once a foreign body is ingested, it risks lodging at three anatomically narrow areas of the esophagus: the upper esophageal sphincter or the thoracic inlet (70% of foreign bodies), the aortic notch (20%), and the lower esophageal sphincter (10%).2 If a foreign body becomes lodged in the esophagus, it can cause obstructive-like symptoms such as dysphagia, aspiration, and there is risk of perforation through the esophageal wall.

Esophageal foreign bodies can cause dysphagia, aspiration, and perforation; however, BB ingestion causes additional risks of caustic necrosis from the isothermal hydrolysis reaction of the battery against the esophagus lining. Significant caustic burns can occur in as little as two hours after ingestion.1,3 This tissue injury can lead to the development of devastating conditions such as tracheoesophageal fistula, aortoenteric fistula, vocal cord paralysis, and mediastinitis, all of which can be fatal.2 As a result, patients with esophageal BB must undergo emergent direct laryngoscopy and esophagoscopy for removal under direct visualization as soon as possible. 1

This patient underwent esophagoscopy with subsequent removal of a 2 centimeter lithium button battery; direct visualization showed some edema around the mucosa but no signs of stricture or perforation. The patient subsequently tolerated food and was discharged home the next day.

Topics: Button battery, esophageal foreign body ingestion.

Pediatric Foreign Body Aspiration

ABSTRACT: History of present illness: A 10-month-old male presented after choking on a carrot. Mom reported coughing with perioral cyanosis. On examination, the child had no retractions, but wheezing was heard in the right lung fields particularly when coughing.

Significant findings: Chest radiograph showed increased radiolucency (red arrow) and flattening of the diaphragm on the right side (blue arrow) consistent with hyperinflation of the right lung, as well as left mediastinal shift (green arrow), indicating obstruction.

Discussion: Foreign body aspiration is a common condition in pediatrics and can be life- threatening. It happens most commonly in children younger than 2 years due to a natural curiosity for putting objects in their mouth and an immature swallowing mechanism.1 Most foreign bodies are located in the right main bronchus due to its wider diameter and more direct extension of the trachea.2 Witnessed choking has the highest sensitivity and specificity for this pathology (sensitivity 75.4% and specificity 92.1%).3 These children will often present with coughing, wheezing, and/or decreased lung sounds that suggest an aspiration.4

Chest radiographs are excellent in detecting radiopaque objects. However, most aspirations are from radiolucent organic matters such as nuts or seeds.3 Radiographs that show focal area of hyperinflation, mediastinal shift, and atelectasis are highly specific for aspiration. Pathological findings on chest radiography showed an 86.1% sensitivity and 63.2% specificity.3 However, it is possible that these finding may not be seen on initial imaging.

It is important to keep a high index of suspicion as undiagnosed foreign body aspiration can lead to chronic pulmonary infections, bronchiectasis, pneumothorax, asphyxia, and death.3 This child had both physical and radiographic findings of a foreign body aspiration in addition to a witnessed choking episode. He was taken to the operation room by the pediatric surgery team for bronchoscopy and a piece of carrot was removed from the right mainstem bronchus.

Topics: Foreign body aspiration, pediatric foreign body, pediatric pulmonology, respiratory.

Achalasia: An Uncommon Presentation with Classic Imaging

ABSTRACT: History of present illness: A 32-year-old male smoker with a BMI of 38.1 kg/m2, history of esophageal stricture, gastroesophageal reflux disease (GERD), and years of intermittent dry cough presented with three weeks of exacerbated, persistent cough worse in the morning and after eating. He denied fever, constitutional symptoms, dysphagia, or vomiting. He presented to the emergency department following an abnormal outpatient chest X-ray. Bilateral expiratory wheezing was noted on exam.

Significant findings: The chest X-ray demonstrated a markedly widened mediastinum (red brackets), raising concern for thoracic aortic aneurysm/aortic dissection, which prompted labs and contrast-enhanced computed tomography (CT) of the chest. The CT revealed a dilated proximal esophagus that narrowed distally (yellow tracing and red arrow), with particulate material, mass-effect on the trachea (purple outline), and bilateral patchy opacities suggesting aspiration. Barium esophagram showed a drastically dilated esophagus filled with contrast (yellow arrow), terminating into the classic “bird’s beak sign” (red arrow) at the lower esophageal sphincter (LES). Esophageal manometry later confirmed achalasia, proving that widened mediastina can have unexpected etiologies.

