Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Pediatric Stroke Presenting as a Seizure Mon, 22 Dec 2014 00:10:10 +0000 Background. Childhood arterial ischemic stroke (AIS) is rare and may be difficult to diagnose. Management of acute stroke in any age group is time sensitive, so awareness of the manifestations and appropriate diagnostic procedures for pediatric AIS is vital to establishing care. We present a pediatric case of arterial ischemic stroke that presented to the emergency department (ED) after two seizures. Case Report. A five-year-old female with an existing seizure disorder presented to a pediatric ED after having two seizures. Postictal upon arrival, she underwent a computed tomography (CT) scan of her head. Family reported that she had complained of a severe headache and vomited; her seizures were described as different from those she had experienced in the past. Loss of grey white matter differentiation on the CT warranted magnetic resonance imaging (MRI), which demonstrated a right-sided stroke. After a complicated course in the hospital, the patient was discharged to a rehabilitation hospital. Why Should an Emergency Physician Be Aware of This? It is important that emergency physicians recognize that a seizure may be the initial symptom of a pediatric stroke regardless of an established seizure history. Pediatric seizures are relatively common; however consideration of the diagnosis of pediatric stroke may prevent unnecessary delays in treatment. Katie L. Ahmadzadeh, Vartika Bhardwaj, Steven A. Johnson, and Kathleen E. Kane Copyright © 2014 Katie L. Ahmadzadeh et al. All rights reserved. Emergency Open Incarcerated Hernia Repair with a Biological Mesh in a Patient with Colorectal Liver Metastasis Receiving Chemotherapy and Bevacizumab Uncomplicated Wound Healing Sun, 21 Dec 2014 00:10:16 +0000 Bevacizumab is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF), often used in combinational chemotherapy regimens for the treatment of patients with colorectal liver metastases. However adverse events have been attributed to the use of bevacizumab including gastrointestinal perforations, thrombotic events, hypertension, bleeding, and wound healing complications. 53-year-old male, with a history of colorectal cancer with liver metastasis, receiving a combination of cytotoxic chemotherapy (FOLFIRI, irinotecan with fluorouracil and folinic acid) with bevacizumab presented as an emergency with an incarcerated incisional hernia. The last administration of chemotherapy and bevacizumab had taken place 2 weeks prior to this presentation. As the risk of strangulation of the bowel was increased, a decision was made to take the patient to theatre, although the hazard with respect to wound healing, haemorrhage, and infection risk was high due to the recent administration of chemotherapy with bevacizumab. The patient underwent an open repair of the incarcerated recurrent incisional hernia with placement of a biological mesh, and the postoperative recovery was uncomplicated with no wound healing or bleeding problems. Alexandros Giakoustidis, Dawn Morrison, Kyriakos Neofytou, Dimitrios Giakoustidis, and Satvinder Mudan Copyright © 2014 Alexandros Giakoustidis et al. All rights reserved. New Onset Refractory Status Epilepticus as an Unusual Presentation of a Suspected Organophosphate Poisoning Wed, 17 Dec 2014 11:26:10 +0000 New onset refractory status epilepticus (NORSE) is a new entity in medical literature. It has different infectious and noninfectious etiologies showing a devastating impact onto the clinical outcome of patients. Therapy with anaesthetic and antiepileptic agents often fails to improve the condition, unless the primary cause is rectified. Here is presented the case of a young female with a history of depression who after a recent bereavement came to the Emergency Department of Aga Khan University Hospital with complaints of drowsiness that lasted for few hours. Though she had no history of organophosphate poisoning, her physical examination and further investigations were suggestive of the diagnosis. During her hospital stay, she developed refractory status epilepticus. Her seizures did not respond to standard antiepileptic and intravenous anesthetic agents and subsided only after intravenous infusion of atropine for a few days. Organophosphate poisoning is a very common presentation in the developing world and the associated status epilepticus poses a devastating problem for emergency physicians. In patients with suspected organophosphate poisoning with favoring clinical exam findings, the continuation of atropine intravenous infusion can be a safe option to abate seizures. Shahan