Clinical Practice and Cases in Emergency Medicine

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When a patient with acute blindness presents to the emergency department (ED), the evaluation typically suggests one of the “can’t miss” diagnoses ingrained in emergency physicians during training. How does the differential change when the patient’s presentation does not neatly reveal an expected pathology? A 59-year-old woman presented to the ED with acute binocular blindness in the setting of three days of a flu-like illness. This case offers a practical approach to opening the lens on the presentation of acute blindness. 

Introduction: Shoulder dislocations comprise approximately half of all major joint dislocations evaluated in the emergency department. Despite often being considered a simple injury, diagnosing a dislocation can be difficult, especially when accompanied by a fracture associated with unusual mechanism, or when the physical examination is limited. Missed and delayed diagnoses can result in poor patient outcomes and legal risks for clinicians, necessitating a high level of vigilance. 

Case Series: We review three medical malpractice cases centered on the failure to recognize shoulder dislocations. Key issues included missed diagnosis, limited physical examination documentation, and inadequate discharge instructions. 

Conclusion: Shoulder dislocations can be challenging to identify, and missed diagnoses give rise to subsequent clinical and legal risks. Emergency physicians must maintain a high index of suspicion for this injury, recognize the limitations of standard imaging, and thoroughly document clinical decision-making during both initial evaluation and patient discharge.

Introduction: Anaphylaxis is a life-threatening emergency that can involve significant cardiovascular manifestations. Transient electrocardiographic (ECG) changes during anaphylaxis and following epinephrine administration may closely mimic acute coronary syndrome, creating a diagnostic dilemma in the emergency department (ED). Failure to recognize these reversible patterns can result in delayed anaphylaxis treatment or unnecessary activation of invasive cardiac pathways.

Case Series: We report a case series of three adult patients presenting to the ED with anaphylaxis who developed alarming ECG changes, including ST-segment elevation, ST-segment depression, and hyperacute T waves. One patient demonstrated transient ECG changes temporally related to intramuscular epinephrine administration, while two patients exhibited features suggestive of hypersensitivity-associated coronary vasospasm or thrombosis manifesting as ECG changes. In all cases, serial ECGs, high-sensitivity cardiac troponin testing, and focused echocardiography revealed resolution of ECG abnormalities without dynamic biomarker elevation or regional wall motion abnormalities. All patients improved with prompt anaphylaxis-directed therapy and were managed conservatively without coronary intervention.

Conclusion: Transient ECG changes during anaphylaxis and after epinephrine administration can closely resemble acute coronary syndrome but may resolve completely with appropriate allergy-directed treatment. Serial ECG assessment, cardiac biomarkers, and focused echocardiography are essential tools for emergency physicians to differentiate transient allergic or catecholamine-mediated effects from true myocardial ischemia. Recognition of these patterns allows timely treatment of anaphylaxis while avoiding unnecessary invasive cardiac interventions.

Introduction: Rib fractures in older adults carry high morbidity and mortality, leading many hospitals to admit patients based on age alone. The Rib Injury Guidelines (RIG) offer a triage system; under RIG 2, patients are typically admitted to inpatient care. 

Case Series: This study evaluated whether older adults categorized as RIG 2 solely due to age could be safely managed in an emergency department observation unit. We conducted a 14-month case series at an academic trauma center, reviewing 23 patients 60 years and older with rib fractures. Twenty met RIG 2 criteria, including those later admitted for nontrauma reasons. The mean observation stay was 26.6 hours, and the total hospital stay was 1.8 days. Seventeen patients (85%) were discharged directly from observation, three (15%) were admitted to medicine, and none returned within 72 hours. 

Conclusion: Carefully selected older adults with rib fractures may be safely managed in observation units, optimizing resource utilization and patient safety.

Introduction: Variceal hemorrhage is a life-threatening complication of portal hypertension that requires rapid hemorrhage control. Gastroesophageal balloon tamponade devices are effective temporizing measures when endoscopic or definitive therapies are delayed or unsuccessful, but placement can be technically challenging during active bleeding. A bougie-assisted technique has been proposed to improve ease and success of placement.

Case Series: We describe three patients with cirrhosis and varices who presented with massive upper gastrointestinal bleeding and hemorrhagic shock. All received standard medical therapy and required escalation due to ongoing bleeding. In each case, a Sengstaken-Blakemore tube was placed using a bougie tracheal tube introducer as a semirigid stylet. The device was advanced under laryngoscopy through the esophagus and into the stomach without procedural complications. Hemostasis was achieved in all cases following balloon inflation, allowing hemodynamic stabilization and transition to definitive therapies. Two patients ultimately died due to complications of hypoxic-ischemic injury, while one survived to discharge. Use of the proximal gastric aspiration port appeared to reduce the risk of tip displacement compared to distal port insertion.

Conclusion: Bougie-assisted gastroesophageal balloon tamponade device placement is a practical and effective modification for managing catastrophic upper gastrointestinal hemorrhage, and this approach may improve placement success and speed when standard technique has been unsuccessful. Wider adoption of this readily available adjunct could enhance procedural reliability, although further study is needed to better define outcomes and optimal technique.

Introduction: Heat stroke is a time-sensitive condition that requires early intervention to prevent morbidity and mortality. Heat-related deaths are also increasing. Multiple studies have evaluated various cooling methods and assessed their effectiveness, safety, and practicality across diverse settings and populations. Earlier and faster cooling leads to improved patient outcomes. The National Association of Emergency Medical Services Physicians recommends initiating prehospital cold-water immersion before emergency medical services (EMS) transport. 

Case Series: This case series evaluated the feasibility and effectiveness of prehospital cold-water immersion initiated before and continued during EMS transportation from the scene to emergency department arrival in this critically ill patient population. 

Conclusion: Rapid initiation and maintenance of prehospital cold-water immersion in undifferentiated heat stroke was both feasible and effective. Over the course of the case series, no deaths were reported, and all patients were eventually discharged home.

Introduction: Spontaneous pneumomediastinum is a rare condition characterized by the presence of air in the mediastinum without preceding trauma. It is often triggered by minor events such as coughing, physical exertion, or traditional therapies. 

Case Report: A 52-year-old male with a history of pulmonary tuberculosis developed sudden left-sided chest pain and swelling following traditional chest massage therapy. Examination revealed subcutaneous emphysema with palpable crepitus. Imaging showed characteristic signs of pneumomediastinum with bilateral lung opacities. As a complication of pneumomediastinum the patient developed mediastinitis and a mediastinal abscess, requiring open thoracotomy and drainage. He recovered with multidisciplinary care. 

Conclusion: Early recognition of spontaneous pneumomediastinum in emergency settings is crucial, especially when chest pain is accompanied by subcutaneous emphysema, to prevent serious complications.

Introduction: Group A streptococcus (GAS, Streptococcus pyogenes) is commonly associated with pharyngitis and skin and soft tissue infections, but invasive infection can occur. Primary bacterial peritonitis due to GAS is rare, especially in healthy children without nephrotic syndrome or immunocompromise.

Case Report: We present a 21-month-old previously healthy male with four days of fever, irritability, and refusal to walk. Examination revealed abdominal distention and peritonitis. Computed tomography showed ascites and a normal appendix. Diagnostic laparoscopy revealed copious purulent peritoneal fluid; both peritoneal fluid and blood cultures were positive for GAS. He was treated with ampicillin-sulbactam followed by oral amoxicillin-clavulanate with complete recovery.

