A 34-year-old male with a history of rheumatoid arthritis and interstitial lung disease presents to the emergency department with joint pain unimproved with home medications. He suspects the precipitant is a recent illness, describing cough and nasal congestion. He also noted a “crunching” sensation when turning his neck not otherwise associated with fevers, recurrent vomiting, chest pain, abdominal pain or difficulty breathing.

A chest radiograph was obtained which demonstrated pneumomediastinum.

Imaging from several months prior to presentation is shown below:

The patient was placed on supplemental oxygen, a repeat chest CT was obtained.

The etiology of the patient’s spontaneous pneumomediastinum was deemed to be related to his underlying interstitial lung disease provoked by viral respiratory tract infection related coughing. He was observed for two days without decompensation and was discharged with outpatient follow-up.

Pathophysiology of Pneumomediastinum

Spontaneous pneumomediastinum results from the rupture of terminal alveoli with subsequent tracking of gas along the bronchovascular tree through interstitial lung tissue to the mediastinum and adjacent structures (pleural, pericardial, retropharyngeal, retroperitoneal, intraperitoneal and subcutaneous spaces)¹.

Secondary pneumomediastinum arises from non-alveolar sources including the gastrointestinal tract (most gravely, esophageal rupture though also from other intraperitoneal sources²), and upper respiratory tract (including facial fractures³).

Management of Pneumomediastinum^5-7

The management of spontaneous pneumomediastinum focuses on treatment of the underlying precipitant, supportive care, administration of supplemental oxygen (to promote gas reabsorption) and observation for complications including rare progression to tension pneumomediastinum⁴.

Secondary pneumomediastinum is of significantly more concern and should be suspected in patients with any of the following features:

Management is aggressive including resuscitation, maintenance of NPO status, broad-spectrum antibiotics, and emergent surgical consultation.

Differential Diagnosis of Pneumomediastinum^5-11

References:

1. Macklin, M., Macklin, C. (1944). Malignant Interstitial Emphysema of the Lungs and Mediastinum as an Important Occult Complication in Many Respiratory Diseases and Other Conditions: an Interpretation of the Clinical Literature in the Light of Laboratory Experiment Medicine 23(4)
2. Fosi, S., Giuricin, V., Girardi, V., Caprera, E., Costanzo, E., Trapano, R., Simonetti, G. (2014). Subcutaneous Emphysema, Pneumomediastinum, Pneumoretroperitoneum, and Pneumoscrotum: Unusual Complications of Acute Perforated Diverticulitis Case Reports in Radiology 2014(), 1-5. https://dx.doi.org/10.1155/2014/431563
3. Luca, G., Petteruti, F., Tanga, M., Luciano, A., Lerro, A. (2011). Pneumomediastinum and Subcutaneous Emphysema Unusual Complications of Blunt Facial Trauma Indian Journal of Surgery 73(5), 380-381. https://dx.doi.org/10.1007/s12262-011-0310-x
4. Shennib, H., Barkun, A., Matouk, E., Blundell, P. (1988). Surgical Decompression of a Tension Pneumomediastinum Chest 93(6), 1301-1302. https://dx.doi.org/10.1378/chest.93.6.1301
5. Bakhos, C., Pupovac, S., Ata, A., Fantauzzi, J., Fabian, T. (2014). Spontaneous pneumomediastinum: an extensive workup is not required. Journal of the American College of Surgeons 219(4), 713-7. https://dx.doi.org/10.1016/j.jamcollsurg.2014.06.001
6. Iyer, V., Joshi, A., Ryu, J. (2009). Spontaneous Pneumomediastinum: Analysis of 62 Consecutive Adult Patients Mayo Clinic Proceedings 84(5), 417-421. https://dx.doi.org/10.4065/84.5.417
7. Takada, K., Matsumoto, S., Hiramatsu, T., Kojima, E., Shizu, M., Okachi, S., Ninomiya, K., Morioka, H. (2009). Spontaneous pneumomediastinum: an algorithm for diagnosis and management. Therapeutic advances in respiratory disease 3(6), 301-7. https://dx.doi.org/10.1177/1753465809350888
8. Al-Mufarrej, F., Badar, J., Gharagozloo, F., Tempesta, B., Strother, E., Margolis, M. (2008). Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. Journal of cardiothoracic surgery 3(1), 59. https://dx.doi.org/10.1186/1749-8090-3-59
9. Takada, K., Matsumoto, S., Hiramatsu, T., Kojima, E., Watanabe, H., Sizu, M., Okachi, S., Ninomiya, K. (2008). Management of spontaneous pneumomediastinum based on clinical experience of 25 cases Respiratory Medicine 102(9), 1329-1334. https://dx.doi.org/10.1016/j.rmed.2008.03.023
10. Bejvan, S., Godwin, J. (1996). Pneumomediastinum: old signs and new signs. American Journal of Roentgenology 166(5), 1041-1048. https://dx.doi.org/10.2214/ajr.166.5.8615238
11. Langwieler, T., Steffani, K., Bogoevski, D., Mann, O., Izbicki, J. (2004). Spontaneous pneumomediastinum The Annals of Thoracic Surgery 78(2), 711-713. https://dx.doi.org/10.1016/j.athoracsur.2003.09.021

The post Pneumomediastinum appeared first on Differential Diagnosis of.

