Clinical Practice and Cases in Emergency Medicine

Case presentation: An 86-year-old female presented to our emergency department with chest pain and orthopnea and was diagnosed with heart failure and ST-elevation myocardial infarction, prompting hospitalization. During hospitalization, she developed a fever. A chest and abdominal contrast-enhanced computed tomography (CT), conducted to investigate the cause of the fever, coincidentally revealed sedimentation of contrast agent in the descending aorta. To differentiate from aortic dissection, we conducted dynamic CT, and it was confirmed that the contrast agent within the aorta decreased over time. On the same day, an echocardiogram revealed a left ventricular ejection fraction of 36% with reduced contractile function, and a stagnant, hazy echo within the descending aorta.

Discussion: In aortic dissection, the retention of contrast agent in the false lumen of the aorta is a crucial finding for diagnosis. However, we experienced a case where contrast agent accumulated in the descending aorta, caused by low ejection fraction of the left ventricle. Differential diagnosis from aortic dissection may be possible due to the gradual decrease in contrast agent over time. This case is valuable to report given the limited number of previous reports on this phenomenon.

Case Presentation: An 89-year-old male who had been holding dabigatran in the setting of transcarotid artery revascularization presented to the emergency department with sudden onset leg pain and weakness. Computed tomography angiography revealed acute aortic occlusion and thrombosis of the bilateral common iliac arteries. He underwent aortoiliac and femoral embolectomies and stenting of the bilateral common iliac arteries and returned to his baseline functional status.  

Discussion: Acute aortic occlusion is a rare but often devastating vascular emergency characterized by obstruction of the aorta by an embolus or thrombosis. Diagnosis can be challenging as it may be mistaken for spinal pathology, which can lead to delays in diagnosis. Despite advances in diagnostic modalities and interventions, acute aortic occlusion often results in high rates of major morbidity and mortality.

Case Presentation: A 19-year-old male presented for evaluation of breakthrough seizures after inability to refill his medication following recent immigration from Haiti. Previously, the patient had never received neuroimaging due to financial constraints and resource scarcity. Computed tomography and magnetic resonance imaging obtained in the emergency department was significant for large right frontoparietal open-lip schizencephaly with mass effect, a rare congenital neurologic disorder previously undiagnosed in this patient with intractable epilepsy.  

Discussion: Schizencephaly is a rare congenital neurodevelopmental disorder, which has diverse presentations ranging from intractable epilepsy to variable degrees of neurocognitive dysfunction. Treatment is generally focused on seizure management and rehabilitation. Furthermore, emergency physicians must be cognizant of patients with social determinants of health, which may have formerly prevented thorough evaluation and aid in appropriate treatment of these patients.

Case Presentation: A 63-year-old female presented to our emergency department with altered mental status and hypotension. She was transferred from the outpatient interventional radiology suite after becoming unresponsive during the removal of an inferior vena cava filter. The patient arrived somnolent with no other history available. Her physical exam was unremarkable. We used point-of-care-ultrasound to perform a rapid ultrasound for shock and hypotension (RUSH) exam. A large pericardial effusion along with signs of cardiac tamponade were identified. The cardiothoracic surgery team was notified, and the patient was taken to the operating room where pericardial blood and a large hematoma were evacuated. She recovered uneventfully and was discharged one 
week later.

Discussion: The above case describes a very unstable patient whose diagnosis was obtained using the RUSH exam. History and physical did not point to a clear etiology. Options were very limited. She was too unstable to go for computed tomography, and other tests such as electrocardiogram, chest radiograph, and lab work would have been non-diagnostic. It was only after the cardiac view of the RUSH exam was obtained that a pericardial effusion and developing tamponade were identified, facilitating timely management. The RUSH exam, like the extended focused assessment with sonography for trauma, is used to help determine pathologies that need immediate intervention. Incorporation in the evaluation of critically ill patients reduces the time to diagnosis. Our case is a unique example of how point-of-care ultrasound can be used to urgently identify a life-threatening pathology.