Conclusion: This case highlights a rare presentation of invasive GAS as primary peritonitis in a healthy child. Clinicians should consider this diagnosis when peritonitis is present but imaging does not confirm appendicitis. Early surgical evaluation and targeted antimicrobials are essential.

Introduction: Acute abdomen is a common emergency presentation, and gastrointestinal perforation can be rapidly fatal if not promptly identified. Point-of-care ultrasound (POCUS) offers a rapid bedside alternative when advanced imaging is delayed or unavailable. 

Case Report: We report a 40-year-old man presenting in cardiac arrest, resuscitated after ten minutes, with subsequent findings of abdominal distension and prior epigastric pain. Point-of-care ultrasound demonstrated classic signs of pneumoperitoneum, and intestinal perforation was confirmed by the drainage of feculent fluid. Despite intervention, the patient expired. 

Conclusion: This case underscores the value of POCUS in diagnosing perforation in unstable patients, guiding emergent decisions when transfer or definitive imaging is not feasible.

Introduction: Hip fractures are a concern in older adults, with incidence expected to rise as the population ages. Despite advances in surgical technique and hardware design, complications remain, influenced by patient factors and surgical choices. Rarely, hardware migration into the pelvis occurs, which poses serious risks. In the emergency setting, abdominal pain is a common complaint, and when evaluating patients with complex histories or prior orthopedic surgeries, clinicians must maintain a broad differential. This case details the discovery of a medially displaced hip screw into the pelvis as the cause of abdominal pain in a patient in the emergency department (ED).

Case Report: A 44-year-old female with end stage renal disease on hemodialysis, anemia, and osteoporosis presented to the ED with sudden-onset, bilateral lower quadrant abdominal pain, vomiting, and diarrhea. The patient reported undergoing left hip open reduction and internal fixation seven months prior. Imaging of the abdomen noted medial displacement of the cephalomedullary nail through the left acetabulum into the pelvis with associated extraperitoneal hematoma. She underwent hardware removal and exploratory laparotomy without bowel injury. 

Conclusion: Orthopedic screw migration is a rare but serious complication, with limited documentation in the literature. Risk increases in patients with poor bone quality and healing, often due to chronic conditions. In patients with multiple comorbidities, careful history and a thorough exam when presenting to the ED are critical to identifying complications. Strategic use of imaging and clinical judgement can help emergency physicians refine their differential diagnosis.

Introduction: Seizures are a frequent reason for emergency department (ED) evaluation, and new-onset events carry a wide differential in which medication toxicity can be overlooked. Toxicity from seldomly prescribed drugs, such as theophylline, can be particularly challenging to recognize because they can cause nonspecific adverse effects, including palpitations, nausea, vomiting, and seizures. Although theophylline use was widespread in the 1980s, current prescribing patterns are unknown. Nevertheless, theophylline toxicity continues to result in ED visits and poison center calls. Because adverse effects may be acute or chronic, identifying theophylline toxicity remains difficult. 

Case Report: A 74-year-old woman presented to the ED with status epilepticus. After thorough history and extensive medical work-up, medication toxicity was suspected as the cause of her seizures. Upon further investigation, the patient was found to have theophylline toxicity. Prompt treatment was initiated resulting in cessation of seizures, highlighting the importance of considering medication toxicity in geriatric patients with new-onset seizures.

Conclusion: Theophylline toxicity can present with vague, multisystem symptoms, with status epilepticus being one of its most severe complications. Rapid identification of the underlying toxic etiology is essential to guide treatment and stop the seizures. Moreover, clinical suspicion should be elevated in the geriatric population related to frequent polypharmacy. In this case, confirming the medication history with a family member raised concerns for medication misuse, enabling timely intervention. Although rarely prescribed, physicians should counsel patients on the risks and adverse effects of theophylline and emphasize close monitoring.

Introduction: Cardiac tamponade typically develops from the accumulation of blood and other fluids, although it can occur from pneumopericardium.

Case Report: A 62-year-old man presented to the emergency department with chest pain and was found to have a pneumopericardium on computed tomography. He developed signs of obstructive shock with hypotension refractory to intravenous fluids and vasopressors. The patient stabilized with bedside pericardiocentesis and pericardial drain placement.

Conclusion: Gastrointestinal-pericardial fistulae are a rare cause of pneumopericardium. Emergency physicians typically rely on cardiac point-of-care ultrasound to evaluate for tamponade and guide pericardiocentesis. However, air artifacts interfere with images, complicating diagnosis and procedures. 

Introduction: Needle thoracostomy is the only procedure in the United States for paramedic treatment of suspected tension pneumothorax within the most recent emergency medical services (EMS) national scope of practice model. We present a rare complication of an out-of-hospital left needle thoracostomy performed by paramedics after intracardiac placement of the catheter. The patient’s imaging studies in the receiving emergency department (ED) confirmed that the needle thoracostomy insertion location was correct, but the catheter entered the heart due to the patient’s existing atypical anatomy. 

Case Report: A 64-year-old unrestrained male driver in a roll-over motor vehicle accident was found in respiratory distress with difficulty auscultating left-sided lung sounds, left chest wall pain on palpation, and confusion. The first-arriving paramedics performed a left needle thoracostomy for suspected tension pneumothorax in advance of helicopter EMS transport. However, pulsatile blood flow from the catheter suggested intracardiac placement, which was confirmed on multiple imaging modalities in the ED. Imaging showed the catheter in the anterior second intercostal space at the midclavicular line. It was also revealed that the patient’s heart was prominently superior and nearly extended to the left chest wall with a majority of his left lung positioned posteriorly within the thorax. There were no signs of pneumothorax, hemothorax, subcutaneous emphysema, diaphragmatic injury, sternotomy wires, or other evidence that his atypical anatomy was the result of an exogenous process.

Conclusion: Intracardiac placement of a needle thoracostomy catheter is a rare complication. In this case, the patient’s atypical anatomy contributed to asymmetric lung sounds and suspicion of tension pneumothorax. Regardless of which insertion site was chosen, the likelihood of intracardiac placement was potentially high due to the patient’s anatomy. Anatomical variation can cause lung sound asymmetry that mimics a pneumothorax, which emergency clinicians and paramedics must consider when assessing for tension pneumothorax.

Introduction: Uncontrolled hypertension is frequently evaluated in the emergency department (ED), with the goal of identifying those patients with hypertensive emergencies. Spontaneous spinal epidural hematoma is rare and not considered a typical manifestation of hypertensive emergency.

Case Report: A 31-year-old man presenting to the ED with chest pain and hypertension subsequently developed lower extremity neurologic deficits and was diagnosed with a spontaneous spinal epidural hematoma. After thorough testing, no other risk factors for this medical condition were identified, and the hemorrhage was attributed to hypertensive emergency.

Conclusion: Spontaneous spinal epidural hematoma is a rare complication of hypertensive emergency and should be considered when evaluating patients with hypertension, back pain, and neurologic deficits.

Introduction: While abdominal pain is a common complaint in the emergency department (ED), it is key to obtain a diligent history and maintain a broad differential diagnosis. The development of exercise-induced diaphragmatic hernia is rare but can result in a high risk of morbidity and mortality.

Case Report: This is a case of a 24-year-old man who presented to the ED with acute-onset epigastric abdominal pain that began while performing “burpee” (squat thrust) exercises. Computed tomography of the abdomen and pelvis revealed diaphragmatic rupture with gastric herniation into the left hemithorax. The patient underwent emergent surgical intervention to reduce the intra-abdominal contents and repair the diaphragmatic defect.

