Case Reports in Emergency Medicine http://www.hindawi.com The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Man with a Forehead Mass: Detection of a Forehead Pseudoaneurysm with Bedside Ultrasonography Thu, 24 Jul 2014 12:29:33 +0000 http://www.hindawi.com/journals/criem/2014/647175/ 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 http://www.hindawi.com/journals/criem/2014/689157/ 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 http://www.hindawi.com/journals/criem/2014/783268/ 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 http://www.hindawi.com/journals/criem/2014/164245/ 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 http://www.hindawi.com/journals/criem/2014/591820/ 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 http://www.hindawi.com/journals/criem/2014/685381/ 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 http://www.hindawi.com/journals/criem/2014/735820/ 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 http://www.hindawi.com/journals/criem/2014/870580/ 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 http://www.hindawi.com/journals/criem/2014/173810/ 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 http://www.hindawi.com/journals/criem/2014/570751/ 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. Delayed Upper-Airway Injury after Accidental Alkaline Ingestion Mon, 09 Jun 2014 10:53:01 +0000 http://www.hindawi.com/journals/criem/2014/503205/ A 62-year-old man presented to the emergency department one week after accidentally drinking an alkaline cleaning agent stored in unlabeled bottle. The day of the incident the patient presented to an outside hospital where he was admitted for an upper endoscopy of the esophagus which was found to be negative for acute injury. An initial chest X-ray taken the day of the incident was also found to be normal. After discharge the patient continued to have a sore throat and marked dysphagia which caused him to vomit repeatedly. Moreover, the patient began to develop chest pain with associated shortness of breath. We present a case of delayed airway injury and tracheal thickening and associated chest pain after alkaline ingestion and we discuss herein the pathophysiology and management of alkaline ingestions. Matthew F. Ryan, Mindy Fernandez, and Karen Laauwe Copyright © 2014 Matthew F. Ryan et al. All rights reserved. Necrotizing Myositis in a Neutropenic Patient: The Use of Ultrasound in the Diagnosis of Atypical Presentations Mon, 09 Jun 2014 09:19:43 +0000 http://www.hindawi.com/journals/criem/2014/685263/ We report a case of fatal necrotizing soft tissue infection (NSTI) due to Clostridium perfringens (CP) in a neutropenic patient with diabetes mellitus. As in many cases, by the time a diagnosis was made, the condition had rapidly progressed to its late stages, resulting in a fatal outcome. The emergency physician should be aware of NSTI as a complication when patients present with pain out of proportion to physical findings and/or signs of soft tissue compromise. Negative prognostic factors for survival are diabetes mellitus, immunosuppression, age, and toxic shock syndrome. A bedside ultrasound scan allows for rapid evaluation in time-sensitive critically ill patients and can promote prompt treatment without the need to delay for further imaging studies. Maria Del Carmen Torrejón, Edgardo Celi, David Cancho, Ailie Knox, and Cesar Henriquez-Camacho Copyright © 2014 Maria Del Carmen Torrejón et al. All rights reserved. Hemoperitoneum from Corpus Luteal Cyst Rupture: A Practical Approach in Emergency Room Sun, 01 Jun 2014 13:06:53 +0000 http://www.hindawi.com/journals/criem/2014/252657/ Corpus luteum cyst rupture with consequent hemoperitoneum is a common disorder in women in their reproductive age. This condition should be promptly recognized and treated because a delayed diagnosis may significantly reduce women’s fertility and intra-abdominal bleeding may be life-threatening. Many imaging modalities play a key role in the diagnosis of acute pelvic pain from gynecological causes. Ultrasound study (USS) is usually the first imaging technique for initial evaluation. USS is used to confirm or to exclude the presence of intraperitoneal fluid but it has some limitations in the identification of the bleeding source. Contrast-enhanced computed tomography (CT) is the imaging modality which could be used in the acute setting in order to recognize gynecological emergencies and to establish a correct management. Magnetic resonance imaging (MRI) nowadays is the most useful technique for studying the pelvis but its low availability and the long acquisition time of the images limit its usefulness in characterization of acute gynecological complications. We report a case of a young patient with hemoperitoneum from hemorrhagic corpus luteum correctly identified by transabdominal USS and contrast-enhanced CT. Valeria Fiaschetti, Aurora Ricci, Angela Lia