Transcript A Picture is worth 1000 words! But you only get 10 to
Emergency Snippets
Kelly Kasteel CCFP-EM 2007-2008
The 55 year-old man depicted in the photos below presented to the ED following a witnessed generalized seizure. He had no prior history of seizures. What is your diagnosis?
Herpes Zoster Encephalitis: rare neurologic complication of varicella zoster virus infection that typically occurs in the immunocompromised patient. VZV encephalitis is most likely to occur in the setting of Herpes Zoster Opthalmicus because this site of infection can facilitate viral entry into the CNS: the ophthalmic branch (V1) of the 5th CN branches to the tentorium via the recurrent nerve of Arnold .
7yo male, swallowed a game die while playing 7 days ago. Hasn’t noticed it in his stools. X-ray below. Should it be removed? What is a rare complication that may occur secondary to Die swallowing. (Bonus points if you know it!) Although dice may seem inert, some dice contain lead. This may not be immediately obvious. A serum lead level from this child was 84 mcg/dL (high) and his RBC's showed basophilic stippling. He was, however, asymptomatic, now 11 days post ingestion. A gastroenterologist was then consulted for endoscopic retrieval but the die was then passed in his stool.
Ten days later (21 days post ingestion) he presented with abdominal pain, diarrhea, and emesis. He also was noted to have gingival discoloration and speckling at the tip of the tongue. He was hospitalized at this point. His serum lead level was now 48 mcg/dL and his urine lead level was 253 (nl<80). He was thus treated with EDTA chelation for 3 days. He then became asymptomatic and was discharged home in stable condition.
What does this ECG show?
Trifascicular block
Complete Right Bundle Branch Block
– wide QRS, more than 120 ms (3 small squares) – secondary R wave in lead V1 – other features include slurred S wave in lateral leads and
T wave changes in the septal leads
left anterior hemiblock
–
QRS axis more left than -30 degrees
– initial R wave in the inferior leads (II, III and aVF) – absence of any other cause of
left axis deviation
long PR interval (also called first degree heart block)
– PR interval longer than 0.2 seconds
What does this show?
What are the 4 ssx?
Tenosynovitis
inflammation of the tendon and the surrounding synovial sheath Staphylococcus aureus is the most common organism most specific sign of tenosynovitis is pain with passive extension of the digit The abductor pollicis longus (APL), the extensor pollicis brevis (EPB), and the wrist are the most common sites for tenosynovitis Characterized by the four signs of Kanavel (described for a finger flexor tendon): – – – – mild flexion contracture fusiform swelling along the volar finger surface (sausage digit) tenderness along the entire tendon sheath especially at the palmar surface of the metacarpophalangeal (MCP) joint – and severe pain with passive extension
What does this show?
Epiglottitis
thumbprint sign of epiglottis characterized by sudden onset of fever, toxicity, moderate to severe respiratory distress with stridor, and variable degrees of drooling Haemophilus influenzae type B (HIB)
A 24 year old male presents with an itchy rash to his arms Allergic contact dermatitis Toxicodendron species ( poison ivy)
Poison Ivy
Allergic contact dermatitis Toxicodendron species ( poison ivy) Susceptible individuals Type IV allergic reaction Urushiol containing compounds (also mango skin, unroasted cashew nutshells)
A 34 year old female presents with lesions to her legs
Erythema nodosum
Painful nodules most commonly to shins Prodromal “flu-like” symptoms +/- arthralgias Causes of Erythema Nodosum?
Infectious – Strep – Staph – TB – Fungal (coccidiomycosis) Drugs – OCP – Sulfonamides Pregnancy Hodgkin’s, NHL Sarcoid IBD Behcet’s
What is this ?
DDX, treatment?
Hair Tourniquet
A strand of hair has encircled the middle toe in two places, causing erythema and swelling.
DDX-Insect bites, trauma, or cellulitis of the digit may have a similar appearance Tx- retract the skin around the proximal aspect of the edema. consider local digital block prior to removal. Elevation of the involved digit after removal of the constricting agent provides resolution of the edema and erythema within 2 to 3 days. Subspecialty consultation should be considered whenever neurovascular integrity is in question .
What are these two fractures called?
Hint: They are angled in opposite directions!
2 1
What are these two fractures called?
1=SMITH Fracture Also called a reverse Colles fracture a transverse fracture of the distal radial metaphysis with palmar (as opposed to dorsal) displacement of the distal fracture fragment. If the fracture is intraarticular, it is called a reverse Barton fracture. This fracture results from a backward fall onto the outstretched hand 2= Colles Fracture also Colles fracture, is a distal radial fracture with dorsal angulation Often found with forced extension or foosh injury
What is this?
Appendicitis
What can cause the following skin changes?
