Clinical Practice and Cases in Emergency Medicine

Introduction: Breakthrough pain is frequently experienced by patients with gastrointestinal malignancies and is a common reason for presenting to the emergency department (ED). After ruling out acute pathology, ED management typically consists of intravenous opioids, though high doses of opioids can be associated with potentially severe adverse events and complications in certain high-risk populations. Regional anesthesia strategies, such as the erector spinae plane block (ESPB), have shown to be effective for several etiologies of non-malignant visceral abdominal pain. This case series sought to evaluate whether the ESPB can be effective for ED patients with breakthrough pancreatic and hepatobiliary cancer pain. 

Case Report: Three patients with breakthrough hepatopancreatobiliary cancer pain underwent successful ESPBs performed by an emergency medicine physician in the ED. All patients reported considerable reduction in their pain. Two patients with cancer of the pancreatic head reported complete pain relief and were able to be discharged from the ED. The third patient with metastatic colorectal cancer involving the hepatobiliary system was admitted for further medical work-up, though did not require any additional analgesics for nearly 13 hours after the block. 

Conclusions: The ESPB appears to be a safe and effective strategy for managing breakthrough pain related to pancreatic and hepatobiliary malignancy in the ED.

Introduction: Nitrous oxide (N2O) toxicity is an uncommon but important-to-recognize presentation of neurologic deficits and hematologic abnormalities, which may never resolve in some patients. In the United States, nitrous oxide is legal to possess and easily obtainable for purchase in stores and online. Nitrous oxide abuse and its long-term sequelae must be recognized by the emergency physician to ensure proper follow-up and maximize neurologic outcomes.

Case Report: A 28-year-old male with past medical history of alcoholism and polysubstance abuse presented to the emergency department with progressive paresthesias, shortness of breath, and neurologic complaints following daily inhalation of N2O for three weeks. He was diagnosed with N2O toxicity due to functional vitamin B12deficiency in the setting of elevated B12 levels from prophylactic self-supplementation.

Conclusion: While most recreational users of nitrous oxide will experience transient neurologic symptoms resolving within minutes of cessation, frequent or heavy users may develop permanent neurotoxicity. Exposed patients require close follow-up with neurology and vitamin B12 supplementation to maximize neurologic recovery. In this patient, there was persistence of neurologic symptoms over 24 hours after cessation of use despite self-supplementation of vitamin B12.

Introduction: Perinatal stroke is a rare but clinically significant condition that can present in a variety of ways, which can result in diagnostic challenges in a particularly vulnerable population.  We present the case of a term neonate who presented with left arm swelling, ultimately diagnosed with perinatal stroke.

Case Report: A term male neonate presented to the emergency department with left arm swelling noted the day prior, with abnormal tone of the left arm since birth.  Physical examination revealed mild erythema and edema localized to the left upper extremity, with the arm held in flexion.  Neurological examination was otherwise unremarkable.  Further evaluation, including imaging studies, demonstrated thrombi in the left axillary and subclavian arteries, as well as an infarct involving the right middle cerebral artery (MCA) and anterior cerebral artery (ACA) with diffusion restriction, consistent with perinatal stroke.

Conclusion: Through this case report, we aim to increase awareness of perinatal stroke among healthcare professionals and highlight the importance of prompt recognition and appropriate management in optimizing outcomes for affected infants.

Introduction: Osteomyelitis is a bone infection that presents with swelling, erythema, pain, and possible systemic symptoms.  Immunocompromised patients are at higher risk of developing osteomyelitis.  While bacterial osteomyelitis is the most common source causing infection, fungal osteomyelitis is even more uncommon with very few case reports published.  Work up should include imaging studies to investigate infections when there is clinical suspicion for osteomyelitis.  Bone biopsy is performed to identify the causative agent with bacterial infections being the most common.  Osteomyelitis can be treated both surgically with debridement or amputation and medically with extended courses of antimicrobials or antifungals.  Our case describes acute onset fungal foot osteomyelitis after an uncomplicated appendectomy. 

Case Report: A 19-year-old previously healthy female underwent laparoscopic appendectomy for nonperforated, non-gangrenous appendicitis.  Fourteen days later, she developed gradually worsening right foot pain, swelling, and erythema.  After multiple failed treatments for the management of osteomyelitis, bone biopsies and courses of antibiotics, patient was ultimately diagnosed with a rare osteomyelitis secondary to Coccidioides species, which was managed and improved with antifungals.

