Modern Resident - The newsletter of AAEM/RSA
April/May 2014
Volume 5: Issue 6  |  FacebookTwitterLinkedIn


Your 2013-2014 Leaders:

President
Meaghan Mercer, DO

Vice President
Rachel Engle, DO

Secretary-Treasurer
S. Terez Malka, MD

Immediate Past President
Leana Wen, MD MSc

At-Large Board Members
Michael Gottlieb, MD
Calvin Hwang, MD
Sean Kivlehan, MD
Nicole Piela, MD
Edward Siegel, MD
Victoria Weston, MD

Medical Student Council President
Mary Calderone

Modern Resident Contributors

Copy Editor: Victoria Weston, MD
Managing Editor: Lauren Johnson, AAEM/RSA Staff

Special thanks to this issue's contributors:
Karina Bartlett, MSIV; Nicole Battaglioli, MD; Shawna Bellew, MD; Jenna Erickson, MSIII; Kaitlyn Fries, OMSIII; Ashley Grigsby, MSIV; Nate Haas, MSIV; Alexandra Murray, OMSIII; Jennifer Stancati, MSIII; Michael Voronov, MD

Interested in writing?

Email submissions to: info@aaemrsa.org

Please submit articles by May 20th for the June/July edition.

Articles appearing in Modern Resident are intended for the individual use of AAEM members. Opinions expressed are those of the authors and do not necessarily represent the official views of AAEM/RSA. Articles mey not be duplicated or distributed without the explicit permission of AAEM/RSA. Permission is granted in some instances in the interest of public education. Requests for reprints should be directed to the AAEM/RSA, 555 East Wells Street, Suite 1100, Milwaukee, WI 53202, Tel (800) 884-2236; Fax: (414) 276-3349, Email: info@aaemrsa.org.

Uncorking the Spinal Tap: A Review of Three Technique Tweaks
Shawna Bellew, MD
Mayo Clinic Emergency Medicine Residency

Lumbar puncture (LP) has been performed by physicians since the 1890s. Since then, the procedure has changed little. Yet, difficulty with this procedure has been reported to occur as often as one-third of the time.1 Some physicians have advocated for variations in technique to optimize changes at success, such as ultrasound guidance, upright position and the paramedian approach.

Applying ultrasound (US) for optimizing LP was first described in anesthesia literature in the 1970s. Though initial studies comparing failure rate of US versus blind LP revealed conflicting results, a recent meta-analysis of fourteen of these studies indicated a reduced rate of failed LP with US guidance with a NNT of sixteen.2 Furthermore, a subgroup analysis of the same data set limited to LP specific studies, as opposed to those including epidural anesthesia, revealed a NNT of only six.3 The potential downside to the application of US is increased duration of the procedure. Thus far, a static methodology of US guidance has been primarily described in the literature, where the ultrasound is only used to identify and mark landmarks prior to procedure itself. Using a paramedian approach, dynamic US guidance of LP is also possible.

Many physicians emphasize correct patient positioning at the start of the procedure as the key to success. The classic patient positioning is lateral recumbent position with the plane of the back perpendicular to the surface of the bed. However, some clinicians prefer the upright sitting position, using a pillow or a cart to support the upper body and a footstool in order to help the patient flex the hips. Anatomic studies have suggested that the interspinous space is significantly greater in this position when compared to the classic lateral recumbent position (mean difference in one study of 0.11cm).4

Classically, LP is performed by puncturing the skin in the midline of the back. This approach involves navigating the spinous processes as well as the sometimes calcified (particularly in the elderly) supraspinous ligament which connects them. These structures can bypassed via the paramedian (also known as lateral) approach in which one goes approximately 1cm inferior and 1cm lateral to the estimated targeted space at a 45 degree angle pointing cranially. Much like the other techniques mentioned, the majority of the literature comparing this method to the median approach has been done within the field of anesthesia. In one recent study of forty elderly patients undergoing hip surgery the rate of successful first attempt spinal puncture was 85% in those who underwent a paramedian approach versus 45% in those in the median group.5

Lumbar puncture, or the dreaded “spinal tap,” as some patients call it, though common, remains a challenging and daunting procedure that can result in unnecessary pain and frustration. Though ultimately experience and diligent practice is the most essential element to mastering any procedure, novel techniques such as ultrasound guidance, upright positioning and the paramedian approach may assist in improving this experience for practitioners and patients alike.

