Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Damage Control Surgery for Hepatocellular Cancer Rupture in an Elderly Patient: Survival and Quality of Life Sun, 04 Oct 2015 15:17:32 +0000 Spontaneous rupture of hepatocellular carcinoma (HCC) is a rare emergency condition with high mortality rate. Successful management depends on patients’ hemodynamic condition upon presentation and comorbidities, correct diagnosis, HCC status, liver function, and future liver remnant, as well as available sources. There is still a debate in the literature concerning the best approach in this devastating complication. Nevertheless, the primary goal should be a definitive bleeding arrest. In most cases, patients with spontaneous rupture of HCC present with hemodynamic instability, due to hemoperitoneum, necessitating an emergency treatment modality. In such cases, transcatheter arterial embolization (TAE) should be the treatment of choice. Emergency liver resection is an option when TAE fails or in cases with preserved liver function and limited tumors. Otherwise, damage control strategies, as in liver trauma, are a reasonable alternative. We report a case of an elderly patient with hemoperitoneum and hypovolemic shock from spontaneous rupture of undiagnosed HCC, who was treated successfully by emergency surgery and damage control approach. Konstantinos Bouliaris, Grigorios Christodoulidis, Dimitrios Symeonidis, Alexandros Diamantis, and Konstantinos Tepetes Copyright © 2015 Konstantinos Bouliaris et al. All rights reserved. A Missed Case of Occult Bilateral Temporomandibular Dislocation Mistaken for Dystonia Mon, 07 Sep 2015 05:57:22 +0000 A 24-year-old male with a history of psychiatric disorder and no prior significant temporomandibular joint (TMJ) pathology presented to the emergency department for “lockjaw.” Plain film X-rays of the mandible were read as unremarkable by an attending radiologist, leading to the initial diagnosis of medication-induced dystonic reaction. Following unsuccessful medical treatment a maxillofacial computed tomography (CT) was ordered. CT confirmed bilateral dislocation, illustrating the importance of clinical judgment, and limitations of certain radiographic images. The authors believe this case to be the first reported case in the medical literature of bilateral anterior TMJ dislocation with a false negative X-ray. Evelyn Lee, Jan Shoenberger, and Jonathan Wagner Copyright © 2015 Evelyn Lee et al. All rights reserved. Speaking Tracheostomy Tube and Modified Mouthstick Stylus in a Ventilator-Dependent Patient with Spinal Cord Injury Thu, 27 Aug 2015 12:36:12 +0000 Communication is a serious problem for patients with ventilator-dependent tetraplegia. A 73-year-old man was presented at the emergency room in cardiopulmonary arrest after falling from a height of 2 m. After successful resuscitation, fractures of the cervical spine and cervical spinal cord injury were found. Due to paralysis of the respiratory muscles, a mechanical ventilator with a tracheostomy tube was required. First, a cuffed tracheostomy tube and a speaking tracheostomy tube were inserted, and humidified oxygen was introduced via the suction line. Using these tubes, the patient could produce speech sounds, but use was limited to 10 min due to discomfort. Second, a mouthstick stylus, fixed on a mouthpiece that fits over the maxillary teeth, was used. The patient used both a communication board and a touch screen device with this mouthstick stylus. The speaking tracheostomy tube and mouthstick stylus greatly improved his ability to communicate. Eiji Mitate, Kensuke Kubota, Kenji Ueki, Rumi Inoue, Ryosuke Inoue, Kenta Momii, Hiroshi Sugimori, Yoshihiko Maehara, and Seiji Nakamura Copyright © 2015 Eiji Mitate et al. All rights reserved. Late Onset Traumatic Diaphragmatic Herniation Leading to Intestinal Obstruction and Pancreatitis: Two Separate Cases Mon, 24 Aug 2015 13:44:18 +0000 Although diaphragmatic injuries caused by blunt or penetrating trauma are rare entities, they are the most commonly misdiagnosed injuries in trauma patients and occur in approximately 3–7% of all abdominal or thoracic traumas. Acute pancreatitis secondary to late presenting diaphragmatic hernia is very rare. Here we present two separate cases: one with acute bowel obstruction and the other with acute pancreatitis secondary to late onset traumatic diaphragmatic hernia (three and twenty-eight years after chest trauma, resp.). Tolga Dinc, Selami Ilgaz Kayilioglu, and Faruk Coskun Copyright © 2015 Tolga Dinc et al. All rights reserved. Scombrotoxinism: Protracted Illness following Misdiagnosis in the Emergency Department Wed, 19 Aug 2015 09:49:05 +0000 Background. Scombrotoxinism is an acute toxin-induced illness caused primarily by bacterial synthesis of histamine in decomposed fish. Case