Resident COVID Airway - Managing the - EMRA

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Resident COVID Airway - Managing the - EMRA
             Official Publication of the Emergency Medicine Residents’ Association
                                                                 April/May 2021
                                                                    VOL 48 / ISSUE 2


         The Pediatric Elbow
     Near-Death by Nasal Packing
    Developing a Diversity Pipeline
Resident COVID Airway - Managing the - EMRA
We Help Healers
Reach New Heights                              SCP

Meet Your Medical
Career Dream Team                              SCP

Step Right Up, Residents!
As you’re transitioning from
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                                  TOGETHER, WE HEAL
Resident COVID Airway - Managing the - EMRA
Post-Match            Priyanka Lauber, DO
                                                   Editor-in-Chief, EM Resident
                                                  Lehigh Valley Health Network

                              HAPPY post #matchday!!
          If there’s one anxiety-provoking day in a young physician’s life,
                                   it’s Match day.

I still remember the EXACT time, place, and overwhelming emotions I experienced when I found out I matched into my
  No. 1 choice of EM residency. The nights leading up to the match were filled with apprehension, racing thoughts, loss
of sleep, and pendulation between overwhelming excitement and crushing anxiety. It’s the most career-defining (and
life-defining, to a certain degree) moment of your life: four years of college, a year of research, four years of med school,
all leading up to this very moment.
     Some of you have gone through match day with a significant other matching with you (couple’s match) or with an
ideal location in mind — only adding to the anxiety and fear.
     Although it is an exciting and celebratory time for many, it can also be a devastating season for those who didn’t
match — or who matched in locations or programs they don’t feel are the best option. Just remember, it DOESN’T take
away your worth. Read that again. The outcome of the match does not take away your worth!
Unmatched? Remain Unfazed
   If you didn’t match into your choice of residency, try and try again. Our program recently matched a surgical resident
and a family medicine resident; medicine can offer more flexibility than the match implies.
   EM is a competitive residency, and I want to see all of you succeed. EMRA is also here to help. Reach out to us on
ways to succeed in the next cycle, get involved in research, and how to make the best use of the interim year as you
prepare to enter the match again.
Prep and Celebrate
    And for those who matched, cherish every second. Let this achievement soak in, and realize YOU did this! All too
often in life and in medical school, we don’t celebrate our successes enough. So, celebrate this moment with family
(zoom or in-person, if vaccinated). Enjoy a nice meal and your favorite activities with loved ones. We will see you on-shift
soon, doctor! ¬
Resident COVID Airway - Managing the - EMRA
4    Class of 2022,
     We’re Here for You         32 Near Death by Nasal
                                   Packing: A Rare Complication
                                                                              EDITORIAL STAFF
     LEADERSHIP                      Due to the Fatal                           EDITOR-IN-CHIEF
                                     Trigeminocardiac Reflex                   Priyanka Lauber, DO
5    Spring Awards
                                                                           Lehigh Valley Health Network

                                     Blunt Cardiac Injury
8    Management of the
     COVID-19 Airway                 Manifesting as RBBB
                                                                                 Erich Burton, DO
                                                                             Greenville Health System
     COVID-19, AIRWAY                on Electrocardiogram
                                                                                Marc Cassone, DO
                                     TRAUMA, CARDIOLOGY,
10 Kawasaki Disease or MIS-C?
                                                                             Geisinger Medical Center
     PEDIATRICS, COVID-19                                                        Sean Hickey, MD

13 TEE in the ED              36 Rare Presentation of
                                 Newly Diagnosed HOCM
                                                                             Icahn SOM at Mount Sinai
                                                                                Amie Kolimas, DO
     ULTRASOUND, CARDIOLOGY,         CARDIOLOGY                             University of Illinois Hospital
     TRAUMA                                                                          – Chicago

14 How to Approach the        38 Sudden Post-Coital
                                 Hemopericardium with                            Emily Luvison, MD
     Pediatric Elbow                 Cardiac Tamponade
     PEDIATRICS, ORTHOPEDICS         on Apixaban                                 Devan Pandya, MD
                                                                                   UC Riverside
19 Hemoperitoneum  in a
   Reproductive-Age Woman
                                     HEMATOLOGY, TOXICOLOGY,
                                     CARDIOLOGY                               Gabrielle Ransford, MD
                                                                            East Virginia Medical School
                                40 Building Global EM and Its
                                                                                  Sarah Ring, MD
20   Caustic Ingestions
                                   Next Generation of Leaders
                                     INTERNATIONAL MEDICINE
                                                                             Icahn SOM at Mount Sinai
                                                                            Samuel Southgate, MD, MA

22 Autism  Spectrum Disorder
   in the Pediatric Patient
                             43 Developing a Diverse
                                and Inclusive Pipeline
                                                                                Regions Hospital

                                                                                   MSC Editor
     PEDIATRICS,                     in Emergency Medicine:                       David Wilson
     BEHAVIORAL HEALTH               Part 1                                 Thomas Jefferson University
                                     DIVERSITY, MEDICAL EDUCATION
24 AEmphysema
     Case of Subcutaneous                                                       ECG Faculty Editor
     Pneumoscrotum              44   A Letter from a
                                     Paramedic to an EM Doc
                                                                               Jeremy Berberian, MD
     Disguised as Angioedema         PREHOSPITAL, EMS
                                                                              PEM Fellowship Editor

                                46 Navigating
     TRAUMA                                   the Military                       Emine Tunc, MD

                                                                             University of Washington
     Pediatric Gonococcal          Match through COVID
     Hip Arthritis                   GOVERNMENT SERVICES, MATCH             Toxicology Faculty Editor

                                48 Medical
     ORTHOPEDICS, PEDIATRICS,                                           David J. Vearrier, MD, MPH, FACMT,
                                           Student-Led                            FAACT, FAAEM
                                   PPE Redistribution During                 University of Mississippi

28 Epiploic Appendagitis
   as a Rare Cause
                                     the COVID-19 Pandemic
                                     COVID, MEDICAL EDUCATION
                                                                    EM Resident (ISSN 2377-438X) is the bi-monthly
     of Abdominal Pain
                                50   Defining Procedural
                                     Competency in
                                                                    magazine of the Emergency Medicine Residents’
                                                                    Association (EMRA). The opinions herein are
                                     Emergency Medicine             those of the authors and not of EMRA or any

29 AArthritis
      Case Report of Septic
              of the Shoulder
                                     OP-ED, MEDICAL EDUCATION       institutions, organizations, or federal agencies.
                                                                    EMRA encourages readers to inform themselves

     caused by P. aeruginosa
                                51 ECG Challenge
                                                                    fully about all issues presented. EM Resident
                                                                    reserves the right to edit all material and does

                                53 Board Review Questions
                                                                    not guarantee publication.

30 Bleeding Risk
   after NSAID Use
                                     PEER ASSISTANCE                © Copyright 2021
                                                                    Emergency Medicine Residents’ Association
Resident COVID Airway - Managing the - EMRA
© 2020 CEP America, LLC. Vituity® is a registered trademark of CEP America, LLC

                                                                                  April/May 2021 | EM Resident 3
Resident COVID Airway - Managing the - EMRA

  Class of 2022,
   We’re Here
     for You
                       RJ Sontag, MD
                       EMRA President
                 Mid Ohio Emergency Services

  What made you choose                                              evolves in 2021, major EM groups have once again stepped up
                                                                    to provide a unified roadmap to the away rotation and eSLOE
  emergency medicine                                                process. This is so important, since so many questions
                                                                    require answers this year, such as:
  for your career?                                                  ● What is the earliest I can start an away rotation?