Nikolsky’s sign Causes?
– Erythema multiforme major (SJS) – Staph scalded skin syndrome (SSSS) – Toxic Epidermal Necrolysis (TEN) – Toxic Shock Syndrome – Bullous pemphigus – Burns Treatment?
Burn unit Fluid resuscitation
A 28 year old male presents with a non-pruritic rash to his torso that over time spreads to his extremities:
Kaposi’s Sarcoma
Cause: HHV-8 Initial presentation: cutaneous Tumour cells --> spindle cells Can spread to mucous membranes, internal organs
A 48 year old gentleman presents with a painful red face
How to differentiate cellulitis from erysipelas?
Cellulitis More indiscreet margins Erysipelas Sharply demarcated borders Fiery red, indurated Lymphatic involvement “St. Anthony’s Fire” Causes-
Elevation of the antistreptolysin of illness.
O titre occurs after around 10 days Depending on the severity, treatment involves either oral or intravenous antibiotics, using penicillins , clindamycin or erythromycin . While illness symptoms resolve in a day or two, the skin may take weeks to return to normal
What fracture is this and what is it associated with Maisonneuve Fracture a proximal fracture of fibula resulting from external rotation; injury may occur w/medial malleolar fractures or deltoid ligament rupture Due to syndesmosis disruption.
What is this? Treatment?
SEPTIC OLECRANON BURSITIS
The fluid collection may be bacterial gouty, or, most commonly, inflammatory characterized by pain, tenderness, and swelling at the extremes of motion (vs septic joint) Tx – Rest, bulky compression dressings, and NSAIDs. – Reducing the volume of the inflammatory effusion by aspiration may provide temporary relief, although the effusion has a propensity to recur.
– Septic bursitis requires aspiration, gram-positive antibiotic coverage, and consideration of open incision and drainage. – Most patients can be treated as outpatients with close follow-up
A 17 year old female involved in an MVC complains of neck pain Clay shoveler’s fracture Mechanism?
– Forced hyperflexion Stable or unstable?
– Stable Treatment?
Two patients injured their thumbs: Patient 1
Patient 2
Name the two fractures
Rolando: Comminuted fracture / dislocation base of 1st MCP Usually three main fragments: “Y” shaped Less common; poorer prognosis Bennett: Intrarticular fracture base of 1st MCP
Most common of all thumb fractures
Both are treated surgically and ortho/plastics follow-up arraged
A 40 year old female tripped and fell when she stepped into a gopher hole while running and now has pain to her foot:
Lisfranc injury
Normal alignment: PA view: – Medial edge of 2nd metarsal should align with 2nd cuneiform Oblique view:
– Medial edge of 3rd metatarsal should align with 3rd cuneiform
A 12 year old boy injured his leg after sliding into base during a ball game:
Tillaux fracture
Salter-Harris Type III; adolescents Mechanism: External rotation injury of the foot in a
Anterior tibiofibular ligament intact: avulsion of epiphysis
What is this and how do you calculate for fractures
Bohler’s angle
which is the angle defined by 2 intersecting lines: one drawn from anterior process of the calcaneus to the peak of the posterior articular surface and a second drawn from the peak of the posterior articular surface to the peak of the posterior tuberosity. The average angle is 25-40°.
In severe fractures with subtalar joint involvement, this angle may decrease or become negative
Bohler’s angle
A 25 year old female fell onto her knee: What are the Ottawa knee rules?
A knee x-ray is only required for knee injury patients with any of these findings: age 55 or over isolated tenderness of the patella (no bone tenderness of the knee other than the patella) tenderness at the head of the fibula inability to flex to 90 degrees inability to weight bear both immediately and in the casualty department (4 steps - unable to transfer weight twice onto each lower limb regardless of limping).
Now, what’s the fracture?
Patellar fracture Treatment?
Non-surgical – Undisplaced – Vertical – Peripheral – No step-off Surgical – Displaced
Hearing Loss Tinnitus Vertigo
What is it?
Meniere’s disease
Fever, RUQ pain, jaundice Charcot’s triad Ascending cholangitis Combined with CNS changes and hypotension --> Reynaud’s pentad
Clenched fist by patient to describe chest pain
Levine’s sign
What does this picture show?
List the most common symptoms?
Uveitis
perilimbal hyperemia Symptoms of uveitis include: - light sensitivity - blurring of vision - eye pain (often described as an aching sensation) - redness of the eye.
