Volume 33 Number 10 October 2019

Breakdown
Rhabdomyolysis is a potentially life-threatening
condition precipitated by the death of striated muscle
fibers — a process that results in a toxic release of
myoglobin into the bloodstream. The disorder, which
is typically caused by infections, crush injuries,
excessive exercise, or the use of certain prescription
or illicit drugs, can lead to acute renal failure and
dangerous electrolyte disturbances. The timely
identification of at-risk patients is critical.

Twist and Shout

Scrotal pain and swelling are common pediatric
complaints in the emergency department. Such
symptoms can be caused by a wide variety of
conditions, many of which can be successfully
treated with gentle reassurance and supportive
care. However, clinicians must also be prepared
to recognize and manage more serious scrotal
pathologies, including testicular torsion. Clinicians
must be able to differentiate these sensitive
abnormalities based on the nuances of each case.

THE OFFICIAL CME PUBLICATION OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS

IN THIS ISSUE
Lesson 19 n Rhabdomyolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Critical ECG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Critical Decisions in Emergency Medicine is the official
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Critical Cases in Orthopedics and Trauma . . . . . . . . . . . . . . . . . . . . . . . . . 10
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Lesson 20 n Pediatric Scrotal Emergencies . . . . . . . . . . . . . . . . . . . . . . . 15 Northeastern Ohio Universities,
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 Breakdown
Rhabdomyolysis

LESSON 19

By Juan Marcos Rendon, MD; and Amanda Elizabeth Opfer, DO

Dr. Rendon is an assistant professor of emergency medicine at UT Southwestern
Medical Center and an attending physician at Parkland Memorial Hospital in Dallas,
Texas. Dr. Opfer is an emergency medicine physician with Campbell County Health
in Gillette, Wyoming.

Reviewed by Joseph F. Waeckerle, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Identify the common signs and symptoms of n What pathophysiological factors should be
rhabdomyolysis. considered when evaluating a suspected case of
2. Understand the common causes of rhabdomyolysis and rhabdomyolysis?
explain the risk factors.
n What clinical and laboratory findings should raise
3. Describe the workup and management of
suspicion for rhabdomyolysis?
rhabdomyolysis.
4. Discuss the long-term complications of rhabdomyolysis. n What acute treatments should be initiated in the
emergency department?
FROM THE EM MODEL n When is inpatient admission warranted?
11.0 Musculoskeletal Disorders (Nontraumatic)
11.4 Muscle Abnormalities
11.4.2 Rhabdomyolysis

Rhabdomyolysis is a potentially life-threatening condition precipitated by the death of striated muscle fibers — a
process that results in a toxic release of myoglobin into the bloodstream. The disorder, which is typically caused by
infections, crush injuries, excessive exercise, or the use of certain prescription or illicit drugs, can lead to acute renal failure
and dangerous electrolyte disturbances. The potential multisystem complications of rhabdomyolysis warrant its immediate
recognition, diagnosis, and timely management to prevent acute and long-term detrimental effects.

October 2019 n Volume 33 Number 10 3

 CASE PRESENTATIONS
■ CASE ONE
A 19-year-old woman presents
with flank pain, myalgias, and
reports of dark urine; her symptoms
began this morning after she ran an
ultramarathon. She denies any recent
illnesses, has no significant medical
history, and takes no medications. Her
current vital signs are blood pressure
108/76, heart rate 86, respiratory
rate 13, temperature 37.2°C (99°F),
and oxygen saturation 99% on room
air. She appears uncomfortable, is
clutching her flank, and complains
of diffuse body aches. Peripheral IV
access is established, and the patient is
placed on a cardiac monitor.
■ CASE TWO
A 36-year-old man arrives via
ambulance with altered mental
status. Paramedics report that he was
found wandering near a warehouse,
where a passersby called 911 after
witnessing the patient talking to
himself and behaving erratically. He
is unable to provide a medical history;
however, the EMTs report seeing drug
paraphernalia at the scene. The patient
appears agitated and tremulous and is
muttering to himself.
His current vital signs are blood
pressure 158/90, heart rate 124,
respiratory rate 18, temperature 38.1°C
(100.6°F), and oxygen saturation 100%
on room air. Peripheral IV access is
obtained, and basic laboratory tests
are ordered, including a creatine kinase
(CK) concentration and urinalysis. The
patient receives 1 L of normal saline
and is placed on a cardiac monitor.
■ CASE THREE
An 82-year-old woman with
a history of hypertension and
hyperlipidemia arrives via ambulance
after being found on the floor by her
home health care worker. The patient
explains that she fell a day earlier when
her walker slipped on a broken tile;
she was unable to reach the telephone
and call for help. She denies any loss of
consciousness but complains of pain
in her left hip and thigh. She appears
frail and in pain. The EMTs obtained
IV access, and the patient was given
50 mcg of fentanyl before arrival. Her
current vital signs are blood pressure
143/85, heart rate 113, respiratory
rate 23, temperature 35.6°C (96.1°F),
and oxygen saturation 91% on room
air.
The patient is placed on a 2-L
nasal cannula, which increases her
oxygen saturation to 96%. Her left,
lower extremity is shortened, and
her hip is held in internal rotation.
The emergency physician suspects
a hip fracture. IV analgesia and
x-rays of the woman’s pelvis and left
leg are ordered. Laboratory studies
are initiated, and the orthopedic
surgery service is paged. During the
examination, the patient asks for
her home medications of lisinopril
and atorvastatin, explaining that she
missed her dose this morning.

CRITICAL DECISION A variety of culprits can lead (eg, cocaine, amphetamines), viral and
to muscle cell damage, including bacterial infections, and genetic and
What pathophysiological factors
trauma (eg, crush injuries and burns), connective tissue disorders.3 Despite
should be considered when
prolonged immobilization, excessive the large number of potential causes
evaluating a suspected case of exercise, medications (particularly (Table 1), the cell death that precipitates
rhabdomyolysis? statins and antipsychotics), illegal drugs rhabdomyolysis comes from two
Rhabdomyolysis directly affects
muscle function and contraction FIGURE 1. Unilateral Forearm Swelling After Resistance Training
through a complex process mediated
by many different systems. This
mechanism requires both the exchange
of various electrolytes, which create an
electrochemical gradient, and oxygen,
which is used to form adenosine
triphosphate in the cells.
The key players in muscle cell death
that lead to rhabdomyolysis are potassium,
calcium, and phosphate (electrolytes
required for a variety of intracellular
functions) as well as myoglobin (a heme
protein that resides in muscle cells and
reversibly binds oxygen). When a cell
dies, these products are released into
the bloodstream; in cases of large-scale
muscle breakdown, cellular byproducts
overwhelm the body’s intrinsic clearance
mechanisms and accumulate in the body.1,2

4 Critical Decisions in Emergency Medicine

 CRITICAL DECISION
FIGURE 2. Potential Complications of Rhabdomyolysis
What clinical and laboratory
Acute Kidney Injury
Direct effect of myoglobulin findings should raise suspicion
DIC (late)
Thromboplastin release and +/- hypovolemia Compartment Syndrome for rhabdomyolysis?
thrombotic microangiopathy Treatment: IV fluids, Muscle ischemia and fluid
Treatment: fresh bicarbonate, hemodialysis sequestration As is the case with most complex
frozen plasma Treatment: fasciotomy disorders, rhabdomyolysis is more
evident in some situations than in others.
Hyperkalemia Emergency physicians are unlikely to
Potassium released from miss the syndrome in a trauma patient
damaged muscles and Hypovolemia with compartment syndrome, but it can
decreased clearance from Complications of From sequestration
acute kidney injury Rhabdomyolysis be significantly harder to diagnose in a
of fluids in the muscles
Treatment: IV fluids, diuresis, Treatment: IV fluids nonverbal elderly patient who recently
sodium polystyrene sulfonate, started a new medication.
calcium gluconate, glucose +
The classic triad of rhabdomyolysis
insulin, hemodialysis
symptoms are pain in the postural
Hypocalcemia
muscles (eg, shoulders, thighs, or lower
Hyperphosphatemia Inward flux and binding Hypercalcemia (late)
to phosphatidylinositol back); muscle weakness or trouble
Muscle breakdown Efflux from damaged muscles
Treatment: diuresis, Treatment: Avoid giving and slow clearance if acute moving the arms and legs; and dark
hemodialysis calcium, as calcium levels kidney injury present red or brown, “tea-colored” urine or
are likely to increase later Treatment: IV fluids, diuresis
without treatment. decreased urination. However, it is
important to keep in mind that 50% of
patients with the condition may have no
distinct pathways: Traumatic injuries hyperkalemia and subsequent cardiac
muscle-related symptoms.
can cause direct damage to the cell dysrhythmias.
The clinical presentation of muscle
and blood supply, a process that leads However, potassium is not the only
breakdown is variable; symptoms can
to ischemia and cell death. In cases electrolyte affected by the disorder. When
include muscle soreness, stiffness, or
caused by medication or connective muscles break down, calcium binds to
swelling (Figure 1) and nonspecific
tissue disorders, a disruption in cell necrotic muscle tissue; this can lead
findings such as malaise. In many cases,
metabolism leads to tissue death. to systemic hypocalcemia (the earliest
the key to diagnosis is in the patient’s
Direct and indirect injuries cause electrolyte abnormality seen in cases of
history, which may suggest strenuous
cellular swelling and, eventually, lysis rhabdomyolysis), which predisposes the
activities or new medications. If the
of the cells. Lysis results in the systemic cardiac muscle to instability. Perhaps the
patient is comatose or unstable and the
buildup of intracellular components, most severe complication of this process
history is limited, subtle clues such as
including phosphate, potassium, CK, is disseminated intravascular coagulation
pressure sores or skin discoloration may
uric acid, and myoglobin. Although (DIC). Although the etiology of DIC is
suggest prolonged immobility.
the release of myoglobin can lead unclear, it is likely due to the large-scale
Additionally, the McMahon risk
to acute renal failure, the cardiac activation of the clotting cascade caused
prediction score can be used to identify
system is particularly vulnerable to the by muscle breakdown.
patients with rhabdomyolysis who are
electrolyte disturbances that take place Importantly, treatment for
at risk for renal failure or death. This
during cell breakdown. In addition, hypocalcemia should only be initiated
prognostic tool has been shown to
rhabdomyolysis can trigger the release if the patient is symptomatic. Common
reliably evaluate patients based on the
of potassium into the patient’s systemic complaints include fatigue, muscle cramps,
demographic, clinical, and laboratory
circulation, a process that can lead to carpopedal spasms, and seizures.
variables available on admission.
Although several blood tests are
necessary to diagnosis rhabdomyolysis,
perhaps the most relevant is CK
concentration, which can confirm the
syndrome in any patient whose CK
n An early ECG can help identify signs of hyperkalemia, including sine waves, concentration is 5 times the upper
T-wave tenting, and widening of the QRS complex interval. limit of normal, or roughly 1,000 U/L.1
n Only treat hypocalcemia if the patient is symptomatic (eg, fatigue, muscle Because this concentration can rise
cramps, carpopedal spasms, or seizures). for 12 hours after the cells have been
n Remember to administer normal saline fluids to achieve a goal urine output of damaged, repeat studies can aid in
200 to 300 mL/hour. Fluids that contain lactate or potassium should be avoided.
diagnosis (Table 2). CK concentration
n Consider using bicarbonate infusions to prevent acute renal failure and to
typically peaks within 48 to 72 hours
increase urine pH in severely ill patients.
and then begins to fall.4 The test should