Waheed, Amber Sabeen, and Nadeem Ullah Khan Copyright © 2014 Shahan Waheed et al. All rights reserved. Histamine Poisoning from Ingestion of Fish or Scombroid Syndrome Sun, 07 Dec 2014 09:33:53 +0000 The scombroid poisoning is due to the ingestion of poorly preserved fish (especially tuna, sardines, and mackerel) out of the cold chain. Under the influence of the proliferation of gram negative bacteria that occurs for heating, the histidine content in the muscle of the fish is converted into histamine, by the action of the enzyme histidine decarboxylase. If the histamine is ingested in large quantities, it causes an anaphylactoid reaction with a variety of symptoms from moderate to severe to life-threating. We will describe two cases that came under our observation after consuming a meal of bluefin tuna. The diagnosis of scombroid syndrome was made on the basis of the anamnestic data and the clinical one. The rapid resolution of the signs and symptoms after treatment with histamines H1-H2 receptor blockers confirmed the suspected diagnosis. Vincenzo Tortorella, Peppino Masciari, Mario Pezzi, Assunta Mola, Simona Paola Tiburzi, Maria Concetta Zinzi, Annamaria Scozzafava, and Mario Verre Copyright © 2014 Vincenzo Tortorella et al. All rights reserved. What Lies behind the Ischemic Stroke: Aortic Dissection? Tue, 02 Dec 2014 11:01:41 +0000 Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind. Turgut Deniz, Ersel Dag, Murat Tulmac, Burcu Azapoglu, and Caglar Alp Copyright © 2014 Turgut Deniz et al. All rights reserved. The Management of Gas-Filled Eyes in the Emergency Department Wed, 26 Nov 2014 11:53:55 +0000 Background. Intraocular gas bubbles are commonly used in retinal surgery. There are specific management guidelines that need to be followed to ensure surgical success, and there are also unique ophthalmic and systemic complications that can occur in such patients. Objective. To educate emergency department personnel about important issues in the management of patients who have a gas-filled eye following retinal surgery. Case Report. A patient with a gas-filled eye developed several complications including pain, severe vision loss, high-grade atrioventricular (AV) block, and pneumocephalus. Conclusion. Awareness of potential problems that may arise in patients with gas-filled eyes who present to the emergency department may help minimize morbidity for such patients. Lik Thai Lim, Elliott Y. Ah-kee, Beve P. House, and Jonathan D. Walker Copyright © 2014 Lik Thai Lim et al. All rights reserved. Lazy Lips: Hyperkalemia and Acute Tetraparesis—A Case Report from an Urban Emergency Department Tue, 25 Nov 2014 16:31:58 +0000 A 58-year-old male patient was admitted to our emergency department at a large university hospital due to acute onset of general weakness. It was reported that the patient was bradycardic at 30/min and felt an increasing weakness of the limbs. At admission to the emergency department, the patient was not feeling any discomfort and denied dyspnoea or pain. The primary examination of the nervous system showed the cerebral nerves II–XII intact, muscle strength of the lower extremities was 4/5, and a minimal sensory loss of the left hemisphere was found. In addition, the patient complained about lazy lips. During ongoing examinations, the patient developed again symptomatic bradycardia, accompanied by complete tetraplegia. The following blood test showed severe hyperkalemia probably induced by use of aldosterone antagonists as the cause of the patient’s neurologic symptoms. Hyperkalemia is a rare but treatable cause of acute paralysis that requires immediate treatment. Late diagnosis can delay appropriate treatment leading to cardiac arrhythmias and arrest. Christian T. Braun, David S. Srivastava, Bianca Maria Engelhardt, Gregor Lindner, and Aristomenis K. Exadaktylos Copyright © 2014 Christian T. Braun et al. All rights reserved. An Uncommon, Life-Threatening, Traumatic Hematoma in the Neck Area Mon, 24 Nov 2014 08:31:07 +0000 It is well known that blunt neck trauma, when compared to a penetrating injury in the same anatomical area, is very rare. We report a case of an 81-year-old Caucasian woman with a blunt life-threatening neck trauma due to a bully goat. Although rare, direct evaluation should always be done in these cases because any misinterpretation may result in unfavorable outcomes. We have to highlight that close medical attention and prompt surgical treatment should be always considered in order to avoid dramatic consequences. Michalis Peroulis, Georgios D. Lianos, Vasilios Nousias, Zoi Anastasiadi, Aikaterini Lianou, Christos Katsios, and Miltiadis Matsagkas Copyright © 2014 