Case 9

30 year old female
Punched in the left eye after quarrel with boyfriend.
What is the diagnosis?
How would you manage this condition?

(P.S : ignore the radio-opaque artifact in the right orbit)

Answer : Blow-out Fracture


As shown above, a blow-out fracture results from a direct compressional force to the orbit, which results in increased intraorbiral pressure. The weakest part of the orbit is its inferomedial floor (lamina papyracea). The fracture may lead to the herniation of the orbital contents into the maxillary antrum.

Approach

1. As for all trauma cases, ensure ABCs are secure, esp. with respect to head injuries or cervical spine injuries that may require earlier attention than the orbital fracture.
2. Examine the affected eye to rule out urgent ocular injuries e.g. penetrating globe injury/ compressive orbital emphysema/ retrobulbar hemorrhage --> refer to Eye stat!
   
3. Test eye-movements to look for impingement on upward gaze (demonstrated in the clinical photograph above), which may suggest herniation and entrapment of extraocular muscle.
   
4. Test for infraorbital anesthesia - tap incisors on both sides to see if there's any difference in sensation.
   
5. Plain facial (OM view) X-rays to look for 'tear-drop' sign (suggestive of herniation into maxillary antrum and seen in X-ray above) and fluid-level/ opacification in affected maxillary antrum (likely to be bleeding in trauma setting).
6. Disposition - Refer to Plastics/ Eye. Consider antibiotics if there is evidence of blood in maxillary antrum.
7. Offer referral to counselling/ PSY in the setting of abuse. Document all findings carefully because this is a potential legal case and you may be asked to appear in court later.
   

Breaking Bad News at the A&E

A recent resuscitation case at the department prompted me to write this post.

Attending to collapse and resuscitation cases is something we are prepared to do as emergency doctors and nurses, but sometimes we may be too caught up with the medical situation (What is the cause of the collapse/ what drugs should I give/ Should I defibrillate etc) that we do not give enough thought to the anxious family members waiting outside the resus room. Managing them can be as difficult, if not more difficult, than managing the collapsed patient himself.

Throughout my career in emergency medicine I have had my fair share of resus cases. In some cases we manage to restore a rhythm and BP, but the majority of cases do not make it despite our best efforts. Below are some practical points that might be helpful for the doctor who is about to break the bad news to the anxious and expectant family members.

(1) Always prime and prepare the family members. The resuscitation period may be prolonged, and during this time, someone should update the family members regularly. If the outcome does not look good, the family members should be prepared mentally to be ready for the worst, so that when the eventual bad news is broken, the impact would (hopefully) be less devastating.

(2) When it's time to break the bad news,

• location - choose an empty consultation room where all the family members can be gathered around. Some departments have specific grieving rooms for this purpose. Do not break the news in the common areas (e.g. at the counter/ waiting area) if possible. This is to allow the family members privacy and dignity while they grieve, and also to minimize emotional disturbance to the other patients in the department.
• Have another staff on hand to assist you while you break the bad news. You never know how people may react.
• If possible, have enough chairs around the room so people can be seated. The last thing you want is a vasovagal syncope and head injury after you break the bad news.
• Speak in a slow and clear manner. Be factual. Explain the sequence of events that has taken place during the resuscitation but avoid excessive jargon or details. Maintain good eye contact all the time.
• Be direct and non-ambiguous. Say something like, 'Despite our efforts, we were unable to revive so-and-so. He has died/ passed away.' Do not use vague terms such as 'he has gone to a better place' or 'he is no longer with us' - you may find it easier speaking this way, but the family members may end up confused.
• Do not talk too much ! After breaking the news, it is useful to pause and allow the information to sink in. Keep a respectful and sympathetic silence, but do not rush out of the door straight away (even though you have another 10 patients waiting). Allow the family to grieve, but be on-hand to answer any questions or render assistance they need.
• Avoid saying things like 'I understand how you feel' or 'Don't worry the pain will ease with time'. You do NOT understand how they feel - you will go home to your loved ones after your shift, but their loved one will never come back. The pain may indeed ease with time, but this is neither the time nor place to say it.

