Joseph Shiber

Pyomyositis due to anabolic steroid injection.

e69 there was no crepitus or fluctuance (Figure 1). Laboratory studies found an elevated white blood cell count of 19,000/mm with 86% neutrophils. A computed tomographic (CT) scan of the right thigh revealed a loculated collection involving the vastus lateralis muscle from just below the lesser trochanter to above the knee (17 cm length by 9 cm transverse by 6.5 cm anterior-posterior), with fluid and inflammatory changes of the rectus femoris and tensor fascia lata and overlying subcutaneous edema

Ketamine Causing Apnea

everolimus. To our knowledge, this is the first case of everolimus-induced diabetic ketoacidosis in a cancer patient, although one case was reported in a cardiac transplant patient. Severe hypertriglyceridemia has been reported at approximately 0.8% in patients with breast cancer treated with everolimus. One case of everolimusinduced hypertriglyceridemia and acute pancreatitis has been published, although several phase III clinical trials of everolimus did not report any pancreatitis or diabetic ketoacidosis as adverse effects. With expanding indications of the use of everolimus in cancer patients, the incidence of everolimus-induced oncologic emergencies is expected to increase. Emergency physicians need to be aware of these potential complications to diagnose them early and initiate timely management.

Prostatitis or Prostatic Abscess

A 65-year-old Hispanic man with a history of type 2 diabetes mellitus, coronary artery disease, and peripheral vascular disease presented to the Emergency Department (ED) complaining of fever and constipation with lower back and rectal pain. During the previous 6 weeks, he had experienced progressive urinary retention and had presented to his primary care provider (PCP) and to the ED several times for dysuria and lower back pain. He had initially been treated by his PCP with a 12-day course of trimethoprim-sulfamethaxozole, despite having a normal urinalysis. One month later, he returned to his PCP and, again, despite normal urinalysis and culture, was treated with a 7-day course of ciprofloxacin. Three days later (7 days before presentation), he presented to the ED with dysuria, flank pain, and urinary retention for 2 weeks, along with constipation. His prostate was found to be slightly tender and prostatitis was suspected. The patient was given ibuprofen, phenazopyridine, and doxazosin, and told to complete his course of ciprofloxacin. The next day (6 days before presentation) he followed up with his PCP and was given lactulose for constipation. Five days later (1 day before presentation), the patient returned to the ED with the complaint of suprapubic pain and urinary retention. He reported that antibiotics had not helped his pain and that he was urinating only very small amounts. A Foley catheter was placed

Alternative payment models: can (should) trauma care be bundled?

Background Recent legislation repealing the Sustainable Growth Rate mandates gradual replacement of fee for service with alternative payment models (APMs), which will include service bundling. We analyzed the 2 years’ experience at our state-designated level I trauma center to determine the feasibility of such an approach for trauma care. Methods De-identified data from all injured patients treated by the trauma service during 2014 and 2015 were reviewed to determine individual patient injury profiles. Using these injury profiles we created the ‘trauma bundle’ by concatenating the highest Abbreviated Injury Scale score for each of the six body regions to produce a single ‘signature’ of injury by region for every patient. These trauma bundles were analyzed by frequency over 2 years and by each year. The impacts of physiology and resource consumption were evaluated by determination of the correlation of the mean and SD of calculated survival probability (Ps) and intensive care unit length of stay (ICU LOS) for each profile group occurring more than 12 times in 2 years. Results The 5813 patients treated over 2 years produced 858 distinct injury profiles, only 8% (71) of which occurred more than 12 times in 2 years. Comparison of 2014 and 2015 profiles demonstrated high frequency variation among profiles between the 2 years. Analysis of injury patterns occurring >12 times in 2 years demonstrated an inverse correlation between the mean and SD for Ps (R2=0.68) and a direct correlation for ICU LOS (R2=0.84). Discussion These data indicate that the disease of injury is too inconsistent a mix of injury pattern and physiologic response to be predictably bundled for an APM. The inverse correlation of increasing SD with increasing ICU LOS and decreasing Ps suggests an opportunity for measurable process improvement. Level of evidence Economic and value-based evaluations, level IV. Study type Economic/decision.

DVT and pulmonary embolism with stroke

An 86-year-old woman tripped over her dog fracturing her right femur and left ankle; she had operative repair of her femur but conservative treatment with immobilization of the ankle injury and received 6 weeks of subcutaneous heparin for prevention of deep venous thrombosis (DVT). One week later she noticed soreness in her right thigh and became acutely dyspneic when walking to the bathroom. On arrival at the hospital she was tachycardic and tachypneic, requiring high-flow oxygen to maintain her oxygen saturation above 90 %. Bilateral proximal pulmonary emboli (PE) were diagnosed by chest CT angiography (Fig. 1) and a heparin infusion was started. A transthoracic echocardiogram (TTE) demonstrated right ventricular dilation with leftward bowing of the interventricular septum, moderate-severe tricuspid regurgitation, and elevated pulmonary artery pressures. Based on these findings, tissue plasminogen activator (TPA) was given intravenously since no contraindications were present. Additionally, duplex ultrasonography found she had DVT of her right femoral and left popliteal veins. One hour after infusion was complete, her heart rate, respiratory rate and oxygenation had improved but she became somnolent with a left-sided gaze preference, clumsy movements of her right upper extremity, and dysarthria. A non-contrast brain CT did not demonstrate any intracranial hemorrhage. There had not been any significant change in her blood pressure and her blood glucose remained normal. Her symptoms improved over the next hour and several hours later resolved. A non-contrast brain MRI demonstrated three areas of subacute ischemia (Fig. 2): left temporoccipital, right parietal, and left frontal. The next day, a contrast-enhanced transesophageal echocardiogram (TEE) confirmed a patent foramen ovale (PFO), but resolution of the previous findings indicating elevated right heart pressure. She was continued on aspirin, heparin infusion, and an inferior vena cava filter was placed when a subsequent ultrasound demonstrated persistent DVT in both legs.

Olivier syndrome: traumatic asphyxia.

A 51 year-old woman was found confused while crawling across a field. She had marked facial cyanosis and edema with cutaneous petechiae, subconjuctival hemorrhages, and echymosis across her anterior neck (image 1). Mild cerebral edema and a non-displaced thyroid cartilage fracture were found on computed tomography (CT). The patient recovered full neuro-cognitive function within 24 hours and reported that she had been assaulted and choked by the throat. Her airway remained stable and the laryngeal injury was treated conservatively; she was discharged home after three days. Figure. Patient with facial cyanosis and edema with cutaneous petechiae, subconjuctival hemmorhages, and echymosis across the anterior neck. Olivier described this syndrome over 150 years ago after thoraco-abdominal crush injuries. It is essentially a prolonged valsalva maneuver that results in increased venous pressure and stasis above the level of the compressive force.1,2 The consequent findings on the chest, neck and face are startling but of no prognostic significance, and the majority of patients have a favorable outcome.2,3

Bilateral traumatic renal artery dissection

We present a case of bilateral renal artery dissection, with the related computed tomographic images, caused by blunt torso trauma. Discussion includes the etiologies of this type of injury, the diagnostic modalities, and treatment options.