Discussion: Achalasia is a rare (prevalence ~0.3-9.5/100,000, increasing with age) digestive disorder characterized by denervation to the distal esophagus, promoting regional aperistalsis and tonic contraction of the LES.1-3 Achalasia most commonly presents as acute, simultaneous dysphagia to both solids and liquids, but can present as heartburn, regurgitation, or even unexplained cough.1-3 A dilated esophagus with narrowing at the LES (“Bird’s Beak Sign”) and delayed esophageal emptying on barium esophagram are pathognomonic for achalasia (sensitivity 90%, specificity 95%),4 as is distal aperistalsis with increased resting LES tone on high-resolution manometry (sensitivity 98%, specificity 96%).5 Pharmacologic LES relaxation may be trialed, but surgical myotomy is usually necessary.1,2,3,6 Our patient underwent laparoscopic Heller myotomy resulting in a dilated, aperistaltic esophagus with no evidence of obstruction and is being followed for continued GERD and dysphagia.

Topics: Achalasia, widened mediastinum, acute dysphagia, barium esophagram, lower esophageal sphincter, esophageal dysmotility, aspiration, gastroenterology.

Right Ventricular Dilation in Patient With Submassive Pulmonary Embolism

ABSTRACT: History of present illness: A 73-year-old female with a past medical history of tracheobronchomalacia, obstructive sleep apnea, diabetes, chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) presented to the emergency department with four days of moderate to severe dyspnea on exertion. She endorsed right calf pain for the last few weeks and bilateral leg swelling, as well as productive cough, orthopnea, and non-radiating chest tightness but denied any hemoptysis. She had no history of thromboembolic disease, nor did she have any family history of clotting disorders. She was not currently on any anticoagulation. The patient lives a sedentary lifestyle at baseline. Upon arrival, her vital signs were as follows: temperature 97.3 F, pulse 60 per min, respirations 34 per min, blood pressure 113/85 mmHg, and oxygen saturation 97% on 4L nasal cannula. Physical exam was notable for jugular venous distension and bilateral lower extremity pitting edema. Lungs were clear to auscultation.

Significant findings: Bedside echocardiography four chamber view revealed enlarged right ventricular (RV) to left ventricular (LV) ratio (greater than 1) on apical four-chamber view (see red and blue outlines respectively). The right atrium is not clearly delineated in this image and therefore is not outlined. One can also rule out a large pericardial effusion as the cause of her dyspnea, since there is no large hypoechoic collection surrounding the heart on either four- chamber view or parasternal long view.

Discussion: Point of care ultrasound is a powerful tool that can aid in the diagnosis of undifferentiated dyspnea. Right ventricular size is one parameter that can signify right heart strain possibly due to an increase in resistance in the pulmonary vasculature. The normal RV should be approximately two-thirds the size of the left ventricle. Any RV between two-thirds and equal to the size of the LV is considered moderately dilated, and any RV greater in size than the LV is considered severely dilated.1,2 The RV to LV size ratio is best measured from the apical four-chamber view. Right ventricular shape will also change as afterload increases in the pulmonary circuit. As pulmonary vascular resistance increases, the RV (which has significantly less myocardium and thus greater compliance as compared to the LV) begins to lose its typical triangular shape and takes on a more rounded appearance.3 Likewise, the intraventricular septum becomes flattened during early diastole due to higher RV:LV pressures causing the LV to take on a “D” shaped appearance. These findings, collectively referred to as signs of “right heart strain,” typically improve with resolution of the clot burden.4

Unfortunately, while right ventricular dilatation and consequently an asymmetrical LV appearance are commonly encountered findings, they do not help distinguish acute from chronic right heart strain. Evaluation for McConnell’s sign, or right ventricular mid-free wall akinesia with RV apical sparing is important because it is considered to be the most specific finding (94%) for acute right heart strain.5

The decision to anti-coagulate empirically with heparin was delayed until the diagnosis could be confirmed with a CT angiogram of the chest. This patient had other underlying reasons for having a dilated RV (mainly her history of COPD, which can chronically increase afterload in the pulmonary circuit and require higher RV filling pressures to maintain cardiac output).6 As such, patients with COPD can develop cor pulmonale and exhibit right heart strain.7-9 Furthermore, this patient also had no clinical signs of deep venous thrombosis.

In a patient with no underlying disease that might cause a chronic RV dilation and no electrocardiographic evidence of RV ischemia or infarction (usually in association with an inferior myocardial infarction),10 a dilated RV on bedside echocardiogram in the acutely dyspneic patient should make one immediately suspicious for acute pulmonary embolism and may even prompt the clinician to begin empiric anticoagulation.

The patient’s lab work was significant for an elevated Troponin T of 0.03 ng/mL (normal ≤ 0.02 ng/mL), suggestive of right heart strain. The diagnosis of pulmonary embolism was confirmed on CT angiogram of the chest, which revealed large filling defects in the right and left pulmonary arteries extending into their respective segmental branches. Upon confirmation of the diagnosis, the patient was taken for emergent endovascular catheter-directed tissue plasminogen activator (tPA) and was subsequently admitted to the medical intensive care unit. She had an inferior vena cava (IVC) filter placed after five days and was discharged from the hospital seven days after admission.