October 2019 n Volume 33 Number 10 5

 TABLE 1. Etiologies of Rhabdomyolysis

Category Condition Examples

Direct muscle Crush trauma Building collapse, earthquakes, cave-ins, motor vehicle collisions, farm and
injury Bite wounds industrial accidents
Deep burns Electrical injuries, effect of lightning strikes, effect of cardioversion
Necrotizing myopathy related
to carcinomas
Fights/beatings Effects of boxing, karate, torture, assault, child abuse
Repetitive blows Effects of playing bongo drums, using a computer keyboard, using a jackhammer,
riding a mechanical bull, riding on a personal watercraft, CPR
Excessive Intense physical exercise Weight lifting, running marathons, training for police cadets and military recruits in
physical boot camp
exertion Tonic-clonic seizures
Psychoses Mania, drug-induced psychosis
Severe agitation Effects of restraint in a straitjacket, delirium tremens, decerebrate posturing
Muscle Generalized ischemia Shock, hypotension, carboxyhemoglobinemia, status asthmaticus, hydrocarbon
ischemia inhalation, near-drowning
Localized compression Tourniquets, tight dressings or casts, prolonged use of air splints and pneumatic
antishock garments
Immobilization Prolonged intraoperative positioning, “found down,” spinal cord injury
Compartment syndrome
Reperfusion injury
Arterial or venous occlusions Heparin-induced white clot syndrome, diving-related air emboli, severe sickle cell
crisis, vasculitis
Temperature Cold Generalized hypothermia, frostbite injuries
extremes Heat Exertional hyperthermia, malignant hyperthermia, neuroleptic malignant
syndrome
Electrolyte Chronic hypokalemia Overuse of diuretics, hyperemesis gravidarum, ingestion of black licorice, renal
and osmolality tubular acidosis
abnormalities Other electrolyte disturbances Hypophosphatemia, hyponatremia, effect of sodium replacement therapy
Hyperosmolar states Hyperglycemic hyperosmolar nonketotic coma, effects of aggressive mannitol
therapy for diabetes insipidus
Endocrinologic Electrolyte-wasting conditions Diabetic ketoacidosis, hyperaldosteronism, Addison disease
disorders Hypermetabolic conditions Thyroid storm, pheochromocytoma
Genetic and Genetic disorders Muscular dystrophy
autoimmune Autoimmune disorders Polymyositis, dermatomyositis
disorders
Infections Bacterial infections Pneumococcal sepsis, Staphylococcus aureus sepsis, Salmonella infections,
Listeria infections, leptospirosis, Legionnaires’ disease, tularemia, gas gangrene,
tetanus, necrotizing fasciitis
Parasitic infections Malaria
Viral infections Infection with influenza A and B viruses, varicella-zoster virus, HIV, enteroviruses
Drugs, toxins, Ethanol
and venoms Recreational drugs and stimulants Use of heroin, lysergic acid diethylamide, cocaine, N-methyl-D-aspartate (ecstasy),
phencyclidine, caffeine, aminophylline, pseudoephedrine; sniffing glue
Toxic plants and animals Ingestion of hemlock, toxic mushrooms; effects of blowpipe dart poison, snake
venoms, hymenoptera stings, envenomation by giant desert centipede
Pharmaceutical agents Use of benzodiazepines, corticosteroids, narcotic analgesics, immunosuppressants,
salicylates, lipid-lowering statins, paralytics, antibiotics, antidepressants,
antipsychotics, thrombolytics, chemotherapeutic agents

be repeated throughout the course of the
hospitalization to monitor the patient’s
response to treatment. Urinalysis should
be used to evaluate for the presence of
myoglobin; however, it is important
to note that RBCs will be absent in a
patient with rhabdomyolysis.5
In addition to studies that can be
used to confirm the diagnosis, an ECG
should be obtained to evaluate for signs
of hyperkalemia, such as tall, “tented”
T waves; widening of the QRS complex;
and sine waves.1 Other important studies
to evaluate for potential complications
(Figure 2) include metabolic panels (eg,
BUN), a CBC, urinalysis, a liver function
panel, a calcium level test, and blood
gas measurements (to assess the level of
acidosis).
CRITICAL DECISION
What acute treatments should
be initiated in the emergency
department?
For many patients, rhabdomyolysis
treatment (Figure 3) can be started
before the diagnosis has been confirmed
by laboratory tests. In particular, earlier
intervention can improve outcomes for
crush victims; many experts advocate
beginning fluid resuscitation before
extricating these patients from the scene.1
The mainstay of rhabdomyolysis
treatment is fluid resuscitation. As such,
IV access should be obtained promptly,
and a normal saline fluid bolus should
be initiated. Fluids that contain lactate
or potassium should be avoided. In
young, otherwise healthy patients,

6 Critical Decisions in Emergency Medicine


TABLE 2. Diagnosing Rhabdomyolysis Based on CK Level
Diagnosis CK Level
Normal CK level ~40-200 U/L
MILD rhabdomyolysis 1,000-5,000 U/L
MODERATE 5,000-15,000 U/L
rhabdomyolysis
SEVERE >15,000 U/L
rhabdomyolysis
treatment may begin with 2 to
3 L of fluid. Elderly patients with
congestive heart failure should receive
500 mL of fluid and undergo serial
ultrasound evaluations of the inferior
vena cava and lungs to assess fluid status.
The guiding factor for fluid resuscitation
is urine output, with a goal output of
200 to 300 mL/hour. Placement of a
urinary catheter enables strict intake and
early output measurements.4
Renal failure, perhaps the most
feared complication of rhabdomyolysis,
arises from the buildup of myoglobin
Clinical
Significance Treatment
Low risk of kidney Possibly; depends
injury on context
Increased risk of renal Yes
injury
Increased risk of Yes
dialysis
in the renal tubules. By administering
sodium bicarbonate, urine becomes
more alkaline, which can decrease the
toxic effect of myoglobin on the kidneys.
Many hospitals provide a specific
protocol for this treatment; however, the
simplest method is to place 3 ampules
of sodium bicarbonate in a bag of 5%
dextrose and administer it at a rate of
100 mL/hour.4 However, because of its
pKa value, carbonate can only function
as a buffer in an extremely acidotic
environment and is most functional at a
pH less than 7.1.
Any suspicion for rhabdomyolysis
should prompt swift intervention
to reduce potassium levels; special
attention should also be paid to the
patient’s acid-base status. Additional
treatments include calcium (to stabilize
the cardiac membrane), nebulized
beta-agonists, and insulin with glucose
(to encourage potassium movement
intracellularly).4
Further systemic interventions to
reduce potassium levels, including
potassium-wasting diuretics and
hemodialysis (in cases of renal failure),
are crucial. In particular, hemodialysis
should not be delayed in severely ill
patients who fail to respond to fluid
resuscitation.
CRITICAL DECISION
When is inpatient admission
warranted?
Because fluid resuscitation is the
mainstay of rhabdomyolysis treatment,
it is essential to closely monitor
the patient’s volume status. Large

FIGURE 3. Rhabdomyolysis Treatment Algorithm

Rhabdomyolysis(CK
Rhabdomyolysis (CK>1,000
>1,000U/L)
U/L)with
withananindication
indicationfor
forvolume
fluid resuscitation:
resuscitation:
CK
CK >5,000 U/LU/L
-or-
McMahon
McMahon score ≥6 ≥6

Clinical evaluation of volume status

History (eg, input/output balance, oral intake, weight changes)
Physical examination
Review chest x-ray or CT scan, if available, to evaluate for peripheral and pulmonary edema.
Echocardiography

Hypovolemia
Euvolemia Hypervolemia

Prompt resuscitation
ALL STOP
Volume challenge at ~150-200 mL/hour
Do not give fluid.
Normal electrolytes (most patients): lactated Ringer or PlasmaLyte solution
If the patient is severely congested,
Nonanion gap metabolic acidosis: isotonic bicarbonate
consider gentle diuresis.

What is the urine output over several hours?

GOOD urine output POOR urine output

Patient is running net even or slightly positive. Patient is accumulating substantial volume
(ie, significantly net positive).

