Clinical Practice and Cases in Emergency Medicine

Introduction: Frostbite is a painful condition that requires rapid identification and wound care to optimize outcomes. The Posterior Tibial Nerve (PTN) block, however, has yet to be described in the literature for pain control of frostbite injuries on the plantar surfaces.

Case Series: In this case series we discuss three patients who presented with bilateral frostbite on the plantar surfaces. Ultrasound-guided PTN blocks were performed on these patients and pain control was achieved in under 10 minutes, facilitating burn care. No patient experienced adverse effects. All patients had been scheduled for future debridement that was either not performed or performed using intravenous (IV) medications due to pain control issues.

Conclusion: The ultrasound-guided PTN block facilitated proper wound debridement that was previously intolerable with oral and IV pain medications. This case series highlights the efficacy, safety, and accessibility of this block for frostbite pain control in the emergency department.   Additionally, it emphasizes the potential role of ultrasound-guided PTN blocks as part of a multi-modal pain control strategy in other clinical settings.

Introduction: Pain scales are often used in peripheral nerve block studies but are problematic due to their subjective nature. Ultrasound-measured diaphragmatic excursion is an easily learned technique that could provide a much-needed objective measure of pain control over time with serial measurements.

Case Series: We describe three cases where diaphragmatic excursion was used as an objective measure of decreased pain and improved respiratory function after serratus anterior plane block in emergency department patients with anterior or lateral rib fractures.

Conclusion: Diaphragmatic excursion may be an ideal alternative to pain scores to evaluate serratus anterior plane block efficacy. More data will be needed to determine whether this technique can be applied to other ultrasound-guided nerve blocks.

Introduction: Tetralogy of Fallot (TOF) is a congenital heart defect with characteristic features leading to unique physical exam and ultrasound findings. In settings where there is limited prenatal screening, TOF can present with cyanosis at any time from the neonatal period to adulthood depending on the degree of obstruction of the right ventricular outflow tract.

Case Report: This case describes a pediatric patient who presented with undifferentiated dyspnea and cyanosis, for whom point-of-care ultrasound (POCUS) supported the diagnosis of TOF. We highlight the important role POCUS can play in a setting with limited access to formal echocardiography or consultative pediatric cardiology services.

Conclusion: This report highlights the utility of POCUS as an inflection point in the diagnostic and management pathway of this patient, which is particularly important when working in a limited-resource or rural setting.

Introduction: Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of infant vomiting. Emergency department (ED) diagnosis is usually made by pyloric ultrasound and treated by pyloromyotomy.

Case Report: An eight-week-old boy with a history of IHPS about six weeks status post pyloromyotomy presented to the ED with vomiting and failure to thrive, and a critically narrowed pylorus was identified by ultrasound. An upper gastrointestinal series confirmed recurrent pyloric stenosis, necessitating another pyloromyotomy.

Conclusion: Prolonged vomiting after pyloromyotomy should be concerning for recurrent IHPS. Upper gastrointestinal series should augment ultrasound to diagnose recurrent IHPS and determine whether a second pyloromyotomy is warranted.

Introduction: Legionnaires’ disease is a multisystem disease involving respiratory, gastrointestinal, and neurologic systems. This is a case of a previously healthy 44-year-old man who was diagnosed with Legionella pneumonia causing acute kidney failure and rhabdomyolysis.

Case Report: The patient presented with four days of chills, shortness of breath, chest discomfort, diarrhea, and myalgias. Laboratory testing revealed hyponatremia, leukocytosis, elevated inflammatory markers, renal failure, and rhabdomyolysis. He was admitted to the intensive care unit for acute hypoxemic respiratory failure, received a course of antibiotics, and more than two weeks of intermittent hemodialysis with full recovery of renal function. The pathophysiologic mechanisms by which Legionella causes rhabdomyolysis and acute kidney failure are not fully understood, although numerous mechanisms have been proposed including direct invasion of myocytes and renal tubular cells.