Conclusion: There are no prior reports of diaphragmatic hernia due to burpee exercises in the emergency medicine literature. Consideration of exercise-induced diaphragmatic hernia is necessary due to the high morbidity of this condition.

Introduction: Electrical storm is an emergent medical condition in which a patient experiences recurrent episodes of ventricular tachycardia or ventricular fibrillation. Traditional management includes intravenous antiarrhythmics and/or electrical cardioversion. However, in some cases, cardiac arrhythmias may persist despite these interventions. In rare circumstances, traditional therapies in the emergency department (ED) may prove to be futile. In such cases, a stellate ganglion nerve block (SGNB) can be considered.

Case Report: We present a novel case in which a SGNB was performed in the ED on an awake patient experiencing recurrent cardioversions from his implantable cardioverter defibrillator shocks for ventricular tachycardia. 

Conclusion: In the setting of refractory ventricular dysrhythmias, sympathetic blockade of the left stellate ganglion can be a useful adjunct to conventional management in the ED.

Introduction: Point-of-care ultrasound (POCUS) is well established as a useful adjunct for airway management in both adult and pediatric patients, including confirmation of successful endotracheal intubation. While suprasternal ultrasound of the trachea is the most described method for confirming endotracheal tube (ETT) placement, a focused lung exam can be used to rapidly identify appropriate ventilation in otherwise apneic patients.

Case Report: This case involves a one-month-old male infant who experienced an out-of-hospital cardiac arrest secondary to suspected sudden infant death syndrome. During resuscitation, an accidental extubation occurred after an attempt at securing the ETT with a commercial pediatric tube holder. Loss of end-tidal carbon dioxide (ETCO2) waveform was recognized immediately; however, emergency medical services clinicians questioned the device’s accuracy due to earlier failures of the ETCO2 monitor and the ETT remaining secured at an expected depth. A rapid POCUS lung examination demonstrated absence of bilateral lung sliding. The patient was immediately extubated, revealing a kinked ETT in the oropharynx with the distal tip positioned above the vocal cords. A supraglottic airway device (SGA) was placed with a successful return of ETCO2 waveform, followed shortly by successful reintubation because of difficulty ventilating through the SGA.

Conclusion: Lung ultrasound is a rapid and effective alternative for identifying ETT dislodgment when conventional verification methods are unreliable or unavailable. As ultrasound becomes increasingly available in prehospital and resource-limited settings, it may be effectively used by nonphysician clinicians to confirm airway placement and detect airway complications.

Introduction: Venous leg ulcers disproportionately affect people experiencing homelessness and contribute to recurrent emergency department (ED) use. Standard wound care protocols often require daily dressing changes and leg elevation, which are unrealistic in unstable housing environments.

Case Report: A 71-year-old male with a 10-year history of venous leg ulcers and 15 ED visits achieved complete wound epithelialization after four months of weekly Unna boot compression therapy, despite eviction during treatment. He has not returned to the ED for this condition.

Conclusion: Emergency department-initiated compression therapy with structured wound care referral may reduce recurrent ED use among unhoused patients with venous leg ulcers.

Introduction: A Bezold abscess is a neck abscess characterized by inflammation and infection of the mastoid process that can invade deep into local anatomical musculature and vasculature.

Case Report: We highlight the case of a 62-year-old man who presented with ongoing left-sided neck pain, headache, and tinnitus that started two weeks prior to arriving at the emergency department. Physical examination showed tenderness to the left trapezius muscle, left-sided mastoid tenderness, and pearly tympanic membranes bilaterally. A computed tomography angiogram of the head and neck was performed due to concerns of vertebral dissection, which eventually led to a diagnosis of Bezold abscess.

Conclusion: Although Bezold abscess has been described in the medical literature, it is rarely encountered in modern clinical practice because the widespread use of antibiotic therapy prevents acute mastoiditis from progressing to abscess formation. We highlight the complexity of clinical presentation that can easily be mistaken for other medical conditions, such as occurred with our patient who presented with symptoms more consistent with vertebral dissection: neck pain; tinnitus; and headache, without associated ear pain or discharge.

Introduction: Luxatio erecta is a rare glenohumeral dislocation. The standard treatment is reduction under procedural sedation; however, decision-making becomes more nuanced in patients with comorbidities. This report describes a hyperglycemic patient with type 1 diabetes with luxatio erecta.

Case Report: An 18-year-old man resented with a traumatic inferior shoulder dislocation. Laboratory tests indicated severe hyperglycemia without diabetic ketoacidosis. The emergency department team performed a risk-benefit assessment before proceeding with procedural sedation. Closed reduction was successful, and hyperglycemia was managed with intravenous fluids.

Conclusion: Inferior shoulder dislocations are rare; severe hyperglycemia in diabetics is not an absolute contraindication to procedural sedation, but the patient may need individualized risk-benefit assessment.

Introduction: Hemopericardium from chest compression-related cardiac injury is an underrecognized complication of cardiopulmonary resuscitation, with bleeding risk amplified in anticoagulated patients.

Case Report: A 66-year-old man on apixaban and hemodialysis presented in cardiac arrest. Post resuscitation ultrasound revealed pericardial tamponade. With no pericardiocentesis kit available, a seven French triple-lumen central venous catheter was placed under ultrasound guidance via a subxiphoid approach. Approximately one liter of bloody fluid was drained; the patient died within 24 hours.

Conclusion: Hemopericardium is an underrecognized complication of resuscitation in anticoagulated patients. A triple-lumen central venous catheter offers a familiar bedside drainage alternative when a commercial kit is unavailable. 

Introduction: Vertebral augmentation procedures, including vertebroplasty and kyphoplasty, can result in cement extravasation, which is often clinically silent. Less commonly, cement may migrate intravascularly into the inferior vena cava (IVC) and pulmonary arterial circulation, resulting in pulmonary cement embolism, a potentially life-threatening complication. Early recognition in the emergency department (ED) is essential to guide appropriate imaging, specialty consultation, and timely management.

Case Report: A 76-year-old woman with recent third lumbar vertebral augmentation presented to the ED with acute worsening low back pain and burning bilateral radicular symptoms approximately one week after the procedure. Computed tomography (CT) of the abdomen and pelvis with intravenous contrast demonstrated linear hyperdense material extending from the treated vertebral body into the IVC, concerning for intravascular cement migration. Additional CT of the chest demonstrated multiple bilateral subsegmental pulmonary cement emboli. Interventional radiology was consulted emergently, and the patient was transferred for endovascular retrieval of the IVC cement fragment, which was successfully removed. The pulmonary cement emboli were small, peripheral, and asymptomatic and were managed conservatively. The patient remained hemodynamically stable and was discharged after monitored hospitalization.

Conclusion: Inferior vena cava cement migration with pulmonary cement embolism is a potentially life-threatening complication of vertebral augmentation. Emergency physicians should maintain suspicion for this diagnosis in patients with acute pain or new cardiopulmonary symptoms following recent spinal procedures. Early imaging, multidisciplinary consultation, monitored admission, and endovascular retrieval when indicated may reduce morbidity. 

Introduction: Acute aortic dissection is a life-threatening emergency that may present with nonspecific symptoms, particularly in older adults, leading clinicians to anchor on more common diagnoses.

