Life-threatening Cause Research Articles

Limited utility of MRA for acute bowel ischemia after portal venous phase CT

Mesenteric ischemia and ischemic colitis are uncommon but potentially life-threatening causes of acute abdominal pain. Portal venous phase computed tomography (CT) is routinely ordered in the emergency room setting for abdominal pain, but subsequent MR angiography may be requested for additional evaluation of the mesenteric vasculature. We compare the concordance of CT and magnetic resonance angiography (MRA) for acute bowel ischemia. Thirty-two patients who underwent contrast-enhanced MRA for bowel ischemia after having undergone CT evaluation within the preceding 2 weeks were identified. A retrospective review of imaging, treatment history, surgical, and pathology reports was conducted. Two radiologists each reviewed the imaging studies in a blinded fashion. Ten cases of bowel ischemia were confirmed by endoscopy and/or surgical pathology. CT correctly identified bowel findings in all cases. Intraobserver agreement between CT and MRA for all vessels was 0.68 and 0.63, highest for the superior mesenteric artery. Interobserver agreement was 0.74 for MRA and 0.78 for CT. Vascular findings were only directly mentioned in 10 of 32 CT reports (and 7 of 10 cases with confirmed bowel ischemia). MRA only detected two additional or alternative diagnoses. Portal venous phase CT and MRA demonstrate a high degree of concordance for vascular evaluation. Reviewed CT examinations were sufficient to assess the patency of the mesenteric vasculature, but vascular findings were not reported in most cases. A direct description within the report may have obviated the request for further MR imaging. MRA adds little value after portal venous CT in assessing bowel ischemia.

The Speed of Sound

Figure: CT angiogram demonstrating dissection at the arch of the aorta.FigureFigureFigureIf you'll remember, last month we discussed a 69-year-old woman who presented with extremity weakness in her left arm and right leg, and was subsequently found to be hypotensive. Initial evaluation in the ED revealed a normal head CT but a widened mediastinum on chest x-ray. Bedside ultrasound demonstrated that an intimal flap was present to the aorta. When we left the case last month, the patient was en route to radiology for an emergent CT angiogram of the aorta. The patient's CTA revealed a complex type A aortic dissection. The intimal flap extended into her left carotid, left subclavian, and right innominate arteries, and traveled distally through the abdominal aorta to occlude her right common femoral artery. Once these findings were discovered, she was immediately consented for emergent surgical repair. This case demonstrates some of the pitfalls in diagnosing acute aortic dissection. Classically, acute aortic dissection is described as a sudden tearing or ripping chest pain that is greatest at onset. Most patients are described as being hypertensive and having pulse deficits on presentation, but few patients actually present with this classic picture. Aortic dissection can be a great mimicker of other conditions depending on the anatomic distribution of the vessels affected. Patients can present with syncope, abdominal or flank pain, shortness of breath, neurologic symptoms resembling an acute CVA, or findings consistent with an acute ST segment myocardial infarction. Hypotension is an atypical finding in patients with aortic dissection, and is a red flag for complications. This patient's case provides us with the opportunity to review the possible etiologies of hypotension in dissection. Beginning proximally, a type A dissection can cause acute aortic regurgitation by involving the aortic valve. Acute aortic regurgitation causes an abrupt increase in left ventricular end-diastolic volume and subsequently causes acute heart failure, pulmonary edema, and cardiogenic shock. If the dissection involves the pericardium, pericardial effusion and resulting tamponade can cause profound hypotension. A dissection involving the ostia of the coronary arteries can also lead to acute myocardial ischemia and acute heart failure. Rupture is another serious and life-threatening cause of hypotension in aortic dissection. Increased shearing forces can lead to dissection through the adventitia and result in exsanguinations into the thoracic and abdominal cavities.Figure: View of the aortic valve demonstrating regurgitation.Figure: Reconstructed CT angiogram demonstrating the extensive nature of the dissection.Figure: Parasternal long axis view demonstrating presence of a pericardial effusion. The free wall of the right ventricle (arrow) can be seen to be bowed inward, indicating mass effect and possible tamponade.Diagnosing acute aortic dissection remains challenging in the ED because its presentation is often atypical. CT angiography is considered the test of choice, but bedside ultrasound can be used, as it was in this case to help confirm the diagnosis once it is considered. The abdominal aorta can be visualized from the xiphoid process to its bifurcation at approximately the umbilicus. It should be less than 3 cm with a smooth inner wall. The thoracic aorta can be more difficult to evaluate by ultrasound because of the surrounding lung, but it can be examined at its root (using the parasternal long axis cardiac view), at its arch (using the suprasternal view), and in a portion of its descent (in the apical cardiac view). These views should be examined for enlargement of the aorta and the presence of an intimal flap. Bedside ultrasound also has great power to evaluate for complications of dissection, most notably pericardial effusion and acute aortic regurgitation. An effusion can be quickly identified using standard cardiac windows (subxiphoid or parasternal views). Signs of tamponade include right atrial or ventricular collapse during diastole and IVC dilation from elevated right atrial pressure. Using the parasternal long axis or apical views, color Doppler can be applied to the aortic valve to assess for regurgitation. The patient in this case underwent an extensive repair of her aorta. She was transferred to the ICU in critical condition, and was weaned off mechanical ventilation over the next several weeks. She did well, and was discharged to a rehab facility. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Development of a new laparoscopic Foramen Epiploicum Mesh Closure (FEMC) technique in 6 horses.

