Category Archives: Medical Students

A Case of Herpes Simplex Virus Keratitis in The Emergency Department

Posted on by

A Case of Herpes Simplex Virus Keratitis in The Emergency Department – A Medical Student Clinical Pearl

Patrick Gallagher, MED III

MUN Class of 2022

Reviewed by Dr. Robin Clouston

Copyedited by Dr. Mandy Peach

Case

A 53-year-old female presents to the emergency department with a two-day history of left-eye pain, which she describes as “something being stuck in her eye.” The patient endorses left eye tearing, pruritis, and photophobia. She notes that her eye has been “blurry” since she awoke this morning. The patient denies any infectious symptoms at present but states that a cold sore erupted on her upper lip seven days ago. She does not use contact lenses.

Past medical history: T2DM and hypothyroidism.

Past surgical history: None.

Medications: Metformin 500 mg OD and Synthroid 125 mcg OD.

Physical exam:

Upon inspection, the patient has conjunctival injection and tearing in the left eye. Mild periorbital edema and erythema is noted. The patient’s pupils are equal and reactive to light, and visual acuity is 20/20 in the left eye and 20/40 on the left eye. Extraocular eye movements and visual fields are normal. The patient has decreased corneal sensation.

On slit lamp examination using fluorescein-based dye, a small branching dendritic ulcer was seen (Figure 1).

Figure 1: Dendritic ulcer noted on slit-lamp exam with fluorescein-based dye.

 

What is the differential diagnosis of dendrites?

• Herpes simplex keratitis
• Acanthamoeba keratitis
• Other keratitis caused by Varicella zoster virus (VZV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), or adenovirus.
• Dendritiform keratopathy
• Ramous epithelial changes
• Limbal stem cell deficiency
• Drug induced corneal changes (epinephrine, antivirals, beta-blockers) 1,2

Herpes simplex virus keratitis :

Herpes simplex is a DNA virus that can cause a wide variety of infections, most commonly involving the mouth, genitalia, and eyes3. While HSV-1 and HSV-2 can involve the eye, HSV-1 is the most common cause of keratitis1. Herpes simplex keratitis (HSK) is characterized by recurrent infections of the corneal epithelium and stroma2. HSK can be classified as primary or recurrent and further divided into three subtypes: epithelial, stromal, and endothelial3. Epithelial keratitis is the most commons subtype of ocular herpes (50% to 80%)2.

Herpes simplex virus (HSV) infections are the leading cause of infectious corneal blindness in developed countries3. It is estimated that 1.5 million people worldwide experience HSV keratitis every year2.

Pathophysiology:

Primary HSV eye infections occur when the virus enters mucous membranes by direct contact. This initial infection is usually subclinical, but it can cause unilateral blepharitis, follicular conjunctivitis, and occasional epithelial keratitis (Figure 2)4. The initial infection is typically asymptomatic, and it occurs in children less than five years old5.

Figure 2: Pictorial representation of blepharitis (inflammation of the eyelid), keratitis (inflammation of cornea), conjunctivitis (inflammation of conjunctiva), and ocular anatomy. Diagram retrieved from 7

After the initial infection, the virus can remain latent in the ophthalmic division of the trigeminal ganglion for the lifetime of the host. HSV reactivation in the latently infected ganglia can lead to corneal scarring, thinning, stromal opacity, and neovascularization5. The cumulative effect of numerous infections results in vision loss and eventually blindness if left untreated.

History and physical:

Diagnosis of HSK is primarily diagnosed by clinical presentation on slit lamp exam using fluorescein and either rose bengal or lissamine green3. However, it is crucial to complete a thorough history and physical exam to narrow the differential diagnosis (Table 1).

Table 1: Key points on history and physical

Figure 3: Slit-lamp corneal findings for patient’s diagnosed with HSV epithelial keratitis. A: Classic dendritic lesion with terminal bulbs. B: More advanced dendritic lesion presenting as geographic ulcer. Figure modified from 6.

Investigations:

The diagnosis of HSVK is based off of clinical findings and does not require additional investigations; however, for atypical lesions, polymerase chain reaction has been used to confirm HSVK. Enzyme-linked immunosorbent assay and viral cultures are also effective in the diagnosis of the HSVK subgroups3.

Treatment/management of HSVK in the emergency department:

In the emergency department, typical findings on the slit lamp exam is diagnostic for epithelial HSVK.

Care providers should initiate treatment immediately to reduce the risk of complications; however, the patient must be referred to ophthalmology within the next few days for follow-up.

Topical and oral antiviral treatments effectively treat epithelial HSVK, although no topical ophthalmic antivirals are currently available in Canada7. It is crucial to adjust the dose of oral antivirals according to the patient’s renal function. See Table 2 for available oral antiviral treatments. For symptomatic management, artificial tears or eye lubricants can ease eye discomfort and over-the-counter analgesics can help relieve pain7.

Table 2: Oral antiviral treatment for epithelial HSVK in adults. Modified from 7

Back to the case:

Given our patient’s classic symptoms of epithelial HSVK (conjunctival injection, tearing, vision changes, foreign body sensation, photophobia, hx of HSV infection) and finding of dendritic ulcers on slit lamp examination, we treated this case as epithelial HSVK until proven otherwise. Therefore, we prescribed the patient valacyclovir 1000mg PO TID and arranged an urgent ophthalmology consult for the following day.

References:

  1. Roozbahani, M., & Hammersmith, K. M. (2018). Management of herpes simplex virus epithelial keratitis. Current opinion in ophthalmology, 29(4): 360-364.

  2. Wilhelmus, K. R. (2015). Antiviral treatment and other therapeutic interventions for herpes simplex virus epithelial keratitis. Cochrane Database of Systematic Reviews, 1.

  3. Azher, T. N., Yin, X. T., Tajfirouz, D., Huang, A. J., & Stuart, P. M. (2017). Herpes simplex keratitis: challenges in diagnosis and clinical management. Clinical Ophthalmology, 11:185–191.

  4. Sibley, D., & Larkin, D. F. (2020). Update on Herpes simplex keratitis management. Eye, 34: 2219–2226.

  5. Toma, H. S., Murina, A.T., Areaux, R.G., Neumann, D.M., & Bhattacharjee, P.S. (2008). Ocular HSV-1 Latency, Reactivation and Recurrent Disease. Seminars in Ophthalmology, 23(4), 249–273.
  6. Leon, S., & Pizzimenti, J. (2017). Be a Hero to Your HSVK Patients. Review of Optometry-Leadership in clinical care. Retrieved from https://www.reviewofoptometry.com/article/ro0717-be-a-hero-to-your-hsvk-patients2
  7. Institut national d’excellence en santé et en services sociaux. (2018). Herpes Simplex Eye Disease. INESSS Guides. Retrieved from https://www.inesss.qc.ca/fileadmin/doc/INESSS/Outils/GUO/Herpes/Guide_HerpesSimplex_web_EN_VF.pdf

 

Continue Reading

Lateral Canthotomy

Posted on by

Lateral  Canthotomy – A Medical Student Clinical Pearl

Scott Clarke

Med III, Class of 2022

Dalhousie Medical School New Brunswick (DMNB)

Reviewed by Dr. Fraser MacKay

Copyedited by Dr. Mandy Peach

 

Case:

You are a clinical clerk working your first shift in a busy emergency department when you hear overhead those heart stopping, adrenaline pumping words: “Trauma team activation, room 24”. You arrive to find an unconscious 45 year old male. Report from the paramedics tells you there was a workplace accident whereby a tree had fallen and struck the patient in the face. The team works swiftly and efficiently to secure an airway and stabilize his vitals. From the team leader, your role is to perform a brief neurological exam.

Despite heavy sedation and swelling in the face, you are able to identify significant proptosis of his left eye. His right pupil is reactive to light but you notice his left responds significantly less and there is a positive relative afferent pupillary defect (RAPD). You relay your findings to the team lead and suggest an urgent CT scan of the head.

 

Before departing for CT your attending asks you – what diagnosis are you concerned for? What clinical findings support this diagnosis?

Orbital Compartment Syndrome1

Vision threatening condition where intraocular pressure (IOP) exceeds 40 mmHg.

Clues on exam:

  • Impaired extraocular movements (from a retrobulbar hematoma)
  • Decreased visual acuity
  • RAPD
  • Blown Pupil

Your attending agrees there is concern for orbital compartment syndrome and ophthalmology should be urgently paged – do you wait for CT to confirm retrobulbar hematoma?

No – You quickly grab a tono-pen and measure the intraocular pressure to be 50mmHg. In order to save this patient’s vision, a lateral canthotomy is immediately performed in an attempt to temporarily release pressure before definitive hematoma evacuation can occur.

Procedural Overview:

Equipment:

  1. Tono-pen
  2. Hemostat
  3. Local anesthesia
  4. Curved iris scissors (or scalpel)

Anatomy review:

The globe of the eye is held firmly in place by the strong tarsal plates and the medial and lateral canthal ligaments (Figure 2). By dividing the lateral canthus (inferior limb or both inferior and superior limbs), the globe has room to expand which can greatly reduce pressure3.

Figure 2: Anatomy of the components holding the globe of the eye4.

Procedure5:

  1. Clean the lateral portion of the eye using chlorhexidine or a similar solution.
  2. Inject 2-3cc of 1% lidocaine with 1:100,000 epinephrine into the site of the lateral canthus primarily for hemostasis
  3. Insert the hemostat into the lateral portion of the eye and crush the lateral canthus. Hold this for 30-45 seconds. This will devascularize the tissue resulting in further reduction in bleeding.
  4. Using the curved iris scissors (or scalpel), cut the lateral canthus to the rim of the globe, ~1-2cm at a slight downward angle.
  5. The inferior limb of the lateral canthal ligament will be able to be palpated and resembles a guitar string. This should be divided as well.
  6. If significant intraocular pressure remains, divide the superior limb of the lateral canthal ligament as well.
  7. Reassess ocular pressure.

 

Once the procedure is completed you wait 5 minutes and reassess the intraocular pressure. You notice that it has gone from 50mmHg to 38mmHg. The patient is sent for CT head which confirms a retrobulbar hematoma.

You follow up with the patient during his hospital stay and discover his vision eventually returns to his normal pre-injury.

 

Keys to remember6:

Indications include trauma patients with:
– Proptosis
– Impaired ocular movements
– Elevated Intraocular pressure, usually >40mmHg
– Decreased visual acuity
– RAPD

Ideally performed within 60-120 min of features of ischemia to the optic nerve1.