Case Report: An 85-year-old man presented with four days of cough, weakness, and constipation after a recent emergency department (ED) visit due to food impaction after he choked on a carrot. A chest radiograph obtained the day before admission showed left basal consolidation, prompting referral for suspected aspiration pneumonia. In the ED, he appeared comfortable with no complaints of chest pain. Physical examination noted mild tachycardia and wheezes bilaterally and treatment was initiated with antibiotics and bronchodilators. A low-voltage electrocardiogram led to immediate point-of-care echocardiography, which demonstrated a large circumferential pericardial effusion, a markedly dilated aortic root, and right ventricular collapse. Computed tomography angiography confirmed an extensive Stanford Type A aortic dissection. 

Conclusion: This case highlights how deceptively calm presentations can mask catastrophic disease and why clinicians must be ready to abandon their first diagnosis when the data demands it.

Introduction: While the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) becomes increasingly commonplace in overdose, questions about its role in various shock states remain. The application of VA-ECMO with impaired myocardial function is well established, and use in cardiogenic shock precipitated by poisoning has continued to increase. In poison-induced vasoplegia with preserved myocardial function, the role of VA-ECMO remains undefined. Many atypical antipsychotic and antidepressant agents are known to cause mild hypotension via alpha-1 adrenergic blockade. Intravenous fluids and vasopressors alone are generally effective for single-substance ingestions. In the setting of polysubstance intoxication, synergism leading to bradycardia and refractory vasoplegia refractory to conventional therapies may result, prompting consideration for extracorporeal support. 

Case Report: A 71-year-old woman presented to the emergency department (ED) after being found obtunded near bottles of quetiapine, olanzapine, trazodone, mirtazapine, levomilnacipran, eszopiclone, and clonazepam. She underwent prehospital intubation and received push-dose epinephrine for hypotension. In the ED, the patient remained hypotensive with a relative bradycardia, requiring escalating doses of norepinephrine, vasopressin, epinephrine, angiotensin II, and methylene blue infusions. Her extremities remained warm, and point-of-care echocardiography revealed hyperdynamic function, consistent with vasoplegic shock. She subsequently underwent VA-ECMO cannulation, which was followed by a rapid decrease in vasopressor requirements and decannulation on hospital day 3. The patient recovered and was transferred to inpatient psychiatry neurologically intact. Urine mass-spectrometry revealed large peaks for quetiapine, olanzapine, milnacipran, mirtazapine, trazodone, and zopiclone. 

Conclusion: While overdose data are limited, levomilnacipran may precipitate or potentiate relative bradycardia with hypotension and a preserved ejection fraction. Significant ingestions and synergism with other agents causing peripheral alpha-1 antagonism may lead to hemodynamic instability refractory to conventional therapies. Extracorporeal life support may aid in recovery. 

Introduction: Vertebral artery dissection is a rare but life-threatening complication of strangulation.  Symptoms are often nonspecific and may not manifest immediately, complicating diagnosis. If prior neck trauma is not elicited during assessment, clinicians may miss a mechanistic link to prompt vascular imaging, leaving patients at risk for irreversible outcomes, as illustrated in this case.

Case Report: A 24-year-old woman presented to a critical access emergency department (ED) with nonspecific neurological symptoms that had largely resolved upon arrival. Her only reported history was vague head and neck pain, which she attributed to stress after leaving an abusive relationship several weeks earlier.  Hours later, while still in the ED, the patient experienced abrupt neurological deterioration. She was transferred to a regional medical center, where magnetic resonance imaging eventually revealed vertebral artery dissection with basilar artery hypoperfusion and extensive pontine infarction. Collateral history obtained from family revealed a preceding strangulation event.  Police at the scene had documented neck injury, but the patient declined their offer of a medical assessment. By the time vertebral artery dissection was diagnosed, she had developed irreversible neurological damage leading to locked-in syndrome. She survived in this state for years before succumbing to complications of quadriplegia. The death was certified as a homicide due to inflicted blunt force neck injury.

Conclusion: This case underscores the importance of timely, skilled medical assessment after strangulation and highlights the need for targeted screening of patients with vague neurological symptoms or disclosure of intimate partner violence.

Introduction: Delayed cardiac tamponade is a rare but life-threatening complication following permanent pacemaker placement and may present with non-specific symptoms. 

Case Report: We report the case of a 66-year-old woman on oral anticoagulation who presented with generalized weakness, nausea, and profound hypotension four days after dual-chamber pacemaker placement. Initial evaluation demonstrated atrial fibrillation with rapid ventricular response, a normal chest radiographic findings, prerenal azotemia, and no evidence of device malfunction on interrogation. Point-of-care ultrasound (POCUS) performed in the emergency department revealed a large pericardial effusion with right atrial and right ventricular collapse and a plethoric inferior vena cava, consistent with cardiac tamponade. Emergent pericardiocentesis yielded 400 mL of sanguinous pericardial fluid with rapid hemodynamic improvement. Subsequent imaging revealed a 2-mm protrusion of the right atrial lead into the myocardium, which was suspected to be the source of the effusion, but pacemaker revision was not necessary. 

Conclusion: This case highlights the limitations of routine diagnostic testing following permanent pacemaker placement and emphasizes the importance of early POCUS in patients with atypical presentations, particularly in the setting of anticoagulation.

Introduction: Ifosfamide is an alkylating chemotherapeutic agent commonly used in the treatment of sarcomas and other malignancies. Neurotoxicity is a recognized adverse effect, most often presenting as encephalopathy. Acute movement disorders such as dystonia are rare and may be underrecognized in the emergency department.

Case Report: We report a 22-year-old woman receiving combination chemotherapy with doxorubicin, ifosfamide, and mesna for breast angiosarcoma who developed acute right-sided neck spasms and involuntary movements within five minutes of initiating ifosfamide infusion. Vital signs were as follows: temperature, 98.0 degrees Fahrenheit; heart rate, 97 beats per minute; respiratory rate, 18 breaths per minute; blood pressure, 130/88 millimeters of mercury; and oxygen saturation, 99% on room air. Examination revealed sustained contraction of the right sternocleidomastoid and trapezius muscles with involuntary head deviation. She had no exposure to medications commonly associated with dystonia. She was treated with intravenous thiamine, benzodiazepines, intravenous fluids, and baclofen, with subsequent improvement.

Conclusion: Acute dystonia represents a rare manifestation of ifosfamide-induced neurotoxicity. Emergency clinicians should consider chemotherapy-related neurotoxicity in patients presenting with acute movement disorders, as early recognition and supportive management may prevent progression.

Introduction: Choledochal cysts are rare congenital dilatations of the biliary tree that may present with nonspecific gastrointestinal symptoms in children, posing diagnostic challenges. 

Case Report: We report a 3-year-old girl who presented with recurrent vomiting and abdominal pain. Initial laboratory testing revealed a mildly elevated lipase. An abdominal ultrasound demonstrated a pancreatic cyst; the patient was discharged with outpatient follow-up. She returned with worsening symptoms and a markedly elevated lipase of 2,247 U/L (reference range, < 160 U/L). Computed tomography subsequently revealed a type I choledochal cyst. She underwent operative resection with an uncomplicated postoperative course.

Conclusion: Persistent gastrointestinal symptoms with uptrending lipase in children should prompt consideration of hepatobiliary etiologies. Choledochal cysts may be missed on initial presentation as the classic triad of jaundice, palpable abdominal mass, and right upper quadrant pain is present in a minority of cases.

