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Man With Acute Respiratory Distress
IMAGES IN EMERGENCY MEDICINE Clare Scott, MPAS, PAC 0196-0644/$-see front matter Copyright © 2016 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2015.05.007
Figure 1. Echogenic mobile oscillating mass on tricuspid valve.
Figure 2. Echogenic mobile oscillating mass on tricuspid valve.
[Ann Emerg Med. 2016;67:295.] A 49-year-old-man with a history of end-stage renal disease, hypertension, deep venous thrombosis, and intravenous drug use presented to the emergency department with acute respiratory distress. The patient reported worsening dyspnea on exertion and chest pain for 1 week. On evaluation, initial vital signs were blood pressure 203/130 mm Hg, pulse 119 beats/min, respiration 28 breaths/min, oxygen saturation 100% on a nonrebreather mask, and temperature 38.4 C. The patient was alert and in moderate respiratory distress, with bilateral expiratory rales on auscultation; cardiovascular examination revealed tachycardia and 2þ pitting edema in bilateral lower extremities. The ECG revealed sinus tachycardia with left-sided ventricular hypertrophy without any ST-wave abnormalities. A portable chest radiograph was ordered and bedside point-of-care ultrasonography was immediately performed. The apical echocardiographic image can be seen in Figures 1 and 2. The echocardiography clip can been seen in Video 1 (available online at http://www.annemergmed.com).
For the diagnosis and teaching points, see page 300. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 67, no. 2 : February 2016
Annals of Emergency Medicine 295
Raam et al
EM:RAP Commentary
15.
16. 17.
18. 19. 20.
21.
22.
Epidemiology, and End Results Program. Cancer. 2009;115: 1531-1543. Widhe B, Widhe T. Initial symptoms and clinical features in osteosarcoma and Ewing sarcoma. J Bone Joint Surg Am. 2000;82: 667-674. Rud NP, Reiman HM, Pritchard DJ, et al. Extraosseous Ewing’s sarcoma. A study of 42 cases. Cancer. 1989;64:1548-1553. Mendenhall CM, Marcus RB Jr, Enneking WF, et al. The prognostic significance of soft tissue extension in Ewing’s sarcoma. Cancer. 1983;51:913-917. Laine JC, Kaiser SP, Diab M. High-risk pediatric orthopedic pitfalls. Emerg Med Clin North Am. 2010;28:85-102. Tenenbein M, Reed MH, Black GB. The toddler’s fracture revisited. Am J Emerg Med. 1990;8:208-211. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133: e477-489. Lehmann CL, Arons RR, Loder RT, et al. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006;26: 286-290. Matava MJ, Patton CM, Luhmann S, et al. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of
300 Annals of Emergency Medicine
23. 24.
25. 26.
27.
28. 29.
30.
initial presentation and treatment. J Pediatr Orthop. 1999;19: 455-460. Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004;113:e322-325. Skaggs DL, Roy AK, Vitale MG, et al. Quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility. J Pediatr Orthop. 2002;22:265-267. Hagglund G, Hansson LI, Ordeberg G, et al. Bilaterally in slipped upper capital femoral epiphysis. J Bone Joint Surg Br. 1988;70:179-181. Pinkowsky GJ, Hennrikus WL. Klein line on the anteroposterior radiograph is not a sensitive diagnostic radiologic test for slipped capital femoral epiphysis. J Pediatr. 2013;162:804-807. Green DW, Mogekwu N, Scher DM, et al. A modification of Klein’s line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. 2009;29:449-453. Karli A, Belet N, Danaci M, et al. Iliopsoas abscess in children: report on five patients with a literature review. Turk J Pediatr. 2014;56:69-74. Knight RM, Cuenca PJ. Torsion of the undescended testis in a 14month-old child refusing to bear weight. West J Emerg Med. 2011;12:515-519. Barkin RM, Barkin SZ, Barkin AZ. The limping child. J Emerg Med. 2000;18:331-339.
Volume 67, no. 2 : February 2016
Figure 1. Echogenic mobile oscillating mass on tricuspid valve.
Figure 2. Echogenic mobile oscillating mass on tricuspid valve.