Report. Immediately after taking 2-3 bites of cooked salmon, a clerical worker developed oral burning, urticaria, and asthma. In the emergency department, she was diagnosed with “allergies”; scombrotoxinism was never considered. She then developed wide-ranging symptoms (e.g., chronic fatigue, asthma, anxiety, multiple chemical sensitivity, and paresthesiae) and saw many specialists (in pulmonology, otorhinolaryngology, allergy, toxicology, neurology, psychology, and immunology). During the next 500+ days, she had extensive testing (allergy screens, brain MRI, electroencephalogram, electromyogram, nerve conduction velocity, heavy metal screen, and blood chemistry) with essentially normal results. She filed a workers’ compensation claim since this injury occurred following a business meal. She was evaluated by a Qualified Medical Evaluator (GL) on day 504, who diagnosed scombrotoxinism. Comment. Scombrotoxinism should be considered in all patients presenting to the emergency department with “oral burning” or allergy symptoms following “fish consumption.” Initial attention to such history would have led to a correct diagnosis and averted this patient’s extended illness. Specialist referrals and tests should be ordered only if clinically indicated and not for diagnostic fishing expedition. Meticulous history is crucial in resolving clinical dilemmas. Ghan-Shyam Lohiya, Sapna Lohiya, Sunita Lohiya, and Vijay Krishna Copyright © 2015 Ghan-Shyam Lohiya et al. All rights reserved. Novel Therapies for Myocardial Irritability following Extreme Hydroxychloroquine Toxicity Mon, 17 Aug 2015 08:48:35 +0000 Introduction. Hydroxychloroquine (HCQ) overdose is rare and potentially deadly when consumed in large doses. Management of severe HCQ toxicity is limited and infrequently reported. This report presents the case of a massive ingestion of HCQ. Case Report. A 23-year-old female presents following an intentional ingestion of approximately 40 g of HCQ. Within six hours after ingestion, she developed severe hemodynamic instability resulting from myocardial irritability with frequent ventricular ectopic activity leading to runs of polymorphic ventricular tachycardia (PMVT) and ventricular fibrillation (VF) requiring multiple defibrillations. Additional treatments included intravenous diazepam, epinephrine, norepinephrine, sodium bicarbonate, and magnesium sulfate. Despite the ongoing hemodynamic instability, the patient was also treated with Intralipid (ILE) and received hemodialysis. Improvements in her hemodynamics were observed after 18 hours. She survived her massive overdose of HCQ. Conclusion. HCQ poisoning is rare but serious because of its rapid progression to life-threatening symptoms. Hemodynamic support, gastric decontamination, electrolyte monitoring and replacement, and management of arrhythmias are the mainstays of treatment. The combined role of dialysis and ILE in the setting of massive HCQ overdose may improve outcomes. Paul B. McBeth, Perseus I. Missirlis, Harry Brar, and Vinay Dhingra Copyright © 2015 Paul B. McBeth et al. All rights reserved. Subclavian Artery Pseudoaneurysm Formation 3 Months after a Game of Rugby Union Mon, 17 Aug 2015 08:32:23 +0000 Pseudoaneurysms of the subclavian artery remain a rare complication after fracture of the clavicle. We report a case of delayed diagnosis of a subclavian artery pseudoaneurysm after a closed fracture of the clavicle in a 15-year-old patient, 3 months after the original injury while playing rugby union. Despite several attendances to the Emergency Department with vague symptoms, the final diagnosis was confirmed by duplex ultrasound and Computed Tomography of the thorax. Surgical repair was indicated due to acute limb ischaemia from distal embolisation from a large pseudoaneurysm, with the patient making a full recovery. This case highlights the need for clinical vigilance when assessing patients, particularly on repeated occasions when their recovery appears to be impaired. A thorough history and clinical examination can raise suspicion of even rare occurrences and aid prompt management. T. Evans, S. Roy, and M. Rocker Copyright © 2015 T. Evans et al. All rights reserved. A Case of Unrecognized Intrathoracic Placement of a Subclavian Central Venous Catheter in a Patient with Large Traumatic Hemothorax Tue, 11 Aug 2015 07:39:23 +0000 Traditional recommendations suggest placement of a subclavian central venous catheter (CVC) ipsilateral to a known pneumothorax to minimize risk of bilateral pneumothorax. We present the case of a 65-year-old male with a right hemopneumothorax who was found to have intrathoracic placement of his right subclavian CVC at thoracotomy despite successful aspiration of blood and transduction of central venous pressure (CVP). We thus recommend extreme caution with the