Introduction: Point-of-care ultrasound (POCUS) allows emergency physicians to rapidly diagnose vascular abnormalities, including pseudoaneurysms. Although commonly identified following vascular catheterization, traumatic pseudoaneurysms of superficial scalp arteries are rare.

Case Report: An 85-year-old woman receiving anticoagulation presented to the emergency department (ED) for removal of a scalp staple placed during treatment of a previously bleeding scalp wound. Physical examination revealed a persistent scalp hematoma. Point-of-care ultrasound demonstrated a hypoechoic collection with Doppler flow consistent with a pseudoaneurysm. Computed tomography angiography confirmed the diagnosis. Ultrasound-guided compression attempted in the ED resulted only in transient thrombosis. The patient subsequently underwent elective percutaneous embolization.

Conclusion: Emergency physician–performed POCUS can rapidly identify traumatic scalp pseudoaneurysms and facilitate timely consultation and treatment.

Introduction: Idiopathic fascicular ventricular tachycardia is a rare form of ventricular tachycardia that is commonly seen in young, otherwise healthy individuals without structural heart disease. This rhythm can be difficult to distinguish from other forms of tachyarrhythmia, including supraventricular tachycardia, yet acute pharmacologic management of this condition varies significantly from more common forms.

Case Report: We describe a 42-year-old woman with no cardiac history who presented with palpitations and lightheadedness. She was found to be in a hemodynamically stable, wide-complex tachycardia. Given no prior cardiac history, supraventricular tachycardia with aberrancy was initially considered as a leading diagnosis; however, a trial of adenosine and lidocaine was ineffective. Her electrocardiogram revealed a regular wide complex tachycardia at 262 beats per minute with a right bundle branch block morphology and right axis deviation, consistent with a rare left anterior fascicular subtype of ventricular tachycardia. She later underwent successful ablation of the left anterior fascicle with no recurrence of symptoms at follow-up.

Conclusion: This report highlights a case of idiopathic fascicular ventricular tachycardia successfully treated with intravenous verapamil and left anterior fascicle ablation, addressing the diagnostic challenges of this arrhythmia. Early recognition by emergency physicians is essential to avoid treatment delays and ensure appropriate definitive management.

Introduction: Lyme disease is most prevalent in the Northeast and Midwest regions of the United States, as well as northern California; however, cases have been reported in nonendemic areas, including the Southwestern United States. Atypical presentations or underreporting can cause delay in diagnosis. 

Case Report: We present the case of a 22-year-old previously healthy man, who presented to our emergency department in metropolitan Phoenix with five days of headache, fever, meningismus, and photophobia, and later developed focal neurologic deficits consistent with Lyme meningitis. Cerebrospinal fluid was notable for lymphocytic pleocytosis, and Western blot for Borrelia burgdorferi Immunoglobulin-M antibodies was positive, which led us to Lyme meningitis as the unifying diagnosis. He was treated with intravenous ceftriaxone and his symptoms resolved. 

Conclusion: This case highlights the importance of considering this pathology in nonendemic areas.

Introduction: Hyperbaric oxygen therapy carries a risk of central nervous system oxygen toxicity, which can result in seizures. Seizure-induced spinal fractures are uncommon complications that occur during generalized convulsive activity. While often benign, lumbar vertebral body burst fractures may result in cauda equina syndrome. Additionally, patients with beta-thalassemia may have decreased bone mineral density due to ineffective erythropoiesis and bone marrow expansion increasing the risk for pathologic and traumatic fractures.

Case Report: A 35-year-old man with beta-thalassemia major presented to the emergency department after a witnessed, first-time generalized tonic-clonic seizure during hyperbaric oxygen therapy for chronic venous ulcers. Initial evaluation revealed severe low back pain and midline lumbar tenderness. Computed tomography revealed an acute third lumbar vertebra (L3) burst fracture with retropulsion. The patient rapidly developed progressive right lower-extremity weakness and acute urinary retention. Magnetic resonance imaging revealed 70% loss of height of L3, severe thecal sac stenosis at L2-L3 and L3-L4, and a ventral dural hematoma resulting in stenosis at L4-L5. The patient was diagnosed with cauda equina syndrome and underwent emergent neurosurgical decompression.

Conclusion: This case represents a rare convergence of multiple complications: central nervous system oxygen toxicity during hyperbaric oxygen therapy, seizure-induced lumbar burst fracture with retropulsion, and traumatic cauda equina syndrome in a patient with beta thalassemia. Physicians must maintain a high index of suspicion for vertebral fractures and monitor for evolving neurological deficits when managing the patient with acute back pain following seizure activity.

Introduction: Bacterial meningitis affects about 1.2 million people worldwide each year. Streptococcus pneumoniae is responsible for the majority of cases of bacterial meningitis in the United States and Europe, with visual impairment seen in 6.3% of patients. The etiology of acute vision loss in the setting of bacterial meningitis remains wide-ranging, most often occurring in the setting of endogenous endophthalmitis, optic neuropathy, and cortical blindness. Retinal necrosis is rare, and typically associated with viral meningitis, but has not been reported in bacterial meningitis.

Case report: A 66-year-old man with headache, malaise, and intermittent blurry vision, initially diagnosed with viral upper respiratory infection and presumed trigeminal neuralgia, presented to the emergency department with altered mental status, meningismus, and progressive bilateral vision loss. He was diagnosed with bacterial meningitis, and subsequent cerebrospinal fluid and blood cultures were positive for S pneumoniae. Ophthalmologic evaluation demonstrated bilateral nonreactive pupils, retinal ischemia, optic nerve pallor, and retinal necrosis but no intraocular inflammation. Brain magnetic resonance imaging showed multifocal cortical ischemic infarcts thought to be of embolic source. His hospitalization was complicated by mitral valve regurgitation, endocarditis, and cardiac tamponade requiring extensive surgical repair.

Conclusion: This case represents a rare presentation of bilateral retinal ischemia and necrosis in the setting of S pneumoniae meningitis without evidence of endophthalmitis. Awareness of atypical ocular presentations and differential diagnoses is vital in providing early diagnosis, treatment and specialist involvement.

Introduction: Acute motor and sensory axonal neuropathy is a rare, severe axonal variant of Guillain–Barré syndrome characterized by rapidly progressive motor and sensory dysfunction. Early recognition in the emergency department (ED) is challenging because patients may initially present with subtle neurologic findings, preserved reflexes, and normal cerebrospinal fluid (CSF) studies. 

Case Report: A 29-year-old woman with a history of generalized anxiety disorder presented to the ED with progressive distal numbness and mild weakness, with weakness being her chief complaint. Neurologic examination demonstrated preserved reflexes without focal deficits, and she was noted to be anxious. Given the reassuring examination, the patient was discharged with strict return precautions, including instructions to seek immediate reevaluation for worsening weakness, numbness, or progression of neurologic symptoms. She returned 48 hours later with rapidly worsening ascending weakness. The patient’s clinical progression prompted neurology consultation and hospital admission despite initially reassuring examination findings. During a five-day hospitalization, electrodiagnostic testing and clinical findings established the diagnosis of acute motor and sensory axonal neuropathy. 
This case illustrates how acute motor and sensory axonal neuropathy may initially mimic benign or functional conditions, particularly in patients with underlying anxiety, preserved reflexes, and normal early CSF findings. In the ED, anchoring bias and premature diagnostic closure may delay recognition of serious neurologic disease. Serial neurologic examinations, maintaining a broad differential diagnosis, and early neurology consultation are critical when evaluating patients with progressive neurologic symptoms. 

