Clinical Practice and Cases in Emergency Medicine

A seven-year-old girl presented to the pediatric emergency department with three days of nonbloody, nonbilious vomiting, nonbloody diarrhea, and decreased oral intake. She also had weight loss and fatigue over the preceding month. The examination showed persistent tachycardia despite antipyretics and fluids. This presentation addresses the many causes of persistent tachycardia in a child with a diagnostic test sent from the emergency department revealing the ultimate diagnosis. 

Introduction: Ocular ultrasound is highly effective for diagnosing traumatic eye injuries such as retinal detachment, vitreous hemorrhage, foreign bodies, and retrobulbar hematomas. However, it is contraindicated in cases of suspected globe rupture, as applying external pressure to the eye could cause further damage. When globe injury is clinically suspected, computed tomography is typically used to confirm the diagnosis. However, delays can occur if other life-threatening injuries require immediate attention or there are long wait times. We propose a novel method for performing ocular ultrasound in such cases—the modified water bath technique—which allows for the diagnosis of globe rupture upon the patient’s arrival in the emergency department.

Case Series: We present five cases where the modified water bath technique was used. A glove partially filled with saline is prepared and gently placed on the affected eye while the patient lies supine. A small amount of gel is applied to a high-frequency linear probe, which is then positioned transversely on the glove. An ocular scan is then conducted in dual mode to compare both eyes. 

Conclusion: This method produces clear, well-defined images and offers the advantage of being performed bedside immediately. This eliminates diagnostic delays and allows for prompt initiation of treatment. Additionally, the high-quality images provided by this technique can be used to diagnose other eye emergencies through ultrasound.

Introduction: Agitation in the emergency department (ED) poses a significant safety concern for staff and patients. Multidisciplinary responses, such as Code Violet activations, are common but resource-intensive. Early identification and intervention may reduce escalation, but ED-specific data are limited. The objective of the study was to evaluate the implementation of a novel agitated behavior score (ABS) and assess whether higher ABS scores are associated with increased risk of Code Violet activation.

Case Series: This prospective observational study included adult patients admitted to a behavioral health unit in a community teaching hospital ED. Trained staff administered a novel 25-point ABS incorporating altered mentation, verbal agitation, and motor agitation. The primary outcome was Code Violet activation; secondary outcomes included pharmacologic interventions and substance use. Among 83 patients, 27 (33%) experienced ≥ 1 Code Violet activation. And those patients with Code Violet activation had higher initial ABS scores (mean 10.9 [6.35] versus 4.6 [4.43]; P <.001). Overall rates of psychotropic medication use were similar between groups; however, time to first medication was longer in the Code Violet group (4.0 versus 2.7 hours). Patients with Code Violet activations more frequently received parenteral medications, whereas those without the code activation more commonly received oral agents.

Conclusion: The agitated behavior score was associated with Code Violet activation and may help identify patients at greater risk of behavioral escalation. While it measures current agitation rather than predicting future agitation, its structured format may facilitate early recognition and management of agitation.

Introduction: Immunoglobulin A (IgA) vasculitis, formerly known as Henoch–Schönlein purpura, is a small-vessel leukocytoclastic vasculitis caused by IgA immune complex deposition. While it is the most common systemic vasculitis in children, adult cases can present with more severe systemic manifestations. The classic clinical tetrad includes palpable purpura, arthralgia, abdominal pain, and renal involvement. Gastrointestinal symptoms, occurring in approximately two-thirds of cases, result from inflammation of small bowel vessels resulting in bowel wall edema and hemorrhage, which may serve as lead points for intussusception.

Case Report: A 21-year-old male presented with two days of severe periumbilical abdominal pain, bilateral knee pain, and a nonblanching palpable purpuric rash on his lower extremities. Physical examination revealed a soft but tender abdomen. Lab results were remarkable for leukocytosis. Computed tomography (CT) of the abdomen and pelvis demonstrated small bowel wall thickening and ileoileal intussusception. The patient was initially consented for a partial ileal resection; however, an exploratory laparotomy failed to localize the telescoping segment, suggesting spontaneous resolution. He was observed for 24 hours and discharged with outpatient follow-up.

Conclusion: Intussusception is the most common surgical complication of IgA vasculitis. In adults, this condition requires high clinical suspicion and prompt diagnostic imaging with ultrasonography or CT, as small bowel involvement may be inaccessible by contrast enema. This case underscores the importance of recognizing IgA vasculitis-associated intussusception as a critical and potentially self-limiting complication in the adult population.

Case Presentation: A one-year-old girl presented with acute-onset dyspnea persistent for two days and recurrent choking episodes. Physical examination revealed stridor and sub-costal retractions. Despite initial treatment with inhaled nebulized epinephrine, stridor persisted. Lateral chest radiography finding indicated tracheal stenosis. Contrast-enhanced neck and chest computed tomography (CT) showed an aberrant right subclavian artery compressing the esophagus posteriorly, causing esophageal stenosis with associated food residue accumulation. The proximally dilated portion of the esophagus caused mass effect with compression of the trachea, resulting in tracheal stenosis. Despite medical management, the patient experienced recurrent stridor and could only swallow liquids. Therefore, surgical translocation of the right subclavian artery to the right common carotid artery was performed. Postoperatively, the patient swallowed age-appropriate food, and the stridor resolved.

Discussion: The most common cause of stridor in children is viral croup, which is typically treated with nebulized epinephrine and corticosteroids in moderate to severe cases. However, recurrent or persistent stridor with dysphagia should raise concern for vascular anomalies (eg, aberrant right subclavian artery), bacterial tracheitis, epiglottitis, retropharyngeal abscess, foreign body aspiration, mediastinal tumors, or other compressive pathologies. Early symptomatic presentation with dysphagia and stridor in young children is unusual, as aberrant right subclavian artery symptoms typically develop after age 40. When clinical presentation deviates from typical croup, particularly if associated with dysphagia, ultrasound, magnetic resonance imaging, or contrast-enhanced CT can identify vascular anomalies. Surgical intervention is indicated for symptomatic aberrant right subclavian artery when symptoms persist despite medical management (nutrition monitoring, feeding support, airway support, and growth assessment).

Case Presentation: A 28-year-old woman was brought to the emergency department after being found collapsed at home. Because she was unable to provide a history, contextual bedside clues were important during the initial assessment. Bright yellow granular material with a medicinal odor was noted adherent to her hair. This unusual finding raised suspicion of overdose with an acetaminophen-containing over-the-counter (OTC) cold medication. Her serum acetaminophen concentration was elevated at 135 micrograms per milliliter, and N-acetylcysteine was promptly administered. She did not develop hepatic injury and was discharged after recovery.

Discussion: This case highlights the diagnostic value of visible bedside clues when history is initially unavailable. The yellow residue was not pathognomonic, and no chemical analysis of the material was performed. However, in the context of the increasing incidence of overdoses involving OTC medications in Japan, especially among young women, the finding was clinically sufficient to raise suspicion for possible ingestion of an OTC combination cold medication containing acetaminophen. This mattered because it directly prompted serum acetaminophen measurement and timely antidotal treatment with N-acetylcysteine, which can prevent or mitigate acetaminophen-induced liver injury. 

Case Presentation: An 83-year-old man with a history of left corneal transplant presented to the emergency department with several days of left eye pain, redness, and tearing. Visual acuity was 20/50 in the right eye and bare light perception in the left eye. Intraocular pressure was 15 millimeters fo mercury in the right eye and unobtainable in the left. The left conjunctiva and sclera were injected, and slit-lamp examination revealed a full-thickness corneal perforation with corneal haze in the transplanted cornea. We placed a rigid eye shield, provided systemic analgesia, kept the patient nil per os, and obtained urgent ophthalmology consultation.

