Clinical Practice and Cases in Emergency Medicine

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A 51-year-old male presented to the emergency department with back pain, bilateral groin pain, and bilateral leg numbness for four days. He was hypothermic, tachycardic, tachypneic, and hypotensive on presentation. A diffuse purpuric rash with bullae and desquamation was noted on exam. This case explores the differential diagnosis and evaluation of an ill patient who presented with an impressive rash.

Introduction: Tibial plateau fractures, which comprise about 1% of all fractures, can be challenging to diagnose in the emergency department setting. Missed and delayed diagnoses can result in poor outcomes for patients and legal risks for clinicians, necessitating a high level of vigilance.

Case Series: In this article we review three malpractice cases related to tibial plateau fractures. Key issues included missed or delayed diagnosis, mismanagement of associated complications, inadequate discharge instructions, and lack of documentation.

Conclusion: Tibial plateau fractures can be challenging to identify, heightening the risk of downstream complications. As a result, emergency physicians must remain vigilant in assessing patients who are at increased risk for these injuries and document their efforts to both evaluate for and communicate these risks to patients.

Introduction: Buprenorphine is used for treating opioid use disorder, but its role as an analgesic in the emergency department (ED) is frequently overlooked. Emerging evidence indicates that, at low doses, it can be used safely and advantageously as an alternative to full-agonist opioids for treating acute pain.

Case Series: This case series examines the novel use of intravenous (IV) low-dose buprenorphine for acute pain management in the ED for five patients presenting with diverse past medical history and varied painful indications.

Conclusion: Intravenous low-dose buprenorphine may represent an important new tool in our ED armamentarium, and research into its role in emergency pain management is warranted. Further work is needed to determine optimal dosing strategies and identify which patients will be most likely to benefit from IV low-dosebuprenorphine in the ED.

Introduction: Despite the success of emergency department (ED)-based universal HIV screening programs in select cities, widespread integration of similar programs across the United States has not followed. Within the US Centers for Disease Control and Prevention (CDC)-designated “Ending the HIV Epidemic (EHE)” areas, ED-based HIV screening is low. This case series highlights successful strategies for notification and linkage to care of patients with various challenging social determinates of health (SDoH). The goal is to inspire more EDs to offer universal HIV screening by providing insight into these challenging SDoH and successful strategies to overcome them.

Case Series: We describe four cases, two from a site in upstate South Carolina and two from Cuyahoga County in Ohio, that highlight successful notification and linkage to care of these perceived “worst-case” scenarios. Both ED-based programs are located in CDC-designated EHE
areas. We discuss ED screening opportunities and successful linkage for these minority patients (21-36 years of age), and highlight the concomitant and challenging mental health and substance use disorders, and SDoH that were overcome. All four of these patients are currently receiving treatment for HIV and 3 of the 4 have reached viral suppression.

Conclusion: Despite challenging SDoH including unstable housing and lack of transportation, phone, and even legal identification documentation, these ED-identified patients with HIV were successfully notified of their disease status and linked to care. The patient navigators used perseverance, connections to local community resources, and leveraged family support toachieve linkage success. The cases serve as both a roadmap and source of inspiration to other EDs in priority EHE areas to begin ED HIV screening programs.

Introduction: First described in 1982, the Wellens wave is an electrocardiographic (ECG) finding indicative of a critical lesion of the left anterior descending artery. These T-wave findings are classically found in ECG leads V2 and V3, although they may extend into the lateral leads V4-V6.

Case Series: We present three cases of patients with Wellens waves that were found only in leads V3 and V4 and did not include V2.

Conclusion: We suggest that the classical definition of T-waves in leads V2 and V3 is not the only manifestation of Wellens waves to indicate pathology. Wellens waves found in two contiguous leads in leads V1-V6 can be considered Wellens corollaries, thereby requiring the same emergent treatment as classical Wellens syndrome. We also recognize the need for a consensus on the inclusion criteria of Wellens syndrome, particularly the laboratory and ECG findings that define the disease.

