Transcript Blue Step Gradients - Jacobi Emergency Medicine

Diagnosis At A Glance
Harry Kopolovich
31 y/o female presents with tooth pain and a
swollen neck
Ludwig's Angina
- Submandibular space is primary site of
infection
- Subdivided by mylohyloid muscle
- Sublingual space superiorly
- Submandibular space inferiorly
- Odontogenic source in >90% cases
- Others include: Trauma, tongue
piercing, sialedenitis, neoplasm, other
parapharnygeal infections
- Definitive Airway Management is Key
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Direct vs. fiber optic visualization
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No blind nasotracheal attempts
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May rupture abscess
- Empiric antibiotics
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Primary flora: Strep, Staph, Bacteroides
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3rd Generation Cephalosporins plus clindamycin
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No definite role of steroids
- Definitive management is surgical
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Prior to antibiotics: Mortality >50%
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Currently: Antibiotics + Surgery Mortality 8%
 75 y/o white man presents with 5 days of rash and pain to
forehead
Herpes Zoster Opthalmicus
 VZV causative agent
 Reactivation produces typical dermatomal distribution
 Dissemination occurs in immunocompromised patients
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Anterior horn cells Muscular weakness, diaphragmatic
paralysis, colon pseudo obstruction
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Spinal cord  GBS like syndrome, Transverse myelitis
Phases of Presentation
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Three phases
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Pre-eruptive
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Eruptive
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Pain or dysesthesia occurs 48-72 hours prior
Heralded by emergence of skin lesion
Erythematous macules Vesicles  Ruptured Vesicles  Ulcers  Crusted lesions
Lesions can last 10-15 days
Not considered healed until lesion are crusted
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Considered a TORCH infection
Post-Eruptive
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Post-herpetic neuralgia is pain lasting or recurring >30 days
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Most t frequent complication: Occurs in 9-45% of cases
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Higher incidence in elderly males
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Herpes Zoster Opthalmicus
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Reactivation of VZV in trigeminal nerve CN V
Usually V1 affected
Hutchinson’s Sign
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Lesion on tip of nose
Indicates higher likelihood of ocular involvement (76% vs. 34%)
Pseudo-dendrites
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Peripherally located, poorly stain with fluorescein
Partial thickness (can be wiped clean as compared to dendrites in herpes keratitis
which are full thickness and cannot be wiped clean)
Ophthalmology Consult
 Complications
 Post-herpetic neuralgia
 Corneal Anesthesia or hypoesthesia
 Secondary Infection
 Treatment
 Anti-virals
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Proven benefit when instituted within 48-72 hours
 Reduces viral shedding and accelerated resolution of
symptoms
 Corticosteroids
 Controversial at best
 Two studies conducted using steroids + acyclovir only
 Current indications
 Only in moderate to severe pain
 Or in severe CNS symptoms or paralysis exist
 Use of steroid contraindicated in isolation
 Concern exists for promotion of viral replication
 Optimal Duration uncertain
 Should not exceed duration of anti-viral agent
 24 year old man presents with pain to nose after being hit in
the head with a soccer ball
 Examination reveals the following
Nasal Septal Hematoma
 Uncommon complication
following direct nasal trauma
 Associate with fracture of
septal cartilage
 Nasal septum composed of a
thin cartilaginous plate with a
closely adherent
perichondrirum and mucosa
 Septal Hematoma
 Occurs as perichondrium separated from septum
 Accumulation of blood results
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Avascular necrosis  Septal perforation, saddle nose deformity
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Abscess
 Possible meningitis, encephalitis, cavernous sinus thrombosis
 Make sure to examine nostril on all patients with facial
trauma
 Visual inspection with otoscope or nasal speculum
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Nasal septum 2-4mm thick (possible bilateral hematomas)
 Digital inspection
 Treatment is I & D
 70 year old Asian woman present with headache, nausea and
eye pain while watching a movie at a local movie theater
Acute Angle Closure Glaucoma
 Aqueous humor produced in
ciliary body in the posterior
chamber
 It diffuses through the pupil
into the anterior chamber
 Drains into the vascular
system through the canal of
Schlemm
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Acute Angle Closure Glaucoma (AACG)
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Defined by the presence of 2 of the following symptoms
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Ocular pain, nausea/vomiting, hx of intermittent blurring of vision with halos
And 3 of the following signs
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IOP >21mmHg (Usually >50), conjunctival injection, corneal epithelial edema, mid-dilated non-reactive pupil, shallow
anterior chamber
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End result is sustained production of aqueous humor which is unable to pass from posterior to anterior chamber,
resulting in an increased IOP, culminating ultimately in retinal damage, and visual loss
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Risk Factors
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Older age, female, Asian descent, shallow anterior angle, excessive sympathetic tone, thin iris, darkened environment
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Essentially, any condition which cause the iris to heap up, and become closer to pupil, thus preventing egress of
aqueous humor
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Or any condition that disrupts the egress of aqueous from the anterior chamber
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Diagnosis
 Clinical suspicion: Anyone with headache and eye pain, make sure to examine eye
 Tono pen
 If not working or stolen, use your finger
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Treatment
 Lie patient flat: May cause separation of Iris from lens
 Analgesia
 Topical β- blockers or α- agonists
 Decreases aqueous humor production (Timolol 0.5% 1 drop)
 Topical Steroids
 Reduce inflammation (Prednisolone 1 drop Q15min
 Hyperosmotic agents
 Decrease fluid volume in eye (Mannitol 1-2 g/kg IV over 30-60min)
 Topical Miotics
 Pulls the iris back away from pupil (Pilocarpine ½% 1 drop Q6hr)
 Will not work unless IOP <40mmg
 50 year old female presents with headache and blurry vision
CN III Palsy
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Anatomy
Originates in the brainstem  continues within sub-arachnoid space 
traverses the cavernous sinus  terminates within the orbit after exiting
the superior orbital ridge
 Contains voluntary muscle fibers and parasympathetic control
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Responsible for majority of EOM
Pupillary Constriction
Raises eyebrow (Levator palpebrae superiorus has dual innervation)
Presentation
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Typically down and out pupil, which doesn't’t constrict or accommodate
Ptosis
Why is the anatomy important?