Discussion: Corneal perforation is a full-thickness corneal defect that disrupts globe integrity and allows aqueous leakage. It may result from infection, ocular surface disease, autoimmune disorders, trauma, or prior keratoplasty, with graft–host junction instability representing a key risk factor. Diagnosis is clinical, based on visible perforation, a positive Seidel test, or anterior chamber shallowing.

Case Presentation: A 62-year-old male presented to the emergency department with a three-day history of right knee, calf, and foot pain following a bout of prolonged crouching while gardening. The physical examination revealed a cold and pale foot with absent pulses. A point-of-care ultrasound (POCUS) performed at bedside revealed a thrombosed popliteal artery aneurysm. A heparin infusion was initiated, and vascular surgery was consulted. Subsequent imaging confirmed the diagnosis of a thrombosed popliteal artery aneurysm with thrombus extension into the superficial femoral artery. The patient underwent a femoropopliteal bypass, resulting in successful revascularization of the limb.

Discussion: While POCUS is a well-established imaging modality for the diagnosis of deep vein thrombosis, its utility in diagnosing acute peripheral arterial pathologies is less well-known. This case demonstrates how prompt bedside POCUS evaluation can circumvent potential delays associated with traditional imaging such as computed tomography angiography, allowing for expedited surgical consultation and timely therapeutic and procedural intervention. This case highlights the potential role of POCUS in the rapid diagnosis of acute limb ischemia from arterial thrombosis in the acute care setting.

Case Presentation: Temporary transvenous pacemaker placement is frequently performed in the emergency department for the management of symptomatic bradyarrhythmias. We report the case of a 93-year-old male who presented with profound bradycardia, hypotension, and altered mental status requiring emergent pacing. Initial transcutaneous pacing achieved hemodynamic improvement but necessitated escalation to transvenous pacing due to patient discomfort and high current requirements. During attempted transvenous pacemaker placement, resistance was encountered and capture could not be achieved despite appropriate technique. Subsequent cardiology consultation and imaging revealed an undiagnosed tricuspid valve myxoma obstructing catheter advancement.

Discussion: This case highlights a rare mechanical complication of transvenous pacemaker placement caused by an intracardiac mass. Awareness of structural cardiac pathology as a potential cause of pacemaker placement failure is critical, particularly when resistance is encountered despite correct procedural technique

Case Presentation: A 78-year-old woman who presented to the emergency department with abdominal pain was found to have a tender, pulsatile abdominal mass on examination. Point-of-care ultrasound demonstrated an abdominal aortic aneurysm with findings concerning for active rupture. Emergent computed tomography angiography confirmed rupture with a large retroperitoneal hematoma. 

Discussion: Ruptured abdominal aortic aneurysm is a catastrophic diagnosis associated with high mortality, particularly when recognition is delayed. Point-of-care ultrasound is well established for identifying aneurysmal dilation; however, direct visualization of active rupture is rarely described. 

Case Presentation: A 46-year-old woman presented to the emergency department after stepping on an object while playing in shallow seawater. Examination revealed a barbed foreign body protruding from the plantar aspect of the left foot. Plain radiography demonstrated that the retained stingray barb had fragmented into three pieces within the soft tissue. Because deeper extension was a concern, computed tomography was additionally obtained to better assess the depth and extent of penetration. The fragments were removed through staged incisions, and repeat radiography confirmed complete extraction. The wound was irrigated, a Penrose drain was placed, and levofloxacin was prescribed at discharge.

Discussion: Stingray injuries are among the most common marine vertebrate envenomations and should not be regarded as simple puncture wounds when retained foreign body is suspected. This case highlights that even when a stingray barb is externally obvious, internal fragmentation may alter procedural planning. Radiography can reveal retained fragments, and additional imaging may be useful when injury depth is uncertain.

Case Presentation: A 60-year-old male from the country of Jordan presented to the emergency department with swelling, pain, black lesions on his fingertips and thumb, and a red streak up his arm. The patient had been trimming sheep wool and goat skin two weeks prior to onset of symptoms and cut his left thumb with trimming shears. 

Discussion: Cutaneous anthrax is caused by Bacillus anthracis, a Gram-positive, spore-forming rod found naturally in the soil. Populations at greatest risk include those who consume undercooked meat with contaminated spores or who live and work in rural/agricultural areas. Occupations considered to be at a higher risk include farmers, wool sorters, and veterinarians. Although cutaneous anthrax is rare in the United States (U.S.), there have been cases reported since the bioterrorism attacks in 2001 when mail laced with anthrax was sent via the U.S. Postal Service. Human infection occurs in countries where the disease is endemic in livestock. Because there are no rapidly available diagnostic tests the diagnosis is primarily clinical. It is important to consider the possibility of cutaneous anthrax in the appropriate setting, despite the rarity of cases in the U.S. High clinical suspicion should be maintained in anyone presenting with the appropriate skin findings, especially in those traveling from endemic countries (South and Central Asia, Sub-Saharan Africa, Southern and Eastern Europe, Central America, South America, and the Caribbean).

Introduction: Carotid free-floating thrombus is a rare and potentially devastating cause of ischemic stroke. Diagnosis remains challenging due to the dynamic nature of the lesion.

Case Report: We report the case of a 46-year-old female presenting with neck pressure and gait instability, who was found to have a free-floating thrombus at the brachiocephalic-carotid junction. Despite early anticoagulation, she developed biparietal ischemic strokes.

Conclusion: This case highlights the challenges in management of carotid free-floating thrombus including appropriate anticoagulation, contraindications to thrombolysis, and the need for multidisciplinary involvement. Emergency physicians must maintain high suspicion for vascular pathology in atypical neurologic presentations and recognize that even optimal medical therapy does not eliminate stroke risk.

Introduction: Shoulder pain is a common emergency department (ED) presentation. Scapular winging is a rare condition often associated with long thoracic nerve injury. This case report describes an even rarer case of dorsal scapular nerve injury caused by a nontraumatic first rib fracture in a young weightlifter, an injury mechanism not previously reported in the literature.

Case Report: A 17-year-old male presented to the ED with left shoulder pain following weightlifting. Physical examination demonstrated scapular winging, and a clinical diagnosis of dorsal scapular neuropraxia was made. Imaging revealed a nontraumatic first rib fracture. The patient was treated conservatively with nonsteroidal anti-inflammatory drugs and rest, resulting in complete resolution of symptoms within two weeks at clinic follow-up.

Conclusion: To our knowledge, this is the first case in the emergency medicine literature of a nontraumatic rib fracture with associated dorsal scapular nerve injury and scapular winging. This case highlights the importance of thorough visual inspection and movement assessment by emergency physicians in patients presenting with shoulder pain, as key findings such as scapular asymmetry and neurologic injuries may otherwise be missed. Recognizing rare injuries like nontraumatic first rib fractures with associated neurologic deficits is critical for timely diagnosis and management, which can lead to excellent outcomes.

Introduction: Primary spontaneous pneumothorax generally presents with symptoms of chest pain and shortness of breath. Progression to a tension pneumothorax results in a medical emergency. Rare presentations with abdominal pain are possible and must be considered to expedite appropriate treatment of pneumothorax.