References:

  1. Shah KH, Richard KM, Nicholas S, Edlow JA. Incidence of traumatic lumbar puncture. Acad Emerg Med. 10 (2003) 151-154.
  2. Shaikh F, Brzezinski J, Alexander S, et al. Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. BMJ. 346 (2013) f1720.
  3. Swaminathan A, Hom J. Does ultrasonographic imaging reduce the risk of failed lumbar puncture? Ann Emerg Med. 63 (2014) 33-34.
  4. Sandoval M, Shestak W, Sturmann K, Hsu C. Optimal patient position for lumbar puncture, measured by ultrasonography. Emerg Radiol. 10 (2004) 179-181.
  5. Rabinowitz A, Bourdet B, Minville V, et al. The paramedian technique: a superior initial approach to continuous spinal anesthesia in the elderly. Anesth Analg. 105 (2007) 1855-1857, Table of Contents.


Name That Fracture...
Nicole Battaglioli, MD
York Hospital

Question: What type of fracture is demonstrated on this X-ray?

Answer: Bennett's fracture
This image demonstrates a Bennett's fracture, an oblique fracture across the base of the first metacarpal joint. This fracture occurs when there is an axial load against a partially flexed metacarpal joint. Patients may experience pain and swelling around the base of the thumb and decreased function of the CMC joint with a weak pincher grasping function. Failure to recognize this fracture and treat appropriately may lead to long-term dysfunction of the thumb and arthritis. In cases with minor displacement less than 1mm, the patient should be placed in a thumb spica. Fractures with more than 1mm displacement require reduction and orthopedic fixation.


The Potential Role of Sugammadex in Rapid Sequence Induction
Michael Voronov, MD
Nathan Haas, MSIV
Loyola University Chicago Stritch School of Medicine

Rapid sequence induction (RSI) is commonly performed in emergency departments worldwide, and the pharmacologic approach to RSI could change in coming years with the approval of Sugammadex. Sugammadex is a steroidal neuromuscular blocking drug (NMBD) direct antagonist, and exerts its effect by directly encapsulating and inactivating steroidal NMBD, including rocuronium. Sugammadex is currently in use in much of Europe and could be approved in the United States soon, pending an investigation of an association with anaphylactic reactions. In essence, Sugammadex could be used to reverse the paralysis induced by rocuronium, which can be advantageous on many levels.

Succinylcholine has long been the paralytic of choice in RSI, given its rapid onset, short duration, availability and familiarity. However, succinylcholine is associated with several potentially serious adverse drug reactions (ADR), including hyperkalemia with potential for cardiac arrest, malignant hyperthermia, arrhythmias, increased intraocular and intragastric pressures, myopathy, and prolonged paralysis in patients with acetylcholinesterase deficiency. Of note, succinylcholine cannot be reversed pharmacologically.

Rocuronium, a non-depolarizing NMBD, was introduced in the 1990s as a safer alternative to succinylcholine. High dose rocuronium (1-1.2mg/kg) can induce paralysis in 45-90 seconds, which is similar to the onset of succinylcholine (30 seconds) without the risk of many of the serious ADR. However, the paralysis induced by rocuronium lasts 35-75 minutes, whereas the duration of paralysis of succinylcholine is 5-10 minutes. This increased duration of paralysis is one of the major barriers to the use of rocuronium, a potentially safer NMBD than succinylcholine, in RSI.

