Community EM

Meeting Uncle Rhabdo

rhabdo.png

THE PATIENT:

A 28 year old previously healthy male presents to the emergency department with concerns for worsening back pain that is predominantly left sided and along the lumbar spine. Two days prior to the visit he recalls a work out that consisted of many dead lifts. He also played basketball the following day and rode his bike into work, which is more activity than usual for him. He tried NSAIDs for pain control, but his pain is more intense and he noticed his urine looked brown today. He denies any fevers, history of IVDU, weight gain or loss, urinary tract infections or STDs, immunosuppression, recent spinal fracture or procedure, incontinence or retention.

PHYSICAL EXAMINATION:

144/83, 82, 37.1, 18, 98%

Gen: well appearing, no acute distress

HENT: normocephalic, MMM

CV: RRR

Pulm: CTAB

Abd: soft, nontender, nondistended

MSK: muscle spasms along the left lumbar paraspinal muscle, no midline tenderness to palpation, muscle compartments in the upper and lower extremities are soft

Neuro: L1-S5 strength 5/5 and sensation to light touch is intact

Skin: pink, warm, dry

THE COURSE:

As an experienced clinician you are able to quickly arrive at a diagnosis of rhabdomyolysis from the brief history and physical exam, but what else needs to be done? In the emergency department we need to initiate diagnostic studies to evaluate the severity of illness and help plan for an appropriate disposition. Thankfully, your history and exam reveal no red flag findings for more concerning etiologies of back pain, so your evaluation can be quite focused. The patient had lab work sent off and was provided with IVF boluses and given analgesia with marked improvement in his symptoms. He was admitted to the medical floor for continued care for the next couple days.

THE WORK UP:

CK >20,000 IU/L (labs upper limit for reporting without further analysis and quantitative estimates, normal range 20-210, remained >20,000 for 5 consecutive days) finally on day 6 CK 10, 933 IU/L

BMP: Glu 113, BUN 19, Cr 1.0 (on discharge was 0.84), Na 139, K 3.8, Cl 104, CO2 29, Ca 8.9

Urinalysis: Brown, cloudy, trace ketones, specific gravity >1.03, blood 3+, protein >300

Urine microscopic analysis: RBC none seen, WBC 3, amorphous crystals present

Urine myoglobin: >8,750 mcg/ml (normal range < 28mcg/ml)

DISCUSSION:

The key clinical manifestations of rhabdomyolysis include a triad of muscle tenderness and weakness as well as dark urine, so the triage note already had it set up on a silver platter for you. Remember, however, as with any triad in medicine this classic presentation is rare. Some studies revealed that over half of patients do not report muscle pain or weakness. Rhabdomyolysis occurs due to muscle necrosis and the release of intracellular contents into the circulation. Patients may present with a wide range of symptoms and the most concerning complications include hyperkalemia, renal failure and rarely disseminated intravascular coagulation. Patients who present with concomitant acute kidney injury tend to have worse outcomes and the mechanism of injury is primarily related to the nephrotoxic effects of myoglobin. In an acidic environment myoglobin may precipitate and subsequently damage the kidneys by obstruction of the renal tubules, cause oxidative damage and vasoconstriction.

The etiologies of rhabdomyolysis can be broken up into four broad categories: impaired production or use of ATP, dysfunctional oxygen or nutrient delivery, increased metabolic demand exceeding capacity, and direct myocyte damage. Recently, on EM: RAP Dr. DeLaney argued that this can be further simplified into two broad categories, exertional and non-exertional. Classic cases include trauma patients who have crush injuries but can also occur with heat related illnesses such as heat exhaustion or stroke, or in cases of hyper-kinetic states. Medications implicated in this disease process include antipsychotics and statins as well as others such as illegal drugs like cocaine.