Case Report: We report a case of a 21-year-old male with primary spontaneous pneumothorax who initially presented to the emergency department with right lower quadrant abdominal pain. History and physical exam were suggestive of acute appendicitis. A large right pneumothorax was incidentally found on computed tomography.

Conclusion: This case highlights unusual presentations of pneumothorax. Emergency physicians should consider atypical presentations of chest pathology such as pneumothorax in patients presenting with symptoms consistent with an acute abdomen.

Introduction: Globe injuries constitute true ophthalmologic emergencies and require prompt surgical intervention. When direct physical examination is limited, due to trauma or swelling, point-of-care ultrasound (POCUS) can serve as a valuable adjunct in evaluating globe integrity. 

Case Report: We report the case of a 31-year-old male who presented to the emergency department with a barbed fishing hook embedded in his right eyelid. The patient reported pain localized to the eyelid but denied any visual disturbances or direct eye involvement. On examination, a large fishing hook embedded in the right upper eyelid was visualized. His eye was swollen, and he was unable to fully open it, limiting direct assessment of the globe. Given the limited exam, POCUS of the right eye revealed a foreign body traversing the anterior chamber toward the lens, raising concern for globe injury. Ophthalmology was consulted, and computed tomography of the orbits was obtained. The following morning, the patient underwent surgical removal of the barbed fishing hook and repair of the globe.  

Conclusion: Point-of-care ultrasonography is a valuable diagnostic adjunct in the evaluation of traumatic eye injuries and useful when physical examination is limited. In this case, POCUS was used to differentiate an intraocular foreign body and globe injury from eyelid foreign body. While POCUS is not routinely recommended in cases of suspected globe rupture, when physical exam is unclear it may be a useful adjunct.

Introduction: Lemierre syndrome is a rare but potentially severe thrombophlebitis of the internal jugular vein. It most often presents after oropharyngeal infection, likely stemming from anaerobic bacteria, commonly Fusobacterium necrophorum. The potential severity of this condition underscores the importance of early and accurate diagnosis. The gold standard diagnosis relies on computed tomography and blood cultures; however, point-of-care ultrasound offers a rapid and cost-effective tool.

Case Report: A 58-year-old woman with chronic obstructive pulmonary disease, migraines, and recent dental extractions presented with two days of worsening right-sided neck pain and swelling. She denied fever, chills, or recent upper respiratory symptoms. Examination revealed a tender anterior neck mass without airway compromise. Point-of-care ultrasound demonstrated a 1.22 x 1.80 centimeters hyperechoic intraluminal mass within the right internal jugular vein with surrounding cobblestone edema; the external jugular vein and carotid artery were normal. Computed tomography imaging confirmed the diagnosis. Laboratory studies were unremarkable. Blood cultures were obtained, and empiric intravenous beta lactamase-resistant antibiotics was initiated. Anticoagulation was considered but not started.

Conclusion: A delayed diagnosis of Lemierre syndrome is common, as its early presentations are commonly nonspecific. The classic triad is a recent oropharyngeal infection, internal jugular vein thrombosis, and septic emboli. The importance of early diagnosis and treatment cannot be overstated, as it improves outcomes while reducing costs and radiation exposure for the patient. Point-of-care ultrasound is a valuable first-line imaging modality for Lemierre syndrome. Its use in patients with symptoms such as unexplained neck swelling and tenderness can facilitate timely diagnosis and treatment, thereby averting serious adverse outcomes.

Introduction: Brugada syndrome is an important differential diagnosis for unexplained sudden cardiac arrest, particularly in younger patients. The electrocardiographic (ECG) pattern characteristic of Brugada syndrome can be provoked by fever and may vary with changes in body temperature. Therefore, targeted temperature management following cardiac arrest may obscure the distinctive morphology, increasing the risk of misdiagnosis.

Case Report: We report the case of a 44-year-old man who experienced out-of-hospital cardiac arrest due to ventricular fibrillation following influenza B infection. Initial evaluation revealed transient ST-segment elevation in leads V1-V3, while coronary angiography and echocardiographic findings were normal. Although Brugada syndrome was suspected, the diagnosis was deferred because the ECG findings normalized during targeted temperature management at 36°Celsius. However, after completion of temperature management, the patient developed a high-grade fever, accompanied by the emergence of a characteristic coved-type Brugada ECG pattern. Subsequent genetic testing identified a sodium channel protein type 5 subunit alpha mutation return, confirming Brugada syndrome.

Conclusion: Brugada ECG morphology can be affected by core temperature, and repeat electrocardiography during febrile episodes may be informative

Introduction: Many emergency physicians will never perform a lateral canthotomy and cantholysis, and one-third of those who try will be unsuccessful at relieving the pressure that threatens  permanent vision loss. This procedure is notoriously difficult and rare, but a recently proposed alternative—the vertical lid split—may be simpler and more effective.

Case Report: We report the case of a 35-year-old woman with motor vehicle collision-related orbital trauma who presented to a community emergency department. Initially, she had intact vision and extraocular movements. Imaging showed a comminuted inferior orbital blowout fracture with retrobulbar hemorrhage, and the transfer process was initiated. However, after coughing she developed vision loss and elevated intraocular pressure. Lateral canthotomy and cantholysis was performed for suspected orbital compartment syndrome but did not fully address the elevated pressures or restore vision. The emergency physician then performed a vertical lid split procedure, which fully restored vision and normalized pressures.

Conclusion: To the best of our knowledge, this is the first case report of orbital compartment syndrome to be treated with vertical lid split, and the first case report of any full-thickness eyelid incision technique being used for salvage of an unsuccessful lateral canthotomy and cantholysis; the result was excellent.

Introduction: Hyperkalemia is a common and potentially life-threatening complication of end- stage renal disease, often producing nonspecific symptoms but profound cardiac effects. While nonadherence and dietary indiscretion are typical precipitants, clinicians must also consider the adequacy and effectiveness of dialysis.

Case Report: We report a patient with end-stage renal disease on thrice-weekly hemodialysis who presented with significant bradycardia and altered mental status. Initial prehospital electrocardiogram (ECG) was suspicious for acute coronary syndrome after automated ECG interpretation suggested anterior ST-segment elevation. In the emergency department, the patient was in a junctional escape rhythm with diffuse peaked T-waves. Serum potassium was 7.8 millimoles per liter with concomitant uremia. Despite administration of potassium-shifting therapies bradycardia persisted, and temporary pacing attempts failed. An epinephrine infusion was initiated while arranging for emergent hemodialysis. Following dialysis, the potassium normalized, cardiac conduction returned to sinus rhythm, and the patient’s mental status improved. In the absence of missed dialysis sessions, increased potassium intake, or access site dysfunction, nephrology determined the likely etiology to be dialysis access recirculation from improper cannulation.

Conclusion: Dialysis recirculation is an uncommon but important cause of inadequate clearance leading to life-threatening hyperkalemia. Clinicians should consider this mechanism when confronted with otherwise unexplained electrolyte derangements in compliant dialysis patients.

Introduction: Cardiac arrest in the setting of cocaine use portends high morbidity and mortality secondary to its powerful sodium channel blockade effects. Intravenous (IV) lipid emulsion has long been used as a rescue therapy in lipophilic toxicities.

Case Report: We report a case in which IV lipid emulsion was used to successfully stabilize a patient who suffered cocaine-associated, out-of-hospital cardiac arrest.

Conclusion: Intravenous lipid emulsion was used in the successful resuscitation of a cocaine overdose and could be considered for use in patients with cocaine-associated cardiac arrest.

