Clinical Practice and Cases in Emergency Medicine Volume 8 Issue 3 by Western Journal of Emergency Medicine

Volume 8, Number 3, August 2024

Clinical Practice and Cases in Emergency Medicine

In Collaboration with the Western Journal of Emergency Medicine

Clinicopathological Cases from the University of Maryland

182 A 77-Year-Old Male with a Rapid Change in Mental Status

Andrew Piner, Spencer S. Lovegrove, Laura J. Bontempo, T. Andrew Windsor

Case Reports

189 Pneumothorax Identified by a Remote Physician Using Paramedic-obtained Tele-ultrasound: Case Report

Shriman Balasubramanian, Michael DeFilippo, Michael Stone, Gabriela Galli, Matthew McCarty, Brock Daniels

194 Renal Artery Aneurysm Rupture as a Dangerous Mimic of Ovarian Cyst Rupture: A Case Report

Lauren Kaplan, Kaushal H. Shah, Christie Lech, Mary-Kate Gorlick

197 Capnocytophaga ochracea Septicemia After a Dog Bite: The Case of a Usual Suspect Transmitting an Unusual Organism

Clifford Chang, Vakula Atthota, Madison Lord, Michael P. Bonk, Muhammad Durrani

202 High-altitude Cerebral Edema and High-altitude Pulmonary Edema Diagnosed in the Desert: A Case Report

Bryn Walsh, Suneil Agrawal

206 Acute Confusional Migraines: A Case Report

Devin M. Howell, Garrett Lamouree

211 Spontaneous Osteomyelitis and Intraosseous Abscess: A Case Report

Meghan Chamberlain, Simon A. Sarkisian

215 A Case Report of Wünderlich Syndrome Causing Massive Hemorrhage During Hemodialysis

Karalee Bluhm, Ravali Kundeti, Nicole Maguire

Contents continued on page iii

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Clinical Practice and Cases in Emergency Medicine

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Rick A. McPheeters, DO, Editor-in-Chief

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Clinical Practice and Cases in Emergency Medicine

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JOURNAL FOCUS

Clinical Practice and Cases in Emergency Medicine (CPC-EM) is a MEDLINE-indexed internationally recognized journal affiliated with the Western Journal of Emergency Medicine (WestJEM). It offers the latest in patient care case reports, images in the field of emergency medicine and state of the art clinicopathological and medicolegal cases. CPC-EM is fully open-access, peer reviewed, well indexed and available anywhere with an internet connection. CPC-EM encourages submissions from junior authors, established faculty, and residents of established and developing emergency medicine programs throughout the world.

219 A Case Report of Crotalidae Immune F(ab’)2-associated Coagulopathy Recurrence in a Preschool-age Child

Jean C.Y. Lo, E. Lea Walters, Brian Wolk

222 A Case Report of Delayed Opioid Toxidrome After Administration of Naloxone Maiya Cowan, Prasanna Kumar, Jenny McManus, Sean Bilodeau, Andrew Beck

226 Testicular Traction Technique with Intact Cremasteric Reflex, a Novel Approach for Manual Detorsion: Case Report

Garrett Trang, Taz Brinkerhoff

231 A Case Report of Hematogenous Osteomyelitis of the Manubrium Caused by Seeding from a Colovesicular Fistula Celina Wong, Tammy Phan, Emmelyn Samones, Sharmin Kalam

235 Ultrasound-guided Supraclavicular Brachial Plexus Block for Therapeutic Management of Postoperative Compressive Brachial Plexus Neuropathy: A Case Report

Daniela Usuga, Sofia Portuondo, David Farcy, Michael Shalaby

239 Neurogenic Pulmonary Edema Associated with Hyponatremia, Primary Polydipsia, and Cannabis Use: A Case Report

Christian Treat, Nicholas Ulloa, Alyssa Kettler, David Lawrence

243 Spontaneous Intracranial Hypotension Associated with Marfan Syndrome: A Case Report

Faiza Tariq, Wesley Eilbert

246 Atrial Fibrillation Occurring After Smoking Marijuana: A Case Report and Review of the Literature

Mary Unanyan, Christopher Colbert, Wesley Eilbert

250 ST-Elevation Myocardial Infarction Due to Coronary Vasospasm Associated with Eosinophilic Granulomatosis with Polyangiitis: A Case Report

Christopher Allen, Christopher Poyorena, Lauren B. Querin

254 Point-of-Care Ultrasound Findings in Occlusive Iliac Vein Thrombus During Pregnancy: A Case Report Donald Pettet III, John Forrester, Mathew Nelson, Tanya Bajaj

259 Rectus Sheath Blocks for Umbilical Hernia Reductions in the Emergency Department: A Case Series Katherine Vlasica, Amanda Hall

264 Angioedema Secondary to Tenecteplase Use in a Patient with Acute Ischemic Stroke: A Case Report Babette Newman, Matthew Poremba, R. Gentry Wilkerson

268 Tension Pyopneumothorax in an Immunocompetent Adolescent: A Case Report

Elizabeth May-Smith, Marc Olshan, Mark Supino

Policies for peer review, author instructions, conflicts of interest and human and animal subjects protections can be found online at www.westjem.com.

No. 3: August 2024

Clinical Practice and Cases in Emergency Medicine

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JOURNAL FOCUS

Table of Contents continued

273 Community-Acquired Candida albicans Empyema Leading to Tension Physiology: A Case Report

Jason Cinti, Paula Gomez, Suneil Agrawal

277 “K Cramps,” Recurrent Abdominal Pain in a Patient with Chronic Ketamine Use: A Case Report

Tucker Avra, Jesus Torres, Kumar Felipe Vasudevan, Elizabeth A. Samuels

282 Pupil Unleashed: Unraveling the Enigma of an Unusual Traumatic Head Injury: A Case Report

Akash Daswaney, Shuchi Abhishek, Sanjan Asanaru Kunju, Priya Pattath Sankaran, Ahlam Abdul Rahman

287 Spontaneous Hemothorax from Pulmonary Intralobar Sequestration: A Case Report

Clayton Korson, Jasmine Yu, John M. Pester

291 Median Nerve Measurement and Steroid Injection for Carpal Tunnel Syndrome: A Case Report

Gregory Oliva, Joseph McShannic, Yonghoon Lee, Michael Shalaby

Images in Emergency Medicine

295 Bezold Abscess in a Case of Eosinophilic Otitis Media

Satoshi Tsuruta, Takashi Fujiwara

298 Point-of-care Ultrasound Diagnosed Intraocular Breast Metastasis

Hamzah M. Yusuf, Timothy Batchelor, Nicholas Ashenburg

300 Spinal Arachnoid Web

Maiya Smith, Morgan Ketterling, Alexander Gallaer, Rowan Kelner, Christine Raps, Allison M. Beaulieu

302 A Woman with Right Shoulder Pain

Kitan Akinosho, William Weber

305 Point-of-Care Ultrasound for Earlier Detection of Pediatric Pneumonia

John H. Priester, Prasanna Kumar, Jesse Naumann, Katherine Dolbec, Peter Weimersheimer, Christian D. Pulcini

308 Painful Enlarging Cervical Mass in Young Male

Jacob Lawing, Jeremy Towns, Matthew A. Heimann

311 Atraumatic Infected Septal Hematoma in a Pediatric Patient

Osher Shefer, Jacqueline Le, Eshaan Daas, Eugene Hu

314 Brugada Syndrome and Sudden Cardiac Death: An Electrocardiographic History

Mark L. Moubarek, Gordon X. Wong, James S. Ford

Policies for peer review, author instructions, conflicts of interest and human and animal subjects protections can be found online at www.westjem.com.