Conclusion: Bacterial osteomyelitis has been described in two English case reports as a postoperative complication of appendectomy, particularly when the appendicitis is perforated, gangrenous or purulent.  Fungal osteomyelitis is an even rarer cause of postoperative bone infection in immunocompetent patients.  The goal for treatment is surgical intervention or pharmacologic management.  Emergency Department practitioners should maintain a high suspicion for fungal osteomyelitis in otherwise healthy patients presenting with musculoskeletal complaints, and should consider the possibility of fungal species as the cause.  

Introduction: Lipschütz ulcers are a rare immune-mediated reaction that commonly occurs in premenarchal females, usually associated with a recent viral illness.¹
The treatment for Lipschütz ulcers consists of pain relief, topical steroids, and, in severe cases, a course of systemic steroids.¹ A thorough history and exam, as well as an appropriate workup to rule out other causes of vaginal ulceration, should be completed.²

Case Report: A premenarchal, 12-year-old female presented to the emergency department (ED) with her mother due to significant vulvar pain. Two days prior, the patient had a gastrointestinal illness associated with vomiting, diarrhea, and fever. On exam, she had significant swelling of the labia minor, discoloration with a necrotic appearance of the introitus, and brown vaginal discharge.The patient denied sexual intercourse, concern for retained vaginal foreign body, or vaginal trauma. Gynecology suggested the diagnosis of a rare post-viral immune-mediated reaction causing acute genital ulcerations, also known as Lipschütz ulcers. The patient’s treatment regimen included topical and systemic steroids, enteral opioid pain medication, and topical lidocaine. Her symptoms had resolved at her two-month follow-up visit.

Conclusion: In summary, this case report discusses a previously healthy 12-year-old premenarchal female who presented to the ED due to vulvar swelling, pain, and vaginal discharge in the setting of a recent viral gastrointestinal illness. The patient was seen in the ED by gynecology and diagnosed with Lipschütz ulcers. Lipschütz ulcers are an uncommon condition causing acute genital ulcers.

Introduction: A brain abscess is a localized collection of purulent infection within the brain parenchyma. It most often occurs due to contiguous spread from sinus, otogenic, and odontogenic infections; however, it can also develop from direct intracranial contact via trauma or surgery. Fusobacterium necrophorum, an obligate anaerobic, gram-negative bacillus, is part of the normal flora of the oral cavity. Given its inherent location, F necrophorum has been shown to contribute to complications stemming from infection of the tonsils, pharynx, and teeth. Invasive infections of F necrophorum are seldomly seen in immunocompetent patients.

Case Report: We report a case of a previously healthy 20-year-old man who presented to our emergency department with headache, facial pain, and neck stiffness. He was ultimately found to have an F necrophorum intracranial abscess and underwent right frontal craniotomy with evacuation of epidural abscess and partial sinus obliteration. He was placed on broad-spectrum antibiotics, including vancomycin, cefepime, and metronidazole for six weeks. His treatment course was
complicated by recurrence of intraparenchymal abscess requiring repeat craniotomy with abscess evacuation and advancement of antibiotic regimen to meropenem. To our knowledge, there are no reported cases in the literature of monomicrobial F necrophorum brain abscesses arising secondary to invasive sinusitis in immunocompetent adults.

Conclusion: This report highlights the clinical presentation, diagnostic strategies, management challenges, clinical outcomes, and complications of invasive sinusitis leading to brain abscess formation in an otherwise healthy adult male.

Introduction  
Tetanus is a now rare disease due to the widespread administration of scheduled and prophylactic vaccines, making it exceptionally uncommon to appear in many emergency departments.  Clinical suspicion alone is used to make the diagnosis as there are currently no immediate diagnostic tests available to the clinician.  If left unrecognized and untreated, however, tetanus can lead to airway compromise and death.   
Case Report 
We report a case of a young male who presented to the emergency department with intermittent full body spasms and lockjaw in the setting of recent assaults and lacerations weeks prior who had not received tetanus since 2008.  Immediate calls were placed to infectious disease consultants and the patient was treated with intravenous immunoglobulin, tetanus immunization, metronidazole, and ceftriaxone.  Further work up revealed rhabdomyolysis, elevated lactate, and unremarkable imaging. 
Conclusion  
His symptoms improved to resolution with completion of his therapy, effectively confirming the diagnosis of tetanus.   