interpretation of CVC placement by blood aspiration and CVP measurement alone in patients with large volume ipsilateral hemothorax. Dina Wallin, Alicia R. Privette, Andre R. Campbell, and Julin F. Tang Copyright © 2015 Dina Wallin et al. All rights reserved. Necrotizing Fasciitis Secondary to a Primary Suture for Anoperineal Trauma by Motorcycle Accident in a Healthy Adult Mon, 10 Aug 2015 14:07:21 +0000 A 41-year-old man experienced a swollen scrotum three days after a motorcycle accident and presented to our hospital. He had had a primary suture repair for anoperineal trauma in an outside hospital at the time of the injury. He presented to us with general fatigue, low grade fevers, and perineal pain. Abdominal computed tomography showed subcutaneous emphysema from the scrotum to the left chest. The sutured wound had foul-smelling discharge and white exudate. We made the diagnosis of necrotizing fasciitis and immediately opened the sutured wound and performed initial debridement and lavage with copious irrigation. We continued antibiotics and lavage of the wound until the infection was controlled. Fortunately, the necrotizing fasciitis did not worsen and he was discharged after 15 days. Our experience indicates that anoperineal injuries should not be closed without careful and intensive follow-up due to the potential of developing necrotizing fasciitis. Susumu Saigusa, Masaki Ohi, Hiroki Imaoka, Ryo Uratani, Minako Kobayashi, and Yasuhiro Inoue Copyright © 2015 Susumu Saigusa et al. All rights reserved. Subcutaneous Emphysema, Pneumomediastinum, and Pneumorrhachis after Cocaine Inhalation Wed, 08 Jul 2015 06:33:39 +0000 Introduction. The most prominent complications of cocaine use are adverse effects in the cardiovascular and central nervous systems. Free air in the mediastinum and subcutaneous tissue may be observed less frequently, whereas free air in the spinal canal (pneumorrhachis) is a very rare complication of cocaine abuse. In this report we present a case of pneumorrhachis that developed after cocaine use. Case. A 28-year-old male patient was admitted to the emergency department with shortness of breath, chest pain, and swelling in the neck and face which started four hours after he had sniffed cocaine. On physical examination, subcutaneous crepitations were felt with palpation of the jaw, neck, and upper chest area. Diffuse subcutaneous emphysema, pneumomediastinum, and pneumorrhachis were detected in the computed tomography imaging. The patient was treated conservatively and discharged uneventfully. Discussion. Complications such as pneumothorax, pneumomediastinum, and pneumoperitoneum that are associated with cocaine use may be seen due to increased intrathoracic pressure. The air then may flow into the spinal canal resulting in pneumorrhachis. Emergency physicians should know the possible complications of cocaine use and be prepared for rare complications such as pneumorrhachis. Tuğba Atmaca Temrel, Alp Şener, Ferhat İçme, Gül Pamukçu Günaydın, Şervan Gökhan, Yavuz Otal, Gülhan Kurtoğlu Çelik, and Ayhan Özhasenekler Copyright © 2015 Tuğba Atmaca Temrel et al. All rights reserved. Toxic Effects of Rhamnus alaternus: A Rare Case Report Wed, 01 Jul 2015 12:42:28 +0000 In Tunisia, there are about 478 species of plants commonly used in folk medicine. Medicinal plants and herbal remedies used are responsible for 2% of intoxications listed by Tunisian National Poison Center. Most cases are related to confusion between edible plants and toxic plants lookalikes or to an excessive consumption of therapeutic plants. We report the case of a 58-year-old man admitted to the Emergency Department of the Regional Hospital of Zaghouan (Tunisia), with renal failure and rhabdomyolysis. The patient reported having daily consumption of a homemade tea based on Mediterranean Buckthorn roots, during the last 6 months to treat type 2 diabetes. The aim of this work was to establish an association between the consumption of the herbal remedy and the occurrence of both renal failure and rhabdomyolysis. No similar cases have been reported in recent literature. H. Ben Ghezala, N. Chaouali, I. Gana, S. Snouda, A. Nouioui, I. Belwaer, J. Ouali, M. Kaddour, W. Masri, D. Ben Salah, D. Amira, H. Ghorbal, and A. Hedhili Copyright © 2015 H. Ben Ghezala et al. All rights reserved. A Case Report of Prilocaine-Induced Methemoglobinemia after Liposuction Procedure Tue, 23 Jun 2015 06:35:30 +0000 Prilocaine-induced methemoglobinemia is a rarely seen condition. In this paper, a case is presented with methemoglobinemia developed secondary to prilocaine use in a liposuction procedure, and the importance of this rarely seen condition is emphasized. A 20-year-old female patient presented with complaints of prostration, lassitude, shivering, shortness of breath, and cyanosis. It was