 I knew this was the specialty for me on my first EM rotation.      ● How many EM rotations should I do this year?
   After spending my third year of medical school convinced         ● What do I do if I don’t have an EM residency associated
  I was going to be a pediatrician, then a surgeon, then an              with my medical school?
  obstetrician, then a family physician, I realized I needed a      ● What is an eSLOE, and how many should I have this year?
  specialty that would allow me to do everything. EM gave me        ● How can programs support students without a “home”
  the chance to treat every patient, day or night, regardless            EM rotation?
  of their ability to pay, all while providing a mix of acuities,   ● How should programs address issues like COVID-19
  procedures, and intellectual challenges. Exploring this field          vaccine status?
  during away rotations reinforced my choice, and I made                 EMRA is proud to be a leader in advocating for physicians-
  friends in those rotations that I remain close to.                in-training, and we were excited to help lead the development
      COVID-19 upended this process. Last year, national            of the 2021-2022 recommendations below. Use this QR code
  EM organizations came together to provide clarity with a          to find this year’s full recommendations with answers to those
  consensus statement outlining our approach. As the pandemic       questions and more.
                                                                         EMRA will also host our popular EMRA Hangouts on the
                                                                    2021-2022 application season. Mark your calendar for these
                                                                    engaging sessions, as we will be breaking down the entire
                                                                    landscape piece by piece there, with updates as the situation
                                                                    We’re Here for You
                                                                        Have a question about this process? Let me know. I want
                                                                    to help you thrive this year, despite the uncertainty. Send me
                                                                    an email at or reach out to us on social
                                                                    @emresidents. ¬

4 EMRA | •
Resident COVID Airway - Managing the - EMRA
The U.S. Army health care team wants the brightest
students to shape the future of medicine. Through the
Health Professions Scholarship Program, the best
pre-med students in the nation can qualify for full
tuition paid at a medical school of their choice,
receive a monthly stipend to help with expenses,
and may be eligible for a signing bonus.
That’s the Army difference.
Learn more about the Health Professions Scholarship
Program at

                                                        April/May 2021 | EM Resident 5
                                                        ©2021. Paid for by the United States Army. All rights reserved.
Resident COVID Airway - Managing the - EMRA
                for our #EMRAfamily
              You know about our chock-full EMRA Member Kit boxes.
              But how about better mortgage and student loan rates?
             Or special pricing for exam prep? Plug in to all the valuable
             discounts, access, and information you get through EMRA.

         Board Prep Education
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               and get the most from your membership

                                     Medical Students | Residents | Fellows | Alumni
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6 EMRA | •
Resident COVID Airway - Managing the - EMRA
EMRA is pleased to recognize the following individuals
                              as recipients of EMRA’s Winter 2021 Awards.
               Join us for a Virtual Awards Ceremony on Sunday, April 11 at 7 pm Central.

             Bo Burns, DO, FACEP                             Jason Seamon, DO, MHS, FACEP                           David Peak, MD
          University of Oklahoma School                              Spectrum Health/                         Massachusetts General Hospital
            of Community Medicine                                 Michigan State University                        Associate Residency Director
               EMRA Chair of the Year                           Residency Director of the Year                          of the Year Award

      Robert Dixon, DO                         Bryn Eisfelder, MD                      Collin Michels, MD                Jeffrey Tadashi Sakamoto, MD
      Stanford University                      Stanford University                     Stanford University                      Stanford University
    Chief Residents of the Year              Chief Residents of the Year             Chief Residents of the Year             Chief Residents of the Year

      Kelli Jarrell, MD                       Cindy Chang, MD                           Jake Toy, DO                            Thomas Ems, MD
    University of Cincinnati             Harbor-UCLA Medical Center              Harbor-UCLA Medical Center                       Prisma Health
        Fellow of the Year                  EMRA Resident of the Year                Jean Hollister Contribution                   Rosh Review
                                                                                     to Prehospital Care Award                One Step Further Award

      Chelsea Harrison                         Samita Heslin, MD                             Fiona Chen                         Ashley Penington
    Northwestern University                   Stony Brook University                       Brown University                Pacific Northwest University
      Residency Coordinator                 Academic Excellence Award                 Dr. Alexandra Greene                    Dr. Alexandra Greene
            of the Year                                                               Medical Student Award                   Medical Student Award

                    Robert Allen, MD                                Akash Desai, MD                           Alexander Garrett, MD
                      Kings County                                     Mt. Sinai                           Harbor-UCLA Medical Center
                     ACEP Scientific                              ACEP Travel Scholarship                 ACEP/CORD Teaching Fellowship
                   Review Subcommittee

     Scott Brensel, DO, MS                     Sophia Gorgens, MD                       Monica Logan, MD                         Donna Okoli, MD
       Henry Ford Hospital                   Zucker-Northwell NS/LIJ              Advocate Christ Medical Center          Advocate Christ Medical Center
EMRA/ACEP ED Directors Academy          EMRA/ACEP ED Directors Academy           EMRA/ACEP ED Directors Academy          EMRA/ACEP ED Directors Academy
      Travel Scholarship                      Travel Scholarship                       Travel Scholarship                      Travel Scholarship

Henry Schwimmer, MD               Nicole Prendergast, MD          Jonathan Hootman, MD             Katherine Wegman, MD             Uche Nkemdilim Erica
  Highland Hospital/                Stanford University              Stanford University            Boston Medical Center               Medical Student
   Alameda Health                 EM Basic Research Skills          Critical Care Medicine           FeminEM FIX 2021                   SAEM Annual
EM Basic Research Skills                                            Conference Scholarship                                             Meeting Scholarship

                                                                                                                           April/May 2021 | EM Resident 7
Resident COVID Airway - Managing the - EMRA

                        Management of the
                         COVID-19 Airway
               Connor Greer, MD                  hypoxic and crashing patients are difficult    failure with decreased surfactant levels,
            PGY-2 Emergency Medicine             to manage, with the added challenge of         direct cytopathic effect on pneumocytes,
              University of Kentucky                                                            lymphocytic pneumonitis, and acute
                                                 provider safety being ever-present. The
               Robert Razick, MD                                                                fibrinous organizing pneumonia leading
     Assistant Professor of Emergency Medicine
                                                 decision of oxygen delivery method,
                University of Kentucky           escalation of care, physiologic goals, and     to diffuse alveolar damage. Other aspects
                Joel Hamm, MD                    intubation procedure will be discussed         of this illness include a cytokine storm
                   Medical Director,             below.                                         as well as disseminated intravascular
     Assistant Professor of Emergency Medicine                                                  coagulation with marked systemic
                University of Kentucky           Background                                     inflammation and direct endothelial

 T    here are many perspectives                     COVID-19 is a viral respiratory            injury.8,11 The most likely and significant
      available and early data to guide our      infection caused by a positive sense           modes of transmission are droplet and
  management of COVID-19 patients that           RNA coronavirus that binds type 2              contact transmission, with aerosol/
  present with respiratory failure. This         alveolar cells, intestinal epithelial cells,   airborne transmission being possible
  article will review practice-altering data     and vascular endothelial cells via the         but less likely to contribute to severe
  and the approach used by the authors           ACE2 receptor. This viral syndrome             disease burden.4 Infection prevention and
  at their institution with success. These       is marked by hypoxemic respiratory             control measures must include a variety