Introduction: Wolff-Parkinson-White syndrome is a congenital conduction disorder involving an accessory pathway that predisposes patients to reentrant tachyarrhythmias and, in rare cases, sudden cardiac death. While often asymptomatic, it may predispose patients to serious tachyarrhythmias, particularly under conditions that enhance atrioventricular (AV) conduction. Risk stratification using noninvasive and invasive tools such as electrophysiologic studies is critical to identifying high-risk individuals and guiding treatment decisions such as catheter ablation. Pharmacologic agents that alter autonomic tone may unmask latent pre-excitation. Dicyclomine, an anticholinergic agent used for gastrointestinal disorders, is not an AV-nodal blocking drug but exerts vagolytic effects that can increase sinus rate and AV nodal conduction. Dicyclomine’s vagolytic effects and potential for interaction with other proarrhythmic drugs warrant caution in patients with conduction abnormalities, structural heart disease, or autonomic sensitivity.

Case Report: We report a case of a 36-year-old male who presented to the emergency department with abdominal symptoms and was incidentally found to have Wolff-Parkinson-White pattern following administration of intramuscular dicyclomine.

Conclusion: This case highlights the potential importance of cardiac monitoring, even in patients with non-cardiac chief complaints, particularly when anticholinergic agents are administered.

Introduction: Penetrating neck injury is rare in children, but it can have devastating consequences due to the vital structures in the neck. Having a high index of suspicion is crucial for detection and management of such injuries. Superficial-appearing wounds can mask underlying injury. In this case report, we present a case of penetrating neck injury in a patient who presented with what appeared to be a simple laceration to his neck.

Case Report: A three-year-old male presented with a laceration to his neck caused by a piece of shattered glass. On evaluation, he had normal vital signs and no hard or soft signs of penetrating neck injury. During bedside examination, a track was found extending beyond the platysma. The patient developed hoarseness in his voice, prompting computed tomography (CT). The CT revealed three foreign bodies lodged between the right common carotid artery and tracheal wall, abutting the wall. The patient underwent open exploration with removal of the foreign bodies. No significant damage to vital structures was found.

Conclusion: While rare, this case exemplifies the importance of having a high index of suspicion for penetrating neck injury in children presenting with even superficial-appearing neck lacerations, especially if caused by glass. Because the neck is typically uncovered, it carries an increased risk for foreign body penetration. Glass is generally radiopaque, but detection may be limited by the surrounding tissue, fragment size, and glass composition. Patients demonstrating hard signs of penetrating neck injury require operative management, while those with soft signs should undergo assessment with CT. 

Introduction: Retrograde intubation is a seldom used but valuable technique in managing difficult airways, especially in resource‑limited settings when advanced equipment is unavailable or ineffective.

Case Report: We report the case of a 64‑year‑old male with advanced ankylosing spondylitis and severe cervicothoracolumbar kyphosis who presented with altered mental status and respiratory distress. Extreme fixed cervical flexion, markedly restricted mouth opening, and an inaccessible anterior neck rendered direct laryngoscopy, video laryngoscopy, fiberoptic intubation, and surgical airway approaches unfeasible. Retrograde nasotracheal intubation was successfully performed, resulting in airway stabilization and hemodynamic improvement.

Conclusion: This case highlights retrograde intubation as a lifesaving low‑technology technique in complex anatomic and physiologic airways, demonstrating its continued relevance under the updated Difficult Airway Society 2025 guidelines.

Introduction: Kounis syndrome describes anaphylaxis-induced coronary vasospasm and is often misdiagnosed as acute coronary syndrome. We report a similar phenomenon of cerebral vasospasm following anaphylaxis, a rare and under-recognized mimic of stroke.

Case Report: A previously healthy 45-year-old gentleman developed sudden right-sided hemiparesis and dysarthria while working outdoors, accompanied by generalized pruritus, rash, presyncope, dyspnea, palpitation, and abdominal pain. He received prompt intramuscular epinephrine and other anti-inflammatory agents, resulting in rapid symptom resolution and complete recovery in the emergency department. Computed tomography of the brain and other studies were unremarkable. This case underscores a rare neurological manifestation of anaphylaxis. 

Conclusion: Cerebral vasospasm is an unusual sequela of anaphylaxis that may lead to a diagnostic dilemma. Prompt administration of epinephrine is crucial for recovery. This case highlights the association between hypersensitivity reactions and cerebrovascular events, emphasizing the need for early recognition and timely intervention. 

Introduction: Spinal cord infarction is a rare but critical cause of acute neuromuscular paralysis, accounting for approximately 1.2% of all strokes. Timely diagnosis is essential but challenging due to its clinical overlap with more common etiologies. Failure to promptly identify spinal cord infarction can result in irreversible neurological deficits and missed opportunities for secondary prevention. 

Case Report: A 66-year-old female presented to the emergency department with progressive bilateral limb weakness, numbness, and urinary incontinence. The examination revealed symmetric weakness, impaired coordination, and diffuse sensory loss. She was admitted and empirically treated with intravenous immunoglobulin for suspected atypical acute inflammatory demyelinating polyneuropathy. Despite mild improvement, worsening hyperreflexia and spasticity raised concern for a central process. Cervical magnetic resonance imaging revealed extensive cord edema, and further workup identified a cerebellar infarct and a patent foramen ovale, suggesting an embolic source. Evolving myelomalacia on follow-up imaging confirmed a diagnosis of anterior spinal artery infarction. The patient was started on secondary stroke prevention and discharged to rehabilitation with persistent motor and autonomic deficits. 

Conclusion: Spinal cord infarction may initially resemble peripheral neuropathy, leading to misdiagnosis and delayed treatment. This case highlights the importance of repeat imaging and reconsideration of central causes in atypical or evolving presentations. Emergency physicians should maintain a high index of suspicion for spinal cord infarction in cases of rapidly progressive paralysis. Early imaging and multidisciplinary evaluation are critical to minimize long-term morbidity.

Introduction: Nontraumatic subarachnoid hemorrhage (SAH) is a life-threatening neurological emergency, accounting for 5-10% of strokes. While most cases result from aneurysm rupture, perimesencephalic nonaneurysmal SAH is a distinct subtype characterized by blood localized to the midbrain cisterns and a venous pathophysiology. Perimesencephalic nonaneurysmal SAH is often associated with activities increasing intracranial venous pressure. Reports linking it to low-impact exercise such as yoga are rare.

Case Report: A 45-year-old female with no significant medical history presented with acute onset of severe headache and subjective unilateral hearing loss. Symptoms began immediately after a sudden, startled hyperextension movement during a yoga session. Noncontrast computed tomography of the brain revealed hemorrhage localized to the perimesencephalic and basal cisterns (modified Fisher Grade 4). Magnetic resonance imaging confirmed hemorrhage extension into the fourth ventricle and communicating hydrocephalus. Comprehensive workup, including echocardiography and serial digital subtraction angiography, ruled out aneurysm, arteriovenous malformation, or cardiac source.

Conclusion: The patient was diagnosed with perimesencephalic nonaneurysmal subarachnoid hemorrhage, likely precipitated by an abrupt Valsalva-like maneuver during yoga. She was managed conservatively with strict blood pressure control, chemical thromboprophylaxis, and vasospasm prophylaxis, achieving a full recovery. This case highlights that neurovascular events can occur during low-impact activities in susceptible individuals. Recognition of a distinct radiological pattern of perimesencephalic nonaneurysmal—confirmed by negative serial angiography—is vital, as it carries a significantly more favorable prognosis than aneurysmal SAH, allowing for conservative management and reassurance.