Absolute contraindication:
– Globe rupture

Medical treatment can also be initiated with the goal to help decrease intraocular pressure 1:

  • mannitol
  • acetazolamide
  • pilocarpine
  • timolol

See below for video of a lateral canthotomy on an actual patient (viewer discretion advised):

References

  1. Helman, A. Swaminathan, A. Austin, E. Strayer, R. Long, B, McLaren, J. Brindley, P. EM Quick Hits 24 – Lateral Canthotomy, Cannabis Poisoning, Hyperthermia, Malignant Otitis Externa, BBB in Occlusion MI, Prone CPR. Emergency Medicine Cases. December, 2020. https://emergencymedicinecases.com/em-quick-hits-december-2020/. Accessed [May 5, 2021].
  2. Retrobulbar Hematoma from Warfarin Toxicity and the Limitations of Bedside Ocular Sonography – The Western Journal of Emergency Medicine. https://westjem.com/videos/retrobulbar-hematoma-from-warfarin-toxicity-and-the-limitations-of-bedside-ocular-sonography.html. Accessed March 29, 2021.
  3. Amer E, El-Rahman Abbas A. Ocular Compartment Syndrome and Lateral Canthotomy Procedure. J Emerg Med. 2019;56(3):294-297. doi:10.1016/j.jemermed.2018.12.019
  4. Chan D, Sokoya M, Ducic Y. Repair of the Malpositioned Lower Lid. 2017. doi:10.1055/s-0037-1608711
  5. How to do Lateral Canthotomy – Eye Disorders – Merck Manuals Professional Edition. https://www.merckmanuals.com/en-ca/professional/eye-disorders/how-to-do-eye-procedures/how-to-do-lateral-canthotomy. Accessed March 29, 2021.
  6. Lateral Canthotomy – YouTube. https://www.youtube.com/watch?v=Qs5Smx-cxbo. Accessed March 29, 2021.
Continue Reading

An interesting derm case in the ED: Mycosis Fungoides

Posted on by

Mycosis Fungoides: A Medical Student Clinical Pearl

 

Nicholas Relja, B.Sc.(Hon), M.Sc.
Dalhousie Medicine New Brunswick
M.D. Candidate, Class of 2022

All case histories are illustrative and not based on any individual

Reviewed by Dr. Devon Webster

Copyedited by Dr. Mandy Peach

Case

A 55-year-old male presented to the ED after concerned family brought him in due to ongoing generalized weakness lasting approximately one month. On inspection he had erythematous, scaly, ulcerative lesions covering his entire body with only facial sparing. He mentioned burning-like pain originating from his ulcerative lesions. He had been previously diagnosed with T-cell lymphoma 30 years ago and had gone through multiple rounds of chemo and radiation therapy since that time.

Picture from: Denis D, Beneton N, Laribi K, Maillard H (2019). Management of mycosis fungoides-type cutaneous T-cell lymphoma (MF-CTCL): focus on chlormethine gel. Cancer Management and Research. Vol 11: 2241-2251

Differential for itchy, erythematous rash:

Condition
Atopic dermatitis
Contact dermatitis
Drug eruptions
Erythrodermic psoriasis
Psoriasis
Sezary syndrome
Various lymphomas

 

When reviewing the patient’s past medical history you see they were previously diagnosed with Mycosis Fungoides – a rare cutaneous form of T-cell lymphoma.

Epidemiology

Mycosis fungoides has an incidence of approximately 6 cases per million per year in the United States. It is more common in adults over 50 years of age, with a male to female ratio of 2:1. The disease is also more common amongst the Black population than in Caucasians or Asians.8,9

Etiology

The exact cause of mycosis fungoides is not known; however, there a variety of mechanisms that have been postulated:2

• Genetic and epigenetic abnormalities.3,4
• Environmental and occupational exposure to noxious substances and chemicals.5
• Human T-lymphotropic virus Type 1 – a suspected infection-type etiology.6
• Cytokines such as IL-2 and IL-4 due to their increased presence in patients with mycosis fungoides and Sezary syndrome.7

 

There are three stages of mycosis fungoides and therefore clinical presentation will vary depending on the stage of disease:

Patch stage: Erythematous, or brownish scaly patch, which may show some atrophy. It is possible to have one or multiple lesions develop in areas such as the gluteal region or on the proximal thighs. The likeness of this stage has been compared to “small-plaque” or “large plaque” parapsoriasis; however, the plaques are actually not plaques but patches instead.10

Plaque stage: This is the second stage – lesions will be larger, more numerous and will show infiltration. The lesions appear annular, are raised and have well-defined edges as well as asymmetry in terms of their distribution. Face and scalp involvement can also be seen starting at this stage.11

Tumor stage: The final stage – erythematous-purplish papules or nodules of larger diameter.12

There are other clinical variants of mycosis fungoides, but they are not as common, and some are quite rare.

Sezary syndrome:
In advanced form of the mycosis fungoides, Sezary syndrome may be present. This syndrome involves erythroderma with pruritus, lymphadenopathy and atypical circulating lymphocytes (referred to as Sezary or Lutzner cells).13

Evaluation in the ED

A detailed history and physical exam including checking for lymphadenopathy (most commonly cervical nodes) and organomegaly14,15 in addition to documenting the rash characteristics.

Labs: CBC, liver function tests, LDH

Radiological tests: depends on extent of lymphadenopathy and organomegaly. Can do a CXR in the ED for lung involvement, but otherwise advanced imaging can be decided upon by specialist consultant and may include CT, US, PET or MRI.

Biopsy: lymph nodes and rash – by consultants

Treatment and Management – refer to your friendly neighborhood dermatologist.

Early stage:

Treatment options include topical therapies such as corticosteroids and other agents, UV therapy, local radiation and systemic immunosuppressants 15,16,17.

Advanced Stage:

Treatment for the advanced stages of mycosis fungoides are directed at disease control and symptom relief. Localized radiation, targeted immunotherapy or chemotherapy. 15, 18

Prognosis

The prognosis of mycosis fungoides is variable but in general as the stage gets more advanced and with patients over the age of 60, the prognosis becomes poorer. Other poor prognostic factors include increased LDH, tumor distribution and organ involvement.2

Case Conclusion

The patient seen in hospital by the dermatologist on call and was deemed to be in the plaque stage. He was admitted due to the advancing course and and inability to manage his symptoms from home. Further care will involve palliation and a focus on quality of life.

 

References:

  1. Olisova, O. Y. et al. [Current possibilities of the differential diagnosis of plaque parapsoriasis and the early stages of mycosis fungoides]. Arkh. Patol. 81, 9–17 (2019).
  2. Lim, H. L. J. et al. Epidemiology and prognostic factors for mycosis fungoides and Sézary syndrome in a multi-ethnic Asian cohort: a 12-year review. J. Eur. Acad. Dermatol. Venereol. JEADV 33, 1513–1521 (2019).
  3. Bergallo, M. et al. DNA from Human Polyomaviruses, MWPyV, HPyV6, HPyV7, HPyV9 and HPyV12 in Cutaneous T-cell Lymphomas. Anticancer Res. 38, 4111–4114 (2018).
  4. Väisänen, E. et al. Cutavirus DNA in Malignant and Nonmalignant Skin of Cutaneous T-Cell Lymphoma and Organ Transplant Patients but Not of Healthy Adults. Clin. Infect. Dis. Off. Publ. Infect. Dis. Soc. Am. 68, 1904–1910 (2019).
  5. Slodownik, D., Moshe, S., Sprecher, E. & Goldberg, I. Occupational mycosis fungoides – a case series. Int. J. Dermatol. 56, 733–737 (2017).
  6. Blaizot, R., Ouattara, E., Fauconneau, A., Beylot-Barry, M. & Pham-Ledard, A. Infectious events and associated risk factors in mycosis fungoides/Sézary syndrome: a retrospective cohort study. Br. J. Dermatol. 179, 1322–1328 (2018).
  7. Fujii, K. New Therapies and Immunological Findings in Cutaneous T-Cell Lymphoma. Front. Oncol. 8, 198 (2018).
  8. Amorim, G. M., Niemeyer-Corbellini, J. P., Quintella, D. C., Cuzzi, T. & Ramos-E-Silva, M. Clinical and epidemiological profile of patients with early stage mycosis fungoides. An. Bras. Dermatol. 93, 546–552 (2018).
  9. Amorim, G. M., Niemeyer-Corbellini, J. P., Quintella, D. C., Cuzzi, T. & Ramos-E-Silva, M. Hypopigmented mycosis fungoides: a 20-case retrospective series. Int. J. Dermatol. 57, 306–312 (2018).
  10. Pimpinelli, N. et al. Defining early mycosis fungoides. J. Am. Acad. Dermatol. 53, 1053–1063 (2005).
  11. Burg, G., Dummer, R., Nestle, F. O., Doebbeling, U. & Haeffner, A. Cutaneous lymphomas consist of a spectrum of nosologically different entities including mycosis fungoides and small plaque parapsoriasis. Arch. Dermatol. 132, 567–572 (1996).
  12. Keehn, C. A., Belongie, I. P., Shistik, G., Fenske, N. A. & Glass, L. F. The diagnosis, staging, and treatment options for mycosis fungoides. Cancer Control J. Moffitt Cancer Cent. 14, 102–111 (2007).
  13. Lopez, A. T., Bates, S. & Geskin, L. Current Status of HDAC Inhibitors in Cutaneous T-cell Lymphoma. Am. J. Clin. Dermatol. 19, 805–819 (2018).
  14. Prince, H. M. & Querfeld, C. Integrating novel systemic therapies for the treatment of mycosis fungoides and Sézary syndrome. Best Pract. Res. Clin. Haematol. 31, 322–335 (2018).
  15. Wain, T., Venning, V. L., Consuegra, G., Fernandez-Peñas, P. & Wells, J. Management of cutaneous T-cell lymphomas: Established and emergent therapies. Australas. J. Dermatol. 60, 200–208 (2019).
  16. Dairi, M., Dadban, A., Arnault, J.-P., Lok, C. & Chaby, G. Localized mycosis fungoides treated with laser-assisted photodynamic therapy: a case series. Clin. Exp. Dermatol. 44, 930–932 (2019).
  17. Photiou, L., van der Weyden, C., McCormack, C. & Miles Prince, H. Systemic Treatment Options for Advanced-Stage Mycosis Fungoides and Sézary Syndrome. Curr. Oncol. Rep. 20, 32 (2018).
  18. Alpdogan, O., Kartan, S., Johnson, W., Sokol, K. & Porcu, P. Systemic therapy of cutaneous T-cell lymphoma (CTCL). Chin. Clin. Oncol. 8, 10 (2019).

 

Continue Reading

Well, that’s a pain – in the lower back: A case of back pain in the ED

Posted on by

Lower Back Pain: Medical Student Clinical Pearl

Grace Dao, CC4

MD Candidate

Class of 2021

Case Presentation

Mr. Payne Bach is a 54 yo male who presents to the emergency department via EMS with lower back pain.
He reports that he hurt his back this afternoon when he was picking up a heavy, antique chair. Immediately, he felt something “give out” in his back and reports a sharp 10/10 central lower back pain that radiates unilaterally to the left side. It did not radiate down his legs. He was unable to ambulate due to the pain and called EMS.

He received 975 mg Acetaminophen in the ambulance which did not alleviate his pain. Mr. Bach reports that before picking up the chair he was feeling well. He denies any history of back pain or activities of back overuse. He denies any history of trauma or injury to his back recently or in the past. In the emergency department he reports his pain remains at 10/10 and cannot sit up or move in bed due to the pain.

He denies any change in sensation or pain to his legs. He denies any change in sensation to his perineum or any bowel incontinence. He has not urinated since the incident. Incidentally when reviewing a past medical history he reports an unintentional weight loss of 15 lbs in the last 2 months. He denies any history of a prior cancer diagnosis. On review of systems he denies history of cough, fevers, night sweats, hematochezia or gross hematuria. Mr. Bach has a 20 pack year smoking history.

Mr. Bach had difficulty with the physical exam due to pain. He appeared very distressed. All vital signs were within normal limits. An order for IV opiods was ordered and he was reassessed 30 minutes later.

Physical exam

Inspection: there were no obvious deformities of the back, no scarring or bruising or abrasions. Mr. Bach continued to look uncomfortable but was no longer in any acute distress.
Palpation: Mr. Bach was tender to palpation over L4-5. There was tenderness to palpation of the paraspinal muscles at the same level.
ROM: Mr. Bach was very hesitant to move, thus, it was difficult to assess his range of motion.
Neuro: Reflexes at the knee and ankle were normal. Babinski was negative. Normal sensation throughout all dermatomes. 5/5 strength on flexion/extension at the hip, knee and ankle.
Special tests: Straight leg raise and Lasegue’s test were negative.

