We describe a case of left internal jugular central venous access with rare malpositioning into the internal mammary vein. Despite various confirmatory measures at the time of placement including ultrasonography of the internal jugular vein, as well as blood gas analysis consistent with venous blood by oxygen saturation and good venous flow in all three ports of the catheter, subsequent imaging confirmed misplacement into the internal mammary vein.
A 72-year-old female presented to the emergency department (ED) with exacerbation of chronic obstructive pulmonary disease and congestive heart failure. The patient required intubation for airway protection and hypercapnic respiratory failure. The ED team used a video laryngoscope, Macintosh 3 blade and bougie as the endotracheal tube delivery device. Despite a grade 2a Cormack-Lehane airway view, the bougie repeatedly missed left posterolateral to the airway. During these missed attempts, the emergency medicine (EM) resident’s shoulder was noted to be abducted. The EM resident then readjusted his technique by adducting the shoulder. which allowed the tip of the bougie to pass the vocal cords resulting in successful intubation.
Acute traumatic limb injury is a common complaint of patients presenting to the emergency department (ED). Ketamine is an effective analgesic administered via intravenous (IV), intranasal (IN), intramuscular (IM), and nebulized routes in the ED. It has also been used in the prehospital setting via IV, IM, and IN routes. Recent studies have proposed the prehospital use of nebulized ketamine via breath-actuated nebulizer (BAN) as a noninvasive and effective method of analgesic delivery, as well as an alternative to opioid analgesia.
An acute subdural hematoma is a collection of blood in the space between the dural and arachnoid membranes overlying the brain. Head trauma is the most common cause. Less frequently, low cerebrospinal fluid pressure, due to a spontaneous or iatrogenic cerebrospinal fluid leak can result in a subdural hematoma.
The Portuguese man o’ war, an aquatic invertebrate, is responsible for a large proportion of cnidarian stings worldwide. Cnidaria is a phylum that contains the genus Physalia. These injuries result in severe pain and skin irritation, which are often difficult to control. Traditionally, cnidarian stings have been treated by emergency physicians with warm water, vinegar and, in severe cases, opioids. However, no concrete guidelines have been established for pain management in man o’ war stings.
Popliteal artery aneurysms are in most cases asymptomatic but cause significant complications if ruptured. An acute popliteal aneurysm rupture is relatively rare, and few cases have been documented secondary to blunt trauma. Common presenting signs and symptoms include distal limb ischemia and absent dorsalis pedis pulses. Timely management and recognition of this rare presentation are crucial as this condition can result in limb loss or death if not treated in a timely manner.
Intramuscular administration of vaccines into the deltoid muscle is the recommended route for most vaccines in adults. Ectopic injection into the subdeltoid/subacromial bursa can produce an inflammatory bursitis that is associated with significant long-term morbidity.
Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care.
Citrullinemia type 1 (CTLN1) is a urea cycle disorder caused by defective argininosuccinate synthetase leading to impaired ammonia elimination. Urea cycle disorders are typically diagnosed on neonatal screening but rarely can lie dormant until a metabolic stressor causes initial onset of symptoms in adulthood.
In reporting this case of a patient with spontaneous iliac vein rupture, we highlight the importance of maintaining a high clinical suspicion of this vascular emergency in the at-risk patient.
Ectopic pregnancy is the most common cause of maternal mortality in the first trimester.1 Bilateral tubal pregnancy is the rarest subset with an estimated incidence of one in 725 to 1,580 ectopic pregnancies.2 Of the cases of bilateral tubal pregnancy reported in the literature, most were associated with the use of assisted reproductive techniques.3 Here we present the case of a patient, without a prior history of reproductive technology use, who underwent treatment for a tubal pregnancy and was subsequently found to have a second, contralateral tubal pregnancy 11 days later.
Longus colli calcific tendonitis (LCCT) is a calcium deposition disease that causes acute or subacute atraumatic neck pain. It is important for the emergency physician to consider LCCT in the differential diagnosis because the clinical presentation of this benign condition may mimic life-threatening disease processes that require invasive diagnostic measures.
A 45-year-old male presented to the emergency department (ED) with bilateral lower extremity pain, swelling, and associated atypical rash in the setting of polysubstance use and unstable housing. Laboratory tests showed an elevated white blood cell count and inflammatory markers.