CK levels classically rise within two to twelve hours after the onset of injury and peak within three days. The level should return to baseline within ten days. The diagnosis is often considered if the CK level is above five times the upper limit of normal at presentation, roughly 1,000 IU/L. More discrete categories can also be used to differentiate mild to severe cases based on CK levels, however, it is the degree of renal impairment that likely has the greatest role on patient outcome. Emergency department management includes aggressive IVF hydration with a target urine output of approximately 250 ml/hr and attempts to identify and correct the underlying pathology. Some argue for urinary alkalinization; however, the literature is limited with regards to strong recommendations on this topic. Common electrolyte abnormalities include: hyperkalemia, hyperphosphatemia, hyperuricemia, and hypocalcemia. Disseminated intravascular coagulation can rarely be seen as a result of thromboplastin and prothrombotic agents released from damaged myocytes. Acute kidney injury is more common if the presentation includes a CK >5,000 IU/L and in cases with sepsis, acidosis, or dehydration. Ultimately, most patients do well during their hospital courses and rarely require significant interventions, but mortality may be upwards of 20% in those that present with significant kidney injury noted at the time of presentation, therefore, careful evaluation of the patient’s lab studies and admission for close observation remains the mainstay of treatment.

Faculty Reviewer: Dr. Gita Pensa

SOURCES:

  1. DeLaney, M. “Rhabdomyolysis: Part 1 Diagnosis and Treatment.” www.emrap.org March 2018, 18 (3)

  2. DeLaney, M. “Rhabdomyolysis: Part 2 Disposition.” www.emrap.org March 2018, 18 (3)

  3. Majoewsky, M. “Rhabdomyolysis: C3 Project.” www.emrap.org June 2012, 2 (6)

  4. Sauncy, H. (2017). Don’t Get Broken Up About Muscle Breakdown. In Mattu, A. Marcucci, L. et al (Eds.), Avoiding Common Errors in the Emergency Department: Second Edition (pp. 414-16). Philadelphia: Wolters Kluwer.

Do You 'See More' Fractures? Don’t Overlook 'Seymour' Fractures!

Co-Authors: Dr. Madalene Boyle and Dr. Andrew Beck

Case 1

A 10-year-old male presents to the ED with his parents after his finger was slammed in a car door. His parents are concerned that it’s bleeding and appears deformed. The incident occurred 30 minutes prior to presentation. His parents state that there was “a lot of bleeding.” His past medical history is notable for asthma, and there is no history of fragility fractures, connective tissue disorders, or bleeding diatheses. Physical exam reveals the injury as shown. Flexion of the digit is preserved and extension is limited due to pain and deformity. Neurovascular exam is intact. 

 Car door injury to 5th digit.

Car door injury to 5th digit.

Screen Shot 2018-08-24 at 11.41.07 AM.png

An x-ray was taken to assess for fracture and/or foreign body. The original film was unavailable, but an illustrative lateral view is shown(3). No foreign body was noted, but a characteristic injury pattern was observed.


 

Case 2

A 14-year old right-handed football player presents to the community Emergency Department with a right middle finger deformity. Patient was playing football when he went to make a tackle and his finger was crushed beneath another player.  

Screen Shot 2018-08-24 at 11.45.28 AM.png

On exam, his middle finger has dried blood at the base of the nail. The proximal nail appears partially avulsed. His finger appears flexed at the DIP although he is able to fire his extensors/flexors at the DIP.  He has no sensory deficits. 

 Image from Azburg, 2013.

Image from Azburg, 2013.

 

The Seymour Fracture

Definition & Epidemiology(1,2): Originally described in 1966 by Seymour, the eponymous Seymour fracture is defined as an open, displaced distal phalangeal fracture with associated nail bed injury. This injury can easily be overlooked as minor trauma to the nail which can have consequences for infection and growth arrest, leading to chronic deformity and loss of function.1 20-30% of phalangeal fractures in children involve the physis, and the long finger is most commonly affected. The mechanism is typically a crush injury in a door. These are Salter-Harris Type 1 or 2 fractures and the nailbed injury is commonly a laceration or plate avulsion. Often, interposition of soft tissue at the fracture site impedes bedside reduction. 

The Seymour fracture will often resemble a mallet finger. For this reason, any pediatric patient with an apparent mallet finger deformity and blood at the nail fold should be evaluated seriously for this fracture. The mallet finger appearance occurs because of an imbalance between the flexor and extensor tendons.  The extensor tendon inserts at the epiphysis of the distal phalanx. The flexor digitorum profundus inserts at the metaphysis.  There is no actual injury to the extensor tendon (as in Mallet finger). The imbalance is created through the physis or fracture site (see image). 


