Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Phencyclidine Induced Oculogyric Crisis Responding Well to Conventional Treatment Tue, 26 May 2015 06:58:50 +0000 Background. Oculogyric crisis is a form of acute dystonic reaction characterized by involuntary upward deviation of eye ball. Its causes are broad with antipsychotics and antiemetics as the most common causes. Case Presentation. A 25-year-old man with the past medical history of marijuana use presented to ED with involuntary upward deviation of eye 1 day after using phencyclidine (PCP) for the first time. He did not have any other symptoms and was hemodynamically stable. All laboratory investigations were normal except urine drug screen which was positive for PCP. Patient was treated with IV diphenhydramine which improved his symptoms. Conclusion. Illicit drug abuse is a growing problem in our society with increasingly more patients presenting to ED with its complications. The differential diagnosis of acute dystonic reactions should be extended to include illicit drugs as the potential cause of reversible acute dystonias especially in high risk patients. Hassan Tahir and Vistasp Daruwalla Copyright © 2015 Hassan Tahir and Vistasp Daruwalla. All rights reserved. A Rare and Serious Syndrome That Requires Attention in Emergency Service: Traumatic Asphyxia Sun, 24 May 2015 08:48:53 +0000 Traumatic asphyxia is a rare syndrome caused by blunt thoracoabdominal trauma and characterized by cyanosis, edema, and subconjunctival and petechial hemorrhage on the face, neck, upper extremities, and the upper parts of the thorax. Traumatic asphyxia is usually diagnosed by history and inspection; however, the patient should be monitored more closely due to probable complications of thoracoabdominal injuries. Treatment is conservative, but the prognosis depends on the severity of the associated injuries. Herein we present a traumatic asphyxia due to an elevator accident in a 32-year-old male patient and discuss the diagnosis, treatment, and prognosis by reviewing the relevant literature. Gultekin Gulbahar, Tevfik Kaplan, Ahmet Gokhan Gundogdu, Hatice Nurdan Baran, Burak Kazanci, Bulent Kocer, and Serdar Han Copyright © 2015 Gultekin Gulbahar et al. All rights reserved. Food Particle Aspiration Associated with Hemorrhagic Shock: A Diagnostic Dilemma Tue, 19 May 2015 06:28:23 +0000 The hemodynamic compromise caused by a large aspirated food particle in the airway can become the focus of medical attention and a distraction from rare but fatal Heimlich maneuver related injuries after an incident of food aspiration. We herein present a case of an 84-year-old man who was brought to the emergency department after an episode of choking at a restaurant followed by several failed Heimlich maneuver attempts. Despite relieving the airway obstruction by extracting a large piece of steak from the airway, the patient remained hypotensive and required continued hemodynamic support. Repeated laboratory tests within 24 hrs of aspiration showed a significant decline in the hemoglobin level. A computed tomography (CT) scan of the abdomen and pelvis showed a lacerated liver with a large subcapsular hematoma draining into the pelvis. Conclusion. Hepatic rupture is a rare complication of Heimlich maneuver; this paper represents the second case report in the literature. It emphasizes the necessity of early identification and surveillance of fatal Heimlich maneuver complications in a high risk population. Basheer Tashtoush, Jonathan Schroeder, Roya Memarpour, Eduardo Oliveira, Michael Medina, Anas Hadeh, Jose Ramirez, and Laurence Smolley Copyright © 2015 Basheer Tashtoush et al. All rights reserved. Intravenous Lipid Emulsion Therapy for Acute Synthetic Cannabinoid Intoxication: Clinical Experience in Four Cases Mon, 11 May 2015 11:40:14 +0000 There is no specific antidote for intoxication with synthetic cannabinoids. In this case series, we considered the efficiency of intravenous lipid emulsion therapy in four cases, who presented to emergency department with synthetic cannabinoid (bonzai) intoxication. The first patient had a GCS of 3 and a left bundle branch block on electrocardiography. The electrocardiography revealed sinus rhythm with normal QRS width after the treatment. The second