Back Pain

Back pain is an extremely common condition. It is estimated that 70-85% of people will experience back pain at some point in their life1. A recent study out of an emergency department in Halifax, found that 3.17% of patients presented with to the emergency department with a complaint of lower back pain2. Back pain is within the top 5 reasons for primary care visits3. The differential diagnosis for lower back pain ranges from mechanical lower back pain to critical conditions that need to be recognized 4. Due to its prevalence and potentially sinister causes it is important to have an evidence-based approach to lower back pain.

 

To Image or Not to Image-That is the Question

Choosing Wisely Canada has put out recommendations for both Family and Emergency physicians with regards to low back pain. For family medicine the recommendation is “don’t do imaging for lower-back pain unless red flags are present” 5. It has been found that imagining those without red flags before 6 weeks does not improve outcomes.5

Similarly, for emergency medicine the recommendation is “don’t order lumbosacral (low back) spinal imaging in patients with non-traumatic low back pain who have no red flags/pathologic indicators.”6

Red flags 6:

Cauda Equina Syndrome
Severe worsening pain, especially at night
Significant trauma
Weight loss
History of Cancer
Fever
Night sweats
Steroid use
IV drug use
First episode of back pain in age > 50, especially concerning if age > 65
Widespread neurological signs (loss of sensation, loss of motor function, loss of reflexes in the legs)

 

It is also important to remember that not all red flags are created equal and to include clinical judgement in the decision making process.8 A systematic review examining the predictive value of commonly assessed red flags found that for fracture older age, prolonged steroid use, severe trauma, and contusion/abrasion increased the probability of fracture to 10-33%, and if multiple red flags are present fracture risk increases to 42-90%.

When considering red flags that increase risk of malignancy, previous history of malignancy increased risk 7-33%; while older age, unexplained weight loss, and failure to improve after one month all were found to have post-test probabilities of less than 3% when predicting malignancy risk8.

Back to our case

Mr. Bach has red flags for both fracture and malignancy:

Severe, worsening pain
Age > 50
Weight loss

XRs of the lumbar spine were ordered and indicated several compression fractures, with one area suspicious for a metastatic lesion. Follow CT spine was ordered and confirmed metastatic disease. Mr. Bach was admitted to hospital for pain control, physiotherapy and a malignancy work up.

 

References
1. Andersson, G. B. (1999). Epidemiological features of chronic low-back pain. Lancet 354(9178):581-585. doi:10.1016/S0140-6736(99)01312-4
2. Edwards, J., Hayden, J., Asbridge, M., & Magee, K. (2018). The prevalence of low back pain in the emergency department: A descriptive study set in the Charles V. Keating Emergency and Trauma Centre, Halifax, Nova Scotia, Canada. BMC Musculoskeletal Disorders, 19(1), 306. https://doi.org/10.1186/s12891-018-2237-x
3. Finley, C. R., Chan, D. S., Garrison, S., Korownyk, C., Kolber, M. R., Campbell, S., Eurich, D. T., Lindblad, A. J., Vandermeer, B., & Allan, G. M. (2018). What are the most common conditions in primary care? Systematic review. Canadian family physician Medecin de famille canadien, 64(11), 832–840.
4. Patel, A.T., & Ogle, A.A. (2000). Diagnosis and management of acute low back pain. Am Fam Physician 61(6):1779-1790.
5. College of Family Physicians of Canada. Choosing Wisely Canada. Thirteen Things Physicians and Patients should question. July, 2019. Retrieved from: https://choosingwiselycanada.org/family-medicine/
6. Canadian Association of Emergency Physicians. Choosing Wisely Canada. Ten things Physicians and Patients Should Question. July, 2019. Retreived from: https://choosingwiselycanada.org/emergency-medicine/
7. Toward Optimized Practice (TOP). (2011). Guideline for the evidence-informed primary care Management of Low Back Pain. Retrieved from: https://portal.cfpc.ca/resourcesdocs/uploadedFiles/Directories/Committees_List/Low_Back_Pain_Guidelines_Oct19.pdf
8. Downie, A., Williams, C. M., Henschke, N., Hancock, M. J., Ostelo, R. W. J. G., de Vet, H. C. W., Macaskill, P., Irwig, L., van Tulder, M. W., Koes, B. W., & Maher, C. G. (2013). Red flags to screen for malignancy and fracture in patients with low back pain: Systematic review. BMJ, 347.

Copyedited by Dr. Mandy Peach

Continue Reading

Detection of Foreign Bodies in Soft Tissue – A PoCUS-Guided Approach

Posted on by

 

Medical Student Clinical Pearl

Sophia Miao, CC4

MD Candidate, Class of 2021

Dalhousie University

 

Reviewed & Edited by Dr David Lewis (@e_med_doc)

All case histories are illustrative and not based on any individual.

 

Case Report

A 33-year-old woman presents to the ED with pain and swelling over the third digit of her right hand.  One week prior to this, she had shattered a jar and a small glass splinter lodged into her finger.  This was promptly removed at home, and the puncture wound healed without intervention.

She presented to the emergency room 7 days later with new pain and swelling surrounding the initial puncture wound.  There is no significant past medical history and most recent Td booster was given 2 years ago.  On examination, there was some mild erythema, swelling, and tenderness on palpation of the lateral aspect of the middle phalanx of the right hand.  She is otherwise well.  You wonder about the possibility of a retained foreign body.

 

PoCUS-Guided Approach to the Detection of Foreign Bodies in Soft Tissue

Foreign bodies in soft tissue are a common complaint in the emergency department, with open wounds comprising 5.7 million (or 4.5% of total) visits to the ED in 2010.[1]  Foreign bodies were found in up to 15% of wounds.[2]  If retained, complications of these include allergic reaction, inflammation, delayed wound healing, damage to adjacent tissue structures, neurovascular damage, tetanus, and infectious complications including cellulitis, necrotizing fasciitis, synovitis, and abscess formation.[3],[4]  Proper detection, and subsequent removal, of retained foreign bodies is therefore essential to evaluate the wound and prevent associated complications.

Diagnosis of a retained FB requires a high index of suspicion.  Clinical suspicion should be raised when there is a compelling history and physical exam.  The latter may include signs of inflammation and/or infection, including warmth, swelling, erythema, tenderness, abscess formation, and discharging wound).[5],[6]

Conventional radiography is known to commonly miss radiolucent materials such as wood and plastic.  It has been shown that plain radiographs have only a 7.4% sensitivity in the detection of wood foreign bodies.5  Remarkably, even glass – a radiopaque material – has been demonstrated to have been missed in up to 35% of x-ray film studies.[7]  There is increasingly compelling evidence for the clinical usefulness and accuracy of bedside ultrasonography in the detection of soft-tissue foreign bodies.  It has been shown to have a specificity of 92% (95% CI = 88%-95%) and sensitivity ranging from 83.3% to 100%.[8],[9]

PoCUS Technique

Probe selection: the use of a high-frequency ultrasound probe is recommended.  This allows for greater axial resolution at the expense of less penetration, which is suitable for the detection of small foreign bodies, as they typically lodge in superficial tissues.[10]

If the wound is open, a transparent covering such as a Tegaderm or probe cover can be used to cover either the wound or probe before scanning.[11]

Medium: standard technique for assessment of soft-tissue structures by ultrasound involves the use of a standoff pad or gel mound.  However, this is not always possible due to the irregular curvature of extremities such as fingers and feet, which may result in poor contact between the probe and skin, decreased field of view, and patient discomfort.  A water-bath technique can circumvent this and has been shown to be superior in such cases.[12]

Method: the area of interest should be scanned in both longitudinal and transverse planes.  Foreign bodies are best detected when the transducer aligns with the longitudinal axis of the foreign body, and therefore revealing the span of the object.[13]  As foreign bodies tend to embed less than 2 cm below the surface of the skin, the depth of field should remain superficial in order to avoid false positives.

US Probe: Ultrasound Water Bath for Distal Extremity Evaluation

 

Findings

Ultrasonography and plain film findings of foreign bodies in soft tissue are summarized in the table below.

Table 1. Ultrasound and x-ray findings of foreign bodies.6,[14],[15],[16]

Material Ultrasound findings X-ray findings
Wood Hyperechoic; may become isoechoic with surrounding tissue as it denatures over time

Posterior acoustic shadowing

 Radiolucent, often undetectable
Glass Hyperechoic, bright

Posterior acoustic shadowing

± Posterior comet tail reverberation, diffuse beam scattering

 Radiopaque
Plastic Hyperechoic

Posterior acoustic shadowing

 Radiolucent, often undetectable
Metal Hyperechoic, bright

Posterior acoustic shadowing

± Posterior comet tail reverberation

 Radiopaque

 

Foreign bodies may also display a straight or regular contour.6

 

Image 1 – Wood splinter in volar aspect digit, mildly hyperechoic, surrounding hypoechoic halo, irregular acoustic shadowing

Image 2 – Plastic FB, within tendon sheath, volar aspect digit, brightly hyperechoic, long axis

Image 3 – Plastic FB, within tendon sheath, volar aspect digit, brightly hyperechoic, short axis

 

Image 4 – Glass FB – brightly echogenic, posterior reverberation, FB long axis

 

Image 5 – Metal FB – brightly echogenic, posterior reverberation, FB long axis

 

 

It is important to note that the acoustic shadowing may be complete or partial, as this is dependent on the angle of sonography and foreign body material.[17]  It is also possible to see a hypoechoic halo around the FB, which may be suggest edema, abscess formation, granulation tissue, or other inflammatory process.[18]  As the inflammatory reaction develops, the halo effect becomes more apparent; therefore the foreign body is therefore best visualized by PoCUS several days after the initial injury.6

PoCUS-Guided Foreign Body Removal

There are several options for removal of a foreign body with PoCUS:[19]

  1. Needle localization. Once the foreign body has been identified on PoCUS, a hollow injection needle can be inserted under ultrasound guidance and local anesthetic is delivered through this.  This can be done in either the transverse or longitudinal plane.  The ultrasound probe is then removed, and an incision is made along the needle.  Through the incision site, tweezers or forceps can be used to remove the foreign body.
  2. Real-time ultrasound-guided extraction. This technique is similar to the needle localization method. However, rather than removing the transducer following the needle insertion, the entire procedure is done under direct ultrasound visualization.  The probe is held in the longitudinal plane to visualize both the forceps and the foreign body during the extraction process.

 

There is a risk of obscuring the view of the foreign body on ultrasound with air as a result of the incision itself or through anesthetic delivery.  Saline may be used to irrigate and therefore mitigate the issue.19

The patient’s tetanus status should be verified and updated, if required.  Antibiotic therapy may also be provided, should the risk of infection justify it.

Limitations

There is the possibility of false positives.  Foreign bodies must be differentiated from other hyperechoic body structures, including ossified cartilage, sesamoid bones, scar tissue, gas bubbles, and intermuscular fascia.14  Visualization is therefore important in both longitudinal and transverse planes, as well as comparison with the opposite side.  Acoustic shadowing, hypoechoic halo, and posterior comet tails, if present, can also be indicative of a FB rather than organic body tissue.

Traumatic air injection as a result of penetrating injury can create a scatter artifact on ultrasound, which can be misinterpreted as an acoustic shadow associated with a foreign body.  To differentiate this from a true acoustic shadow, pressure may be applied through the transducer to displace the scatter artifact.6

As is commonplace with all emergency ultrasonography, limitations also include the technical skill of the operator.[20]  A foreign body may also be too small to be detectable by ultrasound.  It is therefore important to remember that a negative scan does not necessarily rule out the possibility of a retained foreign body, and the history and physical examination must be considered in conjunction with the ultrasound findings.

 

 

References

[1] National Center for Health Statistics. Emergency Department Visits. Available from: http://www.cdc.gov/nchs/fastats/emergency-department.htm.