Conclusion: Acute motor and sensory axonal neuropathy may present atypically during the early stages of disease, and initial examination and laboratory findings may be misleading. Clinical progression, rather than isolated examination or diagnostic findings, should guide disposition and prompt reassessment to facilitate timely diagnosis and treatment, with the potential to improve patient outcomes. 

Introduction: Acute ischemic stroke is a leading cause of morbidity and mortality, with tenecteplase being a cornerstone of acute management. While tenecteplase carries a known risk of bleeding, major thrombotic events such as acute myocardial infarction (AMI) after stroke reperfusion are less commonly described.

Case Report: We present the case of a 67-year-old man who presented with acute stroke symptoms. After ruling out intracranial hemorrhage and managing blood pressure, he received tenecteplase, and all neurological deficits resolved. Soon after, he developed acute chest pain, and his repeat electrocardiogram confirmed a ST-elevation myocardial infarction. He underwent emergent cardiac catheterization, revealing 100% occlusion of the left circumflex artery, which was successfully revascularized with thrombectomy and angioplasty. Intravascular ultrasound further supported the presence of embolic phenomenon. Pathology of the retrieved material identified thrombus alongside atherosclerotic plaque fragments. The patient experienced complete symptom resolution and was discharged after a short hospitalization.
This case highlights the complexities encountered when a patient with acute ischemic stroke who is treated with tenecteplase subsequently develops an AMI. Potential mechanisms include a coincidental plaque rupture, possibly exacerbated by the stress of the acute stroke, a rare paradoxical prothrombotic effect of thrombolysis, or a combination thereof. The pathological finding of mixed thrombus and atherosclerotic plaque underscores the underlying disease contributing to this event.

Conclusion: This case accentuates the importance of maintaining a high index of suspicion for new cardiovascular events in post-thrombolysis patients, especially those with significant cardiovascular risk factors. Rapid and judicious diagnostic evaluation is crucial for timely management of these complex, life-threatening complications.

Introduction: Labial frenulum tears in infants are commonly associated with minor trauma but may raise concern for nonaccidental injury. These injuries are typically benign and self-limiting; however, persistent or excessive bleeding should prompt evaluation for an underlying bleeding disorder. Hemophilia A is an X-linked factor VIII deficiency with clinical symptoms that vary based on the level of severity.

Case Report: A previously healthy 14-month-old male presented to the pediatric emergency department three times within 10 days for persistent bleeding from a superior labial frenulum tear sustained after minor trauma. Initial examination was reassuring, and he was discharged without laboratory evaluation. On repeat presentation, he was found to have normocytic anemia and isolated prolonged activated partial thromboplastin time. Despite topical and oral antifibrinolytic therapy, he returned with worsening anemia, melena, hematemesis, pallor, and tachycardia. He required a packed red blood cell transfusion, intravenous aminocaproic acid, and hospitalization. Further hematologic evaluation revealed a low factor VIII activity level, confirming mild hemophilia A. There was no prior personal or family history of abnormal bleeding.

Conclusion: This case highlights that hemophilia A may initially present with disproportionate bleeding from a minor mucosal injury, even in the absence of a known bleeding history. Persistent bleeding after minor trauma warrants prompt coagulation evaluation to prevent diagnostic delay and serious complications.

Introduction: Retrocaval ureter (RCU) is a rare congenital anomaly resulting from abnormal development of the inferior vena cava, leading to ureteral obstruction and hydronephrosis. Patients often present with nonspecific symptoms, making diagnosis challenging. Point-of-care ultrasound (POCUS) is frequently used in the emergency department (ED) to evaluate abdominal pain and may identify clinically important abnormalities requiring further investigation.

Case Report: A 30-year-old woman presented to the ED with a two-day history of nonspecific abdominal pain. Physical examination was notable only for mild epigastric tenderness. Abdominal POCUS performed by the emergency physician demonstrated moderate right-sided hydronephrosis. The patient had no urinary symptoms and normal renal function. Follow-up renal ultrasound confirmed hydronephrosis and proximal hydroureter without nephrolithiasis. Contrast-enhanced computed tomography subsequently revealed a RCU with the characteristic fish-hook configuration. Renography demonstrated preserved renal function with delayed drainage secondary to ureteral obstruction. The patient underwent surgical correction with ureteral reconstruction and stent placement.

Conclusion: This case highlights the value of POCUS in the evaluation of patients with nonspecific abdominal pain. Detection of hydronephrosis prompted further diagnostic evaluation and led to the diagnosis of a rare congenital urologic anomaly requiring surgical intervention. Emergency physicians should consider further investigation when hydronephrosis is identified on POCUS, even in the absence of urinary symptoms. 

Introduction: Inguinal bladder herniation is a rare subtype of inguinal hernia in which the urinary bladder protrudes into the inguinal canal. It is often asymptomatic but can present with a range of clinical severity in the emergency department (ED).

Case Report: We present a case report of two patients with inguinal bladder hernias. The first case describes a stable patient with bladder herniation without urinary obstruction, successfully managed with outpatient follow-up. The second case illustrates a more severe presentation with bladder involvement causing bilateral hydroureteronephrosis, requiring admission after failed reduction. This patient subsequently re-presented with urosepsis and developed multiple complications, including bacteremia and infective endocarditis.

Conclusion: Inguinal bladder herniation can present with a wide clinical spectrum in the ED. Early recognition, appropriate imaging, and thorough clinical assessment are critical in guiding management and preventing complications.

Introduction: Acute ST-elevated myocardial infarction (STEMI) is a medical emergency requiring timely revascularization to preserve myocardial injury. Rural populations often experience delays in treatment leading to increased risk of complications and mortality. Emergent treatment of STEMI in a patient on long-term direct oral anticoagulation facing delays to revascularization is a complex scenario for rural physicians. 

Case Report: A 55-year-old male presented to the emergency department in rural Alaska and was diagnosed with acute inferior STEMI. The patient’s history was notable for pulmonary embolism with long-term direct oral anticoagulation. Thrombolytic therapy was not recommended and prompt revascularization via percutaneous coronary intervention (PCI) was needed; however, the nearest PCI-capable hospital was hundreds of miles away, increasing the risk of ischemic cardiomyopathy and death. The patient achieved revascularization after transport and, in the following year, experienced multiple episodes of ventricular tachycardia leading to ablation and need for implantable cardioverter-defibrillator placement.  

Conclusion: This case illustrates a complex but not uncommon scenario that rural physicians face.  In rural patients requiring acute STEMI treatment but without timely access to a PCI-capable hospital, systemic thrombolysis and immediate transfer of care is often the only option for revascularization. There is a need for clear STEMI management guidelines in anticoagulated patients who present in rural settings. 

Introduction: Hemophilia A is an X-linked recessive bleeding disorder characterized by deficiency of factor VIII. The clinical features of this disease are hemorrhage and can be life-threatening when major organ systems are involved.

Case Report: We report the case of a 13-year-old boy with severe hemophilia A and factor VIII inhibitors who presented with fever and septic arthritis, later developing refractory shock with tachyarrhythmia. Despite initial suspicion of sepsis-related myocarditis, point-of-care ultrasound (POCUS) revealed massive hemorrhagic pericardial effusion with tamponade physiology. Recombinant factor VIIa was transfused as hemostatic rescue therapy; the patient was subsequently started on fresh frozen plasma and emicizumab. Ultrasound-guided pericardiocentesis resulted in rapid hemodynamic recovery.