A77-Year-OldMalewithaRapidChangeinMentalStatus

AndrewPiner,MD* SpencerS.Lovegrove,MD†

LauraJ.Bontempo,MD,MEd†

T.AndrewWindsor,MD†

SectionEditor:JoelMoll,MD

*UniversityofMarylandMedicalCenter,Baltimore,Maryland † UniversityofMarylandSchoolofMedicine,DepartmentofEmergencyMedicine, Baltimore,Maryland

Submissionhistory:SubmittedJanuary17,2024;RevisionreceivedMarch25,2024;AcceptedApril4,2024

ElectronicallypublishedJune14,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.7213

A77-year-oldmalewhopresentedtotheemergencydepartmentwithgeneralizedweaknessand worseningchronicdysphagiawasdiagnosedwithpneumonia.Shortlyafterreceivingvascularaccessfor histreatment,hehadarapidchangeinhismentalstatusandneurologicalexamination.[ClinPract CasesEmergMed.2024;8(3)182–188.]

Keywords: airembolism;stroke;CPC.

CASEPRESENTATION(DR.PINER)

A77-year-oldmalepresentedtotheemergency department(ED)forgeneralizedweaknessaswellas worseningchronicdysphagia.Hewasaccompaniedbyhis wife,whoassistedinprovidingthehistory.Hispastmedical historyincludeddiabetes,hypothyroidism,athyroidgoiter, rightinternaljugular(IJ)thrombusforwhichhewastaking anticoagulation,andcirrhosis.Hissurgicalhistorywas signiﬁcantforremotebilateralpercutaneousnephrostomy tubeplacement,yearsprior.Threeweeksprecedingthis hospitalvisit,hehadbeenadmittedanddischargedfromthe samehospitalafterreceivingathoracentesiswithdrainageof asimpletransudativepleuraleffusion.Thisincompletely relievedhishypoxia,andhewasdischargedonthreelitersper minute(L/min)ofoxygenvianasalcannula.

Sincereturninghome,thepatientthoughthisbreathing hadslightlyimproved,buthehaddifﬁcultycompletinghis dailyactivities.Hehadapoorappetiteandwhenhedideat, heexperienceddysphagiafromhisgoiter,whichhefeltwas gettingworse.Hereportedgeneralmalaiseandchills.Hedid notfeelshortofbreathonexertion,ashehadduringhislast hospitalization,andhewasnotexperiencinganychest discomfort.Hedeniedanynausea,vomiting,constipation, diarrhea,dysuria,orurinarychanges.Hewasableto ambulatebuthaddifﬁcultydoingsoduetohisweakness.

Thepatientwasrecoveringfromalcoholusedisorderand deniedhavinganyalcoholicdrinksinmultipleyears.Hehad aremote, ﬁvepack-yeartobaccohistorybutdidnotsmoke anylonger.Hedeniedanyuseofillicitdrugs.Hiswife

oversawhismedications,whichhadnotchangedsincehis hospitaldischarge.Hetookmetoprolol,spironolactone, levothyroxine,andapixaban.Hehadnoknown drugallergies.

Thepatient’svitalsignsrevealedanoraltemperatureof 100.4° Fahrenheit(38° Celsius),heartrateof90beatsper minute,abloodpressureof90/40millimetersofmercury (mmHg),arespiratoryrateof15breathsperminute,andhis oxygensaturationwas94%on3L/minvianasalcannula.He weighed64kilograms(142pounds)andwas170centimeters tall(5feet7inches)withabodymassindexof22.1.

Onphysicalexamination,thepatientwasalertand orientedtoperson,place,time,andevents.Hewasableto speakinfullsentenceswithoutdyspnea.Hedidnotappearin acutedistress.Hehadevidenceofalargegoiteranddenied tendernessorthesensationofitexpandingorchanging.His breathsoundswerediminishedattherightlowerbasewith scatteredrhonchiandanoccasionalcough.Hisheartsounds wereregularwithoutmurmurs,rubs,orgallops.His abdomenwaslarge,protuberant,andhadasoft ﬂuidwave thatcouldbeappreciated.Itwasnotincreasedinsizeperhis wife.Therewasnoguardingortenderness.Hehadtrace pedaledemawithoutlateralizingswelling.Hemovedall extremitieswithoutlocalizingweakness.Althoughhe reportedweakness,hisstrengthwas5/5symmetricallyinhis upperandlowerextremities.Hiscranialnerves(CN)II–XII wereintact.HisGlasgowComaScale(GCS)scorewas 15/15 – Eye4,Verbal5,Motor6.Hispupilswereequal, round,andreactivetolight.Hewasnotambulatedinthe

Table. Initiallaboratoryresultsofa77-year-oldmanwitharapid changeinmentalstatus.

Completemetabolicpanel

–99mg/dL

–17mg/dL

–1.04mg/dL

–10.2mg/dL

1.51.6–2.6mg/dL

2.92.5–4.5mg/dL

–8.2g/dL

10.3–1.2mg/dL

Aspartateaminotransferase4614–36units/L

Alanineaminotransferase210–34units/L

Alkalinephosphatase 8238–126units/L

Coagulation

–38seconds

–400mg/dL

–4mIU/L

6.60.8–1.8ng/dL

Additionaltests

Lactate 1.70.5–2.2mmol/L Ammonia 99–30 mcmol/L TroponinI0.02 <0.06ng/mL

dL, deciliter; g,grams; K,thousands; mcL,microliter; mcmol, micromole; mg,milligram; mIU,milli-internationalunits; mmol, millimole; ng,nanogram; L,liter.

Whatdowealreadyknowaboutthis clinicalentity?

Airembolismisararebutpotentiallylifethreateningcomplicationofvarious procedures,includingcentrallineplacement.

Whatmakesthispresentationof diseasereportable?

