Archive | January, 2013

How to you tell its a right middle lobe infiltrate?

January 30, 2013

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This patient presented with a cough, fever, and dyspnea.  Here is her Chest Xray:

PNA RML

This is a great example of a right middle lobe (RML) pneumonia.  Some features that help distinguish the lobe include:

The right diaphragm is visible.  The lobe overlying the diaphragm is the lower lobe and a RML will sometimes not “silhouette” the right diaphragm.  “Silhouette” is when a radiographically dense material such as fluid comes into contact with another radiodense thoracic structure such as the diaphragm.  Silhouetting can be seen with the right heart border.  Thus, this fluid on the xray is touching the right heart border but not the diaphragm.  The lobe that corresponds with this is the RML.

A lateral radiograph can also help you identify which lobe is involved (not provided here).

Author:  Russell Jones, MD

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WWWTP#4 Answer

January 27, 2013

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Answer to the WWWTP#4 posted on Jan. 14th:

The hardware on the femoral component is loose.  You can see a lucency in the proximal femur surrounding the proximal portion of the prosthesis:

knee-replacement-loose-2

The best XR you have in evaluating for hardware failure is a prior XR.  If you go back to the post on Jan. 14th you can see the comparison shows no lucency in this area and an obvious difference.

Other things to consider when looking at hardware:

1.  Is the actual hardware intact…no breaks

2.  Commonly screws will loosen or break

3.  Look at the cement around the hardware, has it changed?

4.  Look at the bones around the hardware, commonly small fractures will occur that can be difficult to see

For a crash course on types of hardware here is an interesting website from the University of Washington Department of Radiology:

ORTHO HARDWARE

Author:  Russell Jones, MD

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Its RSV season again!

January 24, 2013

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Don’t you love working Jan and Feb in the Peds ED?  Or as I like to refer to it as the Mucus ED.

What findings on Chest Xray are consistent with viral pneumonia?

Viral CXR 2Viral CXR

Viral respiratory infections commonly cause an “interstitial” pattern on Chest XR.   Interstitial patterns can also be found in atypical bacterial pneumonia from organisms such as Bordatella pertussis, Chlamydia pneumonia, and Mycoplasma.  Findings include peribronchial cuffing, perihilar infiltrates or “haze”.  Peribronchial cuffing can be seen on the XR above:

PB Cuffing

Other findings in interstitial patterns can include fluid in fissures, bands of atelectasis.

Bronchioles are usually very difficult, if not impossible to identify in cross-section on a Chest XR.  They look like a small clear circle with a thin wall.  However, when they are inflammed and have surrounding edema peribronchial cuffing occurs.  Basically you see a dense fluid around an air-filled bronchiole.  This can be seen in asthma, viral illnesses, heart failure, pertussis, and other pathology (1).  Here is a link to a good web image of peribronchial cuffing close up and on crossection:

http://www.torontonotes.ca/interstitial-disease/peribronchial-cuffing

It is important to note that the Chest XR can support your diagnosis of viral respiratory infection but it is not 100%.  Keep in mind the atypical organisms and prescribe antibiotics if highly suspicious.  Prescribing antibiotics in respiratory infections is a controversial topic with many different thoughts and practice patterns.  I’m not going to poke that sleeping bear…

Author:  Russell Jones, MD

References

1.  Broder JS.  Diagnostic Imaging for the Emergency Physician.  Elsevier 2011.  Pg. 241.

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What to do with incidental nodules…

January 20, 2013

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This patient is a 73 year-old female who came in the other day with chest pain.  Her Chest XR shows:

Two calcified nodules can be seen in the lateral R mid lung field.  These are not the cause of the patient’s ED presentation and referred to as “incidental” findings on her Chest XR.