The history should focus on rheumatic illness, dermatologic problems, bowel disease, infectious exposures, and sexual history
uveitis
Key diagnostic features of anterior uveitis are a miotic pupil, ciliary flush, and the finding of cells and flare in the anterior chamber Anterior Chamber Cells Cells in the anterior chamber are a sign of inflammation or bleeding and appear similar to particles of dust in a sunbeam Anterior Chamber Flare . Flare seen in a slit-lamp beam appears similar to a car headlight cutting through the fog
Give a differential diagnosis for a DECREASED anion gap Hyponatremia Low serum albumin Ocult neoplasm --> multiple myeloma Hyperchloremic acidosis Lithium toxicity (sodium effect) Kidney disease (unmeasured cations)
A gentleman presents with the following: Questions?
Differential Diagnosis?
Chancroid Herpes Syphilis Behcet’s Other: Lymphogranuloma venereum (LGV) Granuloma inguinale (GI) Drug eruption Systemic/dermatologic
The minimum toxic dose for an
acute ingestion
of Tylenol (ie. occurring within a time frame of four hours) is:
a) Adults: 7.5g (or ~140mg/kg) b) Peds: 150mg/kg
While minding his own business, this patient broke a tooth which is now very painful: Ellis I: enamel Ellis II: dentin Ellis III: pulp Treatment Dentist Analgesia Antibiotics
Protective barrier: Chewing gum?
A RN accidentally injected herself with epinephrine in her thumb The thumb is cool and pale How would you treat it?
Phentolamine Alpha antagonist Dilute 1.5 mg of phentolamine mesilate (vials contain 10mg/cc) = 0.15 cc in 1 cc of 2% lidocaine Inject subcutaneously into the site and stop when skin becomes pink Management of adrenaline induced digital ischemia in children after accidental injection from an Epipen Emerg Med J 2004;21:387-388
A 50 year old man has very painful burning sensation to hands after working with a rust remover: Hydroflouric acid Treatment?
Calcium Gluconate How to administer?
1 amp= 10% Ca gluconate= 10 cc Reference: E-medicine
Calcium Gluconate
Gel: Mix one amp with one ounce of surgical gel (10 packets of muco) Nebules: Mix one amp with 30 cc NS to form a 2.5% solution IV Calcium: one amp + 5000 units heparin diluted in 40 cc D5W; use a Bier block Intra-arterial calcium: Mix one amp with 40 cc D5W; infuse over a 4 hour period
What is the treatment for Acute Angle Closure Glaucoma?
pilocarpine 1 or 2%, one drop every 5 min x 2. If the pupil does not respond, one drop every hour x 4 should be administered Aqueous outflow is increased A- alpha-adrenergic agonist (apraclonidine, 1%, one drop every 12 h) B-Beta Blocker (timolol maleate, 0.5%, one drop every 12 h) C- carbonic anhydrase inhibitor (Diamox 500mg po) D- Diuretics- Mannitol 1g/kg bolus
What is wrong with this ECG
What is wrong with this ECG
Acute inferior myocardial infarction ST elevation in the inferior leads II, III and aVF reciprocal ST depression in the anterior leads
Cardiac Zones of MI – Inferior-II, III, aVF – Anteroseptal-V1 to V3 – Anterior-V3 and V4 – Anterolateral-V4 and V6, I, aVL – Posterior-V1 to V3 look for ST-segment depression
What is this?
Xanthochromia
Relates to the discoloration of the CSF from RBC breakdown subsequent to hemorrhage.
Present as early as 6 hours after SAH and can persist for 2-3 weeks Xanthocromia takes time to develop ie. Seen in 70% by 6h, 90% by 12h after SAH. No utility if less than 2 hrs.
Can also be seen in jaundiced patients and those with high CSF protein levels.
Name these two forearm fractures 1 2
Name these two forearm fractures
#1=Monteggia's Fracture frx of proximal 1/3 of ulna in association w/ anterio dislocation of radial head Ummmmmm
#2=Galeazzi's Fracture (Adults)
frx of radial shaft (between middle and distal 1/3's) and dislocation of radioulnar joint.
Grrrrrr
What is wrong here?
Subarachnoid hemorrhage
90-95% of all intracranial aneurysms are located in the carotid system. The anterior communicating artery is the most common site (30%) followed by the posterior communicating artery (25%) and the middle cerebral artery (20%).
What is the sensitivity of CT in SAH? (24 hrs/3 days)
Within first 12 hours after onset of the headache, CT sensitivity approaches 98% Acad Emerg Med 3; 827-831, 1996 Three days after onset of the headache, the CT is only 85% sensitive, and at 7 days, it is only 50% sensitive.
Thanks to….
The internet ECGs: medstat.med.utah.edu/kw/ecg/image_index X-rays: www.rad.washington.edu/teachingfiles.html
Eye cases: icarus.med.utoronto.ca
Trauma pics: trauma.org/imagebank Derm pics: dermis.net
Medical pictures: www.mic.ki.se/MEDIMAGES.html
Eponyms: www.whonamedit.com
Online teaching: www.mdchoice.com