Introduction: Herpes zoster ophthalmicus, a reactivation of varicella-zoster virus involving the ophthalmic branch of the trigeminal nerve, is a known but under-recognized risk factor for acute cerebrovascular and cardiovascular events. 

Case Report: We report the case of an 84-year-old female with herpes zoster ophthalmicus who suffered a fatal ischemic stroke and bilateral submassive pulmonary emboli within days of diagnosis. Despite early identification and appropriate antiviral treatment, the patient experienced rapid neurological decline and ultimately succumbed to complications. 

Conclusion: This case underscores the critical association between herpes zoster ophthalmicus and increased risk of stroke and myocardial infarction, as supported by growing epidemiologic evidence. Physicians should be aware of these severe complications, consider close monitoring and cardiovascular risk stratification in patients with herpes zoster ophthalmicus, and they should provide patients with clear return precautions for symptoms suggestive of stroke or embolic disease. Further research is needed to determine preventative strategies beyond antiviral therapy for high-risk patients.

Introduction: Subungual myiasis is an infection under the fingernail or toenail caused by an infestation of fly larvae. It is rarely reported internationally, with only one previously reported case in the United States.

Case Report: An 80-year-old female with a history of polyneuropathy, peripheral artery disease, peripheral venous insufficiency, and chronic bilateral lower extremity edema presented to the emergency department (ED) after staff at her skilled nursing facility noted what appeared to be several whitish-colored maggots moving under the nail of the patient’s left great toe. Thorough examination was consistent with subungual myiasis with associated onycholysis without evidence of associated cellulitis or soft tissue infection. Manual extraction of six larvae was performed, and the patient’s foot was soaked in chlorhexidine. She was discharged back to her facility with a plan for daily chlorhexidine soaks and prompt follow-up with a podiatrist. To date she has not presented to the ED since with the same issue.

Conclusion: Due to its extraordinarily rare incidence, there is little consensus regarding the treatment of subungual myiasis beyond the manual extraction of larvae. Oral ivermectin has been reported as an additional treatment option for myiasis, but research is limited. Antibiotics are generally only recommended when there is evidence of associated bacterial infection. This case should raise awareness for emergency physicians regarding the recognition and management of subungual myiasis.

Introduction: Duloxetine, a serotonin-norepinephrine reuptake inhibitor, has been associated with extrapyramidal symptoms and tardive syndromes; however, such adverse reactions are rare and remain sparsely documented, particularly in the setting of non-psychiatric use.

Case Report: A young, healthy, active-duty military service member developed acute extrapyramidal symptoms—restlessness, dystonic movements, and acute dystonia—shortly after initiating duloxetine for postsurgical neuropathic pain. 

Conclusion: This case highlights the need for vigilance regarding movement disorders in patients prescribed duloxetine, even in the absence of psychiatric comorbidity or antipsychotic exposure.

Introduction: Tetanus is a rare but life-threatening disease caused by Clostridium tetani, characterized by generalized muscle rigidity, autonomic instability, and respiratory compromise. 

Case Report: We present a case of a 65-year-old male poultry hobbyist with type two diabetes who developed severe tetanus following a rooster-peck injury to his finger. The patient presented with progressive trismus and respiratory distress necessitating fiberoptic nasotracheal intubation and subsequent tracheostomy. Despite appropriate antimicrobial therapy, immunoglobulin administration, and sedation, the patient continued to exhibit spasms when sedation was reduced. 

Conclusion: This case highlights the ongoing risk of tetanus in under-immunized agricultural populations, the challenges of airway management in severe trismus, and the importance of maintaining vaccination awareness even in developed healthcare settings.

Introduction: The “lucky nut” is the seed of the yellow oleander plant, often sold as a medicinal supplement in unregulated markets and known to contain cardiac glycosides, which may cause life- threatening bradycardias and Digoxin-like toxicity upon ingestion. Diagnosis is typically clinical, with treatment including Digoxin immune Fab with supportive intensive cardiac care. 

Case Report: A 70-year-old male presented to the emergency department after ingesting one-fourth of a Peruvian nut he found at a local market to reduce his nocturnal polyuria. The patient brought a part of the Peruvian nut with him, which was identified as a seed of the yellow oleander. His clinical presentation was consistent with a digoxin-like toxicity, requiring multiple vials of Digoxin immune Fab and admission to the cardiac intensive care unit. 

Conclusion: Yellow oleander can cause a cardiac glycoside-related cardiotoxicity similar to a digoxin-like toxicity. Digoxin-like toxicity should be considered in the bradycardic patient with a recent ingestion of a plant or seed. It is important to obtain a thorough history including medication reconciliation and supplement use. Despite well-documented dangers, yellow oleander continues to appear as an unregulated ingredient or contaminant in dietary supplements. This case highlights the severity of oleander toxicity, the challenge of managing digoxin-like cardiac glycoside poisoning, and the public health risk posed by unintentional ingestion of supplements containing yellow oleander.

Introduction: Magnet ingestions are a growing pediatric emergency due to the use of widely available stronger magnets in toys. A legislative ban briefly reduced injuries, but cases rose after its reversal in federal court. Magnet ingestions are resulting in increasing morbidity and mortality, specifically due to bowel obstruction and perforation. 

Case Report: We present a complex case involving a child with global developmental delay presenting to the emergency department for evaluation of abdominal pain. While the initial evaluation focused on working up appendicitis, which he was found to have, he was also found to have ingested multiple magnets causing small bowel obstruction and perforation. 

Conclusion: This case highlights the need for emergency physicians to maintain a high level of suspicion when evaluating pediatric patients with abdominal pain, especially those with developmental delay. It also encourages parental education and further advocacy to help stem the increase in pediatric morbidity and mortality resulting from the ingestion of magnets.

Introduction: Acquired idiopathic laryngomalacia causing dynamic airway collapse is rare in adolescents and may be overlooked because it mimics more common causes of acute dyspnoea and stridor in the emergency department (ED). Airway point-of-care ultrasound (POCUS) provides a rapid, non-invasive means to visualize dynamic supraglottic obstruction when laryngoscopy is not immediately feasible or tolerated.​

Case Report: A 13-year-old boy presented with sudden-onset respiratory distress and dyspnoea that worsened on lying flat and improved when sitting upright, without history of fever, trauma, allergy, or foreign body aspiration, and with similar prior self-limiting episodes. He was anxious with nasal flaring, subcostal retractions, tachypnoea, tachycardia, distended neck veins, and a squeaky tracheal inspiratory sound, yet he maintained normal oxygen saturation with equal air entry on auscultation. Airway POCUS showed abnormal downward displacement of the epiglottis with every distressful inspiration, indicating dynamic airway collapse, and non-contrast computed tomography of the neck demonstrated a heart-shaped, mid-epiglottis deformity consistent with acquired idiopathic laryngomalacia. The patient was given supportive treatment to reduce mucosal oedema, resulting in gradual symptom resolution, and after two days of observation and otorhinolaryngology evaluation he was discharged in stable condition.​

Conclusion: Acquired idiopathic laryngomalacia should be considered in adolescents with unexplained positional respiratory distress and discordant findings of significant work of breathing but preserved oxygenation. Airway point-of-care ultrasound can delineate real-time dynamic laryngeal abnormalities at the bedside, thereby facilitating early diagnosis and appropriate management of dynamic airway collapse in the emergency department.

Introduction: Entrectinib is a kinase inhibitor used in ROS1-positive non-small cell lung carcinoma. Cardiovascular toxicity is rare, with only one prior report of myocarditis related to entrectinib use. The triangular QRS-ST-T waveform electrocardiographic pattern is a ST-elevated myocardial infarction equivalent and is rarely associated with myocarditis.