Introduction: Brugada syndrome, a cardiac channelopathy, manifests with ventricular arrhythmia. Diagnosis relies on a type 1 Brugada electrocardiogram (ECG) pattern, while type 2 and type 3 patterns may necessitate electrophysiologic testing to uncover an underlying type 1 Brugada pattern. Differentiation between these patterns is important, as type 1 patterns pose a significantly greater risk of arrhythmia relative to types 2 and 3 counterparts.

Case Report: A 14-year-old male with autism presented after a syncopal episode following a lurasidone dosage increase. His ECG revealed a type 2 Brugada pattern. He was monitored
overnight in the pediatric intensive care unit, where he remained asymptomatic. After being discharged with a Holter monitor, a quaternary hospital’s procainamide challenge test weeks later contradicted an official diagnosis of Brugada syndrome, as dictated by elucidation of a type 1 Brugada pattern. After reverting to the initial lurasidone dose, a follow-up ECG after two months showed no Brugada pattern.

Conclusion: In syncope cases, an ECG is crucial for identifying arrhythmogenic causes, including Brugada syndrome. This case highlights an ECG suggestive of Brugada syndrome with negative pharmacological tests and resolution post-discontinuation of the offending agent. Emergency physicians should be vigilant for Brugada and long QT syndromes in patients on antipsychotic medications.

Introduction: Altered mental status presentations are commonplace in the emergency department (ED), but not all are due to psychiatric etiologies, even if the patient has had a previous psychiatric diagnosis. It is critical to evaluate for organic causes of a patient’s altered presentation. This case highlights the necessity of a broad workup to correctly diagnose an altered patient.

Case Report: A 23-year-old Haitian male with a past medical history of bipolar 1 disorder, seizure disorder, and developmental delay presented to a critical access ED for altered mental status. The patient was given 300 milligrams of ketamine for delirious hyperactivity and agitation by emergency medical services in the field. On physical examination, the patient was in acute respiratory distress, hypoxic, not tolerating secretions, tachycardic, lethargic, and was subsequently intubated for airway protection. Computed tomography (CT) of the brain without contrast was obtained and revealed findings consistent with Fahr disease.

Conclusion: Fahr disease is a rare neurodegenerative condition that causes accumulation of calcium deposits in the basal ganglia as demonstrated on CT. Phenotypes can be variable, including
symptoms such as parkinsonism, chorea, dystonia, cognitive impairment, and ataxia. This case illustrates the importance of a broad differential diagnosis and emergent medical interventions for emergency physicians practicing in critical access facilities.

Introduction: Sympathetic crashing acute pulmonary edema (SCAPE), also known as flash pulmonary edema or hypertensive acute heart failure, is a critical condition characterized by a rapid escalation of sympathetic outflow, excessive afterload, and worsening heart failure. Although rare, contrast
media-induced pulmonary edema is a severe adverse reaction, occurring in 0.001-0.008% of patients
receiving intravenous contrast and accounting for 10-20% of lethal contrast reactions.

Case Report: A 70-year-old male developed acute respiratory distress shortly after undergoing an outpatient, contrast-enhanced computed tomography. Despite treatment for suspected anaphylaxis, the patient’s condition continued to deteriorate until a diagnosis of SCAPE was ultimately recognized. Treatment with high-dose nitroglycerin, non-invasive positive pressure ventilation (NIPPV), and eventual intubation resulted in the patient’s full recovery.

Conclusion: This report highlights the importance of recognizing SCAPE in patients presenting with sudden dyspnea after contrast administration and emphasizes the need for early intervention with NIPPV and vasodilators to reduce morbidity and mortality.

Introduction: Grammostola rosea (Chilean rose tarantula) is a common exotic pet belonging to the Theraphosidae (tarantula) family. Case reports of theraphosid bites in adults commonly describe local tissue damage and local pain. Muscle spasms have also been described as a result of the bites but are rarer. We present a case of severe and persistent muscle spasms after a G rosea bite, which is uncommonly reported in the literature.