Case Presentation: We describe a case of an elderly female patient with a history of pseudogout who presented to the emergency department with atraumatic neck pain, fever, and malaise, who was found to have crowned dens syndrome on computed tomography imaging. 

Discussion: It is important that emergency physicians consider crowned dens syndrome in elderly patients presenting with neck pain and signs of inflammation to ensure timely diagnosis, treatment, and to minimize unnecessary invasive testing.

Case Presentation: We present a case of a patient who presented to the Emergency Department with palpitations, nausea, vomiting and chest discomfort found to have a reduced Ejection Fraction and basal wall hypokinesis on Point of Care Ultrasound concerning for reverse Takotsubo cardiomyopathy. 

Discussion: Reverse Takotsubo cardiomyopathy is a rare variant of Takotsubo cardiomyopathy and involves basal ballooning instead of apical ballooning. Ultrasound findings concerning for reverse Takotsubo cardiomyopathy are basal wall hypokinesis or akinesis. 

Case Presentation: A 32-year-old male with a history of left eye keratoconus presented to the emergency department with left eye pain and blurry vision for two days. Out of concern for corneal hydrops, ophthalmology was consulted, and the diagnosis was confirmed. Per ophthalmology recommendations, the patient was started on hypertonic saline and prednisolone eye drops and referred to a corneal specialist.

Discussion: Corneal hydrops is characterized by stromal edema caused by leakage of aqueous humor due to rupture of Descemet membrane. This case describes a patient with a keratoconus deformity who developed corneal hydrops.

Case Presentation: A patient with a known history of pustular psoriasis presented with sub-acute development of diffuse erythema and scaling of the skin with areas of exfoliation consistent with erythroderma.  She was ill appearing and required admission and aggressive treatment with steroid-impregnated wet dressings, topical emollients, analgesics and systemic immunosuppressants.

Discussion: Erythroderma is a dermatologic emergency characterized by diffuse erythema and scaling spanning >90% of skin surfaces and is associated with a mortality rate as high as 64%.  It is initially a clinical diagnosis and needs to be recognized and aggressively treated expeditiously to improve chances of a good outcome.

Case Presentation: A 13-month-old child with past medical history of congenital adrenal insufficiency presented to the emergency department with vomiting and diarrhea. Initially the child was noticed to have bradycardia with normal blood pressure. An electrocardiogram (ECG) showed tall T waves, broad QRS complex, and widened PR interval suggestive of severe hyperkalemia. The initial blood gas showed potassium of 10.7 millimoles per liter. The patient was started on calcium gluconate with immediate resolution of ECG changes. Further management with insulin, dextrose, and sodium olystyrene sulfonate led to normal potassium levels.

Discussion: Hyperkalemia is a life-threatening condition in children, especially in those with congenital adrenal insufficiency. The ECG showed different changes as the levels of serum potassium levels increased ranging from tall T waves, wide QRS complex, increased PR interval to arrythmias. Immediate treatment with calcium gluconate in such cases has significant cardioprotective effect. It is important to recognize the ECG changes manifested by changes in serum potassium levels. Our patient had classic ECG changes manifested in severe hyperkalemia.

Introduction: Achenbach syndrome is a rare, benign condition characterized by painful discoloration of
a finger. Recognition of this syndrome prevents unnecessary costly workup and risky interventions.

Case Report: A healthy, 54-year-old female was transferred to our emergency department (ED) from a
community ED for vascular evaluation of discoloration and numbness to her finger. After extensive
workup, medical intervention, and consultation with multiple specialists, she was diagnosed with
Achenbach syndrome.

Conclusion: Emergency physicians may practice good healthcare stewardship and limit invasive,
potentially harmful, and expensive workup by reassuring patients of the benign nature of this condition.

Introduction: Point-of-care ultrasound (POCUS) is a screening and diagnostic modality frequently used in the emergency department to assess patients with abdominal pain.

Case Report: We present a case describing the unusual finding of intraperitoneal fluid with loculations visualized in the right upper quadrant of the abdomen in a patient ultimately diagnosed with pelvic inflammatory disease (PID) with ruptured tubo-ovarian abscess caused by group A streptococcus (GAS), a pathogen rarely implicated in the disease.