Case Report: A 42-year-old male with metastatic non-small cell lung carcinoma presented with presyncope, palpitations, and dyspnea three days after initiating entrectinib. Electrocardiograph (ECG) revealed a “shark-fin” T-wave morphology with diffuse ST elevation, QTc prolongation, and elevated troponin. ST-elevated myocardial infarction protocol was initiated with tenecteplase, heparin, clopidogrel, and aspirin. Left heart catheterization was normal. The ECG showed an ejection fraction of 20–25% with global hypokinesis. Myocarditis with heart failure associated with entrectinib use was suspected. Cardiac magnetic resonance imaging confirmed myopericarditis with subsequent recovery of ejection fraction to 57%. The patient was discharged after five days with complete recovery.

Conclusion: This is the second reported case of myocarditis associated with entrectinib use and the second documented case of myocarditis presenting with a T-wave ECG pattern. Clinicians should be aware that entrectinib is associated with early-onset myocarditis and that the T-wave pattern, while strongly correlated to occlusive myocardial infarction, may rarely occur in myocarditis. Prompt recognition is critical to avoid mismanagement.

Introduction: Blunt thoracic aortic injury is a rare but potentially fatal consequence of motor vehicle collisions. While commonly associated with hemodynamic instability, some cases present with normal vital signs, delaying diagnosis and treatment. We present the case of a 42-year-old unrestrained backseat passenger who sustained a blunt thoracic aortic injury following a motor vehicle collision and underwent emergent endovascular repair. This case emphasizes the critical role of early imaging and multidisciplinary coordination in the management of high-risk trauma patients.

Case Report: A 42-year-old female presented to the emergency department (ED) following a high-risk motor vehicle collision. She was an unbelted passenger in a vehicle traveling at approximately 35 miles per hour that collided with a telephone pole. The patient was unconscious at the scene but regained consciousness en route. Upon arrival at the ED she was alert, oriented, and hemodynamically stable. Her vital signs were as follows: blood pressure, 107/58 millimeters of mercury; heart rate, 62 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 100% on room air. Physical examination revealed anterior chest wall tenderness but no signs of respiratory distress. Imaging revealed a high-grade blunt thoracic aortic injury with a left-sided hemothorax. The patient underwent emergent thoracic endovascular aortic repair and remained hemodynamically stable throughout hospitalization. 

Conclusion: Blunt thoracic aortic injury can present with hemodynamic stability despite its life-threatening nature. This case highlights the necessity of early imaging and multidisciplinary coordination in optimizing outcomes for high-risk trauma patients.

Introduction: Adult ileocolic intussusception is rare and typically associated with a pathological lead point. Diagnosis can be challenging in the emergency department (ED), particularly when initial vital signs and laboratory studies are reassuring. Point-of-care ultrasound (POCUS) may allow for earlier recognition and expedited management.

Case Report: A woman with ulcerative colitis presented to the ED with abrupt, severe, waxing-and-waning abdominal pain. Initial vital signs and lab studies were normal. Bedside POCUS performed at the point of maximal tenderness revealed a target sign in the right mid-abdomen, prompting concern for intussusception. This finding was used to advocate for urgent surgical evaluation and expedited computed tomography of the abdomen and pelvis, which confirmed ileocolic intussusception with early distal small-bowel obstruction and no identifiable mass. Despite reassuring objective data, the patient’s persistent severe pain and serial examinations raised concern for evolving ischemia. Following continued emergency physician advocacy, the patient was admitted for operative management. Diagnostic laparoscopy was converted to open laparotomy, during which manual reduction and right hemicolectomy were performed for an ischemic, near-perforated colon, followed by creation of an end ileostomy and mucus fistula. The patient recovered well postoperatively. She had been taking curcumin–qing dai (CurQD) for ulcerative colitis, a supplement with rarely reported associations with intussusception.

Conclusion: This case highlights the value of emergency POCUS in identifying high-risk abdominal pathology, the importance of early surgical involvement despite reassuring initial tests, and a potential supplement-associated risk factor in patients with inflammatory bowel disease.

Introduction: Hepatopulmonary syndrome is a rare but serious cause of pediatric hypoxemia.

Case Report: A 10-year-old obese male with obstructive sleep apnea and asthma presented to the emergency department with low baseline oxygen saturations and exertional hypoxia, despite normal physical exam and outpatient pulmonary function testing. Workup revealed liver cirrhosis, hepatosplenomegaly, gastroesophageal varices, and an elevated alveolar-arterial gradient, raising concern for hepatopulmonary syndrome. He was diagnosed with this disease at a tertiary hepatology center and underwent liver transplantation.

Conclusion: Emergency physicians should consider hepatopulmonary syndrome in children with unexplained hypoxia and liver disease, especially in a child with a normal lung exam and no bronchodilator response.

Introduction: Tension hydrocele is a rare but serious complication that can threaten testicular viability. This case report describes how testicular point-of-care ultrasound (POCUS) enabled timely recognition of a large hydrocele compromising testicular perfusion and guided management.
Case Report: A 57-year-old male presented to the emergency department (ED) with painful right scrotal swelling. Testicular POCUS demonstrated a large hydrocele with reduced intratesticular blood flow. A scrotal centesis performed by the emergency physician led to symptom resolution and restoration of normal flow.

Conclusion: Testicular POCUS can rapidly identify impaired perfusion and guide scrotal centesis in the ED, a temporary yet potentially testis-saving intervention.

Introduction: Hernias are a common presenting complaint in the emergency department. If they are not promptly identified and reduced, patients may need urgent surgery, which entails an increase in morbidity and mortality. The diagnosis and reduction of hernias can be challenging due to a patient’s large body habitus. In this case, we demonstrate the utility of using point-of-care ultrasound (POCUS) to detect an abdominal wall defect and provide real-time guidance to reduce a hernia and avoid surgery in a patient who was a poor surgical candidate. 

Case Report: A 48-year-old morbidly obese male with multiple comorbidities presented with abdominal pain at the location of a known ventral hernia. Computed tomography (CT) of the abdomen confirmed a ventral hernia; however, three different physicians attempted reduction and were unsuccessful. We then used POCUS to identify the ventral hernia and the abdominal wall defect and to guide the subsequent reduction efforts. Guidance of the reduction started with locating the abdominal wall defect, which allowed for gentle, steady pressure to be applied at the site of the defect and visualization of the successful reduction in real time. This led to immediate improvement in the patient’s symptoms. 

Conclusion: The success of this reduction highlights how POCUS can be used to improve the success rate for manual ventral hernia reduction without the need for confirmatory CT. It can also help to avoid increased morbidity and mortality from unplanned, unoptimized surgical hernia repair in high-risk patients.

Introduction: High-risk pulmonary embolism (PE) is an uncommon but potentially reversible cause of out-of-hospital cardiac arrest, frequently presenting as pulseless electrical activity (PEA). Early identification and multidisciplinary intervention are critical, yet confirmatory imaging is often delayed. Current guidelines recommend consideration of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in specialized centers when high-risk PE is suspected and the patient presents with cardiogenic shock or cardiac arrest. 