Epiploic foramen entrapment (EFE) is, based on the number of reports in the literature, a relatively important life-threatening cause of colic in horses that could be prevented by closing the epiploic foramen (EF) in horses at risk of developing EFE. To describe the laparoscopic foramen epiploicum mesh closure (FEMC) technique and its outcome. Descriptive experimental study. The EF of 6 horses was closed with the FEMC technique. A diabolo-shaped constructed mesh was introduced into the omental vestibule through the EF under laparoscopic visualisation in the standing sedated horse. Clinical and laboratory parameters were recorded during the post operative period. Four weeks after the intervention, repeat laparoscopy was performed in all horses. Three horses were subjected to euthanasia one, 2 and 3 months after the intervention, and were examined on necropsy and histopathology. The remaining 3 horses were followed clinically for 6 months. The 6 FEMC procedures were performed successfully in a median surgery time of 22 min (range 18-27 min). One horse was treated for large colon impaction in the immediate post operative period. On repeat laparoscopy at 4 weeks all 6 EFs were closed and no undesired adhesions were identified. This was confirmed on gross and histopathological examination of the 3 horses that were subjected to euthanasia. The 3 remaining horses were clinically normal in the 6-month post operative observation period. This FEMC technique provides a fast, simple, reliable and safe procedure to obliterate the EF and may be useful in horses at risk for EFE.

Effect of epileptic seizures on the cerebrospinal fluid – A systematic retrospective analysis

Analyses of the cerebrospinal fluid (CSF) are obligatory when epileptic seizures manifest for the first time in order to exclude life-threatening causes or treatable diseases such as acute infections or autoimmune encephalitis. However, there are only few systematic investigations on the effect of seizures themselves on CSF parameters and the significance of these parameters in differential diagnosis. CSF samples of 309 patients with epileptic and 10 with psychogenic seizures were retrospectively analyzed. CSF samples were collected between 1999 and 2008. Cell counts, the albumin quotient, lactate and Tau-protein levels were determined. Findings were correlated with seizure types, seizure etiology (symptomatic, cryptogenic, occasional seizure), and seizure duration. Pathological findings were only observed in patients with epileptic but not with psychogenic seizures. The lactate concentration was elevated in 14%, the albumin quotient in 34%, and the Tau protein level in 36% of CSF samples. Cell counts were only slightly elevated in 6% of patients. Different seizure types influenced all parameters except for the cell count: In status epilepticus highest, in simple partial seizures lowest values were seen. Symptomatic partial and generalized epileptic seizures had significantly higher Tau-protein levels than cryptogenic partial seizures. In patients with repetitive and occasional epileptic seizures, higher Tau-protein levels were seen than in those with psychogenic seizures. Duration of epileptic seizures was positively correlated with the albumin quotient, lactate and Tau-protein levels. High variability of investigated CSF parameters within each subgroup rendered a clear separation between epileptic and psychogenic seizures impossible. Elevated cell counts are infrequently observed in patients with epileptic seizures and should therefore not uncritically be interpreted as a postictal phenomenon. However, blood-CSF barrier disruption, increased glucose metabolism and elevation of neuronal damage markers are observed in considerable percentages of patients and depend on many factors such as etiology, seizure type and duration.