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Disposition
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Because of the origin and course CN III, deficits can indicate
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PCA Aneurysm
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Uncal Herniation
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Compressive Neoplasms
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Inflammatory Conditions
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Trauma
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Cavernous sinus neoplasm
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Cavernous sinus thrombosis
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Carotid-Cavernous fistula
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MRI/MRA Imaging and neurology consult strongly recommended
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It is possible to have isolated CNIII deficits affecting primarily the EOM and rarely the pupil
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Adjunct indicator for micro vascular disease in HTN and DM
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Usually a painful condition
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Low threshold for neurology involvement
 20 year old wrestler presents with ear pain
Auricular Hematoma
 Develop when the ear sustains blunt trauma
 Causing auricular perichondrium to separate from underlying
cartilage
 Tearing of the perichondrial blood vessels results in subsequent
hematoma
 Chronic presence of blood stimulates new cartilage deposition
and subsequent cauliflower ear
Auricular Hematoma
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Treatment
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>7 days
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<7 days
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Referral to ENT
I&D
 Needle aspiration no longer recommended as hematoma tends to reaccumulate
Pressure dressing
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Follow-up in 24 hours
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Most pressure dressing are inadequate, tend to allow hematoma to reaccumulate
 18 year old woman presents with ear pain and fever
 Examination reveals a tender, erythematous bulge posterior
to ear
Mastoiditis
 Mastoid bone is directly contiguous to and is an extension of
the middle ear cleft
 Mastoidits is the result of an extension of purulent otitis media
 Medial wall erosion can result in
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Cavernous sinus thrombosis, CN VII palsy, Meningitis, Brain
abscess
 Treatment
 Flora is similar to causes of AOM
 Strep Pneumo most common
 Risk Factors
 Likely multifactorial
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Invasive species vs. host anatomy (Eg. Congenitally narrow
mastoid antrum)
 Disposition
 Broad spectrum antibiotics: Semi-synthetic PCN’s, 3rd
generation cephalosporins, Vanco
 Imaging
 Admission
 Surgery in refractory cases
 20 year old man presents with eye pain and fever after being
scratched by his cats claws 2 days ago
Orbital Cellulitis
 Orbital septum is a fascial
layer which extends vertically
from the periosteum of the
orbital rim to the inferior
border of the tarsal plate in
the lower eyelid
 Orbital cellulitis is an
infection posterior to the
septum
 Etiology
 1) Extension of an infection from the periorbital structures
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Usually ethmoid sinusitis
 2) Direct inoculation from trauma or surgery
 3) Hematogenous spread from bacteremia
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Veins in this region are valveless allowing retrograde and
anterograde flow
 Presentation
 Pain, fever, chemosis
 Important findings are proptosis, painful EOM’s
 Disposition
 Imaging: CT with contrast
 Broad spectrum abx (MRSA becoming common)
 Admission
 Complications
 Visual Loss
 Cavernous sinus thrombosis
 Meningitis
 Abscess
 Osteomyelitis
 7 year old boy is brought in by mom for evaluation of a
bump next to his eye
Dacrocystitis
 Lacrimal excretory system
 Drain tears from the medial aspect of the eye through a series
of canal which ultimately terminate in the nose
 Prone to infection as system is contiguous with conjunctiva
proximally and nasal mucosa distally
 Infection usually develops when stagnation occurs secondary
to obstructed lacrimal sac
 Microbiology
 Usual nasal and skin flora
 Management
 Most case are self limited
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Warm compresses, massage lacrimal sac, oral anti-biotic (βlactamase resistant)
 Consider imaging for recurrent causes
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Obstruction caused by malignancy
 25 year old brought to ER screaming.