Introduction: Bradycardia, Renal failure, Atrioventricular nodal blockade, Shock, Hyperkalemia (BRASH syndrome) is commonly misdiagnosed in the emergency department, which can lead to a delay in care and poor patient outcomes.

Case Report: We present a case of BRASH syndrome in a patient with no underlying renal disease, which further complicated diagnosis and delayed treatment.

Conclusion: Prompt recognition of the underlying pathophysiology in cases of BRASH syndrome is essential to guide treatment and avoid delays in care.

Introduction: A gastrosplenic fistula (GSF) is a pathologic connection between the spleen and stomach that can lead to life threatening complications.  A GSF can arise spontaneously but is often secondary to a variety of etiologies.  Most commonly, GSFs arise from gastric or splenic non-Hodgkin’s diffuse large B-cell lymphomas.  Only 46 cases of GSFs have been published to date and due to its rarity, extensive literature review is insufficient for characterization of GSFs. 

Case Report: This case discusses a patient with intermittent abdominal pain and weight loss which led to the diagnosis and treatment of a gastrosplenic fistula (GSF) and diffuse large B-cell lymphoma (DLBCL).  The patient later went into remission for his DLBCL but succumbed to respiratory failure from a secondary abdominal-pleural fistula formation. GSFs have the potential to cause fatal massive upper gastrointestinal hemorrhages, infections, fistulas, or obstructions.  Delayed diagnosis corresponds with a higher morbidity and mortality; thus, prompt detection and treatment are imperative.  The management of GSFs is complex due to their rare nature and requires a multidisciplinary approach to care. 

Conclusion: The intention of this report is to provide information and increase awareness of GSFs in the medical community to facilitate their diagnosis.

Introduction : A De Garengeot hernia is defined as a femoral hernia that contains the vermiform appendix.  While femoral hernias carrying the appendix are uncommon, strangulation of the appendix in the hernial sac with concurrent acute appendicitis is an extremely rare and life-threatening condition often presenting with an atypical clinical picture.    

 Case Report:  A 51-year-old man presented to the emergency department with two weeks of persistent right inguinal pain after heavy lifting.  Imaging revealed suspicion for an Amyand’s hernia, an inguinal hernia containing a portion of the appendix.  However, intraoperative findings revealed a strangulated De Garengeot hernia with gangrenous appendicitis.   

Conclusion: De Garengeot hernias are femoral hernias containing the appendix which are diagnostically challenging and require urgent surgical evaluation and intervention given high risk for strangulation.   

Introduction: Paradoxical vocal cord motion (PVCM) is a primarily neuropsychiatric condition that causes inappropriate adduction of the vocal cords during respiration. This condition is commonly misdiagnosed and treated as refractory asthma or upper airway obstruction requiring intensive care unit-level of care. Recent expert opinion suggests that ketamine administration may promote PVCM symptom resolution; however, this phenomenon has not yet been documented in the literature.

Case Report: This is the case of a 23-year-old female who presented to the emergency department (ED) with acute PVCM exacerbation. After failing to respond to standard-of-care therapies including benzodiazepines, the patient was administered intravenous, sub-dissociative dose ketamine, which led to symptom resolution and discharge.

Conclusion: Sub-dissociative dose ketamine may be a safe and effective therapy for PVCM exacerbations in the ED. In this report we explore the patient factors that likely mediated the clinical outcome in this case. 

Introduction: Patients with human immunodeficiency virus (HIV) often present with overlapping stages and less obvious signs of syphilis, with potential serious complications including neurosyphilis. Neurosyphilis is a neurological manifestation resulting from the progression of syphilis, a sexually transmitted infection caused by the bacterium Treponema pallidum. 

Case Report: We report the case of a 39-year-old previously incarcerated male with a history of HIV on antiretroviral therapy and previous methamphetamine use who was referred to the emergency department from an Ophthalmologist with a diagnosis of anterior uveitis and papilledema, with reported associated symptoms of blurry vision, tinnitus, and forgetfulness. Comprehensive diagnostic testing, including lumbar puncture and cerebrospinal fluid analysis corroborated the diagnosis of neurosyphilis with otic and ocular involvement. The patient received intravenous aqueous crystalline penicillin G resulting in symptom improvement. 

