Volume 33 Number 5 May 2019

Recent Acquisitions
Acquired heart conditions, including myocarditis,
pericarditis, Kawasaki disease, and infective
endocarditis, can place children at risk for potentially
devastating complications. Given their relative
infrequency and proclivity for mimicking common
viral illnesses, these cases can be particularly difficult
to diagnose. As such, emergency physicians must be
adept at identifying at-risk pediatric patients and
interpreting the often-subtle clues that should raise
suspicion for acquired heart disease.

Southern Junction
Groin pain, a common complaint among athletes, is
often related to rapid changes in directional movement
or quick acceleration or deceleration. Although most of
these patients can be managed conservatively and seldom
require emergent surgical interventions, sports-related
groin injuries are associated with a significant reduction
in playing time. To ensure optimal outcomes, emergency
physicians must be prepared to identify and manage
the acute and chronic sequelae of these diagnostically
challenging cases.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 9 n Pediatric Acquired Heart Disease . . . . . . . . . . . . . . . . . . . . . . 3
LLSA Literature Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Critical Decisions in Emergency Medicine is the official
CME publication of the American College of Emergency
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Physicians. Additional volumes are available.
Critical Cases in Orthopedics and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 14
EDITOR-IN-CHIEF
Critical Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Michael S. Beeson, MD, MBA, FACEP
Lesson 10 n Sports-Related Groin Injuries . . . . . . . . . . . . . . . . . . . . . . . 19 Northeastern Ohio Universities,
Rootstown, OH
Critical Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
SECTION EDITORS
CME Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Joshua S. Broder, MD, FACEP
Drug Box/Tox Box . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Duke University, Durham, NC
Andrew J. Eyre, MD, MHPEd
Brigham & Women’s Hospital/
Contributor Disclosures. In accordance with the ACCME Standards for Commercial
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ISSN2325-0186(Print) ISSN2325-8365(Online)
 Recent
Acquisitions
Pediatric Acquired
Heart Disease

LESSON 9

By Garrett S. Pacheco, MD; and Priti Rawani-Patel, MD

Dr. Pacheco is an assistant professor and Dr. Rawani-Patel is chief resident in the
Departments of Emergency Medicine and Pediatrics at the University of Arizona
College of Medicine in Tucson, Arizona.

Reviewed by Amal Mattu, MD, FACEP; and Jennifer L. Martindale, MD, MSc

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify the pediatric acquired heart diseases that
n Which pediatric acquired heart diseases can be
are most injurious to patients when overlooked in the
emergency department. life-threatening when missed?
2. Describe the examination findings that should raise n What examination findings should raise suspicion
suspicion for a pediatric acquired heart disease. for an acquired heart disease?
3. Determine which studies are most appropriate for
n Which diagnostic studies are most valuable for
diagnosing pediatric acquired heart diseases.
evaluating pediatric acquired heart disease?
4. Acutely manage critically ill children with acquired heart
diseases. n How should these potentially critical cases be
managed in the emergency department?
FROM THE EM MODEL
3.0 Cardiovascular Disorders
3.5 Diseases of the Myocardium, Acquired
3.6 Diseases of the Pericardium
3.7 Endocarditis

Acquired heart diseases comprise myriad conditions that can place children at risk for critical illnesses,
including potentially devastating pathologies such as myocarditis, pericarditis, Kawasaki disease (KD), and
infective endocarditis (IE). Given their relative rarity and proclivity for mimicking common viral infections, these
cases can be particularly difficult to diagnose. As such, emergency physicians must be adept at identifying and
interpreting the subtle clues that should raise suspicion for these dangerous disorders.

May 2019 n Volume 33 Number 5 3

 CASE PRESENTATIONS
■ CASE ONE
A 14-month-old girl presents with
2 days of fever, increased fussiness,
rhinorrhea, nasal congestion, and
decreased oral intake. Her fever
at home has been as high as 39°C
(102.2°F). Her mother also reports
nonbilious and nonbloody vomiting,
no rash, no diarrhea, and decreased
urine output. The child received
acetaminophen at home. On arrival,
her vital signs are blood pressure
72/54, heart rate 198, respiratory
rate 43, and temperature 37.7°C
(99.9°F).
The patient is given ibuprofen
and ondansetron. After treatment,
she still refuses a popsicle and apple
juice. On re-evaluation, she seems
listless and has delayed capillary
refill, sunken eyes, and decreased
skin elasticity. She also has an
additional episode of emesis in
the emergency department. Given
that the patient failed her oral
administration challenge, peripheral
intravenous (IV) access is obtained,
and she is given a 20-mL/kg bolus
of normal saline (NS). Despite this
effort, her severe dehydration does
not improve. An additional
20-mL/kg bolus of NS is adminis­
tered. On reassessment, she is
tachypneic and somnolent, and the
emergency physician is unable to
wake her.
CRITICAL DECISION
Which pediatric acquired heart
diseases can be life-threatening
when missed?
Pediatric acquired heart disease is
an umbrella term that includes many
potentially deadly — and often elusive
— pathologies. Diagnostic delays
can be particularly dangerous when
managing myocarditis, pericarditis,
IE, and KD, which can cause a host of
deleterious consequences if missed.
The age distribution of patients
4 Critical Decisions in Emergency Medicine
■ CASE TWO
A 15-year-old boy with a history of
exercise-induced asthma presents after
track practice with acutely worsening
chest pain. He reports a 30-day
history of intermittent retrosternal
chest pain. He has shortness of breath,
but no cough, and reports associated
fevers as high as 39.8°C (103.6°F).
His discomfort is worse with deep
inspiration. He has no history of chest
wall trauma and no family history of
premature coronary artery disease or
hypercoagulability.
The patient’s chest pain continues
to worsen while in the emergency
department. He is diaphoretic, and his
vital signs are blood pressure 94/38,
heart rate 142, respiratory rate 26,
temperature 39.2°C (102.6°F), and
oxygen saturation 90% on room air.
■ CASE THREE
A 6-month-old girl presents with
fever, eye redness, and a rash for
the past 3 days. Her father states
that she is fussier than normal and
has been eating less; however, she is
drinking liquids without difficulty. Her
temperature at home has been as high
as 40°C (104°F). Suspecting a viral
exanthem, the emergency physician
discharges the patient and instructs her
parents to keep her hydrated, continue
antipyretics at home, and apply
warm compresses to her eyes to treat
presumed viral conjunctivitis.
Within 24 hours, however, the
with myocarditis is typically bimodal;
the disease is most common in infants
younger than 2 years and adolescents
aged 14 to 18 years. Pericarditis and IE
can affect children of all ages. The peak
incidence of KD occurs in infants aged
6 to 12 months; the disorder rarely
occurs in patients older than 8 years
or younger than 3 months. Patients
diagnosed with KD who are outside the
typical incident age range are at greater
risk for more severe coronary artery
lesions.
parents return with the child. They
report that she is inconsolable and
has not had a wet diaper in the past
12 hours. Her vital signs are heart
rate 195, respiratory rate 39, and
temperature 39.9°C (103.8°F); her
blood pressure cannot be obtained
due to fussiness. She has cracking at
the edge of her lips and new left-
sided neck swelling. The emergency
physician is concerned about a more
aggressive viral illness with central
nervous system involvement, such as
an adenovirus. Her parents consent to
peripheral IV access, laboratory tests,
procedural sedation, and a lumbar
puncture.
■ CASE FOUR
A 7-year-old boy with hypoplastic
left heart status post a Fontan
procedure presents with shortness
of breath and a fever. The patient
has a history of multiple tube
thoracostomies for a right-sided
chylothorax. His Fontan circuit
was fenestrated 3 months prior to
presentation. His mother describes
him as weak, not his usual self, and
somewhat confused. She is concerned
that he may have the flu and explains
that he has not had an influenza
vaccination this year.
The patient’s vital signs are blood
pressure 100/57, heart rate 135,
respiratory rate 28, temperature
39.1°C (102.4°F), and oxygen
saturation 95% on room air.
CRITICAL DECISION
What examination findings
should raise suspicion for an
acquired heart disease?
Myocarditis
Symptoms of myocarditis are
frequently misattributed to other more
common pediatric illnesses. In some
cases, several emergency department
visits for flu-like symptoms (eg, fatigue,
malaise, nausea, poor feeding, chest
pain, shortness of breath) can arise
before the child demonstrates the classic
symptoms of heart failure and cardiogenic
shock.1,2 Fulminant myocarditis, however,
can occur suddenly with the onset of
cardiogenic shock (<3 days into the
illness) and is more commonly diagnosed
in infants. Respiratory distress, a frequent
unifying symptom of myocarditis, may
be accompanied by physical examination
findings like tachypnea, retractions,
and grunting. Such symptoms can lead
clinicians down an erroneous diagnostic
pathway toward pathologies such as
pneumonia, asthma, or sepsis.3
Most children with myocarditis have
clear lungs and good air movement upon
auscultation.4 Alternatively, isolated
gastrointestinal symptoms, including
nausea, vomiting, and abdominal pain,
can lead to a mistaken diagnosis of
gastroenteritis. Myocarditis and other
more serious pathologies should remain
in the differential, especially in the
absence of diarrhea. In these scenarios,
the administration of IV fluids to treat
suspected sepsis or dehydration may be
detrimental and can exacerbate heart
failure. 3
Cardiac complaints (eg, palpitations
or chest pain) are more common in
school-aged children and adolescents,
FIGURE 1. “Strawberry Tongue,” a Sign of KD
likely because younger patients may be
developmentally unable to communicate
such symptoms.3 Other cardiac-specific
physical examination findings like
abnormal heart sounds, murmurs,
and hepatomegaly are uncommon.
Myocarditis that has progressed to the
point of heart failure may be heralded
by diaphoresis, palpitations, orthopnea,
shortness of breath, and exertion-
related dyspnea. The initial presentation
can include syncope or sudden death,
given the high risk of associated
dysrhythmia.2,5
In addition to respiratory distress,
tachycardia that is out of proportion
to the patient’s temperature should
raise suspicion for myocarditis.1,2 A
cardiac etiology should be suspected
when managing any infant with clear
lungs and good air exchange who
presents with severe respiratory distress,
tachycardia, or poor perfusion.4
Pericarditis
Unlike the variable signs and
symptoms of myocarditis, pericarditis
usually manifests with chest pain with
or without fever.6 This characteristic
symptom, which can be sharp, stabbing,
and retrosternal, often worsens on deep
FIGURE 2. Polymorphous Rash in a Child With KD
inspiration and is relieved by sitting up
and leaning forward.2 The pain typically
radiates to the scapular region due to
irritation of the phrenic nerve.7 Other
nonspecific symptoms, such as a cough,
shortness of breath, and nausea, can also
be present.
On physical examination, the
presence of a pericardial friction rub is
pathognomonic for pericarditis. This
audible sign coincides with maximal
movement of the heart within the
pericardial sac and is generated by the
friction between the two inflamed layers
of the pericardium. It is loudest when the
patient is upright and leaning forward
and is best heard in the second to fourth
intercostal spaces along the left sternal
border or midclavicular line.7 The pain
can vary in intensity and can also come
and go over a period of hours; as such,
frequent re-evaluation is crucial.
Kawasaki Disease
The evanescent signs of KD, the
leading cause of pediatric acquired
heart disease in the United States, can
make this diagnosis particularly easy to
miss.8 Coronary artery lesions, which
can range from mild dilatations to
prodigious aneurysms, can predispose
COURTESY OF THE KAWASAKI DISEASE FOUNDATION
May 2019 n Volume 33 Number 5 5

