External Signs Of Internal Problems “ A Visual Diagnosis” Troy Pennington, DO, MS, FAAEM EMS Director- ARMC Mercy Air California, SBCFD & Barstow FD
Hyphema <ul><li>Blood or clots in the anterior chamber. Hyphema may be traumatic or spontaneous. Traumatic hyphema results from a ruptured iris root vessel. Spontaneous hyphemas are frequently associated with sickle cell disease. </li></ul><ul><li>Treatment </li></ul><ul><li>Elevate Patient ’s Head </li></ul><ul><li>Dilate the eye to avoid “Pupilary Play” </li></ul><ul><li>Control of intraocular pressure- topical B-Blockers, IV mannitol, topical alpha adrenergic agonists and oral, topical or IV carbonic anhydrase inhibitors (CAIs) such as Diamox. </li></ul><ul><li>Rebleeding can occur 3 to 5 days later in up to 30%, causing severe increase in intraocular pressure necessitating surgical anterior chamber “washouts” </li></ul>
A patient with a history of alcohol abuse presented to the Emergency Department complaining of acute upper abdominal pain. Examination revealed the findings in the images below. The physician repeatedly questioned the patient about recent trauma, but the patient adamantly denied this. The physician simply assumed that the patient sustained trauma while intoxicated and did not recall the event.
What ’s Your Diagnosis? Cullen's Sign The patient exhibits Cullen's sign - ecchymosis in the periumbilical region. In acute pancreatitis, Cullen's or Turner's sign (ecchymotic discoloration of the flank) occurs in approximately 3% of patients and is associated with a mortality of 37% (2). Although most commonly considered a sign of hemorrhagic pancreatitis, neither of these signs is specific to this condition. In fact, Cullen's sign has been described in a variety of conditions including retroperitoneal bleed after coronary angiography, splenic rupture, hip dislocation, perforated duodenal ulcer and ruptured abdominal aortic aneurysm (1-4). Cullen's sign arises from the spread of retroperitoneal blood into the falciform ligament and subsequently to subcutaneous umbilical tissues through the connective tissue covering of the round ligament (5). It is named after Dr. T S Cullen who described the sign in 1919 in a patient with a ruptured ectopic pregnancy. References: (1) Spence M, Webb S. Images in cardiology: Cullen's sign after coronary angiography Heart 2000;83: 640. (2) Mookadam F, Cikes M. Images in clinical medicine: Cullen's and Turner's signs N Engl J Med 2005;353: 1386. (3) Chung MA, et al. Cullen's sign: it doesn't always mean hemorrhagic pancreatitis Am J Gastroenterol 1992;87: 1026-8. (4) Sayers RD, Porter KM. Cullen's sign: a new association with central dislocation of the hip joint Injury 1988;19: 280-1. (5) Sugimoto M, et al. MPR-hCT imaging of the pancreatic fluid pathway to Grey-Turner's and Cullen's sign in acute pancreatitis Hepatogastroenterology 2005;52:1613-1616.
PATTERNS <ul><li>HANDPRINTS OR FINGER MARKS ON FACE, TRUNK, UPPER ARMS, BUTTOCKS </li></ul><ul><li>BELT MARKS </li></ul><ul><li>LOOP MARKS FROM ROPE OR WIRE </li></ul><ul><li>LIGATURE MARKS </li></ul>