Ultrasound Diagnosis of Bilateral Quadriceps Tendon Rupture After Statin Use

Simultaneous bilateral quadriceps tendon rupture is a rare injury. We report the case of bilateral quadriceps tendon rupture sustained with minimal force while refereeing a football game. The injury was suspected to be associated with statin use as the patient had no other identifiable risk factors. The diagnosis was confirmed using bedside ultrasound.

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Retrobulbar Hematoma from Warfarin Toxicity and the Limitations of Bedside Ocular Sonography

The following case describes a 26-year-old female who presented to the emergency department with a nontrauamtic retrobulbar hematoma associated with warfarin toxicity. The application and limitations of focused bedside ocular sonography for this condition are discussed.

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Toxic Epidermal Necrolysis From a Cigarette Burn

Toxic epidermal necrolysis is a rare disease that is most often drug-induced but can be of idiopathic origin. We present a case that originated at the site of a cigarette burn to the forearm and review the key elements of physical exam findings and management of this life-threatening dermatological condition, which needs to be promptly recognized to decrease patient mortality.

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Cecal Volvulus In Adolescence Presenting As Recurring Visits For Abdominal Pain

Repeat visits to an emergency department (ED) within a short period of time for recurring or continuing abdominal pain should make physicians suspicious for relapsing or episodic disease processes. I present a case of a 17-year-old female with cecal volvulus found only after multiple ED visits.

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Ileocecal Intussusception in the Adult Population: Case Series of Two Patients

Intussusception is a condition found primarily in the pediatric population. In the adult population, however, intussusception is usually due to a pathological process, with a higher risk of bowel obstruction, vascular compromise, inflammatory changes, ischemia, and necrosis. Radiographic and sonographic evidence can aid in the diagnosis. Surgical intervention involving resection of affected bowel is the standard of care in adult cases of intussusception.

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Catatonia Associated with Initiating Paliperidone Treatment

We present a case of catatonia, which occurred shortly after starting a new antipsychotic, paliperidone, an active metabolite of risperidone. Catatonia may be caused by a variety of conditions, including metabolic, neurologic, psychiatric and toxic processes. Interestingly, risperidone, which has been thought to cause several cases of catatonia, has also been recommended as a potential treatment. We discuss potential mechanisms for causes of drug-induced catatonia as well as potential treatment options.

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Critical Care

Luxatio Erecta Complicated By Anterior Shoulder Dislocation During Reduction

Luxatio erecta humeri is an uncommon form of glenohumeral dislocation, resulting in the inferior displacement of the humeral head. Treatment with traction-counter traction techniques is usually successful in reducing most cases. We describe an unusual complication of this condition where initial reduction attempts of a luxatio erecta humeri repositioned the shoulder to an anterior dislocation position. After a thorough search of the literature, we were unable to find a similar case report of this type of complication during the reduction of a luxatio erecta shoulder dislocation.

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Necrotizing Fasciitis of the Paraspinous Muscles

Necrotizing fasciitis (NF) is a rare and lethal soft tissue infection that requires urgent surgical intervention. It is most often found in the extremities occurring with precipitating trauma or in immunocompromised states. Signs and symptoms are often vague or missing making early diagnosis very difficult. Our patient presented with flank pain and altered mental status but no known precipitating factors. Computed Tomography showed gas within and around the right paraspinous muscle suspicious for NF. Given NF’s high lethality, early suspicion by emergency physicians of NF in patients with soft tissue infections or with systemic findings of unknown etiology is necessary.

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Atypical Guillain-Barré in the Emergency Department

Guillain Barré Syndrome (GBS), although an uncommon diagnosis in the emergency department (ED), usually presents as one of the more common chief complaints—weakness. In this report we present an unusual case of weakness, initially seen in the ED and sent home only to return with worsening symptoms and ultimately found to be GBS.

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Small Bowel Obstruction from Capsule Endoscopy

Over the past decade, capsule endoscopy has become the accepted modality for small bowel imaging in the United States. It is very helpful in making the diagnosis of Crohn’s disease; however, this patient population is also at an increased risk of small bowel obstruction secondary to capsule impaction. We present the case of a 60-year-old female with undiagnosed Crohn’s disease who presented to the emergency department with small bowel obstruction after capsule ingestion. She was successfully disimpacted with diatrizoate upper gastrointestinal (GI) series with small bowel follow-through and intravenous steroids. Review of the endoscopic video images revealed findings consistent with Crohn’s disease.