Conclusion: This case highlights the importance of considering obstructive shock in unstable hemophilia patients and demonstrates that timely POCUS-based diagnosis and factor-supported pericardiocentesis can be lifesaving.

Introduction: Urticarial rash is a common condition but can present atypically, making it difficult to clinically diagnose. Thorough assessment with awareness and exclusion of differentials is crucial for definitive treatment. 

Case Report: This is a case of a 23-year-old woman who presented with signs and symptoms suggestive of streptococcal pharyngitis and was treated with clarithromycin by primary care. Two weeks later, the patient was referred to the emergency department for malaise and an acute, rapidly progressing pruritic rash. Further evaluation revealed an Epstein-Barr virus (EBV) infection.

Conclusion: This case highlights the differential diagnoses and diagnostic reasoning required for a patient with a rash and concurrent respiratory symptoms. Differential considerations include viral exanthem, delayed drug-induced reaction, EBV-associated antibiotic rash, scarlet fever, and urticarial vasculitis. Early identification of atypical urticarial lesions and the exclusion of clinical mimics are vital to guide appropriate therapy and optimize patient outcomes.

Introduction: Recurrent chest pain in postpartum patients frequently results in repeated emergency department (ED) visits despite negative cardiopulmonary investigations, creating diagnostic uncertainty and increasing healthcare resource utilization. We report a case highlighting the value of a structured postexclusion assessment to identify clinically relevant behavioral triggers after life-threatening causes have been excluded.

Case Report: A 33-year-old woman, six weeks postpartum, presented repeatedly with nocturnal chest pain, palpitations, and dyspnea. Serial electrocardiograms, cardiac biomarkers, chest imaging, and transthoracic echocardiography were consistently normal, excluding acute cardiopulmonary pathology. Careful reassessment of symptom chronology and behavioral history identified a reproducible temporal association between symptom onset and nocturnal binge-eating episodes. Following outpatient psychiatric and clinical psychological evaluation confirming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria for binge-eating disorder, targeted behavioral counseling led to a marked reduction in symptom frequency and no further ED presentations during follow-up.

Conclusion: This case demonstrates that, after exclusion of life-threatening cardiopulmonary disease, a structured assessment emphasizing symptom temporality and behavioral triggers can uncover clinically actionable mechanisms underlying recurrent postpartum chest pain. Incorporating this approach into emergency department evaluation may facilitate appropriate management while reducing unnecessary repeat investigations and ED utilization. 

Introduction: Partial segmental thrombosis of the corpus cavernosum is a rare vascular condition that may present with nonspecific groin or pelvic pain and mimic more common surgical or urologic emergencies.

Case Report: A 33-year-old man presented to the emergency department with acute left-sided groin and pelvic pain after straining during defecation. Initial history and evaluation raised concern for incarcerated inguinal hernia, epididymo-orchitis, renal colic, lymphadenopathy, and soft tissue infection. Computed tomography demonstrated asymmetric enlargement of the left corpus cavernosum, while penile ultrasound showed diminished cavernosal flow. Magnetic resonance imaging confirmed segmental thrombosis of the left corpus cavernosum. The patient was treated conservatively with rivaroxaban and analgesia, resulting in symptomatic improvement.

Conclusion: Partial segmental thrombosis of the corpus cavernosum should be considered in patients presenting with unexplained groin or perineal pain when standard abdominal, penile, testicular, and hernia evaluations are unrevealing. Magnetic resonance imaging may be necessary for definitive diagnosis, and conservative management is frequently successful. 

Introduction: Acute pain crises are a common emergency department presentation in patients with sickle cell disease. Pain management typically relies on multimodal analgesia, with opioids often playing a central role. We propose incorporating regional anesthesia techniques into the pain management regimen.

Case Report: We present a case of a young patient with sickle cell disease experiencing an acute pain crisis with severe knee pain. A genicular nerve block was performed, resulting in significant pain reduction in the affected knee. 

Conclusion: Regional anesthesia, including isolated nerve blocks, may be safe and effective as part of a multimodal pain approach for patients suffering from acute pain crises due to sickle cell disease. This may help reduce the need for opioid or other sedating pain medications, as well as the inherent risks associated with increasing doses, such as respiratory depression. 

Introduction: Caused by portosystemic venous shunting, the focal hepatic hot spot sign (or hot quadrate sign) is a radiologic finding most commonly associated with superior vena cava (SVC) obstruction. On contrast-enhanced imaging, this finding may mimic active hepatic extravasation or focal hepatic pathology, posing a diagnostic challenge in the emergency department (ED). 

Case Report: We report a case of a 70-year-old man with progressive cognitive decline and hypoxemic respiratory failure requiring intubation. Computed tomography (CT) angiography of the chest demonstrated a focal area of intense contrast enhancement in the left hepatic lobe, initially concerning for active extravasation. Further review of the imaging revealed a right upper lobe lung mass and a large mediastinal mass causing high-grade SVC stenosis. The hepatic finding was subsequently identified by the reading radiologist as a focal hepatic hot spot sign representing a vascular pseudolesion due to collateral venous flow. The patient was diagnosed with SVC syndrome secondary to malignancy and underwent chemotherapy before transitioning to comfort care. 

Conclusion: The focal hepatic hot spot sign represents a hepatic pseudolesion resulting from altered venous return and collateral circulation, most commonly in the setting of SVC obstruction. In the ED, this finding may be misinterpreted as hemorrhage or focal hepatic pathology, potentially leading to unnecessary diagnostic or therapeutic interventions. Recognition of the focal hepatic hot spot sign is essential for emergency physicians to avoid misdiagnosis and identify underlying central venous obstruction. Awareness of this imaging pitfall can improve diagnostic accuracy and guide appropriate management in patients undergoing contrast-enhanced CT imaging.

Introduction: Drug-induced immune thrombocytopenia (DITP) is a rare process in which specific drugs induce antibodies against platelet antigens, resulting in the destruction, consumption, or impaired production of platelets.1,3 Sulfamethoxazole-trimethoprim can result in DITP.2

Case Report: This is a case of a 64-year-old man who developed severe thrombocytopenia after sulfamethoxazole-trimethoprim use. He presented to the emergency department with oral hemorrhagic lesions, mucositis, and petechiae. Laboratory evaluation revealed a low platelet count. Drug-induced immune thrombocytopenia was suspected, and the sulfamethoxazole-trimethoprim was discontinued. The patient’s platelet count responded rapidly after discontinuation of the offending drug and administration of dexamethasone.

Conclusion: This case highlights the importance of early recognition of DITP and the avoidance of re-exposure to the causative agent. Prompt drug withdrawal and adjunctive corticosteroid therapy can facilitate complete clinical recovery.

Introduction: Subacute combined degeneration (SCD) is an uncommon neurologic complication of vitamin B12 deficiency characterized by demyelination of the dorsal and lateral columns of the spinal cord, resulting in weakness, paresthesias, sensory deficits, and gait ataxia. Recreational nitrous oxide inhalation has emerged as an important cause of functional vitamin B12 deficiency and may precipitate SCD, particularly in otherwise healthy individuals.

Case Report: We report a case of nitrous oxide-associated SCD in a patient who presented to the emergency department with progressive neurologic symptoms. This case illustrates a rare but increasingly recognized complication of recreational nitrous oxide use.