Continue fluid infusions. ALL STOP

Follow input/output balance carefully. Do not give additional fluid. Inducing a state of volume
Stop fluids if the patient begins running substantially net positive. overload may increase the risk of kidney injury.

October 2019 n Volume 33 Number 10 7

 CASE RESOLUTIONS
■ CASE ONE
Although the young runner’s
urine was very dark, her urinalysis
revealed only 2 RBCs. This finding
raised the clinician’s suspicion for
rhabdomyolysis, which was likely
induced by excessive exercise. Her CK
concentration was 45,000 U/L.
The patient received IV fluids
with a goal urine output of 200 to
300 mL/hour. She remained hemo­
dynam­ically stable in the emergency
department and was eventually admitted
to a general floor. After a 4-day
hospitalization, her symptoms improved,
and her CK level trended down.
■ CASE TWO
The man with altered mental
status continued to behave erratically,
swiping at nurses and pulling at his
quantities of fluid can lead to congestive
heart failure and pulmonary edema,
particularly in older patients and those
with underlying cardiopulmonary
disease.6
A diagnosis of rhabdomyolysis
almost always warrants inpatient
care for aggressive fluid resuscitation,
electrolyte monitoring, and close
observation of renal status. Most
cases can be managed in unmonitored
units; however, ICU admission may be
necessary depending on the etiology
of the case, the severity of illness at
presentation, and the presence of any
comorbid conditions. For example,
patients with severe or persistent
hyperkalemia require continuous
n Failing to monitor urine output early. This is a key marker of resuscitation and
should not be ignored.
n Neglecting to address hyperkalemia in a patient whose history and symptoms
are consistent with rhabdomyolysis.
n Delaying hemodialysis when managing severe cases that do not respond to
fluid resuscitation.
8 Critical Decisions in Emergency Medicine
lines. He was given a low dose of
benzodiazepines, which improved
his symptoms. Toxicology studies
for salicylate and acetaminophen
were negative, but the patient’s
urine drug screen was positive for
amphetamines. His laboratory
work was remarkable for a
creatinine level of 2.1 mg/dL and
a total CK level of 145,000 U/L. A
Foley catheter was placed to closely
monitor his urine output, which
was initially low (100 mL/hour).
The patient’s heart rate
improved with fluid resuscitation,
and a bicarbonate drip was added
to boost his renal clearance. Out
of concern for his safety, he was
admitted to the hospital under
close one-on-one supervision.
cardiac monitoring. Additionally,
patients with rhabdomyolysis
secondary to compartment syndrome
may require an emergent fasciotomy
and ICU management.7 In certain
cases, amputation may even be
required in the field.
Summary
By understanding the etiologies
and risks of rhabdomyolysis,
emergency clinicians can choose
appropriate strategies for addressing
this life-threatening syndrome. The
pathophysiological consequences of the
disorder, which range from challenging
to severe, include fluid and electrolyte
imbalances, cardiac disturbances,
permanent renal damage, and DIC.
■ CASE THREE
The emergency clinician suspected
that the elderly woman sustained
kidney damage during her fall. Despite
receiving a small fluid bolus (500 mL)
and pain medications, her urine output
remained poor. An x-ray revealed a closed
intertrochanteric fracture of her left femur,
which required operative management.
Her laboratory results showed a CK level
of 38,000 U/L and creatinine concentration
of 3.2 mg/dL; when admitted 1 month
ago, her creatinine concentration was
1.0 mg/dL. She continued to have poor
urine output despite the administration of
fluids, so a bicarbonate drip was initiated.
The patient was admitted to the ICU
out of concern for potential compartment
syndrome and optimization of her
hemodynamics. She became anuric
overnight and required hemodialysis.
Fortunately, the prognosis is generally
very good when rhabdomyolysis is
detected early. Key laboratory values
and an adequate history, including
details about the mechanism of
injury and any comorbidities, can aid
diagnosis.
When managing any patient with
rhabdomyolysis, early and careful fluid
resuscitation is critical, and treatment
should be tailored according to the
severity of the condition. It is imperative
to address potential complications,
including electrolyte imbalances, cardiac
disturbances, acid-base imbalances, and
coagulation abnormalities.
REFERENCES
1. Khan FY. Rhabdomyolysis: a review of the literature.
Neth J Med. 2009 Oct;67(9):272-283.
2. Vanholder R, Sever MS, Erek E, Lameire N.
Rhabdomyolysis. J Am Soc Nephrol. 2000 Aug;11(8):
1553-1561.
3. Counselman FL, Lo BM. Rhabdomyolysis. In: Tintinalli
JE, Cline MD, Ma OJ, Cydulka RK, Meckler GD,
Handel DA, Thomas SH, eds. Tintinalli’s Emergency
Medicine Manual. 7th ed. New York, NY: McGraw-Hill;
2011:622-624.
4. Homsi E, Barreiro MF, Orlando JM, Higa EM.
Rhabdomyolysis guideline. Maricopa Medical Center
website. www.aztraumacenter.com. Accessed
December 19, 2017.
5. Simon E, Koyfman A. EM at 3AM—acute kidney
injury. emDocs website. www.emdocs.net. Published
April 15, 2017. Accessed December 19, 2017.
6. Zutt R, van der Kooi AJ, Linthorst GE, Wanders RJ, de
Visser M. Rhabdomyolysis: review of the literature.
Neuromuscul Disord. 2014 Aug;24(8):651-659.
7. Parekh R, Care DA, Tainter CR. Rhabdomyolysis:
advances in diagnosis and treatment. Emerg Med
Pract. 2012 Mar;14(3):1-15.
 A 62-year-old man with a permanent pacemaker presents with chest pain, dyspnea, and nausea.

The Critical ECG

100% paced rhythm, rate 70. Electronic pacer spikes precede each QRS By Amal Mattu, MD, FACEP
complex. A leftward axis is present, which is typical of a right ventricular Dr. Mattu is a professor, vice chair, and
director of the Emergency Cardiology
pacemaker site. Widening of the QRS complexes and “discordant” ST segments Fellowship in the Department of
are present, findings that are also typical of electronic pacemakers. Myocardial Emergency Medicine at the University
ischemia can be difficult to determine in the presence of an electronic pacemaker; of Maryland School of Medicine in
Baltimore.
however, the loss of this discordant relationship between the QRS complexes and
ST segments may suggest the presence of ischemia.

ß The right ventricular-paced electrocardiographic rhythm

markedly reduces the diagnostic power of the 12-lead
ECG in the evaluation of a patient suspected of myocardial
ischemia or infarction. The appropriate relationship of the QRS
complex with the ST segment/T wave is called “appropriate
discordance.” In this relationship, the major, terminal portion
of the QRS complex is oriented on the opposite side of the
isoelectric baseline from the ST segment and T wave. In lead III,
the QRS complex (small arrow) is located opposite from the ST
segment/T wave (large arrow) — in this case, demonstrating
discordant ST-segment elevation. In lead aVR, the QRS
complex (small arrow) is positive because the ST segment
and T wave (large arrow) are located on opposite sides of the
electrical baseline — here, manifesting discordant ST-segment
depression. Both of the electrocardiographic findings are the
normal or expected ST-segment/T-wave configurations for the
right ventricular-paced electrocardiographic rhythm.

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

October 2019 n Volume 33 Number 10 9

 Critical Cases
in Orthopedics and Trauma
Knee Dislocation
By Andrew Grozenski, MD; and John Kiel, DO, MPH
University of Florida College of Medicine – Jacksonville

A 65-year-old man presents via ambulance after being struck by a car

FIGURE 1. Dislocated
while crossing the street. His vital signs are stable, but he has an obvious, Left Knee
painful deformity of his left leg (Figure 1). The patient has a history of
hypertension, coronary artery disease, chronic obstructive pulmonary
disease, peripheral vascular disease, HIV, and substance abuse. His dorsalis
pedis (DP) pulses are 1+ bilaterally. His left, lower extremity is sensitive
to light touch in the superficial fibular, deep fibular, and tibial nerve
distributions; motor function is intact in the extensor and flexor hallucis
longus muscles, Achilles tendon, and gastrocnemius muscle. X-rays confirm
an anterior dislocation of his left knee (Figures 2 and 3).

Knee Reduction
Reduction of a dislocated knee requires the application of longitudinal traction to the
affected extremity. If traction fails to resolve the dislocation, force should be applied in the
opposite direction of the injury. Anterior dislocations can be reduced by applying anterior
force to the distal femur while maintaining traction; posterior dislocations, on the other hand,
may require the application of anterior force to the proximal tibia. The “dimple sign,” an
anteromedial skinfold at the medial joint line, is suggestive of a posterolateral dislocation.
Closed reduction should not be attempted for posterolateral dislocations; these injuries are
irreducible. Skin necrosis can also develop if the skin overlying the femoral condyle is entrapped.
Once the tibia and femur have been manipulated into natural alignment, it is critical to
stabilize the limb with a knee immobilizer or long leg splint (with 20 degrees of flexion at
the knee). It is also important to document clear vascular and neurologic examinations both FIGURE 2. AP View
before and after reduction.

CASE RESOLUTION
After consulting with trauma surgery and orthopedics, the emergency physician
admitted the patient for serial examinations of his DPs; additional studies were
not required. An MRI performed 1 day later confirmed a partial tear of the
popliteus attachment; a partial tear of the proximal aspect of the lateral head
of the gastrocnemius muscle; a complex tear of the medial meniscus; a bucket-
handle tear of the lateral meniscus; and a 0.8-cm, full-thickness cartilage defect
of the posterior aspect of the lateral femoral condyle. The morphology of the
popliteal artery and vein was normal.
The patient remained hemodynamically stable, and his DPs remained intact.
He was discharged to a skilled nursing facility and was scheduled to undergo a
staged reconstruction within 30 days.