Thispatientexperiencedacerebralair embolismbutdidnothaveapatentforamen ovale,andtheairembolismremainedwithin thevenoussystem.

Whatisthemajorlearningpoint?

Althoughrare,cliniciansshouldconsiderair embolismforapatientwhohasanunexpected declineintheirconditionshortlyafteran intravascularprocedure.

Howmightthisimproveemergency medicinepractice?

Thiscasediscussestre atmentofthisserious condition,includingbedsidetreatmentand hyperbaricoxygentherapy.

roombuthadbeenseenearliermovingfromahospital wheelchairtothestretcherwithassistance.Therewasnoskin rashorjointswelling.

Initiallaboratoryresultsareshownin Table.An electrocardiogram(ECG)wasperformedandshowedasinus rhythmwithoutectopyorST-segmentchangesandwas unchangedfromhisprevioushospitalization.Chest radiography(CXR)wasobtained,shownin Image1.The radiologist’sinterpretationwas “[p]atchyopacityintheright lowerlobesuggestiveofpneumoniainthecorrectclinical setting.Goiterredemonstratedwhencomparedtoprevious. Normalcardiac ﬁndings.” Apoint-of-careultrasound (POCUS)oftheheartshowednopericardialeffusion,no suggestionofrightventriclestrain,novolumeoverload,and anormalleftventricle.

Beforetreatmentforpneumoniacouldbestarted,the nursealertedthephysiciantothelossofvascularaccess. Therewerenoreliableperipheralveinsseenviaultrasound; so,centralaccesswasobtainedintheleftIJveinvia ultrasoundguidancewhilethepatientwasinasemi-reclined position.Thewirewasconﬁrmedintheveinandremoved. Thephysicianinstilledabolusofagitatednormalsaline, conﬁrmingthecentralaccesswasinthevenoussystemby PopulationHealthResearchCapsule

Image1. Initialchestradiographshowinganopacityintheright midlung(blackarrow)ina77-year-oldmanbeforeheexperienced arapidchangeinmentalstatus.

visualizingturbulent ﬂowintherightatriumwithPOCUS. Thelinewassuturedanddressed.

Fifteenminuteslater,thephysicianwascalledtotheroom asthepatient’soxygenrequirementincreasedandhewasless responsive.Repeatphysicalexaminationrevealednew tachycardiawithameanarterialpressureof59mmHg.The patient’srespiratoryratewas20,andhisoxygensaturation remained94%on15L/minviaanon-rebreathermask. RepeatPOCUSshowedunchangedcardiacfunctionandno evidenceofpneumothorax.Thepatientwasunabletofollow commands,hiseyesopenedonlytopain,andhemuttered incomprehensiblewords.Hewasnotedtowithdrawtopain ontherightarmandleg,theleftarmwas ﬂaccid,andtheleft legwas ﬂexed.HisnewGCSwas8/15 – Eye2,Verbal2, Motor4.Hislefteyewasmidline,buthisrighteyewasnoted todeviatelaterallyandinferiorly.

Thepatientwasintubated,andaconﬁrmatoryCXR demonstratedintervalchangesofanewleftIJcentralline catheterandanendotrachealtubethatbothappeared adequatelypositionedasseenin Image2.

Atestwasperformed,andadiagnosiswasmade.

CASEDISCUSSION(DR.LOVEGROVE)

Thisisacaseofanelderlygentlemanwhoacutely decompensatedintheEDafterinitiallypresentingdueto worseningweaknessanddysphagia.Whenthereisapatient whoacutelydecompensatesintheED,asthispatientdid,itis importanttoconsiderwhetherthiswastheresultofthe

Repeatchestradiographofa77-year-oldmanaftera rapidchangeinmentalstatusshowingtheplacementofan endotrachealtube(blackarrows)andleftinternaljugularcentral line(whitearrows).

patient’snaturaldiseasecourse,somethingthathappenedin theED(iatrogenic),orevenalittlebitofboth.

Thepatient’sinitialcomplaintisworseningdysphagiaas wellasweakness.Hehasanextensivemedicalhistorythat includesdiabetes,hypothyroidism,goiter,rightIJthrombus, andanticoagulantuse.Hisphysicalexamisnotablefor multipleabnormalitiesincludingfever,hypotension, abnormalbreathsoundsinhisrightlung,andascites.Itis alsoimportanttopointoutthathisneurologicexamis normal,includingfullstrengthinallextremities.

Lookingoverthelabsandimaging,Idonotbelievethey provideasigniﬁcantamountofnewinformationbutcouldbe usedtoremovesomedifferentials.Thepatient’schemistry hadsomeslightabnormalitiesbutnothingunexpectedgiven hiscomorbidities.Hiscoagulationstudieswereconsistent withsomeonewithcirrhosis.Thereweresomeabnormalities inhisthyroidfunctionpanel,butIdonotthinktheyexplain hisacutechange.Wealsodonotknowthetimingofhis levothyroxinedose,andhisthyroidstimulatinghormone indicatesthathehaslikelybeentakingit.Theetiologyof hematuriaisunclear,buthisurineisotherwisewithoutany signofinfection.Hiscompletebloodcountdoesshow leukocytosisaswellasmildanemia.Lastly,hisCXRis subtle,butanopacityintherightmidlung,asinterpretedby radiology,wouldbeconsistentwithhisabnormal breathsounds.

Basedoffthehistory,physicalexam,anddiagnostic studies,thepatient’sinitialpresentationwasconcerningfor

Image2.

sepsis,potentiallyfrompneumoniaassociatedwith aspirationorduetospontaneousbacterialperitonitis(SBP). However,Idonotbelievetheseissuesalonewould necessarilyprogresstocausesuchanabruptchangeinmental statusandneurologicfunction.Washisdysphagiabeing causedsimplybymasseffectofhisgoiter,orwasitsomething else?Couldtherebeanotherunderlyingetiologythatwas exacerbatedbythepatient’ssepticstate?

Oncehedecompensated,hisexamchanged,andthe differentialexpanded.HenowhadaGCSof8withgaze deviationofhisrighteye “downandout” totheright,buthis leftpupilismidline.Healsohada ﬂaccidleftarmandhisleft legremained ﬂexed.Hisrightarmandlegwithdrewtopain.I consideredthefollowingdifferentials,groupedbycategory, basedoffhisinitialpresentationandchiefcomplaintaswell astheeventsofhisEDvisit,asitisunclearwhetherthey arerelated.