TABLE 1. Duke Criteria12
MAJOR CRITERIA
• Positive blood cultures
­— Typical organism from two separate blood draws
­— Viridans streptococci, Streptococcus bovis, AAECK group, Staphylococcus aureus,
community-acquired enterococci (without a primary focus)
• Endocardial involvement
­— Positive echocardiographic findings of valvular vegetations
MINOR CRITERIA
• Predisposing heart condition or IV drug use
• Fever >38°C (>100.4°F)
• Immunological phenomenon
• Vascular phenomenon
• Microbiological evidence that does not meet major criteria, or serological evidence of
an active infection with an organism consistent with IE
these children to acute myocardial
infarctions. Emergency physicians should
consider this potentially dangerous
disease in any child who presents with
a prolonged fever, as prompt evaluation
and management can greatly reduce the
risk of serious complications.
Children with KD are also at risk
for the development of myocarditis,
myocardial ischemia from coronary
artery thrombosis, stenosis, valvular
insufficiency (mitral greater than aortic),
and dysrhythmias. KD shock syndrome
is a particularly ominous complication
that leads to cardiovascular collapse in
7% of children with KD.9 These patients
require volume expanders and vasoactive
agents. Although the timely initiation
of intravenous immunoglobulin (IVIG)
reduces the incidence of coronary artery
aneurysms from 25% to 4%, KD shock
syndrome is often resistant to IVIG
therapy and may require additional anti-
inflammatory adjunctive treatments.9,10
KD is diagnosed based on the
presence of distinct criteria but cannot
be confirmed by a specific test.10
Affected patients generally report a
high fever (>39°C [>102.2°F]) for at
least 5 days (3-4 days in expert hands),
plus four of five key principal features,
which include:
1. Bilateral conjunctival injection:
usually painless and nonpurulent;
typically involves the bulbar
conjunctivae but spares the limbus
of the eye
2. Mucosal changes: erythema,
dryness, fissuring, and cracking
of the lips; a “strawberry tongue,”
in which the tongue becomes
6 Critical Decisions in Emergency Medicine
erythematous with prominent
papillae (Figure 1). Tonsillar
exudates and discrete oral ulcers
are not typically seen in children
with KD.
3. Polymorphous rash: various
possible presentations, most
commonly scattered macules and
erythematous papules or urticarial
exanthem (Figure 2); prominent
rash in the perineal area with early
desquamation. Bullous or vesicular
lesions suggest an alternative
diagnosis.10
4. Extremity changes: erythema and
edema of the palms and soles,
sometimes with desquamation;
periungual peeling of the fingers and
toes, beginning 2 to 3 weeks after
the onset of fever (Figure 3)
5. Cervical adenopathy: usually
unilateral, with lymph nodes that
are often firm, nontender, and
without overlying erythema; the
diameter of the involved node is
typically 1.5 cm or larger
Patients can also present with a
variety of other clinical complaints,
including arthralgia, extreme
irritability, and gastrointestinal
symptoms.8-11 It is important to note
that infants younger than 6 months
TABLE 2. Application of the Duke Criteria12
DEFINITE IE
• 2 major criteria, OR
• 1 major criterion and 3 minor criteria, OR
• 5 minor criteria
POSSIBLE IE
• 1 major criterion and 1 minor criterion, OR
• 3 minor criteria
are at high risk for coronary artery
lesions and often lack the typical clinical
features.
Infective Endocarditis
Although it is an uncommon
diagnosis, IE is a significant cause of
pediatric morbidity and mortality. The
disease most often arises in children
with underlying congenital heart disease
(CHD).12 IE is more common in patients
with cyanotic CHD and endocardial
cushion defects than in those with left-
sided cardiac lesions and septal defects.
Pediatric patients who have undergone
recent cardiac surgery (<6 months earlier)
are at greater risk of developing IE.13
The incidence of the disease in children
without pre-existing heart conditions
is rising, potentially secondary to the
increased use of indwelling central venous
catheters.12,14
These cases are often indolent;
patients frequently present with several
weeks of nonspecific symptoms. An infant
may have a history of low-grade fevers,
poor feeding or intolerance, irregular
breathing, or lethargy. An older child may
voice additional symptoms like malaise,
anorexia, or arthralgia, and may manifest
signs of heart failure. Occasionally, acute
cases are accompanied by high-spiking
fevers and a rapidly developing illness
that progresses to septic shock. The
classic physical examination findings of
Roth spots (small retinal hemorrhages),
Janeway lesions (painless, hemorrhagic
lesions on the palms and soles), Osler
nodes (painful nodules on the fingers and
toes), and splinter hemorrhages (linear
streaks beneath the nail beds) are rarely
seen in pediatric patients.12
Cardiac findings are highly variable
and depend on the underlying heart
disease, if any, and the site of infection.
Valvular lesions can result in a new
murmur; however, in patients with
CHD who have undergone corrective
surgery, the pre-existing murmur may
remain unchanged. Patients with a
right-sided, catheter-related infection
can present with asthma-like symptoms
and no specific cardiovascular signs.14
The Duke criteria, which include both
laboratory and physical examination
findings, can aid in diagnosing pediatric
IE (Tables 1 and 2).15
CRITICAL DECISION
Which diagnostic studies are
most valuable for evaluating
pediatric acquired heart disease?
Myocarditis
Despite its myriad clinical
presentations, myocarditis is commonly
associated with ECG, cardiac imaging,
and serum biomarker abnormalities.15
Emergency physicians should maintain
a low threshold for performing these
ancillary tests, especially when an
alternative diagnosis is uncertain or
does not correlate with the physical
examination findings.
Although ECG abnormalities are
almost always present in children
with myocarditis, they are widely
variable. Sinus tachycardia is the most
common such irregularity. Low-voltage
QRS complexes and ST-segment
or T-wave changes, including ST-
FIGURE 3. Periungual Peeling, Indicative of KD
elevation myocardial infarction, have
also been reported.15 Axis deviation has
been associated with worse outcomes,
including death.1 Other irregularities,
such as atrial and ventricular delays;
premature beats; and tachy- or
bradydysrhythmias, including complete
heart block, can also occur. Given the
test’s low cost and potentially high-
yield results, a screening ECG should be
performed, especially when evaluating
adolescents who can describe their chest
pain.
Chest radiography can be crucial
for distinguishing between pulmonary
and cardiac pathologies in children who
present in severe respiratory distress.
Radiographic findings associated with
myocarditis include cardiomegaly,
pulmonary vascular congestion, and
pleural effusion.16 Because a normal
ECG or chest x-ray cannot independently
rule out myocarditis, it is reasonable to
order both studies when screening for
the disease. Most patients will show an
abnormality on at least one of the two
tests. 3
Atypical laboratory findings, including
nonspecific markers of inflammation,
can also herald myocarditis. A patient’s
WBC count, C-reactive protein (CRP)
level, or erythrocyte sedimentation
rate (ESR) may be increased, but the
COURTESY OF THE BURNETT FAMILY
absence of abnormalities does not
rule out myocarditis.15 One pediatric
study found elevated serum aspartate
aminotransferase (AST) levels to be
common in such cases; however, AST
elevations are not specific to myocarditis
and can be seen in KD and other viral
syndromes.3 Cardiac troponin T and I
elevations are only observed in a
minority of children.15 B-type natriuretic
peptide (BNP) levels can also be
increased. BNP tests can help distinguish
between cardiac and noncardiac
etiologies of respiratory symptoms.17
Point-of-care echocardiography
can be used at the bedside to quickly
assess cardiac structure and function
and to aid in resuscitation. Consultative
echocardiography is mandatory when
myocarditis is of concern and to help
exclude alternative diagnoses such as
valvular causes of heart failure. The
most common finding associated with
myocarditis is dilated cardiomyopathy
with left ventricular dilatation and a
reduced ejection fraction. Segmental
wall-motion abnormalities can also be
seen.15 Cardiac MRI is a noninvasive
modality for assessing the left ventricle
ejection fraction, tissue injuries, wall
thickness, and ventricle size.
Although the test has become
more routine, its role may be limited
when evaluating critically ill children,
who typically require general
anesthesia during imaging procedures.
An endomyocardial biopsy using
pathological measurements (ie, Dallas
criteria — the gold standard for this
diagnosis) is reserved for patients
with fulminant myocarditis or acute
dilated cardiomyopathy who develop
symptomatic ventricular tachycardia
or high-degree heart block and fail
to respond to standard heart failure
therapies. This approach is also
appropriate for patients suffering from a
systemic disease that is known to cause
left ventricular dysfunction. 2
Pericarditis
Patients who present with pleuritic
chest pain and a friction rub should be
carefully evaluated for pericarditis. A
friction rub that is augmented by sitting
or inspiration supports this diagnosis;
May 2019 n Volume 33 Number 5 7

FIGURE 4. Diffuse ST-Segment Elevation With PR Depression in Lead II
however, the physical examination
may be normal.2 An ECG is the most
reliable test for confirming the disease.
Laboratory and imaging studies can
sometimes support the diagnosis, but
they are often normal or unrevealing.
ECG changes, which result from
an inflamed pericardium adjacent to
the underlying myocardium, classically
evolve through four stages.7
● Stage 1: seen within the first few
hours to days; characterized by
diffuse ST-segment elevations with
reciprocal changes in aVR, V1, and
PR-segment depressions (Figure 4)
● Stage 2: seen within the first week;
characterized by normalization of ST
and PR segments; history and physical
examination clues are crucial to an
accurate diagnosis of pericarditis
during this time frame, as the ECG
can appear virtually normal
● Stage 3: development of diffuse
T-wave inversions; unseen in some
patients
● Stage 4: normalization of ECG or
persistent inverted T waves indicative
of chronic pericarditis
Certain ECG findings can be
harbingers of an associated pericardial
effusion or cardiac tamponade. Low
QRS voltage, another common finding,
can return to normal as the effusion
resolves or is drained. Electrical
alternans, if present, may suggest cardiac
tamponade.
8 Critical Decisions in Emergency Medicine
Chest radiography is usually normal
in patients with acute pericarditis. A
significant pericardial effusion can
create a “water bottle heart” silhouette
(Figure 5).7 Although this finding may
have little value for confirming the
disorder, it can reveal an underlying
etiology, such as a lung or mediastinal
disorder (eg, malignancy or tuberculosis).
Laboratory abnormalities in patients
with pericarditis, which are similar
to those seen in cases of myocarditis,
generally represent a state of systemic
inflammation. Increased WBC counts,
ESRs, and CRP levels are common.
Increases in cardiac troponin levels,
which occur in approximately one-
third of children with pericarditis, are
indicative of concurrent myocardial
involvement.2 Additional studies like
blood cultures; viral studies; a tuberculin
skin test; and measurements of thyroid-
stimulating hormone, rheumatoid factor
(RF), and antinuclear antibody levels
can also be useful for identifying the
disorder.
Echocardiography is a rapid and
noninvasive modality that can help
clinicians assess cardiac function and
gross anatomy.6 For hemodynamically
unstable patients, point-of-care
echocardiography can quickly reveal
the presence of a large pericardial
effusion or evidence of tamponade.
The modality can also be used to guide
pericardiocentesis.
Kawasaki Disease
KD is primarily diagnosed based
on the fulfillment of the criteria
mentioned earlier. However, an atypical
presentation is associated with a
comparable risk for the development
of coronary artery lesions. While no
single test can confirm the diagnosis, a
combination of physical examination
findings, laboratory abnormalities,
and echocardiography results can help
differentiate KD from other entities.
The American Heart Association
guidelines for the evaluation and
treatment of incomplete KD describe
using an algorithm to assess laboratory
values and echocardiographic findings
suggestive of atypical disease.9
Leukocytosis, with a predominance
of immature and mature granulocytes, is
common. Thrombocytosis, defined by a
platelet count of more than 500,000/mm3,
is a later finding that typically occurs
in the second or third week of illness.
Inflammatory markers, specifically ESR
and CRP, are almost universally elevated
in children with KD. Treatment with
IVIG can increase the ESR and should
not be used as a primary marker of
inflammation. Liver panel abnormalities
are seen in about 40% of patients, with
mild to moderate elevations of serum
transaminases and plasma gamma-
glutamyl transpeptidase. Hypoalbum­
inemia can herald a longer, more severe
disease course. Urinalysis reveals sterile
pyuria in approximately 33% to 80% of
these patients.9,18
Although extreme irritability is not
specific to KD, it is a common complaint
in children with the disorder. Because
inconsolability is often assumed to be
secondary to meningeal inflammation, a
lumbar puncture is frequently included in
the workup of extremely fussy children.10
A positive cerebrospinal fluid (CSF) cell
count can be misattributed to aseptic
meningitis secondary to CSF pleocytosis
with a negative CSF culture.9,10
Cardiac imaging plays a critical role
in the evaluation of any patient with
possible KD. Echocardiography should
be performed as soon as the diagnosis is
suspected; however, treatment should not
be delayed if the test is not immediately
available. It is important to visualize
all major segments of the coronary
arteries to assess for aneurysms. The
most commonly affected vessels are
the proximal left anterior descending
coronary artery and proximal right
coronary artery. Left ventricular
function should also be evaluated, as
some degree of myocarditis is present
in most of these cases. A normal initial
echocardiogram does not rule out the
diagnosis of KD.
Infective Endocarditis
The Duke criteria combine physical
examination findings and laboratory
abnormalities to aid in the diagnosis of
IE. In such cases, blood cultures play
a crucial role. At least three or more
cultures, on separate occasions, should
be obtained to reduce the likelihood of
contamination. The presence of fever
is unimportant when timing blood
cultures, as IE-associated bacteremia is
continuous. Adequate volumes of blood
cultures are also important; 3 to 5 mL
for small children per bottle and 10 mL
for older children per bottle are usually
sufficient.
Although additional nonspecific
laboratory findings (eg, increased ESR,
anemia, positive RF, hematuria, and
FIGURE 5. “Water Bottle Heart” Sign Seen With Acute Pericarditis
low complement levels) can support the
diagnosis, the absence of these findings is
insufficient to rule out IE. Increased BNP
and troponin levels may suggest cardiac
injury.
Echocardiography, the primary
imaging modality for evaluating
suspected IE, enables the visualization
of vegetations, abscesses, and prosthetic
valve dehiscence. Although transthoracic
echocardiography is insensitive for
the evaluation of adult patients, the
test is highly sensitive in children.
Transesophageal echocardiography is
seldom required. Early in the disease,
vegetations may be absent. The test
should be repeated in 7 to 10 days if
suspicion for IE continues.
CRITICAL DECISION
How should these potentially
critical cases be managed in the
emergency department?
Myocarditis and Pericarditis
Supportive therapy remains the
cornerstone of treatment for pediatric
myocarditis and pericarditis. When
managing either of these illnesses, it is
crucial to identify cardiac tamponade
and the potential need for an emergent
pericardiocentesis early in the clinical
course.
When managing hemodynamically
unstable children, the initial focus should
be on restoring cardiac function. In such
cases, fluid balance is crucial; IV fluids
should be administered judiciously, if
at all. In particular, diuretics (typically
furosemide) should be initiated as
soon as heart failure is suspected.6
Inotropic agents, afterload reducers, and
antidysrhythmics can also be used to
restore myocardial function. Milrinone
and dobutamine both elevate cardiac
contractility, increase lusitropy, and
decrease afterload.6
Amiodarone and lidocaine are the
preferred agents for the management
of dysrhythmias, keeping in mind
that cardioversion may be necessary if
unstable tachydysrhythmias develop.
Immunosuppressive therapies remain
controversial and are not routinely
indicated in the acute phase of the illness.
Patients with severe disease may require
extracorporeal life support, a ventricular
assist device, or even a heart transplant.
Similarly, supportive therapies
remain the cornerstone of treatment
for pericarditis. Nonsteroidal anti-
inflammatory drugs (NSAIDs),
particularly ibuprofen, are the first-line
therapy for both idiopathic and viral
pericarditis. Ibuprofen is preferred
because of its positive effect on coronary
blood flow and its low side-effect profile.
While the use of colchicine has mostly
been studied in adults, the European
Society of Cardiology recommends
the medication for reducing the risk of
disease recurrence in pediatric patients.
There is little evidence to support the
use of corticosteroids in this population.
Current guidelines recommend reserving
corticosteroids for patients who are
refractory to NSAID treatment or
have an autoimmune or connective
tissue disease–related illness, or uremic
pericarditis.19
When managing both myocarditis
and pericarditis, antiviral medications
should be prescribed only when a specific
etiology is known. Broad-spectrum
antibiotics should be given to any
child who presents in undifferentiated
May 2019 n Volume 33 Number 5 9
 Although some children with IE
eventually require surgical intervention,
such measures are typically necessary
only after antibiotic therapy fails. Surgery
should be considered for patients with
n The time constraints and high patient volumes inherent in emergency prosthetic valve endocarditis and those at
medicine practice can make it particularly challenging to differentiate high risk for embolic events, worsening
between a routine viral illness and the initial stages of progressive myocarditis. heart failure, or an uncontrolled
n Respiratory distress despite a normal lung examination should trigger infection.12
suspicion for a cardiac etiology.
Summary
n Early identification and rapid intervention can dramatically reduce the risk of
coronary artery aneurysm development in patients with KD. Because acquired heart diseases are
n Point-of-care echocardiography can help with the acute resuscitation of patients difficult to diagnose, given their relative
with pediatric acquired heart diseases; however, many of these conditions infrequency and ability to mimic common
require consultative echocardiography to assess the severity of the disease. viral illnesses, it is crucial for emergency
n Pediatric patients with an underlying CHD are at high risk for the develop­ physicians to consider these potentially
ment of IE. dangerous pathologies when evaluating
pediatric patients.
shock.6 Coverage for specific pathogens syndrome may require volume expanders Despite its myriad clinical
like Mycobacterium tuberculosis and and vasoactive medications. Due to the
presentations, myocarditis is commonly
Trypanosoma cruzi should be considered risk of IVIG resistance, such cases may
associated with ECG, cardiac imaging,
when evaluating special populations at also warrant additional doses of IVIG or
and serum biomarker abnormalities.
risk for these pathogens. anti-inflammatory adjunctive therapies.9
An ECG should be used to carefully
Most pediatric patients with
Infective Endocarditis evaluate patients who present with
myocarditis require ICU admission
The management of endocarditis pleuritic chest pain and a friction rub
for ongoing management. Pericarditis
focuses on ensuring hemodynamic ­­— findings that should raise suspicion for
without a large pericardial effusion
stability and the early initiation pericarditis. Supportive therapy remains
or tamponade often portends a self-
of antibiotics. These patients can the cornerstone of treatment for both
limited course, so hospital admission
present with signs of septic shock; disorders.
or outpatient management can be
however, underlying CHD may be the
considered. KD is primarily diagnosed based on
predisposing factor for the development
the fulfillment of specific clinical criteria;
Kawasaki Disease of IE. As such, fluids should be
however, an atypical presentation is
The primary goal in the management administered judiciously to those with
associated with a comparable risk for the
of KD is early diagnosis and treatment poor volume responsiveness. Once blood
cultures are obtained, empiric antibiotics development of coronary artery lesions.
to prevent the development of coronary
should be initiated immediately. In such cases, the primary goal is early
artery lesions. Treatment should
ideally be initiated within 7 days of the Vancomycin and gentamicin, which diagnosis and expedient treatment. When
onset of fever. Current management provide coverage against the most managing children with suspected IE,
recommendations include IVIG and common pathogens (ie, Staphylococcus it is paramount to ensure the patient’s
high-dose aspirin.8-11 The routine use aureus and viridans streptococci), are hemodynamic stability and initiate
of corticosteroids is controversial recommended.12,14 antibiotics early in the clinical course.
for the treatment of KD. While
corticosteroids offer no proven benefit
when administered in conjunction with
the standard therapy of IVIG and high-
dose aspirin, these agents may still be
considered for patients with potential
treatment resistance. Treatment fails n Failing to recognize that aggressive fluid resuscitation can be detrimental to a
in an estimated 10% to 20% of these pediatric patient with undiagnosed acquired heart disease.
patients, in whom fevers and increased n Failing to obtain a chest x-ray to help distinguish between pulmonary and
inflammatory markers persist.8 These cardiac etiologies.
n Misdiagnosing a viral syndrome instead of considering a diagnosis of Kawasaki
children are at high risk for developing
disease.
coronary artery aneurysms and other
n Delaying antibiotic treatment for a child with suspected IE. These patients can
cardiac complications. As previously deteriorate rapidly if untreated.
mentioned, patients with KD shock

