Clinical Practice and Cases in Emergency Medicine

Amphetamine-induced Reverse Takotsubo Syndrome: Further Implications

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: 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: 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: Acute focal bacterial nephritis is an underdiagnosed condition. It clinically resembles acute pyelonephritis. If unrecognized and undertreated, it may progress into complications (kidney abscess and scars). Contrast-enhanced computed tomography (CT) reveals specific images of the disease and is considered the gold standard to make the diagnosis. 

Case Report: A 63-year-old male patient with solitary kidney presented with symptoms compatible with acute pyelonephritis. Kidney ultrasound was not conclusive. Because of persisting high-grade fever not resolving after 48 hours of antibiotics, a contrast-enhanced CT was then performed, and the diagnosis of acute focal bacterial nephritis was made. A repeat CT after three weeks of intravenous (IV) antibiotics showed marked improvement of the intrarenal lesions, and a fourth week of IV antibiotics was dispensed.

Conclusion: Diagnosing acute focal bacterial nephritis is important (particularly in a patient with solitary kidney). This will dictate the therapy duration. Unlike acute pyelonephritis, acute focal bacterial nephritis requires at least three weeks duration of antibiotics to avoid progress into further complications. 

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: 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: 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: 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: 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: Wernicke encephalopathy is a clinical diagnosis that requires a high degree of clinical suspicion to recognize. We report a case of a pregnant patient developing Wernicke encephalopathy in the setting of severe hyperemesis gravidarum. 

Case Report: The patient was a 22-year-old female 13 weeks pregnant presenting to the emergency department (ED) with neurological deficits after several weeks of hyperemesis gravidarum requiring hospitalization. Exam and workup ultimately revealed the diagnosis of Wernicke encephalopathy. Her symptoms improved after administration of thiamine. 

Conclusion: Wernicke encephalopathy is a consequence of thiamine deficiency, commonly seen in patients with alcohol use disorder but also with other causes of nutritional deficiency, such as hyperemesis gravidarum. Wernicke encephalopathy is a clinical diagnosis that requires a high degree of suspicion and is, therefore, often missed in the ED setting. Treatment is supplemental thiamine and management of the root cause for nutritional deficiency.

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: 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: 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: 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.

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 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.