Conclusion: Given the prevalence of syphilis and its diverse manifestations, clinicians must maintain a high index of suspicion in patients who are immunocompromised or engage in high-risk behaviors to facilitate early diagnosis and treatment, which are crucial for optimal outcomes and enhanced prognosis.

Introduction: Delayed post-hypoxic leukencephalopathy (DPHL) is a rare cause of acute neuropsychiatric decline diagnosable in Emergency Departments, but it has not been described in the Emergency Medical literature.   We present a case report of a pathognomonic presentation.

Case Report: A man developed akinetic mutism fourteen days after being discharged from a hospitalization for fentanyl overdose.   His presentation and MRI were pathognomonic for DPHL.  

Conclusion: DPHL can present to the ED as altered mental status days to weeks after apparent full recovery from an initial episode of cerebral hypoxia.   This report will help Emergency Providers avoid missing this diagnosis.

Introduction: Physician-assisted dying (PAD) is a practice that allows terminally ill patients to self-administer prescribed lethal medication.  In the 11 U.S. states where PAD is legal, the incidence of PAD cases is rapidly increasing.  Despite the majority of these cases occurring in the out-of-hospital setting, states lack specific emergency medical services (EMS) protocols to guide prehospital clinicians who may encounter PAD in the field.  Here, we describe a case in which a patient called 9-1-1 for a medical emergency and requested to ingest their prescribed lethal medication while in EMS care.

Case Report: EMS was dispatched for a 56-year-old female who was bleeding from her tracheostomy stoma.  Despite the clinicians’ recommendation for transport to the emergency department, the patient refused transport and instead requested to ingest her PAD medication.  The crew, unfamiliar with PAD laws, were unsure if they could legally honor the patient’s refusal.  Clinicians consulted with on-line medical control, who were also unaware of PAD.  After extensive deliberation, the crew eventually decided to honor the patient's refusal and thoroughly document the situation.  The patient self-administered her medication as EMS cleared the scene.

Conclusion: This case highlights the logistical challenges and ethical dilemmas faced by the responders, and underscores the complexity of balancing patient autonomy with legal and medical responsibilities in prehospital PAD situations.  As PAD becomes increasingly prevalent, equipping EMS clinicians with clear protocols and ongoing education about prehospital PAD cases is vital to preserving patient rights while protecting clinicians from legal and ethical uncertainty.

Introduction

The prevalence of high-potency synthetic opioids (HPSOs), such as fentanyl and its analogs, present significant treatment challenges to current strategies for Emergency Department (ED) medication for opioid use disorder (MOUD).  While most EDs traditionally use buprenorphine for MOUD, its effectiveness can be limited in patients exposed to HPSOs due to risk of precipitated withdrawal or inadequate control of withdrawal symptoms.  Methadone, a full agonist, is an alternative MOUD agent that addresses the severe withdrawal symptoms and cravings associated with HPSO dependence and will not cause precipitated withdrawal. Traditional methadone protocols often fail to provide adequate doses, but new federal guidelines allow higher initial doses and rapid titration to therapeutic levels.

Case Report

We report on a case of rapid methadone titration in the ED for a patient with a history of high HPSO utilization.  The patient received an initial dose of 50 mg methadone, followed by titration of hourly 10 mg doses to a cumulative 70 mg at discharge.  Vital signs, mental status, and Clinical Opiate Withdrawal Scale (COWS) scores were monitored to guide dosing.  

Conclusion

The protocol allowed for safe, individualized care, achieving therapeutic dosing levels that alleviated withdrawal symptoms and enabled the patient to transition to outpatient follow-up treatment.  This approach addresses the need for rapid, effective methadone initiation in an era where HPSOs pose challenges to traditional opioid use disorder treatment.

Introduction: Body stuffing is defined as ingesting small quantities of drugs in poorly sealed packets often to avoid repercussions from law enforcement. Cocaine is one of the drugs most commonly involved. Complications reported with stuffing include aspiration, esophageal obstruction and fatal toxicity. Survival from mechanical airway obstruction due to drug stuffing has not been reported. 