A 43-year-old female with a history of hypertension, diabetes and obesity presents with right-upper quadrant abdominal pain for the past 1 week. The pain is characterized as burning, non-radiating, intermittent (with episodes lasting 10-30 minutes), resolving spontaneously and without apparent provoking features. She notes nausea but no vomiting, no changes in bowel or urinary habits. She similarly denies fevers, chest pain or shortness of breath. Vital signs were normal, and physical examination was notable only for right upper quadrant tenderness to palpation without rigidity or guarding.

An ECG demonstrates normal sinus rhythm, laboratory tests including liver function tests and lipase were normal and a bedside ultrasound of the right upper quadrant was performed demonstrating gallstones and a positive sonographic Murphy sign. The patient was diagnosed with acute cholecystitis, antibiotics were initiated, the patient was maintained NPO while general surgery was consulted.

Evaluation of Right-Upper Quadrant Abdominal Pain

The initial evaluation of a patient presenting with right-upper quadrant (or adjacent) abdominal pain typically includes laboratory tests such as a complete blood count, chemistry panel, liver function tests and serum lipase. In patients at risk for atypical presentations for an acute coronary syndrome or with other concerning symptoms, electrocardiography and cardiac enzymes may be indicated.

The differential diagnosis is broad. A systematic approach proceeds anatomically from superficial to deeper structures centered around the site of maximal pain.

Ultrasound in the Evaluation of Right Upper Quadrant Abdominal Pain

The diagnosis is unlikely to be made based on laboratory tests alone ¹. However, the addition of bedside ultrasound, particularly for the evaluation of gallbladder pathology, is both rapid and reliable ^2-8. The algorithm below provides a pathway for the incorporation of bedside ultrasound of the right upper quadrant in the evaluation of suspected gallbladder disease.

A normal-appearing gallbladder absent gallstones should prompt a traversal of the anatomic approach to the differential diagnosis detailed above. If gallstones are identified, the association with a positive sonographic Murphy sign is highly predictive of acute cholecystitis ^2,5,6,9. Acute cholecystitis may be associated with inflammatory gallbladder changes such as wall-thickening (>3mm) or pericholecystic fluid ^3,5,6,10-13. However, in the absence of cholelithiasis or a positive sonographic Murphy sign, these features are non-specific and may be the result of generalized edematous states such as congestive heart failure, renal failure, or hepatic failure and critically-ill patients may develop acalculous cholecystitis ^7,11,14. Finally, common bile duct dilation may be due to intra-luminal obstruction as in choledocholithiasis, luminal abnormalities such as strictures, or extra-luminal compression from masses or malignancy.  Dilation is generally described as a diameter >6mm – allowing an additional 1mm for every decade over 60 years-old as well as more vague accommodations for patients with prior cholecystectomy ^3,5,7,15.

Gallery

The POCUS Atlas
The ultrasound images and videos used in this post come from The POCUS Atlas, a collaborative collection focusing on rare, exotic and perfectly captured ultrasound images.