Scarano, Valeria Liberto, Daniele Citraro, Silvia Arduini, Giuseppe Sorrenti, and Giovanni Simonetti Copyright © 2014 Valeria Fiaschetti et al. All rights reserved. Spontaneous Pneumomediastinum with a Rare Presentation Tue, 20 May 2014 12:38:24 +0000 http://www.hindawi.com/journals/criem/2014/451407/ Spontaneous pneumomediastinum is an unusual and benign condition in which air is present in mediastinum. A 20-year-old male patient presented to ED with complaint of hoarseness and odynophagia from the day before, after weightlifting. The patient was nonsmoker and denied history of other diseases. On physical examination he had no dyspnea with normal vital signs. Throat examination and pulmonary auscultation were normal and no crepitation was palpable. We could not find subcutaneous emphysema in neck and chest examination. In neck and chest X-ray we found that air is present around the trachea. There was no apparent pneumothorax in CXR. In cervical and chest CT free air was present around trachea and in mediastinum. Subcutaneous emphysema was also evident. But there was no pneumothorax. The patient was admitted and went under close observation, oxygen therapy, and analgesic. The pneumomediastinum and subcutaneous emphysema gradually resolved within a week by conservative therapy and he was discharged without any complication. Many different conditions could be trigged because of pneumomediastinum but it is rarely seen in intense physical exertion such as weightlifting and bodybuilding. Two most common symptoms are retrosternal chest pain and dyspnea. But the patient here complained of hoarseness and odynophagia. Ehsan Bolvardi, Elham Pishbin, Mohsen Ebrahimi, Azadeh Mahmoudi Gharaee, and Farhad Bagherian Copyright © 2014 Ehsan Bolvardi et al. All rights reserved. Peganum harmala L. Intoxication in a Pregnant Woman Wed, 14 May 2014 11:22:57 +0000 http://www.hindawi.com/journals/criem/2014/783236/ Peganum harmala L. is a plant widely distributed in the Mediterranean region. It is commonly used in traditional medicine in Morocco as sedative and abortifacient but exposes users to the risk of overdose and poisoning. The pharmacologically active compounds of this plant include a number of β-carboline and quinazoline alkaloids responsible of its pharmacological and toxicological effects. We report the case of a 24-year-old woman, 22 weeks pregnant, intoxicated with the seeds of Peganum harmala L. On admission, she had disturbance of consciousness, uterine contraction, and oliguria. Laboratory tests revealed renal failure and liver injury, and she benefited then from hemodialysis. During hospitalization, she was intubated after deterioration of consciousness and presented a spontaneous expulsion of the fetus. After extubation, she kept unusual sequelae: cerebellar ataxia and peripheral polyneuropathy. Physicians in regions using Peganum harmala L. as traditional medicine must be able to detect symptoms of its toxicity, in order to establish early gastrointestinal decontamination. The prognosis of this intoxication is variable; most cases can be managed successfully; but in high doses of intoxication, evolution can be fatal. Mohamed Adnane Berdai, Smael Labib, and Mustapha Harandou Copyright © 2014 Mohamed Adnane Berdai et al. All rights reserved. Pneumomediastinum Associated with Pneumopericardium and Epidural Pneumatosis Tue, 13 May 2014 08:43:10 +0000 http://www.hindawi.com/journals/criem/2014/275490/ Spontaneous pneumomediastinum is a relatively rare benign condition. It may rarely be associated with one or combination of pneumothorax, epidural pneumatosis, pneumopericardium, or subcutaneous emphysema. We present a unique case with four of the radiological findings in a 9-year-old male child who presented to our emergency department with his parents with complaints of unproductive cough, dyspnea, and swelling on chest wall. Bilateral subcutaneous emphysema was palpated on anterior chest wall from sternum to midaxillary regions. His anteroposterior and lateral chest radiogram revealed subcutaneous emphysema and pneumomediastinum. His thorax computed tomography to rule out life-threatening conditions revealed bilateral subcutaneous, mediastinal, pericardial, and epidural emphysema without pneumothorax. He was transferred to pediatric intensive care unit for close monitorization and conservative treatment. He was followed-up by chest radiographs. He was relieved from symptoms and signs around the fifth day and he was discharged at the seventh day. Diagnosis of pneumomediastinum is often made based on physical findings and plain radiographs. It may not be as catastrophic as it is seen. Close cardiopulmonary monitorization is mandatory for complications and accompanying conditions. Most patients with uncomplicated spontaneous pneumomediastinum respond well to oxygen and conservative management without any specific treatment. Ozlem Bilir, Ozcan Yavasi, Gokhan Ersunan, Kamil