Asynchrony PEM: Pediatric Gonadal Emergencies

Today, we’re talking gonads! Specifically, painful pediatric gonadal emergencies.  

Gonadal emergencies present in the pediatric emergency department so many different ways; it's not as straightforward as kids complaining of testicular swelling or 'my ovaries hurt'. They usually present as pediatric abdominal pain.  And because both that chief complaint and gonadal emergencies in general can cause you and your patient to cry, here's this week's theme song:

 

Kicking things off: Twist and Shout?

From our friends in Cincinnati, some key history and physical tips for your pediatric patients complaining of testicular pain.  Important questions that our urology colleagues will ask about the physical exam include symmetry, testicular lie, and, most importantly, is there a cremasteric reflex? This was found to be 83.3% accurate in a 2004 study by Paul et al.

Patients with the bell-clapper deformity (a horizontal lie due to a defect in posterior attachment) are at an increased risk for torsion, based on the testicular lie.

What is your differential for pediatric testicular pain? More from our friends in Cincinnati: The emergency, the painful, and the treat or not to treat? And if you want more info on appendix testis torsion, or epididymitis PEDS EM Morsels has some brief input to check out.

But what if your patient has ovaries and not testicles?

These patients will present with acute onset abdominal pain, unilateral, and constant. Depending on how long the ovary has been twisted, pain can subside and become dull and mimic many different abdominal presentations, which is why it is often missed!

Ultrasound is not 100% in diagnosis and if you have high clinical suspicion, please call the urologists.  Remember to ask our radiology colleagues to comment on the spermatic cord and flow in their report. And ask nicely!

Testicular torsion can even happy perinatally (no age is safe!).  Check half way down the page for some quick tidbits on perinatal torsion. Check here for more information, but, in summary, testicular torsion can happen any time prenatally after the 6th week of gestation (when gonads form) to just before, during and after birth.  Depending on when the torsion occurs, the infant might present with just a dusky hemiscrotum, firm hemiscrotum, or may just be an inconsolable infant.

But the gonads can do more that just twist, right? You betcha.

For the auditory learners listen to this quick (<10 minutes) podcast on ruptured ovarian cysts. (Note, we will not do transvaginal ultrasounds at Hasbro hospital, our home institution.)

Teenagers are also sexually active.  Make sure to talk to patients about pregnancy, get a urine or serum b-HCG, and screen for PID. The American Academy of Pediatrics has guidelines for screening for STIs in adolescents.  Basically: screen for gonorrhea, chlamydia, trichomoniasis, and syphilis as indicated. Don’t forget oral and anal swabs, as teens will have oral, vaginal, or anal sex.

And finally some Y chromosome specifics for when your patient gets their penis caught in a zipper or suffers from summer penile syndrome (for audio learners and readers).

That's it! Now you're ready to grab any gonadal emergency by the...horns.

See you next time in Asynchrony PEM!

 

 

Clinical Image 22: The Stuck Sub

WELCOME BACK TO ANOTHER CLINICAL IMAGE FROM THE CASE FILES OF THE BROWN EM RESIDENCY!

Case:

HPI: A 27 year-old male with no significant past medical history presents to the ED with chest pain. The patient states about 30 minutes prior to arrival he was eating a meatball sub and got the feeling “like something was stuck in my chest”. He drank water in an attempt to push the food into his stomach but it did not help.  He then tried to self induce vomiting multiple times when he developed acute chest pain. Over the course of several minutes his chest pain worsened and was now associated with shortness of breath, nausea and dry heaving, dysphagia, and odynophagia. He also feels as though his voice sounds hoarse.  He denies dizziness, syncope, palpitations, or abdominal pain. He’s been otherwise well leading up to this.   

Vitals: T: 99.4 BP: 138/68 P: 86 R: 16 SpO2: 100% on room air

Physical examination: Patient found sitting up in the stretcher and appears extremely uncomfortable. He is cool and clammy. He has diminished breath sounds bilaterally. He is noted to have right facial and neck swelling as well as underlying crepitus. Heart sounds are regular rate and rhythm without murmur, rub, or gallop. He has no abdominal tenderness, guarding, rebound, or distention. No other pertinent exam findings.