Autoimmune: Forapotentialautoimmunecause,Idid considerpotentiallyundiagnosedmyastheniagravis(MG). Hehadaknownhistoryofgoiterandthyroiddisease,which doeshaveanassociationwithdevelopingMG.Patientswith MGcanpresentwithasymmetricmuscleweaknessthat commonlyinvolvestheextraocularmuscles.Asymmetric presentationscanmimicastroke.Perhapshisworsening dysphagiaandweaknesswerebeingcausedbyMG, andherapidlydeterioratedintheEDduetohissepsis. Hemayhavehadunrecognizedrespiratorymuscle compromiseandmayhavebecomehypercapnic,causinghis alteredmentalstatus.Thisisunlikelysincehehadno evidenceofanyweaknessonhisinitialexam,butitcould notreadilyberuledoutbytheresultsIwasgiven,soIkeptit onthedifferential.

Infectious: Aswediscussedearlier,itispossiblethathe haspneumoniaorSBP;however,Idonotthinktheywould causethesefocalneurologicabnormalities.Hisblood pressureisonthelowerend,potentiallyduetosepsis,butIdo notbelievehewouldhavesufferedawatershedinfarct causingthesespeciﬁcabnormalities.Similarly,Iconsidered meningitisorencephalitisduetohisfeverandalteredmental status,butagainIdonotthinktheyexplainhisrapid deteriorationandfocaldeﬁcits.Healsodidnotcomplainof anyneckpainorheadachepriortohisdecompensation.

Cardiac: Arrythmiaisalwaysapotentialcauseofacute decompensation.Iwouldhavelovedtohaveseenarepeat ECGorrhythmstripatthetimeofdecompensation,but therewasnomentionofhimbeingparticularlytachycardic orbradycardicwithhisrepeatvitals,soIfeelthisisunlikely. Iconsideredthepossibilityofacuteheartfailureorcardiac tamponadecausinghypotensionandsubsequentpoor cerebralperfusionandalteredmentalstatus,butthepointof-careechocardiogramremainedessentiallynormal.

Pulmonary: Iconsideredpneumothoraxasa complicationofcentrallineplacementasacauseofthe acuterespiratorydecompensation;however,thiswasnot

seenonCXRafterplacement,anditshouldnotcausefocal neurologicdeﬁcits.

Endocrine/metabolic: Hypoglycemiaandhyponatremia canbothcauseacutealteredmentalstatus;however,the patient’slabsshowednoevidenceofhyponatremiaor hypoglycemia,andthetreatmentshereceivedintheED shouldnothavecausedthem.Uremiaandhyperammonemia wereruledoutinhischemistrypanel.Iconsideredthyroid stormduetohisfeverandelevatedfreeT4;however,this patient’sT4ispresumablycomingfromhislevothyroxine. Withoutacutechangestohisregimenorsuspectedoverdose ofhismedications,Ifeltthiswasunlikely.

Toxicological: Thereisnohistoryofabnormalexposures. Hewasstartedonantibiotics,aswellasnorepinephrine. Someantibiotics,suchascefepime,canproduceneurologic abnormalitiessuchasseizures,butitwouldbeunlikelyto occurthisrapidlyafterinitialadministration.Healso presumablyreceivedlidocaineaspartofhiscentralline placement.Lidocainetoxicitycancausealteredmentalstatus andseizure.Often,whenadministeredaspartofcentralline placement,about5–10milliliters(mL)of1%lidocaineis used, andprecautionsaretakentoavoidvascular injection.Thisdosageshouldnotbehighenoughtocause acutelidocainetoxicity.

Hematologic: Ididconsiderthrombotic thrombocytopenicpurpura(TTP)asapotentialcause. InfectioncanpromptthedevelopmentofTTPandcould potentiallyexplainthepatient’sneurologicdeﬁcits hematuriaandproteinuria.However,Ieliminatedthisfrom thedifferentialashehadonlymildanemiaandnosigniﬁcant thrombocytopeniaorevidenceofrenalfailure.

Neurologic: Thepatient’sacuteabnormalitiesthat developedintheEDwereprimarilyneurologic,whichmeans thisistheorgansystemIconsideredthemostheavily.The newphysicalexamisinterestingbecauseclassicallyina hemisphericstrokethereisconjugategazedeviation,with botheyeslookingtowardthelesion.Inseizure,theconjugate gazedeviationisclassicallyawayfromthelesion.The disconjugategaze,aswellastheleftarmweaknessinvolving theoppositesideasthegazedeviation,ledmeawayfroma largehemisphericischemicorhemorrhagicstroke.While consideringdiagnosesthatcouldcauseunilateralgaze deviation,Iagainconsideredmuscularweaknessbeing causedbyadisorderattheneuromuscularjunction,suchas MG;however,Ialsoconsideredischemicorcompressive lesionstoCNIII.Cavernoussinusthrombosishasbeen knowntocauseisolatedcranialnervepalsies,includingCN III,IV,V,andVI.Thispatientdidhaveahistoryof thrombosiswithapreviousIJthrombus,buthewascurrently takingananticoagulantandhadnotbeencomplaining ofheadache.

Thepatient’ssymptomswerefairlyconsistentwitha strokeinthemidbrainandWebersyndrome,whichis describedashavinganipsilateralCNIIIpalsywith

contralateralhemiplegia.However,thosepatientsgenerally havearelativelynormalmentalstatus,whereasourpatient hadaGCSof8.Itcouldbepossiblethathehadmultiple areasofinfarctordiseasethataremakingitdifﬁcultto pinpointtheexactlocationofhislesionorlesions.

Afterconsideringthesedifferentialsandtheresultsthat wereavailable,Iultimatelynarrowedthedifferentialdown tothree ﬁnaldiagnoses.Anundiagnosedneuromuscular junctiondisorder,suchasMG,wouldpotentiallyexplainhis multipledeﬁcitsandincorporatehisoriginalchiefcomplaint. Mylasttwodifferentialsaresimilarinthattheyareboth iatrogenicandrelatedtohiscentrallineplacementinvolving differenttypesofemboli.Hedecompensatedshortlyafterthe placementoftheline;so,apotentialiatrogeniccauseneeded heavyconsideration.

HehadaknownhistoryofpriorrightIJthrombus;so, perhapsacentrallinewasplacedthroughanew, undiagnosedleft-sidedIJthrombusandcausedashowerof embolicthrombi.However,forthistohavecausedastroke insteadofapulmonaryembolism,hewouldhavealsoneeded tohaveapatentforamenovaletoallowshuntingtothe arterialcirculation.Iftheclinicianusedultrasoundduring theplacementofthecentrallineandthepatienthasbeen takinghisanticoagulation,hopefullyplacementthrougha thrombuswouldhavebeenavoided.Thisright-to-left cardiacshuntingcouldalsohavebeendetectedduringthe bolusofagitatedsalinevisualizedforlineconﬁrmationon point-of-careechocardiogram,andtherewasnomention ofthis.

