Archive | December, 2013

Lumbar mets and fracture…

December 27, 2013

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Elderly male came in with acute onset pain in lumbar spine.  He indicentally has had weight loss over the past 6 months, about 40 lbs:

Path Fx L Spine 2 Path Fx L spine

This patient has a pathologic compression fracture of L1 vertebral body.  Also demonstrated are sclerotic lesions in L4 without a fracture. 

What is the most likely primary lesion?

Author:  Russell Jones, MD

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Elderly male with syncope…

December 18, 2013

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One of my colleagues had an interesting case the other day.  An elderly patient came in after a syncopal event.  The only complaint was mild lower back discomfort.  Bedside ultrasound revealed the etiology (later visualized on this CT):
AAA 2

AAA 3

This CT shows a large infrarenal abdominal aortic aneurysm (AAA) that extended down into the iliac arteries bilaterally.   The aneurysm had intraluminal clot and concern for impending complete rupture near the iliac bifurcation.  The patient was expeditiously taken to the OR for operative repair.

This is a good case that demonstrates the utility of bedside ultrasound in the ED.  Syncope is an event that can be caused by a large variety of pathophysiology, AAA being one of the most feared.  It is very important in this situation to have a high index of suspicion and make the diagnosis quickly, accurately, and disposition the patient to the appropriate care.

For a brief tutorial on bedside aortic ultrasonography I refer you to a great blog from Mount Sinai:

Sinai EM Ultrasound

Image Contributor:  Rupi Chima, MD

Author:  Russell Jones, MD

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LeFort would cringe…

December 14, 2013

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Motorcycle accident:

CT face 2 CT face 3 CT face...

CT face 3D

This patient has severe facial trauma, comminuted fractures of most (if not all) of his facial bones, a ruptured right globe. 

A review of facial fractures including the LeForte classification, courtesy of the University of Washington:

Facial Fractures

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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WWWTP #14 Answer…

December 10, 2013

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Adolescent male with asthma…presents with throat pain, difficulty swallowing, and dyspnea.  WWWTP?

Pneumomediastinum

This patient has subcutaneous emphysema in the upper neck and air in the upper mediastinum (see arrows above).  The patient had a CT chest further delineating the mediastinal air:

Pneumomediastinum 2 Pneumomediastinum 3

Spontaneous pneumomediastinum (SPM) is a rare consequence of asthma.  It is most often seen in thin, adolescent males (1).  The proposed pathogenesis is air leaking due to small alveolar rupture with air escaping into the bronchovascular sheath.  The exact prevalence is difficult to establish but has been proposed in 0.3% of asthmatic patients presenting to the ED.

SPM, when not complicated by pneumothorax, is usually a self-limited condition that corrects when the underlying pathology (usually asthma) is treated.  It rarely can result in massive pneumomediastinum requiring surgical intervention to release the air.

SPM should not be confused with traumatic pneumomediastinum, this is a different pathology and many times causes much more morbidity.

Author:  Russell Jones, MD

References

1.  Saadoon AA, Janahi IA.  Spontaneous pneumomediastinum in adolescents and children.  http://www.uptodate.com.  Last updated 11/2013.  Accessed 11/2013.

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WWWTP #14 (What’s Wrong With This Picture?)…

December 6, 2013

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Adolescent male with asthma…presents with throat pain, difficulty swallowing, and dyspnea:

Pneumomediastinum 1

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones, MD

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Answer: Can you find the abnormalities?

December 2, 2013

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I gave you this xray a couple days ago, can you find all the abnormalities?

GSW

1.  Intubated into the right mainstem bronchus

2.  Metallic foreign bodies coursing up the left chest to the neck

3.  Completely opacified left lung:  differential diagnosis of pulmonary contusion, hemothorax, or complete atelectasis from right mainstem intubation

4.  There is a chest tube in the right chest cavity, it looks to be in good position but could be coursing into the fissure between the left lobes

5.  Deep sulcus sign on the left side indicates possible pneumothorax vs. hemothorax

6.  Orogastric tube courses below the diaphragm in good position

7.  Subcutaneous emphysema in upper neck

8.  Two radiodense objects in the midline cardiac silhouette near the mid-portion of the coursing orogastric tube

Interestingly, this patient was shot in the chest coursing to the upper neck and the bullet was found in his posterior pharnyx.  He had a tooth found on chest CT (calcified opacity seen below) among other injuries.   Later EGD intraoperatively showed two tooth fragments in the stomach.  The radiodensities seen #8 above were presumed to be these teeth in the esophagus.

Tooth

Image Contributor:  Julie Phan, MD

Author:  Russell Jones, MD

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