Therein lies the potential role of Sugammadex in RSI. If intubation is unsuccessful (i.e., a difficult airway) and a return to spontaneous ventilation is desired, the time to reversal of paralysis is paramount. One study demonstrated a significantly faster reversal of rocuronium induced paralysis with Sugammadex compared to neostigmine (1.5 minutes vs. 18.6 minutes to reversal).1 The use of Sugammadex also avoids the autonomic instability associated with anticholinesterase agents such as neostigmine. Another study measured time from intubation to return of spontaneous ventilation, and found rocuronium plus Sugammadex achieved return of spontaneous ventilation about three minutes faster than succinylcholine alone.2

High dose rocuronium induces paralysis nearly as rapidly as succinylcholine without many of the serious ADR. Paralysis can be reversed more rapidly using rocuronium plus Sugammadex than with succinylcholine, which cannot be pharmacologically reversed. If approved, this novel agent may provide an overall safer pharmacologic approach to RSI in coming years.

References:

  1. Blobner M, Eriksson L, Scholz J, et al. Reversal of Rocuronium-induced Neuromuscular Blockade with Sugammadex Compared with Neostigmine during Sevoflurane Anaesthesia: Results of a Randomised, Controlled Trial. European Journal of Anaesthesiology. 10 (2010): 874-81. Web. 19 Mar. 2014.
  2. Sorensen MK, Bretlau C, Gatke MR, Sorensen AM, Rasmussen LS. Rapid Sequence Induction and Intubation with Rocuronium-sugammadex Compared with Succinylcholine: A Randomized Trial. British Journal of Anaesthesia. 108.4 (2012): 682-89. Print.


A Killer Workout: Crossfit Participants May Be at Risk for Rhabdomyolysis
Ashley Grigsby, MSIV
Midwestern University

Exercise has many health benefits, but what happens when the exercise regimen goes too far? This is a growing concern with the new popular extreme workouts.

Founded in 2001 by Greg Glassman, Crossfit is a high intensity workout regimen that pushes its users to their limits in strength and endurance. Some people can push themselves too far and in a recent study of Crossfit participants, it was found that 73.5% of people reported injuries of varying severity from their Crossfit workout.1 The risk of injury may be increased due to the high numbers of beginners that start the regimens and a lack of understanding of physical boundaries. Crossfit Journal boasts that at one of their clubs, 80% of users stated they "haven't been in a gym in 5 years," prior to starting Crossfit.2 Physical exercise is an important staple to good health however can be detrimental when taken too far.

Perhaps the most severe injury being reported is rhabdomyolysis. Some Crossfitters reportedly refer to an unofficial mascot named "Uncle Rhabdo," a cartoon depicting a muscular clown connected to a dialysis machine with his kidney hanging out of his body.3 The New York Times, quoted Glassman as saying, “It can kill you, I’ve always been honest about that.”4 The number of Crossfit participants has been increasing across the United States, with the number of affiliated gyms exceeding 10,000.2 With the growing number of users, it is important for providers to consider rhabdomyolysis in these patients.

Clinical manifestations of rhabdomyolysis include muscle pain, red or brown urine, and weakness.5 Laboratory findings include elevated creatinine kinase (CK) and myoglobinuria. Creatine kinase is usually at least five times the upper limit of normal and starts to rise 2-12 hours after injury, peaking at 24-72 hours.5 Electrolyte disturbances are also very common due to muscle cell breakdown and release of intracellular components. Such disturbances include hyperkalemia, hyperphosphatemia, hypocalcemia and metabolic acidosis, often with elevated anion gap.5

Acute kidney injury is a common complication of rhabdomyolysis, with a rate between 15-50% of cases. These cases often require dialysis and can be life threatening.5 Compartment syndrome and disseminated intravascular coagulation are also complications that may be seen in severe cases.

If you suspect rhabdomyolysis, appropriate lab workup in the emergency department includes creatinine kinase, urinalysis to look for myoglobinuria, basic metabolic profile, serum calcium, and EKG.5 Further workup should be based on clinical symptoms and any complications that the patient has developed.