10 Critical Decisions in Emergency Medicine

KEY POINTS
n A knee dislocation is an orthopedic and vascular
emergency that occurs when three of the knee’s four
major ligaments (ie, anterior cruciate, posterior cruciate,
medial collateral, lateral collateral) are disrupted
(Figure 4). Additionally, a two-ligament knee injury is
the functional equivalent of a knee dislocation, but
it may not acutely present as such. The incidence of
knee dislocations is unknown due to the likelihood of
spontaneous reduction, which occurs in about 50% of
cases.
n Multidirectional instability due to a multiligament knee
injury suggests that the dislocation has occurred in a
spontaneously reduced knee; however, the absence of
an obvious dislocation in the emergency department
should not exclude the possibility of an earlier,
prehospital dislocation.
n Knee dislocations can be caused by both high- (eg,
motor vehicle collision) and low-energy (eg, athletic
injury) mechanisms. Hyperextension precipitates anterior
dislocations, while forces that translate the tibia and
fibula posteriorly result in posterior injuries. Patients
often describe a “popping in and out” sensation, which
should not be dismissed automatically as subluxation of
the patella.
n The initial treatment of a knee dislocation should begin
with an assessment of the DPs and neurologic integrity
of the common peroneal nerve. Vascular compromise is
found in approximately 32% of cases; common peroneal
nerve injuries affect an estimated 14% to 35% of patients.
Violations of the common peroneal nerve can decrease
sensation in the first dorsal web space and lead to
difficulties with dorsiflexion of the foot and extension of
the toes.
n An absence of DPs should prompt an immediate attempt
to restore blood flow via reduction. Abnormal pedal
pulses have a sensitivity of 0.79 and a specificity of 0.91
for the detection of arterial injuries that require surgical
treatment. However, the presence of DPs cannot exclude
vascular insults; adjunctive studies (eg, ankle-brachial
index [ABI] test, Doppler ultrasound, CT angiography
[CTA]) should be used to evaluate for vascular compromise.
CTA can also be used to detect osseous injuries. Missed
vascular injuries can progress to further ischemia or
thrombus formation within hours to days.
n The popliteal artery is the most commonly damaged
vascular structure in patients with knee dislocations due
to its fixed position under surrounding musculature and
stretching of the vessel during dislocation. Hard signs of
vascular compromise include absent DPs, active bleeding,
ischemia, an expanding hematoma, or a palpable thrill or
bruit over the popliteal artery. Suspected popliteal injuries
require immediate surgical intervention; a lack of a DP or
posterior tibial (PT) pulse indicates vascular compromise
until proven otherwise.
n Although the absence of DPs is consistent with
compartment syndrome, this is a late finding, as are
pain, pallor, paresthesia, and poikilothermia. Prolonged
ischemia due to popliteal artery compromise leads to
compartment syndrome that necessitates surgical repair
and a fasciotomy. Ischemia that lasts more than 6 to 8
hours often mandates amputation.
n Prior to performing a reduction or assessing the ligamen­
tous integrity of the limb, anteroposterior (AP) and lateral
x-ray views of the knee should be obtained to evaluate for
fractures. If radiography is unavailable, reduction should
be performed to prevent further vascular compromise.
n Indications for an emergent surgical intervention include
evidence of prolonged ischemia, an inability to maintain
the reduction, an irreducible dislocation, vascular injury,
and an open dislocation or fracture. Following reduction,
patients should be admitted for continuous monitoring of
circulation.

FIGURE 4. Algorithm for the Management of Knee Dislocations

FIGURE 3. Lateral View
A knee dislocation is identified
or suspected post reduction.

DP/PT pulses are absent after

reduction, or an expanding
hematoma, palpable thrill or Consult vascular/orthopedic
bruit over the popliteal artery, surgery.
hemorrhage, or open joint are
noted.
Consult vascular/orthopedic
DP/PT pulses return after surgery. Obtain an ABI test,
reduction. CTA, or ultrasound. Discuss
the need for surgery.

Consult vascular/orthopedic
Pulses are always present. surgery. Obtain an ABI test,
CTA, or ultrasound. Discuss
the need for operative repair.

October 2019 n Volume 33 Number 10 11

 The Critical Procedure
Closed Reduction of Posterior
Elbow Dislocations
By Jennifer C. Chapman, MD
Orange Park Medical Center, Orange Park, Florida
Reviewed by Steven J. Warrington, MD, MEd

The elbow, the second most commonly dislocated large joint, is particularly vulnerable
to axial load injuries (eg, a fall onto an outstretched hand) and sports-related trauma.
Although posterior injuries account for nearly 90% of all elbow dislocations, the direction
of the insult can be anterior, medial, or lateral — a description that refers to the abnormal
position of the ulna relative to the humerus. Dislocations that include a fracture or joint
laceration are defined as “complex,” while “simple” dislocations involve no secondary trauma.

Indications to dislocation-related damage. When to immobilization. The most viable

An emergent closed reduction is
indicated for simple posterior elbow
dislocations. Complex dislocations, open
fractures, and entrapped soft tissue or
osteochondral fragments may necessitate
an emergent orthopedic evaluation for
operative repair. Persistent instability
after reduction or extensive ligamentous
damage may also warrant surgical repair.
Benefits and Risks
The brachial artery and median
and ulnar nerves in the anterior
compartment of the elbow are vulnerable
appropriate, early closed reduction can
reduce pain and anxiety while minimizing
the risk of neurovascular compromise.
Risks of a closed reduction include
procedure failure, sedation-related
complications, neurovascular damage,
persistent joint instability, and
compartment syndrome.
Alternatives
Clinicians should consider aspirating
any hemarthroses prior to attempting
a reduction. Aftercare with quick
mobilization is a potential alternative
alternative to a closed reduction in the
emergency department is closed or open
surgical repair.
Special Considerations
There is no evidence to support the
superiority of one reduction technique
over another. As such, it is important
to properly identify patients who are
better suited for a reduction in the
operating room, including those who
may not tolerate emergency department
sedation and those whose injuries
require surgical repair.

12 Critical Decisions in Emergency Medicine

TECHNIQUE
PREPARATION
1. Examine the patient’s shoulder, elbow, and wrist carefully while assessing for additional injuries.
2. Perform a vascular examination distal to the injury.
3. Perform a neurologic exam:
a. Median nerve: Have the patient attempt opposition (ie, bring the thumb tip across to the small fingertip), and
evaluate the patient’s response to sensation by applying light touch over the palmar thumb and 2nd digit.
b. Ulnar nerve: Test the abduction and adduction of the fingers, and evaluate the patient’s response to
sensation by applying light touch over the palmar 4th and 5th digits.
4. Administer anesthesia (a local joint injection plus a parenteral analgesic vs. procedural sedation).

PRONE TECHNIQUE (preferred for the first attempt) Ü

1. Position the patient prone on the stretcher.
2. Abduct the affected arm away from the patient’s
body.
3. Rest the patient’s elbow on the edge of the stretcher
with the forearm dangling over the side.
4. Grasp the patient’s wrist with one hand, and apply
traction with slight supination of the forearm.
5. Push down on the olecranon process with the other
hand while disengaging the coronoid process from
the olecranon fossa.
6. Hold downward pressure on the olecranon process
until a confirmatory “clunk” is felt.
7. Perform a gentle range-of-motion exercise to confirm
the procedure’s success.

Û TWO-PERSON SUPINE TECHNIQUE

1. Position the patient supine on the stretcher.
2. Position the affected arm so that it is slightly abducted
from the patient’s body. The assistant should then
stabilize the patient’s humerus against the stretcher
using both hands.
3. Grasp the patient’s wrist, and flex the elbow while
supinating the wrist.
4. Apply downward traction at the wrist with one hand.
5. Apply slow inline traction on the volar forearm with the
other hand until a “clunk” is felt.
6. Perform a gentle range-of-motion exercise to confirm
the procedure’s success.
Note: When using a two-person prone technique, the assistant should
apply downward force on the olecranon process while the operator
applies downward traction at the wrist.

AFTERCARE
After the reduction, it is important to perform a neurovascular
evaluation and obtain x-rays to confirm the success of the
procedure and reassess for fractures. The patient should
be placed in a posterior splint with more than 90 degrees
flexion for 5 to 10 days or until an orthopedic evaluation has
been conducted. A sling should be provided, and the patient
should be instructed to use ice, elevation, and pain control as
needed. Clinicians should also emphasize the importance of
continued self-monitoring of neurovascular status.

October 2019 n Volume 33 Number 10 13

 The LLSA Literature Review
Thrombolytics for Acute
Pulmonary Embolism
By Seth H. Merker, MD; and Michael E. Abboud, MD
Department of Emergency Medicine, University of Pennsylvania, Philadelphia
Reviewed by Andrew Eyre, MD, MHPEd

Long B, Koyfman A. Current controversies in thrombolytic use in acute pulmonary embolism.

J Emerg Med. 2016 Jul;51(1):37-44.

Up to 25% of acute pulmonary embolisms (PEs) result in sudden death, and between
17% and 50% of these patients die within 3 months of the initial event. However,
overall mortality is dependent on a variety of factors, including the patient’s age,
stability, and initial symptoms as well as the presence of comorbidities.

