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Special catch

10 Apr

Hi all,

Yesterday a 10yo boy presented to our ED after fishing with his friend, who managed to catch him, instead of the Barramundi, with the fish-hook up his nose. The hook was situated just below the cartilage of the nasal septum, in the columella. XRays showed only 1 spike which didn’t cross the midline. We aimed for retracting the hook with a topical anesthetic and Nitrous Oxide, which seemed to work quite well but the hook was firmly anchored in the nose and we were unable to retract the hook without distressing the boy. Eventually we involved the ENT doctor who injected Lignocaine/Adrenalin in the soft part under the septum, the area you can feel with two fingers on either side – the columella again. Approached from the unaffected side with a small needle, a small amount of anaesthetic was deposited in the centre causing diffusion up on either side of the septum. A small nick overlying the spike and preparation of the surrounding tissue off the spike while holding the hook under light tension with a needle driver released the hook from the nose without complications or any pain!

Cheers!

 

What to do when you break your arm?

16 May

We are two lovely (according to our supervisor) EM-residents from Medical Centre Haaglanden, The Hague and Erasmus MC, Rotterdam, working at the Sint Franciscus Hospital, Rotterdam for a month to increase our ultrasound skills. We expected to perform e-FAST and cardiac ultrasound a lot, but instead our supervisor sent us several times to all those broken bones. The first time I performed an ultrasound, I put up my glasses, but couldn’t see anything except a white line, but my supervisor told me ‘bone is blinding’, so that’s okay!

The following days, we saw a great number of patients with broken bones. Inhabitants in this area are not so steady (not to mention the amount of patients with drug abuse) and fall quite easily apparently, which was great for our ultrasound exposure. Therefore we will show you some beautiful ones (not patients but ultrasound images) below.

Case 1: What will happen when a 7 year old decide to fall from her bike and there is no ultrasound addict available, because he is performing PSA at her with propofol. Fig 1en 2.

1

Fig 1

2

Fig 2

An incomplete reposition at the emergency room, followed by reposition at the operating room next morning was the unfortunate result in this case.

Ultrasound is not time-consuming!

27 Jun

In the Netherlands, the majority of Emergency Physicians unfortunately do not use ultrasound frequently at this moment. One of the arguments I often hear is: “I don’t have the time to perform ultrasound at my busy Emergency Department (ED), because there are to many patients to take care of”. Hopefully my case will prove otherwise.

A few months ago, this 40 year old guy from Poland came to our ED. Our secretary called the triage nurse to inform ‘this man doesn’t look good’, maybe you can pick him up. As the nurse went to call for this patient, he indeed didn’t look well and that was not because the use of alcohol. He looked pale and diaphoretic all over, but didn’t speak a word English, German or Dutch. As they walked to a empty room, the nurse shouted for my help as they always do. While I was doing nothing except drinking coffee at my busy ED, she said: Please come over immediately ‘this man doesn’t look good’. I carefully watched the nurse (and the patient as well) and followed them into the room with my ultrasoundmachine, because this man was indeed looking awful. As she put the man on the monitor to get his vital signs, it was my time to shout. I ordered for ECG and regular bloodtest, because he might have STEMI. While I was preparing my device I noticed the man holds his both hands on his belly. Instead of performing an cardiac exam first, I choose to do abdomen (see fig 1 and 2). I diagnosed free fluid in his belly before the needle (for bloodtest) was actually in this specific patient. Later on, we found out that he was using brufen for a week because of backpain and the CT-scan revealed an hole in his stomach, so he went for surgery and did well afterwards.

fig 1 echo

fig 2 echo

I’ll guarantee, everything I just wrote down was for real (except the nurse was checking me out obviously).

I hope this case will stimulate you all to perform ultrasound more rapid and more often in future! Those of you, interested in learning ultrasound, you can always contact me for a four week ultrasound rotation at Sint Franciscus Gasthuis in Rotterdam. Although we are fullly booked until april 2015.

 

All the best,

Arthur Rosendaal

Een bijzondere vergiftiging

22 Jan

Door D.Houtman, anios SEH MC Zuiderzee

Een intoxicatie met amatoxine definitief

Image

Emergency ultrasound case of the month….2014 !! Rest of the case and diagnosis

10 Jan

The ultrasound showed a right kidney with a little bit of hydronefrosis, mild at most, but the “money shot” was in the pelvis ..
A large cystic mass with anechoic to hyperechogenic content, some concrement-like structures were also seen within.

Right kidney                                       Left kidney

Casus EM dutch jan 2014 re nierCasus EM dutchjan 2014 li nier

Pelvic view

Casus EMdutch jan 2014 + uitleg
The patient was sent to gynaecology where a transvaginal ultrasound was done …. with similar findings.

On basis of the findings of  the ultrasound(s) she was brought to the OR. Where the gynaecologist found the large cyst (9 – 6 – 5 cm) which had facilitated a torsion of the right ovary. Luckily the ovary could be spared.

The pathology report showed : Cyst with skin, bone, cartilage and braintissue..  conclusion : mature teratoma

Final diagnosis : Large mature teratoma with torsion of the right ovary (and little bit of  hydronefrosis of  the right kidney)

A few pearls can be taken from this case in my humble opion:

-Be sceptic of other people’s diagnosis when a patient is handed over to your care, don’t let it narrow your frame of thinking

-Emergency ultrasound can guide your management in the right direction within seconds.Without it you might lose valuable time (and in this case an ovary)

-Always scan the pelvis/bladder after doing  renal ultrasound, don’t be satisfied with hydronefrosis, check if you can identify the cause downstream. (also always take a look at the aorta by the way, AAA /iliacal aneurysm can also be a cause of hydronefrosis and mimic renal colic)

– Torsion of the ovary can be a tricky diagnosis, pelvic exam not always helpful.

Love to hear your comments on this case …. Check EMdutch in a month or so for the next emergency ultrasound case !!