Michalis Peroulis et al. All rights reserved. “Don Juan-Fracture” as a Hint to Aortic Isthmus Rupture Tue, 18 Nov 2014 06:45:08 +0000 We report a case of thoracic aortic rupture after blunt trauma in a 23-year-old male patient. The initial investigation found no external injury or bleeding, only a slightly widened mediastinum and a broken left calcaneus. Abdominal lavage was negative, biochemistry was normal, and breathing and oxygenation were not compromised. When changing his position during diagnostics, the patient all of a sudden developed cardiac arrest and typical signs of hypovolemic shock. An immediate sternotomy was done without any further diagnostics on suspicion of aortic isthmus injury. A circular avulsion at the ligamentum arteriosum was found as assumed and repaired under cardiopulmonary bypass. The patient left the hospital for rehabilitation after 12 days in adequate health status. Biodynamics of blunt trauma after high-speed frontal impact and the relationship between calcaneus fracture, called “Don-Juan fracture,” and aortic rupture at the site of ligamentum arteriosum are discussed. Sirilak Suksompong and Benno von Bormann Copyright © 2014 Sirilak Suksompong and Benno von Bormann. All rights reserved. Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction Tue, 18 Nov 2014 00:00:00 +0000 HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. In extreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-old pregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances, and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathy syndrome (PRES) and hepatic infarction. We highlight the approach taken towards this patient and the case management, in which, in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate the systemic microcirculation. Stephanno Gomes Pereira Sarmento, Eduardo Feliz Martins Santana, Felipe Favorette Campanharo, Edward Araujo Júnior, Flavia Ribeiro Machado, Nelson Sass, and Antonio Fernandes Moron Copyright © 2014 Stephanno Gomes Pereira Sarmento et al. All rights reserved. Self-Administered Ethanol Enema Causing Accidental Death Tue, 11 Nov 2014 07:46:50 +0000 Excessive ethanol consumption is a leading preventable cause of death in the United States. Much of the harm from ethanol comes from those who engage in excessive or hazardous drinking. Rectal absorption of ethanol bypasses the first pass metabolic effect, allowing for a higher concentration of blood ethanol to occur for a given volume of solution and, consequently, greater potential for central nervous system depression. However, accidental death is extremely rare with rectal administration. This case report describes an individual with klismaphilia whose death resulted from acute ethanol intoxication by rectal absorption of a wine enema. Thomas Peterson, Landen Rentmeester, Bryan S. Judge, Stephen D. Cohle, and Jeffrey S. Jones Copyright © 2014 Thomas Peterson et al. All rights reserved. A Case of Lemierre Syndrome Secondary to Otitis Media and Mastoiditis Thu, 06 Nov 2014 11:18:13 +0000 Lemierre’s syndrome is a rare clinical condition that generally develops secondary to oropharyngeal infection caused by Fusobacterium necrophorum, which is an anaerobic bacteria. A 62-year-old patient with diabetes mellitus presented with internal jugular vein and sigmoid sinus-transverse sinus thrombophlebitis, accompanying otitis media and mastoiditis that developed after an upper airway infection. Interestingly, there were air bubbles in both the internal jugular vein and transverse sinus. Vancomycin and meropenem were started and a right radical mastoidectomy was performed. The patient’s clinical picture completely resolved in 14 days. High mortality and morbidity may be prevented with a prompt diagnosis of Lemierre’s syndrome. Aynur Turan, Harun Cam, Yeliz Dadali, Serdar Korkmaz, Ali Özdek, and Baki Hekimoğlu Copyright © 2014 Aynur Turan et al. All rights reserved. Out-of-Hospital Perimortem Cesarean Section as Resuscitative Hysterotomy in Maternal Posttraumatic Cardiac Arrest Thu, 30 Oct 2014 06:48:16 +0000 The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early “separation” between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). This strategy is in contrast with the traditional treatment of cardiac arrest characterized by the maintenance of cardiopulmonary resuscitation (CPR) maneuvers without any emergent surgical intervention. We report the case of a prehospital perimortem delivery by Caesarean (C) section of a foetus at 36 weeks of gestation after the mother’s traumatic cardiac arrest. Despite the negative outcome of the mother, the choice of performing a RH seems to represent up to date the