Volume 4, Issue 1, 2020
CPC-EM Full-Text Issue
A 39-year-old female presents to the emergency department with chest pain and shortness of breath. Her electrocardiogram suggests ST-elevation myocardial infarction, but she has no atherosclerotic risk factors. She is gravida 4, para 4, and four weeks postpartum from uncomplicated vaginal delivery. She is diaphoretic and anxious, but otherwise her exam is unremarkable. Cardiac enzymes are markedly elevated and point-of-care echocardiogram shows inferolateral hypokinesis and ejection fraction of 50%. In this clinicopathological case, we explore a classically underappreciated cause of acute coronary syndrome in healthy young women.
Astonishing Cases and Images in Emergency Medicine
Ocular trauma is one of the most common and vision-threatening ophthalmic presentations with a wide spectrum of complications, such as bleeding, infection, vision loss, and enucleation. A 64-year-old-male presented to the emergency department (ED) with a self-inflicted orbital penetrating injury with a hair comb. Computed tomography showed the comb traversed the medial orbit inferior to the medial rectus but did not damage the optic nerve; there were no globe or orbital wall fractures. His ocular exam was significant for a right eye afferent pupillary defect and decreased visual acuity 20/800, consistent with optic neuropathy. Primary concerns were stabilizing and removing the foreign body without causing further damage in the setting of an uncooperative patient. The comb was removed with the aid of local and systemic analgesia using gentle traction and normal saline irrigation. The patient was admitted for systemic and topical antibiotics and showed improvement in visual acuity and resolution of his optic neuropathy. This case illustrates the importance of rapid ED assessment and management of complex penetrating ocular trauma. Examination should specifically look for signs of globe rupture and optic nerve injury. Expedited foreign body removal should be managed together with an ophthalmologist with procedural sedation and broad-spectrum antibiotics to avoid further visual and infectious complications.
Medical Legal Case Report
Beware of Reversal of an Anticoagulated Patient with Factor IX in the Emergency Department: Case Report of a Medical-Legal Misadventure
In this article we present a case of a patient who received reversal of anticoagulation therapy with factor IX in violation of hospital guidelines. As a direct result, myocardial infarction and ischemic stroke occurred, leaving the patient neurologically debilitated. Factor IX is indicated in the setting of warfarin-induced, life-threatening bleeding. The patient’s care was provided by an intern with attending physician supervision. Delayed charting and questionable shared decision-making were present in the care. We discuss usage of factor IX, liability for supervision of physicians in training, and factors that can lead to plaintiff awards.
Administration of Nebulized Ketamine for Managing Acute Pain in the Emergency Department: A Case Series
Ketamine administration in sub-dissociative doses in the emergency department (ED) results in effective pain relief in patients with acute traumatic and non-traumatic pain, chronic pain, and opioid-tolerant pain. This case series describes five adult ED patients who received nebulized ketamine for predominantly acute traumatic pain. Three patients received nebulized ketamine at 1.5 milligrams per kilogram (mg /kg) dose, one patient at 0.75 mg/kg, and one patient at 1 mg/kg. All five patients experienced a decrease in pain from the baseline up to 120 minutes. The inhalation route of ketamine delivery via breath-actuated nebulizer may have utility for managing pain in the ED.
This is a case series of six emergency department (ED) patients who received an ultrasound-guided serratus anterior plane block (SAPB) for a variety of painful conditions. Our cases illustrate the feasibility and analgesic efficacy of the SAPB in providing pain management in ED patients with a variety of painful syndromes, including those with severe pain from multiple rib fractures, herpes zoster, and tube thoracostomy placement. In addition, we found no adverse events in our case series.
- 1 supplemental video
The clinical presentation of diabetic ketoacidosis in pregnancy (DKP) is similar to that observed in nonpregnant women, although reports suggest the presenting blood glucose level may not be as high. It is hypothesized that lower, maternal fasting glucose levels are a result of both the fetus and the placenta consuming glucose. We report the case of a 38-year-old woman gravida 2, para 0, abortion 1 with type 1 diabetes who had euglycemic diabetic ketoacidosis and review the literature on DKP, with a focus on diagnosis, treatment, and monitoring of the mother and fetus.
Musculoskeletal complaints are one cornerstone of urgent issues for which orthopedic and emergency physicians provide care. Ultrasound can be a useful diagnostic tool to help identify musculoskeletal injuries. We describe a case of bilateral patellar tendon rupture that presented after minor trauma, and had the diagnosis confirmed at the bedside by point-of-care ultrasound.Physicians caring for patients with orthopedic injuries should be familiar with the use of ultrasound to diagnose tendon ruptures.
