This case highlights the advances that have been made when skilled sonographers using point-of-care ultrasound (POCUS) are able to evaluate for more than free fluid on the focused assessment with sonography in trauma (FAST) exam. Specific solid organ injury including an active liver bleed can also be detected during FAST exam, as seen in this case of a unstable hypotensive patient.
Gastroduodenal artery embolization is an increasingly common treatment method in patients with upper gastrointestinal (GI) bleeding who fail endoscopy or as a prophylactic procedure to help prevent further episodes. However, this new technique includes new risks including GI tract ischemia and risks associated with endovascular access such as hematoma formation, pseudoaneurysm development, and arterial dissection.
Ludwig angina is a potentially fatal condition characterized by soft tissue infection of the submandibular, sublingual, and submental compartments. Pseudo-Ludwig angina is a rare condition characterized by sublingual swelling of non-infectious etiology, typically in the setting of supratherapeutic anticoagulation. However, other etiologies, such as angioedema and trauma, have been described.
Methemoglobinemia is a rare hematologic disorder of hemoglobin, in which iron contained within the heme moiety becomes oxidized from ferrous iron to ferric iron at a concentration greater than 1% in the blood. This biochemical change reduces binding affinity for oxygen, leading to impaired oxygen deposition in tissues and subsequent hypoxia and hypoxemia. The etiology of methemoglobinemia is often acquired from exposure to oxidizing agents, commonly antibiotics such as dapsone or local anesthetics such as benzocaine. A rare cause results from congenital deficiency of cytochrome b5 reductase, a nicotinamide adenine dinucleotide dependent enzyme within red blood cells that donates electrons to reduce ferric to ferrous iron.
Salicylate poisoning remains one of the most common global accidental overdoses and poses a considerable health threat. Typical presentations for salicylate overdoses include nausea, vomiting, and abdominal pain as well as tinnitus, tachypnea, fever, and dehydration resulting in a concomitant metabolic acidosis and respiratory alkalosis. This may progress to a predominance of neurological symptoms such as mental status changes, confusion, delirium, and hallucinations.
Prevalence of serious infections from Haemophilus influenzae has diminished over the last few decades because of immunizations against the most virulent serotype. However, over the last few years a handful of septic arthritis cases secondary to H influenzae have been documented. Most of the cases documented are in the pediatric and unimmunized population. This is a case of polyarticular septic arthritis in a 69-year-old male who presented with syncope and ankle pain.
Calcium channel blocker (CCB) and beta blocker (BB) overdoses are life-threatening conditions that can lead to vasoplegic and cardiogenic shock. Treatment involves a combination of vasopressors, calcium, glucagon, and/or high-dose insulin euglycemia therapy. The most severe overdoses may require venoarterial extracorporeal membrane oxygenation (VA-ECMO), which often results in interfacility transfers. This report describes two successful VA-ECMO transfers for refractory CCB/BB overdose.
Hydroxyapatite deposition disease (HADD) is caused by the presence of hydroxyapatite crystals in periarticular spaces oftentimes leading to inflammation, pain, and decreased range of motion.
Penile pain in children and adolescents is an uncommon presenting symptom in the emergency department (ED). The differential diagnosis includes trauma, priapism, urethral stone, infection, Mondor disease, Peyronie disease, and thrombosis.
Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis typically affecting dermal capillaries and venules. The condition is often idiopathic but can be associated with infections, neoplasms, autoimmune disorders, and certain drugs.
Ventricular ectopic beats and corrected QT interval (QTc) prolongation are both relatively common entities that are typically benign. It is difficult to predict subsequent dysrhythmias from either electrocardiogram (ECG) feature. The combination of both features may better predict the risk of torsades de pointes. We highlight a case of torsades preceded by a bizarre bigeminal rhythm with QTc prolongation likely caused by memantine use and hypokalemia.
While mild or moderate iron-deficiency anemia may not cause any symptoms, more severe deficiencies may present clinically as fatigue, shortness of breath, exertional dyspnea, lightheadedness, tachycardia, and presyncope or syncope, and, in rare instances, pica. Pica is defined as the developmentally inappropriate ingestion of non-nutritive, non-food substances for more than one month. We present the case of a duodenal obstruction secondary to a pica-associated bezoar in a patient with iron-deficiency anemia who presented to the emergency department (ED) with abdominal pain.
Ventricular ectopic beats and corrected QT interval (QTc) prolongation are both relatively common entities that are typically benign. It is difficult to predict subsequent dysrhythmias from either electrocardiogram (ECG) feature. The combination of both features may better predict the risk of torsades de pointes. We highlight a case of torsades preceded by a bizarre bigeminal rhythm with QTc prolongation likely caused by memantine use and hypokalemia.