most appropriate intervention to improve the outcome in both mother and foetus. Francesca Gatti, Marco Spagnoli, Simone Maria Zerbi, Dario Colombo, Mario Landriscina, and Fulvio Kette Copyright © 2014 Francesca Gatti et al. All rights reserved. Intermittent Brugada Syndrome Presenting with Syncope in an Adult Female Tue, 14 Oct 2014 00:00:00 +0000 Background. Brugada syndrome accounts for 4–12% of all sudden deaths worldwide and at least 20% of sudden deaths in patients with structurally normal hearts. Case Report. A 48-year-old female presented to the emergency department after two witnessed syncopal episodes. While awaiting discharge had a third collapse followed by cardiac arrest with shockable rhythm. Initial electrocardiogram showed wide QRS complex with left axis deviation, ST-segment elevation of <1 mm in V1 and V2, and flattening of T waves in V1. The angiogram did not demonstrate obstructive coronary disease. The electrocardiogram obtained two days after these events showed a right bundle branch block with ST-segment elevation of >2 mm followed by a negative T wave with no isoelectric separation, suggestive of spontaneous intermittent Brugada type 1 pattern. Cardiac magnetic resonance imaging demonstrated neither structural heart disease nor abnormal myocardium. After placement of an implantable cardioverter defibrillator the patient was discharged. Why should an emergency physician be aware of this? Brugada syndrome is an infrequently encountered clinical entity which may have a fatal outcome. This syndrome primarily presents with syncope. It should be considered as a component of differential diagnosis in patients with family history of syncope and sudden cardiac death. Patricia Chavez, Daniel Bamira, Abel Casso Dominguez, Akshai Bhandary, and Eyal Herzog Copyright © 2014 Patricia Chavez et al. All rights reserved. Spontaneous Cervical Epidural Hematoma with Hemiparesis Mimicking Cerebral Stroke Thu, 02 Oct 2014 09:30:06 +0000 Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding. Mehmet Tiryaki, Recep Basaran, Serdar Onur Aydin, Mustafa Efendioglu, Ece Balkuv, and Naci Balak Copyright © 2014 Mehmet Tiryaki et al. All rights reserved. Treatment of Acute Flares of Chronic Pancreatitis Pain with Ultrasound Guided Transversus Abdominis Plane Block: A Novel Application of a Pain Management Technique in the Acute Care Setting Thu, 25 Sep 2014 00:00:00 +0000 The use of transversus abdominis plane (TAP) block to provide either analgesia or anesthesia to the anterior abdominal wall is well described. The technique yields high analgesic effectiveness and is opioid sparing and potentially of long duration with reported analgesia lasting up to 36 hours. When compared to neuraxial analgesia, TAP blocks are associated with a lower incidence of hypotension and motor blockade. TAP blocks are typically described as providing somatic analgesia only without any effect on visceral pain. There may be, however, certain conditions in which TAP blocks can provide effective analgesia in pain of visceral or mixed somatic and visceral origin. We describe two cases in which TAP blockade provided complete control of pain considered to be of visceral origin. Daryl I. Smith, Kim Hoang, and Wendy Gelbard Copyright © 2014 Daryl I. Smith et al. All rights reserved. Pleuritic Chest Pain in a Young Female: A Reminder for Acute Health Care Providers Wed, 27 Aug 2014 11:58:40 +0000 Chest pain is one of the most common reasons for emergency department visits. Emergency medicine doctors should focus their initial assessment on patients’ stability. History, physical examination, and ancillary testing should exclude serious causes such as acute coronary syndrome, acute aortic syndromes, pulmonary embolism, pneumothorax, esophageal perforation, and rupture as well as pericardial tamponade. Young age should not be used alone as a predictor of a benign condition. Below we present a case of a 24-year-old female who was found to have ascending aortic dissection and was sent for emergent surgery. Aibek E. Mirrakhimov, Alaa M. Ali, and Carolyn Stroncek Copyright © 2014 Aibek E. Mirrakhimov et al. All rights reserved. Postpartum Spontaneous Subcapsular Hepatic Hematoma Related to Preeclampsia Sun, 17 Aug 2014 00:00:00 +0000 Subcapsular hematoma of the liver represents an unusual clinical phenomenon in the pregnancy and postpartum period with serious complications in terms of fetal and maternal mortality. Here we report a case of a 32-year-old primiparous female at 36 weeks of gestation, admitted to a maternity ward of a private clinic for preeclampsia. The woman underwent an emergency caesarean section with the extraction of an alive