Case Report: We describe a 50-year-old woman with a remote history of deep vein thrombosis who arrested after acute-onset dyspnea. Emergency medical services documented PEA arrest and initiated advanced cardiac life support. On arrival to the emergency department (ED), the patient remained in PEA arrest without cardiac motion on point-of-care ultrasound. Pulmonary embolism was strongly suspected but could not be confirmed, and VA-ECMO was initiated within 42 minutes of arrest. Pulmonary angiography confirmed massive bilateral PE, followed by mechanical thrombectomy using a catheter-directed device. Extracorporeal membrane oxygenation support continued for four days before successful decannulation, and the patient was discharged on hospital day 17 to a rehabilitation facility with a Cerebral Performance Category score 1, indicating excellent neurological function. 

Conclusion: This case illustrates the potential for favorable neurologic and functional outcomes in cardiac arrest associated with high-risk PE when VA-ECMO is implemented early as a bridge to definitive therapy. In resource-rich settings, rapid ED-based activation of extracorporeal cardiopulmonary resuscitation protocols and access to catheter-directed thrombectomy may represent an optimal strategy for improving survival and neurologic recovery in patients with PEA arrest that may be related to high-risk PE.

Introduction: Aortoesophageal fistula is a rare but life-threatening hemorrhagic complication of thoracic endovascular aortic repair. Without intervention, mortality approaches 100%. Our case highlights the utility of using an esophageal-gastric balloon tamponade device for hemostasis.

Case Report: We report the case of a 70-year-old man who presented after a sentinel episode of hematemesis six days after thoracic endovascular aortic repair. Shortly after admission, the patient developed massive hematemesis and hemorrhagic shock from an aortoesophageal fistula. Hemorrhage was temporarily controlled via bedside placement of a Minnesota tube, a type of balloon tamponade device, by two emergency medicine and critical care physicians, allowing for hemostasis, resuscitation, and definitive diagnosis with esophagogastroduodenoscopy. The device successfully bridged the patient to the operating room, where he underwent definitive endovascular control of the hemorrhage and repair of the aortoesophageal fistula.

Conclusion: Our case highlights the utility and pragmatism of using a balloon tamponade device for massive hematemesis in nonvariceal hemorrhage. It also supports the placement of the device for non-variceal hemorrhage by nonspecialists, including critical care and emergency physicians.

Introduction: Lidocaine toxicity is a rare but potentially dangerous consequence of a frequently used medication. Most commonly, it has generalized neurologic and cardiac effects. Discontinuation of lidocaine is sufficient with less severe symptoms. With more severe symptoms, such as seizures and arrhythmia, intravenous (IV) lipid emulsion therapy can be used. To date, lidocaine toxicity presenting as focal neurologic deficits has rarely been documented in the literature. In the case reported here, the patient was receiving lidocaine injections when she developed palpitations and left arm and facial weakness and numbness, which resolved after IV lipid emulsion therapy. 

Case Report: A 52-year-old female with a past medical history of migraines, cholecystectomy, nephrolithiasis, and hypothyroidism presented to the emergency department (ED) via ambulance from her dental office with acute neurologic symptoms. While receiving an injection of lidocaine intraorally at the dental office, she experienced palpitations and left arm and left facial weakness with numbness. She continued to have symptoms upon arrival to the ED. Given concern for acute stroke, she underwent imaging, which was negative for large vessel occlusions or hemorrhage. She was given IV lipid emulsion therapy for suspected lidocaine toxicity with resolution of symptoms. She was cleared by oral and maxillofacial surgery and discharged with outpatient follow-up.

Conclusion: We identified a patient who developed neurologic symptoms during lidocaine administration, with no radiographic evidence for stroke. Given the timing of symptoms and lidocaine administration, we administered IV lipid emulsion therapy with resolution of the patient’s symptoms. Thus, we strongly suspect our patient had lidocaine toxicity with focal neurologic findings.

Introduction: Exfoliative dermatitis, also known as erythroderma, represents an infrequent clinical presentation in emergency departments (ED) and often contributes to considerable diagnostic uncertainty. The differential diagnosis is broad, and the condition may arise from a wide variety of etiologies. We report a case of severe exfoliative dermatitis characterized by gradual progression and resistance to multiple therapeutic interventions over several weeks, ultimately resulting in significant systemic complications and marked hematological abnormalities.

Case Report: A 57-year-old man presented to the ED with severe pain, pruritus, and widespread skin peeling involving more than 90% of his body surface area. The patient developed a rash following a trip to Korea about six months prior to presentation, which progressively worsened despite multiple prior diagnoses and treatments including corticosteroids, immunosuppressive therapy, and biologic agents. On presentation, the patient met systemic inflammatory response syndrome criteria and was found to have profound leukopenia, thrombocytopenia, hypoalbuminemia, and Staphylococcus aureus bacteremia. Subsequent evaluation confirmed crusted scabies complicated by secondary bacterial infection. 

Conclusion: The case demonstrates the complexity of assessing generalized rash in emergency settings and underscores the importance of a thorough history and physical, as well as maintaining a broad differential diagnosis. It shows both the physical and psychological effects of diagnostic uncertainty on treatment adherence, emphasizes early recognition, and notes systemic complications arising from multifactorial etiologies.

Introduction: The use of antipsychotic drugs can prolong the corrected QT (QTc) interval of the electrocardiogram and cause a life-threatening ventricular arrhythmia. There is no consensus as to what is considered normal or what cutoff indicates QTc prolongation. However, recent literature has described the biological variation of the QTc interval from healthy subjects, with researchers concluding that the best approach at establishing a normal range is to determine an individual baseline interval during health. 

Case Report: A baseline QTc interval (460 milliseconds) had been determined for a 42-year-old female with a history of schizophrenia and depression who was prescribed antipsychotic drugs including escitalopram, olanzapine, haloperidol, clonazepam and divalproex over the course of four years. Over that time frame, she was admitted on 20 occasions with chest pain, but her QTc interval was at or above her baseline level. Acute coronary syndrome was ruled out for each episode. Her medication history was not altered or discontinued until her QTc was greatly prolonged at 530 milliseconds several years later. Fortunately, she did not suffer torsades de pointes.

Conclusion: This case illustrates how results from biological variation studies and a personalized reference level can be helpful to alert physicians earlier of the presence of a potentially toxic condition.

Introduction: Acute aortic dissection is a life-threatening emergency with a wide spectrum of clinical presentations. Neurological deficits as the initial manifestation of aortic dissection are uncommon and may result in delayed or missed diagnosis. This case describes aortic dissection presenting primarily as acute paraplegia without persistent chest pain or other classic features.

Case Report: We report a 52-year-old male who presented with sudden-onset paraplegia. Neurological examination revealed flaccid paralysis of both lower limbs, with loss of pain and temperature sensation below the first lumbar dermatome and preserved dorsal column modalities. The patient was hypertensive on presentation. A clinical diagnosis of anterior spinal artery syndrome was made. Contrast-enhanced computed tomography of the chest and abdomen demonstrated a Stanford type A aortic dissection. The patient was counseled regarding the need for urgent surgical repair but declined operative intervention and opted for conservative management. His hospital course was complicated by progressive renal failure, and he subsequently succumbed to it.

Conclusion: This case underscores the importance of considering aortic dissection in patients presenting with acute, nontraumatic paraplegia, even in the absence of persistent chest pain or other classic features. [Clin Pract Cases Emerg Med. 2026;X(X):XXX–XXX.]

Keywords: aortic dissection; acute paraplegia; anterior spinal artery syndrome; spinal cord ischemia; case report.

Introduction: ST-elevation myocardial infarctions (STEMI) represent complete occlusion of a coronary artery. An electrocardiogram (ECG) is a method of diagnosis; however, on rare occasions clues of myocardial infarction are first noted on imaging. This is a case of myocardial infarction first noted on computed tomography (CT).