(3) Viewing the body

• once the nurses have tidied up the resus area, the family members should be allowed to view the body and say their goodbyes.
• Before they enter the room, prepare them for what they are going to see, e.g. endotracheal tubes/ IV lines/ chest tubes etc, so they are not shocked when they see it.
• If there are any other patients in the same room/ area, transfer them elsewhere so the family has privacy, and the other patients are not emotionally traumatized.
• This is the most emotionally-charged part of the process - expect an outpour of raw emotions, predominantly grief. It is hard as a human being not to be affected by such scenes, hence one must remember to take a step back - remember our job is to be in the background respectfully, giving them the space and time to grieve but be ready to assist them at any time they need us.

(4) Coroner's Case

• Most deaths at the A&E end up being Coroner's cases, because of their sudden and unexpected nature. It can also be a difficult subject to broach with the relatives, sometimes even more difficult than the news that their loved one has died.
• Personally I usually do so at a later time (after they have come to terms with the demise of the patient) rather than give them 2 blows at the same time. Another method I find useful is to speak to someone who seems to be in an authoritative position and who seems less emotionally affected (e.g. the eldest son).
• Again, be firm and factual. Explain that you are obliged under the laws to make the case a Coroner's case rather than sign it up. Explain the process it entails (notifying police, transferring body to SGH Forensic Path dept etc) and reassure them that your staff will assist them in this.
• Most of the time the family will ask whether an autopsy will be conducted. I always tell them it is up to the discretion of the Coroner, who is assisted by the forensic pathologist. Show that you understand their concerns. Sometimes the family members may request you to include in your notes that they hope an autopsy can be avoided. Personally I will include that information in my notes, but I always tell them that the ultimate decision still lies with the Coroner.

Whatever emotional trauma the medical staff may encounter during a resuscitation, remember that the family members experience it a hundred times worse. You have lost a patient, but they have lost a father/ spouse/ child. Respect and acknowledge their grief, do not trivialize nor magnify it. Be empathetic and professional.

Case 8

78 year old female

Brought in by SCDF ambulance. Acutely unwell.
BP 85/50, Temp 37.8. Drowsy and unresponsive.
No family members around to give more history.

What is the diagnosis?
Which drug would you give first in her management?

Answer : Hyperkalemia

On first look, the ECG looks bizarre and not like something which we can fit a pattern to. This in itself should already remind you to think of hyperkalemia. On closer inspection we can see that the QRS complexes are widened and there is also suggestion of tall T waves.

Management

• Immediate management in P1 area. Full monitoring.
• Supplemental oxygen
• IV access; take blood form FBC/ UE/ ABG/ cardiac enzymes & Troponin/ blood cultures; consider IV fluids but need to exclude fluid overload first
• Drugs

1. IV Calcium gluconate/ chloride (10 mls stat) - first drug to be given in treatment of hyperkalemia; to stabilise the myocardium
2. IV Insulin 10 units with IV Dextrose 50% 40 mls - shifts ECF potassium into ICF
3. IV Sodium Bicarbonate (1 meq/kg BW ) IV bolus over 5 mins - also to shift ECF potassium into ICF. Limited use if patient is non-acidotic, and carries risk of fluid overload/ cerebral oedema.

Other drugs which can be considered include Salbutamol nebulisation (be careful in patients with IHD because of resultant tachycardia), as well as Resornium (K-binding resin) but it's not much use in A&E because of relatively longer onset of action (about 1-2 hrs).

This lady has a history of chronic renal impairment on dialysis. Her acute presentation is probably exacerbated by a concomitant infection (chest/ urine).

Remember :

• Consider non-cardiac pathologies when intepreting ECG
• When confronted with bizarre-looking ECG, consider severe hyperkalemia

Case 7

56 year old male, known hypertensive

Found collapsed at home by relatives.
On arrival, GCS 7. BP 170/90

What is the diagnosis?
How would you manage this patient?

Answer : Subarachnoid hemorrhage (SAH)

The CT scan shows presence of blood (the whitish stuff) within the subarachnoid space in the brain, sometimes referred to as the 'Mercedes sign' because it resembles the automaker's logo.