Kayayurt, and Baris Giakoup Copyright © 2014 Ozlem Bilir et al. All rights reserved. A Gut Gone to Pot: A Case of Cannabinoid Hyperemesis Syndrome due to K2, a Synthetic Cannabinoid Tue, 29 Apr 2014 06:35:46 +0000 http://www.hindawi.com/journals/criem/2014/167098/ Cannabinoid Hyperemesis Syndrome (CHS) was first described in 2004. Due to its novelty, CHS is often unrecognized by clinicians leading to expensive workup of these patients with cyclical symptoms. It may take up to 9 years to diagnose CHS. CHS is characterized by cyclical nausea and vomiting, abdominal pain, and an unusual compulsion to take hot showers in the presence of chronic use of cannabinoids. Cannabicyclohexanol is a synthetic cannabinoid, popularly known as K2 spice. It is a popular marijuana alternative among teenagers and young adults since it is readily available as herbal incense. Unlike marijuana, many users know that K2 is not detected in conventional urine drug screens, allowing those users to conceal their intake from typical detection methods. Serum or urine gas chromatography mass spectrophotometry is diagnostic, though not widely available. Thus, it is imperative for clinicians to recognize CHS, even with negative UDS, to provide cost-effective care. We present a 38-year-old man with a 10-year history of cannabis, and 1-year history of K2 abuse admitted with 1-week history of episodes of nausea, vomiting of clear fluids, and epigastric discomfort. Symptoms are relieved only by hot showers. Extensive laboratory, radiologic, and endoscopic evaluation was unrevealing. CHS was diagnosed, based on proposed criteria by Simonetti et al. Anene Ukaigwe, Paras Karmacharya, and Anthony Donato Copyright © 2014 Anene Ukaigwe et al. All rights reserved. ST-Elevation Myocardial Infarction after Pharmacologic Persantine Stress Test in a Patient with Wellens’ Syndrome Wed, 02 Apr 2014 11:08:41 +0000 http://www.hindawi.com/journals/criem/2014/530451/ Wellens’ syndrome, also known as LAD coronary T-wave inversion syndrome, is a characteristic ECG pattern that highly suggests critical stenosis of the proximal left anterior descending (LAD) coronary artery. 75% of patients with this finding go on to develop acute anterior wall myocardial infarction within one week unless prevented by early intervention on the culprit lesion. Most instances of ST-elevation occurring during cardiac stress testing have been observed with exercise, with only seven cases reported in the literature with pharmacologic stress. We present a case of a patient with no known cardiac disease who presented with chest pain and an ECG consistent with Wellens’ syndrome that developed an acute anterior wall ST-elevation myocardial infarction after pharmacologic stress test. Kunal Patel, Fady Alattar, Jayanth Koneru, and Fayez Shamoon Copyright © 2014 Kunal Patel et al. All rights reserved. Hemoperitoneum due to Splenic Laceration Caused by Colonoscopy: A Rare and Catastrophic Complication Mon, 17 Mar 2014 08:07:26 +0000 http://www.hindawi.com/journals/criem/2014/985648/ Numerous studies suggest that in asymptomatic patients, routine follow-up CT is not indicated due to the insignificant findings found on these patients. A 53-year-old man, who denied any underlying disease before, underwent colonoscopy for routine health examination. Sudden onset of abdominal pain around left upper quarter was mentioned at our emergency department. Grade II spleen laceration was found on CT scan. Splenic injury was found few hours later on the day of colonoscopy. It might result from the extra tension between the spleen and splenic flexure which varies from different positions of patients. Shiao-Han Chen, Jiann-Ruey Ong, Hon-Ping Ma, and Po-Shen Chen Copyright © 2014 Shiao-Han Chen et al. All rights reserved. Video-Assisted Minithoracotomy for Pulmonary Laceration with a Massive Hemothorax Thu, 13 Mar 2014 12:44:11 +0000 http://www.hindawi.com/journals/criem/2014/454970/ Severe intrathoracic hemorrhage from pulmonary parenchyma is the most serious complication of pulmonary laceration after blunt trauma requiring immediate surgical hemostasis through open thoracotomy. The safety and efficacy of video-assisted thoracoscopic surgery (VATS) techniques for this life-threatening condition have not been fully evaluated yet. We report a case of pulmonary laceration with a massive hemothorax after blunt trauma successfully treated using a combination of muscle-sparing minithoracotomy with VATS techniques (video-assisted minithoracotomy). A 22-year-old man was transferred to our department after a falling accident. A diagnosis of right-sided pneumothorax was made on physical examination and urgent chest decompression was performed with a tube thoracostomy. Chest computed tomographic scan revealed pulmonary laceration with hematoma in the right lung. The pulmonary hematoma extending along segmental pulmonary artery in the helium of the middle lobe ruptured