Conclusion: Uncommon findings on abdominal POCUS should trigger further investigation. In a patient not responding to antibiotics administered for typical PID coverage, GAS should be considered as a possible etiology and a penicillin-based antibiotic administered to prevent progression to tubo-ovarianabscess formation, peritonitis, and sepsis.

Introduction: More than 40% of Americans are considered obese, resulting in annual healthcare costs estimated at $173 billion.1,2 Various interventions exist to address obesity including lifestyle modification, medications, and several surgical options. A novel ingestible intragastric balloon that self-deflates and is excreted approximately four months post-ingestion is being used in other countries such as Australia, Mexico, and several European countries. Currently, however, there are no US Food and Drug Administration-approved, commercially available options like this in the United States.

Case Report: We present a case of a 31-year-old, obese male who presented to the emergency department for abdominal pain approximately 10 weeks after the ingestion of an inflatable balloon for weight loss treatment in Mexico. He was found to have a gastric perforation and required an emergent exploratory laparotomy.

Conclusion: While ingestible, weight-loss balloons are not yet commercially available in the United States, emergency physicians may still encounter complications of such devices.

Introduction: Tendon injuries of the hand present a diverse spectrum of challenges in emergency medicine, ranging from minor strains to catastrophic ruptures. The superficial anatomy of hand tendons predisposes them to various mechanisms of injury, leading to complex medical scenarios. Here, we present a unique case of flexor tendon exposure secondary to abscess formation and spontaneous rupture, emphasizing the importance of prompt recognition and management of such injuries in the emergency department. 

Case Report: A 69-year-old male with multiple comorbidities presented with diffuse pain and a pale, pulseless right lower extremity, alongside a left hand exhibiting exposed flexor tendons due to recent abscess drainage. Despite broad-spectrum antibiotics and pain management, the patient underwent above-knee amputation due to vascular compromise. Evaluation revealed a complete flexor tendon rupture likely attributable to infection, necessitating emergent hand surgery at the bedside. 

Conclusion: Understanding the nuances of tendon injuries is paramount for emergency physicians, given their potential for lifelong disability if inadequately addressed. Awareness of risk factors and appropriate management strategies, including early surgical intervention when indicated, is essential in optimizing patient outcomes. This case serves as a reminder of the complexities involved in hand injuries and underscores the need for vigilance and tailored care in the emergency setting.

Introduction: Metallic luster dusts are decorative agents for cakes and other confections. While some powders are labeled “non-edible,” they are also marketed as “non-toxic.” We present a case of a child who developed acute metal pneumonitis after accidental aspiration of metallic luster dust. 

Case Report: A four-year-old presented to the emergency department (ED) in respiratory
distress after attempting to ingest gold decorative metallic luster dust. In the ED she was placed on supplemental oxygen. Her initial chest radiograph (CXR) was unremarkable. Her condition worsened despite high-flow nasal cannula oxygen, and she was intubated. A repeat CXR revealed patchy perihilar and peribronchial opacities. While receiving aggressive ventilatory support, her CXR worsened over the next 48 hours as bilateral interstitial and alveolar opacities progressed, likely representing acute metal pneumonitis with acute respiratory distress syndrome (ARDS). She remained intubated until hospital day (HD) 5, requiring supplemental oxygen until HD 9. She was discharged home on HD 10. A CXR obtained four months later demonstrated increased interstitial markings throughout both lungs with overinflation and subsegmental atelectasis. The patient had persistent dyspnea upon exertion, with pulmonology documenting that her symptoms were likely sequelae from inhalation of the cake luster dust. 

Conclusion: Non-edible metallic cake dusts are toxic. “Non-edible” labeling does not convey the health risks associated with handling by children, as evidenced by this case of metal pneumonitis with associated ARDS and chronic pulmonary disease. Accordingly, this descriptor should be abandoned for these products, and physicians should be aware of this potential complication. 

