Clinical Practice and Cases in Emergency Medicine

Massive and submassive pulmonary emboli (PE) are rare but potentially life-threatening medical conditions that necessitate immediate recognition and appropriate treatment. We report a 52-year-old man who was found to have a submassive central saddle and extensive bilateral PEs after experiencing a syncopal event and who had evidence of right heart strain and pulmonary hypertension. He was subsequently treated with catheter-assisted thrombectomy and pulmonary artery tissue plasminogen activator administration. This case report presents an outcome in a patient who received an innovative therapy that has not been well established in this subset of patients.

We describe a patient who presented to the emergency department complaining of generalized weakness, dark stools, and urinary retention who was found to have two large abdominal aortic aneurysms (AAA) compressing his bilateral ureters with associated hydronephrosis and renal insufficiency. In elderly male patients presenting with signs of obstructive uropathy, AAA should be considered as a potential cause.

Infective endocarditis is a deadly disease that can present as a myriad of symptoms and thus itsdiagnosis can be missed. We present a case of infective endocarditis presenting as endogenousendophthalmitis and a ruptured mycotic aneurysm. This case illustrates both the complexity ofinfective endocarditis as a disease process and the more subtle diagnostic criteria as outlined by theModified Duke Criteria.

Gastric outlet obstruction (GOO) is a rare condition occurring as a consequence of numerous processesthat prevent gastric emptying. Presenting symptoms of GOO are non-specific and include nausea, vomiting, epigastric discomfort and decreased appetite. The diagnosis of GOO is often challenging. Emergency physicians must have a heightened awareness of GOO to ensure proper diagnosis and rapid treatment. Although the gold standard for diagnoses of GOO is endoscopy, many patients are identified by computerized tomography imaging. Point-of-care ultrasound (POCUS) is a rapid and non-invasive technique for evaluating patients in the emergency department. Previous literature has validated the use of ultrasound in diagnosing various intra-abdominal pathologies including bowel obstructions and appendicitis; however, there is limited research on evaluating gastric disease.1 We report three cases of GOO diagnosed with the “black-and-white cookie” sign on POCUS.

Atrial thrombi can be a complication in patients with indwelling central-line catheters, and failure to diagnose can potentially be lethal. This condition is generally associated with profound hypoperfused states. Here we present a case of a 77-year-old female who arrived to our emergency department for evaluation of a leg laceration and was incidentally found to have a catheter-related right atrial thrombus using point-of-care ultrasound.

Complete small bowel obstruction (SBO) is a common surgical emergency often resulting from adhesive bands that form following iatrogenic peritoneal injury. Rarely, adhesive SBO may arise without previous intra-abdominal surgery through other modes of peritoneal trauma. We present the case of a male evaluated in the emergency department for a closed-loop small bowel obstruction due to an adhesive band that likely formed after blunt abdominal trauma over two decades earlier. We review the epidemiology, pathophysiology, and treatment options for similar cases of adhesive SBO.

The technique of using percutaneous endoscopic gastrostomy (PEG) for long-term enteral feeding is well established and commonly used. While the technique is relatively safe and simple, the gastrostomy tube itself may deteriorate or malfunction, requiring a replacement tube. We present a case of a 58-year-old woman who was found to have gastric outlet obstruction from the inflated balloon of a Foley catheter being used as a replacement for her PEG tube. This case illustrates a potential complication of using a Foley catheter in place of commercially available gastrostomy tubes.

Occult caustic ingestion in the pediatric population is a challenging diagnosis to make in the emergency department. Failure to suspect and diagnose a caustic ingestion can lead to potentially life-changing comorbidities. Historically, the diagnosis of caustic ingestion has been clinical without any suitable diagnostic tools to aid in the suspicion of occult cases. In this case, we describe a novel use of ophthalmic pH paper to diagnose caustic ingestion in a three-year-old.

Isolated dissection of the superior mesenteric artery is a novel disease often presenting with vague signsand symptoms. Although the disease entity is rare, the potential for morbidity and mortality is high. This isa case report of a healthy 58-year-old male presenting with diffuse persistent abdominal pain. Diagnosedon computed tomography, this patient’s condition was managed conservatively with anticoagulants.

We present the case of a 56-year-old man with a history of type 2 diabetes mellitus who presented to the emergency department in diabetic ketoacidosis (DKA) with only a slightly elevated serum glucose. The patient was taking empagliflozin (Jardiance®), a sodium-glucose cotransporter-2 inhibitor. There are increasing reports of this unusual complication in patients taking this class of medication. Emergency physicians need to be aware of this complication, as the euglycemia and history of type 2 diabetes mellitus can make the correct diagnosis of DKA challenging.