Formy finaldifferential,Iconsideredairembolism. Ashowerofairembolitothemidbrain,aswellasmultiple otherareasofthebrain,couldexplainhisfocalneurologic deficitsaswellashissuppressedmentalstatus.Thisisarare butpossiblecomplicationofcentrallineplacement,and retrogradevenous flowofairispossibleduetobuoyancyif thepatientisupright.Itwasnotedthatthepatientwassemireclinedduringplacement,ratherthaninthepreferable Trendelenburgposition,whichcanbeprotectiveagainstair embolus.Likeathrombus,airembolicouldalsobe transmittedtothearterialcirculationifthispatienthadan undiagnosedpatentforamenovale.

Ultimately,IdidnotchooseundiagnosedMGsincehis initialstrengthtestingwascompletelynormal.Withthe patientalreadytakinganticoagulation,anewthrombusis lesslikely;so,Ioptedtochooseairembolismasmy ﬁnal diagnosisasitmakesthemostsensewiththetimingafter centrallineplacementandthemultipledifferentneurologic deﬁcits.MytestofchoicefromtheEDwouldbecomputed tomography(CT)ofthehead.

CASEOUTCOME(DR.PINER)

ThepatientunderwentanemergentCTofthehead (Image3)duetothechangeinmentalstatus.Theradiology impressionoftheCTrevealed “extensivevenousgas,which

Computedtomographyofthebrainofa77-year-oldman afterarapidchangeinmentalstatusshowingextensivevenous gas(whitearrows)intherightparieto-occipitalregion.

mayindicategasemboluswithpossibleevolvinginfarctionin therightparietalregion.Nohemorrhageorshift.Further evaluationwithmagneticresonanceimaging[MRI]maybe useful.Largegoiter.” Immediatelytheteamassessedthe patient’scentralvenouscatheterandfoundanuncappedline. Aftertheairwaswithdrawnfromtheline,thelinewas capped.Thepatientwastransferredtotheintensivecareunit atourhospitalforfurthermanagementandahyperbaric medicineconsultation.Heunderwentahyperbaricoxygen therapytreatmentwithresolutionofthegasontherepeatCT head.Afollow-upMRIrevealedmultifocalinfarctsin multiplevascularterritories.

Inthefollowingdays,thepatient’smentalstatus unfortunatelyneverimproved.Palliativecarediscussions withthepatient’sfamilyindicatedthathewouldnotwantto haveanyfurtherartiﬁcialprolongationoflifewithoutany meaningfulneurologicfunctioning,andtheteam transitionedhiscaretocomfortmeasuresonly.Hewas transferredtohospicecareanddiedsurroundedby hisfamily.

RESIDENTDISCUSSION(DR.PINER)

Airembolismrepresentsararephenomenonwhenair enters eitherarterialorvenouscirculationwithsubsequent obstructionofthevasculature,preventingdistalblood ﬂow. Theconditionrequiresthattherebeadirectconnection betweenthevasculatureandthegassource.Thiscanbedue tovasculartraumapromptinggasentryordirectentryfrom placementofanintravascularcatheter.Manyofthecasesof airembolisminvolveapreventableiatrogenicprocess, promptingtheCentersforMedicareandMedicaidServices atonepointtoclassifyitasa “neverevent” alongwithother preventableconditionssuchasfalls,retainedsurgicalobjects, andincompatiblebloodtransfusion.1

Image3.

Therateofairembolismfollowingacentralline manipulation(insertion,drugdelivery,orremoval)is estimatedtobebetween0.3–2%.2 Consideringhow commonplacecentralaccessinsertionis,thiscouldinvolvea signiﬁcantlevelofmorbidityandmortality.However,notall casesofairembolismareasdramaticorsymptomaticasin thiscase.Mostairemboliwillbeasymptomaticand unrecognized,astheirvolumeandrateofaccumulationmay beminiscule.Thelethaldosedependsonlocationofthe obstruction,volume,andrateofadministration,butlethal dosesrangebetween3–5milliliters(mL)perkilogramor about200–300mLinadults.3

Otheretiologiesofairembolismsinvolveblastinjuries, barotrauma,anddirectvasculartrauma.Surgeryhasbeen associatedwithairembolism,particularlyneurosurgery, wheretheincidenceofairembolismhasbeenreportedtobe higherwhenthepatientwasundergoinganopencraniotomy inaseatedorsemi-seatedposition.4

Thekeyforairembolismisprevention.Thisisparticularly importanttorememberwhenobtainingvascularaccess, manipulatingexistingcatheters,orotherhigh-risksurgical procedures.High-riskvascularaccessinvolveslarge-bore catheters,emergentplacement,accesssiteabovethelevelof theheart,andpressure-infused ﬂuids(eg,arteriallineor rapidinfusionmachine).Carecanbetakentoproperly positionpatientswhenplacingcathetersandplacingthe vascularaccesspointatorabovetheleveloftheheart.Lines shouldbeimmediatelycappedorclampedtopreventdirect airentry.Althoughdebated,askingyourpatienttoexhale duringremovalmaypreventnegativeintrathoracicpressure, whichenhancesvenousreturnandcanpullairinifthereisan entryportal.Additionally,pressureshouldbeheldafterthe catheterisremovedinallcases.5

Promptrecognitioniscrucialfortreatment.Diagnosis shouldbemaderapidlyby ﬁrsthavingahighindexof suspicionandthenfollowedbytreatment.Thelocationinthe arterialorvenoussystem,amountofgas,andtheorgan affectedwilldictatethemanagement,aswellasthesignsand symptomsguidingtheworkup.

Iftheairembolismoccursinthepulmonarysystem,it couldbeexpectedtobehavelikeathromboticpulmonary embolism.However,ifthereisaconnectionbetweenthe venous/arterialside,asinthecontextofapatentforamen ovale,thenvenousgascouldtraverseandcausesymptomsof arterialischemia.Ourpatienthadcerebralvenousgas, likelyasaresultofretrograde ﬂowwiththepatientinan uprightposition.

APOCUScanbeperformedtolookforagasbubbleinthe rightventricleaswellasalternativeexplanationsforthe changeinapatient’shemodynamics(forexample, pneumothoraxorpericardialtamponade).Transesophageal echocardiogram(TEE)ismoresensitivefordetection; however,thereislimitedaccesstothismethod,anditmaybe moreapplicableintheoperatingroom.Somehigh-risk

proceduresuseaTEEintraoperativelytoproactively monitorforsuchevents.Diagnosticmeasuresshouldbe orderedbasedonthesiteofthesuspectedembolism.These maycommonlyincludeatroponin,ECG,lactate,orrenal function.Imagingwillhelpconﬁrmthediagnosis;CT angiographyisthemostlikelydiagnosticmodality,although aircansometimesbeseenonplain ﬁlms.