10 Critical Decisions in Emergency Medicine

 CASE RESOLUTIONS
■ CASE ONE
The emergency physician initially
suspected that the 14-month-old
girl was suffering from a viral upper
respiratory illness complicated by
dehydration; however, the child’s
worsen­ing condition after fluid
resuscitation raised suspicion for a
cardiac etiology. The patient was
intubated for airway protection and
imminent respiratory failure. Her
ECG was notable for nonspecific
ST-segment changes and sinus
tachycardia. A portable chest
x-ray demonstrated borderline
cardiomegaly and pulmonary
vascular congestion.
The patient was started on an
inotrope, given her hypotension.
Once stabilized, she was given IV
furosemide to facilitate diuresis,
manage her volume overload and
pulmonary edema, and restore
cardiac function. She was admitted
to the pediatric ICU (PICU) for
suspected myocarditis. A subsequent
echocardiogram showed a wall-
motion abnormality and reduced
ejection fraction. Furosemide
was continued, but then she was
transitioned to milrinone. Clues to the
correct diagnosis were tachycardia
that was out of proportion to the
patient’s temperature and clinical
deterioration after aggressive fluid
resuscitation.
REFERENCES
1. Durani Y, Egan M, Baffa J, Selbst SM, Nager AL.
Pediatric myocarditis: presenting clinical character­
istics. Am J Emerg Med. 2009 Oct;27(8):942-947.
2. Tunuguntla H, Jeewa A, Denfield SW. Acute
myocarditis and pericarditis in children. Pediatr Rev.
2019 Jan;40(1):14-25.
3. Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G,
Thull-Freedman J. Pediatric myocarditis: emergency
department clinical findings and diagnostic evaluation.
Pediatrics. 2007 Dec;120(6):1278-1285.
4. Bonadio WA, Losek JD. Infants with myocarditis
presenting with severe respiratory distress and shock.
Pediatr Emerg Care. 1987 Jun;3(2):110-113.
5. Mazor R, Salerno JC. Evaluation and management of
pediatric acute infectious myocarditis. Pediatr Emerg
Med Pract. 2008 Apr;125(4).
6. Bergmann KR, Kharbanda A, Haveman L. Myocarditis
and pericarditis in the pediatric patient: validated
management strategies. Pediatr Emerg Med Pract.
2015 Jul;12(7):1-22.
7. Blanco CC, Parekh JB. Pericarditis. Pediatr Rev. 2010
Feb;31(2):83-84.
■ CASE TWO
The 15-year-old boy received ibuprofen
for his fever, was placed on oxygen, and
was given continuous albuterol treatments
due to his history of exercise-induced
asthma and hypoxia. His symptoms
failed to improve, however. An ECG was
obtained, which showed ST-segment
elevations in leads V1 through V5 , aVF, and
I and ST-segment depressions in lead aVR.
Point-of-care echocardiography revealed
a large pericardial effusion. Given the
patient’s clinical decline and hemodynamic
instability, bedside pericardiocentesis
was performed, resulting in immediate
hemodynamic improvement.
The patient was admitted to the PICU
for close monitoring, with a presumed
diagnosis of pericarditis with effusion-
related tamponade. He recovered and was
back to baseline the following morning. He
was later discharged home with ibuprofen
and a pediatric cardiology follow-up. He
continued to develop recurrent pericardial
effusions and was eventually diagnosed
with systemic lupus erythematosus.
■ CASE THREE
Given her inconsolability, the infant was
initially suspected to have viral meningitis.
However, the Gram stain from the lumbar
puncture showed no organisms, and the
patient’s CSF protein and glucose levels
were both normal. Mild CSF pleocytosis
was also found. Her complete metabolic
panel was notable for hypoalbuminemia
and elevated AST and ALT levels. Her
8. Seaton KK, Kharbanda A. Evidence-based
management of Kawasaki disease in the emergency
department. Pediatr Emerg Med Pr. 2015 Jan;
12(1):1-20.
9. McCrindle BW, Rowley AH, Newburger JW, et al.
Diagnosis, treatment, and long-term management
of Kawasaki disease: A scientific statement for health
professionals from the American Heart Association.
Circulation. 2017 Apr 25;135(17):e927-e999.
10. Son MBF, Newburger JW. Kawasaki disease. Pediatr
Rev. 2018 Feb;39(2):78-90.
11. Bayers S, Shulman ST, Paller AS. Kawasaki disease:
part I. Diagnosis, clinical features, and pathogenesis.
J Am Acad Dermatol. 2013 Oct;69(4):501.e1-11.
12. Bragg L, Alvarez A. Endocarditis. Pediatr Rev. 2014
Apr;35(4):162-167.
13. Rushani D, Kaufman JS, Ionescu-Ittu R, et al.
Infective endocarditis in children with congenital
heart disease: cumulative incidence and predictors.
Circulation. 2013 Sept;128(13):1412-1419.
14. Baltimore RS, Gewitz M, Baddour LM, et al. Infective
endocarditis in childhood: 2015 update: a scientific
statement from the American Heart Association.
Circulation. 2015 Oct 13;132(15):1487-1515.
urinalysis showed 35 WBCs but no
bacteria, and her viral respiratory
panel was negative. These findings
were consistent with KD.
Despite having only 4 days
of fever, she was started on IVIG
and high-dose aspirin. Pediatric
cardiology was consulted regarding
an echocardiographic assessment, and
the infant was admitted to the general
pediatric ward. She was discharged
from the hospital 72 hours later and
showed no evidence of coronary artery
lesions at her follow-up cardiology
appointment 6 months later.
■ CASE FOUR
The 7-year-old boy with known
CHD was at high risk for developing
IE. Three sets of blood cultures
were obtained, and vancomycin and
gentamicin were administered. A
rapid influenza test was negative. The
patient was admitted to the PICU for a
presumptive diagnosis of IE.
A transthoracic echocardiogram
was obtained, which showed
normal cardiac function and no
valvular abnormalities; however,
his blood cultures were positive for
Staphylococcus aureus. IV antibiotics
were continued, and a repeat
echocardiogram performed 1 week
later demonstrated a large anterior
mitral valve vegetation. Despite the
administration of antibiotics, the child
continued to deteriorate and required
emergent valvular surgery.
15. Canter CE, Simpson KE. Diagnosis and treatment of
myocarditis in children in the current era. Circulation.
2014 Jan 7;129(1):115-128.
16. Drucker NA, Newburger JW. Viral myocarditis:
diagnosis and management. Adv Pediatr. 1997;
44:141-171.
17. Koulouri S, Acherman RJ, Wong PC, Chan LS,
Lewis AB. Utility of B-type natriuretic peptide in
differentiating congestive heart failure from lung
disease in pediatric patients with respiratory distress.
Pediatr Cardiol. 2004 Jul-Aug;25(4):341-346.
18. Shike H, Kanegaye JT, Best BM, Pancheri J, Burns JC.
Pyuria associated with acute Kawasaki disease and
fever from other causes. Pediatr Infect Dis J. 2009 May;
28(5):440-443.
19. Seferović PM, Ristić AD, Maksimović R, et al.
Pericardial syndromes: an update after the ESC
guidelines 2004. Heart Fail Rev. 2013 May;18(3):255-
266.
May 2019 n Volume 33 Number 5 11
 The LLSA Literature Review
Nausea and Vomiting
in Pregnancy
By Kelly Mayo, MD; and Laura Welsh, MD, Boston University, Boston, Massachusetts
Reviewed by Andrew Eyre, MD, MHPEd
McParlin C, O’Donnell A, Robson SC, et al. Treatments for hyperemesis gravidarum and nausea and
vomiting in pregnancy: a systematic review. JAMA. 2016 Oct 4;316(13):1392-1401.

Most pregnant women experience nausea and vomiting at some point

during their pregnancy. Symptoms, which generally start between
6 and 8 weeks of gestation and subside by 20 weeks, can affect day-
to-day functioning and lead to dehydration, electrolyte imbalances, and
even hospitalization.