[2] Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration. Am J Emerg Med. 1998 Nov;16(7):627-30. DOI: 10.1016/s0735-6757(98)90161-9. PMID: 9827733.

[3] Skinner EJ, Morrison CA. Wound Foreign Body Removal. In:StatPearls. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554447/.

[4] Ebrahimi A, Radmanesh M, Rabiei S, Kavoussi H. Surgical removal of neglected soft tissue foreign bodies by needle-guided technique. Iran J Otorhinolaryngol. 2013 Winter;25(70):29-36. PMID: 24303416; PMCID: PMC3846242.

[5] Levine MR, Gorman SM, Young CF, Courtney DM. Clinical characteristics and management of wound foreign bodies in the ED. Am J Emerg Med. 2008 Oct;26(8):918-22. DOI: 10.1016/j.ajem.2007.11.026. PMID: 18926353.

[6] Atkinson P, Bowra J, Harris T, Jarman B, Lewis D. Point of Care Ultrasound for Emergency Medicine and Resuscitation. Oxford, United Kingdom: Oxford University Press; 2019. DOI: 10.1093/med/9780198777540.001.0001.

[7] Kaiser, C. William MD; Slowick, Timothy MBA; Spurling, Kathleen Pfeifer RN, JD; Friedman, Sissie MA. Retained Foreign Bodies, The Journal of Trauma: Injury, Infection, and Critical Care: July 1997 – Volume 43 – Issue 1 – p 107-111.

[8] Davis J, Czerniski B, Au A, Adhikari S, Farrell I, Fields JM. Diagnostic Accuracy of Ultrasonography in Retained Soft Tissue Foreign Bodies: A Systematic Review and Meta-analysis. Acad Emerg Med. 2015 Jul;22(7):777-87. DOI: 10.1111/acem.12714. Epub 2015 Jun 25. PMID: 26111545.

[9] Atkinson P, Madan R, Kendall R, Fraser J, Lewis D. Detection of soft tissue foreign bodies by nurse practitioner-performed ultrasound. Crit Ultrasound J. 2014 Jan 29;6(1):2. DOI: 10.1186/2036-7902-6-2. PMID: 24476553; PMCID: PMC3922659.

[10] Dean AJ, Gronczewski CA, Costantino TG. Technique for emergency medicine bedside ultrasound identification of a radiolucent foreign body. The Journal of Emergency Medicine. 2003;24(3):303–8. DOI: 10.1016/S0736-4679(02)00765-5.

[11] Chen KC, Lin AC, Chong CF, Wang TL. An overview of point-of-care ultrasound for soft tissue and musculoskeletal applications in the emergency department. J Intensive Care. 2016 Aug 15;4:55. DOI: 10.1186/s40560-016-0173-0. PMID: 27529031; PMCID: PMC4983782.

[12] Krishnamurthy R, Yoo JH, Thapa M, Callahan MJ. Water-bath method for sonographic evaluation of superficial structures of the extremities in children. Pediatr Radiol. 2013 Mar;43 Suppl 1:S41-7. DOI: 10.1007/s00247-012-2592-y. Epub 2013 Mar 12. PMID: 23478918.

[13] Rooks VJ, Shiels WE 3rd, Murakami JW. Soft tissue foreign bodies: A training manual for sonographic diagnosis and guided removal. J Clin Ultrasound. 2020 Jul;48(6):330-336. DOI: 10.1002/jcu.22856. Epub 2020 May 8. PMID: 32385865.

[14] Mohammadi A, Ghasemi-Rad M, Khodabakhsh M. Non-opaque soft tissue foreign body: sonographic findings. BMC Med Imaging. 2011 Apr 10;11:9. DOI: 10.1186/1471-2342-11-9. PMID: 21477360; PMCID: PMC3079678.

[15] Lewis D, Jivraj A, Atkinson P, Jarman R. My patient is injured: identifying foreign bodies with ultrasound. Ultrasound. 2015 Aug;23(3):174-80. DOI: 10.1177/1742271X15579950. Epub 2015 Mar 26. PMID: 27433254; PMCID: PMC4760591.

[16] Campbell EA, Wilbert CD. Foreign Body Imaging. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470294/.

[17] Anderson MA, Newmeyer WL 3rd, Kilgore ES Jr. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg. 1982 Jul;144(1):63-7. DOI: 10.1016/0002-9610(82)90603-1. PMID: 7091533.

[18] Little CM, Parker MG, Callowich MC, Sartori JC. The ultrasonic detection of soft tissue foreign bodies. Invest Radiol. 1986 Mar;21(3):275-7. DOI: 10.1097/00004424-198603000-00014. PMID: 3514541.

[19] Paziana K, Fields JM, Rotte M, Au A, Ku B. Soft tissue foreign body removal technique using portable ultrasonography. Wilderness Environ Med. 2012 Dec;23(4):343-8. DOI: 10.1016/j.wem.2012.04.006. Epub 2012 Jul 25. PMID: 22835803.

[20] Pinto A, Pinto F, Faggian A, Rubini G, Caranci F, Macarini L, Genovese EA, Brunese L. Sources of error in emergency ultrasonography. Crit Ultrasound J. 2013 Jul 15;5 Suppl 1(Suppl 1):S1. DOI: 10.1186/2036-7902-5-S1-S1. Epub 2013 Jul 15. PMID: 23902656; PMCID: PMC3711733.

Continue Reading

Periorbital Inflammation – Red Eye – Red Flags

Posted on by

 

Medical Student Clinical Pearl

Alysha Roberts

MD Candidate, Class of 2021

Dalhousie University

@aeroberts_21

Reviewed & Edited by Dr David Lewis (@e_med_doc)

All case histories are illustrative and not based on any individual.

Case

A 40 year old male presents to the emergency department with a red, swollen eye. Without a known trigger, he had a one day history of progressive pain, erythema, and edema surrounding his left eye. He denied any fever or chills or visual changes, or headache. A thorough review of systems was negative, except for a complaint of worsening pain with extraocular movement.

On exam, he was afebrile and his vital signs were within normal limits. His visual acuity was normal, and pupils were equal and reactive to light. Extraocular movements were intact but associated with worsening pain. The periorbital tissue was erythematous, edematous, and hot to touch. Examination is limited by the severity of the patient’s swelling. Figure 1 illustrates an example of a patient with severe, unilateral eyelid swelling and erythema.

You suspect periorbital cellulitis.

Figure 1. Unilateral eyelid edema. Retrieved from https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis

 

Periorbital Versus Orbital Cellulitis

Periorbital cellulitis, commonly referred to as pre-septal cellulitis, is an infection of the skin and soft tissue surrounding the orbit. Most commonly, it is the result of an infection spreading from the sinuses or from local trauma.1,2 It presents as a unilateral swelling of the eye-lid. Both periorbital and orbital cellulitis are most commonly caused by Staphylococcus Aureus and Streptococcus Pneumoniae. It is important to distinguish periorbital from orbital cellulitis, which is an infection of the orbit itself extending beyond the orbital septum. Orbital cellulitis is a sight-threatening emergency, and urgent imaging should be acquired in addition to consultation with ophthalmology or otolaryngology.3 Other complications of orbital cellulitis include orbital or subperiosteal abscess, and cavernous sinus thrombosis. Figure 2 illustrates the difference between periorbital (preseptal) and orbital cellulitis, as well as its complications.

Figure 2. Orbital anatomy and potential complications from orbital cellulitis. Retrieved from https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis

Any patient with unilateral eyelid edema should be evaluated for red flags of orbital cellulitis, given its potential seriousness. Red flag signs and symptoms include:3,4

  • Painful or restricted extraocular movements
  • Reduced visual acuity
  • Relevant afferent pupillary defect
  • Diplopia
  • Proptosis
  • Chemosis
  • Severe headache

 

Differential Diagnosis

Other considerations for the differential diagnosis in a unilateral, swollen red eye include:5

  • Periorbital ecchymosis due to blunt trauma
  • Contact dermatitis secondary to local irritant
  • Atopic dermatitis due to allergic sensitivity
  • Orbital tumors

 

Risk Factors

Risk factors for periorbital and orbital cellulitis include:6

  • Sinusitis
  • Dental infection
  • Insect bite
  • Trauma

 

Periorbital cellulitis is most commonly caused by an insect bite in children, and trauma in adults. Comparatively, orbital cellulitis is most often the result of trauma in children, and sinusitis in adults.

 

Diagnostic Investigations

Patients who are febrile or appear unwell should have early initiation of IV antibiotics following blood cultures. Though periorbital cellulitis is a clinical diagnosis, if there is suspicion for orbital cellulitis a CT scan of the orbits and sinuses is the gold standard. Positive findings include inflammation of extraocular muscles, anterior globe displacement, and fat stranding. Inflammation of the sinuses should not be used to differentiate periorbital from orbital cellulitis, as up to 41% of cases of periorbital cellulitis may have CT evidence of sinusitis. Figure 3 displays a labelled CT image with common findings in orbital cellulitis.7

 

Figure 3. Orbital CT image with labels. Retrieved from https://ctscanmachines.blogspot.com/2018/07/ct-scan-of-periorbital-cellulitis.html

In addition to CT imaging, there may be a role for point of care ultrasound (PoCUS) in the diagnosis and management of periorbital and orbital cellulitis. However, research is currently lacking on whether its use may avoid the need for further diagnostic imaging.8 Findings from pediatric emergency medicine suggest that orbital ultrasound may be preferred in evaluating young patients who are unable to cooperate with a thorough physical examination.9 One important application of orbital PoCUS is in the assessment of orbital abscesses. Subperiosteal abscesses may complicate more than 50% of cases of orbital cellulitis, and are not reliably detected by CT.10 Additionally, orbital ultrasound may be an appropriate alternative in settings where advanced imaging is not available, in order to guide early initiation of antibiotics.

Orbital Abscess from – The PoCUS Atlas

 

 

Treatment Best Practices  

Antibiotic choice should be guided by local susceptibility guidelines. An appropriate choice would cover S. aureus, S. pyogenes, and anaerobes.11,12 In this case, we initiated intravenous ceftriaxone and metronidazole while awaiting CT results.

The following therapeutic guidelines are from Bugs and Drugs – It is recommended that that guidelines for therapy are accessed directly from their website or from other reputable sources.

Periorbital Cellulitis

 

Orbital Cellulitis

From Bug and Drugs

 

Case Conclusion

Given this patient’s complaint of increased pain with extraocular movement, a CT orbit was performed. Fortunately, there were no signs of orbital cellulitis. The patient was treated with IV ceftriaxone and metronidazole and scheduled to return to the emergency department the next day for re-evaluation and consideration of step-down to oral antibiotics.

Summary

Orbital cellulitis is a serious condition that should be carefully distinguished from periorbital cellulitis. On history, clinicians should ensure they inquire about recent sinus or dental infections, trauma to the orbit, or possible insect bites. Physical exam should carefully assess for signs of orbital cellulitis, including proptosis, chemosis, and limited extraocular movements. Any positive red flag or clinical suspicion warrants a CT scan of the orbits and sinuses to exclude orbital cellulitis.