Ifanairembolismissuspected,thesiteofairentryshould becoveredifopen,pressureheld,andanyoffendingactions (lineinsertion,insufﬂation,pressureinfusion)shouldbe stopped.Thenextstepinvolvespositioningthepatientto trapgasinthevenoussystemandpreventitfromcausing completecardiovascularcollapseintheformofanairtrap. Thepatientshouldbeplacedintheleftlateraldecubitus positionintheTrendelenburgposition(headdown).Thisis calledtheDurantmaneuver.Thisallowsforbloodtostill passintothepulmonaryarterywhiledisplacingand hopefullytrappingtheairbubbleawayfromtheright ventricularoutﬂowtract.Italsopreventsright-to-left traversingofthegasbubble.5

Treatmentinvolvessupportivecareoftheorganaffected. Supplementaloxygenshouldbeappliedviaanon-rebreather mask.Ifanairembolismissuspectedandthereisacentral catheterinthesuperiorvenacava,thenonecanattemptto aspiratebloodfromthedistaltipinhopesofsuctioningthe airembolism.

Ifthesemeasuresfailtoalleviatethecardiovascular collapse,thenvenous-arterialextracorporealmembrane oxygenationcouldproviderescuetherapyasabridgeto deﬁnitivecare.Interestinglythough,thisprocedureitself hasahighriskofcausinganairembolismifthereisany airinthecatheterswhentheyarehookedtothecircuit. Thegoldstandardinvolveshyperbaricoxygenation therapywithearliertreatmentpreferred;however,cases havebeensuccessfullytreatedafter24hoursofsymptoms, astheavailabilityofdiveresourcesmayvarywidely amonginstitutionsandinvolveprolongedand carefultransport.6

FINALDIAGNOSIS

Cerebralairembolismsecondarytocentral linecomplication.

KEYTEACHINGPOINTS

• Rapidchangesinapatient’sclinicalstabilitymaybe relatedtoprogressionoftheknownpresentingdisease oranewprocessentirely.

• Centralvenouscatheterplacementisnotabenign procedure,andgivenitsfrequentuse,careshouldbe takentoavoidcomplications.

• Cerebralairembolismiscausedbyairentrydirectly intothevascularspace,whichmaypresentasachange inapatient’sneurologicalexamination.

• Preventioniskeyforairembolisms;however,if oneoccursthenoxygen,Durantmaneuver,and hyperbarictherapyarethecornerstonesoftherapy.

TheauthorsattestthattheirinstitutionrequiresneitherInstitutional ReviewBoardapproval,norpatientconsentforpublicationofthis casereport.Documentationon ﬁle.

AddressforCorrespondence:T.AndrewWindsor,MD,Universityof MarylandSchoolofMedicine,DepartmentofEmergencyMedicine, 110SPacaSt.,6thFloor,Suite200,Baltimore,MD21201.Email: awindsor@som.umaryland.edu

Attribution(CCBY4.0)License.See: http://creativecommons.org/ licenses/by/4.0/

REFERENCES

1.MattieASandWebsterBL.CentersforMedicareandMedicaid Services’“neverevents”:ananalysisandrecommendationsto hospitals. HealthCareManag(Frederick). 2008;27(4):338–49.

2.ArcinasLA,LiuS,SchacterGI,etal.Cerebralairembolismfollowing centralvenouscatheterremoval. AmJMed. 2017;130(12):e549–50.

3.ToungTJ,RossbergMI,HutchinsGM.Volumeofairinalethalvenous airembolism. Anesthesiology. 2001;94(2):360–1.

4.GiraldoM,LoperaLM,ArangoM.Venousairembolisminneurosurgery. RevColAnest. 2015;43(Supp1):40–4.

5.McCarthyC,BehraveshS,NaiduS,etal.Airembolism:practicaltipsfor preventionandtreatment. JClinMed. 2016;5(11):93.

6.MurphyRandDonnellanJ.Ahigh-pressuresolutionforahigh-pressure situation:managementofcerebralairembolismwithhyperbaricoxygen therapy. Cureus. 2019;11(9):e5559.

PneumothoraxIdenti

ShrimanBalasubramanian,DO,MSc*

MichaelDeFilippo,DO*

MichaelStone,MD*

GabrielaGalli,MD*

MatthewMcCarty,MD†

BrockDaniels,MD,MAS,MPH†

SectionEditor:ChristopherSampson,MD

*NewYorkPresbyterianHospitalCornellandColumbia,Departmentof EmergencyMedicine,NewYork † WeillCornellMedicine,DepartmentofEmergencyMedicine,NewYork

Submissionhistory:SubmittedApril23,2023;RevisionreceivedSeptember20,2023;AcceptedOctober6,2023

ElectronicallypublishedJune3,2024

Fulltextavailablethroughopenaccessat http://escholarship.org/uc/uciem_cpcem DOI: 10.5811/cpcem.1296

Introduction: Theuseoftelemedicineandultrasoundisemergingandnovelinthe ﬁeldofcommunity paramedicine.However,thereisapaucityofdatasupportingitsuseandevenlessevidencethatshowsa morbidityandmortalitybeneﬁt.Thiscasehighlightsauniquewaytodiagnoseacommonmedical emergency,whichcanleadtoagoodoutcome.

CaseReport: Wedescribetheuseoflungpoint-of-careultrasoundbyatrainedcommunityparamedic thatledtotheidentificationofapneumothoraxinan86-year-oldmaleatascheduledhomevisit.The imageswereinterpretedovertelehealthinreal-timebyanemergencyphysician,andthepatientwas transportedtotheemergencydepartmentwherethediagnosiswasconfirmedbychestradiography.He underwentchesttubeplacementandwasdischarged fivedayslaterafterreturningtohisbaseline.

Conclusion: Despiteminimaldatatosupportorrefutetheuseofparamedictele-ultrasound,thiscase highlightsauniqueopportunitytoexpandtheuseoftelemedicineandultrasoundincommunity paramedicinetoimprovepatientoutcomes.[ClinPractCasesEmergMed.2024;8(3)189–193.]

Keywords: telehealth;casereport;communityparamedicine;pneumothorax;point-of-careultrasound.

INTRODUCTION

Withtheemergenceoftelemedicineandultrasounduse combinedwithcommunityparamedicine,healthsystemsare ﬁndingnovelwaystodiagnoseandtreatbothcommonand unusualdiseases.However,evidenceisstillsparseregarding theuseoftelehealthandultrasoundbyparamedics.Thiscase reporthighlightsanoveluseofultrasoundbyacommunity tele-paramedicprogram(CTP)todiagnoseapneumothorax intheprehospitalsettingandreferthepatienttoemergency care,leadingtoagoodoutcome.