Massive PEs often present as pulseless­
ness, persistent bradycardia, signs of
shock, or sustained hypotension without
a secondary cause. Submassive PEs are
defined by a near-normal blood pressure
with evidence of cardiopulmonary stress,
which may include right ventricular (RV)
dysfunction, a new elevation in brain
natriuretic peptide (BNP) or pro-BNP,
a newly elevated troponin level, a right
bundle branch block, and signs of right
heart strain. Submassive events account
for approximately 20% of all PEs, with an
in-hospital mortality rate as high as 5%.
Morbidity can be severe, with an increased
risk of pulmonary hypertension, impaired
quality of life, persistent RV dysfunction,
and recurrent thrombus formation.
Although treatment is required
to reduce the risk of potentially fatal
complications, the benefits of thrombolytic
therapy must be weighed against its risks.
Thrombolysis is recommended for the
management of massive PEs, and there
is widespread support for the delivery
of systemic thrombolytics to patients
undergoing CPR with echocardiographic
evidence of a massive PE with no other
identified cause.
Research suggests that thrombolytic
therapy may reduce long-term
pulmonary hypertension in patients
with submassive PEs; however, the has remained elusive. The use
treatment is only endorsed for patients of catheter-directed or half-dose
at low risk of bleeding. Thrombolytics systemic thrombolytics or a surgical
may provide little benefit to those with embolectomy may improve long-term
a pulmonary reserve and no prior outcomes while mitigating the risk of
lung disease; however, the treatment bleeding. Catheter-directed therapy and
may be more effective for those with a surgical embolectomy can reduce RV
coexisting conditions (eg, heart failure or dilatation and pulmonary hypertension,
obstructive lung disease). Signs of clinical decrease the clot burden, and minimize
decompensation, including hypoxia, the risk of intracranial hemorrhage.
worsening tachypnea or tachycardia, and These alternative treatments can be
even brief episodes of hypotension, should used for patients with an increased risk
prompt consideration for thrombolysis. of bleeding (ie, patients >65 years) and
Overall, research findings have those who fail to improve with initial
been heterogeneous; some large studies thrombolytic dosing.
have demonstrated the benefits of Ultimately, treating physicians must
thrombolytics, while others have not. use their own judgment regarding the
As such, a definitive recommendation relative merits of each therapy with
for the treatment of submassive PEs input from specialists and the patient.
KEY POINTS
n Thrombolytic therapy is warranted for massive PEs accompanied by
hemodynamic collapse or cardiac arrest.
n Submassive PEs present a clinical quandary due to inconsistent research
findings, various outcome measures, and different treatment protocols.
n Thrombolytic therapy appears to improve long-term functional outcomes in
patients with submassive PEs, but the risk of bleeding significantly increases in
those older than 65 years.
n Half-dose thrombolytic therapy, a surgical embolectomy, and catheter-directed
treatments may provide significant benefits and reduce the risk of bleeding.
n Further studies are needed to assess risk stratification, functional outcomes,
and treatment protocols with thrombolytic dosing.

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.

14 Critical Decisions in Emergency Medicine

 Twist and Shout
Pediatric Scrotal
Emergencies

LESSON 20

By Thomas Cristoforo, DO; Philip Sosa, DO; and

Laleh Bahar-Posey, MD
Dr. Cristoforo is a pediatric emergency medicine fellow at Arnold Palmer Hospital for
Children in Orlando, Florida. Dr. Sosa is a pediatric emergency medicine physician at
the University of New Mexico in Albuquerque. Dr. Bahar-Posey is a pediatric emergency
medicine physician and the vice chair of the division of pediatric emergency medicine
at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida.

Reviewed by Sharon E. Mace, MD, FACEP

OBJECTIVES
On completion of this lesson, you should be able to: CRITICAL DECISIONS
1. Describe the pediatric conditions that can present as n Which historical details are most helpful when
acute scrotal pain and swelling.
assessing acute scrotal pain and swelling?
2. Differentiate swelling-predominant conditions from
those that manifest with pain predominance. n What disorders should be suspected in children
3. Discuss the initial workup of a child with acute scrotal with acute scrotal pain or swelling?
pain and swelling.
n How can ultrasound be used to evaluate scrotal
4. Explain how to manage high-risk scrotal emergencies,
pathologies?
including testicular torsion.
n How should acute scrotal pain and swelling be
FROM THE EM MODEL
managed?
15.0 Renal and Urogenital Disorders
15.5 Male Genital Tract
15.5.4 Structural

Scrotal pain and swelling are common pediatric complaints in the emergency department. Such symptoms
can be caused by a wide variety of conditions, many of which can be successfully treated with gentle reassurance
and supportive care alone. However, clinicians must also be prepared to recognize and manage more serious
scrotal pathologies, including testicular torsion. Particularly when evaluating children, it is paramount to accurately
differentiate these sensitive abnormalities based on the nuances of each case.

October 2019 n Volume 33 Number 10 15

 CASE PRESENTATIONS
■ CASE ONE
A 12-year-old boy presents with
worsening scrotal pain and redness
that began 4 hours earlier. He also
complains of nausea but denies a
recent history of trauma, fever, upper
respiratory symptoms, vomiting,
and diarrhea. He has no history of
urogenital abnormalities, urinary tract
infections (UTIs), dysuria, urinary
urgency, frequent urination, or penile
discharge. In confidence, the patient
denies any history of sexual activity.
The patient’s vital signs are
blood pressure 134/80, heart
rate 110, respiratory rate 12, and
temperature 37.1°C (98.8°F). He
appears anxious and is lying on his
side with his knees drawn up to his
CRITICAL DECISION
Which historical details are
most helpful when assessing
acute scrotal pain and swelling?
A thorough patient history can help
differentiate benign conditions from those
of greater urgency. The diagnosis can be
narrowed based on whether the patient
presents with pain predominance or
swelling predominance (Figure 1). Scrotal
pain suggests scrotal trauma, testicular
torsion, torsion of the appendix testis,
epididymitis, orchitis, Henoch-Schönlein
purpura, an incarcerated inguinal hernia,
or a condition that leads to referred scrotal
pain (eg, renal colic, appendicitis).1 Scrotal
swelling, on the other hand, suggests a
hydrocele, varicocele, spermatocele (ie,
epididymal cyst), inguinal hernia, or
neoplasm (testicular or paratesticular).2,3
In pain-predominant conditions, the
time frame and course of symptoms can
help narrow the list of potential etiologies.
Scrotal and testicular pain that develops
over minutes to hours is more common in
patients with testicular torsion or torsion
of the testicular or epididymal appendages.
Pain that develops over a 24-hour period
or longer is more frequently associated
with epididymitis or orchitis.1,4-6
In addition to the timing of symptoms,
it is important to determine whether
16 Critical Decisions in Emergency Medicine
chest. His abdomen is neither tender
nor distended. A genital examination
reveals an exquisitely and diffusely
tender scrotum and an elevated
left testicle in a horizontal lie, with
erythema of the overlying skin and
an absent cremasteric reflex. His pain
does not appear to worsen with scrotal
elevation, and his physical examination
is otherwise unremarkable.
■ CASE TWO
A 9-year-old boy presents with
24 hours of scrotal redness and pain,
which he describes as aching, constant,
and worsening in severity. His parents
explain that the boy has had a recent
cough, congestion, a runny nose,
and a fever of 38.9°C (102°F) that
began today. They deny any history of
the patient’s pain is direct or referred.
Scrotal pain that includes flank pain
or hematuria may indicate a diagnosis
that heralds renal colic. A history of
voiding difficulties, urinary incontinence
or retention, or recurrent UTIs should
raise suspicion for a mass that affects
the pelvis, rectum, or spine. Scrotal pain
with concurrent vomiting, diarrhea, or
fever may indicate retrocecal appendicitis,
an uncommon but important cause of
referred pediatric pain.7,8
CRITICAL DECISION
What disorders should be
suspected in children with
acute scrotal pain or swelling?
Testicular Torsion
Testicular torsion (Figure 2), one of
the most serious causes of acute scrotal
pain and swelling, can result in loss of the
testicle. Each year, 1 in 4,000 boys and
men younger than 24 years experiences
this condition; although it can occur at any
age, the incidence has a bimodal peak in
the neonatal period and during puberty.9,10
Most cases (~65%) are diagnosed in
patients between the ages of 12 and 18
years. In addition, the left testicle is more
commonly affected than the right.9
The pain associated with torsion
is typically severe and rapid in onset,
urogenital abnormalities, recurrent
UTIs, recent trauma, or complaints
of dysuria, urinary urgency, frequent
urination, or penile discharge.
The patient’s vital signs are blood
pressure 112/74, heart rate 110,
respiratory rate 20, temperature
38.6°C (101.5°F), and oxygen
saturation 100% on room air.
A testicular examination reveals
scrotal erythema and swelling. The
boy’s right testicle is mildly tender,
particularly over the right epididymis.
His cremasteric reflex is intact. His
pain is moderately improved with
elevation of the testicle. His abdomen
is soft but not tender or distended,
and he has normal bowel sounds. No
suprapubic tenderness, flank pain, or
costovertebral tenderness is noted.
developing over minutes to hours. While
the symptoms are often constant, the
testicle may torse and detorse, causing
intermittent pain. Systemic symptoms,
such as nausea and vomiting, point to
true testicular torsion. The physical
examination often reveals an exquisitely
tender and high-riding or hard testicle
as well as an absent cremasteric reflex.1,6,11
Torsion of the Appendix Testis
or Appendix Epididymis
Torsion of the appendix testis or
appendix epididymis usually causes
sudden-onset pain, although symptoms
are usually less severe than in cases of
testicular torsion. A tender mass may be
present at the superior or inferior aspect
of the testicle. Unlike in cases of testicular
torsion, the testicle itself is seldom tender.
A gangrenous appendage may be
visible through the scrotum, creating
the “blue dot” sign (Figure 3). The
cremasteric reflex is typically intact.12
Although the diagnosis can often be made
clinically, it may be supported by Doppler
ultrasound or a nuclear scan.13
Epididymitis
Acute epididymitis is a clinical
syndrome defined by pain, swelling, and
inflammation of the epididymis. The pain
usually develops over a 24-hour period
and is seldom abrupt.6 In most cases, the
testicle is also involved in the process,
a condition called epididymo-orchitis.13
Patients with acute epididymitis may
present clinically with acute scrotal pain,
erythema, or swelling, with or without an
associated fever or dysuria. The physical
examination may reveal an enlarged,
tender epididymis and a normal testis. In
some cases, scrotal elevation may reduce
the patient’s pain (ie, Prehn sign).14
Acute epididymitis affects approxi-
mately one-third of all prepubertal boys
who present with scrotal or testicular
pain. In a retrospective review of 238
pediatric patients (aged 0-19 years) with
acute scrotal pain over a 2-year period,
35% were determined to have epididy-
mitis. Some studies show a bimodal inci-
dence in infancy and prepuberty, whereas
others indicate a peak incidence near
puberty or in late adolescence.5,15-19
In most cases, the exact etiology is
never confirmed, but research suggests
that pediatric epididymitis is usually
caused by viral infections, trauma, or
post-infection inflammation. Urinalyses
and urine cultures in children with
epididymitis are usually negative, and
FIGURE 1. Scrotal Pain Diagnostic Algorithm
High-riding or
TESTICULAR horizontal testicle,
PAIN nausea, or vomiting
YES
Presumed torsion:
order ultrasound and
urology consultation
YES
Torsion of testicular
appendage or
epididymal appendage
urine cultures appear to correlate well with
epididymal cultures.5,15,16,20,21 In adults and
sexually active adolescents, the etiology of
epididymitis is more likely to be bacterial
or the result of a sexually transmitted
infection, such as Neisseria gonorrhoeae
or Chlamydia trachomatis.20
Varicocele
A varicocele (Figure 4) is a collection
of dilated and tortuous veins in the
pampiniform plexus that surrounds
the spermatic cord. Varicoceles are
uncommon in prepubertal boys but
increase in incidence (~15%) by 15 years
of age.22 Although varicoceles can be
asymptomatic, some patients report a
dull ache or heaviness in the scrotum
that worsens when standing. On physical
examination, these veins have the texture
of a “bag of worms.”
This diagnosis can be confirmed
with ultrasound and a careful physical
examination. The vast majority of
varicoceles (90%) are found on the left
side. (The left spermatic vein enters the
left renal vein at a 90° angle, whereas
the right spermatic vein drains directly
into the inferior vena cava.)23 Although
NO
Blue dot sign?
NO
Lack of blood flow on Doppler
ultrasound, absent cremasteric
reflex, and normal CRP
YES NO
Testicular torsion: Relief of pain with
request urgent scrotal elevation, swelling,
surgical evaluation redness, or dysuria
YES
Likely epididymitis,
orchitis,
or epididymo-orchitis
Varicocele
a left-sided varicocele is not a urological
emergency, a right-sided varicocele
without a left-sided varicocele can
indicate a retroperitoneal process.14
Hernias and Hydroceles
A defect in the processus vaginalis can
allow abdominal contents to pass into the
scrotum, resulting in a hydrocele (Figure 5).
A narrowly patent processus vaginalis can
further allow the passage of peritoneal
fluid into the scrotum, a process that can
precipitate a communicating hydrocele.
A noncommunicating hydrocele, which
is caused by fluid from the lining of the
tunica vaginalis, has no connection to the
peritoneum. A widely patent processus
vaginalis can result in herniation of the
bowel through the inguinal ring. Hernias
and hydroceles usually present with
painless scrotal swelling. A hernia or
communicating hydrocele enlarges with
activities that increase intra-abdominal
pressure, such as straining or the Valsalva
maneuver, whereas noncommunicating
hydroceles remain stable in size. Unlike
a nonincarcerated hernia, hydroceles
transilluminate on physical examination
(Figure 6) and are irreducible.
NO
Sensation of heaviness
or “bag of worms” on
physical examination
YES NO
Possible incarcerated
inguinal hernia or
hemorrhagic testicular mass
October 2019 n Volume 33 Number 10 17
 FIGURE 2. Testicular Torsion in a 9-Year-Old Boy FIGURE 3. “Blue Dot” Sign