Case Report: A 42-year-old woman was holding a G rosea tarantula when she was bit on the forearm. Within hours, severe local muscle cramping occurred. Due to worsening cramping, she initially presented to the emergency department the day after the bite, and again on the following day. She was admitted on her second visit and treated with diazepam, cephalexin, diphenhydramine, baclofen, cefpodoxime, doxycycline, prednisone, and topical hydrocortisone. Her laboratory testing was unremarkable, and while medical management may have mildly improved her symptoms, painful cramping persisted. After discharge, her paroxysmal muscle cramping continued for four weeks before completely resolving.

Conclusion: While local tissue damage and pain are common, G rosea bites may lead to severe muscle cramping that persists for weeks. Standard laboratory testing may be completely normal in these cases. Muscle cramps may be persistent and are difficult to manage.

Introduction: Post-pancreatectomy hemorrhage (PPH) is a deadly complication of pancreatectomy procedures. Rapid identification of these life-threatening complications is crucial to mitigating associated morbidity and mortality rates. Delayed PPH is managed similarly to aortoenteric fistulas with damage control resuscitation and emergent endovascular interventions such as embolization and stent placement.

Case Report: Here, we present the case of a delayed PPH presenting to the emergency department as a sentinel bleed secondary to a ruptured common hepatic artery pseudoaneurysm following a pancreatoduodenectomy.

Conclusion: With hepatobiliary procedures being performed with more frequency, emergency physicians must be aware of the deadly postoperative complications such as post-pancreatectomy hemorrhage, their presentations, and their treatments.

Introduction: We present a case of a renal tumor infiltrating the pulmonary arteries that was diagnosed after using point-of-care ultrasound in the emergency department (ED).

Case Report: A 78-year-old female presented with non-specific symptoms of heart failure. Efficient diagnosis and management were possible after using imaging in the ED that showed renal tumor extension from her left kidney to pulmonary arteries.

Conclusion: This is the first case report to our knowledge on diagnosing and managing a newly discovered renal mass in the emergency setting. For non-specific symptoms of heart failure, one
should consider obtaining a point-of-care ultrasound in the ED

Introduction: Infantile subglottic hemangioma is a rare and serious condition characterized by stridor, respiratory distress, and a barking cough. This condition poses a significant risk as it can lead to life-threatening airway obstruction. 

Case Report: We present a patient who was diagnosed in the ED with moderate laryngomalacia via laryngoscopy by otolaryngology and discharged; he returned to the ED the next day with worsening symptoms of recurrent stridor, difficulty feeding, and worsening respiratory distress. A second laryngoscopic exam performed on the return ED visit revealed a subglottic mass which was later identified as a left-sided subglottic hemangioma via bronchoscopy and MRI. The patient was treated with propranolol and discharged from the inpatient unit with dermatology and otolaryngology follow-up. 

Conclusion: Infantile subglottic hemangioma is a rare but serious cause of respiratory distress in infants, posing a risk of airway obstruction. It should be considered in the ED, particularly for patients under two years of age, who present with recurrent stridor and respiratory distress and do not respond to standard treatments for croup or laryngomalacia.

Introduction: Skeletal fluorosis is a complication of excess fluoride which may be associated with chronic inhalation or “huffing” of compressed air cleaners for keyboards and electronics.  The rare presentation of this condition can lead to a missed diagnosis and lack of appropriate intervention.  Clinicians should be aware of the potential development of fluorosis in patients reporting a history of inhalant abuse.

Case Report: We present a case of skeletal fluorosis in a patient with a 4-month history of daily inhalant abuse of computer cleaner containing difluoroethane (DFE).  She presented to the emergency department after developing myalgias for approximately 4 months and noted to have diffuse bilateral swelling to upper and lower extremities, as well as interphalangeal joint swelling and non-mobile lesions to bilateral hands and left forearm on physical exam.  Radiography revealed diffuse periosteal reaction throughout the hand and forearm suggestive of fluorosis.  She was counseled to cease inhalant use and endorsed pain was alleviated by rest, heat therapy, and pain medication.

Conclusion: Skeletal fluorosis is a rare and painful condition, which can have prolonged adverse effects and lasting impacts on quality of life.  Patients who report regular inhalant use should be counseled on the potential toxicities of these products and encouraged to cease use.  Those presenting with diffuse skeletal findings and reported DFE use should be evaluated for skeletal fluorosis.