 Pain began while yawning when trying to fall asleep
TMJ Dislocation
 Mandibular dislocations occur when the mandibular condyle
disarticulates from the articular groove in the temporal bone
 Dislocations can occur in
 Anterior (Most common)
 Superior
 Posterior
 Lateral
 Patients present with an inability to close jaw
 Treatment aimed at analgesia and reduction
 48 year old woman with no past medical history presents
with the following midline neck mass
 She states it is has been present for as long as she can
remember, but now wants it removed
Thyroglossal Duct Cyst
Thyroglossal Duct Cyst
 Most common form of congenital neck cyst
 Arises embryologically from the thyroid gland
 Presence of cysts indicates failure of tract to involute
 Distinguishing feature
 Midline
 Non-tender
 Moves with swallowing and tongue protrusion due to proximal
attachment to hyoid bone
 Treatment
 Rarely gets infected
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Abx
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Imaging if concern for airway exists
 ENT referral for excision
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Send TSH (May contain ectopically located thyroid tissue)
 58 year old man with a 2 week history of progressive DOE,
neck swelling, decreased appetite and fatigue
 Quit smoking in 2012
SVC Syndrome
 Superior vena cava
carries blood form the
head, arms and upper
torso to the heart
 Carries 1/3 of the bodies
circulating volume
 SVC is pliable and easily
compressible
 Compression leads to
retrograde flow into
collateral vessels
 Etiology
 Carcinoma (90%)
 Bronchogenic, Lymphoma, Teratoma, Thymoma
 Infectious
 TB, Syphilis
 Thrombus
 CVP placement
 Symptoms
 Limb/facial edema, Headache, Confusion, Dyspnea
 Treatment
 Directed at underlying condition
 Poor prognosis
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Radiotherapy
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Palliative stents
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Tumor debulking
 EMS brings in a restrained driver who was involved in a
frontal collision on I-95
Seat Belt Sign
 Two and 3 point seat belts, when worn correctly have significantly
reduced mortality in MVC
 Abrasions from seat belts occur in ~20% of MVC
 Presence of these abrasions increases the likelihood of underlying
thoracic injuries four fold and abdominal injury by eight fold
 Neck abrasion: Carotid artery injury, laryngeal injury, c-spine injury
 Chest abrasion fracture of sternum, ribs, clavicles; injuries to aorta
and heart
 Abdomen abrasion: mesenteric injury, bowel perforation/hematoma,
Chance fracture
 Presence of seat belt sign should heighten suspicion of
potential underlying injury
 Thorough exam, liberal imaging, frequent re-assessment are
cardinal points to remember
 50 year old man, was curling 100lb dumbbells at the gym
 The patient heard a pop, and then felt pain in his right arm
Biceps Tendon Rupture
Ruptured Biceps Tendon
 Biceps Anatomy
 Proximal Biceps: Two heads which attach proximally about the
scapula
 Distal Biceps: Solitary attachment to the radial tuberosity
 Biceps function to cause forearm flexion and supination
 Most common location of injury is proximal attachment
 Long head (90-97%)
 Most patient describe a pop and simultaneous loss of
strength in affected arm
 Predisposing Factors
 Repetitive micro trauma
 Steroid injection
 Muscle over usage
 Management
 X-ray: Rule out concomitant avulsion fracture
 Sling, NSAIDS
 Ortho referral
 37 year old man presents with pain to left hand after getting
it scraped along a brick wall
Fight Bite
Clenched Fist Injury
(Fight Bite)
 All wound at the MCP joint, especially when on the
dominant hand are fight bites until proven otherwise
 Infections tend to be polymicrobial and aggressive
 Staph, strep, E. Corrodens, anaerobes
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Complications
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Rapidly progressive infections
Loss of function
Septic Arthritis
Flexor Tenosynovitis
Amputation
Management
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Irrigation
Tendon strength testing
Debridement
Radiography
Prophylactic anti-biotics
Splinting & Elevation
Close follow-up or admission
 42 year old dental assistant presents with painful and swollen
finger
Herpetic Whitlow
 Primary or recurrent HSV lesion
 HSV-1
Seen in children who auto-inoculate their digits with oral
secretions
 Health care workers who are exposed to oral secretions
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 HSV-2
 More common in adults due to digital/genital contact
 May be confused with paronychia
 Clear vesicles seen early, coalesce and may appear purulent,
actually contains necrotic epithelial cells
 Symptoms
 Painful and red distal digit
 Axillary lymphadenopathy
 Treatment
 Local wound care
 Pain control
 Topical Acyclovir: Decreases Duration of Symptoms
 Oral anti-virals
 Do not I & D