Any pediatric patient with an inguinal

FIGURE 4. Varicocele
hernia or a hydrocele should be followed
Bladder closely. Cases that involve an acute change
in the volume or degree of scrotal swelling
should be evaluated within 24 hours.
The development of inguinal or scrotal
pain necessitates an emergent evaluation.
Vas deferens Most pediatric hernias require surgical
Prostate gland
Seminal vesicle intervention, but few require emergent
surgery.
Bulbourethral
gland The parents of a child with a history
of scrotal or inguinal pain should be taught
Regular vein Varicocele to recognize the signs of an incarcerated
inguinal hernia and instructed to seek
Urethra Epididymis
urgent medical attention when necessary.
Infants with an asymptomatic hydrocele
Right testis Left testis
Regular vein Varicocele rarely require surgery. In most cases, the
hydrocele resolves on its own within the
first year of life.24,25

Scrotal Masses
FIGURE 5. Hydrocele Although testicular cancer is much
less common than epididymal cysts or
spermatoceles, a painless testicular or
Epididymis paratesticular mass should be addressed
urgently. On examination, testicular
tumors are often painless, heavy, and firm.
Asymmetry between the two testes should
also increase suspicion for a tumor.1,3,26
It is particularly important to inspect the
paratesticular region (eg, spermatic cord,
epididymis, appendix testis, and tunica
vaginalis) for potential malignancies, such as
rhabdomyosarcoma.3 If a firm intratesticular
Testicle Hydrocele mass is identified with palpation, the lymph
nodes should be thoroughly evaluated for
lymphoma, leukemia, and metastatic disease.

18 Critical Decisions in Emergency Medicine

 imaging, a “hot dot” sign at the site
of the torsion can often be seen;
however, this finding is unreliable if the
symptoms are less than 5 hours old.32
A bedside ultrasound can help
differentiate between a testicular
n Any patient who presents with acute scrotal pain and swelling should be
presumed to have testicular torsion until proven otherwise. and paratesticular mass, which
n Urinalysis and urine cultures should be used to pinpoint the etiology of any may indicate a neoplasia or benign
case of epididymitis. epididymal cyst or spermatocele.
n Patients with testicular torsion should undergo an orchiopexy of both A Doppler ultrasound or nuclear
testicles. scan can also reveal epididymal
n Even patients who undergo successful manual detorsion should undergo inflammation and increased blood flow
surgery for bilateral orchiopexy to prevent recurrences. to the affected epididymis.13

Any child with a scrotal mass and
signs of precocious puberty should
be evaluated for a Leydig cell tumor.
Although an epididymal cyst or sperma­
tocele can present as an extratesticular
mass, these abnormalities are characteris­
tically smooth, round, and located within
the epididymis. If the patient’s imaging
and examination findings suggest an
intratesticular or paratesticular mass,
tumor markers, including beta-human
chorionic gonadotropin, alpha-fetoprotein,
and lactate dehydrogenase, must be
obtained. In most instances, a CT scan of
the abdomen and pelvis with oral and IV
contrast is also indicated.1
CRITICAL DECISION
How can ultrasound be used
to evaluate scrotal pathologies?
A testicular ultrasound should be
obtained when evaluating any patient
with severe, acute-onset testicular
pain, either constant or intermittent.
In cases of intermittent torsion, the
testes may appear normal with regular
blood flow; however, imaging may
show a “whirlpool” sign (Figure 7) or
pseudomass. An ultrasound can detect
intermittent torsion with a sensitivity of
approximately 75%, but the diagnosis is
usually made based on clinical findings.27
A Doppler ultrasound of the testes,
which may reveal decreased perfusion
or twisting of the spermatic cord,
can detect testicular torsion with a
sensitivity between 69% and 100% and
a specificity between 77% and 100%.28-31
In small, prepubertal testes with lower
blood flow, the sensitivity of Doppler
imaging is decreased. Although nuclear
scans can measure perfusion of the
testicle and detect abnormalities with
a high sensitivity and specificity, the
test may take several hours to perform,
delaying diagnosis and treatment.
Blood flow to the testicle may
be normal or increased in patients
with torsion of the appendix testis or
appendix epididymis. Torsion of the
appendage is indicated by a lesion
of low echogenicity with a central
hypoechogenic area.13 On radionuclide
CRITICAL DECISION
How should acute scrotal pain
and swelling be managed?
Testicular torsion is a surgical
emergency that necessitates an
immediate consultation with a pediatric
surgeon or urologist, especially if
ultrasound is unavailable or will delay
care. The treatment for testicular torsion
is an orchiopexy, which involves the
surgical detorsion and fixation of both
testes to the tunica vaginalis. Manual
detorsion, which may be attempted in
the emergency department with adequate
sedation and analgesia, is associated
with higher testicular salvage rates. This
technique should be considered seriously
if surgical correction will be delayed or
the presentation is prolonged.33,34
Manual detorsion can provide
immediate pain relief, but an ultrasound
should be used to confirm the success of
the procedure. Even after a successful
detorsion, patients should undergo an
orchiopexy to prevent recurrence. The
testicular viability rate is between 80%

FIGURE 6. Transillumination of the Testicles FIGURE 7. “Whirlpool” Sign Seen on Ultrasound