foetus. A few hours after delivery, she was transferred to the emergency department of our institution complaining of severe epigastric pain. Diagnostic work-up was suggestive of a subcapsular right lob hepatic hematoma which was successfully managed conservatively. Timely diagnosis is necessary for the prevention of life-threatening events in mother and fetus. For this reason acute care physicians have to be vigilant of the condition and consider this in the differential diagnosis of epigastric pain during pregnancy and postpartum. Dimitrios Anyfantakis, Miltiades Kastanakis, Georgios Fragiadakis, Paraskevi Karona, Nikolaos Katsougris, and Emmanouil Bobolakis Copyright © 2014 Dimitrios Anyfantakis et al. All rights reserved. The Tin Whistle: A Rare and Serious Cause of Penetrating Oropharyngeal Trauma in Children Wed, 13 Aug 2014 12:12:07 +0000 Impalement injuries of the oral cavity are common in children and the potential for serious complications including internal carotid artery thrombosis can be unnoticed. We present a patient who sustained a penetrating injury in which a “tin whistle” caused herniation of the parotid gland which was not detected on clinical examination. We discuss the challenging clinical examination, the role of investigations, and consequences of these injuries aiming at increasing awareness and optimizing patient management. E. C. Francis, K. M. Browne, and P. A. Eadie Copyright © 2014 E. C. Francis et al. All rights reserved. A Foreign Body in the Cervix after Spontaneous Abortion: A Rare Case of a Traumatic Fetal Decapitation Sun, 10 Aug 2014 13:20:44 +0000 Although incomplete spontaneous abortions are common in early pregnancy, fetal decapitation does not specifically appear in the medical literature as a known complication of spontaneous abortion. We present a rare and unusual case of an incomplete spontaneous abortion occurring at home with the mother presenting to the emergency department (ED) with a decapitated fetus and a retained fetal head in the cervical os. Danielle Holland and Johnathan Sheele Copyright © 2014 Danielle Holland and Johnathan Sheele. All rights reserved. Man with a Forehead Mass: Detection of a Forehead Pseudoaneurysm with Bedside Ultrasonography Thu, 24 Jul 2014 12:29:33 +0000 A vascular pseudoaneurysm can present similarly to an abscess; yet incision and drainage of a pseudoaneurysm can lead to uncontrolled bleeding and expose the patient to further morbidity. This is a case of a patient with a forehead pseudoaneurysm who presented to our emergency room after blunt head trauma. Here we review different diagnostic modalities as well as some of the treatment options that are described in the literature. Amin Abdi, Erick Armijo, Dina Seif, and Tarina Kang Copyright © 2014 Amin Abdi et al. All rights reserved. A Paradoxical Triad: Scapulothoracic Dissociation with Clavicle and Humeral Shaft Fractures Tue, 22 Jul 2014 09:25:52 +0000 Scapulothoracic dissociation involves varying degree of discontinuity of the upper extremity from its truncal attachment. An eighteen-year-old male presented to the accident and emergency department following a motor vehicle accident where he was hit by a four wheeler while riding a two wheeler. He had tenderness and deformity over the left clavicle and the left humerus. He was unable to perform active wrist and finger dorsiflexion. A CT subsequently revealed a grade 2 splenic laceration. The splenic laceration was treated conservatively. As his general condition improved, he was gradually weaned off the ventilator and his left upper limb neurology was reassessed. He had isolated radial nerve palsy with an otherwise intact brachial plexus. He underwent internal fixation of the clavicle and the humerus. At 4 months after injury the EMG/NCV report showed signs of renervation of the radial nerve, and the fracture progressed to an uneventful union. This prior unreported triad of scapulothoracic dissociation with ipsilateral clavicular and humeral fractures may represent a parody. An apparent increase in the severity of skeletal injury was associated with a paradoxical decrease in the severity of neurovascular injury. We report this case to create awareness among orthopedic surgeons and emergency physicians about the clinical presentation of such injuries. Sandeep Albert, Viswanath Jayashankar, and Mohamad Gouse Copyright © 2014 Sandeep Albert et al. All rights reserved. Delayed Bleeding and Pelvic Haematoma after Low-Energy Osteoporotic Pubic Rami Fracture in a Warfarin Patient: An Unusual Cause of Abdominal Pain Wed, 16 Jul 2014 12:56:07 +0000 Introduction. Acute abdominal pain may be the presenting symptom in a wide range of