As many as 3% of pregnant women can be used to manage moderate to

suffer from hyperemesis gravidarum, severe cases. Combined treatment with
a severe form of the disorder that is doxylamine and pyridoxine can help
characterized by intractable vomiting. alleviate moderate symptoms (level A,
Treatment should be focused on class IIa); however, there is limited
providing symptomatic relief and evidence regarding the effectiveness of
preventing complications, such as renal antihistamines alone (level B, class IIa).
impairment, Wernicke encephalopathy, It is also unclear whether combined
and extreme weight loss. treatment with psychotherapy and Finally, third-line treatments are
First-line treatments, including vitamin B6 is more effective than reserved for patients with moderate
simple lifestyle changes and over-the- vitamin B6 alone (level B, class IIa). to severe symptoms for whom other
counter remedies, are reserved for mild IV dopamine antagonists therapies have failed. Although
to moderate cases. Both ginger and (eg, metoclopramide, promethazine) are the benefits of corticosteroids
pyridoxine can improve mild symptoms also appropriate second-line treatments (eg, hydrocortisone) are unclear, these
(level A, class IIa), and high doses of (level A, class IIa). In addition, serotonin agents may be considered for patients
pyridoxine may be more effective than receptor antagonists can effectively with severe hyperemesis gravidarum
low doses. Acupressure can also help manage symptoms of any severity (level (level A, class IIb). The benefits of
improve mild nausea and vomiting A, class IIa). IV ondansetron appears to other third-line treatments, such as
(level A, class IIa); however, the benefits be as effective as IV metoclopramide for nasogastric feeding, transdermal
of nerve stimulation and acupuncture managing pregnancy-related nausea and clonidine, and gabapentin, are unclear.
are unclear. vomiting but with fewer adverse effects.
Editor’s Note: There is ongoing debate
Second-line treatments, including There is limited evidence to suggest regarding the safety of ondansetron during
antiemetic medications, intravenous the superiority of dextrose saline over pregnancy. The drug may increase the risk of
(IV) fluids, and electrolyte repletion normal saline (level B, class IIa). congenital malformations; however, further
research is needed. Prior to prescribing
ondansetron, clinicians should counsel
KEY POINTS pregnant patients regarding its benefits and
n As many as 3% of pregnant women suffer from hyperemesis gravidarum. potential risks. For more information, consult
the following references:
n Over-the-counter therapies, including ginger, vitamin B6, and acupressure, are
Huybrechts KF, Hernández-Díaz S, Straub L,
appropriate first-line treatments for mild symptoms.
et al. Association of maternal first-trimester
n Ondansetron can be used to manage symptoms of any severity. ondansetron use with cardiac malformations
n There is limited evidence to support the effectiveness of psychotherapy, and oral clefts in offspring. JAMA. 2018 Dec 18;
metoclopramide, and promethazine for the management of moderate symptoms. 320(23):2429–2437.
Committee on Practice Bulletins-Obstetrics.
n Corticosteroids may help alleviate severe or persistent symptoms; however, more ACOG practice bulletin no. 189: nausea and
evidence is required. vomiting of pregnancy. Obstet Gynecol. 2018
Jan;131(1):e15-e30.

Critical Decisions in Emergency Medicine’s series of LLSA reviews features articles from ABEM’s 2019 Lifelong Learning and
Self-Assessment Reading List. Available online at acep.org/moc/llsa and on the ABEM website.

12 Critical Decisions in Emergency Medicine

 A 41-year-old man with chest pressure and diaphoresis for approximately 30 minutes.

The Critical ECG

Sinus rhythm (SR), rate 60, acute anterior myocardial infarction (MI). By Amal Mattu, MD, FACEP
ST-segment elevation is present in leads V1 through V4, consistent with an acute MI. Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
The morphology of the ST segments is convex upward in leads V2 through V4, which Fellowship in the Department of
Emergency Medicine at the University
may elicit some concern for benign early repolarization (BER). However, the T waves
of Maryland School of Medicine in
in these leads are abnormally large, especially in lead V3 (the T wave is larger than Baltimore.
the QRS complex). These abnormalities, which are often described as “hyperacute
T waves,” are suggestive of early acute cardiac ischemia. Two other findings
exclude the diagnosis of BER: The ST segment in lead V1 is convex upward, and
there is reciprocal ST-segment depression in the inferior leads. Additionally, lead
aVL demonstrates an abnormal biphasic appearance of the T wave, which suggests
some lateral ischemia.

From Mattu A, Brady W. ECGs for the Emergency Physician 2. London: BMJ Publishing; 2008. Reprinted with permission.

May 2019 n Volume 33 Number 5 13

 Critical Cases
in Orthopedics and Trauma
FIGURE 1. Lunate Dislocation

Isolated Volar Lunate

Dislocation
By John Kiel DO, MPH; Chris Kumetz MD; and Andrew Shannon, MD, MPH
University of Florida College of Medicine – Jacksonville

A 21-year-old, mildly intoxicated college student presents via

ambulance after a motor vehicle collision (MVC). His chief complaint
is right hand pain. A physical examination reveals tenderness and
swelling along the carpal bones of his right hand. Subsequent
radiographs identify an isolated volar lunate dislocation (Figure 1).
The patient is neurologically intact, and no additional injuries are
identified. The emergency physician prepares to perform a closed
reduction with the aid of an ultrasound-guided median nerve block.

FIGURE 2. Wrist Innervation STEP 1. Ultrasound-Guided

Median Nerve Block
Branches Palmar
Ulnar Radial Median of ulnar digital As with any nerve block, a thorough
nerve artery nerve nerve nerves neurovascular examination should
be documented pre- and post-
procedure. It is important to avoid
mistaking the median nerve, which is
not associated with a vessel, for the
ulnar or radial nerves, which can be
visualized on ultrasound near their
related arteries (Figure 2). A 22-gauge
needle should be guided in using an
in-plane approach to the nerve. While
visualizing the needle, the fascial
planes should be slowly hydrodissected
away (Figure 3) until the nerve can be
bathed with anesthetic (10-15 mL).

STEP 2. Lunate Reduction

After the administration of an
appropriate anesthesia, the injured
finger should be placed in traction
for a minimum of 10 to 15 minutes.
COURTESY OF THE NEW YORK SCHOOL OF REGIONAL ANESTHESIA
Traction (10-15 lbs) should be

14 Critical Decisions in Emergency Medicine

maintained manually
as the finger traps are FIGURE 3. Ultrasound of the Median Nerve
removed. The clinician
should place one thumb
over the dorsal lunate
to provide a stabilizing
posterior force while
the other thumb applies
pressure dorsally over Probe position
the volar lunate. The
patient’s wrist should be
held in slight flexion to
ease the tension on the
palmer ligaments. As
the lunate is reduced,
the wrist can be brought
back into a neutral or
slightly extended position.
A sugar-tong splint
should be applied, and
post-reduction x-rays
should be obtained. Note
that an immediate open
reduction may be required
if soft tissue (eg, the joint
capsule) is interposed
between the patient’s
carpal bones.

KEY POINTS CASE RESOLUTION

n Lunate and perilunate dislocations are uncommon injuries that result from
high-energy mechanisms, including falls from height and MVCs. Patients
present with pain, swelling, tenderness, and a decreased range of motion.
Deformities can range from subtle to obvious.1 Paresthesia can sometimes
affect the median nerves.
n As many as 10% of these cases involve an open dislocation. Approximately
26% are associated with polytrauma, and 11% involve concomitant trauma
to the ipsilateral upper extremity.1
n As many as 25% of these injuries are initially missed.2 The pathology can
be detected on x-rays; advanced imaging is rarely required. It is important
to note that late presentations can lead to worse outcomes and often
necessitate salvage procedures.3
n All isolated volar lunate dislocations require an open reduction and internal
fixation due to persistent carpal instability. If the acute (closed) reduction
can be maintained in the emergency department and no progressive median
nerve dysfunction is present, surgery can be delayed for 3 to 5 days to allow
the edema to subside.4
n Ultrasound-guided nerve blocks of the forearm are routinely administered
in the emergency department; however, the procedure is a novel approach
for the acute treatment of lunate dislocations. Most nerve blocks appear
to alleviate pain without affecting pressure sensation or proprioception, a
benefit that facilitates a more thorough evaluation of the limb. A short-acting
anesthetic (eg, prilocaine or lidocaine) can enable the re-evaluation of the
median nerve prior to discharge.
The patient’s dislocation was
successfully managed with
a closed reduction in the
emergency department. His hand
was placed in a sugar-tong splint,
and he was instructed to follow
up with a hand surgeon for an
open reduction and internal
fixation.
REFERENCES
1. Budoff JE. Treatment of acute lunate and perilunate
dislocations. J Hand Surg Am. 2008 Oct;33(8):
1424-1432.
2. Herzberg G, Comtet JJ, Linscheid RL, Amadio PC,
Cooney WP, Stalder J. Perilunate dislocations and
fracture-dislocations: a multicenter study. J Hand Surg
Am. 1993 Sep;18(5):768-779.
3. Grabow RJ, Catalano L 3rd. Carpal dislocations. Hand
Clin. 2006 Nov;22(4):485-500; abstract vi-vii.
4. Blazar PE, Murray P. Treatment of perilunate dislocations
by combined dorsal and palmar approaches. Tech Hand
Up Extrem Surg. 2001 Mar;5(1):2-7.
5. Bhoi S, Sinha TP, Rodha M, Bhasin A, Ramchandani R,
Galwankar S. Feasibility and safety of ultrasound-
guided nerve block for management of limb injuries
by emergency care physicians. J Emerg Trauma Shock.
2012 Jan;5(1):28-32.
6. Liebmann O, Price D, Mills C, et al. Feasibility of
forearm ultrasonography-guided nerve blocks of the
radial, ulnar, and median nerves for hand procedures
in the emergency department. Ann Emerg Med. 2006
Nov;48(5):558-562.

May 2019 n Volume 33 Number 5 15

 The Critical Image
A 77-year-old man presents with chest and abdominal pain following a By Joshua S. Broder, MD, FACEP
tractor accident. He explains that he was knocked to the ground and the Dr. Broder is an associate professor and the
residency program director in the Division
vehicle ran over the center of his chest. EMS reports that the patient remained
of Emergency Medicine at Duke University
hemodynamically stable en route but was hypoxic and required high-flow Medical Center in Durham, North Carolina.
oxygen. His vital signs are blood pressure 134/59, heart rate 109, respiratory
rate 28, temperature 37.1°C (98.8°F), and oxygen saturation 100% on 15 L of
oxygen via a nonrebreather mask.
The patient is alert but in respiratory A
distress. His chest and left upper
abdomen are tender to palpation, and
abrasions are seen across his central
and left chest. Decreased breath
sounds are noted on the left side. The
remainder of the trauma examination
Rib
fractures
is normal.
Given the patient’s hypoxia and
abnormal breath sounds, a left chest
tube is placed empirically. A chest
x-ray and CT scan of the head, spine,
chest, abdomen, and pelvis are
initiated.

1. Dev SP, Nascimiento B Jr, Simone C, Chien V. Videos

in clinical medicine. Chest-tube insertion. N Engl J
Med. 2007 Oct 11;357(15):e15.

A. Portable supine anterior-posterior (AP) chest radiograph. Multiple left-sided

rib fractures are visible (ribs 3, 4, and 5). No pneumothorax is seen after chest tube
placement. The chest tube is low-lying, located near the seventh rib.

B B. CT with intravenous (IV)

contrast, axial image, soft-tissue
window. A large splenic laceration
Splenic is present.
laceration

CASE RESOLUTION
The patient underwent
angiographic embolization of the
spleen and was observed in the
ICU. Over the next several hours,
he developed shock and evidence
of peritonitis. The gastric injury
was subsequently noted on CT,
and the patient underwent a
laparotomy for repair of the
injury.

16 Critical Decisions in Emergency Medicine

 KEY POINTS
C
n On AP chest x-ray, an ideally
placed thoracostomy tube
should be oriented apically. The
recommended entry point is the
intercostal space between the
fourth and fifth ribs.1 A chest tube
inserted caudad to this level risks
subdiaphragmatic placement and
injury to the abdominal organs.
n Surface landmarks guide insertion
to reduce the risk of tube
misplacement. The “triangle of
safety” for thoracostomy tube
insertion is bounded medially by
the lateral border of the pectoralis
major muscle, laterally by the
midaxillary line (lateral border
of latissimus dorsi muscle), and
caudad by the nipple line or
Splenic inframammary crease.
laceration n When a chest tube is inserted into
the pleural space to evacuate a
pneumothorax, subcutaneous air
is often evident in the chest wall.
None is seen in this case, perhaps
a clue that the tube never reached
C. CT with IV contrast, coronal image, soft-tissue window. The splenic laceration the pleural space.
is again seen. n The CT demonstrates a splenic
injury, a finding that distracts
D
from the chest tube, which is
visible passing through the
stomach. By hyperfocusing on
the initial abnormality, clinicians
and radiologists can overlook
secondary pathologies. A
systematic approach to image
interpretation, including an
assessment of medical foreign
bodies, can help reduce this risk.

Left
nipple

D. Three-
dimensional
reconstruction
Chest from CT. This image
tube demonstrates the
chest tube entry
point, caudad to
the nipple line and
outside the “triangle
of safety,” the usual
surface landmarks for
thoracostomy tube
insertion.1

May 2019 n Volume 33 Number 5 17

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Let CDEM be your guide.
Don’t miss Critical Decisions’ new podcast,
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18 Critical
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 Southern Junction
Sports-Related
Groin Injuries

LESSON 10

By Andrew Schleihauf, DO, CAQ-SM; and John Kiel DO, MPH

Dr. Schleihauf is a sports medicine physician at Excela Health in Mount Pleasant,
Pennsylvania. Dr. Kiel is an assistant professor in the Departments of Emergency
Medicine and Orthopedics at the University of Florida College of Medicine in
Jacksonville.

Reviewed by Michael S. Beeson, MD, MBA, FACEP

OBJECTIVES
On completion of this lesson, you should be able to:
1. Understand the anatomy and biomechanics of the hip
and groin.
2. Diagnose and acutely manage the most common types
of sports-related groin injuries.
3. Describe the unique groin injuries with which pediatric
patients can present.
4. Determine which patients require an emergent specialist
consultation and which can follow up as an outpatient.
5. Describe the potential acute and chronic sequelae of
sports-related groin injuries.
FROM THE EM MODEL
11.0 Musculoskeletal Disorders (Nontraumatic)
11.5 Overuse Syndromes
CRITICAL DECISIONS
n How should patients with sports-related groin
pain be evaluated?
n What etiologies should be considered when
evaluating an athlete with groin pain?
n What unique pathologies should be suspected
in children with groin pain?
n Which patients require imaging, and which
modalities are most appropriate?
n How should sports-related groin injuries be
managed in the emergency department?