Introduction: Patients living with dementia as well as patients with neurological deficits are at significant risk for injury from multiple sources. Injuries may include falls, neglect, and, in some cases, self-injury. These patients require significant observation and closely monitored care. 

Case Report: A 90-year-old man presented to a suburban emergency department (ED) by his family, who cared for him at home. The following case report describes a patient with dementia, hemineglect, and bruxism from a previous stroke who suffered a self-induced, partial amputation of his own thumb on the neglected side of his body.   

Conclusion: Patients with dementia and neurologic deficits present frequently in the ED. These patients are at considerable risk of self-injury. The emergency physician should maintain vigilance in both screening for injuries and being aware of these risks when planning living arrangements after disposition from the ED.

Introduction: One of the less common and more life-threatening etiologies of adrenal insufficiency is immune checkpoint inhibitor (ICI)-induced primary adrenal insufficiency (PAI). Patients typically present with fatigue, malaise, and nausea and are treated empirically with hydrocortisone.  

Case Report: We present the case of a 59-year-old female who presented with hypotension, which initially was thought to be due to hypovolemia or medication-related, but was ultimately found to have PAI. 

Conclusion: This case highlights the importance of early detection of ICI-induced primary adrenal insufficiency, given its associated morbidity and mortality and its incidence in patients with a history of immunotherapy.

Introduction: An attempt at medical management is often the initial step in addressing esophageal obstruction from an impacted food bolus. Medical management, however, has limited success and often requires urgent endoscopy. We present a case in which standard medical treatment failed, but a swallowing augmentation maneuver resolved the obstruction. 

Case Report: A 67-year-old female presented with esophageal obstruction after eating steak. Transfer to higher level of care for endoscopy was initiated; however, the receiving gastroenterologist suggested an “upright posture, chin tuck, double swallow” maneuver. This immediately resolved the patient’s symptoms, and she was discharged home. 

Conclusion: This case suggests a novel, non-endoscopic technique for esophageal obstruction from food bolus impaction. 

Introduction: Although myocardial injury is common after blunt chest trauma, tricuspid valve injury associated with traumatic atrial septal defect resulting in acute hypoxia is an infrequent event. We report an unusual case of blunt chest trauma referred to us for unexplained hypoxemia, emphasizing the unusual nature of injury and the importance of comprehensive cardiac evaluation in such cases.  
 
Case Report: A 35-year-old male presented to the emergency department after falling from a tree from an approximate height of 15 feet. He sustained multiple rib fractures and a left hemopneumothorax. Examination revealed decreased air entry over the left hemithorax and a systolic murmur over the left sternal border. Electrocardiography showed a junctional rhythm, and troponin levels were significantly elevated. Despite tube thoracostomy, the patient remained hypoxemic. Cardiology evaluation revealed a flail tricuspid valve with severe regurgitation and a traumatic atrial septal defect (ASD). Bidirectional shunting across the atrial septal defect was causing hypoxemia. The patient underwent surgical repair of the ASD and tricuspid valve, which resulted in a successful outcome.   

Conclusion: Our case highlights the need for comprehensive cardiac evaluation in such patients. In addition to sonography for trauma, point-of-care echocardiographic examination should be a part of the focused assessment.

Introduction: Fahr’s disease and Fahr’s syndrome represent clinical entities that result in diffuse intracranial brain calcification, either by way of genetic mutation in the case of the former or by secondary endocrine dysfunction in the latter.

Case Report: We present a case of a middle-aged male with undiagnosed Fahr’s syndrome, identified during evaluation for symptoms of an acute posterior circulation cerebrovascular accident.

Conclusion: Fahr’s syndrome is a clinical constellation of symptoms and radiographic findings often seen in late-stage hypoparathyroidism. The intracranial calcifications associated may be related to an increased risk for intracranial cerebrovascular disorders such as ischemic or hemorrhagic infarct.

Keywords: Fahr’s syndrome; case report; posterior circulation stroke; cerebellar infarct.