As we continue to recommend exercise for our patients, it's important to remember that pushing past one's limits can be dangerous. As such, we should continue to keep rhabdomyolysis on our differential in individuals who participate in intense or extreme forms of exercises.

References:

  1. Hak PT, et al. The nature and prevalence of injury during CrossFit training. (2013). J of Strength and Conditioning Research/National Strength & Conditioning Association.
  2. Cej M. The Business of Crossfit. The Crossfit Journal. (2009). [cited 2014 Mar 17]. Available from: http://library.crossfit.com/free/pdf/CFJ_Cej_BusinessOfCrossFit091016.pdf.
  3. Robertson E. Crossfit’s Dirty Little Secret. The Huffington Post. (2013). [cited 2014 Mar 17]. Available from: http://www.huffingtonpost.com/tag/rhabdomyolysis-crossfit.
  4. Cooperman S. Getting fit, even if it kills you. The New York Times. (2005). Available from: http://crossfittopsfield.typepad.com/my_weblog/files/NYTArticle.pdf.
  5. Miller ML. Clinical manifestations and diagnosis of rhabdomyolysis. Up to Date. [Internet]. 2014. [cited 2014 Mar 17]. http://0-www.uptodate.com.millennium.midwestern.edu/contents/clinical-manifestations-and-diagnosis-of-rhabdomyolysis?source=search_result&search=Clinical+manifestations+and+diagnosis+of+rhabdomyolysis&selectedTitle=1~150.

Image of the Month
Jennifer Stancati, MSIII
Loyola University Chicago Stritch School of Medicine

A 50-year-old male presents with left arm redness, warmth and swelling for 10 days. He otherwise feels well denying fevers, chills, nausea, vomiting, diarrhea, fatigue or malaise. He recently saw his doctor who started him on vancomycin for cellulitis, but the redness and swelling continues to worsen. He has a past medical history significant for renal failure requiring transplant three months ago. His vital signs are normal and physical exam is unremarkable except for the skin findings pictured below.

What is the most likely cause of this patient's symptoms?

  1. MRSA infection
  2. CMV infection
  3. EBV infection
  4. Cryptococcal infection

Answer:
D is correct. MRSA infection would be expected to improve with vancomycin (A), and this presentation is not consistent with CMV or EBV infection (B and C).

Cryptococcal disease, primarily caused by cryptococcus neoformans, is an invasive fungal infection that most often affects immunocompromised individuals. Cryptococcal disease can manifest as CNS, pulmonary, cutaneous or disseminated disease. Cutaneous cryptococcus can present with papular, nodular or ulcerative lesions or as cellulitis. Symptoms of cryptococcal infection depend on the organs involved, but commonly include fever, malaise, headache, cough and dyspnea.

The incidence of cryptococcal disease in solid organ transplant recipients is about 2.8%, the third most common fungal infection in this population. In transplant recipients, the fungus is often present prior to transplantation and is then reactivated when the immune system is adequately suppressed.

Cutaneous lesions caused by cryptococcus in transplant recipients can be the first sign of disseminated disease. Work up for suspected cryptococcal disease includes serum cryptococcal antigen, lumbar puncture, sputum or tissue culture, and chest X-ray to look for pulmonary nodules. Treatment of disseminated cryptococcal infection involves induction therapy with amphotericin B and flucytosine followed by fluconazole. The mortality rate of cryptococcal infection in solid organ transplant recipients is about 15% but may be as high as 49% in those with CNS disease.

In certain patient populations presenting with cellulitis, we must think beyond staph and strep to uncommon organisms, keeping in mind that disseminated cryptococcus can present as cellulitis.

References:

  1. Singh N, Dromer F, Perfect JR, Lortholary O. Cryptococcosis in solid organ transplant recipients: current state of the science. Clinical Infectious Diseases. 2008; 47: 1321-7.
  2. Gupta RK, Kahn ZU, Nampoory MRN, Mikhail MM, Johny KV. Cutaneous cryptococcosis in a diabetic renal transplant recipient. Journal of Medical Microbiology. 2004; 53: 445-449.