Diagnosis (1,2,3): Physical exam demonstrates a flexed dorsal interphalangeal joint, ecchymosis, swelling, and mallet deformity. The nail plate lies superficial to the eponychial fold which will give the appearance of a longer-than-normal nail.1,2,3 Imaging reveals a fracture through the physis along with other potential fractures. The AP radiographic view may be normal since lateral deviation is not commonly seen. The lateral view is more sensitive and will show a widened physis, displacement, and angulation. It is important not to confuse the presentation for a mallet finger which is the key differential diagnosis. Mallet fractures involve the joint while the Seymour fracture is isolated to the growth plate without epiphyseal displacement. 

...any pediatric patient with an apparent mallet finger deformity and blood at the nail fold should be evaluated seriously for this fracture.


Risks: A Seymour fracture has many associated complications. Based on fracture location, the germinal matrix (responsible for nail production) can become entrapped in the fracture site (See image above). This prevents a simple reduction of the fracture. Additionally, damage to the germinal matrix can cause a permanent nail plate deformity.  If soft tissue becomes incarcerated in the physis, it can cause growth arrest and finger length discrepancy. Importantly, failure to treat Seymour fractures as open fractures can result in infection and even chronic osteomyelitis. 


Management: These are open fractures.  In the ER, it is appropriate to give a dose of parenteral antibiotics. A first generation cephalosporin such as Cefazolin is suitable. Patients should be treated with a short (5-7 day course) of oral antibiotics upon discharge. 
A hand specialist should manage Seymour fractures. Appropriate treatment of Seymour fracture consists of removal of the nail plate, exploration of the fracture site (to ensure no tissue entrapment), thorough irrigation and debridement, and reduction. For unstable fractures, a K-wire through the fracture and DIP is sometimes necessary to maintain this reduction.  The nail bed laceration should be repaired. The nail should be replaced or stented with suture packaging material. 
Younger patients may require anesthesia and an operating room for exploration and adequate treatment. Older patients may be able to have treatment within the department with adequate pain control and local nerve blocks. 
Appropriate management of Seymour Fractures is crucial. A recent review by Reyes (2017) evaluated management and associated complications of Seymour fractures.  There was a much higher rate of infection (both superficial and osteomyelitis) in those patients who do not receive proper treatment.  Emergency Medicine providers must be able to recognize this injury in order to initiate antibiotics and facilitate appropriate consultation with a hand specialist. 

Prognosis (3): As mentioned above, nonoperative management may be possible for minimally displaced Seymour fractures. However, by definition, Seymour fractures are open and displaced, and the majority of these injuries require open reduction and fixation. Functional and cosmetic outcomes at two years are equivalent between operative and nonoperative groups when selected for treatment based on degree of displacement. Major complications include reduced range of motion, nail dystrophy, and digit length discrepancy, all of which can have major functional consequences especially if involving the 2nd or 3rd digits on the dominant hand, or if the patient requires the use of multiple digits for a profession (pianist, artist, and typist). 


Case 1 Resolution

This patient received a bedside nail bed repair with avulsion and replacement of the nail plate, then reduction via hyperflexion followed by traction and extension. The patient was splinted and received operative repair within one week of the injury. 


Case 2 resolution

A hand team was not available at the community hospital. Patient was transferred to the Children’s Hospital where he was treated by the hand team.  He underwent I+D in the ER and reduction/repair. He has since had an uneventful follow-up appointment. 

 