The rapid diagnosis and treatment of tuberculosis (TB) is necessary to prevent the spread of infecti onto others and reduce morbidity and mortality. Atypical presentations are not often considered in the differential. This patient presented with fever and abdominal pain. Computed tomography of the abdomen and pelvis showed small bowel obstruction, initially attributed to the patient’s Crohn’s disease. Chest radiograph showed diffuse interstitial lung disease, consistent with his diagnosis of sarcoidosis. He had multiple recent negative tuberculin skin tests documented. After being admitted to the surgical service and started on antibiotics, the diagnosis of abdominal TB was discovered following surgical exploration and tissue sampling.

Pediatric fever is one of the most common presenting complaints to emergency departments (ED). While often due to a viral illness, in young children without a source the most common bacterial infection is pyelonephritis. For this reason, when no focal source can be identified a urinary specimen is recommended. In young children who are unable to urinate on demand, a straight catheter is required to obtain a sterile specimen. This is generally a benign procedure and is performed frequently in EDs. We report a case of a young girl who underwent straight bladder catheterization and was subsequently found to have a retained catheter that had become knotted in the bladder. This case report highlights a rare complication of this common procedure and describes the technique required to remove the catheter. An understanding of these issues may avoid the need for transfer to a pediatric facility or for subspecialty consultation.

Exaggerated arthropod bite reactions causing hemorrhagic or necrotic bullous lesions can mimic other serious conditions such as cutaneous anthrax, brown recluse spider bite, and tularemia. A 55- year-old, healthy woman presented to the emergency department with a 3.5-centimeter painless, collapsed hemorrhagic bulla at the left costal margin. She was afebrile and had no systemic symptoms. Laboratory evaluation was unremarkable. She was prescribed silver sulfadiazine cream and mupirocin ointment. The area denuded two days later and the lesion completely healed. This case illustrates the broad differential to be considered when evaluating patients with hemorrhagic bullous lesions.

Babesiosis, mainly endemic within the Northeastern and upper Midwestern regions of the United States, is a zoonotic disease that invades and lyses red blood cells, which can result in hemolytic anemia. Its decreased incidence in comparison to Lyme disease is often attributed to the greater asymptomatic infection proportion and insufficient physician awareness or suspicion of this disease. Here we describe a case of undifferentiated febrile illness with hemolytic anemia that yielded the diagnosis of babesiosis.

While the use of ultrasound to diagnose a fetal intracranial hemorrhage in utero is not a new concept, the emphasis of point-of-care ultrasound (POCUS) at the initial trauma presentation of the mother to evaluate for fetal injury is novel. A review of the literature failed to reveal a single case report where in POCUS inthe workup of a pregnant trauma patient led to the diagnosis of fetal intracranial hemorrhage. This is such a case.

We present the case of an 88-year-old female who presented to the emergency department (ED) with suspected massive pulmonary embolism (PE) causing respiratory failure, right heart strain, and shock, who despite early and aggressive resuscitation with vasopressors and continuous peripheral infusion of tissue plasminogen activator (tPA), suffered a cardiac arrest in the ED. We describe the approach of a tPA bolus directed through a central venous catheter, resulting in return of spontaneous circulation and immediate improvement in physiologic parameters prior to confirmation of PE with computed tomography angiogram. We further hypothesize that in patients deemed too unstable to be transferred for embolectomy or catheter-directed thrombolysis, central venous catheter-directed bolus tPA may be more effective than peripheral infusion alone.

Mallet finger is a common injury often treated without operative intervention. When there isconcern for skin integrity or a large articular component is involved, simple operative repair maybe needed. This has been performed with transarticular Kirschner wire (K-wire) placement. Thiscase discusses the novel use of an intraosseous vascular access device (IOVAD) as a potentialadjunct to stabilization and alternative to treatment with operative K-wire fixation. A 53-year-old manwas successfully treated using the inner trocar of the EZ-IO® system for a mallet finger injury withlaceration, shown in comparison with another standard manual pinning approach using an 18-gaugeneedle. An IOVAD can be used successfully as an alternative to K-wire placement in patients withmallet finger injuries.

A 20-year-old male United States Marine Corps recruit was admitted to the emergency department with a two-week history of profound, bilateral upper-extremity weakness and numbness. Initially thought to be the result of his military training, the cause was ultimately determined to be genetic. This case represents a rare cause of a somewhat common presenting symptom: chronic symmetric polyneuropathy.

Lemierre syndrome is a rare condition characterized by a septic thrombophlebitis of the internal jugular vein with septicemia and metastatic foci of infection. It typically occurs as the result of an infection in the head and neck, most commonly pharyngitis. For reasons that are unclear, the incidence of Lemierre syndrome has been increasing over the past 15 years. Diagnosis of Lemierre syndrome is often delayed, and identification of internal jugular vein thrombosis is often the first indicator of its presence. We report a case of Lemierre syndrome associated with a laryngeal carcinoma.

Gastrointestinal stromal tumors (GISTs) are rare, and patients usually present with vague and non-specific abdominal symptoms. This report illustrates how point-of-care ultrasound performed in the emergency setting in the evaluation of such patients helped in management of two undiagnosed GIST patients.