Etiologic diagnosis of 204 pericardial effusions

ACADEMIC EMERGENCY MEDICINE 2011; 18:922–927 © 2011 by the Society for Academic Emergency Medicine



Abstract

Objectives:  Emergency physicians (EPs) are beginning to use ultrasound (US) guidance to perform regional nerve blocks. The primary objective of this study was to compare length of stay (LOS) in patients randomized to US-guided interscalene block or procedural sedation to facilitate reduction of shoulder dislocation in the emergency department (ED). The secondary objectives were to compare one-on-one health care provider time, pain experienced by the patient during reduction, and patient satisfaction between the two groups.



Methods:  This was a prospective, randomized study of patients presenting to the ED with shoulder dislocation. The study was conducted at an academic Level I trauma center ED with an annual census of approximately 80,000. Patients were eligible for the study if they were at least 18 years of age and required reduction of a shoulder dislocation. A convenience sample of patients was randomized to either traditional procedural sedation or US-guided interscalene nerve block. Procedural sedation was performed with etomidate as the sole agent. Interscalene blocks were performed by hospital-credentialed EPs using sterile technique and a SonoSite MicroMaxx US machine with a high-frequency linear array transducer. Categorical variables were evaluated using Fisher’s exact test, and continuous variables were analyzed using the Wilcoxon rank sum test.



Results:  Forty-two patients were enrolled, with 21 patients randomized to each group. The groups were not significantly different with respect to sex or age. The mean (±SD) LOS in the ED was significantly higher in the procedural sedation group (177.3 ± 37.9 min) than in the US-guided interscalene block group (100.3 ± 28.2 minutes; p < 0.0001). The mean (±SD) one-on-one health care provider time was 47.1 (±9.8) minutes for the sedation group and 5 (±0.7) minutes for the US-guided interscalene block group (p < 0.0001). There was no statistically significant difference between the two groups in patient satisfaction or pain experienced during the procedure. There were no significant differences between groups with respect to complications such as hypoxia or hypotension (p = 0.49).



Conclusions:  In this study, patients undergoing shoulder dislocation reduction using US-guided interscalene block spent less time in the ED and required less one-on-one health care provider time compared to those receiving procedural sedation. There was no difference in pain level or satisfaction when compared to procedural sedation patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1553-2712.2011.01140.x

A Prospective Comparison of Procedural Sedation and Ultrasound-guided Interscalene Nerve Block for Shoulder Reduction in the Emergency Department

Massive pericardial effusions secondary to hypothyroidism are rarely seen in the emergency department (ED). The case of a patient presenting with a relatively asymptomatic massive pericardial effusion due to hypothyroidism is described. The patient had a history of laryngeal carcinoma post-total laryngectomy and adjuvant radiotherapy 12 years previous. Although underlying malignancy was in the differential diagnosis, hypothyroidism was diagnosed through a detailed history and physical examination, thereby avoiding the need for pericardiocentesis. Thyroid replacement alone is sufficient for resolution of these effusions, although it may take many months. Pericardiocentesis is indicated only if cardiac tamponade develops. This rare but significant condition should be considered, especially when it occurs after acute cold exposure.

A rare case of massive pericardial effusion secondary to hypothyroidism.

Complications of pneumoconiosis: radiologic overview.

Netherton's syndrome, which is classified as an ichthyosiform syndrome, is a dermatose comprising ichthyosis linearis circumflexa and/or congenital ichthyosiform erythroderma, trichorrhexis invagi- nata and atopic features. Here, we present a 56 year-old female who has polycyclic, ery- thematous, double edged scaly lesions on her trunk and limbs as well as brittle hair and bilateral alopecia on the lateral part of her eyebrows. The microscopic examination of the hair shaft showed trichorrhexis invaginata. The histopathologic examination of the lesional skin biopsy is correlated with ichthyosis linearis circumflexa. We used topical steroids and emollients for the treatment of the skin lesions and informed the patient about the prognosis of her dis- ease.

http://www.diclemedj.org/upload/sayi/21/Dicle%20Med%20J-01531.pdf

Olgu sunumu / case report

It is usually thought by emergency physicians that the diagnosis of a pneumothorax is straightforward and easy to make and to treat, but the diagnosis may sometimes pose a challenge. The present report describes a case of a giant pulmonary bulla in a 40-year-old man that progressed to occupy almost the entire left hemithorax and also subsequently ruptured to produce a large left pneumothorax. The giant bulla was diagnosed only as a pneumothorax, and initially managed with a chest tube only. The differentiation between pneumothorax and a giant bulla can be very difficult, and often leads to inaccurate diagnosis and management. This case report demonstrates the clinical presentation of giant bulla and its complications such as pneumothorax and also highlights the difficulty in making this diagnosis and appropriately treating it. In this article, we emphasized how to differentiate between giant bulla and pneumothorax utilizing history, physical examination, and radiological studies including computed tomography (CT) scan.

Giant bulla mimicking pneumothorax

This report describes the case of a young woman who presented to an emergency department with severe abdominal pain and shock. The patient was found to have pericardial tamponade due to a massive pericardial effusion. On further evaluation, the etiology of this effusion was considered to be secondary to hypothyroidism with concominant acute viral pericarditis leading to a fulminant tamponade. The presentation, differential diagnosis, and management of pericardial effusion and tamponade secondary to hypothyroidism and viral pericarditis are discussed. The diagnosis of hypothyroidism in conjunction with acute viral pericarditis should be considered in patients presenting with unexplained pericardial effusion and tamponade.

Hypothyroidism presenting as acute cardiac tamponade with viral pericarditis

A three-page conscious sedation (CS) monitoring datasheet and sedation-analgesia policy were implemented at the Lincoln Hospital Emergency Department (LHED) to maintain compliance with JCAHO and New York State standards on CS monitoring. The datasheet included areas for physical examination, medications, and vital signs. To determine effects of the new datasheet and policy, charts containing all closed shoulder reductions done at LHED from April 3, 1996 to June 30, 1999 (n = 237) were reviewed for use of CS, defined as the use of an analgesic and sedative-hypnotic concurrently. Utilization of CS during equal time periods of 591 days before and after datasheet implementation was analyzed and compared. Before use of the datasheet, 64.3% received CS before closed shoulder reduction, compared with 41.8% after its use began (p < 0.05). A subsequent survey was conducted to determine physician perception of the CS datasheet. Attending-level LHED physicians suggested that use of the datasheet increased charting time and liability.

John Munyak

Papers

Giant bulla mimicking pneumothorax

Hypothyroidism presenting as acute cardiac tamponade with viral pericarditis

Use of a sedation-analgesia datasheet in closed shoulder reductions