References
1)    Nellans KW, Chung KC. Pediatric Hand Fractures. Hand Clin. 2013 Nov; 29(4): 569–578. doi:  10.1016/j.hcl.2013.08.009. 
2)    Watts E. Seymour Fracture. https://www.orthobullets.com/hand/6000/seymour-fracture# Accessed 11/27/2017.
3)    Krusche-Mandl I, Kottstorfer J, Thalhammer G et. Al. Seymour fractures: retrospective analysis and therapeutic considerations. J Hand Surg Am. 2013 Feb;38(2):258-64. doi: 10.1016/j.jhsa.2012.11.015.
4)    Abzug JM, Kozin SH. Seymour fractures. J Hand Surg Am. 2013;38:2267–2270. 
5)    Reyes BA, Ho CA.  The High Risk of Infection With Delayed Treatment of Open Seymour Fractures: Salter-Harris I/II or Juxta-epiphyseal Fractures of the Distal Phalanx With Associated Nailbed Laceration. J Pediatr Orthop. 2017: 37: 247-253. 
6)    Kattan AE, AlShomer F, Alhujayri AK, Alfowzan M, Murrad KA, Alsajjan H. A case series of pediatric seymour fractures related to hoverboards: Increasing trend with changing lifestyle. International Journal of Surgery Case Reports. 2017: 38: 57-60. 

 

FACULTY REVIEWER/EDITOR: Dr. Kristina McAteer


 

Hiding in Plain Sight: Unexpected Findings on Chest X-Ray

Rich Gorilla CT.jpg

Notice anything unusual about this scan? In a study by Melissa Trafton Drew and Jeremy Wolfe, 83% of radiologists didn't notice the gorilla in the top right portion of this image when scrolling through five chest CT scans looking for lung nodules. (1) This is thought to be due to a phenomenon known as inattention blindness. When engaged in a demanding task, we may fail to perceive an unexpected stimulus that is in plain sight. If you don’t believe me, check this out:

The chest x-ray is one of the most commonly performed imaging tests. As emergency medicine physicians, we order chest x-rays to evaluate patients with a wide variety of complaints. Often times, it is our responsibility to interpret the x-ray and create a management plan before a radiologist has a chance to look at the image. This is true in community hospitals without radiologists available during night or weekend hours, in critically ill patients, or in trauma victims at large academic centers. Several studies have shown a discrepancy between the x-ray readings of emergency medicine physicians verses radiologists. (2,3,4,5) There is wide variability in the rate of misinterpretations reported, depending on the type of imaging, the experience level of the clinician, and the difficulty level of the chest x-ray findings, among other factors.

Chest x-ray interpretation is a vital skill as interpretation errors can have significant consequences.  False negatives may result in missing life-threatening conditions and worse patient outcomes. False positives may result in further testing, longer ED course and unnecessary interventions.  We are taught to be systematic in our approach to reading an image. However, it is not uncommon to zero in on the part of the chest x-ray we are interested in and unintentionally brush over the rest of the picture. This can lead to missed diagnoses and poorer patient outcomes.

With the importance of accurate chest x-ray interpretation skills in mind, let’s take a step back and review the basics:

The ABC's of Reading a Chest X-ray: 

First- check the patient information, the projection (AP or PA), the date it was taken. Review the aspects that affect the quality of the film.

  • Check the alignment (medial ends of clavicle equidistant from spinous process)
  • Check the inspiratory effort (10-11 posterior ribs in each lung field)
  • Exposure (is the image too bright or too dark? The vertebrae should be visible behind the heart)

Remember the pneumonic “RIPE” to evaluate the quality of an image - Rotation, Inspiration, Projection, Exposure. 

 https://commons.wikimedia.org/wiki/File:Mediastinal_structures_on_chest_X-ray.svg#/media/File:Mediastinal_structures_on_chest_X-ray,_annotated.jpg

https://commons.wikimedia.org/wiki/File:Mediastinal_structures_on_chest_X-ray.svg#/media/File:Mediastinal_structures_on_chest_X-ray,_annotated.jpg

When ready to review the x-ray, consider the commonly used “A, B, C, D, E, F” system.

A - Airway- trachea, carina, right and left main bronchi

B - Bones and soft tissue- clavicles, ribs- posterior rand anterior, vertebral bodies, and sternum on lateral films. Look for any fractures, dislocations, or lytic lesions.

C - Cardiac- cardiac silhouette and mediastinum. The cardiac silhouette should be less than half of the thoracic cavity. AP films exaggerate heart size, so this rule does not apply. Assess the borders of the heart and the hilar structures

D - Diaphragm- right should be higher than left and you should see a gastric air bubble on the left. Is there any free air under the diaphragm? Evaluate the costophrenic angle and pleura (normally invisible due to thinness).