Apneumothoraxoccurswhenairaccumulatesbetween theparietalandvisceralpleurainsidethechestwall,causing thelungparenchymatocollapse.1 Itcanbeeithertraumatic oratraumaticandisfurtherclassiﬁedassimple,tension,or open.Atraumaticpneumothoraxiseitherprimary,occurring

withoutanincitingevent,orsecondaryasinthesettingof pulmonarydisease.1,2 Traumaticpneumothoraxisseenin 20%ofbluntchesttrauma,andupto40%ofpenetrating trauma.2 Patientscanbeasymptomaticorpresentwith shortnessofbreath,chestpain,tachycardia,decreasedbreath sounds,jugularvenousdistention,hypotension,cyanosis, andcardiacarrest.1

Whilecomputedtomography(CT)remainsthegold standardofdiagnosis(despitesomedebate),thediagnosis canalsobemadewithultrasoundorwithchestradiography.3 Ultrasoundhasa94%sensitivityanduptoa100%specificity dependingontheoperator.2 Ultrasound findingsincludea lossoflungslidinginB-modeandthepresenceofa “barcode sign” onM-mode,signifyingthelossofpleuralmovement.2 ChestradiographyandCT findingsincludespacebetween

thepleuraandchestwall.3 Thedifferentialdiagnosisoften includescardiactamponade,aorticdissection,ribfracture, acutecoronarysyndrome,pulmonaryembolism,and pneumonia.1 Managementdependsontheseverityof pneumothoraxandcanincludethefollowing:needle decompression, ﬁngerthoracostomy,pigtailthoracostomy, andlarge-boretubethoracostomy.

Theuniquenessofthiscaserevolvesaroundthemethodof diagnosis.ThecasepatientwasenrolledinaCTPprogram, whichispartofalarge,urbanacademicemergency department.Patientsarejointlyevaluatedbycommunity paramedics(CP)onsceneaswellasbyanemergency physician(EP)overvideoconference.Theseparamedics underwentaone-hourlongtrainingsessioninlungpoint-ofcare-ultrasound(POCUS)usingtheButterﬂyiQ(Butterﬂy Network,Burlington,MA)connectedtoamobiledevice. ImageswereobtainedbytheCPcrewusingthe “lung” preset ofthedevice,withtheprobemarkerpointingsuperiorly,and interpretedinreal-timebytheEPoverthetelehealth platform.Whilesomestudieshavereportedthefeasibilityof teachingemergencymedicalservices(EMS)professionals howtoobtainandreadPOCUSimages,thereisapaucityof dataregardingtheregularuseofPOCUSintheprehospital settingandevenfewerinvolvingliveimageinterpretationby anEP.7

CASEREPORT

Thiscasehighlightsan86-year-oldmalewhowasbeing followedcloselybytheCTPprogramofanurban,academic hospital-basedEMSsystem.Hismedicalhistoryincluded Parkinsondisease,stroke,peripheralneuropathy,atrial ﬁbrillationstatus-postmultipleablations,direct-current cardioversion,andimplantationofaWatchmandevice, sicksinussyndromestatus-postautomaticimplantable cardioverterdeﬁbrillatorplacement,congestiveheartfailure, chronicobstructivepulmonarydisease(COPD),and frequentfallsrequiringmultiplehospitalizations.He presentedataroutinehomevisitcomplainingofleftribpain andshortnessofbreathafterafalltwodaysprior.Ofnote, amonthbeforethisvisithehadbeenhospitalizedforafall anddeclinedtherecommendedsubacuterehabilitation placement.Theonlyhomecareserviceshereceived atthetimewereweeklyCTPvisits.

Duringhisinitialevaluationbyparamedicshedenied othercomplaints.Initialvitalswerepulse65beatsper minute,bloodpressure122/77millimetersofmercury,pulse oximetry100%onroomair,temperature36.6° Celsius,and respirations19breathsperminute.Hisphysicalexamwas signiﬁcantforlethargy,althoughhewaseasilyarousableto voice;left-sidedchestwalltendernesstopalpation;bruising; crepitus;decreasedleftbreathsounds;andbilaterallower extremitypittingedema.Paramedicsobtainedbilateral anteriorviewsofthelung(Image1a),andimageswere interpretedinreal-timebythephysicianviaavideo

PopulationHealthResearchCapsule

Whatdowealreadyknowaboutthis clinicalentity?

Computedtomographyisgenerally consideredthegoldstandardfordiagnosis ofapneumothorax.

Whatmakesthispresentationof diseasereportable?

Usingreal-timevideo,anemergency physiciandiagnosedapneumothoraxby interpretingultrasoundimagesobtainedby theparamediconscene.

Whatisthemajorlearningpoint?

Theclinician ’ stelehealthconsultwiththe paramediconscenedemonstratesanovel solutiontodiagnosingconditionswheretime todiagnosisaffectsoutcomes.

Howmightthisimproveemergency medicinepractice?

Emergencyphysicianswillbeabletodiagnose andtreatpatientsearlier,potentiallyleading toimprovedpatientoutcomes.

telehealthplatform.TheEPnotedtheabsenceoflungsliding intheleftinferiorlung ﬁeld(Image1b).

Thepatientwasplacedon100%oxygenvianonrebreathermaskandtransportedtoalocalemergency department(ED).UponarrivalattheEDhedeniednew complaints,andhisvitalsandphysicalexamwerenot signiﬁcantlychanged.Hiselectrocardiogram(ECG)showed anatrialsensedpacedrhythmconsistentwithpriorECGs. Hehadachestradiograph(CXR)showingleft ﬁfthandsixth ribfractureswithamoderatecircumferentialpneumothorax (Images2 and 3).

Headditionallyhadnon-contrastCTsoftheheadand cervicalspineshowingintervalresolutionofpriorsubdural andsubarachnoidhemorrhageswithoutanyacute ﬁndings. Serumcompletebloodcount,chemistrypanel,cardiac biomarkers,andcoagulationproﬁlewereunremarkable.He wascontinuedon100%oxygenviaanon-rebreathermask. TubethoracostomyplacementintheEDwasdeferreddueto thepatient’sclinicalstability,presenceofbilateralpleural effusions,andabsenceofasafewindowtoplaceachesttube onultrasound.Thepatientwasadmittedtothesurgical service.Onhospitaldayone,arepeatCXRshowedan unchangedpneumothorax.Heunderwentaninterventional radiologyCT-guidedpigtailthoracostomyplacement.

Image1. (A)Exampleofacommunitytele-paramedicvisitwithvideoconferenceandscreensharingusingmobileultrasound.Thepatientis seenatthetop,andtheemergencyphysicianisseenonthebottomscreen.(B)Thecasepatient’sb-modelungpoint-of-careultrasound, showingaccentuateda-lines,lossofb-lines,andinreal-timevideowithoutlungsliding(notpicturedhere).