- 2 supplemental videos
A 10-year-old male vaccinated against varicella had developed left-sided rashes on his thoracic region in single dermatomal distribution, which is consistent with herpes zoster. Although herpes zoster is uncommon in children, especially with the current vaccination regimen, this case report serves as a reminder to consider it in one’s differential diagnoses, even in the immunocompetent, fully immunized pediatric patient. This is a case report of a previously healthy, fully vaccinated child who developed herpes zoster.
A 27-year-old female presented to the emergency department with sudden onset shortness of breath. A diagnosis of bilateral catamenial pneumothoraces was made following chest radiograph. Catamenial pneumothorax is a recurrent spontaneous pneumothorax that occurs in 90% of affected women 24-48 hours after the onset of their menstruation; 30-50% of cases have associated pelvic endometriosis. Symptoms can be as simple as chest pain or as severe as the presentation of this patient who was initially found to be in significant respiratory distress.
Luxatio erecta is a description for a specific and rare type of shoulder dislocation where the humeral head dislocates directly inferior. This rare form of glenohumeral dislocation accounts for only 0.5% of shoulder dislocations. It is even less common for both shoulders to be bilaterally dislocated inferiorly with the characteristic “hands up” posture. A limited number of these bilateral occurrences are described in the literature to date and most have been from higher energy trauma. We have described a low energy case of bilateral luxatio erecta and the reduction method used and the continued instability following successful reduction under procedural anesthesia.
Carbon monoxide (CO) poisoning is typically treated by administration of oxygen via non-rebreather mask (NRB). High-flow nasal cannula (HFNC) is an alternative to NRB in a variety of disease states. We report a case of the novel use of HFNC in the treatment of acute CO poisoning. A 29-year-old man presented with a carboxyhemoglobin (COHb) level of 29.8%. He was treated with HFNC, and COHb levels declined to 5.4% in 230 minutes. Given several theoretical advantages of HFNC relative to NRB, HFNC is a potential option for use in the treatment of CO poisoning.
Recent epidemiologic data demonstrate increasing rates of neurosyphilis, particularly among those in the community of men who have sex with men and those coinfected with the human immunodeficiency virus (HIV). Here we discuss a case of early neurosyphilis and new HIV diagnosis in a 27-year-old previously-healthy trans woman presenting for the second time with progressive, ascending weakness and cranial nerve VI palsy. Emergency physicians should consider this rare but highly morbid diagnosis, given the rising prevalence of neurosyphilis among at-risk patients and those with new neurologic deficits.
Formic acid, when combined with sulfuric acid, gets dehydrated to form carbon monoxide (CO). A 27-year-old female was found unconscious inside a car, next to a container with a mixture of sulfuric acid and formic acid. Concentrations of up to 400 parts per million of CO were measured inside the car post ventilation. Serum carboxyhemoglobin level was 15% after receiving 100% oxygen for two hours. The patient received hyperbaric oxygen therapy after which she was extubated with normal mental status. On follow-up after three months, she demonstrated neurocognitive abnormalities suggestive of delayed neurological sequelae from CO exposure.
Alteplase, or tissue plasminogen activator (tPA), lyses clots by enhancing activation of plasminogen to plasmin. Conversely, tranexamic acid (TXA) functions by inhibiting the conversion of plasminogen to plasmin, which inhibits fibrinolysis. TXA has proven safe and effective in major bleeding with various etiologies. A 76-year-old male developed acute ischemic stroke symptoms. Systemic alteplase was administered and he showed clinical improvement. Shortly thereafter, the patient became hypotensive and lost pulses. Point-of-care ultrasound revealed cardiac tamponade. TXA was immediately given to inhibit fibrinolysis since cryoprecipitate and blood products were not immediately available. Pericardiocentesis was performed and successfully removed 200 milliliters of blood with return of pulses. Clinicians must consider TXA as a rapidly accessible antagonist of tPA’s fibrinolytic effects.
A paraspinal abscess is an uncommon condition frequently diagnosed late due to equivocal symptoms, which can lead to increased morbidity and mortality. Commonly associated risk factors include prior invasive spinal procedures, diabetes mellitus, trauma, chronic steroid use, malnutrition, intravenous drug use and an immunocompromised state. Pediatric paraspinal abscesses are not well documented in the literature. We report a case of a two-year-old female presenting with fevers, lower back pain, and decreased oral intake ultimately diagnosed with isolated lumbar paraspinal abscess. The patient underwent an ultrasound-guided percutaneous drainage of the abscess, subsequently improving, and was discharged within 48 hours of presentation.