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Fatal Dysrhythmia Following Potassium Replacement for Hypokalemic Periodic Paralysis

We present a case of fatal rebound hyperkalemia in a patient with thyrotoxic periodic paralysis (TPP) treated with potassium supplementation. Although TPP is a rare hyperthyroidism-related endocrine disorder seen predominantly in men of Asian origin, the diagnosis should be considered in patients of non-Asian origins presenting with hypokalemia, muscle weakness or acute paralysis. The condition may present as a life threatening emergency and unfamiliarity with the disease could result in a fatal outcome. Immediate therapy with potassium chloride supplementation may foster a rapid recovery of muscle strength and prevent cardiac arrhythmias secondary to hypokalemia, but with a risk of rebound hyperkalemia.

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Subacute Tension Hemopneumothorax with Novel Electrocardiogram Findings

This case report describes a patient with a subacute right-sided tension hemopneumothorax following an occult stab. The patient’s electrocardiogram (ECG), performed as part of a standardized triage process, demonstrated significant abnormalities that misguided initial resuscitation, but resolved following evacuation of the tension hemopneumothorax. Tension pneumothorax is typically regarded as an immediately life-threatening condition that requires emergent management with needle or tube thoracostomy. However, we believe that subacute tension pneumothorax may be a rarely observed clinical phenomenon and may lead to unique ECG findings. We believe that the ECG changes we observed provided an early clue to the eventual diagnosis of a subacute tension pneumothorax and have not been previously described in this setting.

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Peritonsillar Abscess with Uvular Hydrops

The use of ultrasound by emergency physicians has improved the evaluation of pharyngeal infections. We present a unique case of concomitant peritonsillar abscess and uvular hydrops in which ultrasound provided accurate, timely information in the evaluation.

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Spontaneous Rectus Sheath Hematoma

Abdominal wall pathology is a frequently overlooked cause of acute abdomen. Increasing use of antiplatelet and anticoagulant therapies has led to an increase in the incidence of spontaneous rectus sheath hematoma (RSH). A high index of suspicion is needed for diagnosis as it can closely mimic other causes of acute abdomen. Herein, we report a case of RSH presenting with abdominal pain in which there was a significant delay in diagnosis. We wish to highlight the need to increase awareness among primary and emergency physicians about considering RSH in the initial differential diagnoses of abdominal pain.

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Lidocaine Toxicity Misinterpreted as a Stroke

For more than 50 years lidocaine has been used to treat ventricular arrhythmias. Neurologic dysfunction, manifested as a stroke, occurred acutely in an 87-year-old woman after she had been administered repeated doses of lidocaine, a lidocaine infusion, then an intravenous amiodarone infusion for ventricular tachycardia. This was ultimately diagnosed as lidocaine toxicity with a serum lidocaine level of 7.9 mg/L (1.5–6.0 mg/L). We discuss lidocaine toxicity and risk factors leading to its development, which include particularly hepatic dysfunction, cardiac dysfunction, advanced age and other drug administration.

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Bilateral Psoas Abscess in the Emergency Department

We present the case of a 45-year-old female who presented multiple times to the emergency department with acute low back pain and was subsequently diagnosed with bilateral psoas muscle abscess. Psoas abscess is an uncommon cause of acute low back pain that is associated with high morbidity and mortality. The onset of symptoms is frequently insidious and the clinical presentation vague. Proper diagnosis requires vigilance of the physician to recognize signs in the history and physical examination that are suggestive of a potentially serious spinal condition and initiate further workup. While most patients with acute low back pain have a benign etiology, this case report demonstrates the challenge of diagnosing a patient with bilateral psoas abscess who had few known risk factors and symptoms typical of mechanical low back pain.

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Thyroid Gland Hematoma After Blunt Neck Trauma

Hemorrhage of a previously normal thyroid gland as a result of blunt trauma is a very rare condition. We report a case of blunt trauma that caused acute hemorrhage into the thyroid gland and presented with hoarseness. The diagnosis of thyroid gland hematoma was made with a combination of fiberoptic laryngoscopy, cervical computed tomography, and carotid angiography. The patient was treated conservatively, had a favorable course without further complications, and was discharged four days after admission.

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Lead Toxicity Resulting from Chronic Ingestion of Opium

A 32-year-old man presented to the emergency department (ED) with lower abdominal pain and constipation. He related chronic ingestion of large amounts of opium. Physical examination showed mild abdominal tenderness and gingival discoloration. Diagnostic studies showed a mild hypochromic, microcytic anemia with basophilic stippling of the red blood cells. Abdominal imaging showed no intra-abdominal pathology. A diagnosis of lead toxicity was confirmed through serum lead levels. The patient was put on chelation therapy and his signs and symptoms started to resolve. As a comprehensive search for other sources of lead was unsuccessful, opium adulterants were considered as the culprit. Chemical analysis of the opium confirmed this. Contaminated drugs have been reported as a source of exposure to toxins such as arsenic or lead. While other reports deal with patients from clinics, this report illustrates lead toxicity from ingestion of contaminated opium in the ED.

