Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Reversal of Dabigatran Using Idarucizumab in a Septic Patient with Impaired Kidney Function in Real-Life Practice Wed, 27 Jul 2016 12:01:47 +0000 Background. Immediate reversal of anticoagulation is essential when facing severe bleeding or emergency surgery. Although idarucizumab is approved for the reversal of dabigatran in many countries, clinical experiences are lacking, particularly in special patient-populations such as sepsis and impaired renal function. Case Presentation. We present the case of a 67-year-old male septic patient with a multilocular facial abscess and chronic kidney disease (GFR 36.5 mL/min). Thrombin time (TT) and activated partial thromboplastin time (aPTT) 15 hours after the last intake of 150 mg dabigatran were both prolonged (>120 sec, resp., 61 sec), as well as unbound dabigatran concentration (119.05 ng/mL). Before immediate emergency surgery dabigatran was antagonised using idarucizumab 2 × 2.5 g. Dabigatran concentration was not detectable 10 min after idarucizumab administration (<30 ng/mL). TT and aPTT time were normalised (16.2 sec, resp., 30.2 sec). Sepsis was controlled after surgery and kidney function remained stable. In the absence of postoperative bleeding, dabigatran was restarted 36 hours after admission. Conclusion. Idarucizumab successfully reversed the effect of dabigatran in real-life practice in a patient with sepsis and renal impairment and allowed emergency surgery with normal haemostasis. Efficacy and safety in real-life practice will nevertheless require prospective registries monitoring. Thomas C. Sauter, Sina Blum, Michael Nagler, Fabian L. Schlittler, Meret E. Ricklin, and Aristomenis K. Exadaktylos Copyright © 2016 Thomas C. Sauter et al. All rights reserved. Propofol Infusion Syndrome in Refractory Status Epilepticus: A Case Report and Topical Review Thu, 14 Jul 2016 11:39:47 +0000 Propofol infusion syndrome (PRIS) is a fatal complication when doses of propofol administration exceed 4 mg/kg/h for more than 48 hours. Propofol overdosage is not uncommon in patients with refractory status epilepticus (RSE). We describe a case of refractory status epilepticus complicated by propofol infusion syndrome and collect from 5 databases all reports of refractory status epilepticus cases that were treated by propofol and developed the syndrome and outline whether refractory status epilepticus treatment with propofol is standardized according to international recommendations, compare it with alternative medications, and discuss how this syndrome can be treated and prevented. A total of 21 patients who developed this syndrome reported arrhythmia in all cases (100%), rhabdomyolysis in 9 cases (42%), lactic acidosis in 13 cases (62%), renal failure in 8 cases (38%), lipemia in 7 cases (33%), and elevated hepatic enzymes in 6 cases (28%). 13 patients died (66%). Propofol is still given in a dosage higher than what is internationally recommended, and new treatment modalities such as renal replacement therapy, blood exchange, and extracorporeal membrane oxygenation seem to be promising. In conclusion, propofol should be carefully titrated, the maximal infusion rate needs to be reassessed, and combination of different sedative agents may be considered. Akil Walli, Troels Dirch Poulsen, Mette Dam, and Jens Børglum Copyright © 2016 Akil Walli et al. All rights reserved. Iatrogenic Radial Nerve Palsy following Closed Reduction of a Simple Diaphyseal Humeral Fracture: Beware the Perfect X-Ray Tue, 12 Jul 2016 12:12:20 +0000 Radial nerve injury is a recognised complication associated with humeral shaft fracture. A case of iatrogenic radial nerve injury is presented following fracture reduction. The relevant anatomy, challenges in management of humeral fractures with associated radial nerve injury, and the importance of detailed clinical assessment and documentation are discussed. Morgan Jones, Hean Wu Kang, Christopher O’Neill, and Paul Maginn Copyright © 2016 Morgan Jones et al. All rights reserved. Hemoptysis as the Presenting Clinical Sign of a T8-T9 Spine Fracture with Diffuse Idiopathic Skeletal Hyperostosis Changes Wed, 22 Jun 2016 09:19:22 +0000 Diffuse idiopathic skeletal hyperostosis (DISH) is a noninflammatory degenerative disease that affects multiple spine levels and, in combination with osteoporosis, makes vertebrae more prone to fractures, especially in elderly people. We describe a rare case of thoracic fracture in an ankylosed spine in which hemoptysis was the only clinical sign. The patient (age in the early 80s) presented with chest pain and a cough associated with hemoptysis. The patient had