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: 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.