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Molar Pregnancy in the Emergency Department

A 15-year-old female presented to the emergency department with complaints of vaginal bleeding. She was pale, anxious, cool and clammy with tachycardic, thready peripheral pulses and hemoglobin of 2.4g/dL. Her abdomen was gravid appearing, approximately early to mid-second trimester in size. Pelvic examination revealed 2 cm open cervical os with spontaneous discharge of blood, clots and a copious amount of champagne-colored grapelike spongy material. After 2L boluses of normal saline and two units of crossmatched blood, patient was transported to the operating room. Surgical pathology confirmed a complete hydatidiform mole.

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The Back Alley Revisited: Sepsis after Attempted Self-Induced Abortion

While unsafe abortions have become rare in the United States, the practice persists. We present a 24-year-old female with a 21-week twin gestation who presented to the emergency department with complications of an attempted self-induced abortion. Her complicated clinical course included sepsis, chorioamnionitis, fetal demise, and a total abdominal hysterectomy with bilateral salpingo-oophorectomy for complications of endomyometritis. We discuss unsafe abortions, risk factors, and the management of septic abortion. Prompt recognition by the emergency physician and aggressive management of septic abortion is critical to decreasing maternal morbidity and mortality.

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Methemoglobinemia and Sulfhemoglobinemia in Two Pediatric Patients after Ingestion of Hydroxylamine Sulfate

This case report describes two pediatric cases of immediate oxygen desaturation from methemoglobinemia and sulfhemoglobinemia after one sip from a plastic water bottle containing hydroxylamine sulfate used by a relative to clean shoes. Supplemental oxygen and two separate doses of methylene blue given to one of the patients had no effect on clinical symptoms or pulse oximetry. The patients were admitted to the pediatric Intensive Care Unit (ICU) with subsequent improvement after exchange transfusion. Endoscopy showed ulcer formation in one case and sucralafate was initiated; both patients were discharged after a one-week hospital stay.

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Iatrogenic Digital Compromise with Tubular Dressings

This case report describes a digit amputation resulting from an improperly applied tubular dressing. The safe application of digital tubular dressings, and the rationale behind it, is detailed to raise emergency physician (EP) awareness.

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Violent Hiccups: An Infrequent Cause of Bradyarrhythmias

A hiccup, or singultus, results from a sudden, simultaneous, vigorous contraction of the diaphragm and inspiratory muscles, accompanied by closure of the glottis. Hiccups can be associated with bradyarrhythmias. The mechanism of this phenomenon is likely hiccup-induced Valsalva maneuver and increased parasympathetic tone. We present a case of a patient with violent hiccups producing a bradyarrhythmia.

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Critical Care

Hemopericardium and Cardiac Tamponade in a Patient with an Elevated International Normalized Ratio

This case report describes a 54-year-old male on warfarin for atrial fibrillation who presented to the emergency department (ED) following a syncopal episode with persistent hypotension. The patient’s International Normalized Ratio (INR) returned elevated at 6.0, and a rapid bedside cardiac ultrasound revealed a large pericardial effusion consistent with cardiac tamponade. The anticoagulation was reversed and the patient underwent successful pericardiocentesis with removal of 1,100 mL of blood.

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Injury Prevention

Pseudoaneurysm of the Radial Artery Diagnosed by Bedside Ultrasound

A 42-year-old male presented to the emergency department with pain and swelling of his distal right wrist. Bedside ultrasound placed over the swelling revealed a pseudoaneurysm of the radial artery. The patient received percutaneous thrombin injection of the aneurysm sac followed by direct ultrasound compression therapy of the pseudoaneurysm neck, resulting in thrombosis of the sac. The use of bedside ultrasound by the emergency physician led to appropriate care and proper disposition for definitive management.

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Bottoms Up: Methamphetamine Toxicity from an Unusual Route

Methamphetamine (MA) use is becoming commonplace, and emergency physicians (EPs) are seeing patients with abuse-associated complications. Previous reports have described inhalational and intravenous routes. We present the second case of rectal MA abuse in the literature. Trans-rectal use is important for EPs to consider because ongoing absorption of massive quantities may be averted upon detection. Additionally, trans-rectal abuse risks anorectal trauma and vascular necrosis with colonic perforation.

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