Groin pain, a common complaint among athletes, is most often related to rapid acceleration, deceleration,
and sudden changes in directional movement. Although most of these patients can be managed conservatively
and seldom require emergent surgical interventions, sports-related groin injuries are associated with a significant
reduction in playing time. To ensure optimal outcomes, emergency physicians must be prepared to identify and
manage the acute and chronic sequelae of these diagnostically challenging cases.

May 2019 n Volume 33 Number 5 19

 CASE PRESENTATIONS
■ CASE ONE
An 18-year-old man presents
with acute right groin pain and
right hip stiffness after playing
two consecutive ice hockey games.
While cupping his thumb and
index finger around his anterior
hip, he describes the pain as a
sharp, deep ache that radiates
into his groin region. He recalls
experiencing pain during previous
play and while doing deep squats
in the gym; however, the pain was
only occasional and has never been
this severe.
During the physical
examination, the patient’s pain
is worsened when the right hip is
flexed to 90 degrees and internally
rotated. He also exhibits decreased
internal rotation of the right hip.
Sports-related groin pain generally
results from chronic, repetitive stress
on the musculotendinous portions of
the groin muscles. As many as 58%
of soccer players report a history of
groin pain.1 Other sports with a high
incidence of groin injuries include
ice hockey, American football, and
Australian football. Despite the
prevalence of these pathologies,
information regarding their etiology,
presentation, diagnosis, and
management can be confusing and
contradictory. 2
Risk factors for developing a sports-
related groin injury include increased
competition levels; reduced relative hip
adduction strength, especially compared
to the abductor muscles; lower levels of
training; a lack of off-season or sport-
specific conditioning; older age; and a
history of a previous groin injury. These
disorders, which can be acute, subacute,
or chronic, are frequently associated
with pain and lower strength on an
adductor squeeze test and reduced hip
internal rotation.
In addition, low levels of vitamin D
are associated with an increased risk
20 Critical Decisions in Emergency Medicine
■ CASE TWO
An 8-year-old boy presents with a
painless limp accompanied by left hip
and groin pain. He denies any trauma
but says he has noticed some pain while
doing certain activities during gymnastics
practice. His parents note that his left
thigh looks smaller and less muscular
than his right thigh.
The patient has no fevers, chills, or
systemic symptoms. His family history
is noncontributory, and he has met all of
his developmental milestones. He does
not appear to be in acute distress. On
examination, the boy’s left hip appears
grossly normal, but he has limited
range of motion during abduction and
internal rotation. He also demonstrates
a positive Trendelenburg sign on the left
side. His inflammatory markers and
WBC counts are normal.
of sports-related groin pain and lower-
extremity strains.3 Although there are
no evidence-based recommendations
for the prevention of these injuries,
activity modification, rest, and physical
therapy can help patients achieve optimal
outcomes.
CRITICAL DECISION
How should patients with
sports-related groin pain be
evaluated?
Before evaluating any patient with
sports-related groin pain, it is vital to
understand the complex anatomy and
biomechanics of the hip and groin.
Anatomical Structures
The groin is generally described
as extending from the insertion of
the rectus abdominis muscle to the
adductors in the mid thigh, an area
that encompasses the inguinal canals
and pubic symphysis (Figure 1). The
pubic symphysis is a nonsynovial-lined,
amphiarthrodial joint located centrally
between the two pubic, or innominate,
bones. This joint is connected with a
fibrocartilage disc that enables minimal
■ CASE THREE
A 35-year-old woman presents
with pain in her pubic region that
radiates to her groin bilaterally
and into her lower abdomen. She
plays recreational soccer but had to
stop her training session today due
to worsening pain with kicking,
sprinting, and directional changes.
She explains that the pain is chronic
and has become progressively worse
over the past 3 to 6 months, but she
has never had to stop playing before.
She also reports feeling pain in her
pubic region while getting dressed and
standing on one leg.
She denies fever, chills, night
sweats, or trauma to the area. On
examination, the clinician notes a
slight waddling gait and exquisite
tenderness over the patient’s pubic
symphysis. She also exhibits pain with
resisted adduction and a hop test.
motion. The innominate bones function
as arches, transferring the weight of the
upright trunk from the sacrum to the
hips.
Musculotendinous attachments
to or adjacent to the pubic symphysis
transfer motion through this joint and
stabilize the pelvis during ambulation.
The rectus abdominis muscle, which
stabilizes the abdominal wall, originates
along the superior pubic ramus, lateral
to each side of the pubic symphysis.
The adductor longus muscle, which
originates from the medial innominate
bones inferior and lateral to the pubic
symphysis, stabilizes the pelvis and
adducts the thigh.
The adductor brevis muscle
originates inferior to the adductor
magnus muscle and has a similar action.
The gracilis muscle, which acts to flex
and adduct the hip, originates just
medial and inferior to the adductor
longus muscle. These structures oppose
each other during hip extension and
rotation at the waist. The pectineus
muscle acts as a hip flexor and adductor
and originates from the superior pubic
ramus, lateral to the pubic symphysis.
The primary hip flexor, the iliopsoas
muscle, passes through the pelvis deep
to the inguinal ligament and inserts at
the lesser tubercle of the femur.
The layers surrounding the pubic
symphysis are also interconnected. The
medial crus of the external oblique
muscles are located superficial to
the pubic tubercle and interlace with
the anterior inguinal ligament. The
pyramidalis is a small muscle within
the rectus abdominis sheath that inserts
at the pubic symphysis and is the only
muscle anterior to the pubis. Deep
to the pyramidalis muscle, the rectus
sheath and adductor tendinous junction
connect and form a common tendinous
origin. This blends with the anterior
pubic ligament and fibrocartilage on
the posterior pubic symphysis to form
the pubic aponeurosis. Fibers from the
inguinal ligament, external oblique
muscle, and transverse abdominis
muscle also fuse lateral to this junction,
forming the conjoint tendon. This
tendon arches over the inguinal canal,
which contains the spermatic cord in
men and the round ligament in women.
The inguinal canal also includes the
genitofemoral and ilioinguinal nerves.
The adductor magnus, adductor
brevis, adductor longus, and gracilis
muscles are innervated by the obturator
nerve, which arises from the ventral
FIGURE 1. Groin Anatomy
Internal Transversus abdominis
oblique aponeurosis
aponeurosis
Superficial
inguinal ring
Conjoint tendon
External
oblique
aponeurosis
Inguinal
ligament
Adductor Pubic
longus tubercle
division of the second, third, and fourth
lumbar nerves in the lumbar plexus.
The pectineus and iliacus muscles are
innervated by the posterior division of
the femoral nerve, which also arises
from L2 to L4. The psoas major muscle
is innervated by the direct branches of
the lumbar plexus at the levels of L1
to L3. The rectus abdominis muscle is
innervated by the terminal branches
of the anterior ramus of the lower six
thoracic nerves via the lower intercostal
nerves and the subcostal nerve.
Patient History
Clinicians should obtain a complete
history of the injury, including all
sporting activities; the frequency,
duration, and intensity of participation;
the mechanism of injury; pain
characteristics (eg, duration, location,
description, radiation, relieving and
remitting factors); and any associated
symptoms (eg, swelling, bruising,
locking, popping, instability).
Clinicians must also consider
other organ systems and inquire
about any history or symptoms that
suggest urological, gastrointestinal,
gynecological, dermatological,
neurological, hematological, or
oncological sources. Most muscular
injuries are triggered by a single event
that involves stopping, cutting, or
Superficial Rectus
inguinal ring abdominis
Pubic
Inguinal symphysis
ligament
Adductor
longus
Pubic
symphysis
kicking. A history of “clicking” with hip
movement or a “catching” sensation can
indicate an intra-articular pathology,
such as a labral tear of the hip or a loose
body. Altered sensation or weakness can
indicate nerve entrapment.
Physical Examination
A systematic approach to groin
examinations can increase diagnostic
yield and help facilitate an appropriate
workup. A common technique for
examining the musculoskeletal
system, including the groin, employs
the acronym IP-PASS — inspection,
palpation, passive range of motion,
active range of motion, strength and
neurovascular tests, and special tests.
This approach can help clinicians
retain consistency over time and
reduce the likelihood of missing any
key examination components. When
assessing female patients, pathologies
of proximal systems must also be
considered, including abdominal
wall hernias and genitourinary,
gastrointestinal, and gynecological
abnormalities.
Close inspection can also reveal an
abdominal bulge, edema, erythema,
or ecchymosis, which can help guide
management and further testing.
Ecchymosis in the groin area can be
associated with avulsion injuries,
muscular tearing, or abdominal wall
hematomas. If an abdominal bulge is
found, the physician should note if it is
above or below the inguinal ligament
crease.
Next, the groin area should be
palpated to assess the lower abdominal
musculature and pubic symphysis for
tenderness. The patient should be placed
in a frog-leg position, and the pubic
tubercle and medial inferior pubic rami,
where the adductors originate, should be
palpated. The physician should then move
inferiorly down the adductor musculature
and laterally toward the anterior superior
iliac spine (ASIS), anterior inferior iliac
spine (AIIS), and anterior hip joint to
assess for any tender areas of soft or
bony tissues. Palpation of the superficial
inguinal ring, along with a provocative
maneuver (eg, a cough or Valsalva
maneuver), should also be performed to
assess for a hernia.
May 2019 n Volume 33 Number 5 21

FIGURE 2. Clinical Entities
Outlined by the Doha
Agreement12
n Adductor-related groin pain
n Iliopsoas-related groin pain
n Inguinal-related groin pain
n Pubic-related groin pain
Although the pubic symphysis can
move a small amount, it is not typically
assessed. However, both passive and
active ranges of motion of the hip
joint should be performed. Passive
range of motion is examined by the
clinician, while active range of motion
is demonstrated by the patient. Normal
ranges of motion of the hip include
120 degrees in flexion, 30 degrees in
extension, 45 degrees in abduction,
30 degrees in adduction, 50 degrees
in internal rotation, and 40 degrees
in external rotation. If concerns arise,
comparisons should be made to the
unaffected limb.
Strength examinations should
be assessed on a scale of 1 to 5,
with 5 being normal strength and 3
indicating the patient’s ability to resist
against gravity. These examinations
should include hip flexion (iliopsoas,
rectus femoris, pectineus, and
sartorius muscles), hip extension
(gluteus maximus, biceps femoris,
semimembranosus, and semitendinosus
muscles), hip adduction (adductor
magnus, adductor brevis, adductor
longus, pectineus, and gracilis
muscles), and hip abduction (gluteus
medius, gluteus minimus, and tensor
fasciae latae muscles). A thorough
22 Critical Decisions in Emergency Medicine
neurovascular examination should also
be initiated to test for sensation and
pulses, including the femoral pulse.
Clinical Maneuvers
Only a few special tests exist for
extra-articular groin pain; most validity
studies focus on chronic pathologies. The
single adductor test can be performed by
passively flexing the hip to 30 degrees
while the patient resists examiner
abduction. The hip adduction test can be
performed at 45 degrees and 90 degrees
hip flexion. With this technique, the
examiner places a clenched fist between
the patient’s legs just above the knees
while the patient contracts the adductors
and squeezes the fist.
A bilateral adductor test involves
having the patient flex the hips to
30 degrees with slight hip abduction
and leg internal rotation. The patient
then resists abduction bilaterally,
forcing the contraction of the adductor
muscles while simultaneously engaging
the rectus abdominis muscle. A positive
test is indicated by pain with resisted
adduction. The bilateral adduction test
has a 93% specificity and a likelihood
ratio of 7.7.4
There are numerous methods
for evaluating intra-articular hip
pathologies, including labral tears,
femoroacetabular impingement (FAI),
and hip osteoarthritis. The FADIR
test (flexion, adduction, and internal
rotation), which is particularly helpful
for evaluating such injuries, can detect
a labral tear or impingement with a
sensitivity of more than 90%; however,
the maneuver has poor specificity. 5
The hip quadrant (ie, scour) test,
which works by scouring the femoral
acetabular joint for abnormalities,
involves flexing the hip to 90 degrees,
placing an axial load, and internally and
externally rotating the hip. This method
is fair in sensitivity (50%) but poor in
specificity (29%).6 The FABER test
(flexion, abduction, external rotation)
is helpful but can cause pain in patients
with an intra-articular pathology.
Studies show similar results regarding
validity, with fair sensitivity and poor
specificity.6
The patellar-pubic percussion test
is the most sensitive (96%) and specific
(86%) for detecting femoral neck
fractures.7 With the patient supine,
the clinician places a stethoscope on
the patient’s pubic symphysis and then
percusses each patella while keeping
the leg in a neutral position. The
sounds should be equal in patients with
a normal bone structure. If a bony
disruption exists, the ipsilateral side has
a duller, more diminished sound.
CRITICAL DECISION
What etiologies should be
considered when evaluating
an athlete with groin pain?
Groin pain in athletes typically
occurs with rapid directional changes, a
process that involves many interrelated
structures. This anatomical complexity
can make it difficult to localize a
patient’s symptoms. The 2015 Doha
agreement meeting and resultant
consensus statement attempted to
simplify the terminology used to
describe groin pain by classifying
sports-related groin injuries into three
categories. The first category includes
clinical entities, such as adductor-,
iliopsoas-, inguinal-, and pubic-related
groin pain (Figure 2); the second
category includes hip-related groin
pain; and the third category includes
other etiologies.
Adductor Injuries
To qualify as adductor-related groin
pain, a patient must have tenderness
along the adductor muscles and pain
with resisted adduction. The most
common cause of acute groin pain
in athletes is an adductor strain.
Patients can also have tendinitis or
tendinopathy, with the latter referring to
a more chronic condition that involves
remodeling of the tendon. The diagnosis
is primarily clinical, and the history
of an affected patient usually involves
kicking, directional changes, sprinting,
or jumping activities. Adductor-related
groin pain is more common among
soccer players, hockey players, and track
athletes. The most commonly injured
area is the musculotendinous junction of
the adductor longus or gracilis muscle.
Iliopsoas Injuries
Patients with iliopsoas-related
disorders may present with iliopsoas
tenderness and pain with resisted hip
flexion or stretching. Diagnoses include
iliopsoas strains, tendinitis, and bursitis.
Sports that increase this risk include
soccer, ballet, running, hurdling, and
jumping. Bursitis is caused by overuse,
as the tendon rides over the iliopectineal
eminence of the pubis. Patients report
anterior hip or deep groin pain,
often accompanied by a “snapping”
sensation caused by the iliopsoas
tendon passing over the iliopectineal
eminence, acetabular labral tears,
or subluxation of the hip and loose
bodies. Patients may have pain with
deep palpation of the femoral triangle
(ie, musculotendinous junction of the
iliopsoas) or pain with active flexion or
passive extension of the hip.
Inguinal Injuries
Inguinal-related groin injuries can
be characterized by pain and tenderness
in the inguinal canal, without a
palpable inguinal hernia. This type
of injury, commonly called a sports
hernia or athletic pubalgia, is caused by
a weakening of the posterior inguinal
FIGURE 3. Widening of Pubic Symphysis, Indicating Osteitis Pubis
wall. Although the incidence of sports-
related groin hernias is unclear, patients
often report an insidious onset of deep
groin pain that worsens with resistance
training of the abdominal muscles,
the Valsalva maneuver, coughing, or
sneezing. The pain may radiate to the
testicles.
Groin Disruption
Groin disruption is often described
as a separate injury from a sports hernia,
although the terms are often used
interchangeably. In a groin disruption
injury, the posterior abdominal wall is
altered, but the changes are more varied
and less predictable than with sports
hernias. Abnormalities can include tears
of the external oblique aponeurosis,
tears of the conjoined tendon, dehiscence
of the conjoined tendon and inguinal
ligament, loose inguinal floors, and
thin insertions or tears of the rectus
abdominis muscle.7 Unlike sports-related
hernias, groin disruptions are evidenced
by pain that is typically unaffected by
the Valsalva maneuver or coughing. No
imaging study is considered superior for
evaluating these cases; such diagnoses
are often made intraoperatively.
Pubic Injuries
Pubic-related groin pain includes
localized tenderness to the pubic
symphysis or tenderness immediately
adjacent to the bone. Osteitis pubis
(Figure 3) is characterized by pain at the
pubic symphysis and joint disruption
seen on radiography. The disorder,
which is commonly diagnosed in soccer
players and runners, can be difficult
to distinguish from adductor muscle
injuries. Osteitis pubis is caused by
repetitive stress and shearing forces on
the pubic symphysis or by repetitive
traction of the pelvic musculature.
On examination, patients complain of
tenderness over the pubic symphysis; an
absence of tenderness can help exclude
the diagnosis. The pain is worsened by
active adduction.
Hip Pathologies
Hip pain should always be part of
the differential diagnosis for sports-
related groin injuries. Hip-related groin
pain can be difficult to distinguish
from other causes of groin pain and
can coexist with other pathologies. The
labrum is a fibrocartilaginous rim that
encircles the superior 80% of the hip
socket or acetabulum. Labral tears often
manifest mechanical symptoms (eg,
“catching” or “locking”) and are most
prevalent in sports that require squatting,
jumping, or deep hip flexion.
FAI (Figure 4), which can cause
sharp pain while the patient is in a
deep squat or with hip flexion, can
lead to labral tears. Two types of
impingement that are described with
these injuries are cam and pincer
deformities. A cam deformity involves
overgrowth of the femoral neck; a
pincer deformity involves overgrowth
or overcoverage of the acetabulum.
Patients with labral tears or FAI may
describe their symptoms using the
“C sign,” cupping their thumb and
index finger in the shape of the letter
C near the hip to indicate the pain
deep in their hip or groin region.
Unfortunately, no single discriminatory
test can help diagnose hip-related groin
pain; most are sensitive but poorly
specific.
As the name implies, patients with
snapping hip syndrome may complain
May 2019 n Volume 33 Number 5 23