Gallstones

Many gallstones

Gallbladder wall thickening

Pericholecystic fluid

Choledocholithiasis

Common bile duct dilation

References

1. Trowbridge RL, Rutkowski NK, Shojania KG. Does this patient have acute cholecystitis? JAMA. 2003;289(1):80-86.
2. Scruggs W, Fox JC, Potts B, et al. Accuracy of ED Bedside Ultrasound for Identification of gallstones: retrospective analysis of 575 studies. West J Emerg Med. 2008;9(1):1-5.
3. Ross M, Brown M, McLaughlin K, et al. Emergency physician-performed ultrasound to diagnose cholelithiasis: a systematic review. Acad Emerg Med. 2011;18(3):227-235. doi:10.1111/j.1553-2712.2011.01012.x.
4. Jang T, Chauhan V, Cundiff C, Kaji AH. Assessment of emergency physician-performed ultrasound in evaluating nonspecific abdominal pain. Am J Emerg Med. 2014;32(5):457-460. doi:10.1016/j.ajem.2014.01.004.
5. Kendall JL, Shimp RJ. Performance and interpretation of focused right upper quadrant ultrasound by emergency physicians. J Emerg Med. 2001;21(1):7-13.
6. Summers SM, Scruggs W, Menchine MD, et al. A prospective evaluation of emergency department bedside ultrasonography for the detection of acute cholecystitis. Ann Emerg Med. 2010;56(2):114-122. doi:10.1016/j.annemergmed.2010.01.014.
7. Rubens DJ. Ultrasound Imaging of the Biliary Tract. Ultrasound Clinics. 2007;2(3):391-413. doi:10.1016/j.cult.2007.08.007.
8. Rosen CL, Brown DF, Chang Y, et al. Ultrasonography by emergency physicians in patients with suspected cholecystitis. American Journal of Emergency Medicine. 2001;19(1):32-36. doi:10.1053/ajem.2001.20028.
9. Shea JA. Revised Estimates of Diagnostic Test Sensitivity and Specificity in Suspected Biliary Tract Disease. Arch Intern Med. 1994;154(22):2573-2581. doi:10.1001/archinte.1994.00420220069008.
10. Miller AH, Pepe PE, Brockman CR, Delaney KA. ED ultrasound in hepatobiliary disease. J Emerg Med. 2006;30(1):69-74. doi:10.1016/j.jemermed.2005.03.017.
11. Shah K, Wolfe RE. Hepatobiliary ultrasound. Emergency Medicine Clinics of NA. 2004;22(3):661–73–viii. doi:10.1016/j.emc.2004.04.015.
12. Matcuk GR, Grant EG, Ralls PW. Ultrasound measurements of the bile ducts and gallbladder: normal ranges and effects of age, sex, cholecystectomy, and pathologic states. Ultrasound Q. 2014;30(1):41-48. doi:10.1097/RUQ.0b013e3182a80c98.
13. Engel JM, Deitch EA, Sikkema W. Gallbladder wall thickness: sonographic accuracy and relation to disease. American Journal of Roentgenology. 1980;134(5):907-909. doi:10.2214/ajr.134.5.907.
14. Gerstenmaier JF, Hoang KN, Gibson RN. Contrast-enhanced ultrasound in gallbladder disease: a pictorial review. Abdom Radiol (NY). 2016;41(8):1640-1652. doi:10.1007/s00261-016-0729-4.
15. Becker BA, Chin E, Mervis E, Anderson CL, Oshita MH, Fox JC. Emergency biliary sonography: utility of common bile duct measurement in the diagnosis of cholecystitis and choledocholithiasis. J Emerg Med. 2014;46(1):54-60. doi:10.1016/j.jemermed.2013.03.024.

The post Hepatobiliary Ultrasound appeared first on Differential Diagnosis of.

A 27 year-old female is brought in by ambulance with syncope. Pre-hospital providers report that the patient developed pelvic pain, vaginal bleeding and lost consciousness. On their arrival, her blood pressure was 80mmHg systolic, point-of-care glucose was normal – a peripheral IV was started, fluids were administered and the patient was transported to the emergency department. On arrival, vital signs were notable for tachycardia and hypotension. The patient was lethargic, maintaining arousal only with constant verbal or noxious stimulation. Her abdomen was markedly tender throughout with rebound and involuntary guarding. Her last menstrual period was 5 weeks ago and she suspected that she was pregnant. Peripheral venous access was expanded and uncrossmatched blood products were rapidly transfused. Whole blood on a point-of-care pregnancy test was positive¹, and a bedside FAST demonstrated free intraperitoneal fluid in the hepatorenal recess with large free pelvic fluid. Gynecology was consulted for emergent operative management of suspected ruptured ectopic pregnancy with hemorrhagic shock and the patient was taken to the operating room.

Algorithm for the Evaluation of Suspected Ectopic Pregnancy

Gallery

The POCUS Atlas
The ultrasound images and videos used in this post come from The POCUS Atlas, a collaborative collection focusing on rare, exotic and perfectly captured ultrasound images.

Ruptured Cornual Ectopic

Tubal Ectopic Pregnancy

Ectopic Pregnancy

Positive FAST in Ruptured Ectopic

The evaluation of suspected ectopic pregnancy, as with all complaints in the emergency department, begins with an assessment of patient stability: airway, breathing and circulation. The unstable patient requires immediate interventions to secure each critical component, all temporizing measures until the patient can be taken to the operating room for definitive management.

The evaluation and management algorithm for stable patients is dependent on findings of transabdominal & transvaginal ultrasonography, quantitative hCG level (relative to the institution-dependent discriminatory zone), and the identification of high risk historical and examination features that would prompt specialist consultation despite otherwise benign diagnostic tests.

If ultrasonography demonstrates a definite ectopic pregnancy (extrauterine live embryo,  adnexal mass containing yolk sac), gynecology consultation is warranted – the table below details candidates for attempts at pharmacologic therapy.