Conclusion: Nitrous oxide-induced SCD should be considered in patients presenting with subacute weakness, paresthesia, and ataxia, particularly when there is a history of recreational inhalant use. Early recognition and treatment with intramuscular vitamin B12 replacement, together with cessation of nitrous oxide exposure, are essential to optimize neurologic recovery.

Introduction: Internal carotid artery (ICA) dissection is a time-sensitive vascular emergency that may present with subtle findings, most notably painful Horner syndrome. Mechanical stress to the cervical vasculature is a recognized trigger for this condition.

Case Report: We report a 56-year-old man who developed ipsilateral ptosis, miosis, and head and neck pain after using a home cervical traction device. Computed tomography angiography showed focal critical stenosis of the distal cervical left ICA consistent with dissection, along with a contralateral pseudoaneurysm suggesting prior injury. He was treated with dual antiplatelet therapy.

Conclusion: This case highlights a potential association between cervical traction device use and carotid dissection and underscores the importance of recognizing painful Horner syndrome and bilateral carotid pathology, while prompting clinicians to specifically inquire about traction device use. 

Introduction: This case report discusses the use of point-of-care ultrasound (POCUS) in the diagnosis of a fractured pedunculated osteochondroma in an 8-year-old boy after minor trauma. Although osteochondromas are the most common benign bone tumors, especially in this age, historically only radiographs have been obtained in the emergency department to diagnose these benign bone tumors. 

Case Report: An 8-year-old boy reported ongoing pain for 2 months but had an acute onset worsening of his pain after minor trauma to the medial distal right femur. Point-of-care ultrasound was used to diagnose a fractured pedunculated osteochondroma prior to radiographic imaging.

Conclusion: We demonstrated the practicality and ease of POCUS in assisting with the diagnosis of  an osteochondroma and the subtle fracture of the base. Both POCUS and radiographic imaging may be beneficial when used in conjunction for the diagnosis of benign bone tumors in this age group.

Case presentation: A 57-year-old man with a history of obesity-hypoventilation syndrome, diabetes mellitus, and chronic renal insufficiency was intubated with an 8.0-mm endotracheal tube under video laryngoscopy in the emergency department due to respiratory failure. After successful intubation, bloody secretions were noted in the patient’s mouth. Subsequent examination revealed that the endotracheal tube had caused a through-and-through perforation at the junction of the soft palate and the anterior tonsillar pillar. Because the intubation had been successful, the endotracheal tube was not removed, and the soft palate was transected to free the tube. The patient made an uneventful recovery.

Discussion: Soft palate perforation is an uncommon injury that has been reported more frequently with video laryngoscopy than direct laryngoscopy. To prevent this injury and ensure its rapid recognition, it is recommended that the clinician sequentially look at the “5 M’s” during intubation: Mouth–Monitor–Mouth–Monitor–Mouth.

Case Presentation: A 16-year-old girl presented to the emergency department after being struck in the right eye by another player’s elbow during a basketball game. She had only minimal periorbital swelling but developed persistent nausea, repeated vomiting, and diplopia with upward gaze. Visual acuity, visual fields, and pupillary light reflexes were normal. Extraocular movement testing showed mild limitation of upward gaze of the right eye, and upward gaze reproducibly provoked diplopia, marked nausea, and vomiting. Computed tomography (CT) showed no intracranial hemorrhage, and orbital CT was initially interpreted as showing no obvious orbital floor fracture or extraocular muscle entrapment. Given the discrepancy between the mild external appearance and the severe ocular symptoms, white-eyed blowout fracture with trapdoor-type entrapment and an oculocardiac reflex was suspected. She underwent emergent surgery, after which her vomiting, diplopia, and ocular motility disturbance improved immediately.

Discussion: White-eyed blowout fracture is a trapdoor-type orbital floor injury seen mainly in children and adolescents and may present with minimal external signs and subtle or negative-appearing CT findings.1-3 Gaze-evoked nausea or vomiting, diplopia, and relative bradycardia are important bedside clues to extraocular muscle entrapment with an oculocardiac reflex.1-3 This case highlights that white-eyed blowout fracture may be detected by careful bedside examination even when CT does not clearly show an orbital floor fracture. Emergency physicians should recognize this entity as a clinically important, easily missed diagnosis in pediatric orbital trauma.

Case presentation: A 29-year-old woman presented to the emergency department three months after intragastric balloon placement with nausea, vomiting, constipation, and abdominal pain. Computed tomography (CT) demonstrated spontaneous deflation and migration of the device into the small bowel with resultant mechanical small bowel obstruction. The patient was managed conservatively with bowel rest, intravenous fluids, electrolyte repletion, and nasogastric decompression. Repeat CT on hospital day 2 confirmed distal migration of the balloon into the descending colon with interval decompression of the small bowel. On hospital day 3, the patient reported spontaneous passage of the balloon per rectum with complete resolution of symptoms.

Discussion: Spontaneous deflation and distal migration of an intragastric balloon causing small bowel obstruction is a rare but potentially life-threatening complication. Most reported cases require surgical or endoscopic intervention. This case highlights spontaneous transanal passage as a rare but favorable outcome achievable with conservative management in carefully selected, hemodynamically stable patients without signs of peritonitis, bowel ischemia or perforation, or failure of the intragastric balloon to progress. 

Case Presentation: A 51-year-old woman presented to the emergency department with blurred vision and a large, dark floater in her right eye. Point-of-care ultrasound (POCUS) revealed a Weiss ring, strongly suggesting a diagnosis of a posterior vitreous detachment. 

Discussion: Identifying a Weiss ring with POCUS may be a reasonable and easier alternative for emergency clinicians when used in conjunction with a slit-lamp examination and may aid in timely ophthalmologic management of posterior vitreous detachments. 

Case Presentation: A 30-year-old man presented to the emergency department with severe blunt facial trauma following a fall from height. Examination revealed extensive floor-of-mouth ecchymosis and a large tense sublingual hematoma causing tongue elevation, dysarthria, and swelling mimicking Ludwig’s angina, producing a traumatic pseudo-Ludwig appearance with marked airway crowding. Three-dimensional computed tomography demonstrated severely displaced bilateral mandibular fractures. Owing to pronounced segmental instability with mobile dentoalveolar fragments, temporary interdental bridle wire stabilization was performed in the emergency department. Despite the dramatic anatomical findings, serial airway reassessments confirmed sustained airway stability, permitting delayed definitive open reduction and internal fixation.

Discussion: Traumatic pseudo-Ludwig angina secondary to bilateral mandibular fractures is an uncommon presentation that may closely mimic life-threatening infectious floor-of-mouth swelling. Hemorrhage within the confined sublingual space can rapidly elevate and posteriorly displace the tongue, resulting in progressive airway compromise. This case highlights the importance of dynamic airway assessment, serial airway reassessment, and early multidisciplinary management, including temporary interdental bridle wire stabilization, in carefully selected patients with traumatic hemorrhagic floor-of-mouth emergencies. 

Case Presentation: A 26-year-old man with past medical history of prolactinoma presented two weeks status post endoscopic transsphenoid prolactinoma excision with a positional headache and cerebrospinal fluid rhinorrhea; he was found to have diffuse subarachnoid air.

Discussion: There are few reports of subarachnoid pneumocephalus in the emergency medicine literature. Pneumocephalus, particularly tension pneumocephalus, typically occurs in the setting of traumatic skull fractures. However, emergency physicians should be aware of subarachnoid pneumocephalus in the setting of endoscopic skull base surgeries.

Amphetamine-induced Reverse Takotsubo Syndrome: Further Implications

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