Case Report: In this article, we present a case of a 32-year-old male who was a cocaine body stuffer, complicated by agitated delirium, cardiotoxicity, and airway obstruction requiring resuscitation followed by a surgical tracheostomy to retrieve the obstructing cocaine bag. The patient’s hospital course was further complicated by rhabdomyolysis and acute kidney injury requiring dialysis. He was discharged in stable condition after a four-week hospital stay.

Conclusion: This case highlights the severe risks of cocaine body stuffing, including airway obstruction and cocaine-induced arrhythmias. Endotracheal intubation in such cases warrants a careful airway assessment to mitigate the risks of obstructive complications.

Introduction: The inferior vena cava (IVC) drains a significant portion of the lower body. Pathologies associated with the IVC can present significant diagnostic and therapeutic challenges. We present a case of IVC tumor thrombus in the emergency department.

Case Report: A 76-year-old male with symptoms of volume overload was evaluated, leading to the diagnosis of IVC mass likely from tumor thrombus.

Conclusion: Patients with volume overload should be evaluated for both heart failure and presence of a potential thrombus. Point-of-care ultrasound and other imaging modalities play crucial roles in early diagnosis. Prompt identification and differentiation between bland and tumor thrombi are vital for appropriate management, potentially improving patient outcomes.

Introduction: The mortality rate for refractory ventricular fibrillation (RVF) can be up to 97%. There is no widely accepted treatment plan for this stage of ventricular fibrillation besides the standard combination of defibrillation, amiodarone, and epinephrine. One novel approach that has been documented in a select few cases since 2015 is the combination of double external defibrillation (DED) and esmolol-induced beta blockade.

Case Report: We report the case of a 65-year-old man who presented with RVF after collapsing at work. Upon the simultaneous administration of two defibrillators with a combined shock of 400 joules and 35 milligrams of the beta blocker esmolol, the patient regained pulse and began blinking. He was discharged from the hospital after seven days and walked out of the clinic. 

Conclusion: This case continues the trend of several case reports since 2015 that have featured beta blockade and double external defibrillation as a viable solution to refractory ventricular fibrillation. Since there is limited quantifiable data on the efficacy of this treatment, future studies should aim to evaluate whether the combination of DED and beta blockade has the potential to become the new standard in treating RVF over a broader patient population.

Introduction: Organophosphates (OP) are used as pest control agents worldwide and have been seen in accidental and intentional poisonings.  

Case Report: A patient presented after intentional ingestion of the OP Orthene (50% acephate).  Due to copious secretions, the patient was intubated and given atropine by the paramedic before transport. In the emergency department he displayed both muscarinic and nicotinic effects from OP ingestion. The patient was given multiple doses of atropine and a pralidoxime bolus. He was extubated and transferred to psychiatry two days later. 

Conclusion: Acute OP exposure is a rare but complex presentation in the United States. In the United States there are bans on several organophosphate varieties, which have reduced the number and severity of OP toxicities. Acephate is generally considered a safer OP by United States regulators and the World Health Organization. In this case report, we describe an OP exposure with marked symptoms requiring intubation and successful treatment with atropine and pralidoxime. We also discuss the role of oximes in acephate toxicity. 

Introduction: Hepatic artery aneurysms are exceedingly rare, often asymptomatic, and usually diagnosed when patients present with complications such as rupture or bile duct obstruction.   

Case Report: This report describes a 70-year-old female who presented to the emergency department with Quincke triad (epigastric pain, obstructive jaundice, and gastrointestinal bleeding) and was diagnosed with multiple hepatic artery pseudoaneurysms with a thrombosed fistulous connection to the biliary system. She was treated effectively with extensive embolization and biliary stenting.  

Conclusion: This case underscores the importance of early diagnosis and highlights the role of multidisciplinary intervention in preventing life-threatening complications from hepatic artery aneurysms.

Introduction: Retroperitoneal necrotizing fasciitis is a rare, rapidly progressive, and often fatal infection of the retroperitoneum. In many cases the source of infection is unclear, and cutaneous signs of necrotizing fasciitis may be absent.

Case Report: We present the case of a 64-year-old female with a history of hypertension, hyperlipidemia, and breast cancer who developed acute kidney injury (AKI) and retroperitoneal necrotizing fasciitis following a 20-mile bike ride. The patient’s initial symptoms included severe muscle aches, nausea, vomiting, and flank pain. Diagnostic imaging and laboratory results indicated myositis and severe AKI. Despite aggressive treatment with antibiotics, intravenous fluids, and pain management, the patient developed septic shock and multiorgan failure, ultimately leading to her death. 