learned that the patient underwent nearly 1000 mg prilocaine infiltration 8 hours priorly during a liposuction procedure. At admission, her blood pressure (130/80 mmHg), pulse rate (140 bpm), body temperature (36°C), and respiratory rate (40/min) were recorded. The patient had marked acrocyanosis. The arterial blood gas methemoglobin level was measured as 40%. The patient received oxygen therapy with a mask and was administered vitamin C in normal saline (500 mg tid), N-acetylcysteine (300 mg tid), and 50 mg 10% methylene blue in the intensive care unit of the internal medicine department. Methemoglobin level dropped down to 2% after her treatment with methylene blue and she was clinically cured and discharged 2 days later. Emergency service physicians should remember to consider methemoglobinemia when making a differential diagnosis between dyspnea and cyanosis developing after prilocaine infiltration performed for liposuctions in the adult age group. Birdal Yildirim, Ulku Karagoz, Ethem Acar, Halil Beydilli, Emine Nese Yeniceri, Ozgur Tanriverdi, Omer Dogan Alatas, and Şükrü Kasap Copyright © 2015 Birdal Yildirim et al. All rights reserved. A Rare Entity: Bilateral First Rib Fractures Accompanying Bilateral Scapular Fractures Sun, 14 Jun 2015 11:27:05 +0000 First rib fractures are scarce due to their well-protected anatomic locations. Bilateral first rib fractures accompanying bilateral scapular fractures are very rare, although they may be together with scapular and clavicular fractures. According to our knowledge, no case of bilateral first rib fractures accompanying bilateral scapular fractures has been reported, so we herein discussed the diagnosis, treatment, and complications of bone fractures due to thoracic trauma in bias of this rare entity. Gultekin Gulbahar, Tevfik Kaplan, Hasan Bozkurt Turker, Ahmet Gokhan Gundogdu, and Serdar Han Copyright © 2015 Gultekin Gulbahar et al. All rights reserved. A Woman with Unilateral Rash and Fever: Cellulitis in the Setting of Lymphedema Thu, 11 Jun 2015 16:52:33 +0000 Cellulitis in the setting of lymphedema is an uncommon but clinically important presentation to the emergency department. Stagnant lymph is an ideal medium for bacterial growth and progression can be rapid due to decreased ability to fight infection in the affected area. Infections are commonly caused by gram-positive cocci, though blood cultures are often negative. Treatment should be aimed at rapid initiation of antibiotics targeting these species. There may be a role for antibiotic prophylaxis in recurrent cases. Melissa Joseph, Marissa Camilon, and Tarina Kang Copyright © 2015 Melissa Joseph et al. All rights reserved. Bilateral Wallerian Degeneration of the Pontocerebellar Tracts Wed, 10 Jun 2015 13:42:17 +0000 Wallerian degeneration is the process of progressive demyelination and disintegration of the distal axonal segment following the transection of the axon or damage to the neuron. We report a case of a patient with Wallerian degeneration of the pontocerebellar tracts. She had a history of a pontine infarction 3 months ago. Wallerian degeneration of pontocerebellar tracts is seen bilaterally and symmetrically and is more visible in the middle cerebellar peduncles. Along the middle cerebellar peduncles hyperintense signal was detected on T2 weighted images. Wallerian degeneration of pontocerebellar tracts is a rare entity. It can occur bilaterally after a large pontine infarction. Magnetic resonance imaging seems to be the most effective technique for detection of Wallerian degeneration. In this report we want to mention this rare entity and to prevent wrong diagnosis. Azad Hekimoglu, Ihsaniye Suer Dogan, Aynur Turan, Mehmet Fevzi Oztekin, and Baki Hekimoglu Copyright © 2015 Azad Hekimoglu et al. All rights reserved. A Bullet Entered through the Open Mouth and Ended Up in the Parapharyngeal Space and Skull Base Sun, 07 Jun 2015 12:01:35 +0000 Shot from a revolver from a close range, a bullet pierced the chest of a policeman and entered through the open mouth of a young male person standing behind. The entry wound was found in the cheek mucosa adjacent to the left lower third molar. After hitting and fracturing the body and the ramus of the mandible, the bullet was deflected and was finally lodged in the parapharyngeal space and skull base, anterolateral to the transverse process of the atlas. The great vessels of the neck were not injured. The patient’s condition was very critical but his life could be saved. The bullet was approached through a modified Blair’s incision and was found to be lying over the carotid sheath. It was removed safely and the patient recovered completely. Saileswar Goswami and Choitali Goswami Copyright © 2015 Saileswar Goswami and Choitali Goswami. 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.