no complaints of back pain and no neurological symptoms. Computed tomography (CT) angiography of the chest revealed changes consistent with DISH, with fractures at the T8 and T9 vertebra as well as lung hemorrhage or contusion in the right lung base. CT and magnetic resonance imaging of the thoracic spine showed similar findings, with a recent T8-T9 fracture and DISH changes. The patient underwent percutaneous pedicle screw fixation from T7 to T11 and remained neurologically intact with an uneventful postoperative course. Ioannis Siasios, John Pollina, and Vassilios G. Dimopoulos Copyright © 2016 Ioannis Siasios et al. All rights reserved. Avoidable Compartment Syndrome! High Index of Suspicion for a Newly Presenting Haemophiliac: A Case Series Tue, 31 May 2016 11:39:42 +0000 Bleeding disorders can present at any age and vary in their severity. Haemophilia, which is characterised by its x-linked recessive inheritance, can present with a spontaneous mutation and therefore no family history will be evident. Three cases of trauma induced thigh haematomas as an initial presenting feature for people with haemophilia are discussed. The cases highlight the importance of a coagulation screen if the patients bleeding phenotype does not match the injury sustained. An isolated prolonged APTT with no offending anticoagulant cause should always be investigated to look for underlying haemophilia. Interestingly the cases demonstrate the limitations of a coagulation screen. Factor VIII being an acute phase reactant can result in the fact that the initial coagulation screen may be temporarily normal. Therefore, if there is a high index of suspicion for a bleeding disorder, consider repeating the coagulation screen and seeking haematology opinion. Early diagnosis and appropriate specific factor replacement for an injured haemophiliac prevent haematomas expanding thus avoiding potential complications like compartment syndrome or unnecessary surgical input. A. Niblock, K. Donnelly, F. Sayers, P. Winter, and G. Benson Copyright © 2016 A. Niblock et al. All rights reserved. Severe Cardiomyopathy after Huffing Dust-Off™ Wed, 25 May 2016 09:46:32 +0000 A 34-year-old man was found down in a parking lot after huffing fifteen cans of Dust-Off. Though lucid during the initial hospital evaluation, the patient experienced a generalized seizure followed by a torsades de pointes arrhythmia and was resuscitated. An echocardiogram revealed left and right ventricular dysfunction with an ejection fraction of 25%. This unique outcome of inhalant abuse has scarcely been reported in similar cases. The patient fully recovered and had a normal ejection fraction prior to discharge. Alexis L. Cates and Matthew D. Cook Copyright © 2016 Alexis L. Cates and Matthew D. Cook. All rights reserved. Intramedullary Abscess by Staphylococcus aureus Presenting as Cauda Equina Syndrome to the Emergency Department Mon, 16 May 2016 11:32:01 +0000 Cauda equina syndrome (CES) is a rare entity presenting with low back pain, unilateral or bilateral sciatica, motor weakness of lower extremities, sensory disturbance in the perineal area, and urinary and/or faecal incontinence. Those symptoms are secondary to compression of the cauda equina. If not recognized, CES can lead to irreversible disabilities. We report the case of a 77-year-old lady who presented to the emergency department with a ten-day history of back pain as well as urinary incontinence. Dimitrios Damaskos, Helene Jumeau, François-Xavier Lens, and Philippe Lechien Copyright © 2016 Dimitrios Damaskos et al. All rights reserved. Compartment Syndrome of the Hand: A Little Thought about Diagnosis Thu, 12 May 2016 13:14:20 +0000 Compartment syndrome of the forearm is a well described entity but there have been relatively few case reports in the emergency medicine literature of hand compartment syndromes (HCS). Prompt recognition and treatment of this potential limb threat are essential to minimize morbidity and mortality. Presented is a case of a documented hand compartment syndrome following a motor vehicle collision. Eric F. Reichman Copyright © 2016 Eric F. Reichman. All rights reserved. Pancreatic Pseudocyst Pleural Fistula in Gallstone Pancreatitis Thu, 05 May 2016 08:08:48 +0000 Extra-abdominal complications of pancreatitis such as pancreaticopleural fistulae are rare. A pancreaticopleural fistula occurs when inflammation of the pancreas and pancreatic ductal disruption lead to leakage of secretions through a fistulous tract into the thorax. The underlying aetiology in the majority of cases is alcohol-induced chronic pancreatitis. The diagnosis is often delayed given that the majority of