October 2019 n Volume 33 Number 10 19

 CASE RESOLUTIONS
■ CASE ONE
The emergency physician used
ultrasound to assess the 12-year-old’s
painful scrotum. Testicular torsion of
the left testicle was identified. Following
a urology consultation, the patient
was taken to the operating room for
immediate surgical repair.
and 100% if detorsion is performed
within 6 hours. After 6 hours, testicular
viability declines.28,33
A torsed appendix testis or appendix
epididymis should be managed with
pain control, rest, and scrotal support to
alleviate swelling. Pain usually resolves
in 5 to 10 days. Surgery to remove the
torsed appendix is only needed for
patients plagued by persistent pain.
Epididymitis should be treated
with antibiotics if the urinalysis or
urine culture indicates a UTI or if
the patient is sexually active and has
symptoms or laboratory results that are
consistent with a sexually transmitted
infection. Otherwise, epididymitis can
usually be treated with supportive care
alone, including rest, ice, elevation of
the scrotum, and nonsteroidal anti-
inflammatory medications.
Hydroceles, spermatoceles, and
varicoceles can usually be managed
conservatively with observation alone.
However, elective surgical intervention
may be undertaken if symptoms persist.
These cases should be followed by a
pediatric urologist on an outpatient basis.
Summary
Many disorders that cause acute
scrotal pain and swelling can be diagnosed
n Neglecting to evaluate acute scrotal pain or swelling with ultrasound.
n Missing a diagnosis of testicular torsion, which can ultimately lead to loss
of the testicle.
n Failing to test for gonorrhea and chlamydia when evaluating sexually active
patients with epididymitis.
n Reflexively prescribing antibiotics to treat epididymitis; many cases can be
managed with supportive care alone.
20 Critical Decisions in Emergency Medicine
■ CASE TWO
An ultrasound of the young
boy’s scrotum showed increased
blood flow to the right testicle and
epididymis with signs of an inflamed
epididymis. A urinalysis failed to
show leukocytes or WBCs and was
based on a thorough history and physical
examination, without the need for
supplemental imaging. However, when
evaluating any child with these complaints,
a diagnosis of testicular torsion should
be presumed until proven otherwise. By
differentiating between pain- and swelling-
predominant diagnoses, clinicians can more
accurately distinguish between conditions
that require urgent interventions and those
that can be treated with supportive care.
REFERENCES
1. Lambert SM. Pediatric urological emergencies. Pediatr
Clin North Am. 2012 Aug;59(4):965-976.
2. Palmer LS. Hernias and hydroceles. Pediatr Rev. 2013
Oct;34(10):457-464.
3. Ahmed HU, Arya M, Muneer A, Mushtaq L, Sebire NJ.
Testicular and paratesticular tumours in the prepubertal
population. Lancet Oncol. 2010 May;11(5):476-483.
4. Kadish HA, Bolte RG. A retrospective review of
pediatric patients with epididymitis, testicular torsion,
and torsion of testicular appendages. Pediatrics.
1998 Jul;102(1 pt 1):73-76.
5. Redshaw JD, Tran TL, Wallis MC, deVries CR.
Epididymitis: a 21-year retrospective review of
presentations to an outpatient urology clinic. J Urol.
2014 Oct;192(4):1203-1207.
6. Kass EJ, Lundak B. The acute scrotum. Pediatr Clin
North Am. 1997 Oct;44(5):1251-1266.
7. McGee SR. Referred scrotal pain: case reports and
review. J Gen Intern Med. 1993 Dec;8(12):694-701.
8. Méndez R, Tellado M, Montero M, et al. Acute scrotum:
an exceptional presentation of acute nonperforated
appendicitis in childhood. J Pediatr Surg. 1998
Sep;33(9):1435-1436.
9. Williamson RC. Torsion of the testis and allied
conditions. Br J Surg. 1976 Jun;63(6):465-476.
10. Cuckow PM, Frank JD. Torsion of the testis. BJU Int.
2000 Aug;86(3):349-353.
11. Barbosa JA, Tiseo BC, Barayan GA, et al. Development
and initial validation of a scoring system to diagnose
testicular torsion in children. J Urol. 2013 May;189(5):
1859-1864.
negative for leukocyte esterase
and nitrites.
The condition was diagnosed
as epididymitis. The patient was
discharged home with supportive
care recommendations, including
rest, ice, and scrotal elevation.
12. Boettcher M, Bergholz R, Krebs TF, et al. Differentiation
of epididymitis and appendix testis torsion by clinical
and ultrasound signs in children. Urology. 2013 Oct;
82(4):899-904.
13. Baldisserotto M. Scrotal emergencies. Pediatr Radiol.
2009 May;39(5):516-521.
14. Pillai SB, Besner GE. Pediatric testicular problems.
Pediatr Clin North Am. 1998 Aug;45(4):813-830.
15. Bukowski TP, Lewis AG, Reeves D, Wacksman J, Sheldon
CA. Epididymitis in older boys: dysfunctional voiding as
an etiology. J Urol. 1995 Aug;154(2 pt 2):762-765.
16. Graumann LA, Dietz HG, Stehr M. Urinalysis in children
with epididymitis. Eur J Pediatr Surg. 2010 Jul;20(4):
247-249.
17. Gierup J, von Hedenberg C, Osterman A. Acute non-
specific epididymitis in boys. A survey based on 48
consecutive cases. Scand J Urol Nephrol. 1975;9(1):5-7.
18. Doolittle KH, Smith JP, Saylor ML. Epididymitis in the
prepuberal boy. J Urol. 1966 Sep;96(3):364-366.
19. Cappèle O, Liard A, Barret E, Bachy B, Mitrofanoff P.
Epididymitis in children: is further investigation necessary
after the first episode? Eur Urol. 2000 Nov;38(5):627-630.
20. Berger RE, Alexander ER, Harnisch JP, et al. Etiology,
manifestations and therapy of acute epididymitis:
prospective study of 50 cases. J Urol. 1979 Jun;121(6):
750-754.
21. Berger RE, Holmes KK, Mayo ME, Reed R. The clinical
use of epididymal aspiration cultures in the management
of selected patients with acute epididymitis. J Urol. 1980
Jul;124(1):60-61.
22. Schiff J, Kelly C, Goldstein M, Schlegel P, Poppas D.
Managing varicoceles in children: results with micro­
surgical varicocelectomy. BJU Int. 2005 Feb;95(3):399-402.
23. MacLellan DL, Diamond DA. Recent advances in
external genitalia. Pediatr Clin North Am. 2006 Jun;
53(3):449-464, vii.
24. Lao OB, Fitzgibbons RJ Jr, Cusick RA. Pediatric inguinal
hernias, hydroceles, and undescended testicles. Surg Clin
North Am. 2012 Jun;92(3):487-504, vii.
25. Basile M, Palmerio G, Spina T, Baldassarre N, Ciarelli F.
Suggestion for an alternative transabdominal
laparoscopic technique (rivet technique TART) for quick
inguinal hernia repair: our initial experience. Ann Ital Chir.
2013 Apr 24;84(ePub).
26. Gilchrist BF, Lobe TE. The acute groin in pediatrics. Clin
Pediatr (Phila). 1992 Aug;31(8):488-496.
27. Munden MM, Williams JL, Zhang W, Crowe JE, Munden
RF, Cisek LJ. Intermittent testicular torsion in the pediatric
patient: sonographic indicators of a difficult diagnosis.
AJR Am J Roentgenol. 2013 Oct;201(4):912-918.
28. Lam WW, Yap TL, Jacobsen AS, Teo HJ. Colour Doppler
ultrasonography replacing surgical exploration for acute
scrotum: myth or reality? Pediatr Radiol. 2005 Jun;35(6):
597-600.
29. Yazbeck S, Patriquin HB. Accuracy of Doppler sonography
in the evaluation of acute conditions of the scrotum in
children. J Pediatr Surg. 1994 Sep;29(9):1270-1272.
30. Nussbaum Blask AR, Bulas D, Shalaby-Rana E, Rushton
G, Shao C, Majd M. Color Doppler sonography and
scintigraphy of the testis: a prospective, comparative
analysis in children with acute scrotal pain. Pediatr Emerg
Care. 2002 Apr;18(2):67-71.
31. Atkinson GO Jr, Patrick LE, Ball TI Jr, Stephenson CA,
Broecker BH, Woodard JR. The normal and abnormal
scrotum in children: evaluation with color Doppler
sonography. AJR Am J Roentgenol. 1992 Mar;158(3):
613-617.
32. Melloul M, Paz A, Lask D, Luttwak Z, Mukamel E. The
pattern of radionuclide scrotal scan in torsion of testicular
appendages. Eur J Nucl Med. 1996 Aug;23(8):967-970.
33. Bowlin PR, Gatti JM, Murphy JP. Pediatric testicular
torsion. Surg Clin North Am. 2017 Feb;97(1):161-172.
34. Dias Filho AC, Oliveira Rodrigues R, Riccetto CL,
Oliveira PG. Improving organ salvage in testicular
torsion: comparative study of patients undergoing vs
not undergoing preoperative manual detorsion. J Urol.
2017;197(3 Pt 1):811-817.
 The Critical Image
A 63-year-old man with diabetes, peripheral vascular disease, and By Joshua S. Broder, MD, FACEP
end-stage renal disease presents with right leg pain. He underwent a Dr. Broder is an associate professor and the
residency program director in the Division
below-the-knee amputation 9 months earlier, which was complicated by an of Emergency Medicine at Duke University
infection that required surgical revision. The wound has healed slowly. Over Medical Center in Durham, North Carolina.
the past several weeks, the patient has experienced worsening pain in the
distal portion of his right leg at the amputation site. His knee and thigh are
unaffected. He has noted swelling but no drainage. He has been afebrile and denies recent trauma.
His vital signs are blood pressure 171/89, heart rate 105, temperature 37.3°C (99.1°F), and oxygen saturation 99% on
room air. The patient is generally well appearing. His heart is slightly tachycardic but has a regular rhythm with no
murmur. Edema and tenderness are noted on the distal-most portion of the amputated limb, particularly on the anterior
and lateral aspects.
The emergency physician performs a point-of-care ultrasound examination and obtains radiographs of the patient’s
right leg.

A B C
Soft-tissue
fluid collection

Osteolysis
of the fibula

Calcified
Fibula with a sharply Calcified Lysis blood
defined edge blood vessels of the fibula vessels
A. Point-of-care ultrasound
reveals a 3-cm by 3-cm B. An x-ray of the amputation site, taken C. Radiographs obtained during the
soft-tissue fluid collection, 9 months earlier. The fibula has a sharply defined emergency department visit show osteolysis
which is consistent with an border caused by a bone saw. Calcified blood of the distal fibula, a sign of osteomyelitis.
abscess. vessels are visible, indicating advanced vascular
disease.