Conclusion: This case highlights the rapid progression and complexity of managing necrotizing fasciitis and AKI in the context of rhabdomyolysis. Early recognition and aggressive management are crucial in cases of suspected necrotizing fasciitis and AKI. Patients may not initially present with cutaneous findings suggestive of necrotizing fasciitis. Early involvement of a multidisciplinary team can improve patient outcomes in complex and rapidly deteriorating patients.

Introduction: 

Thoracic outlet syndrome (TOS) is a diagnosis classifying upper extremity symptoms caused by compression of the neurogenic and vascular structures between the clavicle and first rib. It is important to promptly decompress these structures in order to prevent long-term deficits and poor patient outcomes. However, TOS often presents in unique ways with substantial symptom variance, making it difficult to identify, diagnose and promptly treat. Compounding this, common diagnostic tools such as magnetic resonance imaging (MRI) are not independently appropriate for a conclusive diagnosis of TOS. TOS patients can initially present acutely due to symptom exacerbations or emergent situations, which creates an emphasis for the use of multi-modal diagnostic methods and early TOS recognition in order to improve the outcomes for TOS patients, particularly in emergency medical services (EMS) settings. 

Case Report:

A 22-year-old male presented with chronic symptoms of numbness and weakness in his right hand in addition to chest pain that radiated into his right elbow, along with a diminished right radial pulse. The patient also suffered from acute symptomatic exacerbations of total arm asthenia, paresthesia and what the patient described as “an intensely cold hand” during football practice. He was eventually treated with a right first rib resection to decompress the brachial plexus, which resulted in complete symptom resolution and recovery.

Conclusion: 

Due to the serious long-term complications associated with uncorrected brachial plexus compression and the fact that TOS patients can initially present to EMS settings with acute exacerbations, it is important for EMS clinicians to be able to recognize and either treat or appropriately refer patients for treatment. EMS settings are equipped to be able to perform a comprehensive diagnostic assessment because they often have access to the diagnostic modalities necessary for diagnosing TOS.

Introduction

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a rare, inheritable cardiac disorder associated with stress- or exercise-induced syncope or cardiac arrest in children and young adults.  Diagnosis of CPVT is often missed or delayed due to variable presentation and normal cardiac imaging and electrocardiogram results, with about 40% of patients dying within 10 years of diagnosis.¹  This case underscores the importance of cross-departmental communication when managing complex pediatric cases, especially when using an interpreter. 

Case Report

A 16-year-old male presented to the hospital with cardiac arrest in ventricular fibrillation following collapse despite a history of treatment with flecainide and nadolol.  He was resuscitated, stabilized with antiarrhythmic drips, received an implantable cardioverter defibrillator (ICD), and was discharged neurologically intact nine days later.  It is vital for physicians to consider CPVT in young patients with syncope in order to prevent errors in diagnosis of this highly fatal disease. 

Conclusion

This case also underscores the importance of obtaining a detailed family history and coordinating care with other physicians in cases where history is limited.  Treatment decisions for acute CPVT often occur without prior knowledge of the disease, so in patients diagnosed with CPVT, physicians should implement appropriate therapeutic options to prevent future cardiac events.  For patients who remain symptomatic despite beta blocker therapy, interventions like ICD placement or sympathetic denervation may be necessary to prevent life-threatening arrhythmias.  

Introduction: Diphenhydramine overdose is a growing concern, particularly among adolescents influenced by online challenges. Traditionally managed with supportive care and sodium bicarbonate, severe cases may exhibit refractory symptoms due to sodium channel toxicity, necessitating alternative treatments.

Case Report: A 28-year-old male with a history of anxiety and depression presented to the emergency department unresponsive, next to an empty bottle of Benadryl and wine bottles. Vital signs indicated hypotension and hypoxia. The patient was intubated and administered vasopressors. Initial ECG showed a widened QRS complex and terminal R wave in lead aVR, suggesting sodium channel blockade. Treatment with multiple boluses of sodium bicarbonate was ineffective. Lidocaine (95 mg IV) was administered, resulting in improved ECG findings and patient stabilization. Subsequent care focused on supportive measures and treatment for aspiration pneumonia. The patient was extubated on day 2 and discharged on day 7 to a behavioral health facility.