8 EMRA | •
of personal protective equipment, viral        10 cm, making this the ideal method of          Intubation
filters for respiratory support machines,      oxygen supplementation with regard to               The use of a checklist method may
consideration for aerosol-generating           both amount of oxygen delivered and             be helpful in preparing for intubating
procedures (AGPs), and the possible role       safety profile for healthcare workers.          patients, to minimize the opening of
of drying agents or antimuscarinics. Goals     Many of these COVID-19 respiratory              doors in negative pressure rooms as well
in immediate care and resuscitation of         failure patients will require more than         as staff exposures.
the person-under-investigation (PUI)           just additional oxygen, however. When           • Preoxygenate: use a combination of
for COVID-19 in respiratory failure            supplemental O2 alone cannot improve                HFNC with maximal settings with a
include decreased work of breathing,           the patient’s condition, one must consider          NRB mask placed over the patient’s
oxygen saturation greater than 90%,2 and       high-flow oxygen systems (like the high             nose and mouth.
improvement in mental status and other         flow nasal cannula [HFNC]) and non-             • Delayed sequence intubation vs Rapid
markers of end-organ perfusion.                invasive positive pressure ventilation              sequence intubation: consider DSI
Initial Evaluation and Measures                (NIPPV) such as BiPAP or CPAP. HFNC                 if there is a concern for the ability
    Patients should be transferred into        can provide high FiO2 while boasting a              to ventilate the patient once sedated
a negative pressure room as soon as            dispersal distance of only 5-17 cm. This            and paralyzed. Ketamine should be
possible, receiving oxygen via a face-mask     method decreases work of breathing                  the induction agent of choice for DSI
device if necessary (related to “dispersal     and dead space while providing a small              and is a reasonable choice for RSI as
distance” of potentially infectious            amount of positive end-expiratory                   well. Alternatively, etomidate can be
droplets/aerosols specific to oxygen           pressure (PEEP). It involves oxygen-                used. Use rocuronium for paralysis
delivery methods reviewed below).              rich humidified gas with precisely set              for prolonged effect unless otherwise
Minimal personnel should be exposed to         flow levels and oxygen concentrations.5             contraindicated.
the patient at this point in care, including   Importantly, the use of HFNC during the         • Fiberoptic intubation: avoid direct
physician, nurse, and respiratory              SARS-CoV outbreak in 2003 in Toronto                laryngoscopy when possible to
therapist, with other personnel donned         did not contribute to the risk of HCW               reduce exposure during this AGP.
with PPE available to help outside the         transmission.6 Even though HFNC seems               An intubation box may be used over
room. The minimum PPE to be worn by            to be the clear winner when choosing                the patient as a physical barrier to
health care workers in contact with the        how to give extra oxygen, it must also              respiratory droplets and aerosols.
patient includes an inner and outer pair       be stressed that this device may still              Consider leading with a bougie in
of gloves, gown, n95 or PAPR, and sealed       not be enough. Failure of HFNC may be               anticipation of a difficult airway to
goggles.                                       indicated by requirement of vasopressors,           increase the chance of first-pass
                                               worsening RR and asynchrony, and                    success.
Choosing Oxygen Delivery
                                               possibly the ROX index greater than             • Initial ventilator settings: LPV and
                                               4.88. The ROX index is a score created              APRV should be used to manage the
    The key considerations in choosing
                                               by Roca, et al. that combines respiratory           significant atelectasis associated with
an oxygen delivery method are the
                                               rate, oxygenation status, and HFNC                  COVID-19 respiratory failure and
patient’s physiologic requirements
                                               settings to generate an objective measure           ARDS. ¬
and the risk of exposing providers to
potentially infectious particles. The          to predict failure of this form of non-
amount of oxygen deliverable (FiO2)            invasive ventilation and indicate the need       TAKE-HOME POINTS
and the dispersal distance of aerosols/        for endotracheal intubation.7,1,10,9 NIPPV       n The COVID-19 respiratory failure
respiratory droplets vary with each device     is not an ideal choice for the safety profile      patient poses many challenging
and choices may also be institution-           of HCWs. Dispersal distances up to 95cm            aspects of care. Healthcare workers
dependent. Based on high-fidelity              or greater with BiPAP are intimidating,            are at risk of becoming infected
mannequin studies, the following               and if patients are requiring high levels          when working in close proximity
oxygen delivery methods are listed in          of oxygen as well as positive pressure             with patients, especially during
order of increasing dispersal distance of      ventilation with clinical worsening,               AGPs. Liberal use of PPE and
aerosol; Non-rebreather mask (NRM),            the patient may require endotracheal               judicious use of personnel are key
HFNC, nasal cannula, venturi mask,             intubation to precisely control respiratory        to reducing HCW exposures. The
simple mask, nebulizer, NIPPV.3 The            mechanics and reduce staff exposures.              safest and most effective ways to
traditional nasal cannula can provide          One way to minimize the viral dispersal            provide respiratory support before
approximately 45% FiO2 with a dispersal        is to use a BiPAP mask on a ventilator             endotracheal intubation are HFNC
distance of 40 cm. Venturi masks and           with viral filter in place on the expiratory       and NRB, which may be used in
simple masks provide approximately             limb to create a closed circuit, something         combination as well. Intubate with
50% FiO2 with dispersal distances of           that is not possible with BiPAP machines.          extreme caution using fiberoptic
approximately 40 cm as well. NRMs              Similarly, nebulized breathing treatments          technology and consider DSI when
provide FiO2 of approximately 90%              are also risky, and should be replaced             appropriate.
and have a dispersal distance of only          with MDI treatments whenever possible.

References available online                                                                                  April/May 2021 | EM Resident 9

  Kawasaki Disease or MIS-C?

               Blair Gaines, MD                Inflammatory Syndrome in Children           reaction. She was rushed into the
               University of Miami             (MIS-C). Fortunately, approaching this      treatment area for evaluation of possible
             Jackson Health System                                                         anaphylaxis and respiratory assessment.
                                               rapidly progressive and potentially fatal

  W      hile emergency physicians have
         become more accustomed to
  managing COVID-19 in adults, the
                                               disease process under the larger umbrella
                                               of a Kawasaki-Like Hyperinflammatory
                                                                                           She was tachycardic with a heart rate
                                                                                           of 130, tachypneic, and borderline
                                                                                           hypotensive for her age. Initial exam
                                               Syndrome1 can help guide management
  knowledge regarding how the virus                                                        was negative for wheezing or stridor, but
                                               in a condition where early diagnosis and
  affects children still lags behind. A                                                    she had edema of the face and neck with
                                               intervention are crucial to survival.
  major concern for the physician is                                                       a red maculopapular rash covering her
  discharging a child who presents with        Case                                        face. Epinephrine IM, diphenhydramine
  mild upper respiratory or gastrointestinal      A 4-year-old previously healthy          PO, and methylprednisolone IV were
  symptoms only to have the patient            Hispanic female presented to the ED         given to treat anaphylaxis.
  return to the ED several days to weeks       with a diffuse rash and facial swelling,        Additional information from the
  later, presenting with Multisystem           concerning for an apparent allergic         mother revealed no prior history of