patient had bradycardia, hypotension, and a GCS of 14. After intravenous lipid emulsion therapy, the bradycardia resolved, and the patient’s GCS improved to 15. The third patient presented with a GCS of 8, and had hypotension and bradycardia. After the treatment, not only did the bradycardia resolve, but also the GCS improved to 15. The fourth patient, whose electrocardiography revealed accelerated junctional rhythm, had a GCS of 13. The patient’s rhythm was sinus after the treatment. Cardiovascular recovery was seen in all four cases, and neurological recovery was also seen in three of them. Based on the fact that intravenous lipid emulsion is beneficial in patients intoxicated with lipophilic drugs, unstable patients presenting to the emergency department with acute synthetic cannabinoid intoxication may be candidates for intravenous lipid emulsion treatment. Gökhan Aksel, Özlem Güneysel, Tanju Taşyürek, Ergül Kozan, and Şebnem Eren Çevik Copyright © 2015 Gökhan Aksel et al. All rights reserved. Assessment of Musculoskeletal Injuries from Domestic Violence in the Emergency Department Thu, 07 May 2015 16:52:16 +0000 Domestic violence is one of the most common causes of nonfatal injury in women, with musculoskeletal injuries representing the second most prevalent manifestation of this form of violence. It is therefore of great importance that healthcare providers such as emergency department (ED) physicians and surgeons are able to recognize and assess these kinds of injuries. In this case report, a woman is described visiting an ED with injuries caused by a fall. Thanks to the knowledge and attention of the ED physician, the real cause of the injury was discovered. What appeared to be an unsuspicious accident was actually the result of intimate partner violence. Georgios F. Giannakopoulos and Udo J. L. Reijnders Copyright © 2015 Georgios F. Giannakopoulos and Udo J. L. Reijnders. All rights reserved. Temporoparietal Headache as the Initial Presenting Symptom of a Massive Aortic Dissection Wed, 06 May 2015 11:13:14 +0000 Aortic dissection is a life-threatening medical emergency often presenting with severe chest pain and acute hemodynamic compromise. The presentation of aortic dissection can sometimes be different thus leading to a challenge in prompt diagnosis and treatment as demonstrated by the following presentation and discussion. We present a case of a 71-year-old male who presented to the emergency department with complaints of left sided temporoparietal headache and was eventually diagnosed with a thoracic aortic dissection involving the ascending aorta and descending aorta, with an intramural hematoma in the descending aorta. This case illustrates the importance of keeping in mind aortic dissection as a differential diagnosis in patients with acute onset headaches in which any intracranial source of headache is not found. Manan Parikh, Abhinav Agrawal, Braghadheeswar Thyagarajan, Sayee Sundar Alagusundaramoorthy, and James Martin Copyright © 2015 Manan Parikh et al. All rights reserved. Noncardiogenic Pulmonary Edema after Amlodipine Overdose without Refractory Hypotension and Bradycardia Tue, 05 May 2015 12:06:51 +0000 Amlodipine overdose can be life-threatening when manifesting as noncardiogenic pulmonary edema. Treatment remains challenging. We describe a case of noncardiogenic pulmonary edema without refractory hypotension and bradycardia after ingestion of 500 milligram amlodipine with suicidal intent. Mechanical ventilation, dexamethasone, atrovent HFA (ipratropium), pulmicort inhalation, and antibiotic therapy were used for the management. Length of hospital stay was 11 days. The patient was discharged with full recovery. M. Hedaiaty, N. Eizadi-Mood, and A. M. Sabzghabaee Copyright © 2015 M. Hedaiaty et al. All rights reserved. A Broken Toothbrush in the Retropharyngeal Space in a Toddler of Sixteen Months Tue, 28 Apr 2015 09:36:33 +0000 A toddler of sixteen months fell while brushing his teeth and his mouth hit the ground. The toothbrush broke and one-third of it including the head got impacted in his throat. The attempt of his mother to remove it with her fingers further complicated the case and the toothbrush was ultimately lodged in the retropharyngeal space at the level from C1 to C5 