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​Lions and Tigers and Bears​ by Loice Swisher, MD

Dr. Swisher’s daughter had five episodes of unexplained vomiting without a fever in just one month during 1999. Thinking about those, she said she was unable to shake the memory of a young child she saw in the ED with the same complaint 12 years before. The well-looking child had been bounced out of the ED four times with "viral syndrome" and "gastroenteritis." The diagnosis? A posterior fossa tumor.

“How did this happen?” she asked the attending, who shrugged and offered up various possibilities. It was a difficult diagnosis because the symptoms at first are nonspecific and it is uncommon. "The prior docs probably didn't get her up to walk or look in her eyes. They probably didn't think of it," he concluded. "But to an EP, unexplained vomiting is a brain tumor until proven otherwise."

That single phrase altered the course of Dr. Swisher's life—​and her daughter's. A "reassurance MRI" showed her daughter had a 5 cm medulloblastoma. Her daughter navigated a course of radiation, chemotherapy, and multiple complications, and Dr. Swisher started an entirely new medical education in the art of diagnosis.

Amal Mattu, MD, reminds those in emergency medicine to be on the lookout for lions and tigers and bears, not horses and zebras, Dr. Swisher explained. As an emergency physician and mother, she knows the profound impact this approach has on a patient's life. Using real cases, this blog aims to expose the lions and tigers and bears out there ready to bite.

Please share your thoughts about Dr. Swisher's posts.

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Friday, August 31, 2018

A False Appearance of Fine

​Like a million times before, the tech thrust an ECG in front of you. This one, however, grabbed every neuron's attention. Who was this?​

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The tech says the patient is a 70ish-year-old diabetic, hypertensive man brought to the emergency department because he has been feeling weak from a couple days of diarrhea.

Where was he? Was he talking? What was his blood pressure?

The tech pointed at one of the back rooms, and said, "Oh, his blood pressure is good—138/71, and he is talking to his family."

He did look pretty good. His heart rate was 37 bpm as he chatted with his family. Staring back at the ECG, I think maybe I should rethink my initial thoughts of atropine and pacer. Maybe this guy needed a different drug or a different intervention. Maybe he needed calcium and perhaps a Foley.

The labs returned rather quickly confirming these thoughts. His potassium was 8.2 mEq/L, and the creatine was 7.0 mg/dL. This patient may well be on the way to a full-blown BRASH syndrome with four of the five components, which include:

B: Bradycardia

R: Renal failure

A: AV nodal blocker

S: Shock

H: Hyperkalemia

(PulmCrit. Feb. 15, 2016; http://bit.ly/2LVi6QD.)

BRASH occurs when poor renal perfusion leads to renal insufficiency or failure, which causes the AV nodal medication and potassium to build up in the bloodstream. They combine to produce the bradycardic picture, which ultimately will result in shock with potentially severe hypotension. This cascade is often set off by hypovolemia, such as the diarrhea this patient experienced. Often these patients may appear better than expected, and they may not exhibit the typical ECG findings of hyperkalemia beyond the bradycardia.​

This patient was given calcium, D50, insulin, and fluids for his hypovolemia. It was noted that he had urinary retention with a Foley draining a liter for urine. By the next morning, his ECG had returned to normal. Looking back, he probably had more ECG stigmata of hyperkalemia. The QRS complex narrowed significantly, and now the T's in V2 seemed more peaked than initially appreciated.

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Tip to Remember: Take a minute to think hyperkalemia with bradycardia.​

Wednesday, August 1, 2018

See Me Now

​A young woman with known psychiatric illness and a tendency toward self-injury was sent to the emergency department for medical clearance. She had presented in the past after ingesting objects, so an upright chest and KUB radiograph were obtained.​

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Nothing unusual popped out at first glance, but it was an entirely different story when magnified in a dark room. The sharp square edge extending beyond the vertebral body was impossible to miss. The four holes confirmed she had almost certainly swallowed a razor blade. Inversion made it even easier to see.​

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Identifying the object is only half the battle. What is the next step?

We performed a CT scan to determine if the razor was still in her stomach or if it had passed beyond the pylorus into the small bowel. It was clearly shown to be in the stomach. Endoscopy was emergently arranged because sharp objects such as razor blades have as much as a 35 percent perforation risk at the ileocecal valve. (Gastroenterol Rep 2014;2[2]:158; http://bit.ly/2lSHScY.) The razor was removed uneventfully.

Interestingly, multiple references pop up if one searches online for razor blade ingestion. It seems prisoners are a particularly at-risk population. (Ulster Med J 2008;77[2]:110; http://bit.ly/2z86XtM.) Even more interestingly, almost all reports in cases and case series have shown that conservative management of razor blades that pass beyond the pylorus traverse the entire route of the bowel without difficulty. Still, I was glad we got it while it was still in the stomach.​

Tip to Remember: Maximize your ability to identify abdominal foreign bodies with magnification and image inversion in a dark room.

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Monday, July 2, 2018

Look for the Signs

​An AP image of a shoulder flashed up on the screen. My colleagues often bring me interesting, rare, difficult, and classic cases because I write this blog. All are intellectually stimulating cases that remind me of the exciting parts of being an EP. It's a challenge to see how many clues I can find to make the diagnosis. These short interactions also help me form stronger bonds with my colleagues, a bonus for my interest in wellness.​

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First, my eyes were drawn to the wide glenohumeral interval. The space is huge (yellow lines in photo below). The glenoid appeared vacant. It also showed the rim sign where the glenoid rim can be seen without overlap. The normal half-moon appearance of the superimposed glenoid and humeral head was gone.

Next, the shape of the humeral head was wrong. It looked like a lightbulb when it should look like a club (blue circle).

