Joaquín Valle Alonso

Swimming-induced pulmonary oedema an uncommon condition diagnosed with POCUS ultrasound

Swimming Induced Pulmonary Edema, or SIPE, is an emerging condition occurring in otherwise healthy individuals during surface swimming or diving that is characterized by cough, dyspnea, hemoptysis, and hypoxemia. It is typically found in those who spend time in cold water exercise with heavy swimming and surface swimming, such as civilian training for iron Man, triathalon, and military training. We report the case of a highly trained young female swimmer in excellent cardiopulmonary health, who developed acute alveolar pulmonary oedema in an open water swimming training diagnosed in the emergency department using POCUS ultrasound.

Comparación de la regla canadiense y los criterios de New Orleans en el traumatismo craneal leve en un hospital español

BACKGROUND AND OBJECTIVEnTo compare two scales for assessment of patients with mild head injury. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) according to their diagnostic accuracy in patients attending an emergency department, and to determine the most important predictive values.nnnMETHODnCross-sectional study in a first-level Hospital in the period of January 2011 to January 2013. Patients with mild head injury criteria were included. All the patients underwent a computed tomography (CT) of the head as part of internal protocol and the CCHR and NOC criteria were recorded for each patient. We consider the main variable the presence of traumatic lesions on CT and, as secondary variables, neurosurgical intervention and post-concussion syndrome. Sensitivity, specificity, predictive values and validity index (VI) of the CCHR and the NO criteria in the subgroup of patients with a Glasgow Coma Scale (GCS) score of 15 points were compared.nnnRESULTSnA total of 217 patients, of whom 197 had a GCS score of 15 points were evaluated. Both rules showed 100% sensitivity when a significant injury was presented in the CT, the CCHR 100% (95% CI: 97.4%-100%) and the NO criteria 100% (95% CI: 97.4%-100%); but the CCHR achieved higher values of specificity 25.3% (95% CI: 18.6%-32%), positive predictive value (PPV) and VI. The two rules showed a 100% sensitivity regarding neurosurgical intervention; however the CCHR with high-risk criteria showed better specificity, PPV and VI 55.2 (95% CI: 8.3%-62.2%) compared to the NO criteria 7.6 (95% CI: 3.8%-11.5%). With regard to post-concussion syndrome criteria NO criteria showed better sensitivity 100% (95% CI: 96.2%-100%) and predictive values, but lower specificity and VI compared with the CCHR 76.9% (95% CI: 50.2%-100%).nnnCONCLUSIONSnOur study demonstrates the high sensitivity of the CCHR and the NO criteria in patients with mild head injury, both to detect a significant clinical lesion on CT or the need for neurosurgical intervention and better specificity of CCHR compared with NO criteria. The adoption of clinical prediction rules, especially the CCHR, to request a CT scan in patients with mild head injury should be recommended in the emergency department.

Sepsis, fluid resuscitation and bedside echocardiography

Sepsis, fluid resuscitation and bedside echocardiography J.V. Alonso, F.J.F. del Pozo, M. Vaquero and I. Islam From the Department of Emergency Medicine, Royal Bournemouth Hospital, Bournemouth BH7 7DW, UK, Department of Emergency and Critical Care Unit of Montoro, Maimónides Biomedical Research Institute of Córdoba, 14004 Córdoba, Spain and Department of Family Medicine, Jean Health Centre, 23003 Jaén, Spain

Use of POCUS Ultrasound in sepsis, bedside diagnosis of necrotizing fasciitis.

A 60-year-old female patient presented to the emergency department with a threeday history of pain in the left leg. The patient described a three day history of pain in the left inner thigh that was treated by the GP for suspected cellulitis with flucoxacillin. On arrival by ambulance, the patient was tachycardic 130 bpm, blood pressure 76/34, tachypnea 29 rpm, temperature 34.1, oxygen saturation 93% on room air and bilateral livedo reticularis in both legs. The National Early Warning Score (NEWS) at arrival was 15. In the resuscitation room a RUSH (Rapid Ultrasound for Shock) protocol was performed. The Pump: Cardiac Evaluation showed severely decreased LV ejection fraction but no pericardial effusion or right ventricle strain, the Tank: Volume Status showed an IVC diameter of 1.2 cm with total collapse on inspiration and no free fluid on abdomen. The Pipes: circulatory system showed no evidence of DVT and no AAA. Due to the history of suspected cellulitis and no clear source of infection, we added a bedside musculoskeletal pointof-care-ultrasound (POCUS) of both extremities. In the left inner thigh, findings were consistent with necrotizing fasciitis (NF) (Figure 1), including diffuse subcutaneous thickening, fluid accumulation along the deep fascial layer and gas bubbles. The

Acute ischemic stroke what is hidden behind

Acute aortic dissection (AAD) is a rare and potentially fatal disease. The classic presentation is sudden and severe pain in the chest, back, or abdomen, described as tearing or ripping pain radiating to the interscapular region. Cerebral ischemic complications occur in 18-30% of aortic dissections and patients may present to the emergency department (ED) with isolated focal neurology and no chest pain. In AAD patients, presenting with stroke and subsequently thrombolized, a 71% mortality rate has been reported in patients receiving recombinant tissue plasminogen activator (r-TPA). We present a case of a 58-year-old male patient that presented to ED with sudden onset of headache and left-sided hemiparesis, computed tomography (CT) demonstrated an ischemic stroke of the right middle cerebral artery. When the question of whether to start r-TPA or mechanical thrombectomy was discussed, a cardiac point-of-care ultrasound was performed in ED and showed a type A aortic dissection; immediately a CT aortic angiogram was performed and confirmed the diagnosis. The patient was taken to theater and had a favorable outcome. <Learning objective: Acute aortic dissection (AAD) may present as acute ischemic stroke with no chest pain. In patients with acute ischemic stroke with an unclear etiology point-of-care ultrasound (POCUS), cardiac, and aortic ultrasound are important rapidly to diagnose AAD and avoid the deleterious effect of thrombolysis. This case supports the feasibility of emergency physicians performing POCUS assessments for AAD.>.

Catastrophic antiphospholipid antibody syndrome presenting as acute vascular occlusion in a young female patient.

Acquired thrombotic and thromboembolic disorders may be presented initially with symptoms and signs of acute ischaemia or organ dysfunction that will lead many of these patients to seek care in the emergency department. We report a case of a 19-year-old female patient who developed catastrophic antiphospholipid syndrome (CAPS syndrome or Asherson syndrome) 6 weeks post stillbirth with an initial presentation of acute vascular occlusion. The patient was immediately operated and anticoagulated with significant improvement.