Further Reading

Great photo article in Canadian Family Physician

Management algorithm

Patient Information Leaflet

 

 

 

References

  1. Preseptal and Orbital Cellulitis – Eye Disorders – Merck Manuals Professional Edition. (n.d.).Retrieved January 12, 2021, from https://www.merckmanuals.com/professional/eye-disorders/orbital-diseases/preseptal-and-orbital-cellulitis
  2. Lightning Learning: Orbital Cellulitis — #EM3: East Midlands Emergency Medicine Educational Media. (n.d.). Retrieved January 12, 2021, from https://em3.org.uk/foamed/7/5/2019/lightning-learning-orbital-cellulitis
  3. Periorbital cellulitis — entsho.com. (n.d.). Retrieved January 12, 2021, from https://entsho.com/periorbital-cellulitis
  4. Distinguishing Periorbital from Orbital Cellulitis. (2003). American Family Physician, 67(6), 1349.
  5. Differential Diagnosis of the Swollen Red Eyelid – American Family Physician. (n.d.). Retrieved January 12, 2021, from https://www.aafp.org/afp/2015/0715/p106.html
  6. Risk factors of preseptal and orbital cellulitis – PubMed. (n.d.). Retrieved January 12, 2021, from https://pubmed.ncbi.nlm.nih.gov/19149979/
  7. Ct Scan Of Periorbital Cellulitis – ct scan machine. (n.d.). Retrieved January 12, 2021, from https://ctscanmachines.blogspot.com/2018/07/ct-scan-of-periorbital-cellulitis.html
  8. Kang, T. L., Seif, D., Chilstrom, M., & Mailhot, T. (2014). Ocular ultrasound identifies early orbital cellulitis. Western Journal of Emergency Medicine, 15(4), 394. https://doi.org/10.5811/westjem.2014.4.22007
  9. Seguin, J., Le, C.-K., Fischer, J. W., Tessaro, M. O., & Berant, R. (2019). Ocular Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatric Emergency Care, 35(3), E53–E58. https://doi.org/10.1097/PEC.0000000000001762
  10. Derr, C., & Shah, A. (2012). Bedside ultrasound in the diagnosis of orbital cellulitis and orbital abscess. Emergency Radiology, 19(3), 265–267. https://doi.org/10.1007/s10140-011-0993-0
  11. Orbital Cellulitis – StatPearls – NCBI Bookshelf. (n.d.). Retrieved January 12, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK507901/
  12. Periorbital Cellulitis – StatPearls – NCBI Bookshelf. (n.d.). Retrieved January 12, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470408/
Continue Reading

A case of cholecystitis

Posted on by

Medical Student Clinical Pearl

Alana Jewell

M.D. Candidate, Class of 2022

Memorial University Faculty of Medicine

Reviewed & Edited by Dr. Mandy Peach

All case histories are illustrative and not based on any individual.

 

Case Presentation

A 70-year-old gentleman presented with four days of right upper abdominal pain radiating to the LUQ with nausea + vomiting, anorexia, flatulence, and bloating. Patient has PMHx of Crohn’s disease with a history of small bowel obstruction (SBO) and multiple surgeries. He felt these symptoms were like his SBO but he continued to have normal bowel movements. He had a similar episode a few months ago after eating fast food, but did not seek care for.

You suspect cholecystitis.

 

Differential Diagnosis

Can’t miss diagnoses for atraumatic abdominal pain 4:

ruptured AAA
pancreatitis
cholangitis
mesenteric ischemia
obstruction
perforated viscus
complicated diverticulitis
ruptured ectopic pregnancy

Differential for RUQ pain 4 :

hepatitis
biliary colic
cholecystitis
cholangitis
pancreatitis
pneumonia
pleural effusion
pulmonary embolism

 

There is no single exam finding or laboratory test that has the ability to rule out acute cholecystitis5.

 

A combination of clinical evaluation, laboratory values, and diagnostic imaging are key to differentiate abdominal pain and make a diagnosis.

 

Cholecystitis

Cholecystitis is defined as inflammation of the gallbladder, typically caused by persistent stone obstruction in the cystic duct.

Acute cholecystitis (AC): Stone obstruction leads to bile trapping, increased intraluminal pressure, and an acute inflammatory process, typically presenting with RUQ pain, leukocytosis, and fever1.

Chronic cholecystitis: defined as recurrence of these events and is associated with fibrosis and mucosal atrophy2.

Acalculous cholecystitis: consider in chronically debilitated patients, classically elderly patients in ICU on total parental nutrition after sustained trauma or significant burn injury11.

Ascending (or acute) cholangitis: an important complication of cholecystitis – a serious bacterial infection of the common bile duct. It presents with Charcot’s triad of fever, jaundice, and abdominal pain2.

 

Acute cholecystitis is diagnosed and graded on severity by using the Tokyo Guidelines3.

 

 

 

Gallstones (which cause 95% of acute cholecystitis) are common in Western society, with about 10% of people affected, and 80% of those affected being asymptomatic1,3. The risk of pain or complications is 1-4% per year2.

 

Risk factors for cholesterol gallstones (the most common type) 2:

increased age
female gender
pregnancy
parity
race
high calorie
low fibre diet
low activity
obesity

 

 

 Clinical Presentation and findings

Clinical presentation varies with severity.

On history, a patient may have anorexia, emesis, fever, nausea, and RUQ pain.  On examination, guarding, Murphy’s sign (pain upon deep inspiration while palpating RUQ), rebound tenderness, abdominal rigidity, and RUQ tenderness may be seen2. Patients may describe a history of biliary colic, but with the presenting episode being more severe and longer in duration.

Mild-moderate cases have RUQ pain, fever, leukocytosis, and may have a palpable mass in the RUQ2. The most severe patients may have jaundice and, if have a secondary bacterial infection, could have signs of sepsis.

 

Case Continued

 

Physical Exam

Patient was tender to light palpation over RUQ and epigastric region. No rigidity, rebound tenderness, or guarding was noted.

Bloodwork

  • Elevated WBC with neutrophilic shift
  • C reactive protein > 250
  • Normal lipase, liver enzymes and renal function.

The most common laboratory findings in acute cholecystitis are an increased CRP and leukocytosis2.

 

This patient requires imaging to confirm the suspected diagnosis.

 

Diagnostic Imaging

Ultrasound

Ultrasound is the first-choice modality for imaging of AC. It is easily available in any emergency department, cost-effective, and minimally invasive3. Ultrasound findings can include5,6,9, as seen below 6.

 GB wall thickening > 3.5 mm
pericholecystic fluid
biliary sludge
gallstones
sonographic Murphy sign

 

If an ultrasound is positive, there is no need for further testing.

If negative, a CT should be ordered to exclude other diagnoses2,7.

 

CT findings for AC may include 3,6 as seen below 2:

thickening of GB wall
enlargement of GB
gallstones in GB neck or cystic duct
fluid accumulation around GB
pericholecystic fat stranding

 

Many gallstones are not radiopaque and may be missed on CT7. 

 

Management

Assessment with Tokyo Guideline diagnostic criteria can be used every 6-12 hours until a diagnosis is clear if initially uncertain, and to check severity until surgical management8.

In the Emergency Department, a patient is best managed with supportive care.

IV fluids,
NPO
Analgesia (NSAIDs are first-line treatment for AC. If ineffective, opioids are second line2. )

 

Secondary infection can result from bile stasis. Empiric antibiotics may be started against E. coli, Klebsiella, and Enterococcus5.

Definitive treatment for AC is cholecystectomy, with the gold standard being done laparoscopically (lap-C)2,7. Having a lap-C within 24-72 hours of symptom onset is recommended to decrease complication rates. If left unoperated for more than 72 hours chronic inflammation may occur, potentially complicating the surgery1. If a patient is ineligible for surgery, percutaneous cholecystostomy (gallbladder drainage) may be performed7.

 

Case Conclusion

Formal ultrasound found a hydropic gallbladder with pericholecystic fluid, thickened wall, and stranding. Cholecystitis was diagnosed. The patient was given analgesia and covered with ceftriaxone and metronidazole10. He went on to have an uncomplicated lap cholecystectomy.

 

References

  1. Indar, Adrian A, and Beckingham, Ian J. “Acute Cholecystitis.” BMJ, vol. 325, no. 7365, 2002, pp. 639–643.
  2. Wilkins, Thad, MD, MBA, et al. “Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia.” Primary Care, vol. 44, no. 4, 2017, pp. 575–597.
  3. Yokoe, Masamichi, et al. “Tokyo Guidelines 2018: Diagnostic Criteria and Severity Grading of Acute Cholecystitis (with Videos).” Journal of Hepato-Biliary-Pancreatic Sciences, vol. 25, no. 1, 2018, pp. 41–54.
  4. Anjum, Omar, et al. “Ottawa’s Clerkship Guide to Emergency Medicine.” Department of Emergency Medicine, University of Ottawa, Mar. 2018.
  5. Jain, Ashika, et al. “History, Physical Examination, Laboratory Testing, and Emergency Department Ultrasonography for the Diagnosis of Acute Cholecystitis.” Academic Emergency Medicine, vol. 24, no. 3, 2017, pp. 281–297.
  6. Chawla, Ashish, et al. “Imaging of Acute Cholecystitis and Cholecystitis-Associated Complications in the Emergency Setting.” Singapore Medical Journal, vol. 56, no. 8, 2015, pp. 438–444.
  7. Bagla, Prabhava, et al. “Management of Acute Cholecystitis.” Current Opinion in Infectious Diseases, vol. 29, no. 5, 2016, pp. 508–513.
  8. Mayumi, Toshihiko, et al. “Tokyo Guidelines 2018: Management Bundles for Acute Cholangitis and Cholecystitis.” Journal of Hepato-Biliary-Pancreatic Sciences, vol. 25, no. 1, 2018, pp. 96–100.
  9. Flemming, Lewis & Henneberry (2017). PoCUS – Measurements and Quick Reference https://sjrhem.ca/pocus-measurements-quick-reference/
  10. Bugs & Drugs Medical App
  11. Forsythe (2016). Cholecystitis. First Aid for the Emergency Medicine Boards, Third Edition: Abdominal and Gastrointestinal Emergencies. McGraw-Hill Education. China.

 

 

 

 

 

Continue Reading

A Case of Ectopic Pregnancy

Posted on by

 

Medical Student Clinical Pearl – December 2020

Marisa O’Brien

@mbob58

MD Candidate, Class of 2021

Memorial University of Newfoundland

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual

 

Case Report

A 36-year-old G2P1 female presented to the Emergency Department following a pre-syncopal episode at work. The patient noted a sudden onset of significant abdominal cramping, nausea, and vaginal bleeding with clots that morning followed by an episode of lightheadedness while sitting at her desk. The patient denied any loss of consciousness, no dyspnea, no chest pain, no palpitations, and no fevers/chills. She had no known allergies and no current medications. She was a non-smoker and denied any alcohol or drug usage.

The patient’s past medical history was significant for recent treatment with methotrexate for an ectopic pregnancy eight days prior. The patient had a history of amenorrhea for 7 weeks and a serum β-hCG of 302 mlU/mL at that time. A transvaginal ultrasound was performed at 8 weeks for abdominal pain and light spotting which revealed an IUD in situ with no evidence of an intrauterine pregnancy. An early ectopic pregnancy was diagnosed and the patient was consented to receive medical management with methotrexate. She was followed up with serial β-hCG’s which gradually, but slowly, trended down to 110 mIU/ml by day 6. The patient noted slight abdominal cramping and PV bleeding following the methotrexate however this had settled after 3 days with no ongoing symptoms until today.

On initial assessment, the patient appeared well, no acute distress, and all vital signs were stable.  The abdominal exam revealed bowel sounds present in all four quadrants and the abdomen was tympanic to percussion. On palpation the abdomen was soft and nondistended with LLQ and suprapubic tenderness however, no guarding or rebound tenderness was appreciated.

Initial investigations included a CBC, β-hCG, PT & PTT, type and screen, urinalysis, EKG, & POCUS.