Shoulder Dislocations and Reduction Techniques
Alexandra Murray, OMSIII
Ohio University College of Osteopathic Medicine

The shoulder joint is the most mobile joint in the body and is the most commonly dislocated large joint seen in the emergency room.1-7 Of the three types of shoulder dislocations, anterior dislocations account for 90-98% of injuries, whereas posterior dislocations account for 2-10% and inferior dislocations occur <1% of the time.1-7 Each type of dislocation requires urgent reduction after careful evaluation for fracture and nerve damage. Attempts at shoulder reduction are contraindicated in subclavicular dislocations, intrathoracic dislocations and associated fractures of the humeral neck.8 Outlined below are various techniques that have been documented as ways to perform closed shoulder reductions in the emergency department. These methods may be combined and/or modified to accommodate each individual patient. In general, success rates are between 70-90% regardless of
technique.2

Anterior Dislocations
External Rotation Method: The patient is positioned supine and one hand is used to adduct the affected arm tightly to the patient’s side. The other hand is used to grasp the patient’s wrist, bend the elbow to 90° of flexion, and gently rotate the upper arm externally without force or traction. Reduction takes place between 70-110° of external rotation and, sometimes, during return on internal rotation.1-5

Traction and Countertraction Method: The patient is placed supine and the operator applies traction to the injured arm with the patient’s shoulder in abduction. An assistant then wraps a folded sheet around the patient’s torso and applies firm countertraction to the body until the shoulder reduces.1-5

Stimson Maneuver: The patient is given analgesia and placed in the prone position with the dislocated arm hanging straight down off the bed. Approximately 5-10 pounds of weight is then attached to the patient’s arm, causing the muscles to fatigue over time. Eventually the muscle spasms in the shoulder will relax enough so that the shoulder spontaneously reduces.1-5

Milch Technique: The patient’s affected arm is placed in full abduction over the patient’s head, or the patient is instructed to raise their affected arm laterally and behind the head. With arm in full abduction, longitudinal traction and external rotation is applied with one arm. If reduction is not completed, the thumb or fingers are used to push the humeral head upward into the glenoid fossa with gradual adduction of the extended arm still held in traction. 1-5

Spaso Technique: The patient is placed supine and the arm is gently lifted vertically. The shoulder is then gently rotated externally while applying traction. The head of the humerus is then pushed into the axilla and an audible clunk is heard. If an audible or palpable clunk is not heard, the other hand is used to apply direct pressure to the humeral head until the shoulder reduces. 1-5

Eskimo Method: The patient lies on the ground on the side of the non-dislocated shoulder. Two operators lift the patient by the dislocated arm, suspending the opposite shoulder several centimeters from the ground. If reduction does not occur within a few minutes, the operator can exert gentle pressure against the humeral head to complete the reduction.1-4

Scapular Rotation: The patient is positioned prone with the arm hanging down to the floor attached to approximately 5-10 pounds of weights. The patient is then given analgesia and/or sedation and the scapula is rotated. The inferior angle is rotated medially and the superior edge laterally.1-5

Snowbird Technique: The patient is seated with their arm placed over the back of a chair or the patient is sitting up straight with their humerus in anatomical position, elbow flexed and forearm supported by the unaffected limb or operator. The operator applies traction to the affected shoulder using downward pressure on a loop of stockinette wrapped around the patient's forearm. Downward traction from the foot is applied, with additional rotation or pressure from the operator’s hands if needed.1-4,9

Self-Reduction Technique: The patient is positioned sitting upright on the stretcher with the ipsilateral knee flexed. The patient is instructed to clasp the hands together around the flexed knee with the fingers interlocked. The patient leans back slowly until the elbows are locked straight. Then, the patient slowly leans back and extends at the hip, applying gentle pressure until the shoulder dislocation is reduced.1-4

