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Resident
Official Publication of the Emergency Medicine Residents’ Association
April/May 2021
VOL 48 / ISSUE 2
Managing
the
COVID
Airway
The Pediatric Elbow
Near-Death by Nasal Packing
Developing a Diversity Pipeline
We Help Healers
Reach New Heights SCP
Health
Meet Your Medical
Career Dream Team SCP
Health
Step Right Up, Residents!
As you’re transitioning from
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career, our team is here to
create a tailored environment
for you that fosters growth and
delivers rewarding daily work
experiences.
Explore clinical careers at
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TOGETHER, WE HEAL
Post-Match Priyanka Lauber, DO
Editor-in-Chief, EM Resident
Lehigh Valley Health Network
@PriyankaLauber
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! ¬
TABLE OF CONTENTS
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
LEADERSHIP, AWARDS ENT, TRAUMA
Lehigh Valley Health Network
34
EDITORS
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
ULTRASOUND
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
ChristianaCare
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
TRAUMA, OB/GYN
40 Building Global EM and Its
Sarah Ring, MD
20 Caustic Ingestions
TOXICOLOGY
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
and
Pneumoscrotum 44 A Letter from a
Paramedic to an EM Doc
Jeremy Berberian, MD
ChristianaCare
Disguised as Angioedema PREHOSPITAL, EMS
PEM Fellowship Editor
46 Navigating
TRAUMA the Military Emine Tunc, MD
26
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
ULTRASOUND
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
ULTRASOUND,
INFECTIOUS DISEASE
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
HYPERBARIC MEDICINE
51 ECG Challenge
CARDIOLOGY
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
INFECTIOUS DISEASE
© 2020 CEP America, LLC. Vituity® is a registered trademark of CEP America, LLC
April/May 2021 | EM Resident 3
LEADERSHIP
Class of 2022,
We’re Here
for You
RJ Sontag, MD
EMRA President
Mid Ohio Emergency Services
@RJSontagMD
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
evolves.
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 president@emra.org or reach out to us on social
@emresidents. ¬
4 EMRA | emra.org • emresident.org
MOVING MEDICINE FORWARD, ONE INNOVATIVE
MIND AT A TIME. THAT’S THE ARMY DIFFERENCE.
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 healthcare.goarmy.com/aqs7
April/May 2021 | EM Resident 5
©2021. Paid for by the United States Army. All rights reserved.
P E R K S
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
PEER EM:RAP
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Visit emra.org/benefits
and get the most from your membership
Medical Students | Residents | Fellows | Alumni
Oldest & Largest EM Resident Association
6 EMRA | emra.org • emresident.org
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
COVID-19, AIRWAY
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 | emra.org • emresident.orgof 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
Method
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 9PEDIATRICS, COVID-19
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 | emra.org • emresident.organaphylaxis, 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)
11.9
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 11PEDIATRICS, COVID-19
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 | emra.org • emresident.orgULTRASOUND, CARDIOLOGY, TRAUMA
AIRWAY
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
Advantages
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 13PEDIATRICS, ORTHOPEDICS
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
management.2,3
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 | emra.org • emresident.orgmarrow 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
Epicondyle
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
(E).
References available online April/May 2021 | EM Resident 15PEDIATRICS, ORTHOPEDICS
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 | emra.org • emresident.orgD. 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
Olecranon
of the lateral epicondyle
fracture. Non-
concerning for an
displaced
avulsion fracture.
transverse
olecranon
fracture
(yellow arrow).
Associated with
anterior joint
effusion (blue
arrow).
References available online April/May 2021 | EM Resident 17PEDIATRICS, ORTHOPEDICS
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. ¬
Because
someone
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 | emra.org • emresident.orgTRAUMA, OB/GYN
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 19TOXICOLOGY
CAUSTIC
INGESTIONS
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
initiated.
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 | emra.org • emresident.orgYou can also read