 

Definition

An ectopic pregnancy occurs when a fertilized egg implants at a site other then the endometrium of the uterus, most commonly the fallopian tubes. They often present as vaginal bleeding and/or abdominal pain in the setting of a positive β-hCG.1

A critical complication is a ruptured ectopic pregnancy which occurs by erosion through the tissue the zygote has implanted in resulting in intraabdominal bleeding from the exposed vessel and possible hypovolemic shock.2 Rupture should be suspected in patients presenting with hemodynamic instability including syncope, hypotension, and tachycardia. However, young healthy females may appear vitally stable initially due to compensatory mechanisms. Additional physical exam findings suggestive of a ruptured ectopic pregnancy include severe abdominal pain with guarding or rebound tenderness and abdominal distention. Pain may radiate to the shoulder due to irritation of the diaphragm from blood in the peritoneal cavity.1,3

 

Risk factors for ectopic pregnancy4

  • Previous ectopic pregnancy
  • Prior fallopian tube surgery
  • Previous pelvic or abdominal surgery
  • Sexually transmitted infections
  • Pelvic inflammatory disease
  • Endometriosis
  • Cigarette smoking
  • Maternal age > 35 years
  • History of infertility
  • Assisted reproductive technology (IVF)

 

 

Differential diagnosis for vaginal bleeding in early pregnancy1:

  • Physiologic
  • Spontaneous abortion
  • Cervical, vaginal, or uterine pathology
  • Subchorionic hematoma
  • Heterotopic pregnancy
  • Gestational trophoblastic disease

 

Sonography

According to the discriminatory zones, an intrauterine pregnancy is expected to be visualized on a transvaginal ultrasound at β-hCG levels of 1500 – 2000 mlU/mL and on a transabdominal ultrasound at levels of 4000 – 6500 mlU/mL.5

Gestational Age Β-hCG range (mlU/mL)
<1 week 5 – 50
1-2 weeks 50 – 500
2-3 weeks 100 – 5000
3-4 weeks 500 – 10,000
4-5 weeks 1000 – 50,000
5-6 weeks 10,000 – 100,000
6-8 weeks 15,000 – 200,000
8-12 weeks 10,000 – 100,000

Table 1: Estimated β-hCG levels in relation to gestational age.3

In the first trimester of a normal pregnancy, the serum β-hCG should increase by ≥ 53% every 48 hrs until 41 days of gestation.1,3 Serum β-hCG will then continue to rise more slowly until approximately 10 weeks after which it will begin to decline until reaching a plateau. Serum β-hCG levels are noted to raise more slowly in an ectopic pregnancy, thus a slower rate of increase, plateau, or decline in serum β-hCG in the first 41 days suggests a possible miscarriage or ectopic pregnancy.1

Note on β-hCG Discriminatory Zones

The value of discriminatory zones in the emergency management of ectopic pregnancy is low, with many considering it unreliable and potentially dangerous. In short, a low β-hCG does not exclude an ectopic. This useful post provides a good summary on ectopic rule-out in the ED:

Rule Out Ectopic in the Emergency Department

 

An intrauterine pregnancy is confirmed by visualization of a gestational sac and a yolk sac within the uterus (juxtaposed to bladder).1 A gestational sac alone is not sufficient for diagnoses of an intrauterine pregnancy as it may be a pseudogestational sac formed by hormonal stimulation from an ectopic pregnancy.5 Additionally, if an intrauterine pregnancy is visualized, a heterotopic pregnancy should also be considered.1 The risk of heterotopic pregnancy when conceived normally is estimated to be 1 in 30,000.

Figure 1: Visualization of an intrauterine pregnancy on a transvaginal ultrasound.3

 

 

Structure Transvaginal Ultrasound Transabdominal Ultrasound
Gestational Sac 4.5-5 weeks 5.5-6 weeks
Yolk Sac 5-5.5 weeks 6-6.5 weeks
Fetal Pole 5.5-6 weeks 7 weeks
Cardiac Activity 6 weeks 7 weeks
Fetal Parts 8 weeks >8 weeks

Table 2: Ultrasound findings based on gestational age.5

 

Diagnosis of Ectopic Pregnancy

An ectopic pregnancy is suspected in all women with a positive pregnancy test when no intrauterine pregnancy is visualized on ultrasonography. A low β-hCG or declining β-hCG does not exclude an ectopic. Ultrasound findings of an ectopic pregnancy may include an extrauterine gestational sac or embryonic cardiac activity outside of the uterus, a complex adnexal mass, or intraperitoneal fluid.3

From emupdates.com

 

Management of Ectopic Pregnancy

Is the patient unstable?

  • If the patient is hemodynamically unstable (tachycardia or hypotension or pale or syncopal) then commence immediate resuscitation (IV Access, CBC, type & crossmatch,  iv fluids, transfusion, etc) and stat consult to ObGyn.

In stable patients

  • Consult ObGyn
  • The gold-standard of treatment for ectopic pregnancy is surgical management however, treatment options include expectant, or medical management.6 Medical management with methotrexate, a folic acid antagonist that inhibits DNA synthesis and cell production, has a higher success rate when initiated at lower β-hCG levels. Methotraxate is initiated if β-hCG is <5000 mlU/mL and is reserved for those with reliable follow up as β-hCG levels are required to be trended until they are undetectable. Individuals with renal disease, hepatic disease, active pulmonary disease, or immunodeficiencies are not candidates for methotrexate.3,7 Individuals who do not meet the criteria for medical management, are hemodynamically unstable, have failed methotrexate, or a ruptured ectopic is suspected, will receive surgical management.6

 

Case Report Continued

The patient was hemodynamically stable on presentation. Her vital signs were normal. As part of the initial assessment, PoCUS was used to further evaluate for the presence of free fluid in the abdomen or pelvis. Free fluid was identified in the RUQ in both Morrison’s pouch and surrounding the caudal tip of the liver. Intraperitoneal fluid was also seen in the LUQ in both the subphrenic and splenorenal spaces. Free fluid was also visualized in Douglas’ pouch in the pelvic view.

RUQ

LUQ

Pelvis

 

Throughout the PoCUS examination the patient remained well appearing, however she had become hypotensive with a blood pressure of 90/53 mmHg. Her initial bloodwork had come back at this time revealing a β-hCG of 32 mlU/mL and a Hgb of 67 g/L. The patient received 1g of TXA, and a 1L bolus of normal saline while PRBC’s were ordered. She was documented to be Rh+ thus, she did not require RhoGAM (anti-D immune globulin). An urgent consultation to Obstetrics and Gynecology was made following the visualization of intraabdominal fluid and the patient underwent an exploratory laparotomy shortly after.

 

Key Points

  • Ectopic pregnancy should be considered in the differential diagnosis of any female patient, of childbearing age, presenting with abdominal pain, syncope or shock
  • An Intrauterine contraceptive device does not exclude an ectopic
  • Unless a previous ultrasound has documented the presence of an intrauterine pregnancy, an empty uterus in a patient with a positive pregnancy test should be considered to be a possible ectopic until ruled out
  • An intrauterine pregnancy on ultrasound requires the following to be confirmed:
    • A gestational sac and a yolk sac, in the uterus which is juxtaposed to the bladder
    • or a gestational sac containing a normal fetal pole, in the uterus which is juxtaposed to the bladder
  • A low β-hCG or declining β-hCG does not exclude an ectopic
  • Medical management of ectopic pregnancy with methotrexate requires close follow-up. Failure can occur. Ruptured ectopic pregnancy can still occur.

 

Further Reading

Ectopic Pregnancy and Ruptured Ectopic: Pitfalls in Diagnosis

ED Rounds – Early Pregnancy

The Pregnant ED Patient – A Compendium of Pearls

 

 

References

  1. Tulandi, T. (2020, November 2). Ectopic pregnancy: Clinical manifestations and diagnosis. Retrieved from: https://www.uptodate.com/contents/ectopic-pregnancy-clinical-manifestations-and-diagnosis?search=ectopic%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1
  2. Toy, E.C., Simon, B.C., Takenaka, K.Y., Liu, T.H., & Rosh, A.J. (2017). Ectopic Pregnancy. Case Files Emergency Medicine. (4th, pp. 369-376). McGraw-Hill Education.
  3. Hang, B.S. (2016). Obstetrics and Gynecology. Tintinalli’s Emergency Medicine: A Comprehensive Guide. (8th, pp. 629-633). McGraw-Hill Education.
  4. The American College of Obstetricians and Gynecologists. (2018, February). Retrieved from: https://www.acog.org/womens-health/faqs/ectopic-pregnancy
  5. Leonard, N.J. (2019, January 23). The Pregnant Pelvic POCUS. EMRounds. Retrieved from: https://emrounds.org/the-pregnant-pelvic-pocus/
  6. Tulandi, T. (2020, March 31). Ectopic pregnancy: Choosing a treatment. Retrieved from: https://www.uptodate.com/contents/ectopic-pregnancy-choosing-a-treatment?search=ectopic%20pregnancy&topicRef=5407&source=see_link#H2976630177
Continue Reading

Small Bowel Obstruction & PoCUS

Posted on by

Small Bowel Obstruction & PoCUS – Medical Student Pearl

Patrick Rogers, Clinical Clerk (CC3)

Memorial University of Medicine Class of 2021

Reviewed by Dr. Kavish Chandra

Small bowel obstructions (SBO) are a common cause of acute abdominal pain in emergency departments across Canada. Diagnostic imaging plays a key role in the diagnosis and management of SBO as the history, clinical examination and laboratory investigations lack the sensitivity and specificity needed. Furthermore, diagnostic imaging may help differentiate SBO from other causes of abdominal pain (hernias, malignancies, intussusception, etc).

Historically, plain film abdominal radiography (AXR) has been an initial investigation in emergency departments when an SBO is suspected.  However, the current literature suggests that abdominal radiography is a relatively poor test for the diagnosis or exclusion of SBO when compared to other available modalities like US, CT, or MRI. In fact, multiple studies argue for the reduction of abdominal x-rays, especially when patients come in presenting with general abdominal tenderness. 1 Fortunately, there exists a compelling alternative: point of care ultrasound (PoCUS), and is being increasingly used as a first line investigation for SBO. 2

There are several reasons why physicians may start to choose PoCUS over traditional diagnostic modalities:

  • PoCUS avoids the radiation exposure that patients receive from cumulative plain films and abdominal CT’s. 3
  • PoCUS has been shown to reduce time to diagnosis and treatment in comparison to abdominal plain films. 3
  • PoCUS is more sensitive/specific modality when compared to abdominal plain film. 4
  • PoCUS allows for serial examination in the ED. 5
  • PoCUS may be rapidly available to centers with limited access to CT scanner. 6

The current evidence is highly favorable for the diagnostic efficacy of PoCUS in SBO. Here are the findings of peer-reviewed studies on the subject (published between 2013-2020):

  • PoCUS has high diagnostic accuracy and may also decrease time to diagnosis of SBO in comparison to other imaging modalities like CT and plain film.2
  • PoCUS has been found to have superior diagnostic accuracy for SBO in comparison to plain abdominal radiography. 4
  • PoCUS has been shown to be an accurate tool in the diagnosis of SBO with a consistently high sensitivity of 94-100% and specificity of 81-100%. 5
  • Current evidence suggests PoCUS is comparable in sensitivity and specificity to a CT scan when diagnosing SBO. 6
  • Ultrasound was found to be equivalent to CT in terms of diagnostic accuracy with a sensitivity of 92.31% (95% CI, 74.87% to 99.05%) and a specificity of 94.12% (95% CI, 71.31% to 99.85%) in the diagnosis of SBO. 7
  • In a study comparing XR, US, CT, and MRI, the abdominal x-ray was shown to be to be the least accurate imaging modality for the diagnosis of SBO. AXR’s were found to have a positive likelihood ratio of 1.64 (95% CI 1.07 to 2.52). In contrast, CT and MRI were both quite accurate in diagnosing SBO with positive likelihood ratios of 3.6 (95% CI = 2.3 to 5.4) and 6.77 (95% CI = 2.13 to 21.55). The use of ultrasound was found to have a positive likelihood ratio of 9.55 (95% CI = 2.16 to 42.21) and a negative likelihood ratio of 0.04 (95% CI = 0.01 to 0.13) for beside scans. 4