Incidental findings of nodules on Chest XR are a very common ED problem.  What do we do with these?  It turns out this is a very complicated question.  Here is a quick summary of solitary pulmonary nodules (SPN):

The Problem

The incidence of SPN detected by Chest XR in the United States is estimated at 150,000 times per year (1).  Malignancy is the highest concern in these patients, many of which are amenable to discharge.  Lung cancer is the number one cause of cancer-related deaths worldwide, estimated at 1.38 million per year (2).  It is often silent and only discovered when it is extensive and has a poor prognosis of survival.  Nodule-forming cancer is likely to be metastatic or non-small cell lung cancer (NSCLC).  If you’ve discovered a primary lung cancer (NSCLC) and it is stage I, the 5-year survival rate is very high if treated.  However not all of these nodules are malignant.  Herein lies the problem:  who do we work up for these nodules and what is the follow-up we should recommend from the ED?

I did some searching for help and found two evidence-based guidelines discussing SPN management:

American College of Radiology (ACR)

What do the radiologists recommend?  Here is a link to the ACR recommendations on further imaging in SPN:

ACR SPN Guidelines

American College of Chest Physicians (ACCP)

The ACCP also weighs in on SPN management with open access guidelines from 2007:

ACCP SPN Guidelines

Reading these guidelines can help formulate a plan for your patient based on risk profiles, nodule characteristics, and suspicion of malignancy.  I would encourage you to read these so that a plan can be made if you are discharging anyone with an incidental finding of SPN.  My advice:

1.  Show them the nodule and mention the word “cancer.”  I prefer the statement “we need to make sure this isn’t cancer.” In my experience this causes a brief state of shock followed by motivation to listen to your follow up plan.   Be prepared to explain to them why you aren’t admitting them to the hospital.

2.  Explicitly discuss and write down a follow up plan with the patient and/or patient representative.  Make sure this plan is documented in your record.  Missed follow-up of these nodules could cause a early malignancy with a good prognosis to progress to a large malignancy with a poor prognosis.  This is not only bad for the patient but is a significant source of litigation for ED providers.  I usually refer them to primary care and tell them to take my discharge instructions to the provider.  On the discharge papers I provide a description of the nodule and any radiologist’s impression and recommendations.

3.  If you need further information on differential, timing and choice of further studies, etc. call your in-house radiologist and have them give you some recommendations and/or follow the guidelines above.

Author:  Russell Jones, MD

References

1.  Kanne JP, Jensen LE, Mohammed TH, et. al. ACR Appropriateness Criteria® radiographically detected solitary pulmonary nodule. [online publication]. Reston (VA): American College of Radiology (ACR); 2012.

2. Ferlay J; Shin HR, Bray F et al. Estimates of worldwide burden of cancer 2008: GLOBOCAN 2008.  International Journal of Cancer 127 (12): 2893–2917.

3.  Weinberger SE.  Diagnostic evaluation and management of solitary pulmonary nodules.  www.uptodate.com.  Sept. 14, 2012.

4.  Gould MK, Fletcher J, Iannettoni MD et al.  Evaluation of Patients with Pulmonary Nodules:  When is it Lung Cancer?:  ACCP Evidence-Based Clinical Practice Guidelines (2nd Edition).  Chest.  Sept. 2007; 132(Supplement 3): 108S-130S.

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Necrotizing Fasciitis

January 17, 2013

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I saw a patient the other day with a gluteal/perianal swelling consistent with abscess.  It looked erythematous, swollen, tender and indurated as a usual abscess would be…roughly 10cm extending from the external anal sphincter into the gluteal area.  What made this abscess interesting was that we could feel a small amount of crepitus on exam.  Bedside ultrasound was hindered by what appeared to be air (unfortunately I didn’t save the ultrasound!).  Here is what appeared on CT imaging of her pelvis:

Nec Fasc 1

This is a non-contrast CT because the patient’s creatinine was elevated.  However you can see extensive gas formation in the gluteal area.  It extended up near the sacrum and rectum.  The patient was taken to the operating room for debridement with concerns for necritizing fasciitis.  The amount of gas on CT was not anticipated based on physical exam (the patient had only a little bit of crepitus that could have been missed).

Necrotizing fasciitis on imaging shows up as air in the soft tissue.  This can be seen on plain films but the extent is better characterized on CT.

