Volume 1, Issue 2, 2017
Inadvertent Intrathecal Administration of Local Anesthetics Leading to Spinal Paralysis with Lipid Emulsion Rescue
Bupivacaine and ropivacaine are local anesthetics frequently used for interscalene nerve blocks,which are generally well tolerated; however, some complications include pneumothorax, Hornersyndrome, nerve injury and cardiovascular toxicity from vascular injection. On rare occasions, it maybe associated with spinal paralysis. While the treatment is mostly supportive, we report an unusualcase of administering intravenous lipid emulsion (ILE) as part of resuscitative efforts to hastenneurological recovery from spinal shock.
A 29-year-old male presented to our emergency department with complaints of a left frontal headache, similar to his prior headaches. He also reported about 30 minutes of facial and tongue numbness, left arm weakness, slurred speech and changes in hearing that had resolved prior to his arrival. Despite the short duration of the other neurologic symptoms, he also endorsed persistent “dizziness.” Despite his history of recurrent headaches, he had never had any neuroimaging. This, as well as his reports of new neurological symptoms, prompted his care team to obtain a non-contrast brain computed tomography. The findings were consistent with a mass with mild hydrocephalus. Patient underwent neurosurgical resection of the mass at a tertiary center. He did well after surgery and was discharged on postop day 6 with a diagnosis of colloid cyst.
Avulsion of the lesser trochanter is an uncommon injury. In children and adolescents it usually occursas a sports injury via traumatic avulsion of the psoas major tendon. In adults, isolated fractures of thelesser trochanter are most commonly pathological due to metastatic tumor invasion of the proximalfemur. This case report documents how a 14-year-old boy, who presented with an avulsion of thelesser trochanter of the proximal femur following a seemingly atraumatic shot put session at a trackand field event, was diagnosed and successfully treated with a conservative approach.
Pyogenic flexor tenosynovitis is a rare though well known infectious process of the flexor tendon sheath of the hand. This condition is generally diagnosed in adults by the observance of the four Kanavel signs. Application of the Kanavel signs to diagnosis in the pediatric population, however, is of unknown utility. We present the case of a 13-month-old male with pyogenic flexor tenosynovitis who presented with all four of the Kanavel signs.
Emphysematous pyelonephritis (EPN) is a rare, life-threatening infection, and misdiagnosis asuncomplicated pyelonephritis is potentially fatal. Point-of-care ultrasound (POCUS) is a valuable toolfor evaluation of the kidneys in patients with septic shock and pyelonephritis. While used primarilyto assess for the complication of obstruction and hydronephrosis, POCUS may also detect signs ofEPN and prompt surgical consultation for nephrectomy. We present a case in which the emergencyphysician diagnosed EPN by POCUS in a patient with septic shock and pyelonephritis.
Wernicke’s encephalopathy (WE) is traditionally seen in the emergency department in patients with chronicalcohol abuse. WE can result in significant morbidity and mortality if untreated, making early diagnosis andintervention paramount. We discuss a case of WE in a 63-year-old female with no history of chronic alcoholabuse, who presented with bilateral opthalmoplegia that resolved after intravenous thiamine administration.This case report highlights the varied clinical settings other than chronic alcohol abuse in which thediagnosis of WE should be considered.
Myxedema crisis (MC) is a rare but life-threatening illness characterized by multi-system organ impairmentfrom thyroid hormone deficiency that is often brought on by an eliciting event. We present the case of MCwith a rapid progression of hypothermia, altered mental status, and respiratory failure that was instigatedby a flash burn to the face. The patient’s condition was refractory to rewarming and supportive efforts untilthyroid hormone was replaced. This case illustrates the need for a high index of suspicion for patients with arapid onset of metabolic encephalopathy immediately after an injury or burn.
This is a case report of a patient with an unusual presentation of an inferior vena cava (IVC) filter migrationwith a delayed presentation, and without electrical or valvular abnormalities. We discuss considerations andpotential complications from IVC filter placement from the emergency physician perspective.
Phlegmasia cerulea dolens (PCD) is a rare entity that is associated with significant morbidity and mortality, including limb ischemia and pulmonary embolism. Point-of-care ultrasound (POCUS) can expedite the diagnosis, leading to earlier life- and limb-saving treatment. Although primarily used for assessing for the presence of deep venous thrombosis, in the appropriate clinical setting POCUS can also be used to diagnosis PCD as well as to distinguish between venous and arterial occlusion, which can lead to a difference in management. We present a case of phlegmasia cerulea dolens after mild trauma in a patient with an underlying hypercoagulability disorder diagnosed by an emergency physician using POCUS, which expedited treatment with catheter-directed thrombolytic therapy.
Ovarian torsion during pregnancy is a fairly uncommon complication with a high patient morbidity and fetal mortality if not immediately treated. Ovarian torsion should be considered a clinical diagnosis, and a high level of clinical suspicion is needed by the practitioner to ensure that this diagnosis is not missed. We present an unusual case of intermittent ovarian torsion discussing both the presentation and the operative and post-operative management.
