Stepowl’s Weblog

A 26-year-old man with an unknown past medical history arrives to the emergency department (ED) by ambulance. He had been driving his car while unrestrained and was involved in a high-speed motor vehicle collision. There was airbag deployment and significant front-end damage to the vehicle, with intrusion into the passenger compartment of the car. The patient was extricated from the vehicle and placed on a backboard, and a cervical collar was placed by EMS. A non-rebreather facemask and 1 peripheral intravenous (IV) line were placed in the field.

On arrival to the hospital, the patient is ill-appearing and combative. His initial vital signs are a heart rate of 117 bpm, a blood pressure of 85/50 mm Hg, a respiratory rate of 32 breaths/min, and an oxygen saturation of 91% on the non-rebreather mask. On primary survey, his oropharynx is clear, his airway is patent, and his trachea appears to be shifted to the right of midline. On auscultation, the patient’s breath sounds are decreased over the left chest. Percussion of the left chest demonstrates hyperresonance. His carotid pulse is weakly palpable, and his jugular venous pulse is elevated. The patient receives a Glasgow Coma Scale score of 12. The patient’s clothing is removed, revealing no obvious deformities or areas of bleeding. The patient’s abdomen is soft, without any tenderness to palpation. His pelvis is stable. Standard trauma x-rays, including an anteroposterior (AP) chest and pelvis scan, are performed after the primary survey. A complete secondary survey is postponed because of the patient’s poor clinical condition.

A second large-bore peripheral intravenous line is placed, and the patient begins to receive a bolus of 1000 cc of normal saline under pressure. A decision to perform an emergent procedure is made. Immediately after the procedure is performed, the patient is noted to have a dramatic clinical improvement. Subsequent to the procedure, the patient has a pulse of 105 bpm, a blood pressure of 95/60 mm Hg, a respiratory rate of 22 breaths/min, and an oxygen saturation of 98% on the non-rebreather mask. The secondary survey is completed, revealing no major injuries. Additionally, the chest radiograph (see Figure 1) confirms the suspected clinical diagnosis that prompted the emergent procedure.

A 55-year-old woman with a past medical history of congestive heart failure, hypertension, hyperlipidemia, asthma, gastroesophageal reflux disease, and lupus anticoagulant syndrome presents to the emergency department (ED) with severe, progressive shortness of breath that has lasted for the past 12 hours, with associated chest pressure and wheezing. She denies having any leg swelling, chills, sore throat, coughing, or heartburn. Before reaching the ED, she used her albuterol inhaler without relief of symptoms and contacted emergency medical services (EMS). She has a 40-pack-year history of tobacco use, as well as a history of alcoholism (with her last consumption being 4 years before presentation) and remote marijuana use. Her medication regimen includes furosemide, fosinopril, isosorbide nitrate, pantoprazole, spironolactone, and enteric-coated aspirin, but she has a well-documented history of noncompliance.

On physical examination, the patient is afebrile, with a heart rate of 150 bpm, a blood pressure of 202/126 mm Hg, a respiratory rate of 26 breaths/min, and an oxygen saturation of 81% while breathing room air (which improved to 92% when she was given a non-rebreather face mask). In general, she has labored respirations and is unable to speak in full sentences. She has no jugular venous distention of the neck; however, her lung fields are remarkable for bilateral crackles. Her heart sounds include S1 and S2, but no murmurs, rubs, or gallops are noted. The patient has 1+ pitting edema of the lower extremities bilaterally. Incidentally, an atopic dyshidrotic eczematous rash of the skin is noted on the palmar and plantar surfaces of the patient’s hands and feet.

An arterial blood gas drawn while the patient is breathing room air reveals a pH of 7.27, with a partial oxygen pressure of 54 mm Hg and a partial carbon dioxide pressure of 63 mm Hg. The complete blood count (CBC), coagulation profile, serum electrolyte panel, and renal function test are unremarkable. An electrocardiogram (ECG) is performed (see Figure 1), and it shows a tachycardic rhythm of 152 bpm, with a left bundle branch block (which is noted to be pre-existing when compared with a previous ECG). A chest radiograph is performed, which reveals evidence of pulmonary edema.

A 57-year-old man with a history of diabetes mellitus and hypertension presents to the emergency department (ED) with a 2-week history of vesiculobullous lesions on his feet and hands. The lesions first appeared on both of his feet and have been increasing in size and number; over the last several days, they have begun to develop on both of his palms and on the sides of the fingers. The patient was seen at a different clinic approximately 1 week ago and was given an ointment to treat the lesions; this has not resulted in any improvement. The lesions are extremely pruritic. The patient has not had any recent travel history, and he lives alone, without any pets, in a regularly cleaned apartment. He has had no discernible new exposures and has not experienced any fevers or constitutional symptoms. The patient is on insulin, labetalol, and a combination pill of lisinopril/hydrochlorothiazide plus omeprazole; he has been on these medications for a long time and has had no prior complications. The patient has no known allergies.

On physical examination, the patient is well-appearing at rest, without any signs of undue anxiety or discomfort. His vital signs show a temperature of 98.7ºF (37.1ºC), blood pressure of 130/85 mm Hg, heart rate of 70 bpm, respiratory rate of 18 breaths/min, and oxygen saturation of 98% while breathing room air. Fluid-filled vesicles ranging in size from 1 mm to 3 cm are present on the instep and plantar aspects of his feet (see Figures 1 & 2). The vesicles are present on the palms of his hands and the sides of the fingers as well. The lesions are all skin-colored, without any surrounding erythema. No other lesions are found anywhere else on the patient’s body. The lesions are nontender to palpation; additionally, his legs exhibit nonpitting edema up to the knees and reduced sensation to light touch, both long-standing conditions. The oropharynx is clear of any lesions, and the rest of the physical examination is unremarkable.

A 24-year-old man with no significant past medical history presents to the emergency department (ED) with a complaint of several episodes of a sensation of nearly blacking out. The episodes have occurred about 3-4 times over the 3 days before presentation. The duration of each episode has ranged from a few minutes to over an hour. The patient notes that he has felt his “heart beating really fast,” with associated light-headedness. He denies having any chest pain, shortness of breath, or nausea associated with these events. He cannot identify exacerbating or alleviating factors; specifically, he denies exertion as an inciting factor. The remainder of his review of systems is negative except for some mild chronic shortness of breath. The patient takes no medications at home and has no active medical conditions. He smokes 2-4 packs of cigarettes per day and has done so for 5-6 years. He denies any illicit drug use or recent use of over-the-counter medications or herbal remedies. He has no history of any significant cardiac disease or sudden cardiac death in his family.

On physical examination, the patient is afebrile, with a pulse of 65 bpm, a blood pressure of 120/84 mm Hg, and a respiratory rate of 15 breaths/min. His room air saturation reading is 100%. In general, he is well-appearing and in no acute distress. The patient’s neck examination shows no jugular venous distention. The heart sounds, including S1and S2, reveal no audible murmurs, rubs, or gallops. The apical impulse is nondisplaced and of normal impact. The lung sounds are diminished throughout, but there are no wheezes, rales, or rhonchi. He has no edema of the lower extremities, and the distal pulses are easily palpable. All other exam findings, including a neurologic examination, are unremarkable.

The patient is placed on a cardiac monitor, and an 18-gauge intravenous (IV) catheter is inserted into the antecubital fossa. Laboratory tests consisting of a complete blood count (CBC) and serum electrolytes are ordered. A portable chest radiograph reveals slight hyperinflation and hyperlucency of the lung fields, with a flattened diaphragm and central pulmonary artery enlargement. An electrocardiogram (ECG) is obtained (see Figure 1).