A couple learning points from this case:

1.  Use ultrasound on your abscesses!  You never know what you may find.

2.  Crepitus is bad.  Even a little bit.  Consider a deep, serious infection that could spread rapidly.

3.  If Necritizing Fasciitis is suspected:  obtain early broad spectrum antibiotics, resuscitation, surgical consultation, and CT imaging for characterization.

Author:  Russell Jones, MD

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WWWTP #4?

January 14, 2013

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Here is a man that had a remote history of a knee replacement after osteosarcoma resection (>5 years ago).  He presented with knee and leg pain after a minor trauma, here are the AP projections of his femur (at replacement and today):

Knee replacement loose 2Knee replacement loose 1

What’s Wrong With This Picture (WWWTP)?

Author:  Russell Jones, MD

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SVC Syndrome

January 11, 2013

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I received an interesting CT Chest from one of our EM residents in a patient with SVC (Superior Vena Cava) syndrome.  The patient had a PORT in place with clot around the PORT occluding the SVC.  This is an interesting case with a couple common and a couple rare findings:

SVC 1SVC 2SVC 3SVC 4

This is a complicated CT showing multiple findings:

A:  Good example of a right pleural effusion, large, seen on CT.  The patient also has a left sided effusion.

B:  Cross-section of the SVC showing the PORT cath and clot occluding the vessel

C:  Longitudal view of the SVC, again with PORT and clot

D:  The patient had the contrast injected from a right arm peripheral IV.  There are extensive collaterals in the arm and right chest with blood flow returning through these collaterals rather than traditional axillary vein to SVC.

E:  This view shows one of the collaterals actually connecting to the pulmonary vein.

Author:  Russell Jones, MD

Image Contributor:  Julie Phan, MD

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Rolando, Bennett…Answer

January 7, 2013

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I posted a radiograph earlier asking about Bennett’s and Rolando fractures.  This is the patient’s CT obtained later to further characterize the fracture:

MC Thumb fx CT 2

MC thumb fx CT

This is a Bennett’s fracture pattern.  Bennett’s is a fracture of the base of the 1st Metacarpal that involves the articulation and usually has some dislocation of the CMC (carpal-metacarpal) joint.  This fracture does have slight dislocation at the 1st CMC joint.

The Rolando’s fracture pattern is more comminuted, usually T or Y shaped comminution.  It carries a worse prognosis although the Bennett’s also has high incidence of arthritis even with optimal management.

Author:  Russell Jones, MD

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Rolando, Bennett…which one?

January 5, 2013

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This is a patient with pain in the thumb after punching another person:

MC Thumb fx 2MC Thumb fx 1

Fractures of the base of the 1st (thumb) metacarpal are highly morbid injuries.  Most of these should be operative but many end up with severe arthritis of the MCP joint despite optimal therapy.  The thumb is a very important functional joint especially on the dominant hand, as in this patient.

Radiographically there are several eponym fractures for the base of the 1st metacarpal:  Rolando and Bennett are the most widely discussed eponym fractures.

Which one is this (if either)?

Answer to follow.

Author:  Russell Jones, MD

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EPIPEN® in the finger…

January 3, 2013

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I can think of only a couple worse places for an Epipen® to accidently be stuck:

EPIPEN finger 1

This is a pediatric patient that one of my colleagues saw.  Fortunately as you can see from the xray the tip of the needle went right through the bone and exited out the other side and the digit was not ischemic.

Accidental injection of epinephrine into a digit actually occurs somewhat frequently.  There are case reports and articles written on management if the digit is ischemic.  I’ll refer you to one that was published in the UK in 2004:

Velissariou I, Cottrell S, Berry K, Wilson B: Management of adrenaline (epinephrine) induced digital ischaemia in children after accidental injection from an EpiPen. Emerg Med J 2004, 21:387-388.

The article was a summary of three case reports out of the United Kingdom.  They used warm water immersion, topical nitroglycerin, and in one case local injection of 1.5 mg of phentolamine in 1ml of Lidocaine 2% was used with good effect.  Phentolamine is a short acting α blocker and can counteract the α mediated vasoconstriction epinephrine provides.  If you are practicing in the U.S., keep in mind that local Poison Control Centers can be good references if you have questions on management.

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD

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