10 EMRA | •
anaphylaxis, no new food/medication             10 cc/kg bolus was administered.              studying KD and linking it to a post-
ingestions or topical exposures, no             Ceftriaxone and vancomycin were               infectious process, no definitive cause has
known allergies, and no significant past        also initiated in the ED, with blood          been determined.4 Attempts at identifying
medical history. Of note, she had been          and urine cultures pending at the             a viral cause appeared promising when
seen in the ED 3 days earlier, diagnosed        time of admission. EKG showed sinus           Dr. Kawasaki observed a relative spike
with strep pharyngitis, and discharged          tachycardia. Chest X-ray was negative         in children presenting with symptoms
after treatment with IM penicillin G.           for pneumonia or any other acute              consistent with this syndrome following
The patient was tearful, ill-appearing,         cardiopulmonary findings. Additional          a coronavirus rhinitis outbreak in
and withdrawn. On a quick review of             laboratory workup is seen below. She          Japan. However, later studies provided
systems, mom reports that over the              was admitted to the Pediatric ICU             inconsistent results and failed to
past 5 days her daughter initially had          for further management of Kawasaki            establish a link between acutely infected
a high fever (102o F) and sore throat,          disease vs. MIS-C (see figure).               coronavirus patients and KD.5
followed by anterior neck swelling              Discussion                                    MIS-C is defined by the CDC as:
on day 2, with vomiting, diarrhea,                                                            — Patients aged 2 organ system
                                                It has replaced rheumatic heart disease
blanching maculopapular rash, tender                                                              involvement
                                                as the most common cause of acquired
cervical lymphadenopathy, dry lips,                                                           — No alternative plausible diagnosis
                                                heart disease in children in developed
conjunctivitis, and bilateral hand and                                                        — Positive for current or recent
                                                countries. The disease was identified
foot edema and erythema. While her                                                                COVID-19 infection by PCR, serology
                                                by Dr. Tomisaku Kawasaki in the
presentation was most consistent with                                                             or antigen testing, OR exposure to a
                                                1960s, who described it as acute febrile
Kawasaki disease, given the current                                                               suspected or confirmed COVID-19
                                                mucocutaneous lymph node syndrome.
pandemic, MIS-C was also high on                                                                  case within the past 4 weeks6
                                                It usually affects children < 5 years old
the list of differential diagnoses. Other                                                         Although our patient was negative
                                                and appears to peak in the months of
diagnoses considered included other                                                           for COVID antigens and antibodies, it is
                                                January and June/July.2 Development of
viral exanthems (EBV, CMV, measles,                                                           possible that she may have cleared the
                                                the disease also appears to be influenced
adenovirus), scarlet fever, toxic shock                                                       infection by the time she developed KD
                                                by regional and genetic factors, notably
syndrome, staphylococcal scalded skin                                                         symptoms. Furthermore, it is important
                                                in individuals of Asian descent. KD is
syndrome, Stevens-Johnson syndrome,                                                           to note that the novelty of the virus leads
                                                generally self-limiting and rarely fatal,
allergic reaction, and sepsis.                                                                to uncertainties regarding the sensitivity
                                                with an in-hospital mortality rate of
ED Course                                       only 0.17% in the U.S. Almost all deaths      and specificity of COVID-19 RT-PCR
     Considering MIS-C as a likely              attributed to the disease result from         testing as well as antibody detection and
alternative diagnosis, a slower approach        cardiac complications. A significant          interpretation. Recent studies, although
to fluid resuscitation was utilized instead     factor in overall prognosis is the time to    limited by size and duration, have shown
of the traditional 20 cc/kg bolus used          diagnosis and initiation of appropriate       that these Kawasaki-like symptoms
in sepsis/septic shock, due to risk of          treatment. Coronary artery aneurysms          can develop weeks after exposure to
development of acute heart failure. Vital       occur in up to 25% of untreated children      COVID-19, and the majority of patients
signs and repeat physical exam were             and peak mortality is seen in days 15-45      are not acutely infected with the virus
essentially unchanged following the             following the onset of fever.3                at the time of presentation.7 Generally,
first 10 cc/kg NS bolus, so an additional           Despite more than 50 years of             antibodies are fairly reliable 4 weeks

                                                                                             Ca++: 9.1             T.Bili: 3.8 (H)
      138           102       21 (H)                                                         Lactate: 1.6          Alb: 3.8 (L)
                                              86            9.7                  230         Trop: < 0.012         NT-proB NP: 771 (H)
                                                                     35.5                    AST: 60(H)            D-Dimer: 1.67 (H)
      4.4          12 (!)      0.51                                                          ALT: 93 (H)           Ferritin: 259 (H)
                                                                                             Alk Phos: 388 (H)     LDH: 813 (H)

  VBG: 7.31/31/87/15                  ESR: 70 (H)                 EBV lg: Negative
  Lymphocyte %: 13.2 (L)              CRP: 32.5 (H)               COVID PCR: Negative
  Absolute Lymph: 1.3 (L)             Procalcitonin: 3.74 (H)     COVID Ig: Negative