KEY POINTS CASE RESOLUTION

n Osteomyelitis can result from direct inoculation or a contiguous or The fluid was aspirated under
hematogenous spread. ultrasound guidance, and IV
n Radiography has a low sensitivity for detecting acute infections, which antibiotics were administered.
are usually defined by symptoms of less than 2 weeks’ duration. With the The patient was admitted to the
passage of time, x-rays can demonstrate osteopenia, a periosteal reaction, hospital, where he underwent
and cortical destruction. a revision of his previous
n MRI with IV gadolinium contrast, the test of choice in such cases, can amputation. His wound cultures
detect acute infections with a sensitivity of 90% and a specificity of 79%. subsequently grew Escherichia coli.
CT is an alternative modality that can detect soft-tissue abscesses and
1. Mandell JC, Khurana B, Smith JT, Czuczman GJ,
gas, as well as foreign bodies and bony destruction. Radionuclide imaging Ghazikhanian V, Smith SE. Osteomyelitis of the
with a three-phase bone scan can be used as an adjunct when MRI is lower extremity: pathophysiology, imaging, and
classification, with an emphasis on diabetic foot
contraindicated.1 infection. Emerg Radiol. Apr 2018;25:175-188.

October 2019 n Volume 33 Number 10 21

 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 Which medications are most commonly

associated with rhabdomyolysis? 7 Which finding should prompt treatment for
hypocalcemia?
A. Anticonvulsants A. Calcium concentration of 5.4 mg/dL
B. Opioids B. Carpopedal spasms
C. Oral contraceptives C. Low urine output
D. Statins D. Vomiting and abdominal pain

2 Which diagnostic test is required to

confirm rhabdomyolysis? 8 Which early findings can be expected in a
patient with rhabdomyolysis?
A. CK concentration A. Hypercalcemia, hyperkalemia, elevated CK
B. Homocysteine level level
C. Lipoprotein panel B. Hypercalcemia, hyperkalemia, low CK level
D. Mean corpuscular volume C. Hypocalcemia, hyperkalemia, elevated CK level
D. Hypocalcemia, hypokalemia, low CK level

3 What is the earliest electrolyte abnormality

associated with rhabdomyolysis?
9 What is a common and early symptom of
rhabdomyolysis?
A. Hypercalcemia
B. Hyperkalemia A. Confusion
C. Hyperphosphatemia B. Diarrhea
D. Hypocalcemia C. Myalgia
D. Nasal drainage

4 Which factor should guide the volume

of fluid resuscitation when managing a
patient with rhabdomyolysis?
10 Which treatment is most important for patients
with rhabdomyolysis?
A. Absence or presence of myalgia A. Bicarbonate infusion
B. Calcium level B. Fluid resuscitation
C. Mental status C. Mannitol infusion
D. Urine output D. Pain control

5 What is the most commonly affected

muscle group in patients with
rhabdomyolysis?

11 Which characteristic is consistent with acute
epididymitis?
A. Symptoms, including pain and swelling, are
A. Abdominal wall musculature seldom abrupt and typically develop over a
B. Fine muscles of the hand 24-hour period
C. Paraspinal muscles B. The diagnosis can frequently be confirmed by
D. Postural muscles the presence of the “blue dot” sign
C. The disorder affects approximately 75% of all

6 What ECG findings should raise suspicion

for hyperkalemia?
prepubertal boys who present with scrotal or
testicular pain
A. Narrowing of the QRS complex D. Urinalyses and urine cultures are usually
B. RS complexes in the septal precordial positive in prepubertal boys
leads
C. ST-segment elevations
D. Tall, “tented” T waves

22 Critical Decisions in Emergency Medicine


12 A 3-year-old boy presents with scrotal swelling.
His mother explains that for the last 6 months,
the boy’s scrotum has intermittently appeared
15 Which finding signals testicular torsion with the
greatest sensitivity?
A. Absence of a cremasteric reflex
larger on the left. She was initially unconcerned B. “Bag of worms” texture
because the swelling always went away; however,
C. Dull pain
his symptoms have become more persistent
D. Edema
in the last 24 hours and are occasionally
accompanied by pain. The patient is consolable,
and his mother denies any associated vomiting,
fever, or diarrhea. Gross enlargement of the left
16 Any child with a scrotal mass and signs of
precocious puberty should be evaluated for
what pathology?
scrotum is noted, which is augmented when the
A. Leydig cell tumor
patient cries. The lie is normal, and there is no
discoloration of either testicle. The cremasteric B. Hernia
reflex on the left side appears to be present. C. Neisseria gonorrhoeae
Which factor would be most helpful in delineating D. Spermatoceles
the differential diagnosis?
A. Absence of systemic symptoms
B. Normal lie and the presence of a cremasteric
17 Which characteristic can help differentiate a
hydrocele from a nonincarcerated hernia?
A. A hydrocele causes acute pain
reflex
B. A hydrocele decreases in size when the Valsalva
C. Predominance of swelling versus pain
maneuver is applied
D. Timeline of the patient’s symptoms
C. A hydrocele is reducible

13
What disorder should be suspected in a
16-year-old boy whose scrotum feels like a
D. A hydrocele transilluminates

“bag of worms”?
A. Hydrocele
18 Without treatment, most hydroceles will resolve
by what age?
B. Paratesticular mass A. 1 month
C. Testicular torsion B. 6 months
D. Varicocele C. 1 year
D. 3 years

14 A 12-year-old boy presents with severe, sharp,
lower abdominal pain that began 2 hours ago.
He has had multiple episodes of nonbloody, 19 What is the most likely etiology of epididymitis
in a sexually active teenager?
nonbilious emesis, but he denies any fever, dysuria, A. Congenital defect
or chills. He is mildly tachycardic, but his vital
B. Neisseria gonorrhoeae
signs are otherwise normal. The clinician notes an
C. Sports-related trauma
elevated, horizontal left testicle that is markedly
tender, enlarged, and discolored. The cremasteric D. Staphylococcus aureus
reflex on the left side is absent. What is the next
step in this patient’s management?
A. Administer IV antibiotics
20
Which systemic symptom(s) are particularly
suspicious for true testicular torsion?
A. Impetigo
B. Consult urology regarding immediate surgical
B. Inconsolability
exploration
C. Fever and headache
C. Perform a CT scan of his abdomen and pelvis
D. Provide symptomatic relief with ice, rest, scrotal D. Nausea and vomiting
elevation, and analgesics

ANSWER KEY FOR SEPTEMBER 2019, VOLUME 33, NUMBER 9

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
C D C A B C A D C B A A C C B D D A D B

October 2019 n Volume 33 Number 10 23

 Drug Box
LEFAMULIN
By Frank LoVecchio, DO, MPH, FACEP
Maricopa Medical Center, Phoenix, Arizona
Lefamulin is a novel pleuromutilin antibiotic that is approved
for the treatment of community-acquired bacterial pneumonia
(CABP). Early research suggests that the drug may also be
effective for the acute management of some sexually transmitted
diseases and bacterial skin and skin-structure infections.
Lefamulin has also been shown to combat multidrug-resistant
Neisseria gonorrhoeae and Mycoplasma genitalium infections.
Mechanism of Action
Lefamulin inhibits protein synthesis by binding to the peptidyl
transferase center of the 50S bacterial ribosome, a process
that inhibits peptide transfer and protein synthesis. The drug
displays activity against Gram-positive and atypical organisms
associated with CABP, including Streptococcus pneumoniae,
Haemophilus influenzae, Mycoplasma pneumoniae,
Legionella pneumophila, and Chlamydophila pneumoniae.
It also provides expanded, Gram-positive coverage for
Staphylococcus aureus (eg, methicillin-resistant, vancomycin-
intermediate, and heterogeneous strains) and vancomycin-
resistant Enterococcus faecium.
Dosage
150 mg (IV) every 12 hours OR 600 mg (oral) every 12 hours for
a minimum of 5 days
Dosage adjustments are required for patients with moderate to
severe hepatic impairment.
Precautions
Common side effects include diarrhea (~12%) and nausea
(2%–3%).
Lefamulin should be avoided in patients with known QT-interval
prolongation, a ventricular arrhythmia (including torsades
de pointes), or a metabolic disorder that prolongs the QT
interval. Furthermore, the medication should not be taken with
concomitant antiarrhythmic agents or other drugs that prolong
the QT interval.
Tox Box
VAPING-ASSOCIATED LUNG DISEASE
By Christian A. Tomaszewski, MD, MS, MBA, FACEP
University of California, San Diego
Electronic cigarettes are designed to aerosolize liquid
mixtures of nicotine and flavorings. Almost 5% of adults
and 20% of high school students in the US admit to using
these devices. In recent months, more than 800 cases of
vaping-associated pulmonary illnesses have been reported,
12 of which have been fatal. In most cases, patients report
vaping cannabinoid products in the days or weeks prior to
symptom onset.
Mechanism of Toxicity
• Acute interstitial lung disease (eg, diacetyl, flavorings,
solvents)
• Lipoid pneumonia with alveolar macrophages (eg, oils,
vitamin E acetate)
Clinical Manifestations
• Nonproductive cough, dyspnea, chest pain
• Nausea, vomiting, abdominal pain
• Fever, chills, fatigue
Diagnostic Tests
• Pulse oximetry monitoring or blood gas measurements
to evaluate for hypoxia
• CBC (elevated WBC count without infection)
• Chest radiography to evaluate for infiltrates
• CT of the chest (with contrast) if the patient is severely ill
(ground-glass opacities)
Treatment
• Stable patients require close follow-up.
• Provide supplemental oxygen as needed (eg, high-
flow nasal cannula, bilevel positive airway pressure,
intubation).
• High-dose IV steroids may help.
• Consider extracorporeal membrane oxygenation for
refractory acute respiratory distress syndrome.
• Consider notifying the local health department or US
Food and Drug Administration.