diseases in the elderly. Acute abdominal pain related to a delayed bleeding and pelvic haematoma after a low-energy pubic rami fracture is rare and can have important consequences; to the best of our knowledge, only one case has been previously described. Case Report. We present an unusual case of an 83-year-old woman taking warfarin for atrial fibrillation, admitted to the Emergency Department (ED) with acute abdominal pain and progressive anemia related to a delayed bleeding and pelvic haematoma 72 hours after a low-energy osteoporotic pubic rami fracture. Warfarin was withheld, anticoagulation was reversed by using fresh frozen plasma and vitamin K, and concentrated red blood cells were given. Haemoglobin level gradually returned to normal with a progressive resorption of the haematoma. Conclusion. Delayed bleeding and pelvic haematoma after osteoporotic pubic rami fracture should be considered in the differential diagnosis of acute abdominal pain in the elderly. This case indicates the need for hospital admission, careful haemodynamic monitoring, and early identification of bleeding in patients with “benign” osteoporotic pubic rami fracture, especially those receiving anticoagulants, to provide an adequate management and prevent severe complications. Andrea Sandri, Dario Regis, and Nicola Bizzotto Copyright © 2014 Andrea Sandri et al. All rights reserved. An Uncommon Presentation of Spontaneous Rectus Sheath Hematoma with Acute Kidney Injury due to Obstructive Uropathy and Prerenal Azotemia Sun, 13 Jul 2014 07:42:13 +0000 Rectus Sheath Hematoma (RSH) represents an unusual entity which is characterized by acute abdominal pain and tender palpable abdominal mass usually, among elderly patients receiving anticoagulant therapy. We report the case of an 81-year-old woman admitted to our department due to acute abdominal pain and oligoanuria. The patient had recently been hospitalized due to acute myocardial infarction (AMI) and atrial fibrillation (AF) and received both anticoagulant and antiplatelet therapies. The radiological assessments revealed an extended Rectus Sheath Hematoma and bilateral hydronephrosis. Treatment of the hematoma required cessation of anticoagulants and antiplatelet agents, immobilization, blood and fresh frozen plasma transfusion, and administration of vasopressors. The patient recovered gradually and was discharged home fifteen (15) days later. Eleni Paschou, Eleni Gavriilaki, Asterios Kalaitzoglou, Maria Mourounoglou, and Nikolaos Sabanis Copyright © 2014 Eleni Paschou et al. All rights reserved. Acute Testicular Ischemia following Endovascular Abdominal Aortic Aneurysm Repair Identified in the Emergency Department Wed, 09 Jul 2014 08:47:47 +0000 Endovascular aneurysm repair (EVAR) is perhaps the most widely utilized surgical procedure for patients with large abdominal aortic aneurysms. This procedure is minimally invasive and reduces inpatient hospitalization requirements. The case involves a 72-year-old male who presented to the emergency department with right testicular ischemia two days following EVAR. Given the minimal inpatient hospitalization associated with this procedure, emergency physicians are likely to encounter associated complications. Ischemic and thromboembolic events following EVAR are extremely rare but require prompt vascular surgery intervention to minimize morbidity and mortality. Nathan Finnerty, Stephen Rancour, and Andrew King Copyright © 2014 Nathan Finnerty et al. All rights reserved. Pneumomediastinum in Blunt Chest Trauma: A Case Report and Review of the Literature Wed, 09 Jul 2014 00:00:00 +0000 Blunt trauma is the most common mechanism of injury in patients with pneumomediastinum and may occur in up to 10% of patients with severe blunt thoracic and cervical trauma. In this case report we present a 24-year-old man with pneumomediastinum due to blunt chest trauma after jumping from a bridge into a river. He complained of persistent retrosternal pain with exacerbation during deep inspiration. Physical examination showed only a slight tenderness of the sternum and the extended Focused Assessment with Sonography for Trauma (e-FAST) was normal. Pneumomediastinum was suspected by chest X-ray and confirmed by computed tomography, which showed a lung contusion as probable cause of the pneumomediastinum due to the “Mackling effect.” Sonographic findings consistent with pneumomediastinum, like the “air gap” sign, are helpful for quick bedside diagnosis, but the diagnostic criteria are not yet as well established as for pneumothorax. This present case shows that despite minimal findings in physical examination and a normal e-FAST a pneumomediastinum is still