E - Everything else (lines and tubes, pacemakers, artificial valves)

F - Fields- FINALLY, evaluate the lung fields. Lungs are the area of greatest interest, so it is helpful to keep this at the end to prevent distraction. Divide each lung into three “zones” when reading a chest x-ray. These do not correlate with the lobes. Remember, there are 2 lobes on the left (upper and lower) and 3 on the right (upper, middle and lower). 

 https://upload.wikimedia.org/wikipedia/commons/thumb/7/7e/2312_Gross_Anatomy_of_the_Lungs.jpg/1280px-2312_Gross_Anatomy_of_the_Lungs.jpg

https://upload.wikimedia.org/wikipedia/commons/thumb/7/7e/2312_Gross_Anatomy_of_the_Lungs.jpg/1280px-2312_Gross_Anatomy_of_the_Lungs.jpg

There are several things that do not fit perfectly into the A-E categories.

  • Apices
    • Look again at the lung above the clavicles
  • Retrocardiac space
    • Look for consolidation or a mass in this region
  • Below the diaphragm
    • Remember that the lungs extend below the diaphragm posteriorly. Look out for consolidation or lesions on the lateral film.
  • Soft-tissue abnormalities
    • Don’t forget to look for air, foreign bodies, and other soft tissue abnormalities.

Now that we have refreshed your memory, it’s time to practice! Imagine that you are in a small community setting, working the overnight shift. There are no radiologists available until the morning and it is up to you to read the chest x-ray.

Go through the examples below and see what findings you can pick up on these chest x-rays.


Case 1: Find the abnormality.

Case 1 answer: This patient has pneumomediastinum. Air appears as curvilinear lucencies outlining the mediastinum. Note the continuous diaphragm sign- the entire diaphragm is visualized as air in the mediastinum separates the heart and the superior surface of the diaphragm.

Case 2: Find the abnormality

Case 2 answer: This patient has a left shoulder dislocation. The humeral head is displaced from the glenoid of the scapula.

Case 3: Find the abnormality

Case 3 answer: This patient has a right middle lobe collapse. This is easier to visualize on the lateral view, where a triangular opacity overlying the cardiac silhouette can be seen. It can be difficult to see a middle lobe collapse on frontal projections. You may notice that the horizontal fissure is no longer visible or that there is blurring of the right heart border. (6)

For more information, check out https://radiopaedia.org/articles/right-middle-lobe-collapse


Case 4: Find the abnormality 

Case 4 answer: The central line placed in the right neck soft tissue crosses the midline. This line was placed in the carotid artery.
 https://pbs.twimg.com/media/CmVRNRzVIAQCaf9.jpg

https://pbs.twimg.com/media/CmVRNRzVIAQCaf9.jpg


Case 5: Find the abnormality

Case 5 answer: Misplaced tooth. Notice the ovoid, radiopaque foreign body in the right mainstem bronchus.

Case 6: Find the abnormality

Case 6 answer: This patient has a left lower lobe pneumonia. There is a positive spine sign on the lateral projection. The spine normally becomes more radiolucent as you progress inferiorly given the increased amount of air containing lung overlying the spine as you travel downwards. Where there is fluid, a mass, or a consolidation in the lower lung fields, the vertebral bodies appear more radiodense.  

For more information, check out http://learningradiology.com/notes/chestnotes/spinesign.htm and https://radiopaedia.org/cases/left-lower-lobe-pneumonia-10


Case 7: Find the abnormality

https://images.radiopaedia.org/images/627328/6743f24a87021f15266d7385963870_big_gallery.jpg

https://images.radiopaedia.org/images/627329/afc5beac8649e5e1fed60df4863281_big_gallery.jpg

Case 7 answer: This patient has Chilaiditi syndrome. In this syndrome, the colon is positioned between the liver and the diaphragm which can appear as free air under the diaphragm. Notice the rugal folds, this helps differentiate bowel containing gas from free air.