Conclusion: Legionnaires’ disease is one of several infections that can cause rhabdomyolysis and kidney failure. Although rarely described in the literature, it is important for emergency physicians to be aware of this clinical entity in order to implement early diagnostic testing and empiric treatment.

Introduction: Acute compartment syndrome of the hand is a rare medical emergency, most often associated with trauma or fracture.

Case Report: Here, we describe a rare case of isolated thenar compartment syndrome of the hand in the absence of major trauma as the presenting symptom of pancytopenia due to Evans syndrome, an uncommon autoimmune hematologic disorder.

Conclusion: In cases of atraumatic compartment syndrome, it is critical to evaluate for underlying coagulopathy in patients presenting to the emergency department.

Case Presentation: A 13-year-old male presented with right knee pain and swelling from a basketball injury. The right knee exam demonstrated minimal swelling, decreased range of motion secondary to pain, and generalized tenderness. A radiograph of the right knee revealed a tibial spine fracture.

Discussion: Tibial spine fractures are avulsion fractures of the spine of the tibia at the insertion site of the anterior cruciate ligament. The incidence of avulsion fractures is higher in adolescents because the region of the apophyseal growth plate between the soft-tissue attachment site and the body of the bone is weaker in that age group. Tibial spine avulsion fractures are relatively uncommon and occur annually in approximately three per 100,000 children.

Introduction: The clinical course of patients who present to the emergency department (ED) with urinary retention is usually uneventful. In this case, we explore the life-threatening complications of urinary retention and bladder decompression.

Case Report: We report the case of a 57-year-old man who presented to the ED with difficulty voiding. A urinary catheter was placed. The patient had severe post-obstructive diuresis. He developed hematuria and became hypotensive. After aggressive resuscitation, including blood products, the patient required operative intervention for hemorrhage control.

Conclusion: Clinicians should be aware of and be able to manage the rare but life-threatening complications associated with urinary retention.

Introduction: This is a case report of an acute right brachial artery occlusion found on point-of-care ultrasound in the emergency department (ED) that illustrates the developing role of ultrasound in rapid differentiation and identification of acute vascular emergencies.

Case Report: An 87-year-old male with a past medical history of coronary artery bypass graft presented to the ED with acute right upper extremity pain, with point-of-care ultrasound (POCUS) findings consistent with acute right brachial artery occlusion.

Conclusion: Arterial occlusions are vascular emergencies that can be rapidly identified on POCUS.

Introduction: Emergency physicians must maintain a broad differential when seeing patients in the emergency department (ED). Occasionally, a patient may have an undiagnosed, life-threatening medical condition not related to the presenting chief complaint. It is imperative to review all ordered laboratory tests and any available previous laboratory values to assess for any abnormalities that may warrant further evaluation.

Case Report: This case report is regarding the missed diagnosis of acute leukemia and subsequent disseminated intravascular coagulation in a 27-year-old male who presented to multiple EDs with the unrelated chief complaint of finger ring entrapment. This patient ultimately succumbed to his illness.

Conclusion: When evaluating patients in the ED, it is important to review any prior available test results for abnormalities, even if the results do not specifically correlate with the chief complaint. Emergency physicians must remain vigilant to avoid missing a critical diagnosis.

Introduction: Porphyria refers to a group of disorders associated with defects in heme synthesis. They can be associated with severely debilitating features, including abdominal pain, psychiatric symptoms, neurological defects, and cardiovascular irregularities. Although these diseases are rare, patients with attacks often do present to the emergency department (ED) where consideration of porphyria is generally not included in the differential.

Case Report: Here, we examine a case of a 16-year-old male who presented to our ED for evaluation of recurring abdominal pain and auditory hallucinations in which porphyria was considered by the emergency physician.

Discussion: Not considering acute porphyria in patients with recurring neurovisceral symptoms in the ED can lead to missed opportunities for diagnosing such pathologies.