References available online                                                                                 April/May 2021 | EM Resident 11
  post-infection; however, some studies        physical exam findings:                      Steroids are indicated for IVIG resistant
  have shown that even in patients with        — Conjunctivitis (bilateral, painless,       patients. Other agents have been seen
  positive RT-PCR results, 19% may be              non-purulent)                            in smaller trials to improve outcomes,
  IgG seronegative at 4 weeks following        — Mucocutaneous changes (cracked             notably Infliximab and Abciximab,
  exposure and up to 40% at 8 weeks.8              lips, strawberry tongue, erythema,       however, more prospective studies
       There is also significant overlap in        pharyngitis)                             are needed before they can be widely
  symptomatology and pathophysiology of        — Polymorphous rash (diffuse, macular,       recommended.3
  the two disease processes. Initial studies       may be scarlatiniform)                       The clinician must be aware of the
  have provided strong evidence showing        — Extremity changes (erythema, edema,        risk of recurrence, especially in children
  that COVID preferentially targets the            desquamation)                            < 3 years old at the time of diagnosis.
  protein angiotensin-converting-enzyme        — Lymphadenopathy (generally cervical        Repeat echocardiograms are indicated at
  2 (ACE2) on endothelial cells resulting          and unilateral)                          2 weeks and 6-8 weeks following hospital
  in a systemic vasculitis similar to that         Patients with 5 or more days of fever    discharge. Patients should continue
  seen in KD.9 This evidence is further        and < 4 of the above findings should be      taking aspirin daily and may stop once the
  supported by the fact that MIS-C             considered for atypical KD with additional   echocardiogram at the 6-8 week follow-
  generally presents with physical exam        laboratory testing.11 If CRP >30 mg/L and    up visit is negative for coronary artery
  findings consistent with a diagnosis of      or ESR >40 mm/hous; and if positive          abnormalities.
  atypical KD. Additionally, in both severe    echocardiogram OR 3 or more of the below     Case Conclusion
  MIS-C and KD Shock Syndrome, there           criteria are positive, patients should be         The patient received treatment
  may be associated left heart systolic        treated as atypical Kawasaki.                with IVIG upon admission and had
  dysfunction and significant hypotension      — Anemia for age                             an uncomplicated inpatient course.
  requiring vasoactive medications for         — Platelets >450 x 106/microliter after      Transthoracic echocardiogram showed
  hemodynamic support.10 KD has also               the 7th day of fever                     normal cardiac structure and function
  been associated with multiple viruses,       — Albumin level 15 /microliter               artery aneurysm or ectasia. Initial
  linked to the common cold. With this         — Urine >10 WBC /HPF                         urinalysis was consistent with UTI but
  knowledge and understanding, it may be           More severe disease, termed              repeat urinalysis the day following
  more appropriate to describe this disease    Kawasaki Shock Syndrome, often               admission was negative. Stool PCR studies
  process as COVID-19 associated KD            requires the use of vasopressors for         were positive for Enteropathogenic E.
  instead of trying to differentiate between   hemodynamic support and is associated        coli (EPEC). She continued to improve
  MIS-C and KD.5 It is possible that MIS-C     with increasingly high levels of CRP,        and was transferred to the floor after
  has been improperly classified as a          procalcitonin, d-dimer, and IL-6.12          2 days in the Pediatric ICU. Blood and
  separate entity from KD, when perhaps        Elevations in NT-proBNP and troponin         urine cultures were also negative after 48
  it is the same post-viral process we have    reflect cardiac inflammation and edema       hours and antibiotics were discontinued.
  been studying for years with Kawasaki        as opposed to myocardial ischemia.10         Parotid gland ultrasound showed cervical
  Disease. The major difference in this case   Management                                   LAD. She was discharged on hospital day
  is that SARS-Cov-2 would be the first            Urgent echocardiogram is                 4 with a diagnosis of Kawasaki Disease
  virus simultaneously linked to Kawasaki      recommended for all cases of confirmed       based on her negative COVID studies and
  Disease and a global pandemic.               or suspected KD due to coronary artery       relatively quick recovery. Her parents
       Considering these factors, in           manifestations. Although early treatment     were instructed to continue giving her
  combination with the high prevalence of      within 10 days of fever onset may prevent    aspirin daily for continued prevention of
  asymptomatic COVID carriers within the       coronary artery pathology, recent            complications related to coronary artery
  population, the presence of GI symptoms,     studies have shown that up to 44% of         aneurysm.
  and lab results that were consistent with    patients will have coronary artery ectasia        She was seen in the pediatric
  an acute inflammatory syndrome, MIS-C        or aneurysms at the time of hospital         cardiology clinic 2 weeks and 6 weeks
  remained high in the list of differential    presentation.3 Myocarditis and acute         following discharge from the hospital.
  diagnoses.                                   heart failure may also be seen.              Her mother noted persistent bilateral
  Diagnosis                                        Standard therapy for patients with KD    hand and foot swelling at the 2-week
      No single test provides a definitive     involves IVIG (2 g/kg over 10-12 hours)      visit, but by 6 weeks, all symptoms had
  diagnosis of KD. The diagnosis is            and high dose aspirin (80-100 mg/kg/d        resolved. Repeat electrocardiograms
  based on clinical presentation and           divided into four separate doses). After     and echocardiograms at those visits
  supported by characteristic laboratory       fever resolution, the dose of aspirin is     were reassuring with normal cardiac
  abnormalities. According to the AHA,         decreased to 3-5 mg/kg/d. IVIG can           structure and function. Daily aspirin
  in order to make a diagnosis of Typical      result in elevated ESR, thus changes         was discontinued, and she was
  KD, a child must have a fever for at least   in ESR should not be used as a gauge         scheduled to follow up in the clinic again
  5 days AND have 4 of the 5 additional        for disease progression or resolution.       in 6 months. ¬

12 EMRA | •

                                     TEE in the ED
Role of Transesophageal Echocardiography in Cardiac Arrest
               Tara Knox, MS-IV                     have found that the left ventricular              short-axis views), goal-directed protocol
   Geisinger Commonwealth School of Medicine        outflow tract, aortic root or aortic valve        for TEE in cardiac arrest, which
                 @TaraKKnox1                        are located beneath the center of the             represents the minimum standard-
             Mark Olaf, DO, FACEP                   sternum in 50% to 80% of patients.                of-care.9 The protocol was designed
       Regional Associate Dean of Geisinger
        Commonwealth School of Medicine
                                                    Therefore, TEE-directed modifications             with an appreciation for the scope of
                  @learnmeder                       could be used to optimize cerebral                ED echocardiography and emphasizes
                                                    perfusion.5,6 TEE can also be used during
C    ardiac arrest is one of the most de­man­                                                         efficiency, redundancy and views that are
     ding presentations for emergency               post-arrest care for procedural guidance,         anatomically like familiar TTE views.9
physicians to manage, due to its diagnostic         including extracorporeal life support and              A recent prospective observational
                                                    placement of a temporary pacemaker.5              study consisting of thirty-three patients
uncertainty and time-sensitive complica-
tions. High-quality chest compressions              Risks                                             presenting to the ED with out-of-hospital
have been shown to increase survival and                The safety of TEE in cardiac arrest           cardiac arrest used a four-view protocol
improve neurological outcomes.1 Focused             has not been studied directly, so the             for post-intubation TEE during cardiac
transthoracic echocardiography (TTE)                complications can only be deduced from            arrest.11 TEE was used to assist with
can identify critical, potentially reversible,      ambulatory TEE examinations. Major                diagnostic uncertainty, evaluate cardiac
pathology during cardiac arrest: tension            complications such as oropharyngeal               activity and determine CPR quality
pneumothorax, cardiac tamponade and                 trauma, esophageal perforation and major          through AMC assessment. All participating
hypovolemia.2,3 However, TTE results in             bleeding events are rare with incidences          physicians completed standardized
prolonged chest compression pauses5 and             reported as less than 1%. Additionally,           training consisting of at least eight hours
may compromise high-quality CPR. TTE is             since TEE can obtain life-saving                  of didactics, high-fidelity simulation and a
limited by impediments to images generated          information without compromising high-            minimum of ten proctored examinations.11
through the skin surface, such as defibril-         quality CPR, the risk-benefit ratio for TEE            The four-view protocol was obtained
lation pads, body habitus, and gastric air.         in cardiac arrest is extremely favorable.5        in 100% of cases, with an average ED
Focused transesophageal echocardiography            Practicality and Value                            door to TEE time of 12 minutes, which
(TEE) has emerged as an alternative to TTE              In a resuscitative setting, TEE occurs        supports the feasibility of TEE in the
that overcomes these limitations and has the        after endotracheal intubation.5 TEE               setting of cardiac arrest.11 TEE was
added benefit of improving, rather than hin-        transducers require specific storage and          found to have a diagnostic, therapeutic
dering, the delivery of chest compressions.5        cannot stay with the machine, so it is            or prognostic impact in 97% of cases.
                                                    recommended to designate an easily-               Per this protocol, a mid-esophageal
                                                    accessible storage location.5 A recent study      bicaval view was obtained in addition
    The transducer used in TEE is
                                                    focused on TEE in ED cardiac arrest found         to the three-views suggested by ACEP.
inserted into the esophagus and allows
                                                    that is was achievable to perform a focused       The authors report that this view aided
for visualization of clots in transit, clots in
                                                    TEE exam early in resuscitation and that          with the initiation of extracorporeal life
the pulmonary arteries, aortic dissections
                                                    TEE had a therapeutic or prognostic               support in 21% of cases, which suggest
and cardiac tamponade. TEE permits
                                                    impact in 97% of the cases.8-11                   that best practices for TEE during cardiac
the optimization of real-time chest
                                                    Imaging Protocol                                  arrest may consist of a four-view protocol,
compressions relative to cardiac anatomy,
                                                                                                      like the one provided in this study.11
which is particularly useful for people                 The American College of Emergency
whose left ventricle, the target of chest           Physicians (ACEP) published a three-              Future Work
compressions, is not located beneath the            view (mid-esophageal 4-chamber, mid-                  For TEE to become a widespread
sternum. For example, radiologic studies            esophageal long-axis, and transgastric            practice throughout emergency
                                                                                                      departments in the United States, future
                        Mid-esophageal 4             Mid-esophageal             Trans-gastric         work is needed to assess its impact on
                            Chamber                     long-axis                 short-axis          patient outcomes, cost effectiveness and
Structures          4 chambers, mitral and        LA, LV, mitral valve,     Ventricles, pericardium   to ensure resources are available for
                    tricuspid valves, pericardium aortic valve, pericardium
                                                                                                      providers to meet training requirements.
Goal                Assess cardiac activity,      Left-sided function,      Assess ventricular
                                                                                                      The main use of TEE in the ED has
                    cardiac tamponade, intra-     aortic and mitral valve   function, ventricular
                    cardiac thrombus, L V         movement, pericardial     function/size             been cardiac arrest, but indications
                    and RV function/size, fine    effusion                                            will likely expand to include intubated,
                    ventricular fibrillation                                                          septic patients and patients requiring
TTE Counterpart     Apical 4 chamber              Parasternal long          Parasternal short         hemodynamic monitoring. ¬