Chest X-ray imaging was obtained:

Figure 1: Chest x-ray imaging on patient arrival

Figure 1: Chest x-ray imaging on patient arrival

What does the chest x-ray show and what is the presumptive diagnosis?

Pneumomediastinum concerning for esophageal rupture (Boerhaave’s Syndrome)

In the chest x-ray above we can see air tracking along the mediastinum (red arrows), as well as extensive subcutaneous emphysema tracking into the neck (green arrows).

Figure 2: Pneumomediastinum. Air can be seen tracking along the mediastinum (red arrows), and into the subcutaneous tissues of the neck (green arrows).

Figure 2: Pneumomediastinum. Air can be seen tracking along the mediastinum (red arrows), and into the subcutaneous tissues of the neck (green arrows).

The patient’s respiratory distress worsened and he became hypoxic requiring oxygen by NRB. Repeat chest x-ray demonstrated a left sided pneumothorax, as identified by a pleural line (arrows).

Figure 3: Left sided pneumothorax as identified by a pleural line (arrows)

Figure 3: Left sided pneumothorax as identified by a pleural line (arrows)

Some quick facts about Boerhaave’s Syndrome:

  • Full thickness perforation of the esophagus after a sudden increase in intraesophageal pressure, typically in the setting of forceful emesis.
  • Foreign body ingestion and food impaction may also result in perforation either directly or indirectly (forceful vomiting).
  • Blunt or penetrating neck trauma can also cause perforation, as well as instrumentation (endoscopy).
  • Most perforations are left sided and distal, although proximal perforations are more commonly seen with instrumentation.
  • Classic presentation is sudden onset, severe chest pain following forceful emesis. It often radiates into the back, abdomen, neck, and shoulders.
  • Patients are typically ill appearing, diaphoretic, dyspneic, and/or tachycardic.
  • On examination patients may have subcutaneous crepitus appreciated in the chest and neck. Hamman’s crunch, an audible crepitus appreciated on heart auscultation, is sometimes heard in the setting of pneumomediastinum.
  • Chest x-ray imaging may reveal pneumomediastinum, pneumoperitoneum, pneumothorax, subcutaneous air, or pleural effusions (typically left sided), although a normal x-ray does not rule out the diagnosis as mediastinal emphysema takes time to develop.
  • Patients can develop mediastinitis, pneumonitis, or peritonitis from the leakage of esophageal contents, which can rapidly develop into septic shock.
  • ED management includes resuscitation in the setting of septic shock, administration of broad spectrum antibiotics (consider anti-fungals as well), and surgical consultation.
  • Delay in diagnosis and treatment > 24 hours is associated with an increased rate in mortality.
  • Definitive management ranges from conservative for smaller tears with a more indolent clinical course, to surgical management for more severe perforations.

Pneumomediastinum versus Pneumopericardium: Does the distinction matter?  

Of course! The main importance is that pneumopericardium can develop tension physiology, whereas as pneumomediastinum typically does not. With pneumomediastinum, in addition to air tracking along the mediastinum, you can also see a pleural edge along the upper heart border. In this case, the pleural reflection is very thin, versus pneumopericardium in which there is a much thicker edge given the thickness of the pericardium. In pneumopericardium the air is confined to the pericardial space, where in pneumomediastinum it often decompresses into the subcutaneous tissue.

Case Conclusion:

Our patient underwent a left sided chest tube insertion for management of his pneumothorax followed by barium swallow to assess the severity of his perforation. He was found to have a small, focal, contained perforation in the distal esophagus.

Figure 4: Barium swallow demonstrating distal esophageal perforation (arrows).

Figure 4: Barium swallow demonstrating distal esophageal perforation (arrows).

He received broad spectrum antibiotics and was admitted to the cardiothoracic surgery service where he underwent successful conservative management.

Faculty Reviewers: Dr. Alyson McGregor and Dr. Robert Tubbs

More Reading:

https://lifeinthefastlane.com/pulmonary-puzzle-003/

https://radiopaedia.org/articles/pneumomediastinum

https://radiopaedia.org/articles/pneumothorax

References:

1: Gorrochategui, M., et. al. Pneumothorax. Radiopaedia. 2017 <https://radiopaedia.org/articles/pneumothorax>.

