J Emerg Med
-
Emergency ultrasonography is an efficient and cost effective tool for patients who are in respiratory distress. Chest radiographs can yield limited information for these patients. Computed tomography scans have long been the criterion standard for advanced imaging in patients with respiratory complaints, but point of care ultrasound (POCUS) can be performed at bedside, does not expose the patient to radiation, and at times may provide more information than a computed tomography scan. ⋯ A 60-year-old man with a medical history of hypertension presented to the emergency department complaining of a productive cough associated with fever, weakness, and progressively worsening dyspnea on exertion over the previous 1 to 2 weeks. The physical examination was remarkable for rhonchi in the right upper lobe and diminished breath sounds throughout the right lung. POCUS was performed, and the results revealed severe atelectasis and hepatization of the right lung parenchyma with visualized air bronchograms. Complex hypoechoic material with a posterior spine sign was noted, which increased concern for complex consolidation and effusion. The diagnosis of pneumonia with empyema was made. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: POCUS has become a much more commonly used imaging modality within many emergency departments. Ultrasound is more sensitive than chest radiographs for identifying pathologies such as pneumothorax and simple effusions. This case shows how well POCUS can diagnose empyema even in the setting of diagnostic uncertainty of computed tomographic imaging.
-
Heat stroke, heat-related illness, and malignant hyperthermia all present with hyperthermia. The former two are common presentations in the emergency department (ED). On the other hand, malignant hyperthermia (MH) is an uncommon but equally dangerous condition that requires prompt recognition and specific treatment with dantrolene sodium and avoidance of certain medications to reduce morbidity and mortality. Recent research focusing on nonanesthetic or exercise-induced MH has demonstrated a relationship between certain gene mutations and malignant hyperthermia susceptibility. ⋯ We report the case of a 19 year-old man with a family history of MH who was treated for exertional heat stroke, but despite cooling and adequate fluid resuscitation, demonstrated worsening rhabdomyolysis that subsequently responded to the administration of dantrolene sodium. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the importance of recognizing the potential relationship between exertional heat stroke and malignant hyperthermia. The overlap between heat stroke and malignant hyperthermia susceptibility has important implications in the treatment and evaluation of patients presenting with signs and symptoms of heat stroke or heat-related illness in the ED.
-
Acquired uterine arteriovenous malformation (AVM) is a rare cause of postpartum vaginal bleeding and can often be confused with retained products of conception (RPOC). Certain findings on ultrasound (US) increase the likelihood for AVM, such as hypoechoic areas in the myometrium and high velocity, multidirectional blood flow. Recognizing these changes on bedside US can cue the physician to send the patient for further studying and lead to the correct diagnosis. ⋯ A 31-year-old, multigravida, multiparous female presented 5 weeks post-cesarean section with heavy, intermittent vaginal bleeding. Patient had multiple previous visits for similar bleeding, including an evaluation for RPOC. Upon current presentation, the patient underwent an US in the emergency department with color and pulse wave Doppler. US revealed a hypoechoic area within the myometrium, with high velocity, bidirectional blood flow, raising the clinical suspicion for uterine AVM. Following confirmatory studies, the patient underwent successful embolization of the AVM. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The proper diagnosis of AVM is crucial, because the primary treatment modality for the alternative diagnosis of RPOC (i.e., dilation and curettage) can worsen vaginal bleeding and lead to shock or death, and is therefore contraindicated for uterine AVM. US is a quick bedside tool that can be used for rapid diagnosis of uterine AVM.