References available online                                                                                         April/May 2021 | EM Resident 13

                          How to Approach
                         the Pediatric Elbow
            Shahfar Khan, MD, FAAP                          Youck Jen Sui Navarro, MD                     Dorota Pazdrowska-Chawdhry, MD
       Pediatric Emergency Medicine Fellow                     Pediatric Radiology Fellow,                Pediatric Emergency Medicine Attending,
       St Christopher’s Hospital for Children                   Department of Radiology                     St Christopher’s Hospital for Children
                  Brian Novi, DO                          St Christopher’s Hospital for Children                    Erica Poletto, MD
                  Pediatric Resident,                                                                      Section Chief, CT and Cardiac Imaging
        St Christopher’s Hospital for Children                                                              St Christopher’s Hospital for Children

                             Here it is: the dreaded pediatric elbow. Is it a fracture?
                            An ossification center? Shouldn’t there be a bone there?
                                                No, it’s Superman.

 R   adiographic assessment of acute pediatric elbow trauma
     requires a firm grasp of developmental anatomy,
  radiographic landmarks, and common injury patterns. By
                                                                                2. Look for joint effusion and soft tissue swelling
                                                                                    The elbow fat pads are situated external to the joint capsule.
                                                                                On a true lateral radiograph, the normal anterior fat pad is seen
  using a systematic approach to reading elbow x-rays delineated                as a radiolucent line parallel to the anterior humeral cortex;
  below, you can begin to feel more confident and adept at                      and the posterior fat pad is invisible.
  evaluating the subtle signs of pediatric fractures.                               Distention of a structurally intact joint causes displacement
  Why is the pediatric elbow difficult?                                         of the fat pads — the posterior fat pad moves posteriorly and
      The challenge comes from the complex developmental                        superiorly and becomes visible; the anterior fat pad becomes
  anatomy with multiple ossification centers that mature at                     more sail-like.4 (Figure 2)
  different ages. The multiple ossification centers may be difficult                On the lateral x-ray of the elbow, a joint effusion can be
  to differentiate from fractures in the acute traumatic setting.               inferred when there is displacement of the anterior fat-pad
  Familiarity with age-variable anatomy is crucial for an accurate              or presence of the posterior fat pad. An elbow joint effusion
  diagnosis.                                                                    without a visible fracture seen on radiographs can suggest an
                                                                                occult fracture and should prompt further evaluation.
  1. Ensure adequate films
      An AP film should be obtained with the elbow in full
  extension and the forearm supinated (Figure 1). For the true
  lateral projection, the elbow should be flexed 90 degrees with
  the forearm supinated. The routine use of comparative views
  is not recommended, as it comes at a considerable cost of
  radiation exposure to the child;1 several studies have shown
  that the routine use of comparative views does not alter patient

                                                                                Figure 2. a. Normal appearance of the anterior fat pad.
                                                                                b. Effacement with a sail-like appearance of the anterior
                                                                                fat pad (arrow). There is visualization with superior
                                                                                displacement of the posterior fat pad, related to joint
                                      Figure 1. Anteroposterior                 effusion (arrowhead).
                                      (AP) and lateral views of the                 A study by Major et al.5 showed that a joint effusion without
                                      elbow. Normal anatomy and                 visible fracture seen on conventional radiographs is often
                                      positioning.                              associated with an occult fracture and bone marrow edema
                                                                                on MRI. The study found that 57% of imaging where the only
                                                                                finding was joint effusion had a fracture and 100% had bone

14 EMRA | •
marrow edema on MRI. In cases where an occult fracture is
suspected, follow-up radiographs in 7-10 days can be obtained
to evaluate for the presence or absence of sclerosis or periosteal
new bone formation as indicators of healing.. For suspected
occult fractures, standard of care remains posterior elbow
splinting with follow-up radiographs at 7-10 days.
3. Check bone alignment
    The anterior humeral and radiocapitellar lines are used
to assess elbow alignment. The lines assess the geometric
relationship of one bone to the other. Malalignment usually
indicates fractures.
    The anterior humeral line is drawn along the anterior
cortex of the humerus and should bisect the middle third of the
capitellum. Malalignment indicates a fracture — in most cases,
posterior displacement of the capitellum in a supracondylar
fracture. This sign relies on adequate ossification of the
capitellum and therefore is reliable in children over the age of 4   Figure 5. Alteration of the radiocapitellar line, with
years only.6 Figure 3                                                posterior dislocation of the radius and ulna with respect to
                                                                     the humerus.

                                                                     4. Identify ossification centers
                                                                        There are 6 secondary ossification centers in the elbow.
                                                                     They ossify in a sex- and age-dependent predictable order.
                                                                     CRITOE is a mnemonic for the sequence of ossification center
                                                                     appearance. (Table 1 and Figure 6)

                                                                           Ossification Center        Females        Males
                                                                      C    Capitellum                     1-2          1-2
                                                                      R    Radial Head                     3            5
                                                                       I   Internal (Medial)               5            7
Figure 3. a. Normal anterior humeral line, dissecting
the middle third capitellum. b. Anterior displacement of               T   Trochlea                        7            9
the anterior humeral line, with posterior position of the             O    Olecranon                       9            10
capitellum.                                                            E   External (Lateral)              11           12
    The radiocapitellar line evaluates the relationship of the             Epicondyle
proximal radius to the capitellum on all views (Figure 4). If the
integrity of this line is compromised, then dislocation should be
suspected (Figure 5)

                                                                                                     Figure 6. Ossification
                                                                                                     centers. Capitellum (C),
                                Figure 4. Radiocapitellar                                            Radial epiphysis (R),
                                line. Normal relationship of                                         Internal epicondyle (I),
                                the capitellum and radial                                            Trochlear (T), Olecranon
                                epiphysis.                                                           (O), External epicondyle