There are two major barriers identified in the literature that may prevent the effective use of PoCUS in the diagnosis of SBO. First, not every emergency physician has been trained on the use of PoCUS. Fortunately, two recent studies show that even minimally trained ED physicians can use it accurately. 8 Secondly, some surgeons have argued that PoCUS does not show the location of the obstruction accurately. This becomes a concern when the care team elects for surgical management of the patient’s SBO. However, recent evidence suggests that PoCUS may lead to quicker time to diagnosis and enteric tube insertion in conservative management. 8

Finally, how can learners use this technology? 5 Here are some specific sonographic findings to look for when evaluating a patient for SBO with US:

 

  • Dilatation of small bowel loops > 25 mm *
  • Altered intestinal peristalsis *
  • Increased thickness of the bowel wall
  • Intraperitoneal fluid accumulation

Figure 1. Dilatation of small bowel loops. Image courtesy Dr. Kavish Chandra

Figure 2. Altered intestinal peristalsis*. Image courtesy Dr. Kavish Chandra

Figure 3. – abnormal peristalsis “to and fro”9

References

  1. Denham G, Smith T, Daphne J, Sharmaine M, Evans T. 2020. Exploring the evidence-practice gap in the use of plain radiography for acute abdominal pain and intestinal obstruction: a systematic review and meta-analysis. International Journal of Evidence Based Healthcare. DOI: 10.1097/XEB.0000000000000218
  2. Guttman J, Stone M, Kimberly H, Rempell J. 2015. Point of care ultrasonography for the diagnosis of small bowel obstruction in the emergency department. CJEM. DOI: 10.2310/8000.2014.141382
  3. Flemming H, Lewis D. 2016. SBO- A New Focus for PoCUS. Saint John Regional Hospital Department of Emergency Medicine
  4. Taylor M, Lalani N. 2013. Adult small bowel obstruction. Academic Emergency Medicine. DOI: 10.1111/acem.12150
  5. Pourman A, Dimbil U, Shokoohi H. 2018. The accuracy of point of care ultrasound in detecting small bowel obstruction in emergency department. Emergency Medicine International. DOI: 10.1155/2018/3684081
  6. Gottlieb M, Peska, G, Pandurangadu A, Nakitende D, Takhar S, Seethala R. 2018. Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis. The American Journal of Emergency Medicine. DOI: 10.1016/j.ajem.2017.07.085
  7. Tamburrini S, etal. 2019. Diagnostic accuracy of ultrasound in the diagnosis of small bowel obstruction. Diagnostics. DOI: 10.3390/diagnostics9030088
  8. Carpenter C. 2013. The end of X-Rays for suspected small bowel obstruction? Using evidence-based diagnostics to inform best practices in emergency medicine. Academic Emergency Medicine. https://doi.org/10.1111/acem.12143
  9. The PoCUS Atlas. https://www.thepocusatlas.com/bowel-gi

Copyedited by Dr. Mandy Peach

Continue Reading

Spontaneous Abortion

Posted on by

Medical Student Clinical Pearl

Miranda Lees, Clinical Clerk II

Dalhousie Medicine New Brunswick, Saint John

Reviewed by Dr. Mandy Peach

Case

A 21yo G3P1A1 female at 6 weeks gestation presented to the Emergency Department with an 8 hour history of vaginal bleeding and abdominal pain. The bleeding is a mixture of bright red and brown blood with no clots, and the abdominal pain is episodic cramping in her suprapubic region.

Her obstetrical history is significant for 2 prior pregnancies, the first of which was carried to term with an uncomplicated vaginal delivery, and the second of which had resulted in a spontaneous abortion at 6 weeks gestation. She is otherwise healthy. The patient noted with both prior pregnancies she had similar vaginal bleeding around 6-8 weeks gestation. She was given RhoGAM due to her Rh- blood type.

On assessment the patient appeared well with all vital signs within normal limits. On physical exam bowel sounds were present, the abdomen was tympanic to percussion, and pain on palpation was present in the patient’s suprapubic region.

 

Differential for life threatening causes of vaginal bleeding in pregnancy

<20 weeks gestation >20 weeks gestation
      ruptured ectopic pregnancy          placental abruption
       retained products of conception          placenta previa
       complication of termination          post partum hemorrhage

Other causes for vaginal bleeding to consider in pregnancy and in non-pregnant patients

Spontaneous abortion
Acute heavy menstrual bleeding
Genitourinary trauma
Uterine arteriovenous malformation
Ruptured ovarian cyst
Ovarian torsion
Pelvic Inflammatory Disease
Fibroids
Polyps
Foreign body
Coagulation disorder
Medication related
Gynecologic malignancy

 

Investigations

A βhCG was ordered to confirm pregnancy and bedside ultrasound was done to look for intrauterine pregnancy.

Transabdominal ultrasound showed the following:

The presence of a gestational sac within the uterus and a fetal heartbeat within the fetal pole confirmed a viable intrauterine pregnancy (IUP). The patient was diagnosed with threatened abortion.

 

Spontaneous Abortion-an overview

Spontaneous abortion is one of the most common complications of pregnancy, occurring in 17-22% of pregnancies2 and is defined as loss of pregnancy prior to 20 weeks gestation, occurring most often in the first trimester3. There are 3 primary causes: chromosomal abnormalities in the fetus, maternal anatomic abnormalities, and trauma.3

Risk factors for spontaneous abortion

age (below 20 and above 35)
moderate to severe bleeding (especially if passage of clots)
prior pregnancy loss
maternal comorbidities (DM, autoimmune conditions, obesity, thyroid disease)
infection (notably parvovirus, CMV and untreated syphilis)
teratogenic medications
maternal radiation exposure
maternal smoking
caffeine
alcohol use

 

Classification4

Missed abortion is characterized by an asymptomatic death of the fetus with a lack of contractions to push out the products of conception.5

Clinical presentation

Spontaneous abortion most commonly presents with vaginal bleeding and cramping, ranging from mild to severe1. However, most women with first-trimester bleeding will not undergo spontaneous abortion1. Bleeding associated with spontaneous abortion often involves passage of clots or fetal tissue, and the cramping can be constant or intermittent, often worse with passage of tissue1.

Diagnosis

Confirmation of spontaneous abortion requires pelvic ultrasound.

In patients with a prior ultrasound showing intrauterine pregnancy, diagnosis of spontaneous abortion can be made if a subsequent ultrasound shows no intrauterine pregnancy or a loss of previously-seen fetal heartbeat1.

In patients with a prior ultrasound showing intrauterine pregnancy with no fetal heartbeat, spontaneous abortion is diagnosed based on the following1:

  • A gestational sac >25mm in diameter containing no yolk sac or embryo
  • An embryo with crown rump length >7mm with no fetal cardiac activity
  • After pelvic ultrasound showing a gestational sac without a yolk sac, absence of embryo with a heartbeat in >2 weeks
  • After pelvic ultrasound showing a gestational sac with a yolk sac, absence of embryo with a heartbeat in >11 days

Case conclusion

The patient was treated with IM RhoGAM, a formal pelvic and transvaginal ultrasound was arranged for the next day, and she was discharged home. The follow-up ultrasound showed a gestational sac present in the uterus, an embryo with crown rump length of 8.1mm and the presence of a fetal heartbeat.

 

References

  1. Borhart D. Approach to the adult with vaginal bleeding in the Emergency Department. In: UptoDate, Hockberger R (Ed), UpToDate, Waltham, MA. (Accessed on October 8, 2020).
  2. Gracia C, Sammel M, Chittams J, Hummel A, Shaunik A, et al. Risk Factors for Spontaneous Abortion in Early Symptomatic First-Trimester Pregnancies. Obstetrics & Gynecology. 2005;106(5):993-999. doi 1097/01.AOG.0000183604.09922.e0.
  3. Prager, Mikes & Dalton. Pregnancy loss (miscarriage): Risk factors, etiology, clinical manisfestations, and diagnostic evaluation. In: UptoDate, Eckler (Ed), UptoDate, Waltham MA. (accessed Nov 28, 2020)
  4. Diaz. 2018. Types of Spontaneous Abortion. In: GrepMed. Image Based Medical Reference. https://www.grepmed.com/images/5425/classification-spontaneous-obstetrics-diagnosis-abortion-obgyn-types (Accessed Nov 28, 2020)
  5. Alves C, Rapp A. Spontaneous Abortion (Miscarriage) [Updated 2020 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560521/.

 

Continue Reading

Skin and Soft Tissue Infections: A PoCUS Guided Approach

Posted on by

Medical Student Clinical Pearl – November 2020

 

Robert Hanlon

@roberthanlon12

Year: 4
DMNB Class of 2021
 

Reviewed and Edited by Dr. David Lewis

All case histories are illustrative and not based on any individual

 

Case Report

A 25yr old male presents with a 3 day history of a red swollen foot following an insect bite. He has no past medical history. On examination there is some erythema and swelling on the dorsum of the left foot. Palpation is very tender.

You are aware of recommended guidelines that advise I&D for purulent infections and decide to proceed with the procedure. Despite trying to freeze the area with lidocaine, the procedure is still painful and no pus is drained. You point to the minimal serosanguinous exudate and sheepishly suggest to the patient that the I&D was successful and that a course of antibiotics will resolve this issue.

Skin and Soft Tissue Infections: A POCUS Guided Approach

Skin and soft tissue infections (SSTIs) have a variety of potential causes, ranging in severity from mild infections like cellulitis to abscess all the way to life-threatening causes like necrotizing fasciitis.1 SSTIs are commonly encountered in the emergency department, with cellulitis and abscesses being the two most common.2 It is important to be able to recognize SSTIs and provide appropriate treatment. Abscesses require invasive management, whereas cellulitis is treated with systemic therapies; therefore, it is important to be able distinguish the different between the two types. Doing so can be difficult because of the hidden nature of abscesses. However, ultrasound can be a useful tool in establishing the presence of an abscess. This article is a review of the clinical approach and treatment for SSTIs, focusing on cellulitis and abscesses, as well as the use of ultrasound in helping to establish the diagnosis.

Approach

Clinical suspicion is the initial step in the diagnosis of SSTIs. These infections have multiple causes; therefore, obtaining a detailed history is crucial. Information about immunocompromised state, place of residence, travel, any recent trauma or surgery, previous antimicrobial use, lifestyle, hobbies, and animal bites is essential to developing an adequate differential diagnosis.3

A good understanding of the normal skin flora and common infectious organisms is key to assessing SSTIs. The most commons organisms implicated in SSTIs are Staphylococcus aureus and Streptococcus species.4-6 Methicillin resistant S. aureus (MRSA) being an important strain that has increased in prevalence in the past 20 years. Risk factors such as presence of abscess, intravenous drug use, previous MRSA status, antibiotics within 8 weeks, diabetes mellitus, and previous hospital admission within the last year increase the likelihood of the infection being cause by MRSA.4-6

Physical examination findings are crucial for establishing the presence of an SSTI; the typical criteria are a superficial lesion with the classic inflammatory findings of redness (rubor), swelling (tumor), warmth (calor), and pain (dolor).1,2,7 An abscess is defined as a fluctuant mass of puss localized and buried within a tissue, organ, or potential space; however, clinically it can be hard to determine to presence of this mass.2,7 Other associated signs and symptoms, such as crepitus, bullae, and hemorrhage, may be present upon diagnosis or may develop later during the course.2,7 Due to overlapping clinical presentations of the different SSTIs, it can be difficult to differentiate between them.