Requirements for methotrexate administration^2,3

Absolute

Hemodynamic stability

Ultrasound findings consistent with an ectopic pregnancy

Willingness of the patient to adhere to close follow-up

No existing organ dysfunction: hepatic, renal, pulmonary, hematologic, immune

Relative

Unruptured ectopic mass <3.5cm

No fetal cardiac activity detected

hCG <5000 mIU/L

If an intrauterine pregnancy is identified such as a live embryo or yolk sac, barring the presence of risk factors for heterotopic pregnancy (namely, the use of assisted fertilization methods ^{2, 4-6}), then an alternative cause for the patient’s symptoms should be sought.

If the ultrasound is non-diagnostic, patients should be stratified according to risk based on historical features, examination findings and quantitative hCG. If the hCG is above the institutional discriminatory zone, the absence of a definitive IUP is concerning, elevating suspicion for a non-visualized ectopic and warrants gynecology consultation. If the hCG is below the discriminatory zone, then certain features such as the presence of abdominal, adnexal or cervical motion tenderness, or high-risk ultrasonographic features including greater-than-moderate free pelvic fluid, complex fluid, or complex adnexal masses may be secondary features of ectopic pregnancy – again warranting consultation. If no high-risk features are present, close follow-up with repeat hCG and ultrasonography is reasonable.

Algorithm for the Evaluation of Vaginal Bleeding

References:

1. Fromm C, Likourezos A, Haines L, Khan ANGA, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012;43(3):478-482. doi:10.1016/j.jemermed.2011.05.028.
2. Bhatt S, Ghazale H, Dogra VS. Sonographic Evaluation of Ectopic Pregnancy. Radiol Clin North Am. 2007;45(3):549-560. doi:10.1016/j.rcl.2007.04.009.
3. Barash JH, Buchanan EM, Hillson C. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2014;90(1):34-40.
4. Lin EP, Bhatt S, Dogra VS. Diagnostic Clues to Ectopic Pregnancy. Radiographics. 2008;28(6):1661-1671. doi:10.1148/rg.286085506.
5. Winder S, Reid S, Condous G. Ultrasound diagnosis of ectopic pregnancy. Australas J Ultrasound Med. 2011;14(2):29-33. doi:10.1002/j.2205-0140.2011.tb00192.x.
6. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy?: the rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. doi:10.1001/jama.2013.3914.
7. Mol BW, van Der Veen F, Bossuyt PM. Implementation of probabilistic decision rules improves the predictive values of algorithms in the diagnostic management of ectopic pregnancy. Hum Reprod. 1999;14(11):2855-2862.
8. First-Trimester Emergencies: A Practical Approach To Abdominal Pain And Vaginal Bleeding In Early Pregnancy. October 2003:1-20.
9. Paspulati RM, Bhatt S, Nour S. Sonographic evaluation of first-trimester bleeding. Radiol Clin North Am. 2004;42(2):297-314. doi:10.1016/j.rcl.2004.01.005.
10. Anderson FWJ, Hogan JG, Ansbacher R. Sudden Death: Ectopic Pregnancy Mortality. Obstet Gynecol. 2004;103(6):1218-1223. doi:10.1097/01.AOG.0000127595.54974.0c.
11. Lozeau A-M, Potter B. Diagnosis and management of ectopic pregnancy. Am Fam Physician. 2005;72(9):1707-1714.
12. Stone MB. Emergency Ultrasound Diagnosis of Ruptured Ectopic Pregnancy. Academic Emergency Medicine. 2009;16(12):1378-1378. doi:10.1111/j.1553-2712.2009.00538.x.
13. Stein JC, Wang R, Adler N, et al. Emergency Physician Ultrasonography for Evaluating Patients at Risk for Ectopic Pregnancy: A Meta-Analysis. Ann Emerg Med. 2010;56(6):674-683. doi:10.1016/j.annemergmed.2010.06.563.
14. Fromm C, Likourezos A, Haines L, Khan ANGA, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012;43(3):478-482. doi:10.1016/j.jemermed.2011.05.028.
15. Alkatout I, Honemeyer U, Strauss A, et al. Clinical diagnosis and treatment of ectopic pregnancy. Obstet Gynecol Surv. 2013;68(8):571-581. doi:10.1097/OGX.0b013e31829cdbeb.
16. Arleo EK, DeFilippis EM. Cornual, interstitial, and angular pregnancies: clarifying the terms and a review of the literature. Clinical Imaging. 2014;38(6):763-770. doi:10.1016/j.clinimag.2014.04.002.
17. Rodgers SK, Chang C, DeBardeleben JT, Horrow MM. Normal and Abnormal US Findings in Early First-Trimester Pregnancy: Review of the Society of Radiologists in Ultrasound 2012 Consensus Panel Recommendations. Radiographics. 2015;35(7):2135-2148. doi:10.1148/rg.2015150092.
18. Diagnosis and Management of Ectopic Pregnancy: Green-top Guideline No. 21. BJOG. 2016;123(13):e15-e55. doi:10.1111/1471-0528.14189.
19. Hahn SA, Promes SB, Brown MD, et al. Clinical Policy: Critical Issues in the Initial Evaluation and Management of Patients Presenting to the Emergency Department in Early Pregnancy. Ann Emerg Med. 2017;69(2):241–250.e20. doi:10.1016/j.annemergmed.2016.11.002.
20. Lee R, Dupuis C, Chen B, Smith A, Kim YH. Diagnosing ectopic pregnancy in the emergency setting. Ultrasonography. 2018;37(1):78-87. doi:10.14366/usg.17044.