Conclusion: This case underscores the effectiveness of lidocaine as a secondary treatment for diphenhydramine-induced sodium channel toxicity when standard sodium bicarbonate therapy fails. Lidocaine's ability to restore myocardial conduction illustrates its potential as a critical intervention in toxicological emergencies.

Introduction.  M-mode in bedside point-of-care ultrasound (POCUS) transthoracic echocardiography (TTE) remains an important tool for emergency physicians.  M-mode of the mitral valve is used to assess ejection fraction (EF) during assessment of E-point septal separation (EPSS).  Anterior mitral leaflet fluttering visualized on M-mode echocardiography is a known sequelae of aortic regurgitation.  Although not reported in the Emergency Medicine literature, anterior mitral leaflet fluttering also occurs with atrial fibrillation.

Case Report. We present the first case in peer-reviewed Emergency Medicine literature of anterior mitral leaflet fluttering observed on M-mode echocardiography caused by atrial fibrillation.  Our patient was a 54-year-old male with chest pain who was evaluated in the Emergency Department with a point-of-care ultrasound transthoracic echocardiogram that showed anterior mitral leaflet fluttering on E-point septal separation.  Subsequent inpatient workup confirmed the diagnosis of symptomatic atrial fibrillation without ischemia or clinically-significant aortic regurgitation.

Conclusion.  Emergency physicians must rapidly assess and risk-stratify undifferentiated patients presenting with chest pain.  Understanding that anterior mitral leaflet fluttering on M-mode during EPSS may signal atrial fibrillation augments efficient and appropriate disposition of these patients.

Keywords. POCUS, point-of-care ultrasound, transthoracic echocardiogram, TTE, M-mode, aortic regurgitation, atrial fibrillation, anterior mitral leaflet flutter, case report

Introduction: While rare in pregnancy, acute coronary syndrome (ACS) does happen. It has been found to be more common in individuals with risk factors. A case of chest pain in a previously healthy female in her third trimester demonstrates the importance of keeping ACS high on the differential list.

Case Report: A 26-year-old pregnant female gravida five, para three at 37 weeks gestation with a past medical history of diet-controlled gestational diabetes, obesity, and family history of myocardial infarction (MI) presented to an outside hospital for chest pain and was transferred to the closest ST-elevation myocardial infarction (STEMI) receiving emergency department (ED) after she was found to have an electrocardiogram (ECG) concerning for acute STEMI. On arrival to the ED, STEMI protocol was activated based on ST-segment elevations on inferior and antero-lateral leads on the ECG. Bedside assessment of the fetus by obstetrics showed a viable intrauterine pregnancy, and the patient was taken to the cardiac catheterization lab. She was found to have a 100% thrombotic occlusion in the ostium of the right posterolateral artery, and percutaneous coronary intervention was performed. The patient was discharged with plans for cesarean section at 39 weeks.

Conclusion: This case highlights the need for early STEMI activation and consultation with obstetrics when a pregnant patient presents with an ECG suggestive of STEMI. It also emphasizes the importance of maintaining a high level of suspicion for STEMI in pregnant patients presenting with chest pain. Although rare—0.6 in 10,000 pregnancies—mortality rates range from 5.1-37% throughout pregnancy and postpartum. It is important to remember that pregnancy does not preclude a patient from undergoing standard treatment of acute MI.

INTRODUCTION

Rattlesnakes are pit vipers belonging to the Viperidae family and Crotalinae subfamily.  They inject venom into their victims via bites from two long, hollow fangs.  This report describes a rare case of non-penetrating rattlesnake ocular exposure with symptoms.  Prior reports, pathophysiology, evaluation, and treatment recommendations are also discussed. 

CASE REPORT

A 56-year-old male picked up a rattlesnake and was sprayed in both eyes with venom. He had immediate pain and blurred vision. Despite copious initial irrigation, he continued to have worsening symptoms with conjunctival hemorrhage and scleral sloughing. After discussion with poison control, he was given six vials of intravenous antivenom. After additional irrigation and evaluation by ophthalmology, the patient symptoms stabilized but his exam still included blepharitis, subconjunctival hemorrhages, and bilateral small corneal epithelial defects. He was discharged home with corneal antibiotics and artificial tears. One week later, his symptoms were resolved, and his exam was normal.