Causes

• Berry aneurysms (70%) - 30% of which in anterior communicating artery and 20% in posterior communicating artery
• Arteriovenous malformation (10%)
• No cause found (10-15%)

Typical presentation

• sudden onset of severe headache ('worst ever' headache)
• nausea and/ or vomiting
• neck pain
• photophobia
• loss of or altered consciousness

First test for patient with suspected SAH - plain CT head

• 93% sensitivity; but sensitivity diminishes with time
• if high suspicion of SAH but CT normal/ non-diagnostic, proceed with lumbar puncture (if no evidence of raised intra-cranial pressure), looking for xanthochromia and elevated RBC count (which does not diminish with successive collections)

A&E management

• Secure airway - in this patient whose GCS is only 7, endotracheal intubation following rapid sequence induction (RSI) to control airway and reduce risk of aspiration
• Supplemental oxygen, IV access and take blood for FBC/ UE/ Coagulation/ GXM
• Close monitoring of vital signs, keep systolic BP between 90-140 mmHg
  
• Contact neurosurgeon immediately with view to timely intervention (angiography/ coiling/ clipping etc)

I remember reading somewhere that an average doctor should expect to come across 3 cases of SAH in his/her career. Well, I have already seen two cases in my (relatively) short career - perhaps a doctor working in the ER will definitely see more of them.

I still remember the first case - a 30 year old lady with hx of migraine, who came in at 4 am with a headache which she claims is similar to her migraine attack. She was perfectly lucid and comfortable, and the only tiny red-flags I had were (1) I seldom see migraines at 4 am, and (2) there was very mild neck stiffness on examination. Being newly-employed in a private hospital where your license is much more on-the-line, I suggested a CT scan. She was reluctant but her husband persuaded her, and it turned out she had a SAH. She was admitted and underwent endovascular coiling immediately, and I hope she is doing well today.

So the lesson - the next tension-headache that walks in may not be a tension-headache. Keep your eyes open.

Case 6

27 yr old male

Claims he accidentally knocked against edge of table.
'Just stitch it up for me, doc.'
How would you approach this case?

Answer : Fight Bite

This laceration is sustained when one punches another individual in the mouth with a clenched fist, with the victim's teeth cutting the perpetrator's hand around the metacarpophalangeal joint (MCPJ), as shown :

• All wounds around MCPJ should be considered fight bites until proven otherwise
• Characterized by innoculation of organisms and rapid spread - cellulitis, septic arthritis, tenosynovitis, osteomyelitis, abscess
• Usually polymicrobial
• Initial presentation may be deceptively unremarkable

Management

• Examine all wounds in flexion and extension so as not to miss extensor tendon injuries
• Wounds should not be closed initially
• All wounds should be explored, irrigated and debrided
• Tetanus prophylaxis
• Xray to exclude foreign bodies (e.g. teeth fragment)
• Antibiotics to cover both oral and skin flora
  

Disposition

• Outpatient only if : early presentation, no infection, no comorbidity (e.g. diabetes), no evidence of bone/ joint/ tendon involvement --> refer to Ortho/ Hand surgeon for early review
• All others - admit for definitive wound care and IV antibiotics

This case also illustrates the sad-but-true fact that our patients do not tell us the truth all the time, or even most of the time. Haven't we all at some time or another rolled our eyes at the patient who swallowed 40 Paracetamols because 'the headache won't go away', or the teenage Juliet with 8-9 lacerations on her wrist because she accidentally cut herself opening a can of sardines?

Often patients do not tell us the truth because it is embarrassing, but sometimes also because they are afraid of the medicolegal implications. Do we press them, and how hard do we press?
Personally I usually ask them a direct question once, e.g. 'Did you cut yourself on purpose?'. If they deny there's usually no point persisting, because it only puts them on the defensive and your patient-doctor relationship goes out of the window. As long as it does not affect the medical management, I would just document the negative response to my direct question, and proceed to treat the patient.

In some cases the patient eventually comes around and admits to what really happened. I had a patient with wrists lacerations who, on review a few days later, admits that she had cut herself deliberately after quarreling with her bf. I was then able to refer her forward for counseling and psychiatric review.