patients present with pulmonary symptoms and frequently have large, persistent pleural effusions. The diagnosis is confirmed through imaging and the detection of significantly elevated amylase levels in the pleural exudate. Treatment options include somatostatin analogues, thoracocentesis, endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting, and surgery. The authors present a case of pancreatic pseudocyst pleural fistula in a woman with gallstone pancreatitis presenting with recurrent pneumonias and bilateral pleural effusions. Sala Abdalla, Ioannis Nikolopoulos, and Rajab Kerwat Copyright © 2016 Sala Abdalla et al. All rights reserved. Pneumothorax Caused by an Isolated Midshaft Clavicle Fracture Mon, 11 Apr 2016 08:46:42 +0000 Patients with isolated clavicle fractures are frequent in the emergency department. However, unusual clavicle fractures complications, such as pneumothorax, are rare. Previous reports indicated that all pneumothorax cases were treated via performing thoracostomy. Conservatively, the treatment of the clavicle fracture, like in our case, was successful. Despite the fact that isolated clavicle fractures rarely cause complications and generally heal with immobilization, serious complications may occur requiring urgent treatment. It has been proven that physical examinations, with particular attention to the neurovascular and chest examinations, and radiographs of the clavicle are necessary to prevent overlooking these potentially dangerous complications. Najla Feriani, Hassen Ben Ghezala, and Salah Snouda Copyright © 2016 Najla Feriani et al. All rights reserved. The Use of Plasma-Derived Complement C1-Esterase Inhibitor Concentrate (Berinert®) in the Treatment of Angiotensin Converting Enzyme-Inhibitor Related Angioedema Thu, 31 Mar 2016 10:11:37 +0000 Angioedema of the upper airways is a severe and potentially life-threatening condition. The incidence has been increasing in the past two decades, primarily due to pharmaceuticals influencing the generation or degradation of the vasoactive molecule bradykinin. Plasma-derived C1-esterase inhibitor concentrate is a well-established treatment option of hereditary and acquired complement C1-esterase inhibitor deficiency, which are also mediated by an increased level of bradykinin resulting in recurrent angioedema. We here present a case of severe angiotensin converting enzyme-inhibitor related angioedema (ACEi-AE) of the hypopharynx that completely resolved rapidly after the infusion of plasma-derived C1-inhibitor concentrate adding to the sparse reports in the existing literature. Thorbjørn Hermanrud, Nicolaj Duus, Anette Bygum, and Eva Rye Rasmussen Copyright © 2016 Thorbjørn Hermanrud et al. All rights reserved. Pneumomediastinum following Crystal Use: A Report of Two Cases Mon, 28 Mar 2016 12:33:11 +0000 Crystal is a synthetic substance with an increasing rate of abuse. It may cause patients to present to the emergency department because of its acute complications. We depict two cases of pneumomediastinum following inhalation of crystal. Both cases had used crystal for recreational purposes. In one case, a young man presenting to the ED with the retrosternal chest pain and neck pain was diagnosed to have pneumomediastinum and pneumopericardium. The other patient presenting with dyspnea and chest pain was shown to have collection of air within mediastinum. Both patients underwent a series of diagnostic evaluations and, after a course of observation, were discharged without a surgical intervention. Patients with chest pain following inhalation of crystal may suffer from this complication. Samiramis Pourmotabed and Mohammad Jalili Copyright © 2016 Samiramis Pourmotabed and Mohammad Jalili. All rights reserved. The Second Look after Fights: Why Wounds Might Not Only Be Superficial Thu, 17 Mar 2016 16:50:33 +0000 Introduction. We present a case of intraosseous foreign body penetration due to knife attack and its emergency service management. Case. Seventeen-year-old patient was admitted to the emergency department with a knife cut over the right knee. In the local wound exploration during the extension position of the knee, deep tissue penetration was not observed. Therefore, the patient was discharged after a primary wound saturation without any radiographic evaluation. During the second admission, the detailed anamnesis revealed that the injury occurred while the knee was in the flexion and the radiographic examination displayed a broken knifepoint in the sagittal plane of the femur’s medial patellar region penetrated in the intraosseous tissue. Conclusion. Intraosseous foreign body cases due to the knife attacks are