References available online                                                                             April/May 2021 | EM Resident 15
      The medial epicondyle fuses to the shaft of the humerus at           Joint effusion and soft tissue swelling may provide
  13 years for females and 15 years for males. The growth plates           secondary signs as to the presence of the lateral
  are vulnerable to traction or shearing forces which result in            condylar fracture. (Figure 8 a,b)
  fracture and/or apophyseal injuries. Displaced epicondyle
  fractures can be missed if the normal pattern of ossification
  development is not recognized.7
  5. Identify Distal Humeral Fractures
      Distal humeral fractures in pediatric patients include
  supracondylar, lateral condylar, medial epicondylar, medial
  condylar, and lateral epicondylar fractures. It is vital to
  correctly identify the fracture, as management varies greatly
  depending on the fracture (and severity). Following is a review
  of these fractures.
  A. Supracondylar fractures
      a. The most common pediatric elbow fracture is the
          supracondylar fracture, accounting for 50%-70% of
          cases, with a peak age of 6-7 years old.8 At this age,
          significant bony remodeling of the supracondylar
          process occurs, causing cortical thinning and                                            Figure 8. Lateral condylar
          predisposing to fracture. Falls onto an outstretched                                     fractures. a. Mildly avulsed
          hand account for 95% of supracondylar fractures,                                         lateral condylar fracture. b.
          causing hyperextension stress on the elbow.8 The                                         Complex comminuted lateral
          severity of a supracondylar fracture is identified                                       condylar fracture.
          using the Gartland classification, which is helpful in
          delineating management. Important complications of
          supracondylar fractures include neuropraxia (including    C. Medial epicondylar fractures
          anterior interosseous nerve, radial nerve, and ulnar         a. Fractures of the medial epicondyle make up
          nerve palsies) and vascular compromise. (Figure 7)              approximately 12% of all pediatric elbow fractures.10
                                                                          These fractures are typically due to valgus stress at
                                                                          the elbow joint such as from a posterior dislocation,
                                                                          a fall, or throwing, and usually occurs as an avulsion
                                                                          fracture.10 Peak injury is between 7-15 years old.
                                                                          Usually, patients will present with their elbow in flexion
                                                                          with associated pain at the medial aspect of the joint.
                                                                          Throwing mechanisms of injury may be described by
                                                                          patients as a “popping” sensation just prior to onset of
                                                                          pain. (Figure 9 a,b)

  Figure 7. Supracondylar fracture. Non-displaced
  supracondylar fracture (arrow) associated with joint
  effusion (b).

  B. Lateral condylar fractures
     a. Lateral condylar fractures are the second most
        common pediatric elbow fracture, accounting for
                                                                                                    Figure 9. Medial epicondyle
        10%-15% of elbow fracture, with a peak age of 6-10
                                                                                                    fractures. a. Avulsed medial
        years old.9 Patients usually present with lateral elbow
        pain after a FOOSH with the forearm in supination,                                          epicondyle fracture. b.
        creating a varus force on the elbow. A nondisplaced                                         Avulsed medial epicondyle
        lateral condylar fracture is often very subtle and                                          with an intra-articular position
        challenging to detect on conventional radiographs.                                          (arrow).

16 EMRA | •
D. Medial condylar fractures                                       F. Distal Humeral Epiphyseal Separation
   a. Medial condylar fractures are uncommon, accounting              a. This fracture is rare and has been described in children
      for less that 1% of all distal humeral fractures in                 less than 2 years of age. Common mechanisms include
      children. These fractures usually occur in children                 FOOSH, traction, and rotary forces. A considerable
      8-14 years of age after a fall onto an outstretched hand.           force is required to cause this fracture, and since young
      Typically these fractures present with medial soft tissue           infants are not mobile enough to produce this force,
      swelling with pain in the condylar region. It is difficult          non-accidental trauma must be suspected in these
      to distinguish between these and medial epicondylar                 cases. That being said, it can also occur due to birth
      fractures, however, these usually are NOT related to                trauma- both vaginal delivery and cesarean section. The
      dislocation.10 (Figure 10 a, b)                                     diagnosis can be challenging since the distal humeral
                                                                          epiphysis is cartilaginous and not visualized on x-rays.
                                                                          The most important finding is the posteromedial
                                                                          displacement of the radius and ulna in relation to the
                                                                          distal humerus.12 (Figure. 12)

                               Figure 10. Medial and lateral
                               condylar fractures. a. Non-
                               displaced medial (yellow
                               arrow) and lateral condylar
                               fractures (blue arrow). b. Mod­
                               erate joint effusion with efface­   Figure 12. Distal humeral epiphyseal separation. a. The
                               ment of the anterior fat pad.       capitellum, proximal radius, and proximal ulna are displaced
                                                                   medially. b. There is a small displaced bony fragment,
E. Lateral epicondylar fracture
                                                                   just inferior to the distal humeral metaphysis (arrow),
   a. Lateral epicondylar fractures are extremely rare and
      usually occur between ages 9-15 years. In the older          compatible with fracture through the distal humeral physis
      child, these fractures are due to a direct blow to the       with epiphyseal separation.
      lateral epicondylar region and are usually associated
      with other injuries of the elbow.11 In younger children,     6. Identify Radial and Ulnar Fractures
      avulsion forces from the forearm extensor muscles            A. Olecranon Fracture
      are responsible, likely due to a reaction mechanism.7           1. Olecranon fractures occur in children from a direct blow
      Pain and soft tissue swelling of the lateral epicondylar           to the elbow or from a FOOSH. Clinical presentation
      region are common complaints from patients with this               includes pain and swelling with point tenderness over
      fracture (Figure 11).                                              the olecranon. Most fractures are greenstick fractures,
                                                                         however, special attention should be made in regards to
                                                                         whether the fracture is extra-articular vs intra-articular.
                                                                         Always look for an associated injury, especially
                                                                         dislocation/fracture of the radial head.14 (Figure 13)
                                  Figure 11. Lateral
                                  epicondyle avulsion
                                                                                                                 Figure 13.
                                  fracture. Mild separation
                                  of the lateral epicondyle
                                                                                                                 fracture. Non-
                                  concerning for an
                                  avulsion fracture.
                                                                                                                 (yellow arrow).
                                                                                                                 Associated with
                                                                                                                 anterior joint
                                                                                                                 effusion (blue

References available online                                                                            April/May 2021 | EM Resident 17
  B. Proximal Radial Fracture
     1. Proximal radial fractures can occur in the
        radial head or the radial neck. Most common
        mechanisms of injury include FOOSH with
        the elbow extended or posterior dislocation of
        the elbow. Patients present with tenderness
        over the radial head with pain localized to the
        lateral aspect of the elbow with pronation and
        supination. Radial neck fractures typically are
        classified as Salter Harris II fractures through
        the physis, and radial head fractures are intra-
        articular and typically occur in older children or
        adolescents.13 (Figure 14)

  7. Management
      If a fracture is suspected, immediate orthopedic
  consultation is recommended. In cases of closed displaced
  fractures, a prompt reduction may be necessary. A fracture                                 Figure 14. Radial neck fracture.
  should be splinted in a position of function until outpatient                              a. Lateral cortical radial
  orthopedic follow-up is available. After placement of the                                  neck contour abnormality,
  splint, check that the extremity is neurovascularly intact.                                concerning for a buckle
      Upon discharge, include ED return precautions,                                         fracture, seen also on the
  information on splint care, and provide a sling. Cases that                                lateral view (b)
  require immediate attention in an operating room include
  open reductions, inability to reduce with procedural
  sedation, and any contraindications to procedural
  sedation. ¬

   always takes
   it one step
   too far.                                                       You’re there for them, we’re here for you.