Cunningham Technique: The patient sits without slouching in a hard backed chair with the affected arm adducted to the body and the elbow fully flexed. The operator kneels next to the patient and places his wrist onto the patient’s forearm, the patient’s hand resting on the operator’s shoulder. The patient is asked to shrug the shoulders superiorly and posteriorly, which “squares off” the angle of the shoulder. The biceps is massaged at mid-humeral level to specifically relax the muscle until the humeral head spontaneously reduces without traction.3

Kocher Maneuver: Kocher described this method in 1870 as a leverage method. He instructed, “Bend arm at the elbow, press it against the body, and rotate outwards until resistance is felt. Lift the externally rotated upper arm in the sagittal plane as far as possible forwards and finally turn inwards slowly.“2-5 This technique can be performed painlessly if executed correctly but carries a risk of humeral neck fracture.10,11

Hippocratic Method: Hippocrates described several shoulder reduction strategies as early as 460 BC. In his classical technique, the patient lies supine while the operator's foot is placed in the patient's axilla against the chest wall while leaning backward. Slow, steady and gentle longitudinal traction is applied to the affected arm in 30-40° abduction until the shoulder reduces.2-5 The method must be used with caution as it can cause humeral neck fracture, damage to shoulder ligaments, brachial plexus injuries and axillary vessel damage.10

Posterior Dislocations
Traction-countertraction methods are generally used to reduce posterior shoulder dislocations.6

Inferior Dislocations (Luxatio Erecta)
Axial (Inline) Traction Method: The patient is placed supine and the operator stands on the affected side at the head of the patient. Axial traction is applied in line with the abducted arm. To facilitate this technique, an assistant can apply parallel countertraction by using a sheet wrapped diagonally over the affected shoulder. While applying axial traction, increasing the degree of abduction and applying cephalad pressure to the displaced humeral head can aid in reduction.7,12

Two Step Method: The patient is positioned supine and the operator stands on the affected side near the patient's head. One hand is placed on the lateral aspect of the mid-humerus while the second hand is placed on the medial condyle. The hand on the mid-humerus is pushed anteriorly while the hand on the medial condyle pulls posteriorly. This motion transforms the dislocation from an inferior dislocation to an anterior dislocation. The second step of this method is to reduce the anterior dislocation with the external rotation technique. 7,12,13

References:

  1. Ufberg JW, Vilke GM, Chan TC, Harrigan RA. Anterior shoulder dislocations: beyond traction-countertraction. J Emerg Med. 2004 Oct; 27(3):301-6.
  2. Chung CH. Closed reduction techniques for acute anterior shoulder dislocation: from Egyptians to Australians. Hong Kong J Emerg Med. 2004; 11:178-188.
  3. Cunningham NJ. Techniques for reduction of anteroinferior shoulder dislocation. Emerg Med Australas. 2005 Oct-Dec;17(5-6):463-71.
  4. Mattick A, Wyatt JP. From Hippocrates to the Eskimo--a history of techniques used to reduce anterior dislocation of the shoulder. J R Coll Surg Edinb. 2000 Oct;45(5):312-6.
  5. McBride T, Kalogrianitis S. (2011) Dislocations of the shoulder joint. Trauma. 14:47–56.
  6. Groh GI, Wirth MA, Rockwood Jr. CA. Treatment of traumatic posterior sternoclavicular dislocations. J Shoulder Elbow Surg. 2011 Jan;20(1):107-13.
  7. Saseendar S, Agarwal DK, Patro DK, Menon J. Unusual inferior dislocation of shoulder: reduction by two-step maneuver: a case report. J Orthop Surg Res. 2009 Nov 3;4:40.
  8. Amin AK, Robinson CM. Fractures and dislocations of the shoulder girdle. Surgery. (0263-9319); 2006 Dec; 24 (12): 415-420.
  9. Westin CD, Gill EA, Noyes ME, Hubbard M. Anterior shoulder dislocation. A simple and rapid method for reduction. Am J Sports Med. 1995 May-Jun;23(3):369-71.
  10. Ahmed SM, Singh J, Nicol M. A stepped care approach to reduction of anterior shoulder dislocation in the prone position. Surgeon. 2007 Dec;5(6):363-7.
  11. Chitgopkar SD, Khan M. Painless reduction of anterior shoulder dislocation by Kocher's method. Injury. 2005 Oct;36(10):1182-4. Epub 2005 Mar 19.
  12. Petty K, Price J, Kharasch M, Novack J. Bilateral luxatio erecta: a case report. J Emerg Med. 2014 Feb;46(2):176-9.
  13. Nho SJ, Dodson CC, Bardzik KF, et al. The two-step maneuver for closed reduction of inferior glenohumeral dislocation (luxatio erecta to anterior dislocation to reduction). J Orthop Trauma. May 2006;20(5):354-7.