I guess the only time when I would really try as much as possible is when I strongly suspect deliberate abuse (e.g. child/ elderly/ spouse), when my inaction or failure to find out the truth may inadvertently lead to greater injuries or even loss of life. Luckily these cases don't happen that often!

Case 5

42 year old Thai male

C/o abdominal pain for 2 days.

Temp 37.9, BP 110/65
Not jaundiced
Diffuse tenderness on palpation of abdomen

What is the diagnosis?
How would you manage this patient?


Answer: Perforated hollow abdominal viscus

There is free air under both the hemidiaphragms in this erect CXR. Most commonly due to perforated peptic ulcer, but can also result from perforation of diverticula, Meckel's diverticulum, appendix etc.

Approach

• Manage as a P2 case.

• Large-bore IV access with crystalloid resuscitation
• Take blood for FBC, UE, GXM, PT/PTT, LFT and amylase
  
• If patient is in shock, consider supplemental O2 and urinary catheterisation
• Keep patient nil orally (not that he would have much of an appetite) and insert nasogastric tube
  
• Start IV antibiotics
• Inform surgeon stat and arrange for admission/ surgery

I'm always terrified when I see Thai or Myanmese patients at the A&E (and it's not because of the need of double-gloving mind you). They are usually extremely stoic characters so when they are unwell enough to come to the emergency you'd better search for some serious pathology as hard as you can, rather than just send them home with Panadol.

On the other hand, patients from the South Asian region (e.g. Indians, Bangladeshis) seem to project their symptoms in a rather melodramatic fashion, especially in their response to pain. I used to think it was related to their education level (e.g. the construction worker writhing in an agonized near-faint from a superficial finger laceration), but I've also seen senior bankers behaving in the same manner. It's probably more a product of their socio-cultural upbringing I guess, and we must be cognizant of this.

In short, beware the Thai patient with abdominal pain!

Case 4

19 year old female

C/o abdominal pain and vomiting for 3 days.
No past medical history of note

O/e BP 90/55, HR 120/min
Abdomen soft

Basic blood investigations as below:

FBC : TWC 16,000, Hb 12.1, Platelets 227

U/E : Na 131, K 3.1, Cl 97, Bicarb 12, Creatinine 108

What simple test would give you the diagnosis?
How would you manage this patient?


Answer : Capillary blood glucose

The most striking abnormality in the blood tests is the low bicarbonate level of 12 mmol/L (usual range 22-30). This implies a metabolic acidosis. Next, we can calculate the anion gap (Na + K - Cl - Bicarb) = 131 + 3.1 - 97 - 12 = 25.1. The normal range of the anion gap is usually quoted as 8- 16; hence what we have here is a high anion-gap metabolic acidosis (HAGMA).

Go back to medical school biochemical pathology, and you will (hopefully) remember the causes of HAGMA :

• Diabetic ketoacidosis (DKA)
  
• Severe uremia
• Drugs (salicylate, ethanol, methanol, ethylene glycol)
• Lacticacidosis

In this case, DKA is the most likely diagnosis (assuming no consumption of meds), and a hypocount will reveal a high capillary blood glucose reading. Of course you can do a serum ketone level or an arterial blood-gas (ABG) analysis which will be more definitive, but they take longer for the results to come back.

Approach

• Manage as P1 case - DKA patients may not look apparently ill but they can deteriorate precipitously. Immediate management is needed
• Immediate fluid resuscitation is critical - 1-3 L of normal saline within first hour.
• IV Insulin (usually 5-10 units bolus) followed by IV insulin infusion
• Close monitoring and replacement of electrolytes (esp. K) - remember that insulin shifts K into the cells (hence it is also treatment for hyperkalemia)
• Bicarbonate infusion - not critical as acidosis usually will correct with measures above. Carries risk of cerebral oedema
• Identify and treat underlying cause (e.g. antibiotics for sepsis)
• Admit to Endocrine/ Int Med. May need close monitoring in ICU/ High dependency unit

Remember :

• Patient usually does not have a history of diabetes. Their first presentation will be DKA.
• If not treated in time and aggressively enough, DKA carries a high mortality rate even in a young and apparently healthy individual.

• Not all abdominal pains are surgical in nature!
  

Case 3

35 year old male

'Doctor, am I having a stroke? Do I need a scan of my brain'?