vertebrae. It was strongly impacted due to the presence of the bristles. The broken end of the handle was just protruding into the nasopharynx and was very difficult to locate. The first attempt of its removal was unsuccessful. The toothbrush was removed safely in the second attempt without any complication. Saileswar Goswami and Choitali Goswami Copyright © 2015 Saileswar Goswami and Choitali Goswami. All rights reserved. Pitfalls in Suspected Acute Aortic Syndrome: Impact of Appropriate and If Required Repeated Imaging Mon, 27 Apr 2015 08:01:52 +0000 The incidence of acute aortic syndrome is low, but the spontaneous course is often life-threatening. Adequate ECG-gated imaging is fundamental within the diagnostic workup. We here report a case of a 53-year-old man presenting with atypical chest pain, slight increase of D dimers at admission, and extended diameter of the ascending aorta accompanied by mild aortic regurgitation. Interpretation of an initial contrast-enhanced computed tomography was false negative due to inadequate gating and motion artifacts, thereby judging a tiny contrast signal in the left anterior quadrant of the ascending aorta as a pseudointimal flap. By hazard, cardiac magnetic resonance imaging demonstrated an ulcer-like lesion superior to the aortic root, leading to aortic surgery at the last moment. As sensitivity of imaging is not 100%, this example underlines that second imaging studies might be necessary if the first imaging is negative, but the clinical suspicion still remains high. C. Meier, M. Lichtenberg, P. Lebiedz, and F. Breuckmann Copyright © 2015 C. Meier et al. All rights reserved. The Unexpected Pitter Patter: New-Onset Atrial Fibrillation in Pregnancy Wed, 15 Apr 2015 09:16:50 +0000 Background. Atrial fibrillation is a relatively uncommon but dangerous complication of pregnancy. Emergency physicians must know how to treat both stable and unstable tachycardias in late pregnancy. In this case, a 40-year-old female with a cerclage due to incompetent cervix and previous preterm deliveries presents in new-onset atrial fibrillation. Case Report. A previously healthy 40-year-old African American G2 P1 female with a 23-week twin gestation complicated by an incompetent cervix requiring a cervical cerclage presented to the emergency department with intermittent palpitations and shortness of breath for the past two months. EMS noted the patient to have a tachydysrhythmia, atrial fibrillation with rapid ventricular response. She was placed on a diltiazem drip, which was titrated to 15 mg/hr without successful rate control. Her heart rate remained in the 130s and the rhythm continued to be atrial fibrillation with RVR. Digoxin was then added as a second agent, and discussions about the potential risks of cardioversion in pregnancy ensued. Fortunately, the patient converted to sinus rhythm before cardioversion became necessary. The digoxin was discontinued; the diltiazem was also discontinued after the patient subsequently developed hypotension. “Why Should Emergency Physicians Be Aware of This?” New-onset atrial fibrillation is rare in pregnancy but can increase the mortality and morbidity of the mother and fetus if not treated promptly. Sarah White, Janna Welch, and Lawrence H. Brown Copyright © 2015 Sarah White et al. All rights reserved. Rhabdomyolysis and Acute Renal Failure after Gardening Sun, 12 Apr 2015 07:48:14 +0000 Acute nontraumatic exertional rhabdomyolysis may arise when the energy supply to muscle is insufficient to meet demands, particularly in physically untrained individuals. We report on a psychiatric patient who developed large bruises and hemorrhagic blisters on both hands and arms, rhabdomyolysis of both forearm muscles with a moderate compartment syndrome, and consecutive acute renal failure following excessive work in the garden. Although specifically asked, the patient denied any hard physical work or gardening, and heteroanamnestic data were not available. The diagnosis of rhabdomyolysis was easy to establish, but until reliable anamnestic data were obtained, the etiology remained uncertain. Four days after arrival, the patient recalled working hard in the garden. The etiology of rhabdomyolysis was finally reached, and the importance of anamnestic data was once