                                                                            ACE P A N D E MR A’S OFFICI A L ON LIN E C A R E E R CE N T E R
                                                                                     POWERED BY HEALTH ECAREERS

18 EMRA | •

            Hemoperitoneum in a
          Reproductive-Age Woman
        Rolando Israel Castillo, DO                In the trauma room, large bore
    Good Samaritan Hospital Medical Center
                                                                                          Image 1
                                              intravenous access was obtained and
              David Levy, DO                  resuscitation was started with one
    Good Samaritan Hospital Medical Center    liter normal saline. A bedside RUSH
            Adam Schwartz, DO                 exam was performed, noting free
    Good Samaritan Hospital Medical Center
                                              fluid in Morrison’s pouch and in the

H     emoperitoneum during pregnancy
      is an emergent condition that places
the mother and fetus at risk. In a woman
                                              splenorenal space. Laboratory findings
                                              were significant for: leukocytes 20.9
                                              x10^3 /mcL, hemoglobin 10.4 gm/dL,
of childbearing age, the most common          lactic acid 4.3 mmol/L, and a beta hCG
sources of hemoperitoneum are ectopic         quant 18 mIU/mL (which corresponded
pregnancy and ruptured ovarian cysts.1        to an indeterminate result per the lab’s
The corpus luteum is a functional cyst that                                               Image 2
                                              reference range). The formal abdominal
develops from an ovarian follicle during      ultrasound showed complex free fluid
the luteal phase of each menstrual cycle.     suspicious for hemoperitoneum and
If a vessel supplying the corpus luteum       was otherwise unremarkable (Image 1),
ruptures, the patient may hemorrhage          and transvaginal ultrasound showed a
with blood spilling into the peritoneal       structure of complex echogenicity in the
cavity resulting in hemoperitoneum. We        right adnexa, which included a small
present the case of hemoperitoneum            cystic region with a surrounding thick
in a pregnant woman resulting from a          rim, of approximately 5.9 x 7.9 x 7.7 cm.
hemorrhagic corpus luteum during her          These findings were suspicions for right-
first trimester of pregnancy.                 sided ectopic pregnancy without an          corpus luteum remains, it can fill with
Case                                          intrauterine gestation. (Image 2)           fluid or blood thereby forming a cyst.
                                                   The patient was taken emergently           During early pregnancy there is a
    A 25-year-old G4P3003 female
                                              to the operating room for diagnostic        substantial increase in the stability of the
presented to the emergency department
                                              laparoscopic surgery with OB where          vessels that supply blood to the corpus
(ED) with a chief concern of abdominal
                                              1500 mL of blood was evacuated and          luteum3. When one of those vessels
pain and emesis since the prior evening.
                                              a ruptured hemorrhagic cyst ligated.        supplying the corpus luteum ruptures, the
The patient was brought immediately to
                                              The patient was discharged on post-         patient hemorrhages into the peritoneum.
the ED resuscitation room upon arrival
                                              operative day 2 after receiving one unit    Spontaneous hemoperitoneum can be
due to the severity of her abdominal
                                              of RBCs and having a doubling of her        a gynecological emergency, thus it is
pain as well as her vital signs. Her vitals
                                              beta-hCG, which provided reassurance        important to diagnose early and consult
were: BP 87/64 mmHg; HR 118; Resp
                                              of possible fetal viability.                the gynecology service.
20, SpO2 100%, Temp measured 96.8
                                                                                              In the presented case, performing a
°F, BMI 23.7 kg/m2. The patient’s pain        Discussion
                                                                                          bedside FAST exam was very beneficial
had started the night before while she             Hemoperitoneum due to a ruptured
                                                                                          because it immediately showed the
was laying down. She described it as          corpus luteum in early pregnancy is a
                                                                                          presence of fluid in the abdominal cavity.
severe (10/10), localized to the right        rare occurrence.2 The corpus luteum
upper quadrant, and with radiation            is a functional cyst that develops from     Conclusion
to her shoulder. She had unrelenting          an ovarian follicle during the luteal            In summary, the corpus luteum
nausea and vomited multiple times. She        phase of each menstrual cycle. The          is a functional cyst that produces
also had multiple episodes of non-bloody      area forms a dense network of capillary     progesterone during early pregnancy. In
diarrhea. Her last menstrual period was       vessels that enable the production of       rare occasions, the corpus luteum can
27 days prior to presentation, and she        progesterone needed to maintain early       rupture and result in hemoperitoneum
did not think she was pregnant. ROS           pregnancy until the placenta produces its   and hemodynamic instability. The use
was unremarkable. Of note, the patient’s      own progesterone around week eight.2        of bedside RUSH exam can be used to
past surgical history included the            Normally, if conception does not occur,     visualize peritoneal or pelvic fluid in an
removal of an intrauterine device due to      the corpus luteum goes through apoptosis    unstable patient and thereby reduce the
displacement a couple of months ago.          around the time of menstruation. If the     time from arrival to treatment. ¬

References available online                                                                             April/May 2021 | EM Resident 19

            Feel the Burn

                James Wang, MD                      Case                                      PTSD, but no previous suicide attempts/
                PGY-3 EM Resident                                                             ideation. A call was made to the Regional
                                                        A 56-year-old male with a past
                 TTUHSC El Paso                                                               Poison Control Center while toxicology,
                                                    medical history of alcohol abuse, post-
                Neha Sehgal, DO                                                               GI, and medical ICU consultations were
   Assistant Professor, Director of Undergraduate   traumatic stress disorder (PTSD), and
             Medical Education Services             depression presented via EMS to the
    Assistant Clinical Operations Director, UMC,                                                  Patient’s labs were remarkable
                                                    emergency department for persistent
                  TTUHSC El Paso                                                              for metabolic acidosis with a CO2 of 9
                                                    abdominal pain. Per EMS, the patient
               Susan Watts, PHD                                                               mmol/L, anion gap of 22 mmol/L; initial
                                                    drank approximately half a cup of
      Associate Professor, Director of Research                                               venous blood gas (VBG) with pH of 6.99,
                  TTUHSC El Paso                    battery acid 1 hour prior to arrival.
                                                                                              pCO2 of 48.5, base excess (BE) of -21.6,
                                                        On initial evaluation, the patient
 C    austic ingestions cause either
      coagulative (acidic substance) or
  liquefactive (alkaline substance) necrosis.
                                                    was hemodynamically stable but was
                                                    complaining of burning epigastric
                                                                                              and lactic acid of 4.7 mmol/L. The next
                                                                                              VBG showed worsening pH of 6.9, pCO2
                                                                                              of 54.1, BE of -24.8, and lactic acid of 5.1.
  Management and treatment include                  abdominal pain. Initial vitals were           Patient was intubated as his airway
  observation, labs, imaging, endoscopy, and        temperature 36⁰C, heart rate 72 beats     began to display whitened ulcerations in
  may require more urgent interventions             per minute, respirations 18 breaths       combination with his impending inability
  such as intubation and vasopressors.              per minute, blood pressure 128/82         to compensate for his metabolic acidosis.
  Consider consulting the local poison              mmHg, and O2 saturation 98% on room       He was admitted to medical ICU. The
  control center early and GI, ENT or               air. Physical exam was significant        patient suffered acute decompensation
  surgery depending on severity and types of        for mild tenderness in the epigastric     and was taken for emergent endoscopy
  injuries. Endoscopy is useful for prognosis,      region without rebound tenderness         by general surgery, which revealed
  but early CT imaging may also be useful           or guarding. Chart review indicated       grade 3 caustic esophagitis that
  and more readily available.                       a previous history of depression and      mandated gastrectomy.

20 EMRA | •
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