What medications would you prescribe? How would you prognosticate his illness?


Answer : Bell's palsy (on the left side)

This is a rather common case we see in the ER, and patients are invariably frightened that they are having a CVA. Bell's palsy is an idiopathic lower-motor neurone (LMN) palsy affecting the facial nerve (7th cranial nerve).

The main clinical signs are illustrated here:

Let's review the difference between upper & lower motor neuron lesions of the 7th nerve:

• In general, due to the cross-innervation of nerve fibres, a LMN lesion results in paralysis or weakness of both upper and lower parts of the face, whereas an upper motor neuron (UMN) lesion usually spares the upper part of the face (i.e patient can wrinkle forehead on that side). Note however that this is not always absolute.

• Other signs to look for (more for exam purposes):

1. Inspect ear and do otoscope to look for vesicles (Ramsay-Hunt Syndrome)
2. Test taste function (chorda tympani involvement)
   
3. Check for hyperacusis (nerve to stapedius involvement)

Neuroimaging is usually not indicated in a straightforward case of Bell's palsy. Patient should be reassured that they are not having a stroke.

Treatment

• Prednisolone (1mg/kg BW, up to 60 mg/day) for 7-10 days - recent trials have shown significant improvement in outcome if started within 72 hrs of symptom onset
  
• Acyclovir - benefit is less certain compared to steroids.
• Eye protection - artificial tears and taping of eye at night if it cannot be voluntarily closed
• Refer to neurologist/ ENT for further follow-up.

Prognosis

• 85% complete recovery, 10% residual deficits, 5% severe sequelae
• Poor prognosticating factors include:

1. Older patients
   
2. History of recurrent facial nerve palsy
3. Complete facial paralysis during the acute phase
4. Longer time taken to recover
5. Presence of postaurticular pain, abnormal taste, tearing
6. Diabetic patients
7. Pregnant patients
   

Case 2

25 year old male

Tripped and fell; landed on outstretched right hand
C/o right elbow pain

How would you manage him?

Answer : Occult fracture of right elbow (pathological fat pad sign)

• Normally in lateral xray of elbow in 90 degrees flexion, the anterior fat pad (lucency a) lies along the anterior surface of the distal humerus, and the posterior fat pad (lucency b) is not seen.
• When the joint capsule is distended by fluid (commonly blood in the setting of trauma), the anterior fat pad becomes elevated (the sail sign), and the posterior fat pad becomes visible.

• Most common occult fracture a/w pathological fat pads - head of radius fracture
• Other causes of fluid around elbow joint - inflammation, infection, neoplasm
• Need to have high index of suspicion when xray looks seemingly normal but patient has limited or painful range of motion of the elbow
  

Approach

• Exclude more serious injuries e.g. head/ neck injuries etc
• Analgesia as indicated; arm sling
• Disposition : backslab/ arm sling. Refer to Orthopedics outpatient clinic
  

Case 1

80 year old female

Past medical hx : hyperlipidemia, diabetes
Chief complaint : giddiness and breathless for 2 days
BP 100/60, HR 40

(1) What is the diagnosis?
(2) How would you manage this patient?


Answer : Complete (Third Degree) Heart Block

• Complete dissociation of P waves with QRS complexes
• P-P interval regular; R-R interval also regular

Causes

• Myocardial infarction - in 10% of inferior MI (usually benign); more serious if associated with anterior MI
• Cardiomyopathy (e.g. Lyme disease), acute rheumatic fever
• Overdose of meds (e.g. calcium-channel blocker; beta-blockers)
  

Approach

• Manage as P1 case
• Immediate support of ABC and cardiac monitoring

1. High-flow oxygen
2. IV access - take blood for FBC/ UE/ cardiac enzymes & troponin

• Atropine - 0.6 mg IV every 5 mins up to total of 3 mg
• Consider dopamine
• Transcutaneous pacing if medications ineffective (with analgesia/ sedation)
• Transvenous pacing (by cardiologist) if transcutaneous pacing unsuccessful, or as a definitive procedure after stabilized with transcutaneous pacing
  
• Treat underlying cause (e.g. MI, overdose) and complications (heart failure, shock)