The efficacy of using bisphosphonate therapy to treat osteoporotic patients is becoming more widely known, but the potential side effects may not be. While this class of drugs is generally safe, concerns have emerged regarding risks of atypical subtrochanteric fractures associated with long-term use. There have been a number of case reports discussing the association of patients on bisphosphonates who suffer a non-traumatic or a low-energy mechanism of injury atypical of subtrochanteric fractures. The purpose of this case report is to raise awareness of this potential side effect and provide increased clinical suspicion for this rare type of fracture.
We present a rare case of cesarean scar ectopic pregnancy as diagnosed by transvaginal ultrasonography. Cases such as this are rare, but they are becoming more commonly detected with the growing frequency of cesarean sections, improving technology, and provider proficiency with point-of-care ultrasound. Quick identification of this dangerous diagnosis can be life saving for the patient, as the outcomes of ruptured cesarean ectopic pregnancy may include significant hemorrhage, uterine rupture, and possibly maternal death.
- 1 supplemental video
Infectious mononucleosis is primarily caused by Epstein-Barr virus (EBV) and is a common di-agnosis made in emergency departments worldwide. Subclinical and transient transaminase ele-vations are a well-established sequela of EBV. However, acute cholestatic hepatitis is a rare complication. EBV infection should be considered as part of the differential diagnosis in patients with an obstructive pattern on liver function tests without evidence of biliary obstruction demon-strated on advanced imaging.
Obesity is an epidemic that adversely affects millions of Americans. In 2017, the Center for Disease Control and Prevention reported that 93.3 million Americans suffer from obesity.1 Many individuals have undergone laparoscopic adjustable gastric banding (LAGB) procedures in order to lose weight. The procedure is thought to be safe with complication rates reported as low as 1.6% following surgery.2 We present a case of LAGB-associated discitis and osteomyelitis 20 years after placement and examine the current literature on the complication rates of bariatric surgery along with the rare injuries following LAGB placement.
Thyrotoxic hypokalemic periodic paralysis (THPP) is a condition that results in transient skeletal muscle paralysis secondary to intracellular potassium sequestration. Susceptible individuals often have an underlying channelopathy, which may be exacerbated by lifestyle factors or underlying medical comorbidities such as hyperthyroidism or diarrheal illness. Classically, THPP presents with paralysis of proximal extremity musculature. In this case, we present a rare case of unilateral THPP. Such a presentation is relevant to emergency physicians as it mimics a stroke or transient ischemic attack and should be considered on the differential for unilateral neurologic deficits.
Acute aortic occlusion is an emergent vascular condition not encountered routinely. Given its varied presentations, including neurovascular deficits and mimicking an acute abdomen, the diagnosis is often delayed causing increased morbidity and mortality. We present a case of acute abdominal aortic occlusion masquerading as sudden onset lower extremity pain and weakness in an 86-year-old female requiring emergent thrombectomy. This is only the second case report to discuss the use of point-of-care ultrasound to expedite diagnosis and management.1
Images in Emergency Medicine
Sexually transmitted infections have risen sharply over the last decade in the United States. The incidence of gonorrhea has risen to 172 reported cases per 100,000 people over the past year. This likely represents an under-representation due to many cases going unreported. Disseminated gonorrhea can present with nonspecific symptoms including arthralgia, cutaneous lesions, or tenosynovitis. Diagnosis is based upon a degree of high clinical suspicion and serology. Emergency department treatment includes ceftriaxone and azithromycin.
Literature on ulnar artery thrombosis and acute finger ischemia is scant and usually related to underlying hypercoagulable or occlusive states, such as atrial fibrillation, thrombangiitis obliterans, vasospasm, trauma, and neurovascular compression at the root of the upper limb.1-4 An elderly hypertensive male without an underlying hypercoagulable state, and in otherwise good health, presented to our emergency department with acute multi-finger ischemia, and ulnar artery and palmar arch thromboses. Given his innocuous history, this case demonstrates the importance of maintaining acute arterial thrombosis on the differential for hand pain despite the obvious propensity toward mechanical injuries in the extremities.
A 29-year-old female presented with abdominal pain, nausea, and vomiting. She reported no menstrual period for one year. She did report monthly episodes of severe cramping. A loop electrosurgical excision procedure was performed approximately 10 months prior. On pelvic exam, a smooth cervix with scarring over the os was visualized with no evidence of cervical opening. A pelvic ultrasound showed an enlarged uterus with contents within the endometrial cavity likely representing hemorrhage of different ages and ongoing bleeding. Gynecology was consulted and performed an incisional opening of the cervix. The patient was diagnosed with hematometra from scarred cervical os.