possible in a patient with chest pain after blunt chest trauma. Therefore, pneumomediastinum should always be considered to prevent missing major aerodigestive injuries, which can be associated with a high mortality rate. Gregory Mansella, Roland Bingisser, and Christian H. Nickel Copyright © 2014 Gregory Mansella et al. All rights reserved. Exercise Induced Rhabdomyolysis with Compartment Syndrome and Renal Failure Sun, 06 Jul 2014 11:32:23 +0000 Exertional rhabdomyolysis is sequela that is occasionally seen after strenuous exercise. The progression to compartment syndrome or renal failure is a rare complication that requires prompt recognition and treatment to prevent morbidity (Giannoglou et al. 2007). We present a case of a 22-year-old college football player who presented to the emergency department (ED) after a typical leg workout as part of his weight conditioning. He was found to have rhabdomyolysis with evidence of renal insufficiency. His condition progressed to bilateral compartment syndrome and renal failure requiring dialysis. After bilateral fasciotomies were performed he had resolution of his compartment syndrome. He continued to be dialysis dependent and had no return of his renal function at discharge 12 days after admission. Mary Colleen Bhalla and Ryan Dick-Perez Copyright © 2014 Mary Colleen Bhalla and Ryan Dick-Perez. All rights reserved. Expanding Prevertebral Soft Tissue Swelling Subsequent to a Motor Vehicle Collision Thu, 26 Jun 2014 07:39:56 +0000 Cervical acceleration/deceleration or whiplash injuries are a common cause of cervical spine trauma. Cervical acceleration/deceleration can result in vertebral fractures, subluxations, and ligamentous and other soft tissue injuries. Severe injuries are often evidenced by increased prevertebral swelling on lateral X-ray. Assessment of the prevertebral space on lateral cervical spine films is an essential component for identifying potential traumatic neck injuries. We describe a case in which an 84-year-old man on coumadin presented to the emergency department after a low-impact motor vehicle crash. The patient initially complained of neck and shoulder pain which subsequently progressed to hoarseness, dysphagia, and dyspnea. Imaging studies revealed significant prevertebral tissue swelling with anterior compression of his airway that required airway stabilization via awake fiber-optic intubation and reversal of his anticoagulation therapy. Matthew F. Ryan, David Meurer, and J. Adrian Tyndall Copyright © 2014 Matthew F. Ryan et al. All rights reserved. Use of Ultrasound to Diagnose and Manage a Five-Liter Empyema in a Rural Clinic in Sierra Leone Sun, 22 Jun 2014 11:32:01 +0000 We report the case of a dyspneic patient with a five-liter pleural empyema that was diagnosed and managed in a resource-limited clinic in a rural part of Sierra Leone. The diagnosis and management of this condition are usually guided by imaging modalities such as X-rays or CT scans. However, these resources may not be available in austere settings in developing countries. Because emergency physicians work in a variety of clinical settings, they should be well versed in the use of portable ultrasound machines to diagnose, treat, and manage many different conditions. Masashi Rotte, Jason Matthew Fields, Sergio Torres, Christa Dominick, and J. Daniel Kelly Copyright © 2014 Masashi Rotte et al. All rights reserved. A Rare Cause of Acute Abdomen: An Isolated Falciform Ligament Necrosis Tue, 17 Jun 2014 05:28:05 +0000 The falciform ligament is one of the anatomical structures which attach the liver to the diaphragm and anterior abdominal wall. Primary falciform ligament is very rare. In this article, we present a case of an isolated falciform ligament necrosis, a rare primary pathology of the falciform ligament, who was admitted with acute abdomen. Case presentation: A 64-year-old female patient was admitted with the complaints of pain. Laboratory test results showed a leukocyte count of 17,000/mm3. Imaging studies demonstrated intra-abdominal reactionary fluid along with a heterogeneous mass localized in the falciform ligament. Exploratory laparotomy revealed a necrotic mass of the falciform ligament. No other pathology responsible for falciform ligament necrosis was found. We believe that falciform ligament necrosis should be considered a preliminary diagnosis, if any ligament abnormality, tumor, intraligament air density, or the presence of reactionary fluid surrounding the ligament is detected through abdominal imaging studies. Ziya Taner Ozkececı, Mustafa Ozsoy, Bahadır Celep, Ahmet Bal, and Coskun Polat Copyright © 2014 Ziya Taner Ozkececı et al. All rights reserved.