more confirmed. Zeljko Vucicevic Copyright © 2015 Zeljko Vucicevic. All rights reserved. Colonic Foreign Body Retrieval Using a Modified TAMIS Technique with Standard Instruments and Trocars Tue, 07 Apr 2015 08:48:32 +0000 Background. Reports of retained colorectal foreign bodies (CFBs) are no longer considered uncommon. We present a case where a retained CFB was retrieved using a modified TAMIS technique using standard instruments and trocars. Case Report. A 52-year-old man presented with a CFB. We report our technique of extraction with standard laparoscopic instruments without specialized access platforms. Conclusions. This modified TAMIS technique is well suited for resource poor environments because it requires no specialized equipment, platforms, or additional skill sets compared to conventional laparoscopy. Shamir O. Cawich, Fawwaz Mohammed, Richard Spence, Matthew Albert, and Vijay Naraynsingh Copyright © 2015 Shamir O. Cawich et al. All rights reserved. Body Packing: From Seizures to Laparotomy Thu, 26 Mar 2015 12:21:33 +0000 Body packing is a common method for illegal drug trafficking. Complications associated with body packing can be severe and even lead to rapid death. Thus, a timely diagnosis is warranted. As most body packers initially do not show any symptoms, making a correct diagnosis can be rather challenging. We describe a case of a 41-year-old male, who was admitted with an epileptic seizure and who turned out to be a cocaine intoxicated body packer. Due to neurological and cardiovascular deterioration an emergency surgery was performed. Four bags of cocaine could be removed. We discuss the current management regimen in symptomatic and asymptomatic body packers and highlight pearls and pitfalls with diagnosis and treatment. Joanna M. Janczak, Ulrich Beutner, and Karin Hasler Copyright © 2015 Joanna M. Janczak et al. All rights reserved. An Atypical Case of Methemoglobinemia due to Self-Administered Benzocaine Thu, 19 Mar 2015 12:31:40 +0000 Acquired methemoglobinemia is an uncommon hemoglobinopathy that results from exposure to oxidizing agents, such as chemicals or medications. Although, as reported in the adult population, it happens most often due to prescribed medication or procedural anesthesia and not due to easily accessed over-the-counter medications, the authors will describe an otherwise healthy male adult with no known medical history and no prescribed medications, who presented to the emergency department reporting generalized weakness, shortness of breath, headache, dizziness, and pale gray skin. In addition, the patient reported that he also had a severe toothache for several days, which he had been self-treating with an over-the-counter oral benzocaine gel. Ultimately, the diagnosis of methemoglobinemia was made by clinical history, physical examination, and the appearance of chocolate-colored blood and arterial blood gas (ABG) with cooximetry. After 2 mg/kg of intravenous methylene blue was administered, the patient had complete resolution of all signs and symptoms. This case illustrates that emergency physicians should be keenly aware of the potential of toxic hemoglobinopathy secondary to over-the-counter, nonprescribed medications. Discussion with patients regarding the dangers of inappropriate use of these medicines is imperative, as such warnings are typically not evident on product labels. Thomas M. Nappe, Anthony M. Pacelli, and Kenneth Katz Copyright © 2015 Thomas M. Nappe et al. All rights reserved. P-Chloroaniline Poisoning Causing Methemoglobinemia: A Case Report and Review of the Literature Thu, 12 Mar 2015 13:42:29 +0000 Background. Methemoglobin (MetHb) most commonly results from exposure to an oxidizing chemical but may also arise from genetic, dietary, or even idiopathic etiologies. P-chloroaniline (PCA) was one of the first substances described in the context of acquired methemoglobinemia. Case Report. We report the case of a cyanotic chemistry worker who presented to our emergency department (ED) after working with PCA. His peripheral oxygen saturation (SpO2) measured by pulse oximetry was at 81% and remained on that level despite oxygen administration (100% oxygenation via nonrebreather mask). His MetHb level was measured at 42.8% in arterial blood gas