The post Ultrasound in Ectopic Pregnancy appeared first on Differential Diagnosis of.

A 45 year-old female with a history of pre-diabetes and gastroesophageal reflux disease presents with 3 days of epigastric abdominal pain. She describes constant, burning abdominal pain which worsened on the day of presentation associated with two episodes of non-bloody and non-bilious emesis. The patient was tender to palpation in the epigastrium and right upper quadrant.

Laboratory studies were largely normal. A complete blood count demonstrated minimal leukocytosis (11.6 with normal differential), and liver function tests were normal.

A right-upper quadrant ultrasound was obtained which demonstrated “strongly shadowing structures in the gallbladder fossa which might represent a wall-echo-shadow, calcified gallbladder wall, or air within the gallbladder”.

The patient underwent contrast-enhanced computed tomography of the abdomen and pelvis which is shown below.

Imaging

The patient was taken to the operating room for exploratory laparotomy, possible cholecystectomy and possible small bowel resection for presumed gallstone ileus. Intra-operative findings were notable for a cholecystogastric fistula which was repaired.

Differentiation between Portal Venous Gas and Pneumobilia

The patient’s CT demonstrated mostly central hepatic gas. This finding combined with the presence of an air-fluid level in the gallbladder was most consistent with pneumobilia. This case demonstrates an application of the previously-developed algorithm for the evaluation of hepatic gas in a relatively unique pathologic process.

The post Pneumobilia: Hepatic Gas Applied appeared first on Differential Diagnosis of.

XR Chest: Circular radioopaque foreign body likely in the antrum of the stomach.

A healthy 5 year-old boy is brought to the pediatric emergency department after he informed his parents that he accidentally swallowed a coin just prior to presentation. He has no complaints and on evaluation appears to be breathing comfortably and is tolerating secretions normally. A plain radiograph was obtained and is shown below.

The patient remained well-appearing and was discharged with primary care follow-up.

Indications for Emergent Endoscopy

• Esophageal button battery
• Severe symptoms
• Sharp foreign body in esophagus
• Multiple magnets in esophagus or stomach

Radiographic Findings

Esophageal foreign bodies typically orient coronally. For example, a coin will appear as a circle on an anteroposterior projection.

Tracheal foreign bodies typically orient sagitally. For example a coin will appear as a line on an anteroposterior projection.

Algorithm for the Evaluation and Management of Pediatric Foreign Body Aspiration

References

1. Sahn, B, et al. Foreign Body Ingestion Clinical Pathway. 1 Aug. 2016, www.chop.edu/clinical-pathway/foreign-body-ingestion-clinical-pathway. Accessed 26 Aug. 2017.
2. Wyllie R. Foreign bodies in the gastrointestinal tract. Current Opinion in Pediatrics. 2006;18 N2 -(5).
3. Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005;72(2):287-291.
4. Chung S, Forte V, Campisi P. A Review of Pediatric Foreign Body Ingestion and Management. Vol 11. 2010:225-230.
5. Louie MC, Bradin S. Foreign Body Ingestion and Aspiration. Pediatrics in Review. 2009;30(8):295-301. doi:10.1542/pir.30-8-295.
6. Green SS. Ingested and Aspirated Foreign Bodies. Pediatrics in Review. 2015;36(10):430-437. doi:10.1542/pir.36-10-430.

The post Pediatric Foreign Body Ingestion appeared first on Differential Diagnosis of.

A 62 year-old male with no significant medical history, presented to the emergency department with several days of vomiting. Examination showed suprapubic fullness with tenderness to palpation and a bedside ultrasound was performed:

Ultrasound revealed moderate bilateral hydronephrosis with a relatively non-distended bladder. Labs were notable for new renal failure and the patient was admitted for continued evaluation. He was ultimately diagnosed with idiopathic retroperitoneal fibrosis with bilateral distal ureteral obstruction requiring stenting.

Anatomy of Acute Urinary Retention:

Differential Diagnosis of Acute Urinary Retention:^1,2,3

The post Acute Urinary Retention appeared first on Differential Diagnosis of.