FIGURE 4. Anteroposterior Pelvic View, Demonstrating FAI
of a “snapping” sensation when moving
the hip. The symptoms can be medial or
lateral, with lateral being more common
due to the iliotibial band, tensor fasciae
latae muscle, or gluteus medius muscle
riding across the greater trochanter,
which can cause pain and eventually
lead to greater trochanteric bursitis.
The symptoms can also be deep due to
the iliopsoas tendon passing over the
anterior component of the joint.
Stress Injuries
Stress injuries occur with repetitive
submaximal loading on a bone over
time, a process that can lead to a
mismatch between native bone strength
and the chronic mechanical load.
Stress injuries comprise a spectrum of
disorders from periostitis to complete
stress fractures, including full cortical
breaks. Stress injuries to the pubic
ramus, acetabulum, and femoral neck
can all present as groin pain.
Femoral neck and pubic ramus
stress fractures are especially common
in runners, jumpers, and military
recruits. These pathologies are typically
associated with a sudden increase in
training intensity, with changes in
footwear or training surfaces, or in
young women with poor nutrition
24 Critical Decisions in Emergency Medicine
or hormonal imbalances that lead
to relative decreases in bone mineral
density. Femoral neck stress fractures
present as groin or anterior thigh pain.
The discomfort is exacerbated by
activity and relieved by rest. Patients
with pubic ramus stress fractures often
have pain over the pupic ramus and
can also develop stress injuries to their
acetabulum.
Avulsion fractures can occur at the
ASIS, caused by rapid contractions of
the sartorius muscle; at the AIIS, caused
by rectus femoris muscle contractions;
or at the ischial tuberosity, caused by
the violent hamstring contractions
associated with sprinting and hurdling.
These injuries are associated with
jumping, kicking, and sprinting sports,
respectively.
Nerve Injuries
Compressive groin neuropathies,
an uncommon cause of groin pain,
include the ilioinguinal, genitofemoral,
iliohypogastric, obturator, and lateral
femoral cutaneous nerves. These injuries
can result in chronic pain and can be
challenging to treat. Ilioinguinal nerve
compression is associated with direct
trauma or overtraining of the abdominal
musculature. Patients often experience
discomfort in their genital region and
upper medial thigh. Diagnosis can be
aided by a Tinel test, which involves
repeatedly tapping the area at which the
nerve transverses the inguinal canal. The
genitofemoral nerve provides innervation
to the upper anterior thigh and groin.
Genitofemoral nerve compression is
occasionally seen in bicyclists; however,
it is more commonly iatrogenic and
associated with abdominal wall
surgeries.8
The iliohypogastric nerve provides
motor innervation to some of the
abdominal muscles and sensation to
the skin over the lateral gluteal region.
In athletes, injury can occur due to
trauma or muscle tears of the lower
abdominal musculature. The obturator
nerve provides innervation to the medial
aspect of the thigh and adductors, and
entrapment can cause chronic groin pain
in athletes. Patients report a history of
pain that worsens with exercise and
radiates down the medial thigh, often in
the absence of paresthesias. The lateral
femoral cutaneous nerve, which provides
cutaneous innervation to the lateral
portion of the hip, traverses the inguinal
ligament, where compression can occur,
leading to meralgia paresthetica and
subsequent pain.
Hernias
Inguinal hernias, which can be either
direct or indirect and also cause groin
pain, are the most common type of
hernia in both men and women. Indirect
inguinal hernias are congenital and
caused by a patent processus vaginalis.
Direct inguinal hernias are generally
acquired in middle age. In athletes, direct
inguinal hernias occur when repetitive
valgus stress is placed on the abdominal
musculature, such as with powerlifting.
Patients with an inguinal hernia often
present with a bulge in their groin,
which can extend into the testicles in
men. Femoral hernias present as a bulge
in the femoral canal, are much more
common in women, and are prone to
complications. Patients with groin pain
can also strain the rectus abdominis
muscles without a palpable defect. In
addition, avulsion fractures of the pubic
symphysis can occur with severe rectus
abdominis or adductor strains.
 Diseases of the lumbar spine or
sacroiliac joint can result in referred
pain. Although these patients typically
report a history of back pain or have
reproducible symptoms posteriorly on
examination, an isolated radiculopathy
can present as groin pain, most
commonly at spinal levels L1 or L2 and
less commonly at spinal levels S2 or S3.
Other Etiologies
There are numerous other
causes of groin pain that do not
originate from a musculoskeletal
source. Astute clinicians must
consider a broad range of alternative
etiologies, including infectious
(eg, lymphadenopathy, sexually
transmitted infection), genitourinary
(eg, prostatitis, urinary tract
infection, nephro- or ureterolithiasis,
scrotal or testicular abnormalities),
gastrointestinal (eg, appendicitis,
diverticulitis, inflammatory bowel
disease), gynecological (eg, menses,
dysmenorrhea, pelvic inflammatory
disease), dermatological (eg, herpes
zoster), vascular (eg, aneurysm,
dissection), rheumatological
(eg, spondyloarthropathies), hemato­
logical, and oncological sources. A full
list of possible diagnoses is beyond the
scope of this discussion.
FIGURE 5. Legg-Calvé-Perthes Disease
CRITICAL DECISION
What unique pathologies
should be suspected in
children with groin pain?
Children are participating in athletic
activities earlier in life and at higher
levels of competition than ever before.
As such, complaints of sports-related
groin pain have become increasingly
common, affecting as many as 24% of
children as compared to 6% of adults.9
The unique maturation-related injury
patterns that affect pediatric patients
can make these cases particularly
challenging to assess and manage.
Pubic apophysitis is frequently
seen in soccer and football players.
The pubic symphysis is one of the
last bony structures to mature, with
some reports of full maturation as
late as age 35 to 40 years. Children
with pubic apophysitis typically have
a history of groin pain that worsens
with adduction against resistance and
passive stretching of the adductor
muscle group. Apophysitis of the
ASIS can be caused by repetitive
contractions of the sartorius or tensor
fasciae latae muscles, which can occur
during sprinting or with hip extension.
Apophysitis of the AIIS, on the other
hand, often arises from overuse of the
rectus femoris muscle. These injuries
can also present as avulsion fractures
of the physeal growth plate due to a
single contractile force of the respective
muscles. While most of these cases
resolve with no long-term sequelae,
close follow-up is required for children
who require surgical management.
Legg-Calvé-Perthes disease, or
avascular necrosis of the hip, can
develop when the rapid growth and
ossification of the epiphyses outpace
adequate blood flow. This insidious
injury (Figure 5) is typically unilateral
but is bilateral in up to 10% of children.
Boys aged 4 to 8 years are most
commonly affected. Patients typically
present with a limp and anterior
thigh pain, which can be referred to
the lateral thigh or knee, and have
decreased range of motion, with loss
of internal rotation and abduction.
Children with Legg-Calvé-Perthes
disease are at risk for femoral head
deformities, subluxation, premature
physeal arrest, acetabular dysplasia,
labral tears, osteochondritis dissecans,
and early joint degeneration.
Slipped capital femoral epiphysis
is a hip disorder characterized by
slippage of the metaphysis anteriorly
and superiorly relative to the epiphysis,
which remains anatomically positioned
in the acetabulum. This condition is
more common in obese boys aged 12
to 13 years. Patients often present with
bilateral groin and thigh pain and
an antalgic gait, with decreased hip
motion on examination. Slipped capital
femoral epiphysis (Figure 6) poses
chronic risks that are similar to those
seen with Legg-Calvé-Perthes disease,
including osteonecrosis, chondrolysis,
biomechanical changes, infection,
chronic pain, degenerative changes, and
labral tearing.
Developmental dysplasia of the
hip refers to abnormal development
of the joint, resulting in possible
subluxation or dislocation secondary
to laxity and mechanical factors.
The disorder is fairly common in
newborns. As many as 20% of cases
present bilaterally. Children with
developmental hip dysplasia invariably
develop osteonecrosis and are at risk for
transient femoral nerve palsy.
May 2019 n Volume 33 Number 5 25
 Transient synovitis of the hip, also standard frog-leg view, with subsequent except when contraindicated or when
called toxic synovitis, refers to a self- views focused on the area of clinical MRI has failed to adequately explain the
limited inflammatory condition seen in concern. Although x-rays are frequently patient’s symptoms.
children, usually after a viral infection. normal in patients with soft-tissue In the hands of a skilled operator,
It is the most common cause of hip pain injuries, radiography can identify ultrasound can also be useful for
in patients aged 4 to 8 years, with a avulsion fractures, slipped capital evaluating groin pain. Although it is
boy-to-girl ratio of 2:1. The exact cause femoral epiphysis, avascular necrosis less helpful for diagnosing strains, the
is largely unknown. Patients typically of the femoral head, stress reactions test can provide valuable views of the
present with acute or insidious groin or or fractures, osteoarthritis, cam or musculoskeletal system and can be used
thigh pain, with the hip in the position of pincer lesions of the hip joint, and to detect muscle and tendon tears, joint
comfort (ie, flexed, abducted, externally osteitis pubis. Children with groin pain effusions and labral tears, hematomas,
rotated). Unless septic arthritis is highly must be carefully assessed for physeal and bursitis. In addition, ultrasound-
suspected, these cases can generally be injuries. If the diagnosis is uncertain, the guided diagnostic steroid injections can
managed with rest, nonsteroidal anti- injured side should be compared to the be used when a diagnosis is uncertain.
inflammatory drugs (NSAIDs), and contralateral hip or groin. Bone scintigraphy can be used to
physical therapy. Although the disease is Despite the ubiquity of x-rays, MRI evaluate for osseous causes of groin
generally self-limited, 1% to 3% of these may be the most useful modality for pain. For patients with osteitis pubis, an
children eventually develop Legg-Calvé- assessing sports-related hip and groin isotope bone scan can show uptake at
Perthes disease. injuries. The test is particularly valuable the pubic symphysis, if the diagnosis is in
for evaluating patients with unclear doubt. In the right clinical context, this
CRITICAL DECISION etiologies or refractory pain and for modality can be used to help diagnose
Which patients require visualizing the soft-tissue structures stress reactions, stress fractures,
of the groin. MRI can help diagnose osteomyelitis, sacroiliitis, muscle tears,
imaging, and which modalities
musculotendinous injuries (eg, tears and synovitis.
are most appropriate? and strains), bursitis, avulsion fractures, Electromyography and nerve
There is no gold standard for the stress injuries, avascular necrosis, and conduction studies may be indicated
imaging of sports-related groin pain; attenuation of the abdominal wall for patients with undifferentiated
therefore, clinicians must consider musculofascial layers with possible groin pain of a potentially neuropathic
each patient’s history and physical bulging. It can also be used to evaluate origin. Diagnostic herniography — a
examination findings when selecting an intra-articular hip abnormalities, procedure in which contrast material
appropriate modality. Such decisions including labral tears and articular is injected into the peritoneum and the
may be further complicated by the high cartilage defects. In addition, MR patient is instructed to perform repetitive
prevalence of findings in asymptomatic arthrography can be used to investigate Valsalva-type maneuvers — can also
athletes. In one study of professional suspected intra-articular pathologies at be considered. A positive study shows
soccer players, for example, 76% the discretion of the clinician. abnormal contrast flow outside the
demonstrated radiographic changes CT is useful for evaluating normal contour of the peritoneum.
to the pubic symphysis despite being trauma and may be superior to
asymptomatic.1 MR arthrography for assessing CRITICAL DECISION
Inexpensive and easily obtained, bone deformities or morphological How should sports-related
radiography is often the initial modality abnormalities.10 To avoid radiation
groin injuries be managed in
of choice for evaluating sports-related exposure, MRI should be substituted for
groin pain. Physicians can order a CT when evaluating pediatric patients,
the emergency department?
Several causes of sports-related
groin pain warrant an emergent
orthopedic consultation; however, most
cases can be treated on an outpatient
basis by an orthopedic surgeon, sports
medicine physician, or primary care
provider.
n The terminology for sports-related groin pain has been simplified to include
Tendinitis and tendinopathy of
adductor-, iliopsoas-, inguinal-, pubic-, and hip-related symptoms.
the adductor or hip flexor muscles
n Any child with slipped capital femoral epiphysis should be evaluated by an
generally heal with conservative
orthopedist at the time of presentation. Such cases often require surgery.
management, including physical therapy,
n Radiography is typically sufficient for evaluating groin pain in the emergency
department. CT, MRI, or ultrasound may be indicated in outpatient follow-up. ice treatments, modified activity, and
n Conservative management is the initial step in treating most causes of sports- a graded return to play. Corticosteroid
related groin pain. injections can also provide relief.
Physical therapy is directed at