Introduction

Percutaneous endoscopic gastrostomy (PEG) placement is a common procedure for patients requiring non-oral feeding.  One rare complication of PEG placement is the formation of a gastrocolocutaneous fistula that develops when bowel is caught between the stomach and abdominal wall during placement.  This report explores an elderly patient's gastrocolocutaneous fistula development months post-PEG placement who presented with malodorous leakage from the gastrostomy tube to the Emergency Department (ED).

Case Report

A 73-year-old male on hospice presented to the ED with malodorous leakage from his PEG tube.  He had received the PEG tube four months prior to this presentation and had it replaced once at an outside hospital due to blockages.  In the ED, his PEG tube was found to have a deflated balloon stopper.  The PEG tube was replaced, but the feculent discharge persisted.  Imaging showed the tube's position in the transverse colon.  The patient underwent non-surgical management, with PEG tube removal and nutritional support via nasogastric tube.  He was discharged with improvement of PEG site. 

Conclusion

Gastrocolocutaneous fistula should be considered in patients experiencing unexpected PEG tube drainage or feeding-related complications such as diarrhea.  Careful replacement techniques after dislodgement or blockage are important.  Radiologic confirmation should be considered after replacement of tubes with feculent drainage.  The rarity of gastrocolocutaneous fistula cases in literature explains the lack of standardized management approaches.  Clinical signs such as feculent leakage through PEG tube site should prompt recognition and diagnosis by the ED clinician. 

Introduction: Aortic dissection is a devastating clinical entity with a variety of presentations and requires prompt recognition and management. To our knowledge this is the first reported case of a patient who presented with a globus sensation and was diagnosed with an aortic dissection prior to clinical deterioration.

Case Report: The patient presented with an episode of near-syncope and globus sensation. Imaging studies revealed a type A aortic dissection with hemopericardium requiring emergent operative intervention. Unfortunately, the patient’s course was complicated by significant hemorrhage and periods of hypotension, and the family ultimately decided to pursue comfort care.

Conclusion: Aortic dissections can present with diverse and elusive symptoms, which can mimic other more common conditions, potentially leading to misdiagnosis and delayed intervention

ABSTRACT

Introduction
We present a unique case report of a patient who presented to the emergency department
with stroke-like symptoms found to have a spontaneous left sided internal carotid artery
dissection. 
Case Report
The patient was treated successfully with thrombectomy, and subsequently developed
contralateral symptoms caused by a right sided internal carotid artery dissection. This was
managed with a second contralateral thrombectomy.  The patient’s course was complicated by
persistent and mild hypotension, postulated to be secondary to bilateral carotid baroreceptor
trauma from the dissections. 
Conclusion
This case highlights the importance of close neurological monitoring for patients,
preferably in a neurologic critical care setting, during and after invasive treatments such as
systemic thrombolytic administration or mechanical thrombectomy, as identifying the patient’s
subsequent development of contralateral symptoms in a timely fashion was key to his positive outcome.  An additional factor which had a positive impact on this outcome was the use of the RAPID Artificial Intelligence software which assists in determining whether thrombectomy may
be indicated prior to receiving a formal radiologist read on CT angiography/perfusion studies. 
AI technologies such as this have a great potential to augment and expedite patient care.

Introduction: Propofol is an anesthetic agent commonly used in emergency department (ED) procedural sedation. It is often preferred in orthopedic procedures because of its muscle-relaxing properties. Rarely, however, it can induce agitation and muscle hypertonicity.

Case Report: A 58-year-old man presented to the ED with a left ankle fracture-dislocation. Propofol was used to facilitate procedural sedation, but the patient became mildly agitated. Ketamine was used to achieve full induction, after which propofol was used again to facilitate muscle relaxation. Near the end of the procedure, the patient had opisthotonos and masseter spasm requiring bag-valve-mask ventilation and subsequent intubation. This reaction was ultimately attributed to adverse effects of the propofol.

Conclusion: While propofol is generally well tolerated, it can potentially cause agitation, hypertonicity, and other side effects such as muscle spasms and seizure-like activity. Acknowledging and preparing for these risks can potentially improve patient outcomes.