2: Gorrochategui, M., et. al. Pneumomediastinum. Radiopaedia. 2017. <https://radiopaedia.org/articles/pneumomediastinum>.

3: Raymond, D., Jones, C. Surgical Management of Esophageal Perforation. UptoDate. 2017.

4: Tintinalli, et. al. Emergency Medicine. 8th Edition. 2016. 328; 511-512.

 

AEM Early Access 02: Ketamine for Acute Pain in the ED

Welcome to the second episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an AEM Article in Press, with an author interview podcast and links to curated FOAMed supportive educational materials for EM learners.

    A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

    A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

This month's discussion: Ketamine as an Adjunct to Opioids for Acute Pain in the Emergency Department: A Randomized Controlled Trial. Karen J. Bowers MD, MS, Kelly B. McAllister, PharmD, MBA, Meredith Ray, PhD, MPH, and Corey Heitz MD, MS.

LISTEN NOW: Author Interview with Karen Bowers, MD

 

Karen J. Bowers MD, MS, MEd

Emergency Medicine Resident, PGY-2

Emory University School of Medicine

**This article will be open access digitally until June 30, 2017. Read it in full here.**

Article summary:

Objective: To measure and compare total opioid use and number of opioid doses in patients treated with opioids versus ketamine in conjunction with opioids, pain scores up to 2 hours after presentation in the ED and patient satisfaction in patients treated with opioids versus ketamine in conjunction with opioids, and to monitor and compare side effects in patients treated with opioids versus ketamine in conjunction with opioids.

Methods: Randomized, double-blinded, placebo-controlled trial at a single center academic emergency department evaluating the use of ketamine versus placebo in conjunction with opioids for moderate to severe pain. Patients who had received an initial dose of opioid analgesia were randomized to receive either 0.1 mg/kg ketamine or placebo prior to protocol-cased dosing of additional opioid analgesia, if required. Over 120 minutes, subjects were assessed for pain level (0-10), satisfaction with pain control (0-4), side effects, sedation level, and need for additional pain medication. Total opioid dose, including the initial dose, was compared between groups.

Results: 63 subjects were randomized to the placebo group and 53 to the ketamine group. No significant differences were found in demographics between the groups. Patients receiving ketamine reported lower pain scores over 120 minutes than patients receiving placebo (p = 0.015). Total opioid dose was lower in the ketamine group (mean SD = 9.95 +/- 4.83 mg) compared to placebo (mean SD = 12.81 +/- 6.81 mg; p = 0.02). Satisfaction did not differ between groups. Fewer patients in the ketamine group required additional opioid doses. More patients reported light-headedness and dizziness in the ketamine group. 

Conclusions: Ketamine, as an adjunct to opioid therapy, was more effective at reducing pain over 120 minutes and resulted in a lower total opioid dose as well as fewer repeat doses of analgesia. More side effects were reported in the ketamine group (51% vs. 19%), but the side effect profile appears tolerable. 

 

Related #FOAMed educational resources:

SGEM #130: Low Dose Ketamine for Acute Pain Control in the ED

Review of Dr. Beaudoin's (faculty at Brown University) research on low dose Ketamine for Acute pain, by EM Cases: Low Dose Ketamine Analgesia

EM Crit: "Opioid Free ED". Podcast with Dr. Motov, who published a comparison of 0.3 mg/kg of ketamine versus morphine and found it to be just as good. Also see Dr. Motov's website, painfree-ed.com, where you will find many related resources.

Our friends at NUEM review of Dr. Motov's study: Ketamine versus Morphine for Pain Control

Ped EM Morsels: Ketamine for Analgesia 

EM Docs: Ketamine for Analgesia in the ED

Faculty Reviewer: Dr. Gita Pensa

Like this podcast's hip hop ketamine anthem from The EMC (Dr Christopher Hahn)? Check him and more of his work out at www.theemc.org, or on Twitter at @TheEMCMD.