Cellulitis – No Abscess
Cellulitis – Possible Abscess
Abscess
Early Abscess

Assessment with POCUS:

Due to the similarities between different SSTI cutaneous findings and their different treatments, it is important to establish if there is an abscess present. It was common, before the introduction of ultrasound, to perform a blind needle aspiration of the infected area in order to determine the presence/absence of an abscess.8,9 However, this subjects that patient to the risks of an invasive procedure as well as pain. On the other hand, treating infection with empiric antibiotics in the presence of an unknown abscess delays drainage and allows for potential worsening of the infection.8,9

A study by Tayal et al. demonstrated that the use of ultrasound was beneficial in patients who had both low and high pretest probability for needing incision and drainage. In patients suspected of having simple cellulitis (low pretest), ultrasound was used to change management in over half of participants; establishing the need for drainage due to imaging of a fluid collection. The opposite was true in the patients suspected of having an abscess (high pretest); the study found that ultrasound was able to determine that more than half of this group did not need drainage, because of the absence of a fluid collection on imaging.10 Other studies have had similar findings, but the percent change in management was slightly lower.11

A study by Barbic et al. demonstrated that POCUS provided a rapid, non-invasive, painless, and easily repeatable test, that distinguished between abscess and cellulitis in the vast majority of cases. Their analysis concluded that POCUS had a sensitivity of 96.2% and a specificity of 82.9% in diagnosing the presence of an abscess.12 They concluded that POCUS can accurately diagnose abscess in paediatric and adult populations and is likely superior to clinical examination.12

Cobblestones

Classic finding for cellulitis (but not specific to cellulitis). There will be hyperechoic lobules of subcutaneous fat surrounded by relatively hypoechoic inflammatory fluid.13

Cobblestone – Cellulitis

Purulent Fluid Collection

Classic finding for an abscess; have a rounded shape of anechoic or hypoechoic fluid collection, and there will be surrounding areas of cobblestones from the overlying cellulitis.13 As well, there should be no color flow if doppler is applied to the area (helping to distinguish from lymph node or vessel).14

Abscess – Anechoic Collection
Possible Abscess or Lymph Node? – This is a lymph node – see below
Colour flow differentiates lymph node from abscess

Necrotizing Fasciitis

Because you do not want to miss it! Findings via ‘STAFF’; subcutaneous thickening, air, and fascial fluid.14 Note, that ultrasound does not to exclude the diagnosis. Also need clinical correlation to increase suspicion of such a serious infection.15

Necrotizing Fasciitis – STAFF

Treatment:

According to The Infectious Diseases Society of America (2014) guidelines, management of SSTIs is differentiated based on the presence/absence of purulence (i.e. abscess/fluid collection). They recommend that all purulent infections be treated with incision and drainage, with more severe infections (signs of systemic involvement) being cultured with sensitivities in order to add antibiotics to the treatment.16 Otherwise, non-purulent infections are to be treated with systemic antibiotics; the severity of the infection determining the route and choice of agent.16

Antibiotic therapy, in addition to incision and drainage of a skin abscess, is suggested for patients with any of the following:17

  • Single abscess ≥2 cm or multiple abscesses
  • Large are of surrounding cellulitis
  • Patients with immunosuppression or other comorbidities
  • Signs of systemic involvement (fever > 38°C, hypotension, or tachycardia)
  • Poor clinical response to incision and drainage alone
  • Presence of an indwelling medical device
  • High risk for adverse outcomes with endocarditis (these include a history of infective endocarditis, presence of prosthetic valve or prosthetic perivalvular material, unrepaired congenital heart defect, or valvular dysfunction in a transplanted heart)
  • High risk for transmission of aureus to others (such as in athletes or military personnel)

 

Horizon Health’s local trends recommend the following (see guideline or Spectrum app for full details)

Severity of Infection

 

 

Antibiotic

Mild

Moderate

Severe

Cephalexin 500 – 1000mg PO q6h x 5 days

ceFAZolin 2 g IV q8h x 5 days

ceFAZolin 2 g IV q8h +/- Clindamycin 900 mg IV q8h

If true beta-lactam allergy

Cefuroxime 500 mg PO BID or TID x 5 days

Clindamycin 600-900 mg IV q8h x5 days

 

If MRSA suspected

Septra 800/160 mg or 1600/320 mg PO q12h x 5 days

Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h x 5 days

ADD Vancomycin 25-30 mg/kg IV once then 15mg/kg IV q8 to q12h

 

Some research is suggesting that POCUS can take the assessment of abscesses one step-further and impact management based on the depth and size of the fluid collection seen in imaging. Russell et al. found that abscesses less than 0.4cm below the skin surface could be effectively treated without incision and drainage.18 Another study found that patients, with skin abscesses less than or equal to 5cm in diameter, treatment with oral antibiotics in combination with incision and drainage had improved short-term outcomes compared to those patients treated with the procedure alone.18 While as mentioned above, UpToDate, suggests that antibiotics be used in single abscess greater than 2 cm in size. As well, research has found that ultrasound guided incision and drainage provides lower failure rates (less recurrent infections or multiple incisions) compared to blind incision and drainage. Likely due to better visualization of the abscess and more adequate initial drainage.19

Limitations

There are some limitations to POCUS for SSTIs: ultrasound imaging and interpretation rely on the user’s ability to obtain high-quality images in order to assess whether an abscess is present. It is important for the user to be familiar with different findings on ultrasound to guide appropriate treatment. An abscess may appear hypoechoic, hyperechoic, or anechoic (depending on tissue contents), and usually has posterior acoustic enhancement.19 Determining if it is drainable can be difficult due to this variability in imaging, and it is also quite common for early abscesses to present like cellulitis with erythema, no fluctuance, and an ultrasound that is negative for a fluid collection.20 In cases of a suspected evolving abscess, sometimes referred to as a non-ripe abscess, supportive care, including warm compresses, pain control, and close follow-up, is recommended.20 The practitioner may treat this like cellulitis; however, the patient may return with perceived failure of therapy if discharge advice does not include the possibility of of an abscess forming over time.

Abscess examples from the SJ archives

  • Drainable abscess – Note the anechoic collection with some dependent debris
  • Beard abscess – note the anechoic collection and hyperechoic hair
  • Deep abscess – swirling echoic debris = “pustulasis”
  • Small abscess – another example of “pustulasis”
  • Cellulitis – starting to coalesce but not drainable yet
  • Large abscess in groin – what are those deeper structures?
  • Femoral vessels just deep to groin abscess
  • Large abscess – thick hyperechoic pus
  • Hip incision abscess – thick hyperechoic pus
  • Ischiorectal abscess
  • Lymph node
  • Pilonidal abscess – note the hyperechoic hair
  • Cellulitis – coalesced abscess – drainable

References

  1. Moffarah AS, Al Mohajer M, Hurwitz BL, Armstrong DG. Skin and Soft Tissue Infections. Microbiol Spectr. 2016 Aug;4(4). doi: 10.1128/microbiolspec.DMIH2-0014-2015.

 

  1. Martinez, N. “Skin and Soft-Tissue Infections: Itʼs More Than Just Skin Deep.” Advanced Emergency Nursing Journal, vol. 42, no. 3, 2020, pp. 196–203.

 

  1. Cieri, B., Conway, E., Sellick, J., & Mergenhagen, K. (2019). Identification of risk factors for failure in patients with skin and soft tissue infections. The American Journal of Emergency Medicine, 37(1), 48-52.

 

  1. Borgundvaag, B., Ng, W., Rowe, B., Katz, K., Farrell, Brian, Guimont, Chantal, . . . Gregson, Dan. (2013). Prevalence of methicillin-resistant Staphylococcus aureus in skin and soft tissue infections in patients presenting to Canadian emergency departments. CJEM, 15(3), 141-160.

 

  1. Esposito, S., De Simone, G., Pan, A., Brambilla, P., Gattuso, G., Mastroianni, C., . . . Savalli, F. (2019). Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry. Journal of Chemotherapy (Florence), 31(1), 9-14.

 

  1. Stenstrom, R., Grafstein, E., Romney, M., Fahimi, J., Harris, D., Hunte, G., . . . Christenson, J. (2009). Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus skin and soft tissue infection in a Canadian emergency department. CJEM, 11(5), 430-8.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess: Epidemiology, microbiology, clinical manifestations, and diagnosis In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-epidemiology-microbiology-clinical-manifestations-and-diagnosis?search=abscess%20treatment&topicRef=110530&source=see_link#H2443336514

 

  1. Comer, Amanda B. “Point-of-Care Ultrasound for Skin and Soft Tissue Infections.” Advanced Emergency Nursing Journal, vol. 40, no. 4, 2018, pp. 296–303.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Tayal, V., Hasan, N., Norton, H., & Tomaszewski, C. (2006). The Effect of Soft‐tissue Ultrasound on the Management of Cellulitis in the Emergency Department. Academic Emergency Medicine, 13(4), 384-388.

 

  1. Alsaawi, A., Alrajhi, K., Alshehri, A., Ababtain, A., & Alsolamy, S. (2017). Ultrasonography for the diagnosis of patients with clinically suspected skin and soft tissue infections: A systematic review of the literature. European Journal of Emergency Medicine, 24(3), 162-169.

 

  1. Barbic, D., Chenkin, J., Cho, D., Jelic, T., & Scheuermeyer, F. (2017). In patients presenting to the emergency department with skin and soft tissue infections what is the diagnostic accuracy of point-of-care ultrasonography for the diagnosis of abscess compared to the current standard of care? A systematic review and meta-analysis. BMJ Open, 7(1), E013688.

 

  1. Atkinson DP, Bowra J, Harris T, Jarman B, Lewis D, editors. Point of Care Ultrasound for Emergency Medicine and Resuscitation. Oxford University Press; 2019. pp. 140, 199-200.

 

  1. Gottlieb, M., Schmitz, G., Grock, A., & Mason, J. (2018). What to Do After You Cut: Recommendations for Abscess Management in the Emergency Setting. Annals of Emergency Medicine, 71(1), 31-33.

 

  1. Castleberg, E., Jenson, N., & Dinh, V. (2014). Diagnosis of necrotizing faciitis with bedside ultrasound: The STAFF Exam. The Western Journal of Emergency Medicine, 15(1), 111-113.

 

  1. Stevens, D., Bisno, A., Chambers, H., Dellinger, E., Goldstein, E., Gorbach, S., . . . Wade, J. (2014). Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the infectious diseases society of America. Clinical Infectious Diseases : An Official Publication of the Infectious Diseases Society of America, 59(2), 147-159.

 

  1. Spelman, D., Baddour, LM. (2020). Cellulitis and skin abscess in adults: treatment. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. Retrieved November 11, 2020. From: https://www.uptodate.com/contents/cellulitis-and-skin-abscess-in-adults-treatment?search=abscess%20treatment&topicRef=110529&source=see_link

 

  1. Russell, F., Rutz, M., Rood, L., Mcgee, J., & Sarmiento, E. (2020). Abscess Size and Depth on Ultrasound and Association with Treatment Failure without Drainage. The Western Journal of Emergency Medicine, 21(2), 336-342.

 

  1. Gaspari, R., Sanseverino, A., & Gleeson, T. (2019). Abscess Incision and Drainage With or Without Ultrasonography: A Randomized Controlled Trial. Annals of Emergency Medicine, 73(1), 1-7.

 

  1. Thornton J, Hellmich T. Evaluation and Management of Abscesses in the Emergency Department. Emergency Medicine Reports. 2017 May 1;38(10).
Continue Reading