analysis. After treatment with intravenous methylene blue cyanosis resolved and the patient was discharged after 36 hours of observation. Conclusion. Acquired methemoglobinemia is a treatable condition, which may cause significant morbidity and mortality. The knowledge about the most common causes, fast diagnostic, and proper treatment is crucial. Anna Sarah Messmer, Christian Hans Nickel, and Dirk Bareiss Copyright © 2015 Anna Sarah Messmer et al. All rights reserved. Herbal Weight Loss Pill Overdose: Sibutramine Hidden in Pepper Pill Wed, 11 Mar 2015 13:07:40 +0000 Supposedly herbal weight loss pills are sold online and are widely used in the world. Some of these products are found to contain sibutramine by FDA and their sale is prohibited. We report a case of a female patient who presented to the emergency department after taking slimming pills. 17-year-old female patient presented to the emergency room with palpitations, dizziness, anxiety, and insomnia. She stated that she had taken 3 pills named La Jiao Shou Shen for slimming purposes during the day. Her vital signs revealed tachycardia. On her physical examination, she was restless, her oropharynx was dry, her pupils were mydriatic, and no other pathological findings were found. Sibutramine intoxication was suspected. She was given 5 mg IV diazepam for restlessness. After supportive therapy and observation in emergency department for 12 hours there were no complications and the patient was discharged home. Some herbal pills that are sold online for weight loss have sibutramine hidden as an active ingredient, and their sale is prohibited for this reason. For people who use herbal weight loss drugs, sibutramine excessive intake should be kept in mind at all times. Gul Pamukcu Gunaydin, Nurettin Ozgur Dogan, Sevcan Levent, and Gulhan Kurtoglu Celik Copyright © 2015 Gul Pamukcu Gunaydin et al. All rights reserved. An Unusual Cause of Pulmonary Nodules in the Emergency Department Mon, 23 Feb 2015 09:37:36 +0000 We report a 51-year-old woman who presented to the emergency department with left-sided pleuritic chest pain 2 weeks after subtotal hysterectomy and bilateral salpingo-oophorectomy for a leiomyomatous uterus. Computed tomography scan of the chest revealed bilateral pulmonary nodules. Biopsy showed cytologically bland spindle cells without overt malignant features. Immunohistochemistry confirmed smooth muscle phenotype, in keeping with a clinicopathologic diagnosis of benign metastasizing leiomyoma (BML). BML does not frequently come to the attention of the emergency physician because it is rare and usually asymptomatic. When symptomatic, its clinical presentation depends on the site(s) of metastasis, number, and size of the smooth muscle tumors. Emergent presentations of BML are reviewed. Ryan Yu and Melanie Ferri Copyright © 2015 Ryan Yu and Melanie Ferri. All rights reserved. Unusual Presentation of Meckel’s Diverticulum: Gangrene due to Axial Torsion Sun, 22 Feb 2015 09:29:04 +0000 Meckel’s diverticulum is the most common congenital anomaly of the small bowel. The majority of cases are asymptomatic; however, life-threatening complications can also take place. We present a case of a 37-year-old male who was admitted with symptoms of acute, severe abdominal pain in the right iliac fossa. The patient was operated on with the preoperative diagnosis of acute appendicitis but the operative findings were consistent with torted Meckel’s diverticulum due to presence of mesodiverticular band and he was treated successfully with surgical resection. Ahmet Rencuzogullari, Kubilay Dalci, and Orcun Yalav Copyright © 2015 Ahmet Rencuzogullari et al. All rights reserved. Ovarian Hyperstimulation Syndrome, the Master of Disguise? Sun, 22 Feb 2015 08:29:21 +0000 The use of IVF has risen dramatically over the past 10 years and with this the complications of such treatments have also risen. One such complication is ovarian hyperstimulation syndrome with which patients can present acutely to hospital with shortness of breath. On admission, a series of blood tests are routinely performed, including the d-dimer. We present a case of a 41-year-old lady who had recently undergone IVF and presented with chest pain and dyspnoea. In the emergency department, a d-dimer returned