A case of massive lower gastrointestinal bleeding from a rectal Dieulafoy lesion

Summary A Dieulafoy lesion is an uncommon and sometimes life-threatening cause of gastrointestinal hemorrhage. Typically, it presents as a tiny mucosal defect with an exposed protruding artery with normal surrounding mucosa. An 84-year-old woman developed sudden massive hematochezia and had an unstable hemodynamic status. The source of bleeding was found to be an exposed vessel in the rectum without surrounding ulceration. The patient was treated successfully with an epinephrine injection given endoscopically, followed by hemostatic clipping.

Congenital Leukemia Presenting as Fever in a Neonate

BackgroundEmergency department workup of pediatric fever typically focuses on ruling out serious bacterial infection, but other disease processes can cause fever. Congenital leukemia is a rare but important cause of fever in neonates. We review the presentation, pathophysiology, and potential complications of congenital leukemia presenting to the emergency department as pediatric fever. Case ReportWe report a case of a 4-week-old infant brought to the emergency department for fever and “not acting normally.” Complete blood count demonstrated hyperleukocytosis. Subsequent bone marrow biopsy and flow cytometry confirmed the diagnosis of congenital leukemia. The extreme elevation of the patient's white blood cell count put her at high risk for complications, necessitating aggressive treatment, close monitoring, and appropriate consultation for comprehensive care. Why Should an Emergency Physician Be Aware of ThisCongenital leukemia is a rare but serious cause of neonatal fever. While the workup for fever without a source in young pediatric patients primarily focuses on ruling out serious bacterial illness, emergency physicians must be familiar with other potentially life-threatening causes of this complaint.

Syncope for the General Pediatrician

Pediatric syncope is a common complaint in the primary care, emergency department, and specialty care setting and is often unsettling to patients and providers alike as a symptom of conditions causing sudden death. In all cases, syncope should be thought of as a symptom rather than a diagnosis and explored with a thorough history and physical. Thankfully, the majority of syncope in children and adolescents is not cardiac in origin and carries no increased risk or association with sudden cardiac death. The majority of life-threatening or cardiac causes of syncope can be differentiated on the basis of history alone. Most concerning symptoms associated with cardiogenic syncope are identified at the time of presentation without extensive testing or referral to specialists. Physical examination and ancillary testing are usually of limited benefit in the initial diagnosis; however, cases with concerning symptoms or uncertainty require further investigation, typically through referral to cardiologists. The majority of pediatric syncope is caused by benign common fainting, also referred to as reflex, vasovagal, or neurocardiogenic syncope, which can and should be treated with reassurance and mild lifestyle modifications only. A minority of syncope is cardiogenic and occurs from three general mechanisms: outflow obstruction, arrhythmia, and myocardial dysfunction. Cardiac causes of syncope are potentially life-threatening and must be excluded during the evaluation. The goal of the primary care evaluation of syncope should be to discriminate common fainting, which almost never requires specialty care, from cardiogenic syncope.

Pedicled pericardial patch tracheoplasty as a last-resort repair for acquired and recurrent long-segment tracheal stenosis through resternotomy without CPB

Long-segment stenotic tracheal rings represent a rare but life-threatening cause of respiratory distress. Surgery may be required in an emergency setting, using established techniques and repair materials. In an adult with long-segment tracheal stenosis whose extent was underestimated by conventional diagnostic workup, standard repair materials were unavailable in emergency setting. This case report illustrates a usual surgical technique in a bail out situation, using autologous Pericardium to patch a large tracheal defect. Although several techniques have been described for the treatment of tracheal stenosis, including slide tracheoplasty, tracheal autograft and rib cartilage grafting, here we used a pedicled pericardial patch. The purpose of this case report is to augment pericardial tracheoplasty.