Case Report: A 62-year-old man was brought to the emergency department after being found unresponsive with multiple burns. An ECG performed on arrival did not show changes consistent with myocardial ischemia. Due to reported trauma, a CT incidentally found a heterogeneous low-attenuation area in the posterior wall of the left ventricle of the heart. A repeat ECG subsequently showed an inferior STEMI. 

Conclusion: Computed tomography of the chest obtained in the evaluation of trauma may demonstrate evidence of myocardial ischemia. This case highlights the ability of CT to detect cardiac hypoperfusion. The role of CT in myocardial infarction diagnosis remains limited; however, given that the timing of contrast injection depends on the clinical question, it may not reliably assess the hypoperfusion.

Introduction: Purulent pericarditis is a rare subset of pericarditis that can result in serious morbidity and mortality. Presenting symptoms are often nonspecific, and a high index of suspicion must be maintained to reach an early diagnosis. Point-of-care ultrasound can be pivotal in the emergency department evaluation of purulent pericarditis, providing key information including characteristics of the effusion and a sonographic assessment for signs of tamponade. We present a case of purulent pericarditis first detected using point-of-care ultrasound in the emergency department. 

Case Report: A 55-year-old male presented with chest pain and dyspnea and was found to have cardiac tamponade secondary to purulent pericarditis.

Conclusion: Cases of purulent pericarditis are rare but should be recognized by emergency clinicians. Point-of-care ultrasound is a powerful tool to assist in early diagnosis of pericardial effusion, allowing assessment for signs of cardiac tamponade. Early management with broad spectrum antibiotics and cardiology consultation are mainstays of treatment and can significantly improve outcomes.

Introduction: Natural supplements are readily available without a prescription and are not regulated by the United States Food and Drug Administration. The popularity of berberine, a bioactive compound used for centuries in traditional Chinese medicine, has surged due to its proposed benefits in glycemic control and cardiovascular health. However, use of berberine may lead to possible negative electrophysiologic changes.

Case Report: A 92-year-old male presented to the emergency department (ED) with chief complaints of tremors, urinary incontinence, and brief syncopal episodes that began approximately two weeks after starting berberine. In the ED he had multiple episodes of polymorphic ventricular tachycardia with pulselessness requiring immediate cardioversion, with a rapid return of spontaneous circulation between episodes. Amiodarone was started; however, despite this, he continued to have persistent episodes. Finally, the episodes resolved after starting lidocaine and isoproterenol in the intensive care unit. The patient’s workup was notable for heart rate-corrected QT interval (QTc) prolongation (QTc 616 milliseconds (ms) [male reference range, QTc < 430 ms]) confirming the polymorphic ventricular tachycardia as torsades de pointes. His cardiac evaluation was otherwise normal, including a normal ejection fraction on a transthoracic echocardiogram. Withholding berberine and supportive management resulted in an improved QTc. On hospital day 3, the QTc was 454 ms. The patient had a short inpatient admission and was discharged without any further episodes.

Conclusion: Berberine has numerous effects and is purported to have beneficial effects and cardioprotective properties. Due to induced bradycardia and QT prolongation, patients who take berberine can be vulnerable to life-threatening arrhythmias, such as the R-on-T phenomenon in our patient’s case. Additional research on berberine is needed to better inform clinician–patient discussions about its use.

Introduction: The placement of central venous catheters (CVC) is a common procedure for the administration of chemotherapy. Adverse events include malposition or displacement; there are limited reports of misplaced implanted CVCs.

Case Report: A 59-year-old female with a history of recently diagnosed metastatic small cell lung cancer, hypertension, former tobacco use of over 60 pack-years, and chronic obstructive pulmonary disease without chronic hypoxemic respiratory failure presented to the emergency department following the first outpatient infusion of chemotherapy. She developed acute onset dyspnea, moderate respiratory distress, and hypoxemia. She was found to have a malpositioned subclavian implanted (ie, “port”) CVC that was placed under fluoroscopy the week prior with placement confirmed by chest radiograph. The evaluation revealed a large right pleural effusion secondary to unintentional intrapleural infusion of chemotherapy. The patient was transferred to a tertiary-care center with successful clinical improvement after drainage of the effusion via tube thoracostomy. 

Conclusion: We present an uncommon diagnosis of a chemothorax from a malpositioned central venous catheter in the thorax, despite a radiograph suggesting correct placement, and infusion of chemotherapy causing a common complaint of shortness of breath. This case highlights the limitations of radiographic confirmation of CVCs and a resultant complication from malpositioning.

Introduction: Infective endocarditis (IE) is associated with high mortality (30%). Patients with structural cardiac disease or implanted hardware have higher risk for IE (23-47%). Diagnosis per the 2023 Duke–International Society for Cardiovascular Infectious Diseases criteria is by pathological confirmation or the major/minor criteria. Major criteria include ≥ 2 positive blood culture sets, echocardiography or computed tomography vegetation visualization, and surgical visualization. Septic emboli symptoms (which complicate 25% of IE cases) include neurological deficits or shortness of breath. Early intravenous antimicrobial therapy within one hour for patients who meet sepsis criteria is recommended per Infectious Diseases Society of America guidelines.

Case report: A middle-aged male with recent IE and aortic valve prosthesis presented to the emergency department with altered mental status and hypoglycemia. He had right basilar lung rales but no heart murmur, leg swelling, or jugular venous distension. He met sepsis criteria with leukocytosis and hypothermia. Computed tomography head was performed due to his altered mental status and revealed a right parietal-occipital hypodense lesion concerning for an abscess with edema and mass effect. Given his history of IE and ill appearance, three blood culture sets were drawn and intravenous antibiotics initiated. The patient was admitted to the hospital with magnetic resonance imaging confirming brain abscess; and neurosurgery performed a craniotomy with brain abscess evacuation. Intravenous antibiotics were continued for four weeks for septic brain emboli from recent IE.

Conclusion: Clinicians should keep a broad differential for altered mental status patients. Sepsis patients should have antimicrobials initiated within one hour. Expedited diagnosis with three sets of blood cultures, echocardiography, and surgical consult should be completed in patients with suspected infective endocarditis for improved patient outcomes. Finally, clinicians should evaluate for septic emboli symptoms such as neurological deficits or respiratory symptoms.

Introduction: Duloxetine, a serotonin-norepinephrine reuptake inhibitor, is commonly prescribed for depression, anxiety, and neuropathic pain. Although rare, duloxetine has been associated with hepatotoxicity. 

Case Report: We present the case of a 61-year-old male with multiple comorbidities who developed significant transaminitis two months after initiation of duloxetine therapy.

Conclusion: Emergency physicians should be cognizant of duloxetine-induced liver injury, particularly in patients with increased risk factors who present with unexplained liver injury.

Introduction: Oropharyngeal myxedema is a rare presenting symptom of decompensated hypothyroidism that can mimic more common causes of sore throat.

Case Report: We describe a case of an older woman who presented with throat pain and dysphagia, found to have soft palate edema on exam and imaging. Laboratory testing confirmed severe hypothyroidism, and her symptoms eventually resolved with thyroid hormone replacement therapy.

Conclusion: This case highlights a rare and under-recognized presentation of a common endocrine disorder. Consider myxedema from severe hypothyroidism in patients with subacute oropharyngeal pain and swelling. Without early recognition and treatment, the patient is at risk for two life-threatening conditions: airway compromise from soft palate myxedema and progression of hypothyroidism to myxedema coma.