Application of Point-of-care Ultrasound for Screening Climbers at High Altitude for Pulmonary B-lines.

INTRODUCTION: High-altitude pulmonary edema (HAPE) occurs as a result of rapid ascent to altitude faster than the acclimatization processes of the body. Symptoms can begin at an elevation of 2,500 meters above sea level. Our objective in this study was to determine the prevalence and trend of developing B-lines at 2,745 meters above sea level among healthy visitors over four consecutive days. METHODS: We performed a prospective case series on healthy volunteers at Mammoth Mountain, CA, USA. Subjects underwent pulmonary ultrasound for B-lines over four consecutive days. RESULTS: We enrolled 21 male and 21 female participants. There was an increase in the sum of B-lines at both lung bases from day 1 to day 3, with a subsequent decrease from day 3 to day 4(P<0.001). By the third day at altitude, B-lines were detectable at base of lungs of all participants. Similarly, B-lines increased at apex of lungs from day 1 to day 3 and decreased on day 4 (P=0.004). CONCLUSION: By the third day at 2,745 meters altitude, B-lines were detectable in the bases of both lungs of all healthy participants in our study. We assume that increasing the number of B-lines could be considered an early sign of HAPE. Point-of-care ultrasound could be used to detect and monitor B-lines at altitude to facilitate early detection of HAPE, regardless of pre-existing risk factors.

Pheochromocytoma Leading to Multiorgan Failure in a Pregnant Patient: A Case Report.

INTRODUCTION: Pheochromocytoma, a neuroendocrine tumor that secretes catecholamines, can present with episodic sweating, diaphoresis, headaches, and hypertension, as well as cardiac and pulmonary involvement. In a pregnant patient, it must be differentiated from preeclampsia, a leading cause of maternal mortality in the developed world, which can similarly present with hypertension and multiorgan involvement. Both conditions require early diagnosis and treatment to reduce maternal and fetal morbidity and mortality. CASE REPORT: We discuss the case of a pregnant patient at approximately 24 weeks' gestation presenting with chest pain and shortness of breath who was found to have a left adrenal mass and hypertensive urgency. The patient acutely decompensated during the course of evaluation. She ultimately suffered pregnancy loss and multiorgan failure requiring percutaneous heart pump placement and extracorporeal membrane oxygenation therapy for support before fully recovering. The adrenal mass was confirmed to be a pheochromocytoma after excision and contributed to the development of hypertensive emergency with multiorgan failure. CONCLUSION: Pheochromocytoma during pregnancy is a rare condition but must remain on the differential until ruled out to improve patient outcomes as much as possible. Obtaining blood pressure control is imperative to reducing maternal and fetal mortality. Preeclampsia is similarly serious, and early diagnosis is essential for adequate management of the condition until delivery can occur.

Rapid Airway Narrowing Associated with Hodgkin's Lymphoma, a Case Report.

Hodgkin's lymphoma is a neoplastic proliferation of Reed Sternberg cells and inflammatory cells within the lymphatic system. Common symptoms associated with Hodgkin's Lymphoma include pronounced lymphadenopathy, fever, polynuclear leukocytosis, and anemia.1,2 This case study presents a unique case where an adult patient with nodular sclerosing Hodgkin's lymphoma (NSHL) presents with rapidly progressing dyspnea due to tracheal airway narrowing. CT results showed pathological lymph nodes in bilateral cervical stations, subclavian images and within the mediastinum, concerning for lymphoproliferative disease. Otolaryngology was consulted for a possible tracheostomy; however, an awake fiberoptic intubation was suggested and subsequently performed instead. This case demonstrates the importance of immediate intervention to prevent airway loss in an atypical presentation of NSHL. Topics: Nodular sclerosing Hodgkin's lymphoma, airway loss, intubation.

Loose PEG Tube Leading to Peristomal Leakage and Peritonitis, a Case Report.

We present the case of a 37-year-old male with history of amyotrophic lateral sclerosis (ALS) and recent percutaneous endoscopic gastrostomy (PEG) tube placement presented with abdominal pain, nausea, vomiting, abdominal distention, tenderness and guarding. Given the concern for peritonitis, upright/decubitus chest X-ray was obtained and showed bilateral free peritoneal air suggesting possible perforation or peristomal leakage after PEG tube placement. While PEG complication rates are relatively low, clinicians should consider them and remember that chest X-ray can be a very efficient and accurate method of evaluation for possible gastrointestinal perforation, especially in acute emergencies. Topics: Abdominal/gastrointestinal, peritonitis, perforation, surgical complication.

A Prospective Study of Stingray Injury and Envenomation Outcomes.

BACKGROUND: Stingray injuries result in thousands of emergency department visits annually. OBJECTIVES: This study aimed to assess the complication rate and outcome of field treatment with hot water immersion. METHODS: This was an on-site, prospective, observational study. Subjects were enrolled after having been stung by a stingray. A trained researcher obtained the following information: age, sex, health conditions and medications, and wound description. The efficacy of hot water immersion on pain was recorded. Patients were contacted on postinjury days 3, 7, and 14 for follow up. RESULTS: Twenty-two subjects were included. No obvious foreign bodies were observed in wounds. Ten subjects were treated with hot water immersion and povidone-iodine, 12 with hot water immersion alone. Ongoing symptoms or complications were noted at the 3-day follow-up in 6 of 22 subjects (27.3%). One subject was diagnosed with cellulitis on post-sting day 8 and was treated with antibiotics. Ongoing symptoms or complications were reported more commonly in patients treated with hot water and povidone-iodine compared with those treated with hot water alone (p = 0.056). There was a significant difference in wound size between those with and without ongoing symptoms at the 3-day follow-up (p = 0.0102). No wounds <1 cm developed any complications. Average duration of water immersion was 73.6 min (range 35-145 min). The mean pain score pretreatment was 7.36 and posttreatment was 2.18, with an average decrease of 5.18 (95% confidence interval 4.22-6.15). CONCLUSION: Stingray injuries responded well to hot water immersion for pain control. Skin and soft tissue infection was diagnosed in 1 of 22 patients (4.55%).

Use of Point-of-Care Ultrasound to Guide Pediatric Gastrostomy Tube Replacement in the Emergency Department.

The presentation of a pediatric patient to the emergency department for a malfunctioning or dislodged gastrostomy tube (G-tube) is not uncommon. As such, these tubes are often replaced at the bedside. Improper placement can result in a number of complications, including perforation, fistula tract formation, peritonitis, and sepsis. The current criterion standard method to confirm proper G-tube placement is contrast-enhanced radiography. However, point-of-care ultrasound may be an alternative method to guide and confirm pediatric G-tube replacement in the emergency department. We report a series of cases on this novel point-of-care ultrasound application.