Akutes Aortensyndrom

Acute aortic syndrome (AAS) is a rather rare but often life-threatening cause of thoraco-abdominal pain. AAS includes acute aortic dissection (AD), intramural hematoma (IMH) and penetrating atherosclerotic ulcer (PAU), in which the latter may progress to AD. Suddenly emerging severe pain localized in the chest, back or the abdomen is rather characteristic for acute AD, but painless courses of the disease are also possible. Rapid diagnosis and treatment are crucial for prognosis and survival. Aortic contrast-enhanced computed tomography is the method of choice due to its broad availability, distinguished accuracy and rapid feasibility. In instable patients, transoesophagel echocardiography by an experienced examiner is also applicable. Patients suffering from Type A AD need urgent surgery in most cases, patients.

Cardiac Ultrasound in Patients with Chest Pain

Chest pain is a frequent presenting complaint with a broad differential diagnosis. Emergency physicians routinely train in point-of-care cardiac ultrasound, which has the ability to rapidly and noninvasively assist in the diagnosis of many life-threatening causes of chest pain including acute coronary syndrome, cardiac tamponade, pulmonary embolism, and aortic dissection. In addition, the physician may quickly utilize other bedside ultrasound modalities, such as lung and musculoskeletal ultrasound, to diagnose pneumothorax, pneumonia, rib or sternal fractures, or soft tissue abnormalities. The article reviews the current literature and discusses the utility and performance of ultrasound in patients presenting with chest pain to the emergency department.

A Case of Post-partum Spontaneous Coronary Artery Dissection with Pulmonary Embolism: Survival with Thrombectomy and Stent Implant.

Spontaneous Coronary Artery Dissection (SCAD) is a rare life-threatening cause of acute coronary syndrome. It can affect young patients without atherosclerotic risk factors, particularly women in the antepartum or early post-partum period, as well as geriatric patients at high risk for atherosclerotic disease. The pathogenesis linking SCAD with pregnancy has not been fully elucidated. The few reported cases of SCAD in the setting of concomitant Pulmonary Embolism (PE) may highlight a potential mechanism in the pregnant or postpartum woman. Heretofore, cases of SCAD with the setting of pulmonary embolism have all been treated conservatively with medical therapy. We herein report a case of SCAD in the left anterior descending artery resulting in Non-ST elevation myocardial infarction and low ejection fraction associated with an acute pulmonary embolism in a young post-partum patient who was treated successfully with thrombectomy followed by stent placement. Her cardiac function returned to normal within six months with no recurrence of symptoms. To our knowledge, this is the first case of SC.

APPROACH TO SYNCOPE IN EMERGENCY DEPARTMENT

ABSTRACT Syncope, with the absence of postural tone, a sudden and transient loss of consciousness is characterized by full and often rapid spontaneous recovery. Most of the potential causes of syncope are benign and self-limiting. However, Syncope can be life-threatening causes. Approximately one third of patients during episodes of syncope cause injuries and can be psychologically devastating for patients with recurrent syncope. History, physical examination, and electrocardiogram can be detected an underlying cause in about 50 to 80% of patients. Despite detailed diagnostic tests, reason of syncope is undetectable in 18-41% of patients with syncope. This article is based on the problems of diagnostic approach to syncope in emergency department.

Hypokalemic paraparesis: Presenting feature of previously undiagnosed celiac disease in celiac crisis.