Introduction: Congenital diaphragmatic hernia (CDH) is an embryological defect of the diaphragm that typically presents in the neonatal period with respiratory distress.  However, delayed presentations do occur rarely and can pose diagnostic and therapeutic challenges.

Case Report: We describe the case of a 9-month-old male who presented to the emergency department with respiratory distress and was subsequently diagnosed with congenital diaphragmatic hernia.

Conclusion: This case underscores the importance of considering CDH in the differential diagnosis of pediatric patients presenting to the Emergency Department (ED) with unexplained respiratory or gastrointestinal symptoms, even beyond the neonatal period.

Introduction: Idiopathic intracranial hypertension is a rare but serious cause of headache. Prompt diagnosis and treatment is needed to prevent permanent neurologic sequelae.

Case Report: We present a case of a 32-year-old female with multiple emergency department visits for a headache after having a medical termination of pregnancy. She was found to have severe anemia, retained products of conception, and radiographic findings suggestive of idiopathic intracranial hypertension, which was confirmed by an elevated opening pressure on lumbar puncture. Her symptoms improved after transfusion of packed red blood cells, initiation of acetazolamide and corticosteroids, and manual uterine evacuation. She was ultimately discharged without any neurologic deficits.

Conclusion: Idiopathic intracranial hypertension is a rare but serious cause of headache, and anemia is an underappreciated precipitating factor. The hormonal changes associated with
pregnancy may further predispose patients to this rare medical condition, especially in the setting of vaginal bleeding.

Case Presentation: An 18-year-old female, gravida 0, para 0, with no significant past medical history presented with spontaneous left vulvar hematoma that started two hours prior to arrival. History also revealed amenorrhea for the past nine months, menorrhagia three days ago, and oral contraceptive use. Her vitals demonstrated tachycardia to 130s beats per minute but otherwise were normal, consistent with an early stage of hemorrhagic shock. Physical exam was remarkable for significant left labia majora hematoma with active hemorrhage on computed tomography from the right internal iliac artery. She underwent emergent gelfoam embolization with interventional radiology and subsequent hematoma evacuation with an obstetrician gynecologist. 

Discussion: Etiologies of vulvar hematomas fall within two categories: obstetric or non-obstetric. In rare circumstances, hematomas that lack evidence of obstetric or traumatic events are presumed to be of spontaneous artery rupture origin. Vulvar hematomas are a clinical diagnosis but can be challenging. The hallmark symptom is moderate to severe pain that is usually in the perineum but can be in the groin, abdominal and/or buttock regions depending on the size and location of the hematoma. A proper history and physical exam are essential to rule out the differential diagnoses such as vulvar varicosities, folliculitis, Bartholin gland cysts/abscesses or vulvar cancer. Management of vulvar hematomas is not well defined. Ultimately, clinical decision should be based on degree of hemodynamic stability, size of the hematoma, rate of expansion, risk or presence of pressure necrosis, urologic symptoms and presence of unremitting pain. To date, there are three reported spontaneous vulvar hematomas due to pudendal artery rupture and one due to internal iliac artery rupture. To the best of our knowledge, our case represents the second reported account of non-obstetric, non-traumatic spontaneous vulvar hematoma due to internal iliac artery rupture and the first reported account where the resulting hematoma was contralateral to the affected artery. 

Introduction: The trigeminocardiac reflex (TCR), a physiologic response to irritation of the branches of the trigeminal nerve, was first described in humans in 1870. Gastric hypermobility, hypotension, bradycardia, and even asystole have been reported in response to surgical manipulation of the trigeminal nerve and its branches, but literature is limited in patients not undergoing surgery. Although effects are generally transient and benign, TCR can present a significant diagnostic and therapeutic challenge in patients undergoing surgical manipulation of the trigeminal nerve and its branches.

Case Report: We describe a case of severe bradycardia secondary to facial trauma causing hemodynamic compromise and diagnostic uncertainty.

Conclusion: This case highlights a possible case of TCR, as well as therapeutic considerations, in a patient presenting to the emergency department with severe facial trauma.