Pigtail catheters have emerged as an effective and less morbid alternative to traditional chest tubes for evacuation of pleural air. Rare complications in the literature have been reported. We report a case of a 92-year-old male who presented with dyspnea and shock, noted to have a pneumothorax requiring tube thoracostomy. Computed tomography demonstrated pigtail within the lung parenchyma. We discuss the implications of this occurrence.
A 27-year-old female presented to the emergency department with fevers, nausea, chills, and non-specific bilateral lower quadrant abdominal pain. A pregnancy test was negative. Computed tomography demonstrated moderate left hydronephrosis secondary to tubo-ovarian abscess. The abscess was so large it distorted local anatomy and compressed the ureters. She was prescribed meropenem and admitted for care by obstetrics/gynecology.
Renal Infarct After Endovascular Abdominal Aortic Aneurysm Repair: Consider in Back Pain Differential
As hypertension, obesity, and hyperlipidemia become more widespread, the prevalence of abdominal aortic aneurysms (AAA) has also increased.1 Traditionally those with multiple comorbidities – also those with greatest AAA mortality – were considered too high risk for operative repair. In recent decades, however, endovascular abdominal aortic aneurysm repair (EVAR) has become a popular option, especially for high-risk patients. Overall, short-term outcomes are comparable to traditional open repair despite higher patient baseline risk. However, EVAR comes with its own risks, which the emergency physician should be aware of. Here, we present a rare complication of EVAR: device thrombosis with subsequent renal infarct.
Endotracheal metastasis, a critical complication of primary lung cancer, is an extremely rare lesion. A 73-year-old woman who had previously received treatment for lung cancer presented to our emergency department with dyspnea. A chest computed tomography and nasopharyngolaryngoscopy showed an endotracheal mass below the epiglottis, obstructing the trachea almost completely. The patient had an emergency tracheostomy, and then the mass was removed via median laryngotomy. This lesion was proven to be a recurrent metastasis of lung cancer. Clinicians should recognize endotracheal metastasis as an important differential diagnosis in cancer patients presenting with respiratory symptoms.
A 58-year-old male with past medical history of diabetes mellitus presented with pain to the bilateral groin for six weeks. Magnetic resonance imaging of the patient’s lower extremities revealed acute myoedema, and he was diagnosed with myositis secondary to diabetic muscle infarction.
Internal jugular vein (IJV) thrombosis is an unusual condition, especially when it develops bilaterally. This is a case of bilateral IJV thrombosis in a 77-year old female who presented to the emergency department with neck and arm swelling after discontinuing apixaban and undergoing an oropharyngeal procedure. The diagnosis of bilateral IJV thrombosis was made with the use of point-of-care ultrasound to evaluate bilateral jugular vein distention and bilateral upper extremity pitting edema found on her physical examination.
- 1 supplemental video
Phrygian cap and its rare relative, pseudo-duplication of the gallbladder, are two radiologic findings that may be revealed on ultrasound evaluation. Correct identification of Phrygian cap and pseudo-duplication should trigger a careful survey of the gallbladder in its entirety to rule out pathology. These anatomic variants may lead to partial under-distension of the gallbladder and can cause the gallbladder wall to appear falsely thickened. Asymptomatic patients with this finding may be safely discharged while symptomatic patients may require further surgical consultation.
Traumatic posterior glenohumeral joint (GHJ) dislocation is a rare condition which can be missed if it is not suspected. Clinical presentation may be subtle, but limitation in range of motion in patient with acute trauma should warrant obtaining a thorough history, performing a comprehensive physical examination, and acquiring at least a 3-view plain radiography. Reduction can be achieved with a direct pressure to the posterior aspect of the humeral head.
- 1 supplemental video
A 49-year-old male presented to the emergency department with abdominal pain and generalized weakness. The physical examination was positive for right upper quadrant tenderness and positive Murphy’s sign. Point-of-care biliary ultrasound revealed signs of emphysematous cholecystitis. Emphysematous cholecystitis is a rare biliary pathology with a high mortality rate. It differs from acute cholecystitis is many ways. It has unique ultrasound characteristics. This case highlights the use of point-of-care ultrasound to diagnose a rare biliary condition.
- 1 supplemental video
Electrocardiogram (ECG) artifacts are a common problem in emergency medicine. Generally these artifacts are induced by movement disorders, which generate electrical interference with the ECG recording. If these disorders are not promptly recognized, consequences can lead to hospitalization and execution of unnecessary diagnostic tests, thereby increasing the costs and clinical risks such as nosocomial infections and thromboembolism. We present a pseudoatrial flutter generated by a Parkinson’s-like movement.
- 1 supplemental video