CONCLUSION

Non-penetrating ocular rattlesnake envenomation is rare.  It should be treated as any other ocular exposure beginning with copious irrigation, then detailed examination.  Current recommendations argue against intravenous antivenom administration. However, intravenous antivenom can be considered if symptoms do not improve. 

Case Presentation: A 30-year-old female with a history of alcoholic cirrhosis and esophageal varices presented with massive hematemesis. A gastric balloon tamponade device was subsequently placed to temporize variceal hemorrhage, and point-of-care ultrasound (POCUS) was used to confirm the appropriate placement of the gastric balloon before complete inflation. We describe a novel use of ultrasound for use in severely ill patients with gastrointestinal (GI) bleeding.

Discussion: A fluid-filled and distended stomach has long been recognized as a cause of a false-positive focused assessment with sonography in trauma exam but may also be a vital piece of information in the scenario of a patient with suspected upper GI hemorrhage. There is very little description in the literature of using POCUS to confirm the appropriate placement of a gastric tamponade balloon with none by emergency physicians.. Ultrasound may offer advantages over plain radiography in this application given its speed and safety; thus, its utility for this task is worth further investigation.

Case Presentation: We describe a middle-aged female with past medical history of ulcerative colitis presenting to the emergency department with bilateral painful ulcers rapidly growing on her lower legs in the prior four weeks. She was consulted by a dermatologist and after a thorough clinical and pathology assessment (as a diagnosis of exclusion), treatment for pyoderma gangrenosum was started.

Discussion: Pyoderma gangrenosum is a painful, chronic, ulcerative disorder often occurring in association with systemic disease. We review the clinical presentation of pyoderma gangrenosum and its complications. We describe the characteristics of ulcers with pictures from the patient. Our case illustrates the findings of pyoderma gangrenosum both clinically and pathologically.

Case Presentation

A 73-year-old female with chronic obstructive pulmonary disease presents via emergency medical services for shortness of breath. She is found to be hypoxic, tachypneic, and in notable distress. She is treated with inhaled albuterol, oral dexamethasone, and intravenous magnesium sulfate. Upon arrival to the emergency department her had was noted to have significant bleeding, and on further investigation it was determined that the intravenous catheter has inadvertently become extravasated, and the magnesium had entered the subcutaneous space. The bleed with significant and pulsatile, a tourniquet was applied, and the vessel was ultimately tied off by the trauma surgery service. 

Discussion

Intravenous medication administration is ubiquitous with emergency care in both the hospital and prehospital environments.  Medications use is paramount to treatment of a vast majority of emergent clinical conditions, furthermore, the route of administration is often intravenous in the patient with emergent illness.  The placement of intravenous catheters is a skill that nurses, paramedics, and advanced emergency medical technicians learn early in their training.  The care team is tasked with not only starting intravenous lines, but also in monitoring them and ensuring medication is delivered into the systemic circulation, and not elsewhere.  Certain medications, notably potassium preparations and vasoactive medications, are known vesicants.  We present a case of vascular extravasation of magnesium sulfate, not know for causing significant tissue damage, that led to significant venous and arterial injury.  This case highlights the need for prehospital clinicians as well members of the emergency department care team to be ever vigilant for medication extravasation. 

Introduction: Bell palsy, an idiopathic dysfunction of the seventh cranial nerve, is the leading cause of unilateral facial paralysis, although other more serious entities such as stroke, infection, and tumor may present similarly, leading to both medical and legal risks in cases of misdiagnosis.   

Case Series: We present four malpractice cases revolving around misdiagnosis of Bell palsy. These cases alleged failure to diagnose, failure to obtain informed consent, and failure to provide appropriate discharge instructions. Outcomes ranged from a jury verdict in favor of the physician, to an out-of-court settlment for $400,000, to a jury verdict in favor of the patieint for over $3.1 million.  

Conclusion: Bell palsy is the most common cause of unilateral facial paralysis. While the diagnosis can be made at the bedside without advanced testing, doing so requires a clear understanding of the pathophysiology of the disease, an appreciation for the role of advanced diagnostics, and thorough documentation of a supportive history and physical exam. Misdiagnosis or mismanagement confers both clinical and legal risks.