Posts by JETem

An Observation Medicine Curriculum for Emergency Medicine Education

Danie Ty, MD*, Marney Gruber, MD*, Noah Klein, BS*, Jeremy Branzetti, MD*, Matthew Brown, MD*, Matthew McCarty, MD*, Tracy Svetcov, MD*, Barie Miller, MD*, Maurice Hinson, MD*, Raj Machhar, MD*, Sharon Uralil, MD*, Catherine Capo, MD*, Yitzchak Weinberger, MD*, Melanie Raffoul, MD*, Robert Femia, MD*, Christopher Caspers, MD*

DOI: https://doi.org/10.21980/J87P92 Issue 6:2[mrp_rating_result]
The primary goal of this observation medicine curriculum is to train current EM residents in short-term acute care beyond the initial ED visit. This entails caring for patients from the time of their arrival to the OU to the point when a final disposition from the OU is determined, be it inpatient admission or discharge to home.
AdministrationCurricula

A Pediatric Emergency Medicine Refresher Course for Generalist Healthcare Providers in Belize: Respiratory Emergencies

Adeola Adekunbi Kosoko, MD*, Alicia E Genisca, MD^, Marideth Rus, MD†, Shreya Ramayya**, Lisa Johnson, MD^^ and Joy Mackey, MD††

DOI: https://doi.org/10.21980/J84063 Issue 6:2[mrp_rating_result]
This curriculum presents a refresher course in recognizing and stabilizing pediatric acute respiratory complaints for generalist healthcare providers practicing in LMICs. Our goal is to implement this curriculum in the small LMIC of Belize. This module focuses on common respiratory complaints, including asthma, bronchiolitis, pneumonia and acute airway management.
CurriculaRespiratory
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Point of Care Ultrasound as a Diagnostic Tool to Detect Small Bowel Obstruction in the Emergency Department: A Case Report

Rebecca Nadelman, MD* and Jesper Aurup, MD*

DOI: https://doi.org/10.21980/J8XD1G Issue 6:2[mrp_rating_result]
The ultrasound findings suggestive of small bowel obstruction (SBO) are typically visualized in video; however, certain still images can also demonstrate SBO including greater than three dilated loops of small bowel (>2.5 cm), thickened-walled bowel (>3 mm), visualization of plicae circulares, and extraluminal fluid caused by inflammatory changes along the bowel wall, which are all highly suggestive of SBO.3 In this patient’s case, we were able to visualize several dilated loops of small bowel (red arrow) with oscillating intraluminal contents known as “Whirl Sign.” Additionally, we were able to visualize extraluminal fluid, demonstrated as an anechoic triangular-shaped collection. The characteristic shape of this triangular shaped collection of fluid is known as a “Tanga Sign,” given its name due to way it looks similar to the lower half of a bikini (blue arrow). Tanga sign can occur when the loops of dilated bowel appear prominent in contrast to the inflammatory extraluminal fluid in an SBO. These ultrasound findings were highly concerning for SBO which was later confirmed on CT imaging of the abdomen, which demonstrated SBO with a transition point in the left lower quadrant.
Abdominal/GastroenterologyVisual EM
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Case Report: Altered with PRES

Fatima Dema, MD* and David C Feldman, MD*

DOI: https://doi.org/10.21980/J8NW73 Issue 6:2[mrp_rating_result]
On vitals, the patient was found to be consistently hypertensive to the 230s/160s. Point-of-care glucose was within normal limits. Noncontrast CT imaging of the head revealed no acute intracranial hemorrhage or evidence of ischemic stroke, but was remarkable for areas of biparietal subcortical low-attenuation (white arrows), concerning for PRES. Patient subsequently underwent CT angiogram imaging of the head with perfusion which revealed no large vessel occlusion.
NeurologyVisual EM
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A Case Report of Cardiac Tamponade

