A 60 yo F with sudden onset loss of vision in right eye, painless.  Proceeded by a few episodes of amaurosis fugax.

Physical exam: pupils appear normal on initial inspection, however afferent pupil defect noted.

Fundoscopic exam: cherry red spot, pale retina, +/-boxcar segmentation (not shown in this picture).

DDx for loss/reduction of vision:

Glaucoma, optic neuritis, central retinal artery or vein occlusion

Given the history and physical, the most likely diagnosis is central retinal artery occlusion (CRAO).

Retina can sustain irreversible damage within 90 minutes of complete occlusion, so act fast:

1. Consult ophthalmology
2. Digital massage to convert the CRAO to BRAO (central to branch): first steady pressure on the globe for 15s, followed by sudden release of pressure; repeat several times
3. Administer one drop of Timoptic 0.5% (to suppress aqueous humor production and therefore reducing OIP)
4. Acetazolamide 500mg IV or PO once (to suppress aqueous humor production)
5. Consider having patient breathe into a paper bag for 5-10 minutes if no respiratory contraindications (to increase PaCO2 as CO2 dilates retinal arterioles)

Source: Tintinalli

Filed under: critical care, ENT, ophthomology, Pearls by ling
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55 Chinese woman, no PMH, no meds.  P/w epigastric discomfort x 2 weeks, not responding to Pepcid Maalox.  Presented to Elmhurst ED for worsening epigastric discomfort and generalized weakness.  No fever/chill. + Mild dry cough.  No chest pain. + Mild SOB with exertion.  No abd pain, n/v/d/c/dysuria.  No night sweats or weight loss, denied exposure to TB. No orthopnea, no leg edema.  No recent travel, migrated to US 17 years ago.

EKG and CXR as below.  Labs are within normal limit.  Cardiac enzyme negative.

Bedside ultrasound found to have large pericardial effusion with RV collapse.

Patient was taken to CT surgery for pericardiocentesis.  1 liter bloody output drained.

Pericardial Tamponade

Pericardial space usually has 15-50ml of fluid.  The increase of such fluid can result from trauma (including CT surgery catheter perforation), infection, cancer, CHF, renal/liver failure, uremia, thyroid disease, and post-MI.   In cardiac tamponade, patient can progress quickly to hypotension, bradycardia, and cardiac arrest.

On bedside ultrasound, once RV collapse is seen, diagnosis of pericardial tamponade is made, which mandates emergency pericardiocentesis.

Equipment:

• 18-gauge needle (or spinal needle to avoid dermal tissue clogging)
• 3-way stopcock with flexible tubing (for repeat drainage)
• 20-ml syringe

Technique:

Choose between subxiphoid, parasternal, or apical access.  Parasternal access has become more popular because of its close proximity to the heart (only have to go through chest wall, far from liver) and more direct visualization (the needle is in the same plane as the sono beam).  Once the tip of the needle is in the appropriate space, agitated saline test can be used to confirm the position.

• Parasternal – insert the needle perpendicular to the chest wall in the fifth intercostals space, just lateral to the sternum.
• Subxiphoid – insert needle just below the xiphoid process and left costal margin.  Enter the skin at 30-45 degree angle, aiming towards the left shoulder.
• Apical – insert the needle in the intercostals space below and 1cm lateral to the apical beat, aiming towards the right shoulder.

If an ultrasound machine is not available, use a wire with alligator clips at each end; attach one clip to the needle and the other to the EKG machine.  ST elevation means direct contact of needle to myocardium; withdraw needle until ST segments normalize.

Relative contraindications

• Traumatic pericardial effusion and unstable VS, because they present as an indication for emergency thoracotomy.
• Myocardial rupture
• Aortic dissection
• Severe bleeding disorder

Complications

Ventricular rupture, arrhythmias, pneumothorax, myocardial and/or coronary artery laceration, and infection.