Image2. Chestradiographwitharrowspointingtoleft-sidedmoderatecircumferentialpneumothorax.Thereisalossofsymmetry,avisible lungborder,andlossoflungmarkingsuperiortothelungborder.

Onhospitaldaythree,thechesttubewasclampedand subsequentlyremoved.Hewasrecommendedforsubacute rehabilitation;however,boththepatientandfamily declined.Hewasdischargedhomeonhospitalday ﬁvewith

continuedweeklyfollowupwiththeCTPprogram,visiting nurses,andhomephysicaltherapy.

Thepatientwasseenwithfamilybyhisprimarycare physicianthreedaysafterhospitaldischarge.Homesafety

Image3. Magniﬁedviewofthechestradiographdemonstrating fracturesofribs ﬁveandsix(arrows).

concernswereaddressed,fallpreventionteachingwasgiven, andthepatientchosea “donotresuscitate/donotintubate” status.HecontinuestobefollowedbytheCTPprogramona weeklybasis,andunfortunatelyhashadasubsequent admissionforcongestiveheartfailureexacerbationandtwo EDvisitsforfalls.

DISCUSSION

AlthoughpneumothoraxisnotarareconditionandEPs arequitefamiliarwiththediagnosisandtreatment,clinicians mustbeawareoftheincreasingpresenceofvirtualcare andmobileintegratedhealthcare(MIH).Thenovelty surroundingthiscaseliesinhowthediagnosiswasmade. TheparamedicsarepartofanEMSdivisionunderthe departmentofemergencymedicineatalarge,urban, academicmedicalcenter.TheyarespeciallytrainedasCPs providingscheduledhomevisitstopatientsprimarilywith heartfailure.Theirrolehasexpandedtoincludepost-EDor post-hospitaldischargefollow-upsforconditionssuchas COPDandfalls.

WhiletherearenationalEMSstandardsonCPtraining, therearefewtonostandardsregardingthetrainingofEMS professionalsintheuseofPOCUS.5 Ascopingreview regardingeducationalstandardsrevealedlessthan20 reviewarticles,withaconsensusshowinglittle-to-no

standardizationandnoconsiderationforleveloftraining. However,somestudieshaveshownthatafteratraining programparamedicscanaccuratelyacquireandinterpret lungPOCUSforpneumothoraxortensionpneumothorax withsimilaraccuracytoEPs.6,7 Itshouldbenotedthatmost ofthesestudieshadassessmentsofsimulatedpatientsor patientswithaknownpneumothoraxratherundifferentiated prehospitalpatients.Theresultsofsmallpilotstudieshave suggestedthatprehospitalPOCUSperformedbyparamedics andinterpretedviatelehealthplatformusingcellulardata has “good” to “verygood” qualityandthatremotelung POCUSisfeasible,althoughfurtherresearchonreliability andclinicaloutcomesisneeded.8,9

Thereisapaucityofqualitydatashowingthatimmediate interpretationoflungPOCUSleadstomorerapiddiagnosis, intervention,andbetterpatientoutcomesdespitethe potentialoflungPOCUStopositivelyimpactimmediate care.Inthiscasewedescribeauniquemethodofdiagnosis andrapidtreatmentleadingtoapositivepatientoutcome, whichmayhaveotherwisebeenmissedleadingtoclinical decline,signiﬁcantmorbidityorevendeathifleftuntreated. ThiscasehighlightsanopportunityforbothEPsandEMS professionalstoexpandtheirscopeofpracticewithinthe prehospitalsetting.Theuseofreal-timeinterpretationbyan EPovertelemedicine(ascomparedtoparamedic-only interpretationorasynchronousstoreandforward)affords theopportunitytoguideimageacquisitionforlessexperiencedultrasonographersandincasesofdifﬁcult patientwindows,whileprovidingadditionalclinicalcontext totheEPreadingtheimages.Overall,thishasthepotential toeffectivelytriagepatientstoappropriatedispositions startingfromveryearlyonintheircare.10

Onelimitationisthesmallbodyofliteratureevaluating whetherearlylungPOCUSreadbyanEPimprovesclinical outcomes.Thiscasereporthighlightstheneedforfurther implementationstudiestobetterunderstandtherisksand beneﬁtsofPOCUSintheremotemanagementofpatient populationslivingwithchronicillnesssuchasheartfailure andCOPDwhererapidevaluationanddifferentiationofthe manycausesofdyspneaatthepatient’ssidecanbevaluable fordeterminingthemostappropriatetreatmentandlevel ofcare.

WiththecasereportwealsosoughttoincreaseEP awarenessofthepossibilityofprehospitaluseofPOCUS.A needsassessmentatourinstitutionsuggeststhatwhileEPs involvedintheremotemanagementofmedicallycomplex patientsthroughMIHprogramsbelieveremotelung ultrasoundisvaluable,mostwerenotawareitwasavailable, safe,oreffective.However,thedatareferredtoabove suggeststhatwiththerighttraining,paramedicsareableto obtainultrasoundimages.Asemergencymedicineexpands toinvolvemobileintegratedhealthcareandvirtualcare,we believeEPscanexpecttoseethatpatientassessmentsby paramedicsincludePOCUSimagestointerpret.

CONCLUSION

Thiscaseofcommunitytele-paramedicineuseoflung POCUSreadbyanEPasapneumothoraxshowsboththe diagnosticdiversityofpneumothoraxandthefeasibilityof EMSprofessionalsusingPOCUStoadvancepatientcare.It isimportanttorecognizeapneumothoraxandtreatitearly topreventprogressiontotensionphysiology.Bypartnering withEMS,wemaybeabletoidentifythisdiagnosisand initiateemergenttreatmentearlyon.Emergencyphysicians shouldbeawareofthegrowingprevalenceofprehospital ultrasoundanditsutilityinthediagnosisofcommon lungpathology.

ACKNOWLEDGMENTS

WewouldliketoacknowledgeElisaAponteMD,Sophia Lin,MD,andRahulSharma,MD,fromtheDepartmentof EmergencyMedicineatNewYorkPresbyterianWeill CornellMedicinefortheirhardworkintheCommunity Tele-paramedicineProgram.Withtheirefforts,the departmentisabletoprovidevaluableservicestohigh-risk patientsandvaluableresearchtobetterhelpthecommunity.

TheauthorsattestthattheirinstitutionrequiresneitherInstitutional ReviewBoardapproval,norpatientconsentforpublicationofthis casereport.Documentationon ﬁle.

AddressforCorrespondence:ShrimanBalasubramanian,DO,MSc, NewYorkPresbyterianHospital,DepartmentofEmergyncy Medicine,525E.68th Street,NewYork,NY10065.Email: shb9291@nyp.org