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Archive for May, 2011|Monthly archive page

Radiology finds!

In Uncategorized on May 8, 2011 at 5:35 pm

Left Subdural Hemorrhage

Sternal Fracture

Subxiphoid view on US. LV-Left ventricle. LA-left atrium. RA-right atrium. The star(*) marks the effusion. The white arrows show how the effusion is causing RV-right ventricular collapse.

Intracranial Hemorrahge

Abdominal aortic aneurysm

?cardiomegaly

Intussusception

Subdural Hemorrhage

L large pneumothorax with lung collapse

Subdural Hemmorhage

Displaced maxillary fracture

Chapter Review: Brain and Cranial Nerve disorders

In EM2 on May 5, 2011 at 8:20 pm

Cerebral Venous Thrombosis

It’s a rare entity but should be on our radar. Just like the peripheral venous system, the cerebral venous system may be predisposed to and form thrombus that cause major problems for the patient.

Risk Factors: head and neck infections (sinusitis, otitis media, facial cellulitis etc), trauma, surgery, tumor, pregnancy, dehydration, hypercoagulable states(protein C or S disease, antithrombin III deficiency, factor V leiden etc)), oral contraceptive use.
Clinical Features: headache (primary feature, in 74-90%), papiledema, seizures, altered mental status, lethargy. Cranial nerve palsies may also be present.

Diagnostic strategies: the ‘gold standard’ is cerebral angiography, however, the test of choice is an MRI with MRV. CT scan is not sensitive or specific enough to confirm or exclude the diagnosis but it may rule out other diagnosis on the differential and it may show the presence of an infarct that doesn’t follow an arterial distribution as a hint.

Treatment: Initial management is similar to that of a patient with acute stroke: ABC’s! keep the head of bed elevated or patient in reverse trandelenberg to prevent increase in ICP. IV heparin has been shown to be beneficial. Catheter-based intervention with thrombolysis (i.e tPA) may be helpful but for now is mostly reserved for patients that are rapidly deteriorating neurologically, with  an elevated ICP, or with decreased level of consciousness. Surgery (i.e local thrombectomy) may be indicated in patients with significant deficits who are unresponsive to intense medical treatment.

Disposition: Admit – stroke unit or ICU depending of severity/stability of patient.

Multiple Sclerosis

An inflammatory demylinating neurological disease with a genetic predisposition. Affects multiple parts of the CNS with deficits manifesting in cognitive, cranial nerve, motor, sensory, bowel/bladder and sexual functions.CN II is the most commonly affected cranial nerve, manifesting as optic neuritis (usually the first symptom)

Management: acute MS exacerbation is often handled with IV methylprednisone (250-500mg bid for 3-7days). Treatment of complications include baclofen (for spasticity), propranalol or benzo’s (for tremors or ataxia).

GIB

In EM3 on May 2, 2011 at 5:25 pm

72 yo F with no PMHx presenting to the ED with GI bleed (gastrointestinal bleed – GIB).  Initially had about 4 Units of bright red blood per rectum. Patient stated it filled the toilet bowl prior to arrival, she’s never had GIB before, no abd pain, no Nausea/Vomiting, no other symptoms.  Colonoscopy 5 years ago revealed diverticulosis. Afebrile. Tachycardic to 100’s. BP110/70. Otherwise, pleasant, alert, no distress.

Outcome: After some sarcastic discussions on the phone, Surgery and GI both came down to the ED and at first were unimpressed b/c she had apparently stopped bleeding and had a hgb of 11.  But then she had another emptying of about 2 Units (see attached pic), follow by two more.  She was intubated and sent to CVIR for embolization, then to SICU.  Found right colic artery bleed.  Hgb dropped to 6s, close to 10 Units were transfused (she’s still here 1 week later with a hgb 7).

Teaching Points: Massive Lower GI Bleed.

Differential diagnosis: upper GI bleed, diverticulosis, angiodysplation, aorto-enteric fistula, anal fissure, hemorroids, inflammatory bowel disease, cancer.

Key points: complete a thorough H/P. Be aggressive in your management early! Order type and screen, get surgery and GI involved early even in lower GIB.