A 50 year-old male with a history of colonic mucinous adenocarcinoma on chemotherapy presented with a chief complaint of “vomiting”. He was unwilling to provide further history, repeating that he had vomited blood prior to presentation. His initial vital signs were notable for tachycardia. Physical examination showed some dried vomitus, brown in color, at the nares and lips; left upper quadrant abdominal tenderness to palpation; and guaiac-positive stool. Point-of-care hemoglobin was 3g/dL below the most recent measure two months prior. As his evaluation progressed, he developed hypotension and was transfused two units of uncrossmatched blood with adequate blood pressure response – he was started empirically on broad-spectrum antibiotics for an intra-abdominal source. Notable laboratory findings included a normal hemoglobin/hematocrit, acute kidney injury, and elevated anion gap metabolic acidosis presumably attributable to serum lactate of 10.7mmol/L. Computed tomography of the abdomen and pelvis demonstrated pneumoperitoneum with complex ascites concerning for bowel perforation. The patient deteriorated, was intubated, started on vasopressors and admitted to the surgical intensive care unit. The initial operative report noted extensive adhesions and perforated small bowel with feculent peritonitis. He has since undergone multiple further abdominal surgeries and remains critically ill.

Imaging

Algorithm for the Evaluation of Hypotension¹

This process for the evaluation of hypotension in the emergency department was developed by Dr. Ravi Morchi. In the case above, a systematic approach to the evaluation of hypotension using ultrasonography and appropriately detailed physical examination may have expedited the patient’s care. The expertly-designed algorithm traverses the cardiovascular system, halting at evaluable checkpoints that may contribute to hypotension.

1. The process begins with the cardiac conduction system to identify malignant dysrhythmias (bradycardia, or non-sinus tachycardia >170bpm), which, in unstable patients are managed with electricity.
2. The next step assesses intravascular volume with physical examination or bedside ultrasonography of the inferior vena cava. Decreased right atrial pressure (whether due to hypovolemia, hemorrhage, or a distributive process) is evidenced by a small and collapsible IVC. If hemorrhage is suspected, further ultrasonography with FAST and evaluation of the abdominal aorta may identify intra- or retroperitoneal bleeding.
3. If a normal or elevated right atrial pressure is identified, evaluate for dissociation between the RAP and left ventricular end-diastolic volume. This is typically caused by a pre- or intra-pulmonary obstructive process such as tension pneumothorax, cardiac tamponade, massive pulmonary embolism, pulmonary hypertension, or elevated intra-thoracic pressures secondary to air-trapping. Thoracic ultrasonography can identify pneumothorax, pericardial effusion, or signs of elevated right ventricular systolic pressures (RV:LV, septal flattening).
4. Assuming adequate intra-vascular volume is arriving at the left ventricle, rapid echocardiography can be used to provide a gross estimate of cardiac contractility and point to a cardiogenic process. If there is no obvious pump failure, auscultation may reveal murmurs that would suggest systolic output is refluxing to lower-resistance routes (ex. mitral insufficiency, aortic insufficiency, or ventricular septal defect).
5. Finally, if the heart rate is suitable, volume deficits are not grossly at fault, no obstructive process is suspected, and cardiac contractility is adequate and directed appropriately through the vascular tree, the cause may be distributive. Physical examination may reveal dilated capillary beds and low systemic vascular resistance.

Guided Lecture

Watch “The Transiently Hypotensive Patient: Who Cares?” from EM Ed. In this lecture Dr. Basrai reviews the diagnostic pathway for a patient who presents with transient hypotension.

References

1. Morchi R. Diagnosis Deconstructed: Solving Hypotension in 30 Seconds. Emergency Medicine News. 2015.

The post Hypotension appeared first on Differential Diagnosis of.

Cardiology

Ductal Dependent Lesions

• Present 1^st week to 1^st month
• Normal duct seals by 3 weeks
• If dependent on shunt for pulmonary flow  cyanosis
• If dependent on shunt for systemic flow cold shock (may be worse w/ fluids)
• Prostaglandin E₁
  • 1 mg/kg/min
  • Side effects include apnea, bradycardia, hypotension, seizure
    • Consider intubating prior to administration
  • IVF, cover for sepsis

Congestive Heart Failure

• Present 2^nd to 6^th month
• Presents with respiratory symptoms (wheezing, retractions, tachypnea)
• Difficulty with feeding (the infant stress test)
• Treatment: Supportive

 Tetrology of Fallot

1. Calm the child, knee to chest
2. O₂ = reduction in PVR
3. Analgesia: morphine 0.1mg/kg, fentanyl 1.5 mcg/kg, ketamine 0.25 mg/kg
4. Establish Access: 10-20cc/kg bolus
5. Phenylephrine 0.2 mg/kg IV (to increase SVR)
6. +/- HCO₃ 1mmol/kg (if acidosis)
7. +/- beta blocker (with cardiology consultation)
8. PGE₁ 0.05mcg/kg/min titrating to 0.1mcg/kg/min