And the normally smooth Moloney's arch formed by the medial scapular border and down the humeral shaft had a point (purple inverted V). It should be a Romanesque arch, not a peaked Gothic one. Moloney's arch is just like the gently curved, continuous, contoured Shelton line in the hip. It wasn't right either.​

Finally, there was a subtle "M" (red lines) made by the contours of the greater and lesser tuberosity in the internal rotation. This is a Mouzopoulus sign.

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This must be a posterior dislocation.​

The screen on the Y view confirmed that to be correct. The humeral head sat under the acromion (yellow circle) instead of in the glenoid fossa (red circle). In anterior dislocations, the humeral head sits near the anteriorly located coracoid process (blue circle).

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Tips to Remember:

-Posterior dislocations are often missed. Remember to look for all the signs, including the vacant glenoid sign, the rim sign, the half-moon sign, the light bulb sign, the normal contour of Moloney's arch, and the Mouzopoulus sign to get the diagnosis.

-Share interesting cases with your colleagues. It makes our jobs more intriguing, and reminds us why we do what we do.

Reference:

  1. Weerakody Y, Radswiki et al. Posterior Shoulder Dislocations. https://radiopaedia.org/articles/posterior-shoulder-dislocation​

Friday, June 1, 2018

Inspiratory Stridor and Diaphoresis Spell Emergency

​My relief had arrived, and we were just starting sign-outs. The resident broke in, "This guy with the sore throat. I think he's sick!" Glancing up from the computer, she continued. "He's barely talking. He has inspiratory stridor. And he is sweaty."​

The resident had me at inspiratory stridor. Diaphoresis on a chilly morning in our ED was just icing on the cake. Intrigued and concerned (we did not have ENT or an open OR at that time in our shop), I followed my oncoming colleague to the bedside. The experience was just as sphincter-tightening as the description. The 20ish-year-old man sitting bolt upright and holding on to the bed rails could not even count to one. The back of his throat was normal, and the bedside soft tissue lateral neck radiograph provided no reassurance.

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Decision: immediate intubation. This was going to be tough. Few airways get tougher than this. All hands on deck (anesthesia, surgery, respiratory, CCU). All resources readied, including a scalpel and bougie.

The first look down was disorientingly frightening. It looked like a cervix. The swollen epiglottis and aryepiglottic folds allowed only a tiny opening still available for plastic to pass. With amazing skill, luck, and perhaps some prayer, a 6.0 ET tube made it through that tiny passageway into the trachea.​

The patient was whisked away to the CCU, and we had time to debrief and review. The patient's lateral neck image was placed beside a normal one on the computer screen.

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The epiglottis (red arrow on normal x-ray; cross our patient) had the telltale appearance of an epiglottitis thumbprint sign. Our patient also had a vallecula sign, a shallow vallecula seen with epiglottitis. The aryepiglottic folds (white cross) were more prominent than I had ever seen them. The extremely narrowed glottic opening (green line) explained the bizarrely ballooned hypopharynx; the patient had done everything he could to get air into his lungs. Staring at the images, we all knew that this would be one that would be imprinted on our brains for the rest of our careers. Adult epiglottis carries a mortality of seven to 20 percent. This patient was at the verge of meeting death that morning, and was pulled back from the edge.

Tips to Remember:

-Always respect inspiratory stridor and diaphoresis.

-The epiglottis always bisects the hyoid bone anteriorly. Follow the base of the tongue down into the vallecula, eventually reaching the hyoid. The usually narrow epiglottis (approximately 3 mm) should appear to spring up from the hyoid like a flower immediately posterior to the vallecula.

-Look for the thumbprint and vallecula sign when considering epiglottitis.

Suggested Reading:

1. Ames WA, Ward VMM, et al. Adult epiglottitis: An Under-Recognized, Life-Threatening Condition. Br J Anaesth 2000;85(5):795.​

P.S. If you liked this post, we think you'd enjoy the EMN enews. Receive breaking news and online exclusives delivered right to your inbox.

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Monday, April 30, 2018

Fractured? No, Crushed

​"Doc, I broke my foot about three months ago and was in a boot. Tonight I was in a fight. When I went to kick, I twisted my foot. I can walk, but wanted to come in to get it checked out."​

Simple. Straight-forward. X-ray ordered.

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My eyes were rapidly drawn to the two gaping fracture lines—one posteriorly in the calcaneal tuberosity and the other extending from the posterior facet through the subtalar joint to the plantar surface. Böhler's angle confirmed what can be seen intuitively: This calcaneus was crushed.​

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Böhler's angle is formed from two intersecting lines coming together at the apex of the posterior facet. The first line is drawn parallel to the superior aspect of the tubercle from the highest part on the posterior tubercle to the highest point of the posterior facet. The second line is drawn from the highest point on the posterior facet to the highest point on the calcaneus at the calcaneocuboid joint. A normal angle is between 20 and 40 degrees. An angle less than 20 degrees indicates disruption and collapse of the subtalar joint at the posterior facet.​

How much is new? How much is old? How could he be walking on this? How badly is this calcaneus destroyed? The patient was sent to the donut of truth (the CT scanner), and his prior treating institution confirmed that he had been diagnosed with a calcaneal fracture three months before. Those records indicated that it had been in near anatomical alignment, that he had been sent home with a boot and told not to bear weight, and that he never followed up with orthopedics.

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Clearly, this was no longer in near anatomic alignment. The comminuted fracture fragments were now widely displaced. This is what happens when you walk on a calcaneal fracture involving the subtalar joint—it collapses.

Tip to Remember: Carefully consider weight-bearing in calcaneal fractures, especially those that involve the posterior facet joint.​

P.S. If you liked this post, we think you'd enjoy the EMN enews. Receive breaking news and online exclusives delivered right to your inbox.​

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