Chylothorax represents an uncommon clinical entity with multiple etiologies. Chylothorax following bluntthoracic trauma is typically associated with posterior rib fractures or thoracic vertebral fractures or dislocations.The occurrence of a traumatic chylothorax in the absence of associated injuries is a rare event. We reporta case of a 51-year-old patient who developed bilateral chylothorax after sustaining blunt trauma withoutradiographic evidence of traumatic injury. A 51-year-old male presented to the emergency departmentcomplaining of progressively worsening shortness of breath and associated chest pain for the prior one weekfollowing a fall down several concrete steps. On evaluation, the patient was found to have bilateral pleuraleffusions with no radiographic evidence of traumatic injury, including posterior rib or thoracic vertebral fractures.Subsequent thoracentesis and pleural fluid analysis were performed confirming the diagnosis of chylothorax.Management included repeated thoracentesis, diet modification and octreotide administration, which resultedin dramatic improvement and eventual resolution of symptoms. Non-iatrogenic traumatic bilateral chylothoraxin the absence of other radiographically demonstrated bony or soft tissue injury is a rare event. Chylothoraxshould be considered in the differential diagnosis of patients presenting with chest pain or shortness of breathfollowing blunt trauma and evidence of pleural effusion, even in the absence of obvious traumatic fracture orinjury on radiographic imaging.
Spinal Epidural Abscess Complicated by Meningitis, Sepsis and Thrombocytopenia in a Patient Lacking Traditional Risk Factors
Spinal epidural abscess is a rare diagnosis with a classic triad of fever, spinal pain and neurologicdeficits. Only a small proportion of patients have all three findings, making the diagnosis challenging.Here we present a case of cervical and thoracic spinal epidural abscess complicated by meningitis,sepsis and thrombocytopenia in a patient lacking traditional risk factors. The patient was initiallytreated non-operatively secondary to thrombocytopenia but subsequently required transfer to atertiary care facility for surgical drainage after clinical deterioration. This case report highlights theneed for a high index of suspicion and low threshold for imaging when considering this rare butpotentially deadly condition.
Quality Initiatives May Affect Diagnostic Accuracy: STEMI Mimics in an Age of Decreasing Door to Balloon Time
A 53-year-old male with several cardiac risk factors presented to the emergency department with backpain and an electrocardiogram concerning for an anterior ST-elevation myocardial infarction. The patientdecompensated hemodynamically and a point-of-care ultrasound revealed a small pericardial effusion.An aortic dissection was ruled out by computed tomography angiography and coronary catheterization didnot reveal a culprit lesion. The diagnosis of tamponade was made in the catheterization laboratory aftermeasurement of intra-cardiac diastolic pressures and the patient’s symptoms resolved after drainage of 100mL of pericardial fluid.
- 2 supplemental videos
Should Pharmacies Be Included in Medication Reconciliation? A Report of Recurrent Valproic Acid Toxicity
Including outpatient pharmacies in the medication reconciliation process upon hospital discharge isnot commonly performed. This case highlights the consequences of a patient refilling a discontinuedprescription for valproic acid (VPA). We present a 32-year old male found unresponsive after ingestingdelayed release divalproex sodium. Cerebral edema was visualized on magnetic resonance imaging.Hemodialysis and levo-carnitine treatment led to improved mental status, and VPA was discontinued.The same patient presented with VPA overdose eight months later after he continued to fill an outda tedprescription. This case highlights consequences of VPA toxicity; it also demonstrates an opportunity toimprove patient safety and high-value care by collaborating with outpatient pharmacies in the medicationreconciliation process upon hospital discharge.
Acute ST Segment Elevation Myocardial Infarction and Massive Pericardial Effusion Due to Infective Endocarditis
Chest pain is a common complaint evaluated in the emergency department. While chest pain in a 22-year-old patient is typically a complaint of low acuity, high-acuity cases that rival those of the older patient population are well documented. We describe a case of complicated infective endocarditis in which point-of-care ultrasound (POCUS) aided the diagnosis of ST-elevation myocardial infarction secondary to a septic thrombus in a 22-year-old female with a history of intravenous drug use. Emergency physicians should be aware of the rare high-acuity cases as well as the impact of POCUS on rapid clinical assessment and treatment of patients of all ages presenting with chest pain.
- 2 supplemental videos
Thyrotoxic periodic paralysis is a rare cause of acute paralysis in the emergency department (ED). The disorder is generally thought to be due to acute hypokalemia leading to paralysis. Treatment is generally targeted at correcting the thyrotoxic state with careful potassium repletion. We present a rare case of normokalemic, thyrotoxic periodic paralysis with acute resolution while in the ED.
Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA.
Early antibiotic administration is critical in cases of sepsis and severe community-acquired pneumonia, which is frequently due to Streptococcus pneumoniae, Staphylococcus aureus, Legionella species, or influenza. We describe the case of a 29-year-old previously healthy man who presented to an urban emergency department (ED) in the North Central U.S. with fever, hip pain, severe hypoxemia, and diffuse pulmonary infiltrates. He was intubated and received piperacillin/tazobactam, levofloxacin, vancomycin, and oseltamivir; given his fulminant presentation and predicted high mortality, doxycycline, methylprednisolone, and amphotericin B were also administered empirically in the ED. A respiratory culture eventually grew Blastomyces dermatitidis, and the patient survived. Severe acute respiratory distress syndrome due to fulminant pneumonitis carries a high mortality. Faced with this scenario and no room for error, it is important that the emergency physician cover for all possible pathogens, including zoonotic bacteria and endemic fungi.
Images in Emergency Medicine
- 2 supplemental videos
- 2 supplemental videos