- Our patient: cell analysis of the effusion revealed malignant cells with unknown origin.  :(

http://www.sonoguide.com/pericardiocentesis.html  (Sonoguide for Emergency Physicians by Dr. Beatrice Hoffman)

http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841  (video of pericariacentesis –subxiphoid approach- on NEJM)

Filed under: cardiology, critical care, Pearls, Trauma, Ultrasound by ling
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Which of the following deficits below the level of injury is consistent with anterior cord syndrome?

1. Loss of total sensation and motor function
2. Bladder and bowel incontinence and loss of motor function
3. Loss of motor function only
4. Loss of vibration and position sensation and motor function
5. Loss of pain and temperature sensation and motor function

Answer: E  Loss of pain and temperature sensation and motor functio

• Anterior cord syndrome – most commonly occurs in hyperflexion injures where herniated vertebral discs or body fragments compress the anterior aspect of the spinal cord or anterior spinal artery. The anterior spinal artery supplies the anterior 2/3 of the spinal cord which is comprised of the spinothalamic tract containing pain and temperature sensory input and the corticospinal tract which carries descending voluntary motor signals.

• Complete cord syndrome (transaction of the cord) results in complete loss of motor, sensation and autonomic  function below the level of lesion
• Central Cord Syndrome-  this is seen in older patients with degenerative spinal disease and cervical spondylosis or traumatic with hyperextension mechanism (athletes), disc herniation, trivial trauma or hyperflexion. Findings of bilateral motor weakness upper > lower extremities; distal > proxima with variable sensory involvement.

• Brown-Sequard syndrome-  hemisection caused by penetrating trauma most commonly, also blunt trauma, disc or bone herniation, hematoma and tumors or as a complication of decompression sickness. Ipsilateral loss of motor function, vibration and proprioception but contralateral pain and temperature

• Cervical Cord Neurapraxia- transient quadriparesis or neurapraxia seen in axial loading injuries with flexion or extension (football players who lead with their head). Thought to be a “concussion” of the cervical spinal cord.

Filed under: Pearls by tali
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Retrobulbar hemorrhage can result in what devastating condition?

1. Corneal abrasion
2. Hypopyon
3. Central retinal artery occlusion (CRAO)
4. Hyphema
5. Corneal ulcer

Answer:   Central retinal artery occlusion  (CRAO)

Retrobulbar hemorrhage results from ocular trauma almost always seen with some orbital wall fracture (although not all are associated with trauma it is by far most common cause). A sizeable hematoma compress the optic nerve and retinal artery or vein diminishing flow to the retina leading to irreversible blindness if left untreated (as soon as 90 minutes without treatment).

Patients present with a history  trauma of course, ocular pain and proptosis (hematoma pushing the globe out).  Also decreased visual acuity, Afferent pupilary defect, cherry red macular, optic nerve pallor etc. CT will confirm the diagnosis (and in trauma patients with suspected facial trauma you will be getting dedicated orbital CT).

CT finding retrobulbar hemorrhage

Emergent management includes: Protection of the globe, elevate the head, IV fluids/antiemetics (you don’t want them vomiting and increasing the pressure in the eye) and analgesics. Emergent Lateral Canthotopy to decompress the orbit may be indicated. However ultimately Optho has to be called ASAP as definitive treatment will be performed by them.

Indications for lateral canthotomy: decreased visual acuity, ocular pressure > 40 mmHg, proptosis, afferent papillary defect (Marcus Gunn), Cherry red macular, opthalmoplegia, optic nerve pallor and severe eye pain.

Procedure: Pull down on the lower lid to visualize the tendon, Cut the lateral canthus and extend it toward the orbital rim. Find the superior and inferior crus of the lateral canthal tendon and release the inferior crus from the orbital rim. Recheck pressure if still inadequate (>40 mmHg) repeat with superior crus release.

lateral canthotomy

Filed under: Pearls by tali
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63 M complaining of erythema and pain to right side of his face for 3-4 days after being scratched by some metal. Right eye swollen shut with erythema and tenderness surrounding.

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Filed under: Pearls by tali
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