26 Critical Decisions in Emergency Medicine


FIGURE 6. Left Hip With Slipped Epiphysis
strengthening the surrounding muscle
groups and improving range of
motion. Biomechanical abnormalities,
including muscle imbalances, leg-length
discrepancies, and motion abnormalities
should also be evaluated.
The location of the injury often
dictates recovery time: Musculo­
tendinous junction injuries usually
improve more quickly than strains or
partial tears at the tendinous insertion
site. Tenotomy or partial surgical release
of the adductor longus tendon can be
used to treat refractory cases. Complete
tears require surgical repair. Iliopsoas
bursitis and trochanteric bursitis are
treated in a similar manner. Patients who
require surgical management may lose
some function, preventing them from
returning to their previous level of play.
Sports hernias are more challenging
to manage conservatively, largely
because a definitive diagnosis is
difficult to make. A trial of conservative
treatment for several weeks with activity
modification and therapy is indicated;
however, nonoperative treatment is
rarely successful. On the other hand, the
success rate of surgical exploration and
repair can be as high as 90%.11 Femoral
and inguinal hernias are subject to acute
incarceration and strangulation and
chronic dehiscence of the herniorrhaphy.
Cases that are reducible without
incarceration or strangulation can be
referred to a general surgeon. Groin
disruption may be a variant of a sports
hernia, or a separate entity entirely; the
literature is inconsistent.
osteotomy is definitive. Snapping hip
syndrome, originating from the iliotibial
band, tensor fasciae latae muscle, or
gluteus medius muscle, can be managed
conservatively with physical therapy,
activity modification, and a gradual
return to sport.
Stress fractures of the inferior
femoral neck and compression-type
fractures can generally be managed
conservatively as well. Most patients
experience an uneventful healing course
with a gradual return to running.
Superior femoral neck stress fractures
and tension-type fractures require
open reduction and internal fixation
due to the high risk of progression to a
complete cortical break. Stress fractures
Treatment for osteitis pubis includes of the inferior pubic ramus and
reassuring the athlete that this is a acetabulum are less worrisome and tend
self-limited disease and that activity to improve with 4 to 6 weeks of rest and
modification is the mainstay of recovery. a gradual return to sport.
Comfortable activities should be Avulsion fractures of the ASIS and
increased, while painful activities should AIIS can typically be managed with
be avoided. Physical therapy can help rest, activity modification, physical
with strength and range of motion in therapy, and a gradual return to sport.
the associated muscle groups. Guided Ischial tuberosity avulsions should be
corticosteroid injections can also assessed by an orthopedic specialist,
improve symptoms and speed recovery. as both operative and nonoperative
The management of hip-related groin treatments for these injuries are
pain varies based on the etiology. Labral controversial.
tears can be treated conservatively with Compressive neuropathies
physical therapy, analgesia, and intra- originating from the ilioinguinal,
articular joint injections; however, some genitofemoral, iliohypogastric,
cases require surgical management. FAI obturator, and lateral femoral cutaneous
caused by a cam or pincer deformity nerves can be managed with activity
can be managed conservatively with modification, physical therapy, and
intra-articular injections, but surgical corticosteroid injections. Refractory
n Failing to thoroughly evaluate the joint above and below the point of pain
when assessing children who present with knee pain or a refusal to bear
weight. This mistake can result in missed diagnoses, including slipped capital
femoral epiphysis or Legg-Calvé-Perthes disease.
n Overlooking the possibility of femoral neck stress fractures, which are more
common in women and can potentially develop into occult fractures.
n Failing to differentiate between musculoskeletal etiologies and other causes
of groin pain. Additional systemic complaints or organ system involvement
require a broader differential diagnosis and proper workup.
n Performing a cursory physical examination, without visualization and
palpation of the sensitive groin area. Remember that many genitourinary
disorders and hernias present as groin pain.
May 2019 n Volume 33 Number 5 27
 CASE RESOLUTIONS
■ CASE ONE
The high school hockey player was
suspected to have mixed FAI (both cam
and pincer deformities), a diagnosis that
is more likely in athletes that have played
excessive, high-impact sports throughout
their adolescence. The patient’s use of the
C sign (ie, grasping of his lateral hip) is
a typical indicator of an intra-articular
pathology. The pain he expressed with
the FADIR test was further suspicious
for FAI. The emergency physician
recommended a conservative course of
treatment, including an anti-inflammatory
medication and a trial of physical therapy.
The patient was also instructed to follow
up with an orthopedic surgeon.
cases should be referred to a surgeon for
neurolysis via radiofrequency ablation,
cryoablation, or a neurectomy.
Pediatric Injuries
Pediatric causes of groin pain must
be managed differently. Pubic, ASIS,
and AIIS apophysitis can generally be
treated with activity modification, rest,
and physical therapy. Most athletes can
return to previous sporting levels within
6 months.10 Children with apophysitis
may follow up as outpatients. For those
with a significant fracture displacement
or nonunion, open reduction and
internal fixation should be considered.
The management of Legg-Calvé-
Perthes disease involves maintaining
the femur in an abducted and internally
rotated position so that the femoral head
sits comfortably in the acetabulum. This
is accomplished by non–weight bearing
activity restriction, physical therapy, and
orthotic bracing. These cases require
management by a pediatric orthopedic
surgeon, and evaluation in the emergency
department may be indicated to ensure
close follow-up. For refractory cases or
children older than 8 years, a femoral
or pelvic osteotomy is indicated. Slipped
capital femoral epiphysis must always be
managed surgically.
Infants and toddlers (aged 6-18
months) with developmental hip
dysplasia can generally be managed
conservatively with either a Pavlik
28 Critical Decisions in Emergency Medicine
■ CASE TWO
The young gymnast with a painless
limp was suspected to be suffering
from Legg-Calvé-Perthes disease,
which is five times more common
in boys. Because the patient’s pain
was nonspecific and mild, he was
initially evaluated with radiographs
of the pelvis (anteroposterior and
frog-leg views), which raised further
suspicion for the diagnosis. A pediatric
orthopedic specialist determined that
the child was in the initial stage of the
disease. As such, non–weight bearing
activity restrictions, trials of physical
therapy, and orthotic bracing were
recommended.
harness or spica casting. Children with
developmental dysplasia of the hip can
follow up as outpatients. For patients older
than 18 months, open reduction with
either casting or osteotomy is indicated.
Transient synovitis tends to resolve on its
own with conservative therapy, including
rest, activity modification, NSAIDs,
and physical therapy. If a high index of
suspicion exists for septic arthritis, joint
aspiration, intravenous antibiotics, or
irrigation and debridement of the joint
should be considered. If the diagnosis of
transient synovitis is certain, outpatient
treatment is appropriate.
Summary
Sports-related groin pain is commonly
associated with activities that require
rapid acceleration or deceleration and
changes in direction. The complex
anatomy involving the pubic symphysis
and the many nearby organ systems
make definitively diagnosing these
cases challenging. The most common
acute injuries are strains involving
the adductor or iliopsoas muscles, but
other tendinopathies can present as
acute or chronic complaints. When
managing pediatric athletes, additional
considerations should include pubic
apophysitis, Legg-Calvé-Perthes disease,
slipped capital femoral epiphysis, and
transient synovitis of the hip. Avulsion
injuries of the ASIS and AIIS are more
common in children.
■ CASE THREE
The 35-year-old soccer
player was suspected to have
osteitis pubis, which typically
presents in the third or fourth
decade of life. Plain radiographs
confirmed degeneration along the
pubic symphysis. The clinician
recommended conservative
management, including rest from
the sport, hip strengthening,
and core strengthening through
outpatient care. The patient was
counseled that injection therapy
with corticosteroids may be
required if her symptoms become
refractory.
Plain radiographs are indicated for
many causes of sports-related groin
pain. Although further imaging with
CT or MRI can help make a definitive
diagnosis, such tests are rarely needed
urgently. Most causes of sports-related
groin pain can be treated with activity
modification, anti-inflammatory
medications, and physical therapy.
REFERENCES
1. Harris NH, Murray RO. Lesions of the symphysis in
athletes. Br Med J. 1974 Oct 26;4(5938):211-214.
2. Swan KG Jr, Wolcott M. The athletic hernia: a
systematic review. Clin Orthop Relat Res. 2007 Feb;
455:78-87.
3. Rebolledo B, Bernard J, Werner B, et al. Low vitamin D
is associated with lower extremity strains and sports
hernia injuries in NFL combine athletes. Arthroscopy.
2017 Jun;33(6):e18.
4. Verrall GM, Slavotinek JP, Barnes PG, Fon GT.
Description of pain provocation tests used for the
diagnosis of sports‐related chronic groin pain:
relationship of tests to defined clinical (pain and
tenderness) and MRI (pubic bone marrow oedema)
criteria. Scan J Med Sci Sports. 2005 Feb;15(1):36-42.
5. Martin RL, Irrgang JJ, Sekiya JK. The diagnostic
accuracy of a clinical examination in determining
intra-articular hip pain for potential hip arthroscopy
candidates. Arthroscopy. 2008 Sep;24(9):1013-1018.
6. Maslowski E, Sullivan W, Forster Harwood J, et al.
The diagnostic validity of hip provocation maneuvers
to detect intra-articular hip pathology. PM R. 2010
Mar;2(3):174-181.
7. Tiru M, Goh SH, Low BY. Use of percussion as a
screening tool in the diagnosis of occult hip fractures.
Singapore Med J. 2002 Sep;43(9):467-469.
8. Cesmebasi A, Yadav A, Gielecki J, Tubbs RS, Loukas
M. Genitofemoral neuralgia: a review. Clin Anat. 2015
Jan;28(1):128-135.
9. Whittaker JL, Small C, Maffey L, Emery CA. Risk
factors for groin injury in sport: an updated systematic
review. Br J Sports Med. 2015 Jun;49(12):803-809.
10. Llopis E, Fernandez E, Cerezal L. MR and CT
arthrography of the hip. Semin Musculoskelet Radiol.
2012 Feb;16(1):42-56.
11. Hackney RG. The sports hernia: a cause of chronic
groin pain. Br J Sports Med. 1993 Mar;27(1):58-62.
12. Weir A, Brukner P, Delahunt E, et al. Doha agreement
meeting on terminology and definitions in groin pain
in athletes. Br J Sports Med. 2015 Jun;49(12):768-774.
 The Critical Procedure
Autotransfusion for the Treatment of Acute Hemothorax
By Jennifer C. Chapman, MD
Orange Park Medical Center, Orange Park, Florida
Reviewed by Steven J. Warrington, MD, MEd
Autotransfusion can be used for the treatment of acute moderate and massive hemothoraces. During the procedure, the
patient’s own blood is evacuated through a thoracostomy tube, filtered, and transfused back into circulation via peripheral
intravenous access. Autotransfusion can eliminate or decrease the need for an allogeneic blood transfusion — a far riskier process.