as mildly elevated. Consequential admission onto MAU initiated several avoidable investigations for venous thromboembolism. Careful examination elicited a mild ascites and a thorough drug history gave recent low molecular weight heparin usage. Ultrasound scan of the abdomen subsequently confirmed the diagnosis of severe OHSS. The d-dimer should therefore be used to negate and not to substantiate a diagnosis of VTE. This case report aims to highlight the importance of OHSS as an uncommon cause of dyspnoea but whose prevalence is likely to increase in the forthcoming years. We discuss the complications of the misdiagnosis of OHSS, the physiology behind raised d-dimers, and the potential harm from incorrect treatment or inappropriate imaging. Emily Charlotte Ironside and Andrew James Hotchen Copyright © 2015 Emily Charlotte Ironside and Andrew James Hotchen. All rights reserved. STEMI Associated with Overuse of Energy Drinks Thu, 19 Feb 2015 09:31:01 +0000 Coronary artery disease (CAD) and ST-elevation myocardial infarction (STEMI) are predominantly diseases of middle-aged and older adults and when found in younger adults are usually associated with a strong family history. However, this report details the case of a nonobese 26-year-old Hispanic male who presented with an acute STEMI despite having no family history or other apparent risk factors for CAD or STEMI beyond a two pack-year smoking history and excessive energy drink consumption. The patient reported consuming between eight and ten 473 mL cans per day. Cardiac catheterization subsequently confirmed total occlusion of his left circumflex coronary artery. Daniel Solomin, Stephen W. Borron, and Susan H. Watts Copyright © 2015 Daniel Solomin et al. All rights reserved. An Unusual Presentation of a Massive Pulmonary Embolism with Misleading Investigation Results Treated with Tenecteplase Thu, 19 Feb 2015 06:23:42 +0000 Background. There is no foolproof strategy to identify a pulmonary embolism (PE) in the emergency department, and atypical presentations are common. Negative test results may mislead physicians away from the diagnosis of PE. Objectives. The current report aims to raise awareness of an unusual presentation of massive PE and its diagnosis and management, in the face of limited evidence in the scientific literature. Case Reports. We report the case of a patient with a negative D-Dimer and a negative Computed Tomography contrast angiography of the chest who was diagnosed twenty-seven hours later with a massive PE, as suggested by a bedside echocardiography. The patient was successfully treated with tenecteplase (TNK). Conclusions/Summary. Pulmonary embolism frequently presents atypically and is often a diagnostic challenge. There is limited literature about the treatment of massive PE. Further research on bedside echocardiography for diagnosing PE in unstable patients is warranted. In addition, further study into new thrombolytic agents like tenecteplase in the context of massive and submassive PE is warranted. David Migneault, Zachary Levine, and François de Champlain Copyright © 2015 David Migneault et al. All rights reserved. A Rare and Unexpected Side-Effect of Cannabis Use: Abdominal Pain due to Acute Pancreatitis Wed, 11 Feb 2015 12:47:07 +0000 Acute pancreatitis is a frequently encountered disorder in patients presenting to emergency units. Biliary system disorders, alcohol consumption, infections, and drugs are among the causes of acute pancreatitis. However, it is sometimes difficult to determine the etiology of this disorder, particularly if the patient does not wish to disclose his consumption of cannabis, the use of which is illegal. Mehmet Husamettin Akkucuk and Mustafa Erbayrak Copyright © 2015 Mehmet Husamettin Akkucuk and Mustafa Erbayrak. All rights reserved. Acute Headache at Emergency Department: Reversible Cerebral Vasoconstriction Syndrome Complicated by Subarachnoid Haemorrhage and Cerebral Infarction Tue, 10 Feb 2015 09:57:08 +0000 Introduction. Reversible cerebral vasoconstriction syndrome is becoming widely accepted as a rare cause of both ischemic and haemorrhagic stroke and should be evocated in case of thunderclap headaches associated with stroke. We present the case of a patient with ischemic stroke associated with