Sir, Celiac crisis is a life-threatening cause of acute diarrhea and multiple metabolic emergencies.[1] Clinically, it is characterized by severe diarrhea, dehydration and metabolic disturbances such as hypokalemia, hypomagnesemia, hypocalcemia, hypoproteinemia, etc. Various precipitating factors identified for the crisis are severe malnutrition, infections, hypoproteinemia, and poor compliance with gluten-free diet, bacterial overgrowth in setting of altered motility in celiac disease and anticholinergic drugs. Hypokalemia, a prominent feature in celiac crisis can lead to muscle weakness. Potassium is needed to repolarize the cell membrane to a resting state after an action potential has passed. Lower potassium levels in the extracellular space cause hyperpolarization of the resting membrane potential. This hyperpolarization is caused by the effect of the altered potassium gradient on resting membrane potential. As a result, a greater than normal stimulus is required for depolarization of the membrane to initiate an action potential leading to muscle paralysis. Paralysis usually starts in the legs and progresses to involve the upper limbs. There are only a few reports of celiac crisis presenting as quadriparesis and that too in adults.[2,3,4] We present a 3 years old thriving boy who was admitted with complaints of watery diarrhea and vomiting with dehydration. He was managed with 75 ml/kg RL correction with which dehydration improved, but loose stools persisted though the frequency decreased. On day 2 of admission, the child developed flaccid paraparesis with abdominal distension attributable to hypokalemia. Laboratory reports of electrolytes revealed severe hypokalemia (1.4 meq/L), which was confirmed by an electrocardiogram. Hence, the child was given rapid potassium correction at the rate of 0.3 meq/kg/h for 3 h with subsequently maintenance therapy up to 4 meq/kg/day. Despite potassium replacement paraparesis and hypokalemia did not show improvement. Even with repeated rapid corrections and maintenance dose increased to 6 meq/kg/day hypokalemia, as well as paraparesis persisted (serial potassium values of 1.4, 1.7, 2.3, 2.9, 2.1, 3.2 meq/L) and was accompanied by hyponatremia (serum sodium 124, 131, 134 meq/L) and glycosuria. Review of history elicited intermittent loose stools. At this point of time, the possibility of the celiac crisis was raised. Plasma tissue transglutaminase IgA was returned positive (22.14 U/ml). With a diagnosis of the celiac crisis, the child was started on steroids and gluten-free diet after which he showed significant improvement. A duodenal biopsy in a referral hospital confirmed the diagnosis of celiac disease. The child is currently doing well on a gluten-free diet. Timely diagnosis of such a case is the key to prompt management. Though corticosteroids are the mainstay of management, supportive care, particularly management of electrolyte imbalance is very important.

Laparoscopic repair of gastric volvulus with diaphragmatic hernia: a case report

Gastric volvulus is a rare but potentially life-threatening cause of upper gastrointestinal obstruction. Emergency surgeon must maintain a high index of suspicion in patients who present with signs and symptoms suggesting foregut occlusion. We report an illustrative case and review the pathogenesis, classification, diagnosis and laparoscopic treatment of this rare entity.

PO-0285 Identifying Radiologic Signs Of Life-threatening Causes Of Acute Upper Airway Obstruction In Children: Not That Easy!

Background Soft tissue neck radiographs (STNRs) are viewed as a helpful tool to investigate causes of acute upper airway obstructions (AUAO) among children. Some radiological findings guide clinicians identifying life-threatening causes of AUAO. Do the clinicians are skilled enough to recognise those signs? Methods A retrospective study was conduct and the medical files from children aged 0–17 who had a STNR between January 1st2010 and December 31st 2011 in a Canadian university paediatric hospital were reviewed. Those performed in an AUAO context were analysed. Identification by clinicians of significant findings on STNRs related to life-threatening causes of AUAO were compared to radiologists’ reports. Kappa coefficients were determined to describe inter-rater agreement on SNRT findings. The frequency at which SNRTs were described as technically inadequate by radiologists was also analysed. Results Among 457 STNRs, 11% (n = 52) showed findings of life-threatening causes of AUAO according to clinicians, compared to 17% (n = 77) according to radiologists (global sensibility=35%,specificity=93%; kappa=0.327). Sensibility and specificity differed according to signs evaluated: 26% and 97%, kappa=0.27 for swollen epiglottis/aryepiglottic oedema (n = 23 according to radiologists); 37% and 96%,kappa=0.37 for swelling of the retropharyngeal space (n = 38); 0% and 99% kappa=-0.01 for decrease tracheal diameter/deviation (n = 16); 100% and 99%, kappa=0.86 for the presence of a foreign body (n = 3). Moreover, 15% of SNRTs were described as technically inadequate by radiologists. Conclusion Identification of life-threatening causes of AUAO on STNRs appears quite challenging for clinicians. SNRTs are technically difficult to perform among children. Importance of STNRs need to be reassessed.