Topics: Pulmonary embolism, right heart strain, echocardiography, US, POCUS.

Traumatic Hyphema

ABSTRACT: History of present illness: A 40-year-old male presented to the emergency department with report of being shot in the right eye by a foam dart gun just prior to arrival. He was unable to see out of the affected eye. He initially had some pain in the eye, but it had subsided prior to arrival.

Significant findings: Upon initial evaluation, the patient had an obvious hyphema in the right eye with associated conjunctival injection. Initially, the bleeding in the anterior chamber was cloudy just above the level of the pupil (yellow arrow), appearing to possibly be a grade II hyphema. There were no other signs of trauma to the eye under Wood’s lamp examination with fluorescein staining. The globe was intact. Intraocular pressure in the affected eye was 19 mmHg and 15 mmHg in the unaffected eye. Extraocular movements were full and intact. The pupil was 4 mm round and reactive to direct and consensual light. Visual acuity was greater than 20/200 in the affected eye compared to 20/25 in the unaffected eye. After an observation period of two hours, with the patient remaining upright, the hyphema had settled down to a rim in the lower anterior chamber (green arrow), a grade I hyphema.

Discussion: A hyphema is a collection of blood in the anterior chamber of the eye. Most cases are the result of direct trauma and subsequent bleeding from the ciliary vessels. The incidence of traumatic hyphema is estimated to be 12 per 100,000 with males composing nearly eighty percent of cases.1 Rare atraumatic causes can be attributed to intraocular malignancy, bleeding disorders or antiplatelet and anticoagulant medications.2,3 A hyphema is graded based on the depth of blood in the anterior chamber. A grade I hyphema involves less than one-third of the anterior chamber, grade II is defined as one-third to one-half of the anterior chamber, grade III is greater than one-half of the anterior chamber, and grade IV is a total or “8 ball” hyphema. A microphyphema is only visible on slit lamp examination as floating red blood cells. Visual prognosis is related to the degree of hyphema, with a grade I hyphema having a 10 percent chance of vision worse than 20/50 compared to a grade III hyphema having a 50 to 75 percent chance of vision worse than 20/50.4,5

This case illustrates that on initial presentation a hyphema may appear to be graded higher and that a short observation period with the patient seated upright is required to provide an accurate diagnosis and prognosis. The second image also demonstrates the subtleness of a grade I hyphema. Recognition of a smaller hyphema is important because while the lower grade implies better prognosis, complications such as re-bleeding or uncontrolled intraocular pressure may still occur.5 The patient in this case had improvement of his vision throughout observation. He was discharged home with atropine ophthalmic drops and close ophthalmologic follow up.

Topics: Traumatic hyphema, ophthalmology.

Point of Care Ultrasound Illustrating Small Bowel Obstruction

ABSTRACT: History of present illness: A 38-year-old female presented to the emergency department (ED) with abdominal pain, vomiting and constipation for one day. She had a history of hysterectomy and oophorectomy secondary to severe endometriosis three years prior to her visit. She also reported a history of small bowel obstruction (SBO) which was managed conservatively. Her vitals were unremarkable except for mild tachycardia. Point of Care Ultrasound (POCUS) was performed which showed severely dilated loops of bowel with concern for SBO. A CT scan was performed to confirm the diagnosis and identify the cause and the level of the obstruction. The patient’s CT scan confirmed the SBO and found a transition point near the terminal ilium.

Significant findings: POCUS of the small bowel illustrated significantly dilated loops of bowel (white line), thickened bowel wall (white arrow) and to-and-fro peristalsis, consistent with small bowel obstruction.

Discussion: Approximately two percent of patients who present to the ED with abdominal pain are diagnosed with SBO.1-2 POCUS has been shown to have a sensitivity of 92.4% and specificity of 96.6% for the diagnosis of SBO.3 The proper way to scan patients with suspected SBO is by using the curvilinear probe (3-5 MHz) across the entire abdomen. Pathologic findings include bowel dilatation (which can be measured from the inner wall to the inner wall of the small bowel) greater than 2.5cm. Other positive findings include to-and- fro peristalsis, mesenteric thickening and thickening of valvulae conniventes. Wall thickening greater than 3 mm and free fluid between bowel loops may suggest bowel ischemia.4 Despite the high diagnostic accuracy of the POCUS, it can be operator dependent and is limited by the ability to accurately identify a transition point. CT scan also has the advantage of determining the underlying cause and identifying the exact location of the obstruction.5

Given the findings and diagnosis, this patient was admitted to the surgical ward and managed conservatively. She improved the next day and diet was advanced. She was discharged home on hospital day 3 after resolution of her symptoms.

Topics: Point of care ultrasound, small bowel obstruction.