cortical subarachnoid haemorrhage (cSAH) and reversible diffuse arteries narrowing, leading to the diagnosis of reversible vasoconstriction syndrome. Case Report. A 48-year-old woman came to the emergency department because of an unusual thunderclap headache. The computed tomography of the brain completed by CT-angiography was unremarkable. Eleven days later, she was readmitted because of a left hemianopsia. One day after her admission, she developed a sudden left hemiparesis. The brain MRI showed ischemic lesions in the right frontal and occipital lobe and diffuse cSAH. The angiography showed vasoconstriction of the right anterior cerebral artery and stenosis of both middle cerebral arteries. Nimodipine treatment was initiated and vasoconstriction completely regressed on day 16 after the first headache. Conclusion. Our case shows a severe reversible cerebral vasoconstriction syndrome where both haemorrhagic and ischemic complications were present at the same time. The history we reported shows that reversible cerebral vasoconstriction syndrome is still underrecognized, in particular in general emergency departments. M. Yger, C. Zavanone, L. Abdennour, W. Koubaa, F. Clarençon, S. Dupont, and Y. Samson Copyright © 2015 M. Yger et al. All rights reserved. Detecting Foreign Bodies in a Head Laceration Sat, 31 Jan 2015 07:17:38 +0000 Open wounds represent a potential area of medicolegal risk if foreign bodies are not identified prior to wound closure. The importance of imaging of lacerations was underscored by a recent case where a 20-year-old male collided with a friend’s mouth on a trampoline sustaining a simple, superficial scalp laceration. The wound was evaluated in typical fashion including irrigation and local exploration and was prepared for closure. The friend was then evaluated and noted to have multiple extensive dental fractures. An increased index of suspicion generated further evaluation of the first patient’s wound. Plain radiography obtained of the first patient’s skull was noted to have bony foreign bodies consistent with teeth, which were then removed after further exploration. Superficial wounds are common and complications arising from retained foreign bodies are a potential source of substantial morbidity and consequently medical litigation. This case serves as a reminder to be vigilant and maintain a high index of suspicion regarding the potential for foreign body. Thomas R. Fowler, Steven J. Crellin, and Marna Rayl Greenberg Copyright © 2015 Thomas R. Fowler et al. All rights reserved. Profound Hypoglycemia with Ecstasy Intoxication Tue, 27 Jan 2015 06:34:26 +0000 Background. 3,4-Methylenedioxymethamphetamine (MDMA) or ecstasy is a synthetic drug that is commonly abused for its stimulant and euphoric effects. Adverse MDMA effects include hyperthermia, psychomotor agitation, hemodynamic compromise, renal failure, hyponatremia, and coma. However, endogenous hyperinsulinemia with severe persistent hypoglycemia has not been reported with MDMA use. Case Report. We report the case of a 29-year-old woman who remained severely hypoglycemic requiring continuous intravenous infusion of high-dose dextrose solutions for more than 24 hours after MDMA intoxication. Serum insulin and C-peptide levels confirmed marked endogenous hyperinsulinemia as the cause of the severe hypoglycemia. Why Should an Emergency Physician Be Aware of This? Immediate and frequent monitoring of blood glucose should be instituted in patients presenting with MDMA ingestion particularly if found to be initially hypoglycemic. Early recognition can help prevent the deleterious effects of untreated hypoglycemia that can add to the morbidity from MDMA use. Clinicians need to be aware of this side effect of MDMA so they can carefully monitor and treat it, especially in patients presenting with altered mental status. Perliveh Carrera and Vivek N. Iyer Copyright © 2015 Perliveh Carrera and Vivek N. Iyer. All rights reserved. Diagnosis of Mondor’s Disease in the Emergency Department with Bedside Ultrasound Sun, 18 Jan 2015 07:41:10 +0000 Mondor’s disease is a rare condition characterized by a superficial thrombophlebitis that can occur in the thoracoabdominal and genital areas. Findings with ultrasound in penile Mondor’s disease are readily measurable: a noncompressible penile vein without flow and absence of tears of the corpus cavernosum or tunica albuginea, hematoma, or evidence of fracture of the penis. We present a case of Mondor’s disease, diagnosed with bedside ultrasound, in the emergency department. Ultrasonography is readily available within the emergency department, and we suggest its use in aiding diagnosis of genitourinary disorders such as Mondor’s disease. J. Michael O’Neal, Erik Castleberg, and Vi Am Dinh Copyright © 2015 J. Michael O’Neal et al. All rights reserved. Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenomation Wed, 14 Jan 2015 09:26:04 +0000 The authors present a case report of a 17-month-old female child who ingested a large amount of methamphetamine that looked very similar clinically to a scorpion envenomation specific to the southwestern United States by the species Centruroides sculpturatus. The child was initially treated with 3 vials of antivenom specific for that scorpion species and showed a transient, though clinically relevant neurologic improvement. Her clinical course of sympathomimetic toxicity resumed and she was treated with intravenous fluids and benzodiazepines after blood analysis showed significant levels of d-methamphetamine. This case report is to specifically underline the clinical confusion in discerning between these two conditions and the realization of limited and/or expensive resources that may be used in the process. Joshua Strommen and Farshad Shirazi Copyright © 2015 Joshua Strommen and Farshad Shirazi. All rights reserved. Recurrent Coagulopathy after Rattlesnake Bite Requiring Continuous Intravenous Dosing of Antivenom Mon, 12 Jan 2015 13:18:45 +0000 Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy. Charles W. Hwang and F. Eike Flach Copyright © 2015 Charles W. Hwang and F. Eike Flach. All rights reserved. Development of ST Elevation Myocardial Infarction and Atrial Fibrillation after an Electrical Injury Thu, 08 Jan 2015 08:50:54 +0000 Electrical energy is a type of energy that is commonly used in daily life. Ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bundle branch blocks, and AV block are arrhythmic complications that are encountered in case of electric shocks. Myocardial infarction is one of the rarely seen complications of electric shocks yet it has fatal outcomes. Coronary arteries were detected to be normal in most of the patients who had myocardial infarction following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm is thought to be the primary etiological cause. In our case report, we presented a patient who developed ST elevation MI with atrial fibrillation after an electric shock. Erdal Gursul, Serdar Bayata, Ercan Aksit, and Basak Ugurlu Copyright © 2015 Erdal Gursul et al. All rights reserved. Atypical Presentation of Traumatic Aortic Injury Tue, 30 Dec 2014 07:11:52 +0000 Background. Blunt thoracic aorta injury (BAI) is second only to head injury as cause of mortality in blunt trauma. While most patients do not survive till arrival at the hospital, for the remainder, prompt diagnosis and treatment greatly improve outcomes. We report an atypical presentation of BAI, highlighting the diagnostic challenges of this condition in the emergency department. Case Presentation. A previously well 25-year-old male presented 15 hours after injury hemodynamically stable with delirium. There were no signs or symptoms suggestive of BAI. Sonography showed small bilateral pleural effusions. Chest radiograph showed a normal mediastinum. Eventually, CT demonstrated a contained distal aortic arch disruption. The patient underwent percutaneous endovascular thoracic aortic repair and recovered well. Conclusion. This catastrophic lesion may present with few reliable signs and symptoms; hence, a high index of suspicion is crucial for early diagnosis and definitive surgical management. This paper discusses the diagnostic utility of clinical features, injury mechanism, and radiographic modalities. Consideration of mechanism of injury, clinical features, and chest radiograph findings should prompt advanced chest imaging. Andrew Fu Wah Ho, Tallie Wei-Lin Chua, Puneet Seth, Kenneth Boon Kiat Tan, and Sohil Pothiawala Copyright © 2014 Andrew Fu Wah Ho et al. All rights reserved.