For more information, check out: https://radiopaedia.org/articles/chilaiditi-syndrome

Another example of Chilaiditi Syndrome:

 https://upload.wikimedia.org/wikipedia/commons/6/6c/Chilaiditi_obvious.jpg

https://upload.wikimedia.org/wikipedia/commons/6/6c/Chilaiditi_obvious.jpg

Here is an example of actual pneumperitonium:

 https://upload.wikimedia.org/wikipedia/commons/3/3c/Pneumoperitoneum_modification.jpg

https://upload.wikimedia.org/wikipedia/commons/3/3c/Pneumoperitoneum_modification.jpg


Case 8: Find the abnormality.

https://upload.wikimedia.org/wikipedia/commons/thumb/9/98/Pneumothorax_im_liegen.jpg/689px-Pneumothorax_im_liegen.jpg

Case 8 answer: This patient has a left pneumothorax. This patient is supine at the time of this image (like many of our back-boarded and collared trauma patients). Notice the abnormally deep costophrenic angle on the left. This is known as the deep sulcus sign and is present because air collects in the non-dependent potions of the pleural space (anteriorly and basally when the patient is supine, apex when the patient is upright).

Case 9: Find the abnormality:

http://image.wikifoundry.com/image/1/UyT1bPAhr9Ui2Q1JlkLj_w115368/GW500H488

Case 9 Answer: This x-ray is NORMAL. It looks like this patient has a left pneumothorax on first glance, but the pleural line you think you see is actually a skin fold. (7) Notice that the pulmonary vessels extend to the outer edge of the lung fields.

For more information, check out: http://www.wikiradiography.net/page/Patterns+of+Misdiagnosis+in+Plain+Film+Radiography section 16 on artifacts.


Case 10: Find the Abnormality.

Case 10 Answer: The OGT is malpositioned and is entering the right mainstem bronchus and terminating in the right lung.

Case 11: Find the Abnormality.

https://radiopaedia.org/cases/scapular-fracture-11

Case 11 Answers: There is a comminuted fracture through the body of the right scapula. Fractures of the scapula usually occur in association with injuries to the ipsilateral lung, thoracic cage and shoulder girdle. Presence of a scapula fracture mandates further investigation for associated injuries. (8)

Case 12: Find the abnormality.

Case 12 Answer: This patient has extensive pneumomediastinum extending cranially into the neck. There is extensive soft tissue emphysema about the chest wall. This occurred after a coughing fit (believe it or not). No evidence of pneumonia or pneumothorax is seen, although it is difficult to visualize the lung fields with the overlying subcutaneous emphysema.

Conclusion

Chest x-ray interpretation is a vital skill as errors can lead to missed diagnoses and worse patient outcomes. Adopt a systemic approach to reading a chest x-ray and use it every single time. Use the ABCDEF pneumonic to guide your interpretation and to avoid overlooking an abnormality that are hiding in plain sight.

Faculty Reviewer: Robert Tubbs, MD

References

  1. Drew T, Vo ML, Wolfe JM. The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol Sci 2013;24:1848-53.
  2. Petinaux B, Bhat R, Boniface K, Aristizabal J. Accuracy of radiographic readings in the emergency department. Am J Emerg Med 2011;29:18-25.
  3. Safari S, Baratloo A, Negida AS, Sanei Taheri M, Hashemi B, Hosseini Selkisari S. Comparing the interpretation of traumatic chest x-ray by emergency medicine specialists and radiologists. Arch Trauma Res 2014;3:e22189.
  4. Soudack M, Raviv-Zilka L, Ben-Shlush A, Jacobson JM, Benacon M, Augarten A. Who should be reading chest radiographs in the pediatric emergency department? Pediatr Emerg Care 2012;28:1052-4.
  5. Nitowski LA, O'Connor RE, Reese CLt. The rate of clinically significant plain radiograph misinterpretation by faculty in an emergency medicine residency program. Acad Emerg Med 1996;3:782-9.
  6. Right Middle Lobe Collapse. at https://radiopaedia.org/articles/right-middle-lobe-collapse.)
  7. Patterns of Misdiagnosis in Plain Film Radiography. at http://www.wikiradiography.net/page/Patterns+of+Misdiagnosis+in+Plain+Film+Radiography.)
  8. Baldwin KD, Ohman-Strickland P, Mehta S, Hume E. Scapula fractures: a marker for concomitant injury? A retrospective review of data in the National Trauma Database. J Trauma 2008;65:430-5.