quite rare. There is no algorithm, indicating the necessity of radiographic examination in the stab wounds. Local wound exploration of stab wounds should be done in accordance with the mechanism of injury. Egemen Küçük, Alauddin Kochai, Ümit Fikret Onur, Yasemin Yıldız Kirazaldı, and Ali Murat Başak Copyright © 2016 Egemen Küçük et al. All rights reserved. Right Hydronephrosis as a Complication of Acute Appendicitis Wed, 16 Mar 2016 09:55:08 +0000 Introduction. Acute appendicitis is the most common cause of acute abdomen, but atypical appendicitis may lead to delayed diagnosis and related complications. In this report, we present a very rare case of acute appendicitis causing right hydronephrosis. Case Report. A 54-year-old male patient who had been receiving antibiotic therapy due to the diagnosis of urinary tract infection for the last one week but had no clinical improvement was admitted to the emergency service. Abdominal computed tomography (CT) showed right hydronephrosis and a pelvic abscess. After appendectomy and abscess drainage had been performed, hydronephrosis was completely recovered. Discussion. The use of appendicitis scoring systems, abdominal ultrasonography (USG), abdominal CT, and diagnostic laparoscopy can be useful for the diagnostic process in patients presenting with acute abdomen. In our patient, we considered that the surgical treatment was delayed since the symptoms of acute appendicitis were suppressed by the antibiotic therapy that was being administered due to the complaints including symptoms of urinary tract infections. Conclusion. Atypical appendicitis may cause a delay in the diagnosis of acute appendicitis and thus may lead to serious complications such as right hydronephrosis, prolonged hospital stay, increased morbidity and mortality, and increased antibiotic resistance. Selahattin Koray Okur, Yavuz Savaş Koca, İhsan Yıldız, and İbrahim Barut Copyright © 2016 Selahattin Koray Okur et al. All rights reserved. A Systemic Capillary Leak Syndrome (Clarkson Syndrome) in a Patient with Chronic Lymphocytic Leukemia: A Case Report in an Out-of-Hospital Setting Wed, 16 Mar 2016 07:46:24 +0000 Systemic Capillary Leak Syndrome (SCLS) is a rare disease with poor prognosis, characterized by the occurrence of mucocutaneous and visceral edema with hypotension, hemoconcentration, and unexpected hypoalbuminemia. The disease can be idiopathic (Clarkson syndrome) or secondary to other diseases and treatments. We describe this syndrome in a prehospitalized, 63-year-old patient with chronic lymphocytic leukemia and an idiopathic form of SCLS manifesting as hypovolemic shock. Initial care is hospitalization in intensive care. In addition to etiological treatment if fluid replacement is necessary, treatment must be closely monitored for secondary overload complications. Catecholamine rather than arrhythmogenic support may be associated. Manon Durand Bechu, Antoine Rouget, Christian Recher, Elie Azoulay, and Vincent Bounes Copyright © 2016 Manon Durand Bechu et al. All rights reserved. Removal of a Tungsten Carbide Ring from the Finger of a Pregnant Patient: A Case Report Involving 2 Emergency Departments and the Internet Sun, 06 Mar 2016 14:19:25 +0000 Introduction. Destructive or nondestructive procedures may be used to remove rings from injured fingers. Because of their hardness, tungsten carbide rings present special problems. Case Presentation. The patient was a 33-year-old woman, two weeks before delivery, with a swollen and reddened ring finger. It was decided to remove a tungsten carbide ring from her ring finger. This was achieved by shattering the ring with locking pliers. The patient’s ring finger recovered fully. Alexandre Moser, Aristomenis Exadaktylos, and Alexander Radke Copyright © 2016 Alexandre Moser et al. All rights reserved. Spontaneous Arachnoid Cyst Rupture with Subdural Hygroma in a Child Thu, 18 Feb 2016 11:19:31 +0000 Arachnoid cyst of the brain is common in children but its association with spontaneous subdural hygroma is rare. A case of a nine-year-old boy, without any preceding history of trauma, is presented here who came to the emergency department of a tertiary care hospital with complaints of headache, nausea, and vomiting for the last two weeks but more for the last two days. Examination showed a young, fully conscious oriented boy with positive Cushing’s reflex and papilledema of left eye. MRI (magnetic resonance imaging) of the brain showed left temporal extra-axial cystic lesion of 5.40 × 4.10 cm in size, representing arachnoid cyst, with bilateral frontoparietal subdural hygromas. Cyst was partially drained through left temporal craniectomy and