Introduction: Severe breakthrough pain is a common occurrence in patients with cancer and is responsible for thousands of emergency department (ED) visits each year. While opioids are the current mainstay of treatment, they have multiple limitations including inadequate control for a quarter of patients with cancer. The ultrasound-guided erector spinae plane block (ESPB) has been used in the ED to effectively treat pain for pathologies such as acute pancreatitis, since it provides somatic and visceral analgesia.

Case Report: In this case report we describe the use of an ESPB to treat breakthrough pain safely and effectively in a 54-year-old female with a history of metastatic colon cancer.

Conclusion: The ESPB may have utility in addressing well documented disparities in pain treatment in the ED, but additional research is needed to understand side effects, duration of pain control, and clinical outcomes of the ESPB.

Introduction: Snake envenomation is a serious public health concern. In the Middle East little is known about snakebite envenomation, which raises several challenges for emergency physicians caring for these patients.

Case report: We report the case of a five-year-old boy bitten by a rare snake, Montivipera bornmuelleri, who presented to an emergency department in Lebanon. We also discuss the proper management of snake envenomation.

Conclusion: This case is unique as snakebites in Lebanon are poorly studied, and little is known about the epidemiology and clinical manifestations of local snakebites.

Introduction: Pancreatitis after esophagogastroduodenoscopy (EGD) is not a common occurrence, particularly in the setting of a normal serum lipase. The lack of commonality may delay diagnosis and treatment in some patients presenting to the emergency department (ED) with abdominal pain after an otherwise uncomplicated procedure.

Case Report: A patient with a history of gastroesophageal reflux disease presented to the ED with a complaint of abdominal pain and fever three days after an uncomplicated EGD. The patient was ultimately diagnosed with pancreatitis after a computed tomography showed pancreatic head inflammation, despite having a normal serum lipase. There were no other identified risk factors for pancreatitis in this case.

Conclusion: This case serves to bring awareness to this potential procedural complication and the possibility of pancreatitis with a normal serum lipase.

Case Presentation: A previously healthy 19-year-old man presented to the emergency department with severe, sudden onset of left testicular pain. Physical exam revealed a left high-riding, horizontally oriented testicle without cremasteric reflex. Point-of-care ultrasound was used to confirm the diagnosis of testicular torsion, as well as to guide manual detorsion, verifying return of blood flow after reduction.

Discussion: Testicular torsion is a urologic emergency in which testicular viability is time dependent. Point-of-care ultrasound can be an important and helpful tool to not only confirm suspicion but help guide adequacy of blood flow return after manual detorsion in conjunction with comprehensive ultrasound.

Case Presentation: A 75-year-old man with a history of asbestosis presented to the emergency department with sudden-onset dyspnea and hemoptysis, triggered by coughing. The patient was hemodynamically unstable and in respiratory distress. Computed tomography revealed a massive hemothorax on the left side and compression of the descending thoracic aorta. He underwent emergency surgical exploration after decompression by chest tube insertion. The hemothorax was caused by tears in the pleural adhesions due to asbestosis and induced by coughing.

Discussion: Spontaneous hemothorax is a rare subtype of hemothorax. There have been only a few case reports of spontaneous tension hemothorax. In addition to its typical findings, compression of the thoracic descending aorta was observed in our patient. We hypothesize that severely diminished pulmonary compliance contributed to the extremely high intrathoracic pressure, which led to this unusual finding.

Case Presentation: A 22-year-old male with no known past medical history presented to our emergency department complaining of difficulty breathing. A plain film chest radiograph revealed findings consistent with a tension pneumothorax.

Discussion: However, due to physical examination findings inconsistent with the imaging report, a computed tomography of the chest was ordered which revealed an absent right pulmonary artery.The patient was ultimately treated for high altitude pulmonary edema and discharged on nifedipine and supplementary oxygen.