Vincent L. Ball

A Child with Benign Acute Childhood Myositis After Influenza

BACKGROUND Benign acute childhood myositis (BACM) is a rare transient muscle syndrome classically occurring in children after a viral upper respiratory infection (URI). BACM causes difficulty walking due to severe bilateral calf pain. The incidence of this well-described phenomenon is uncertain but infrequent, and it is typically appreciated during times of large influenza outbreaks and epidemics. The URI symptoms that precede BACM are consistent with an uncomplicated viral influenza infection and include fever, malaise, cough, sore throat, headache, and rhinitis. OBJECTIVES Little is written in the Emergency Medicine literature regarding this clinical entity. In this report, a brief review of BACM from the current literature is provided, as well as tools to aid in differentiating it from more severe but similar disorders such as rhabdomyolysis and Guillain-Barré syndrome. CASE REPORT We present a case of BACM in a 7-year-old boy who presented to the emergency department after a resolving URI with the acute onset of calf pain causing alarming difficulty in his ability to walk. His presentation was typical for BACM and his condition improved with supportive treatment. CONCLUSIONS Although quite alarming and potentially puzzling to the physician who is not familiar with BACM, this syndrome is self limited and spontaneously resolves with no specific intervention. Recognition of this rare but distinct clinical entity by the emergency physician can spare a patient from potentially unneeded invasive testing and hospital admission.

Iatrogenic bacterial meningitis: an unmasked threat.

Iatrogenic bacterial meningitis (IBM) is a rare but serious complication of neuraxial procedures, such as spinal and epidural anesthesia or lumbar puncture. We report a case of a 46-year-old female who presented to the emergency department with bacterial meningitis after spinal anesthesia. We review the existing literature outlining the pathogenesis, vector hypothesis, diagnosis, treatment, and prevention as they relate to IBM. We highlight the role of the emergency physician in the rapid diagnosis of this disease, and underscore the need for sterile technique when performing lumbar punctures.

Emergency Department Evaluation and Treatment of Acute Hip and Thigh Pain

Although the incidence of hip fractures is decreasing, the overall prevalence continues to increase because of an aging population. People older than 65 suffer fractures at a rate of 0.6% per year--2% per year for persons older than 85. One in 5 patients suffering a hip fracture will die within a year. Additionally, the emergency physician must consider entities such as avascular necrosis, compartment syndrome, and muscular disruption. This article reviews patterns and complications of acute hip and thigh injuries and clinically relevant diagnostic, anesthetic, and treatment options that facilitate timely, appropriate, and effective emergency department management.

Traumatic Injury Patterns Associated With Static Line Parachuting

OBJECTIVE We investigated the incidence and injury patterns of acute parachuting injuries evaluated at a level II military facility during a 5-year period to compile medical information that may assist in improving the safety of parachuting. METHODS A retrospective chart review of all parachuting injuries that presented to the Madigan Army Medical Center emergency department in Tacoma, Washington, during a 5-year period from February 2005 to June 2011. RESULTS A total 110 patient charts met inclusion criteria. Lower extremity injuries made up 65% of total injuries, followed by 22% head injuries, 22% neck or back injuries, and 19% upper extremity injuries. One patient died in the emergency department of head injuries, and 1 patient was transferred for an open-book pelvic fracture. The most common phase of the jump in which to sustain injury was at landing. A total of 15 patients were admitted to the hospital. It is of note that some patients had combined injuries. The mechanism of injury documented in 96 of 110 (87%) patients and 10 of 15 (66%) admitted patients was a difficult landing. CONCLUSIONS The rate of injury for each area of the body is within previously reported rates, with lower extremity injuries making up the largest category and leading to the majority of admissions. The most common time to sustain an injury was during landing, which represented a majority of both emergency room visits and hospitalizations.

Accuracy of trans-abdominal ultrasound in a simulated massive acute overdose

INTRODUCTION Toxic ingestions are a common cause of morbidity and mortality in the United States. In 2013, there were nearly 2 million reported ingestions and nearly 1000 deaths from poisonings. There is no well-validated imaging study for confirming the presence of pills in the stomach of an overdose patient. There are case reports of ultrasound used for confirmation of pills in the stomach, and we are aware of one prospective trial to evaluate sonography for this application. OBJECTIVE To determine the sensitivity and specificity of transabdominal ultrasound for visualization of ingested pills. METHODS Randomized, blinded, placebo-controlled study. Twenty Subjects were randomized to one of two groups. The experimental group ingested 50 enteric-coated placebo capsules with 1 liter of fluid. The control group ingested only 1 liter of fluid. At time 0, 60, and 90 minutes after ingestion, expert sonographers performed transabdominal ultrasound in an attempt to visualize pills in the stomach. RESULTS At time 0, 60, and 90 minutes post-ingestion, ultrasound had a sensitivity of 62.5% (41.1%, 81.9%), 20.8% (4.6%, 37.1%), and 25% (7.7%, 42.3%) respectively. The specificity at time 0, 60, and 90 minutes post-ingestion were 58.3% (21.9%, 61.4%), 79.1% (62.9%, 95.5%), and 70.8% (52.6%, 89.0%) respectively. CONCLUSION There is poor sensitivity and specificity for ultrasound detection of pills in the stomach at time 0; these values fell substantially at 60 and 90 minutes post-ingestion. In this pilot study, we did not find ultrasound to be a useful screening tool for detecting pills in the stomach.

Infant With Vomiting and Weight Loss

A 5-week-old boy presented to the emergency department with a 3-day history of vomiting and weight loss. He was an only child, with an uneventful full-term birth history. Systems review and family history were unremarkable. On examination, the infant was somnolent but when offered a bottle, fed vigorously, promptly vomiting projectile, nonbilious/nonbloody vomitus. His laboratory analysis was significant for a potassium level of 3.6 mEq/L and a chloride level of 95 mEq/L. Figure 1. Abdominal radiograph. Figure 2. Ultrasonography of the abdomen. Used with permission of MAJ Vincent Ball, MD, Department of Emergency Medicine, Madigan Army Medical Center, Fort Lewis, WA.