Dermatology

Slapped Cheek/5^th Disease

• Parvo B19
• Slapped cheeks, lacy reticular pattern of rash on body
• Complications:
  • Pregnancy hydrops
  • Sickle Cell Disease  aplastic crisis

Measles

• Koplik spots, conjunctivitis, fever
• Can cause blindness

VZV

• Different stages of development
• Treat with acyclovir if > 12 years old
• Give VZIG in neonates and immunocompromised

Scarlet Fever

• Erythematous rash, palatal petechiae, pastia’s lines
• Strawberry tongue
• Trunk to periphery
• Treat with Pen VK: 50mg/kg BID x10d or Amox 20mg/kg BID x10d
• Pen allergic: Azithro 10mg/kg day 1 then 5mg/kg 2-5

Staphylococcal Scalded Skin Syndrome

• Toxin mediated, negative Nikolsky, good prognosis
• Treatment: Anti-staphylococcal antibiotics
  • Nafcillin 25mg/kg/d IV
  • Augmentin 45mg/kg/d PO in 2 divdied doses 7-10d
  • Keflex 10mg/kg/d QID x7-10d

Henoch-Schonlein Purpura

• Palpable purpura in dependent areas
• Arthralgia/Arthritis (50-84%)
• Abdominal pain (50%): vascular lesions in bowel, may be intussusception lead point
• Renal Disease (20-50%) may develop within 2 months
• Treatment: Supportive, NSAIDs

Kawasaki Disease

• 5 days of fever + 4/5 of criteria
  • Diffuse polymorphous diffuse rash
  • Conjunctivitis
  • Mucous membrane change (strawberry tongue)
  • Cervical LAD (usually unilateral)
  • Extremity changes
• Incomplete and atypical forms more common in infants
• Treatment (drop complications from 25% to 4-5%)
  • Aspirin 20mg/kg/dose Q6H
  • IVIG 2gm/kg over 12H

Gastroenterology

Bilious Vomiting

• Bilious vomiting malrotation with volvulus until proven otherwise  surgical emergency
• 1^st month of life “pre-verbal child’s disease”
• Dx: Upper GI Series (10-15%) false positive rate

Necrotizing Enterocolitis

• 10% of cases full term
• XR w/ pneumatosis intestinalis

Hirschsprung’s

• No meconium, slightly distended abdomen
• Less severe  later presentation, p/w constipation

Pyloric Stenosis

• Presents around 6 wks: vomiting but very hungry
• Diagnosis
  • US pylorus > 4mm thick, >15mm long
  • NGT aspiration 5cc is abnormal
• Treatment
  • Resuscitate
  • Correct metabolic abnormalities
  • Consult surgery

Intussusception

• Most common infant emergency
  • 3 months – 2 years
• Abdominal pain, currant jelly, palpable mass (30% only)
• Typical presentation
  • Lethargy (may be only sign)
  • Vomiting
  • Paroxysms of pain
  • SBO
  • PO intolerance
• Diagnosis: US
• Treatment: Enema (80-95% successful), 10% recurrence

Meckel’s Diverticulum

• Around 2 years of age, boys > girls
• Obstruction, intussusception
• Diagnose with technetium scan

Appendicitis

• 1/3^rd with vomiting and diarrhea (AGE-type syndrome)

Hemolytic Uremic Syndrome

• Watery/bloody diarrhea
• Three components
  • Acute renal failure
  • Thrombocytopenia
  • Microangiopathic hemolytic anemia (MAHA)
• Signs
  • Pallor
  • Abdominal Pain
  • Decreased urine output
  • Low energy/AMS
  • Hypertension
  • Edema
  • Petechiae
  • Icterus
• Treatment: Supportive vs. Dialysis (50%)

GI Bleed by Age

Congenital Disorders

Congenital Adrenal Hyperplasia

• Presents in first two weeks of life
• Chief complaint may be vomiting
• Lyte: HyperK, HypoNa, Hypoglycemia  dysrhythmias, seizures
• Treatment
  • IVF (usual dose)
  • Glucose (usual dose)
  • Hydrocortisone: 25mg (neonate/infant), 50mg child, adolescent/adult 100mg

Inborn Errors of Metabolism

• Possible CC: Vomiting, Lethargy, Seizures, Hepatomegaly, Metab Acidosis, Odor
• May have normal labs and imaging
• Life-threatening: Metabolic acidosis, Hypoglycemia, Hyperammonemia, Sepsis
• Labs
  • VBG (acidosis),
  • CMP (liver, kidney, anion gap)
  • Ammonia, lactate, urine (ketones, reducing substance)
  • Bunch of extra tubes for labs later
• Treatment
  • NPO
  • IVF bolus
  • D10 at 1.5x maintenance
  • Treat Sepsis
  • Control seizures PRN, correct hyperammonemia/acid/lyte (may need dialysis)