Gynecological Emergencies
Kaitlin Fries, OMSIII
Ohio University College of Osteopathic Medicine

Case 1:
A 25-year-old female presents to the emergency department with acute abdominal pain and minimal vaginal bleeding. Her urine pregnancy test is positive. Physical examination reveals abdominal tenderness, adnexal tenderness and an adnexal mass.

Diagnosis: Ectopic Pregnancy
Ectopic pregnancies can occur anytime a fertilized oocyte is unable to travel from the fallopian tubes to the uterus within seven days for implantation. The most common etiology responsible for this delay is salpingitis from a prior pelvic infection.3 Initial workup should include a CBC, Rh factor (to assess if RhoGAM is needed) and a quantitative β-hCG. If the β-hCG result is above 1500mlU/mL, then an intrauterine gestational sac should be identifiable on transvaginal ultrasound. However, ruptured ectopics have occurred at β-hCG levels below the aforementioned threshold. An empty uterus, an adnexal mass separate from the ovary, and pelvic fluid are all ultrasound findings that further support the diagnosis of ectopic pregnancy.3 If the patient is hemodynamically stable and ultrasound is non-diagnostic, then repeat a β-hCG is performed in 48 hours. Studies have shown that “an increase of 1000mlU/mL in two days has been used to differentiate a normal pregnancy from an ectopic pregnancy with a predictive value of 90%, sensitivity of 86% and specificity of 93%.”2,5 If a definitive diagnosis of ectopic pregnancy is unclear, then it is essential to arrange adequate follow up for the patient. Once ectopic pregnancy is diagnosed both medical and surgical management are possibilities depending on the individual circumstance. Obstetrics consultation is advised.

Case 2:
A 22-year-old female presents to the emergency department with a one week history of intermittent unilateral pelvic pain exacerbated by movement. Her LMP was two weeks prior and her urine pregnancy test is negative. She denies any vaginal bleeding or discharge. The patient is also complaining of nausea and vomiting. Patient is afebrile with stable vital signs. Physical exam reveals a tender, unilateral adnexal mass.

Diagnosis: Ovarian Torsion
Risk of ovarian torsion is increased in the setting of an enlarged ovary or ovarian masses.6 An enlarged uterus will push the ovaries anteriorly, thus predisposing pregnant mothers to ovarian torsion.3 Females receiving in vitro fertilization are also prone to torsions due to the enlarged ovaries from hyperstimulation.4 Patients presenting with torsion are at times mistaken for GI etiologies since they may present with nausea, vomiting and an acute abdomen. However, if torsion is suspected, a pelvic ultrasound with color flow Doppler is the diagnostic test of choice. Diminished or absent blood flow confirms the diagnosis and treatment is surgical reduction.