PO-0284 Use Of Soft Tissue Neck Radiographs In Paediatric Acute Airway Obstructions: Current Perspective

Background Soft tissue neck radiographs (STNRs) have been recognised as a helpful tool to differentiate benign causes of acute upper airway obstructions (AUAO) from epiglottitis, retropharyngeal abscess or foreign body aspiration. Based on the frequency at which those life-threatening pathologies now occur, are STNRs still widely used and what is the impact of their clinical use? Methodology A retrospective study was conduct. Medical files from children aged 0–17 who had a STNR between January 1st 2010 and December 31st 2011 in a mid-size Canadian university paediatric hospital were reviewed. Patients were divided in 2 groups according to the conditions clinicians first suspected and compared the STNRs’ interpretations with Fisher exact test. Cases of epiglottitis and retropharyngeal abscess for the same period were reviewed. Results Among 520 STNRs identified, 88% intended to evaluate AUAO among children. Nearly all (99%) took place at the emergency room, with 73% of patients presenting with triage score 3 and above, and 49% necessitating admission. Most STNR were performed among males (67%) aged below 5 y.o. (66%; mode=1 y.o.). A life-threatening cause of AUAO was first suspected by clinicians among 40% of reviewed charts. Convincing radiologic signs of life-threatening pathologies were found in 40 children (9%). Overall, 2 cases of epiglottitis and 8 retropharyngeal abscesses were diagnosed during the study period. Conclusion STNR is a radiologic study that is frequently used among children. The current value of STNRs appears uncertain as few showed solid evidences that may modify how clinicians currently manage paediatric AUAO.

An unusual cause of acute cor pulmonale – Significance of the ‘continuous diaphragm sign’

A patient presented with chest pain and clinical features of acute right heart failure. Initial work up revealed the presence of severe PAH. Acute pulmonary embolism is the commonest and most life-threatening cause for acute cor pulmonale. Even though the clinical picture suggested pulmonary embolism, a subtle sign was missed from the first chest X-ray taken in the emergency department. However on reanalysis the ‘continuous diaphragm sign’ later guided us towards the diagnosis. Our case represents one of the first reports of a rare etiology for acute cor pulmonale – hypersensitivity pneumonitis. Right ventricular dysfunction was caused by an acute rise in pulmonary artery pressures as well as by the compressive effects of pneumomediastinum. We emphasize the role played by a good quality chest X-ray early in the management of acute chest pain syndromes. However pulmonary embolism should be ruled out conclusively before redirecting attention to less malignant conditions.

Urea cycle disorders: a life-threatening yet treatable cause of metabolic encephalopathy in adults

Urea cycle disorders are inborn errors of metabolism that, in rare cases, can present for the first time in adulthood. We report a perplexing presentation in a woman 4 days...

106 Echocardiographic Evaluation Of Post-partum Ventricular Remodelling – Implications For The Detection Of Cardiac Disease

BackgroundPeripartum cardiomyopathy (PPCM) is a potentially life-threatening cause of heart failure that often presents soon after delivery. Diagnosis of the condition may be difficult due to the physiological changes in...

Cerebral Venous Sinus Thrombosis With Ophthalmic Manifestations in 18-Year-Olds on Oral Contraceptives

Cerebral venous sinus thrombosis (CVST) is a rare and potentially life-threatening cause of stroke. In the past few decades, the incidence and patient demographics have changed because of many factors, including the widespread use of oral contraceptives, improved detection of prothrombotic conditions, and advancement of imaging technology. The presentation of CVST is varied and can include ocular signs and symptoms. We present 2 cases of oral contraceptive-induced CVST in 18-year-old women, whose main presenting findings were ophthalmologic.