Introduction: Brugada syndrome is a ventricular arrhythmia and type of sodium channelopathy that can be seen in the absence of structural heart disease. Recognition of this pattern on electrocardiogram (ECG) is important for stabilization and correction of underlying triggers that can be addressed in the emergency department (ED).

Case report: We describe a case of a 58-year-old male who presented with chest pain and was found to have type 1 Brugada pattern in the setting of severe hypokalemia. Repletion of potassium later revealed type 3 Brugada pattern followed by resolution on repeat ECG.

Conclusion: Rapid identification of underlying metabolic derangements that can trigger Brugada syndrome is important in the ED setting. Correction of the underlying abnormality can reveal a type 3 pattern with subsequent resolution of the pattern if well-controlled.

Introduction: Rothia mucilaginosa is a rare cause of endocarditis, typically seen in intravenous (IV) drug users who use needles contaminated with saliva. However, it is rare in individuals who are immunocompetent, have no history of valvular disease, or have not undergone valvular repair. Definitive management of R mucilaginosa endocarditis is valvular repair, but this procedure can be delayed in the setting of intracranial hemorrhage.

Case Report: We document the case of a 35-year-old male IV drug user who developed R mucilaginosa endocarditis, resulting in severe neurologic sequelae due to septic emboli. The patient presented to the emergency department (ED) where work-up revealed a clinical presentation consistent with endocarditis resulting in septic emboli. He was later admitted to the neurosurgical and cardiac intensive care units, where he underwent thrombectomy, monitoring of
his intraparenchymal hemorrhage (IPH), and mitral valve repair. This case highlights the patient’s functional neurologic outcome following delayed mitral valve repair due to IPH.

Conclusion: This case report highlights a rare form of R mucilaginosa endocarditis recognized in the ED, with a hospital course including thrombectomy, IPH monitoring, and mitral valve repair. The patient had progressive neurologic sequelae given delayed mitral valve repair due to concerns that procedural heparinization would worsen his IPH. Given functional decline, the patient underwent mitral valve repair on hospital day six without worsening of his IPH, demonstrating that current guidelines to delay mitral valve repair by four weeks in the setting of intracranial hemorrhage may be too strict for patients who are high risk for continued showering of septic emboli.

Introduction: Tube thoracostomy is a common yet exceedingly painful emergency department (ED) procedure, primarily used for pneumothorax evacuation. To facilitate safe performance, stable patients generally receive intravenous anxiolytic or opioid premedication, or perhaps even procedural sedation, in combination with local anesthetic infiltration of the insertion tract. However, more advanced pain management strategies, such as ultrasound-guided truncal blocks, offer a targeted and effective analgesic alternative without the risks or side effect profile inherent to sedation and opioid administration. Herein, a case is presented of painless ED tube thoracostomy following an ultrasound-guided thoracic paravertebral block (TPVB).      

Case Report: A 74-year-old female presented to the ED with chest pain and dyspnea from a recurrent, large right-sided spontaneous pneumothorax. An ultrasound-guided thoracic paravertebral block was performed for full-thickness chest wall analgesia prior to tube thoracostomy. A pigtail catheter was inserted painlessly into the pleural space without need for rescue analgesia or procedural sedation, and the pneumothorax was successfully evacuated.

Conclusion: Ultrasound-guided regional anesthesia is increasingly employed in the emergency care setting as part of an opioid-sparing, multimodal analgesia strategy to manage acute pain. For chest tube insertion, the ultrasound-guided thoracic paravertebral block provides potent, long-lasting, and non-euphorigenic, hemithoracic analgesia across multiple contiguous dermatomes from skin to parietal pleura, reducing the need for procedural sedation and opioid therapy while avoiding the incomplete chest wall blockade often associated with other truncal blocks. It is a valuable addition to the analgesic armamentarium of the emergency physician, enabling more comprehensive pain control prior to tube thoracostomy.

Introduction: Traumatic injury is the leading cause of death in individuals under 45 years of age, and point-of-care ultrasound (POCUS) has become an essential component of the initial trauma evaluation. However, positive findings on the extended focused assessment with sonography in trauma (eFAST) may be misinterpreted as evidence of an acute surgical emergency, particularly in the context of blunt trauma, underscoring the need for careful clinical correlation.