subdural hygromas were drained through bilateral frontal burr holes. Postoperatively the child recovered uneventfully and was discharged on the seventh postoperative day. Histopathology proves it to be arachnoid cyst of the brain with subdural CSF (cerebrospinal fluid) collection or hygroma. Muhammad Faisal Khilji, Niranjan Lal Jeswani, Rana Shoaib Hamid, and Faisal Al Azri Copyright © 2016 Muhammad Faisal Khilji et al. All rights reserved. Atraumatic Subdural Hematoma in a Third-Trimester Gravid Patient Wed, 17 Feb 2016 13:58:27 +0000 Acute atraumatic subdural hematoma is a rare occurrence and there exist few case studies which describe suspected cases and causes for this condition. We present a case of a 36-year-old female at 32-week gestation who initially presented to the emergency department for evaluation of lower extremity cellulitis but had acute neurologic change while being in the ED. Computed tomography revealed a right subdural hematoma with midline shift and mass effect. The primary cause for the patient’s subdural hematoma is unknown; however, this patient had several risk factors for developing an atraumatic subdural hematoma. D. C. Traficante, A. Marin, and A. Catapano Copyright © 2016 D. C. Traficante et al. All rights reserved. Retained Products of Conception: An Atypical Presentation Diagnosed Immediately with Bedside Emergency Ultrasound Sun, 07 Feb 2016 14:30:08 +0000 Background. Retained products of conception is an important diagnosis to consider in patients presenting with postpartum complaints. Bedside ultrasound is a rapid, accurate, noninvasive modality to evaluate these patients. Objective. To report an atypical case of retained products of conception diagnosed with bedside ultrasound in the emergency department. Case Report. A 27-year-old female who was 1-month postpartum presented with vaginal bleeding, pelvic pain, and no fever. At the time of initial H&P, bedside ultrasound revealed echogenic material within the endometrial cavity with blood flow seen by color Doppler consistent with retained products of conception. The bedside ultrasound rapidly narrowed the differential and allowed a definitive diagnosis immediately. Ob/Gyn was consulted and dilation and curettage was performed in the operating room. Conclusions. Retained products of conception is an important diagnosis for the emergency physician to consider in at-risk patients. The sonographic findings are easily obtained and interpreted by emergency physicians. Earlier diagnosis of this disease process should lead to more focused patient evaluations and management. Kristin Adkins, Joseph Minardi, Erin Setzer, and Debra Williams Copyright © 2016 Kristin Adkins et al. All rights reserved. Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography Thu, 04 Feb 2016 06:45:29 +0000 If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient’s admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis. A. J. Fischer, P. Lebiedz, M. Wiaderek, M. Lichtenberg, D. Böse, S. Martens, and F. Breuckmann Copyright © 2016 A. J. Fischer et al. All rights reserved. An Unusual Case of Spontaneous Esophageal Rupture after Swallowing a Boneless Chicken Nugget Tue, 02 Feb 2016 07:21:42 +0000 A 25-year-old previously healthy man presented to our Emergency Department with shortness of breath and epigastric pain after swallowing a boneless chicken nugget one hour prior to presentation. Physical examination revealed epigastric rigidity and tenderness. Serology was normal except for mildly elevated bilirubin and amylase. Computed tomography (CT) scan of the chest revealed a distal esophageal rupture with accompanying pneumomediastinum and left-sided pleural effusion. Treatment was initiated with administration of intravenous fluids and broad-spectrum antibiotics. Subsequently, an esophageal stent was inserted endoscopically in addition to VATS (Video-Assisted Thoracoscopic Surgery) drainage of the left-sided pleural space. This case illustrates an unusual presentation of Boerhaave’s syndrome: a rare and life-threatening form of noniatrogenic esophageal rupture most often preceded by forceful vomiting. Our case demonstrates that physicians should maintain an index of suspicion for spontaneous esophageal rupture in patients presenting with shortness of breath and epigastric pain even in the absence of preceding vomiting, cough, or seizure. Additionally, ingestion of boneless, shell-less foods may be sufficient to cause rupture in individuals without underlying esophageal pathology. CT scan of the thorax and upper abdomen should be performed in these patients to rule out this rare and life-threatening diagnosis. Zeenia Aga, Jackie