J Emerg Med
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Case Reports
A Unique Case of Valsalva Retinopathy: Preretinal Hemorrhage Identified on Bedside Ultrasound.
Emergency physicians frequently evaluate patients with vision changes. The differential for this chief symptom is broad. We present a unique cause of a fixed scotoma that started while the patient was running sprints. ⋯ The patient described a bright central scotoma that later became a dark oblique line across her central vision. This painless defect moved predictably with eye movements. Ocular ultrasonography was performed and revealed a well-demarcated hyperechoic lesion in the posterior segment of the right eye. There was no similar lesion found in her left eye. In consultation with ophthalmology, the patient's history and examination were consistent with valsalva retinopathy. To our knowledge, this is only the second published case of valsalva retinopathy/premacular hemorrhage identified on ocular ultrasonography in emergency medicine literature. In this article, we further expand on management and provide correlating fundoscopic images. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians frequently evaluate patients with visual changes. Valsalva retinopathy is a rare cause of a visual scotoma that can be diagnosed through history and ultrasound. It often resolves over weeks to months without intervention. However, it does require urgent ophthalmologic evaluation to rule out peripheral retinal tears, which may require laser retinopexy or surgical management.
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Young children present frequently to the emergency department with an immobile, painful arm. It is often difficult to discern a point of tenderness in a frightened, injured child. Common approaches included sending the child for x-ray studies of the extremity or empirically attempting reduction of radial head subluxation. We created a step-by-step point-of-care ultrasound screening protocol of the upper extremity to increase or decrease the probability of fracture before x-ray study or reduction. ⋯ We present the cases of 6 children younger than 4 years without a clear history of pulled elbow and without swelling or deformity on examination, for whom this protocol revealed fracture or lowered the probability of fracture, thereby increasing the safety of radial head reduction. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In most cases, identification of a single fracture on ultrasound allows for focused x-ray study on the area of fracture. Children with a normal ultrasound screen can undergo reduction of radial head subluxation safely.
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There have been few investigations examining the benefits, consequences, and patterns of use for prophylactic antibiotics for nasal packing in the emergency department setting. Given the frequency of epistaxis in the emergency department, it is an ideal setting to study the efficacy and utilization patterns of prophylactic antibiotics in nasal packing. ⋯ There was no observed advantage or disadvantage to using prophylactic antibiotics in anterior nasal packing in the emergency department, regardless of whether patients received absorbable or nonabsorbable packing. However, patients who receive nonabsorbable nasal packing were more likely to receive antibiotic prophylaxis.
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Patients who experienced transient monocular vision loss (TMVL) commonly present to the emergency department for evaluation. Although multiple etiologies can cause TMVL, it is most important to identify patients with retinal ischemia and those with vasculitis (giant cell arteritis) as the cause of TMVL. Patients with transient retinal ischemia have the same risk of cardiovascular events and death as patients who experienced transient brain ischemia. Patients with giant cell arteritis are at imminent risk of visual loss. ⋯ A 65-year-old man noticed three separate episodes of sudden onset of blurry vision in one eye. Ophthalmologic examination was normal but, as his symptoms were compatible with transient retinal ischemic attack, urgent investigations were initiated. He had normal inflammatory markers but computed tomography angiogram of the brain and neck demonstrated a large plaque in the ipsilateral internal carotid artery. Double anti-platelet therapy was started and stenting of the involved carotid artery was performed. The patient was symptom-free at the last follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Patients with retinal ischemia as the etiology of TMVL are at high risk of cardiovascular events and death. Their risk of cerebrovascular accidents is highest within 48 h from the episode of TMVL, thus they should have an urgent ophthalmologic examination and, if it is unrevealing, inflammatory markers should be checked and an urgent stroke prevention protocol should be initiated. Appropriate management with medical or surgical interventions significantly reduces morbidity and mortality in these patients.
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Case Reports
Pneumothorax Complications During Placement of Peripheral Internal Jugular Intravenous Catheters.
A "peripheral IJ" is a 2.5-in angiocatheter placed in the internal jugular vein with ultrasound guidance but typically no barrier precautions. Previously published literature has shown safety with none to minimal complications. ⋯ This report describes 2 cases of iatrogenic pneumothorax that occurred during this procedure. One was caused by an emergency medicine intern, the other by an experienced faculty member. Both occurred in petite women with low body mass indices. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is important to remember that there are risks inherent with using the internal jugular vein for intravenous access. Particular vigilance should be used with patients who are thin.