The use of ultrasound in the emergency department for the detection of thoracic outlet syndrome: A single case study

Introduction

Thoracic outlet syndrome (TOS) refers to a spectrum of syndromes related to the compression of the brachial plexus (neurogenic TOS), subclavian vein or artery in the general region of the thoracic outlet, which is the area just above the first rib and behind the clavicle.

Case report

We report a 27-year-old healthy man who presented to the emergency department with right upper limb pain, tingling and weakness. Point-of-care ultrasonography was performed following a dynamic protocol in the supraclavicular fossa in the right upper limb. A congenital cervical rib, as well as narrowing of the costoclavicular gap, causing vein, artery and spinal roots compression was evidenced. This maneuver reproduced the symptoms, confirming the suspicion of neurogenic TOS.

Discussion

Early diagnosis is important, because the neurogenic compression associated with neurogenic TOS, if prolonged, can lead to muscle weakness and atrophy, being irreversible. Selected patients with neurogenic TOS who have progressive weakness, disabling pain, or who have failed to improve with conservative measures are considered for first rib resection.

Conclusion

Using the dynamic approach during point-of-care ultrasonography examination, in combination with physical examination and cervical radiography, could help identify neurogenic TOS.

Acute Limb Ischemia after Intake of the Phenylethylamine Derivate NBOMe

Objective: N-(2-methoxy) benzyl-phenethylamine (NBOMe) derivatives have a high affinity to the serotonin receptor 2A and emerged as new psychedelic agents. We report the case of a 30-year-old man admitted to the hospital because of acute ischemia of the left arm with clinical symptoms of pallor, pulselessness, paresthesia, and a motoric deficit. The patient had a history of schizophrenia and drug abuse and disclosed during the hospital stay the sublingual intake of a substance bought as 25I-NBOMe the night before the ischemic event. Methods: Routine clinical diagnostics including among others color-coded duplex sonography and computed tomography angiography (CTA) were performed. The remainder of the drugs was analyzed using high performance liquid chromatography. Results: Initial color-coded duplex sonography of the upper left limb showed pathological flow profiles of the axillary, brachial, ulnar, and radial artery with a reduced diameter of the ulnar (0.9 mm) and radial (1.1 mm) artery. In consequence, peripheral vasospasm, distal arterial thrombosis, or arterial embolization was anticipated. As therapeutic measures, the patient immediately received intravenous systemic vasodilators (alprostadil) and therapeutic anticoagulation with low molecular weight heparin. Instant symptom improvement was observed within the first day after therapy initiation. The subsequently performed CTA of the heart and left arm showed no signs of thrombotic material. Treatment was continued for five days and the patient was released thereafter having completely normalized perfusion in his left arm. Outpatient treatment was continued with calcium-channel blockers, as the patient had also displayed arterial hypertension. Drug analysis retrieved a composition of the isomers 25I-NBOMe, 25C-NBOMe, and 25H-NBOMe as well as traces of pentylon. Conclusion: NBOMe ingestion implicates the risk of peripheral vasospasms with severe, limb-threatening ischemia.

An investigation of factors affecting the performance of wheelchair transfers

Purpose: Being able to transfer in and out of their wheelchair is an important task for wheelchair users that can be affected by a variety of different factors. The aim of this study was to investigate the interplay between personal characteristics, wheelchair users' transferring technique and the other factors that can affect the performance of wheelchair transfers. Method: A cross-sectional survey study was designed to recruit wheelchair users, aged 18 or older, performing sitting-pivot or standing-pivot wheelchair transfers, independently or with assistance. Results: Forty-two usable surveys were returned. Transferring technique is usually determined by the individual's impairment. In turn, transferring technique will greatly affect the perceived difficulty of different types of wheelchair transfers and, the number of transfers that people will perform in a day. The presence of upper limb pain increased the difficulty reported for certain types of transfers while the use of assistive technologies appears to be only partially successful in facilitating the performance of wheelchair transfers. Conclusion: This study highlights the complexity of the factors included in the performance of wheelchair transfers. Findings from this survey can be utilized to broaden the boundaries of future research. Implications for rehabilitation Transferring technique is usually determined by the individual?s impairment. In turn, transferring technique will greatly affect the perceived difficulty of different types of wheelchair transfers and, the number of transfers that people will perform in a day. The performance of wheelchair transfers exacerbate the painful symptomatology of the person, regardless of their medical condition or transferring technique. The presence of pain increases the reported difficulty of wheelchair trasnfers. Use of assistive technologies during transfers is linked to the increased body weight of the person, while the choice of the type of assistive technology seems to be dependent of the transferring technique used by the person. Overall, available ATs are only moderately effective in enabling people to perform wheelchair transfer and they can be cause of frustration for the users due to their high cost and limited functionality.