Obstructive shock results from reduced cardiac output due to physical blockage of blood flow, such as cardiac tamponade. Cardiac tamponade compresses cardiac chambers, particularly the left atrium, causing decreased end-diastolic volume and cardiac output. Rapid fluid accumulation within the pericardial sac is the usual cause. Transesophageal echocardiography provides clearer visualization of these structures than transthoracic ultrasound. This case underlines the impact of esophageal pathology on cardiac output and highlights ultrasound’s dynamic diagnostic utility alongside computed tomography.
Group A streptococcus (GAS) manifests as a spectrum of illnesses, ranging from mild to life-threatening. While relatively rare in infants, GAS infections can present with grave consequences.
Point-of-care ultrasound (POCUS) is a rapid bedside tool, particularly in undifferentiated emergency department patients. Point-of-care ultrasound can investigate potential intra-abdominal infections in febrile patients, especially in the elderly, who often present atypically without abdominal pain or localizing symptoms.
Hydrocephalus presents a diagnostic and therapeutic challenge due to its diverse clinical manifestations and underlying causes. Symptoms can vary from feelings of unsteadiness to focal symptoms such as weakness, difficulty ambulating, or urinary incontinence. Due to the wide variety of symptoms, hydrocephalus can present a difficult diagnosis for any physician and may require different interventions depending on the underlying cause.
Cullen sign is an area of periumbilical ecchymosis that results from blood tracking along the round ligament. Any source of retroperitoneal or abdominal hemorrhage can cause Cullen sign, but it is often described in association with acute pancreatitis.
Coinfection with human immunodeficiency virus (HIV) and Treponema pallidum represents a unique challenge in management, with increased risk of neurological complications. Haiti is well-known for being disproportionately impacted by the HIV epidemic, with rates of infection ~6 times higher than in the United States (US). Rates of coinfection in Haiti are incompletely characterized but likely high. The US has seen a marked increase in migration from Haiti, with implications for public health and migrant health management.
Tics in children are commonly diagnosed and not usually a cause for concern. Rarely, they may present as a symptom of underlying intracranial pathology.
Hereditary angioedema (HAE) is a genetic disorder associated with recurrent episodes of angioedema in the absence of urticaria and pruritus. Hereditary angioedema is inherited in an autosomal dominant pattern and results in a quantitative deficiency (HAE type I) or dysfunction (HAE type II) of the C1-esterase inhibitor (C1-INH) protein. A very rare third type of HAE which is associated with normal quantitative and functional levels of C1-INH (HAE-nl-C1-INH) has been described.
Takotsubo syndrome (TTS) expresses transient wall motion abnormality of the left ventricle, reportedly induced by sympathetic overstimulation. Takotsubo syndrome is unlikely to be included in the differential diagnosis of heart transplant patients with sudden cardiac dysfunction given the complete denervation occurring during the transplantation.
A pericapsular nerve group (PENG) block is unique compared to other regional anesthetic techniques (femoral nerve and fascia iliaca blocks) because it is a motor-sparing block. It also provides anesthesia to more nerves that innervate the anterior capsule of the femoroacetabular joint when compared to the femoral nerve and fascia iliaca blocks. Additionally, regional anesthesia carries fewer risks and requires less resources when compared with procedural sedation, which is the typical method for reducing a dislocated femoroacetabular joint.
An 83-year-old male with a history of prostate cancer and prior prostatectomy presented with lower abdominal pain, urethral leakage, and hematuria after a routine suprapubic catheter exchange, which was found to be incorrectly positioned in the bulbar urethra, leading to obstructive nephropathy with mild hydronephrosis.
We present an image and discussion of spontaneous evisceration, or “burst abdomen,” from an anterior abdominal wall hernia. A 61-year-old female with prior history of alcoholic cirrhosis and ascites presented to our emergency department with frank evisceration of multiple loops of small bowel from an open anterior abdominal wall dehiscence. Approximately one year prior to this visit she had also been seen in our department for spontaneous rupture of the skin overlying an umbilical hernia and large-volume external leakage of ascites (Flood syndrome1). She required surgery to repair the abdominal wall at that time but had subsequently developed a new ventral hernia extending from the umbilicus across a large portion of her left lower abdomen as well as several other postoperative complications. On the day of presentation, she suffered dehiscence of that one-year-old surgical site resulting in spontaneous evisceration of her small bowel. She was transferred to a facility with acute care surgical capabilities where she remained in critical condition.