Case Report: We present a case in which a hemodynamically unstable patient had significant free abdominal fluid on eFAST after a fall from standing height. She was ultimately diagnosed with a high-risk pulmonary embolism as the cause of her hemodynamic instability, while the free abdominal fluid was identified as originating both from a ruptured ovarian cyst and from moderate-volume ascites.

Conclusion: The eFAST exam is a valuable tool in rapidly identifying intra-abdominal injuries following blunt trauma. However, the presence of free fluid on eFAST may result from causes other than acute intra-abdominal injury requiring surgical intervention. Therefore, emergency physicians should interpret positive findings with clinical judgment and consider the broader clinical context.

Introduction: There exists a wide differential of etiologies for pediatric torticollis that extend beyond musculoskeletal factors. 

Case Report: We present a novel case of an 8-year-old male with acute, atraumatic hemorrhage of the left cerebellum presenting with gradual worsening torticollis. Upon further diagnostic workup, he was found to have an intracerebral hemorrhage due to a cerebellar cavernous malformation. Though the hemorrhage boundaries were extensive, the patient had only exhibited transient dysmetria and facial weakness, with ultimate resolution of torticollis and these neurological symptoms after several days. 

Conclusion: This case demonstrates the importance of maintaining a broad differential in the workup of acute pediatric torticollis.

Case Presentation: A 54-year-old male presented to the emergency department one month after blunt trauma to the head complaining of two weeks of worsening swelling over his right posterior scalp. Computed tomography of the head without contrast showed a soft tissue lesion. Point-of-care ultrasound (POCUS) was performed to clarify the soft tissue lesion that was found on computed tomography and revealed an occipital artery pseudoaneurysm.

Discussion: An occipital artery pseudoaneurysm is a rare diagnosis. A POCUS performed by the emergency physician ensured an accurate and timely diagnosis for this patient

Introduction: Cardiac myxomas are rare benign tumors of the heart that can become clinically relevant due to cardiovascular effects. Diagnosis can be challenging due to non-specific presenting symptoms. Point-of-care ultrasound (POCUS) provides a convenient first-line screening modality. 

Case Presentation:  A 65-year-old male with a history of tobacco use presented to the emergency department (ED) with a month of progressive dyspnea with exertion and hematemesis. Cardiac POCUS and pulmonary computed tomography with angiography revealed a left atrial mass consistent with a cardiac atrial myxoma. The patient underwent coronary artery bypass grafting with excision of the left atrial myxoma via right atriotomy and atrial septal defect repair. 

Discussion: Presented is a case of a patient presenting with progressive dyspnea diagnosed with a cardiac myxoma using POCUS in the ED. Cardiac myxomas have a wide variety of clinical presentations, and emergency physicians must maintain a high index of suspicion. Point-of-care-ultrasound is well suited for early diagnosis of this unique pathology. Surgical resection and tumor histopathology remain the mainstay of treatment.

Case Presentation: A 28-year-old woman with a history of cocaine and opioid use disorder presented to the emergency department with abdominal pain, nausea, and vomiting for two days. She’d had irregular bowel movements with constipation for quite some time. Physical exam was notable for diffuse peritonitis and melena on digital rectal exam. Patient had a witnessed episode of hematochezia. Computed tomography of the abdomen and pelvis with intravenous contrast demonstrated sigmoid colon intussusception, and the patient underwent emergent surgery for definitive treatment. Specimen was sent to surgical pathology and revealed no lead point.

Discussion: While sigmoid intussusception is not a rare finding, it is exceedingly rare in young adult patients who do not have a pathologic lead point. Lead points are areas of inflammation, lesions, or masses that snag the bowel and initiate the process of telescoping that ultimately results in an intussusception. This patient was not found to have such a lead point on gross examination during surgery or on extensive specimen examination in the pathology lab. Instead, her sigmoid intussusception is hypothesized to be secondary to decreased gut motility in the setting of chronic opioid use disorder.