Derek JC Hunt, DO*, Kevin McLendon, DO* and Matthew Wiggins, MD*

DOI: https://doi.org/10.21980/J8J644 Issue 6:2[mrp_rating_result]
The patient was in noticeable respiratory distress and had oxygen saturation of 94% on room air. Bilateral jugular venous distention with severe right supraclavicular lymphadenopathy and diffuse bilateral wheezing was present. Although muffled heart sounds and hypotension are part of Beck’s Triad, these were not present in this case. Electrocardiogram obtained on arrival showed a sinus tachycardia with low-voltage QRS complexes and electrical alternans. Low voltage QRS can be seen on the ECG provided and is demonstrated by the low amplitude of the QRS complexes seen on all the leads. Electrical alternans may have an alternating axis or amplitudes of the QRS complex. Alternating axis is best visualized in V4-V6 on this ECG while alternating amplitudes are seen throughout the rest of the ECG. Computed tomography angiogram (CTA) of the chest revealed a large pericardial effusion with bilateral pulmonary emboli and a right upper lobe mass. A bedside transthoracic echocardiogram (TTE) was then performed and confirmed the large effusion, but also showed right ventricular collapse during diastole, indicative of cardiac tamponade.
Cardiology/VascularVisual EM
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A Different Type of Tension Headache: A Case Report of Traumatic Tension Pneumocephalus

Travis P Sharkey-Toppen, MD, PhD*, Dominique I Dabija, MD, MS* and Christopher San Miguel, MD*

DOI: https://doi.org/10.21980/J8DH0G Issue 6:2[mrp_rating_result]
CT head without contrast demonstrated a minimally displaced fracture of the frontal sinuses at the midline underlying his known laceration that involved the anterior and posterior tables of the calvarium. This is seen on the sagittal view and indicated by the blue arrow. There was a small volume of underlying subarachnoid hemorrhage along the falx. There was also extensive pneumocephalus most pronounced along the bilateral anterior frontal convexity associated with the frontal sinus fracture, seen on the axial image and indicated by the red arrow. This pattern of air is commonly referred to as the “Mount Fuji” sign.6 Other intracranial air can also be seen on the sagittal image and is indicated by the white arrow.
TraumaNeurologyVisual EM
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Jefferson Fracture and the Classification System for Atlas Fractures, A Case Report

Miguel Angel Martinez-Romo, MD* and Christopher Eric McCoy, MD, MPH*

DOI: https://doi.org/10.21980/J88P9C Issue 6:2[mrp_rating_result]
Computed tomography (CT) revealed a burst fracture (Jefferson) of the anterior arch (white arrows) and of the posterior arch (yellow arrows) of the first cervical vertebrae (C1). There was also a fracture of the right lateral mass (blue arrow) of C1 with mild lateral subluxation of the lateral masses (curved arrows).
TraumaOrthopedicsVisual EM
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Using Point-of-Care Ultrasound to Expedite Diagnosis of Necrotizing Fasciitis: A Case Report

Romero Kupai, MD*, Ashkan Morim, MD*, Lucas Friedman, MD*^ and Eva Tovar Hirashima, MD, MPH*^

DOI: https://doi.org/10.21980/J85051 Issue 6:2[mrp_rating_result]
A consultative scrotal ultrasound was performed, which was read as showing a small right hydrocele, small bilateral scrotal pearls, and normal-appearing testes. Although present, there was no mention of subcutaneous air suggestive of NF, seen in figure 1 as punctate hyperechoic foci (arrowhead) with ring-down artifact known as dirty shadowing (arrow). Also, subcutaneous thickening (asterisk) and free fluid (arrow) were seen as shown in figure 2, although their clinical relevance was not recognized in the radiologist's final report. Figure 3 shows an abdominal and pelvic CT that re-demonstrates subcutaneous air in the scrotum and lower abdomen (arrow) as well as fascial thickening of the perineum and free intra-abdominal air. After these images, the patient was transferred to our hospital for further management. Almost immediately after the patient's arrival, POCUS was employed. As seen in figures 4, we were able to identify in just a few minutes extensive subcutaneous air accompanied by dirty shadowing, as well as re-demonstration of subcutaneous thickening, fluid collections, and a right hydrocele. Even without the outside hospital's CT, the sonographic findings were highly suggestive for the diagnosis of NF of the perineum, also known as Fournier’s gangrene.
Infectious DiseaseVisual EM