Contraindications autotranfusion can conserve valuable thrombocytopenia. Transfusions with

n Possible contamination of pleural blood bank resources and eliminate the inadequately filtered, evacuated blood
blood due to trauma risk of human error associated with can be contaminated with leukocytes,
n Intrathoracic malignancy allogeneic transfusions (eg, incorrect cytokines, and microaggregates. In
n Intrathoracic or overlying infection blood typing). addition, prolonged suction during the
n Sickle cell disease (this process may blood evacuation process can create
cause hypoxemia and sickling of Risks shear stress on red blood cells, leading to
evacuated blood) The risks of the procedure include hemolysis.
n Known coagulopathy or equipment failure (eg, blood wasting),
blood contamination due to an unsterile
Special Considerations
disseminated intravascular
Autotransfusion requires trained
coagulation field or filtration solution, and air
personnel, placement of a large-bore
emboli. It is important to note that
Benefits chest tube and intravenous catheter, and
autotransfused blood contains less
Autotransfusion can help patients a specialized device capable of moving
hemoglobin (~9 g/dL) than normal
avoid the potential complications of blood that has been drained from the chest
allogeneic transfusion methods, including whole blood (~13 g/dL). Autotransfused tube. In addition, the procedure requires
the transmission of communicable blood also has a lower concentration of a minimum volume of blood collection
diseases and acute respiratory distress red blood cells than blood transfused (~700 mL). Depending on the extent of
syndrome. The procedure may provide through allogeneic methods, a factor that the intrathoracic injury and degree of
additional benefits for patients with can result in hemodilution. blood loss, patients may eventually require
rare blood types, autoantibodies, and Large-volume transfusions (>3 L) additional blood products, cardiothoracic
certain religious beliefs. In addition, increase the risk of coagulopathy and surgery, or embolization.

TECHNIQUE
1. Set up the device prior to inserting the
chest tube.
2. Insert a large-bore chest tube
(28-30 Fr), using a standard thoracostomy
technique.
3. Collect the blood in the device reservoir.
Collection should begin immediately
upon insertion of the chest tube.
4. Wash the blood, typically with a citrate-
based compound.
5. Transfuse the blood back into circulation
using a standard transfusion procedure.
Blood must be transfused within 6 hours
of collection (preferably within 4 hours). Redax chest drainage system, one of many
widely available autotransfusion devices Transfer bag

1. Ashworth A, Klein AA. Cell salvage as part of a blood conservation strategy in anaesthesia. Br J Anaesth. 2010 Oct;105(4):401-416.
2. Mattox KL. Thoracic vascular trauma. J Vasc Surg. 1988 May;7(5):725-729.
3. Salhanick M, Corneille M, Higgins R, et al. Autotransfusion of hemothorax blood in trauma patients: is it the same as fresh whole blood? Am J Surg. 2011 Dec;202(6):817-822.
4. Brown CV, Foulkrod KH, Sadler HT, et al. Autologous blood transfusion during emergency trauma operations. Arch Surg. 2010 Jul;145(7):690

May 2019 n Volume 33 Number 5 29

 CME
Reviewed by Lynn Roppolo, MD, FACEP

Qualified, paid subscribers to Critical Decisions in Emergency Medicine may receive

CME certificates for up to 5 ACEP Category I credits, 5 AMA PRA Category 1
Credits™, and 5 AOA Category 2-B credits for completing this activity in its

QUESTIONS entirety. Submit your answers online at acep.org/cdem; a score of 75% or better
is required. You may receive credit for completing the CME activity any time within
3 years of its publication date. Answers to this month’s questions will be published
in next month’s issue.

1
What is the most common symptom of myocarditis?
A. Chest pain 7 Which of the following ECG findings is an early and
reliable sign of pericarditis?
B. Cough A. Diffuse ST-segment elevation with PR-segment
C. Palpitations depression
D. Respiratory distress B. Diffuse T-wave inversion
C. Short PR interval and wide QRS
2 Which of the following interventions can be
detrimental to patients with myocarditis? D. ST-segment elevation in leads II, III, and aVF

8
A. Dobutamine In which scenario should corticosteroids be
B. Furosemide considered for the treatment of pericarditis?
C. IV fluids A. 1-year-old girl with a recent ventricular septal
D. NSAIDs defect repair and a small pericardial effusion

3 What is the most common echocardiographic finding in B. 6-year-old boy with a first episode of acute
children with myocarditis? pericarditis associated with elevated CRP
A. Dilated cardiomyopathy C. 12-year-old boy with a first episode of acute
B. Pericardial effusion pericarditis associated with high fevers
C. Restrictive cardiomyopathy D. 15-year-old girl with systemic lupus erythematosus
D. Valvular abnormality and recurrent pericarditis

4 A 14-year-old boy with a history of asthma presents

with 3 days of fever, nasal congestion, and shortness of
breath. He had one episode of nonbloody, nonbilious
9 A 13-year-old girl with a history of dermato­myositis
emesis but denies any abdominal pain or diarrhea.
His vital signs are heart rate 158, respiratory rate 29,
and temperature 38.2°C (100.8°F); his blood pressure
is normal. Which finding is most likely to indicate
myocarditis?
A. Bilateral conjunctival injection
B. Clear lungs and good air movement upon
auscultation
C. Painful nodules on his fingers and toes
D. Pericardial friction rub
presents with acute-onset chest pain and shortness
of breath. Her pain is worse when she is lying flat
and with deep inspiration. Her vital signs are blood
pressure 89/41, heart rate 139, respiratory rate
24, temperature 39.5°C (103.1°F), and oxygen
saturation 90% on room air. What is the next best
step in her management?
A. Administer broad-spectrum antibiotics
B. Administer IVIG
C. Perform a point-of-care echocardiogram to
evaluate for pericardial effusion
D. Request a cardiology consultation

5 Which of the following clinical presentations is most

consistent with a diagnosis of pericarditis?
10
A. Acute onset of chest pain that radiates to the scapula
B. Diminished femoral pulse
C. Fever for 5 days and irritable mood
D. New holosystolic murmur at the left sternal border
A 2-year-old girl presents with 6 days of fever and
decreased food intake. She is difficult to console,
and her parents report that her fevers have been
as high as 39.8°C (103.6°F). She has right cervical
adenopathy and a polymorphous rash in the
perineal area. What is the next best step?

6 Which diagnostic test is most valuable for detecting

pericarditis?
A.
B.
Administer IVIG
Obtain a chest x-ray and ECG
A. ECG
C. Obtain an echocardiogram
B. Echocardiogram
D. Request a cardiology consultation
C. Elevated ESR
D. Elevated troponin level

30 Critical Decisions in Emergency Medicine

11 Which finding is associated with increased
sports-related groin pain and lower-extremity
strains?
A. Elevated ESR
B. Elevated potassium level
C. Low magnesium level
D. Low vitamin D level
12 Which structure innervates the medial aspect
of the thigh and adductor muscles and can be
a source of entrapment and chronic sports-
related groin pain?
A. Iliohypogastric nerve
B. Ilioinguinal nerve
C.
D.
Obturator nerve
Sciatic nerve
13 What clinical test is most sensitive for detecting
femoral neck stress fractures?
A. Bilateral adductor test
B. FABER test
C. Patellar-pubic percussion test
D. Squeeze test
14 A 28-year-old soccer player presents with left-
sided groin pain that began after he slipped
and slid forward into a “split.” He complains of
tenderness over his left superior pubic ramus
and down the medial thigh. There is no bruising
or swelling, and his x-ray shows no acute bony
abnormalities. What is the most likely source of
his symptoms?
A. Adductor-related etiology
B. Hip osteoarthritis
C. Iliopsoas-related groin injury
D. Labral tear
15 A 34-year-old runner presents with gradual left-
sided pain in her groin and inguinal region. She
was forced to stop in the middle of a 4-mile
run due to progressive pain and a “catching”
sensation. She exhibits pain while undergoing
both scour and FADIR tests. What is the most
likely source of her symptoms?
A. Adductor-related etiology
B. Hip-related disorder
C. Inguinal-related etiology
D. Osteitis pubis
ANSWER KEY FOR APRIL 2019, VOLUME 33, NUMBER 4
1 2 3 4 5 6 7 8
D D B A B B A A
16 What disorder is the most common cause of hip pain
in children aged 4 to 8 years?
A. Apophysitis of the ASIS
B. Developmental dysplasia
C. Slipped capital femoral epiphysis
D. Transient synovitis
17 What finding can indicate an avulsion injury,
muscular tear, or abdominal wall hematoma?
A. Altered sensation
B. “Clicking” sound with hip movement
C. Ecchymosis
D. Elevated inflammatory markers
18 A 40-year-old man presents with right-sided groin
pain after kicking a soccer ball. He has pain when
bearing weight, and minor soft-tissue edema is
noted in his groin area. What diagnostic test should
be initiated first?
A. Bone scintigraphy
B. Electromyography
C. MRI of the right hip
D. X-ray of the pelvis
19 How is Legg-Calvé-Perthes disease typically
managed?
A. Emergency surgical correction with femoral
osteotomy
B. IV antibiotics and joint irrigation
C. Joint aspiration to definitively diagnose the
disease
D. Non–weight bearing activity restrictions, physical
therapy, and orthotic bracing
20 A high school ice hockey player presents with
progressive right-sided groin pain that occurs with
activity and coughing. A bulge in his inguinal region
is noted on examination. An attempted reduction
of the hernia is unsuccessful. The patient complains
of worsening pain, along with nausea and vomiting.
What is the most appropriate next step?
A. Emergent general surgery consultation
B. MRI of the right hip
C. Urgent orthopedic consultation
D. X-ray of the pelvis
9 10 11 12 13 14 15 16 17 18 19 20
B C D A C B A D B D B C
May 2019 n Volume 33 Number 5 31
 Drug Box Tox Box
ERAVACYCLINE GLYPHOSATE
By Frank LoVecchio, DO, MPH, FACEP By Christian A. Tomaszewski, MD, MS, MBA, FACEP
Maricopa Medical Center, Phoenix, Arizona University of California, San Diego
Eravacycline is a fluorocycline antibiotic within the tetra­cycline class. Glyphosate, the most common herbicide in the US, is the
The drug binds to the 30S ribosomal subunit to prevent amino acid subject of several multimillion-dollar lawsuits in which the
residues from incorporating into elongated peptide chains, thereby compound is accused of causing non-Hodgkin lymphoma. In
inhibiting bacterial protein synthesis. most cases, toxicity is seen only in intentional ingestions.
Indications Kinetics
Eravacycline can be used to treat complicated intra-abdominal • ~30% bioavailable after ingestion
infections in adults caused by Escherichia coli, Klebsiella • <1% skin penetration
pneumoniae, Citrobacter freundii, Enterobacter cloacae, • Low vapor pressure and, therefore, low inhalational
Klebsiella oxytoca, Enterococcus faecalis, Enterococcus faecium, exposure
Staphylococcus aureus, Streptococcus anginosus, Clostridium Mechanism of Action
perfringens, Bacteroides species, and Parabacteroides distasonis. • Cell membrane disruption
The drug is NOT indicated for the treatment of complicated • Uncoupling of oxidative phosphorylation
urinary tract infections. • Hypotension from added surfactants
Adult Dosing Clinical Manifestations
1 mg/kg IV every 12 hours for 4 to 14 days Acute
• Abdominal pain, nausea, vomiting, diarrhea, potential GI
If coadministered with strong CYP3A inducers (eg, rifampin),
hemorrhage
increase to 1.5 mg/kg every 12 hours.
• Hypotension from fluid loss and dysrhythmias
Dosing adjustments are required for patients with severe hepatic • Hyperkalemia and rhabdomyolysis
impairment (Child-Pugh class C): 1 mg/kg every 12 hours on • Altered mental status
day 1, then 1 mg/kg every 24 hours. Chronic (inconsistently associated with various cancers)
Precautions According to the World Health Organization, glyphosate is
Adverse effects include anaphylactic or hypersensitivity likely to be carcinogenic. However, the US Environmental
reactions and antianabolic effects (eg, increased BUN Protection Agency and the European Food Safety Authority
levels, azotemia, acidosis, and hyperphosphatemia). Other have deemed it an unlikely carcinogen.
risks (eg, hepatotoxicity, pancreatitis, photosensitivity, and Diagnostic Tests (if patient is symptomatic or ingestion is
pseudotumor cerebri) may be related to the drug’s structural intentional)
similarity to tetracycline. Use may result in fungal or bacterial • BMP to screen for hyperkalemia and renal injury
superinfections, including Clostridioides (formerly Clostridium) • Blood gas and lactate to screen for acidosis
difficile infections and colitis. • CPK
• ECG
Other adverse reactions include hypotension (1%), nausea (7%), • Chest x-ray for pulmonary symptoms
vomiting (4%), diarrhea (2%), and infusion-site reactions (8%).
Treatment
Eravacycline can cause permanent tooth discoloration, enamel
• Skin and ocular decontamination
hypoplasia, and inhibited bone growth in children. Avoid in • IV fluids and vasopressor resuscitation
pregnant patients and children <8 years of age. • Hemodialysis for renal failure (does not remove surfactant)
Potentially significant drug-drug interactions may require dosing • Nontrivial (intentional) exposures: observe 6 hours
adjustments, additional monitoring, and/or alternative therapies. • Significant gastrointestinal or severe symptoms: admit