Avelino, Gail E. Darling, and Jo Jo Leung Copyright © 2016 Zeenia Aga et al. All rights reserved. A Tuboovarian Abscess Associated with a Ruptured Spleen Sun, 24 Jan 2016 14:04:58 +0000 We report the first case of a tuboovarian abscess complicated by a ruptured spleen. Our patient was a 27-year-old female with human immunodeficiency virus (HIV) who presented to the emergency department (ED) with complaints of urinary symptoms and diarrhea. After being diagnosed with a tuboovarian abscess (TOA), she received antibiotics and was admitted to the gynecology service. Shortly thereafter she developed hemorrhagic shock, necessitating a splenectomy and salpingooophorectomy from a ruptured spleen. Jennifer S. Li and Johnathan Michael Sheele Copyright © 2016 Jennifer S. Li and Johnathan Michael Sheele. All rights reserved. The Great Imitator Strikes Again: Syphilis Presenting as “Tongue Changing Colors” Wed, 20 Jan 2016 12:12:23 +0000 Syphilis is known as the great imitator, making its diagnosis in the emergency department difficult. A 29-year-old male presented with the chief complaint of “my tongue is changing colors.” A syphilis rapid plasma reagin (RPR) test resulted as positive. In primary syphilis, the chancre is the characteristic lesion. While chancres are frequently found on the external genitalia or anus, extragenital chancres arise in 2% of patients. With oral involvement, the chancre is commonly found on the lip or tongue. The patient was treated for secondary syphilis with 2.4 million units of long acting penicillin intramuscularly. On follow-up a month later, the patient’s symptoms had resolved. Jessica Swanson and Janna Welch Copyright © 2016 Jessica Swanson and Janna Welch. All rights reserved. Pentobarbital Toxicity after Self-Administration of Euthasol Veterinary Euthanasia Medication Sun, 03 Jan 2016 13:07:55 +0000 Suicide attempt via sodium pentobarbital is uncommon. A 48-year-old woman with a history of depression and prior suicide attempt was found unresponsive by her veterinarian spouse near a syringe containing pink solution. Upon EMS’ arrival, the patient was experiencing apnea, hypoxemia, and miotic pupils; her blood glucose level measured 73 mg/dL. She was bradycardic and administered atropine with transient improvement in heart rate and transported to an emergency department; 2 mg of intravenous naloxone was administered without effect. She was endotracheally intubated via rapid sequence intubation. Rapid urine drug screening detected both benzodiazepines and barbiturates. The patient was transferred to an intensive care unit where she demonstrated a nearly absent radial pulse. Emergent fasciotomy to the left forearm and carpal tunnel was performed for acute compartment syndrome; “Euthasol” had been self-administered into the antecubital fossa. Expanded toxicological analysis via liquid chromatography/mass spectroscopy detected caffeine, atropine, 7-aminoclonazepam, phenytoin, citalopram, and naproxen. The patient’s coma resolved over 48 hours and she was successfully extubated without complication. Emergency physicians must closely monitor patients exposed to veterinary euthanasia agents who develop central nervous system and respiratory depression, hypothermia, bradycardia, hypotension, or skin injury. Consultation with a regional poison center and medical toxicologist is recommended. Steven Jason Crellin and Kenneth D. Katz Copyright © 2016 Steven Jason Crellin and Kenneth D. Katz. All rights reserved. Life-Threatening Retropharyngeal Hemorrhage Secondary to Rupture of the Inferior Thyroid Artery Thu, 24 Dec 2015 11:15:01 +0000 Inferior thyroid artery (ITA) rupture is rare and may progress to life-threatening conditions. We present a patient who visited the emergency department after an episode of syncope and dizziness in which he had a mechanical fall that resulted in abrasions and a hematoma to his left forehead. The patient presented with dysphagia and anterior neck swelling that progressed rapidly into airway compromise requiring endotracheal intubation. Emergent computed tomography revealed a large retropharyngeal hematoma, with active arterial extravasation that was thought to be arising from the thyrocervical trunk on the left. The hematoma measured approximately 6.7 cm transversely and 3.2 cm anteroposteriorly and extended from the level of the lower nasopharynx, down the neck into the retropharyngeal and danger space and into the mediastinum posterior to the esophagus, overall approximately 25 cm. The larynx was deviated anteriorly and there was esophageal compression. An emergent arteriogram and catheterization confirmed bleeding from branches of the ITA, and