[Ann Emerg Med. 2016;67:295.] A 49-year-old-man with a history of end-stage renal disease, hypertension, deep venous thrombosis, and intravenous drug use presented to the emergency department with acute respiratory distress. The patient reported worsening dyspnea on exertion and chest pain for 1 week. On evaluation, initial vital signs were blood pressure 203/130 mm Hg, pulse 119 beats/min, respiration 28 breaths/min, oxygen saturation 100% on a nonrebreather mask, and temperature 38.4 C. The patient was alert and in moderate respiratory distress, with bilateral expiratory rales on auscultation; cardiovascular examination revealed tachycardia and 2þ pitting edema in bilateral lower extremities. The ECG revealed sinus tachycardia with left-sided ventricular hypertrophy without any ST-wave abnormalities. A portable chest radiograph was ordered and bedside point-of-care ultrasonography was immediately performed. The apical echocardiographic image can be seen in Figures 1 and 2. The echocardiography clip can been seen in Video 1 (available online at http://www.annemergmed.com).
For the diagnosis and teaching points, see page 300. To view the entire collection of Images in Emergency Medicine, visit www.annemergmed.com Volume 67, no. 2 : February 2016
Annals of Emergency Medicine 295
Raam et al
EM:RAP Commentary
15.
16. 17.
18. 19. 20.
21.
22.
Epidemiology, and End Results Program. Cancer. 2009;115: 1531-1543. Widhe B, Widhe T. Initial symptoms and clinical features in osteosarcoma and Ewing sarcoma. J Bone Joint Surg Am. 2000;82: 667-674. Rud NP, Reiman HM, Pritchard DJ, et al. Extraosseous Ewing’s sarcoma. A study of 42 cases. Cancer. 1989;64:1548-1553. Mendenhall CM, Marcus RB Jr, Enneking WF, et al. The prognostic significance of soft tissue extension in Ewing’s sarcoma. Cancer. 1983;51:913-917. Laine JC, Kaiser SP, Diab M. High-risk pediatric orthopedic pitfalls. Emerg Med Clin North Am. 2010;28:85-102. Tenenbein M, Reed MH, Black GB. The toddler’s fracture revisited. Am J Emerg Med. 1990;8:208-211. Flaherty EG, Perez-Rossello JM, Levine MA, et al. Evaluating children with fractures for child physical abuse. Pediatrics. 2014;133: e477-489. Lehmann CL, Arons RR, Loder RT, et al. The epidemiology of slipped capital femoral epiphysis: an update. J Pediatr Orthop. 2006;26: 286-290. Matava MJ, Patton CM, Luhmann S, et al. Knee pain as the initial symptom of slipped capital femoral epiphysis: an analysis of
300 Annals of Emergency Medicine
23. 24.
25. 26.
27.
28. 29.
30.
initial presentation and treatment. J Pediatr Orthop. 1999;19: 455-460. Kocher MS, Bishop JA, Weed B, et al. Delay in diagnosis of slipped capital femoral epiphysis. Pediatrics. 2004;113:e322-325. Skaggs DL, Roy AK, Vitale MG, et al. Quality of evaluation and management of children requiring timely orthopaedic surgery before admission to a tertiary pediatric facility. J Pediatr Orthop. 2002;22:265-267. Hagglund G, Hansson LI, Ordeberg G, et al. Bilaterally in slipped upper capital femoral epiphysis. J Bone Joint Surg Br. 1988;70:179-181. Pinkowsky GJ, Hennrikus WL. Klein line on the anteroposterior radiograph is not a sensitive diagnostic radiologic test for slipped capital femoral epiphysis. J Pediatr. 2013;162:804-807. Green DW, Mogekwu N, Scher DM, et al. A modification of Klein’s line to improve sensitivity of the anterior-posterior radiograph in slipped capital femoral epiphysis. J Pediatr Orthop. 2009;29:449-453. Karli A, Belet N, Danaci M, et al. Iliopsoas abscess in children: report on five patients with a literature review. Turk J Pediatr. 2014;56:69-74. Knight RM, Cuenca PJ. Torsion of the undescended testis in a 14month-old child refusing to bear weight. West J Emerg Med. 2011;12:515-519. Barkin RM, Barkin SZ, Barkin AZ. The limping child. J Emerg Med. 2000;18:331-339.
Volume 67, no. 2 : February 2016