Pulmonary

Croup

• Toddlers (6-24 months), 5% of all children, boys > girls
  • PIV #1
  • Rhinovirus, Metapneumovirus, PIV II-IV, RSV, Flu A/B
  • Frequent co-infections with one or more viruses

• Sx: 1-3 days of URI Sx  Abrupt cough/stridor worse for one day, then better
• Signs: Nontoxic, if wheezing likely RSV
• Studies: XR to r/o FB (steeple sign if positive)
• Treatment: Racemic Epi: 0.25-0.75 cc in 3 cc Q 20 minutes, lasts < 2 hours
• Disposition: If stridor at rest then treat if no improvement, then admit

Bronchiolitis

• Children < 2 years old, November through April (peak Jan/Feb)
  • Apnea in neonates and ex-premies < 2 months
  • Bacterial superinfection is very rare
• Presentation: Desat, tachypnea, nasal flaring, intercostal retractions, secretions
• Exam: Fine rales, diffuse/fine wheezing
• Treatment: Suction, O2 (if < 90%), NPPV
• Maybe albuterol, but no steroids/epi/abx

Epiglottitis

• Bimodal (2-6, 20-40y), < 1% URI with stridor, boys = girls, al year
  • Non-typable H.flu, staph/strep, Moraxella
  • Candida, HSV, VZV, crack cocaine
• Symptoms: Muffled voice, drooling rapid progression in hours
• Signs: No pharyngeal findings with severely tender anterior neck
• Studies: XR w/ thumb sign
• Treatment: Laryngoscopy, airway management

Bacterial Tracheitis

• Preschool (1-10y), boys = girls, Downs
• Symptoms: Several days’ URI  toxic in hours, rapid progression
• Signs: Subglottic diffuse inflammation, edema with exudates and pseudomembranes
• Studies: CXR demonstrates narrow trachea
• Treatment: Emergent intubation, 3^rd generation cephalosporin

The post Pediatric Emergencies appeared first on Differential Diagnosis of.

Young male with no significant medical history presenting with progressively worsening right lower quadrant abdominal pain with marked tenderness to palpation and involuntary guarding.

Imaging

Differentiation between Portal Venous Gas and Pneumobilia

References

1. Rabou Ahmed A and Frank Gaillard. “Pneumobilia.” Radiopaedia. http://radiopaedia.org/articles/pneumobilia.
2. Morgan Matt A and Donna D’Souza. “Portal venous gas.” Radiopaedia. http://radiopaedia.org/articles/portal-venous-gas
3. Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics. 2000;20(5):1213–24–discussion1224–6. doi:10.1148/radiographics.20.5.g00se011213.
4. Sherman SC, Tran H. Pneumobilia: benign or life-threatening. J Emerg Med. 2006;30(2):147-153. doi:10.1016/j.jemermed.2005.05.016.

The post Portal Venous Gas appeared first on Differential Diagnosis of.

1. Visceral: distension of hollow organs or capsular stretch of solid organs.
2. Somatic: parietal peritoneal irritation
3. Referred
   • Extra-abdominopelvic
     • Epigastric: inferior MI
     • Pelvic: hip
     • Abdominal: lower lobe pneumonia/infarction
   • Abdominopelvic
     • Shoulder: diaphragmatic irritation (ex. perforated duodenal ulcer, splenic pathology)
     • Mid-back: aortopathy, pancreatitis
     • Flank: renal pathology
     • Low back: uterus, rectum

Concerning Historical Features

• Elderly: increased probability for severe disease with poor clinical diagnostic accuracy
• Immunocompromised: HIV/AIDS, uncontrolled diabetes, chronic liver disease, chemotherapy, other immunosuppression
• Pain preceding nausea/vomiting: increased likelihood of surgical process
• Abrupt onset, duration <48h, constant timing
• Prior abdominal surgical history: consider bowel obstruction
• No prior episodes of similar pain
• Recent antibiotic or steroid use: may mask signs of infection
• Cardiac risk factors (HTN, vascular disease, atrial fibrillation: increased risk for mesenteric ischemia or aortic aneurysm
• Heavy NSAID use or anticoagulation: increase concern for gastrointestinal bleeding

Imaging

• Plain film reserved for those who would otherwise not undergo CT. XR abdomen for bowel obstruction or radiopaque foreign body.
• CT abdomen/pelvis with IV contrast, particularly if elderly or immunocompromised.
• Ultrasound preferred for hepatobiliary pathology
• Bedside ultrasound for identification of IUP, free intraperitoneal fluid, cholecystitis, CBD dilation, ascites, hydronephrosis, aortopathy, volume status.

Causes of Abdominal Pain

References

1. Budhram, G., & Bengiamin, R. (2013). Abdominal Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 223-231). Elsevier Health Sciences.

The post Abdominal Pain appeared first on Differential Diagnosis of.