successful embolization was performed. It is important to recognize the ITA rupture as a potential etiology of an acute airway compromise. In emergent situations, while securing an airway is a priority, rapidly initiating diagnostic testing to confirm the diagnosis and arranging for arterial embolization can be life-saving. Cristina G. Calogero, Andrew C. Miller, and Marna Rayl Greenberg Copyright © 2015 Cristina G. Calogero et al. All rights reserved. Not Just Painless Bleeding: Meckel’s Diverticulum as a Cause of Small Bowel Obstruction in Children—Two Cases and a Review of the Literature Wed, 16 Dec 2015 12:37:04 +0000 Physicians are educated with the classical teaching that symptomatic patients with Meckel’s diverticulum (MD) most often present with painless rectal bleeding. However, a review of the literature reveals that young patients with MD will most commonly present with signs of intestinal obstruction, an etiology not frequency considered in patients presenting to the emergency department with obstruction. We present two cases of intestinal obstruction diagnosed in our emergency department, with Meckel’s diverticulum being the etiology. Khalida Itriyeva, Matthew Harris, Joshua Rocker, and Robert Gochman Copyright © 2015 Khalida Itriyeva et al. All rights reserved. Isolated Proximal Tibiofibular Dislocation during Soccer Wed, 02 Dec 2015 09:03:36 +0000 Proximal tibiofibular dislocations are rarely encountered in the Emergency Department (ED). We present a case involving a man presenting to the ED with left knee pain after making a sharp left turn on the soccer field. His physical exam was only remarkable for tenderness over the lateral fibular head. His X-rays showed subtle abnormalities of the tibiofibular joint. The dislocation was reduced and the patient was discharged from the ED with orthopedic follow-up. Casey Chiu and Johnathan Michael Sheele Copyright © 2015 Casey Chiu and Johnathan Michael Sheele. All rights reserved. Death after Sexual Intercourse Tue, 01 Dec 2015 06:24:27 +0000 Sexuality is an essential aspect of quality of life. Nevertheless, sexual intercourse is physically challenging and leads to distinct changes in blood pressure, heart, and respiratory rate that may lead to vital complications. We present a case report of a 22-year-old female suffering from subarachnoid hemorrhage after sexual intercourse. The patient was immediately transported to hospital by emergency medical services and, after diagnosis, transferred to a tertiary hospital with neurosurgical expertise but died within 24 hours. After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of sexual intercourse and therefore patients admitted to an emergency department with headache after sexual intercourse should always be carefully evaluated by cerebral imaging. Christian T. Braun, Meret E. Ricklin, Andreina Pauli, Daniel Ott, Aristomenis K. Exadaktylos, and Carmen A. Pfortmueller Copyright © 2015 Christian T. Braun et al. All rights reserved. Subdural Hematoma as a Consequence of Epidural Anesthesia Mon, 30 Nov 2015 11:46:19 +0000 Regional spinal and epidural anesthesia are used commonly in operative procedures. While the most frequent complication, postdural puncture headache (PDPH), is a clinically diagnosed positional headache that is usually self-limited, subdural hemorrhage (SDH) is a potentially fatal complication that cannot be missed. We report a case of an otherwise healthy female who presented with persistent positional headache and was ultimately found to have a large subdural hematoma with midline shift requiring surgical evacuation. Tracy M. Bishop, Kareem S. Elsayed, and Kathleen E. Kane Copyright © 2015 Tracy M. Bishop et al. All rights reserved. Low-Intensity Repetitive Exercise Induced Rhabdomyolysis Thu, 26 Nov 2015 11:55:01 +0000 Rhabdomyolysis is a rare condition caused by the proteins of damaged muscle cells entering the bloodstream and damaging the kidneys. Common symptoms of rhabdomyolysis are muscle pain and fatigue in conjunction with dark urine; kidney damage is a common symptom among these patients. We present a case of a 23-year-old woman who displayed myalgia in the upper extremities caused by low-intensity and high-repetition exercise. She was successfully diagnosed and treated for exertional rhabdomyolysis. This patient had no significant medical history that would induce this condition. We urge the emergency medical community to observe and monitor patients that complain of myalgia to ensure they are not suffering from rhabdomyolysis even in atypical cases. Mina Tran, Nicholas Hayden, Brandon Garcia, and Veronica Tucci Copyright © 2015 Mina Tran et al. All rights reserved.