References:

  1. Blechman AN, Mann WJ. Evaluation and management of ruptured ovarian cyst. UpToDate. 2014.
  2. Gronlund B, Marushak A. Serial human chorionic gonadotropin determination in the diagnosis of ectopic pregnancy. Aust N Z J Obstet Gynaecol. 1983; 22: 312-314.
  3. McWilliams G, Hill MJ, Dietrich CS. Gynecologic emergencies. Surgical Clinics of North America 2008. 88: 265-283.
  4. Robson S, Kerin JF. Acute adnexal torsion before oocyte retrieval in an in vitro fertilization cycle. Fertil Steril. 2000; 73: 650-651CrossRef.
  5. Spandorfer SD, Sawin SW, Benjamin I, et al. Postoperative day 1 serum human chorionic gonadotropin level as a predictor of persistent ectopic pregnancy after conservative surgical management. Fertil Steril. 1998; 70: 172-174CrossRef.
  6. Stenchever MA, Droegemueller W, Herbst et al. Comprehensive gynecology. Philadelphia: Mosby. 200ip. 519.


The Unrelenting Cough: More than a Simple URI
Jenna Erickson, MSIII
Chicago Medical School

As winter gradually thaws into spring we often encounter acute illnesses with cough as a presenting symptom. However, cough may also be the chief complaint of a serious condition requiring emergency management. Three life-threatening causes of cough that may present to the ED include acute asthma exacerbation, pulmonary edema and pulmonary embolism.

For patients with a history of asthma, an unrelenting cough is often caused by an acute exacerbation. The cough of an asthma exacerbation will likely be accompanied by wheezing that does not improve with use of short acting bronchodilators. Patients may present to the ED after failing to improve with rescue inhaler use and require urgent evaluation of airway patency.

Another cough that causes concern in the ED is by the patient with pulmonary edema. Typically, these patients will present with a history of pink, frothy sputum production and have associated shortness of breath that worsens when supine. Acute pulmonary edema is a medical emergency and may be caused by any event that increases fluid retention. This includes heart failure, toxin exposure, pneumonia, renal diseases, sepsis, ARDS and high altitude exposure.

Pulmonary embolism is another urgent medical condition that can present with a cough. In this case the patient is likely to present with cough productive of bloody sputum with or without shortness of breath and chest pain. It is important to identify the duration of the symptoms as well as inquiring about leg pain or swelling and history of hypercoagulability.

Though the majority of patients presenting with cough can be managed on an outpatient basis, it is important to keep these conditions in mind as they require emergent management.

References:

  1. “Asthma,” “Pulmonary Embolism,” and “Pulmonary Edema,” Mayo Clinic Staff, www.mayoclinic.com.
  2. Torres-Macho J, Mancebo-Plaza AB, Crespo-Giménez A, et al. Clinical features of patients inappropriately undiagnosed of pulmonary embolism. Am J Emerg Med. 2013 Dec; 31(12):1646-50.

Leukopenia in the ED
Karina Bartlett, MSIV
University of Texas Health Science Center at San Antonio

When a patient presents to the ED with a fever and leukopenia, it often prompts provider concern; however, even more important is the absolute neutrophil count, or ANC. Although neutropenia is defined as ANC <1000/cc, which is associated with a moderate risk of infection, an ANC <500 is associated with a high risk of infection. Calculating the ANC [WBC*(%segs+%bands)] is an important first step in evaluating a febrile leukopenic patient. If there is a known reason for the patient to be leukopenic (chemotherapy, immunosuppression, HIV infection, certain medications), the patient should be evaluated for opportunistic infections. If the patient does not have a reason to be neutropenic, a full workup may be required.

Diseases that are known to cause acute neutropenia are viral infections (including HIV, influenza, adenovirus), sepsis, hepatitis, leukemia, lymphoma and many others. Some chronic diseases which may present with neutropenia include lupus, tuberculosis, cancers and HIV. A patient without a known etiology for their neutropenia and without an easily identifiable cause (such as influenza) should be admitted for an inpatient workup. The first steps include two sets of blood cultures, a CXR, urine studies and culture. If there is cough or diarrhea, sputum or stool cultures should be obtained.

References:

  1. Medscape Reference: Neutropenia
  2. UptoDate. Tintinalli, Chapter 235: Emergency Complications of Malignancy. http://www.uptodate.com/contents/approach-to-the-adult-with-unexplained-neutropenia?source=search_result&search=leukopenia&selectedTitle=3~150