suddenly into the thoracic cavity, resulting in hemorrhagic shock on the fourth day after admission. Emergency right middle lobectomy was performed through video-assisted minithoracotomy. We used two cotton dissectors as a chopstick for achieving compression hemostasis during surgery. The patient recovered satisfactorily. Video-assisted minithoracotomy can be an alternative approach for the treatment of pulmonary lacerations with a massive hemothorax in hemodynamically unstable patients. Hideki Ota, Hideki Kawai, Shuntaro Togashi, and Tsubasa Matsuo Copyright © 2014 Hideki Ota et al. All rights reserved. Spontaneous Rectus Sheath Hematoma in the Elderly: An Unusual Case and Update on Proper Management Tue, 11 Mar 2014 09:50:31 +0000 http://www.hindawi.com/journals/criem/2014/675678/ Spontaneous rectus sheath hematoma (SRSH) is an uncommon medical emergency in the elderly. We present a case of SRSH with an atypical clinical presentation and discuss literature regarding diagnosis and proper management. A 75-year-old female patient was transferred to the emergency department due to acute dyspnoea and confusion. Her medical history revealed a viral infection of the upper respiratory tract, and no coughing or use of anticoagulants. The clinical examination showed tenderness of the left lower abdomen, although palpation was misleading due to patient’s obesity. Laboratory investigations showed light anaemia. Ultrasonography and computed tomography revealed a large rectus sheath hematoma of the left abdominal wall. Despite further deterioration of the patient, conservative management including bed rest, fluid replacement, blood products transfusion, and proper analgesia was successful. No surgical intervention was needed. Prompt diagnosis and management of SRSH plays significant role in the prognosis, especially in elder patients. Independently of size and severity, conservative management remains the first therapeutic choice. Only by failure of supportive management, progressive and large hematoma or uncontrollable hemodynamic patients, interventional management including surgery or less invasive newer techniques is indicated. George Galyfos, Georgios Karantzikos, Konstantinos Palogos, Argiri Sianou, Konstantinos Filis, and Nikolaos Kavouras Copyright © 2014 George Galyfos et al. All rights reserved. Evaluation of a Porcine Dermal Collagen (Permacol) Implant for Abdominal Wall Reconstruction in a Pediatric Multitrauma Patient Mon, 10 Mar 2014 14:01:45 +0000 http://www.hindawi.com/journals/criem/2014/585723/ The presence of a contaminated surgical field in abdominal wall defects caused by trauma presents a challenge for surgeons. Both primary suture and synthetic meshes are strongly discouraged as surgical treatments in such cases. We describe the use of a porcine dermal collagen (Permacol) implant in an eight-year-old patient with multiple injuries. Three months after discharge, the child remains well with good cosmetic results. He is free of pain and has returned to full activity levels with complete wound closure and without any evidence of residual hernia. In conclusion, our experience indicates that the use of Permacol can be considered an efficient technique for reconstructing an infected abdominal wall defect of a pediatric multitrauma patient. Idit Melnik, Youri Mnouskin, Edna Verdiger Kurzbart, and Boris Yoffe Copyright © 2014 Idit Melnik et al. All rights reserved. Ruptured Splenic Artery Aneurysms and the Use of an Adapted Fast Protocol in Reproductive Age Women with Hemodynamic Collapse: Case Series Sun, 09 Mar 2014 10:09:44 +0000 http://www.hindawi.com/journals/criem/2014/454923/ Nontraumatic symptomatic hypotension in all patients requires prompt diagnosis and appropriate treatment for optimum outcome. The female population specifically has an expanded differential diagnosis that should be considered when these patients present with hemodynamic collapse. While the most common causes of hypotension in pregnant patients are dehydration, ruptured ectopic pregnancy, and placental and uterine abnormalities, less common nonobstetrical etiologies such as hepatic rupture and ruptured abdominal and visceral artery aneurysms should also be considered. Splenic artery aneurysms are associated with high rates of mortality and in cases of pregnancy, maternal and fetal mortality. These high rates can be attributed to the asymptomatic nature of the aneurysm, rapid deterioration after rupture, and frequent misdiagnosis. In patients with hemodynamic collapse, the role of traditional imaging is limited mainly due to the critical condition of the patient. Bedside ultrasound has emerged as a diagnostic imaging resource in patients with undifferentiated hypotension and in patients with traumatic injuries. However, its use has not been studied specifically in the female population. We present two patients with ruptured splenic artery aneurysms, discuss the role of bedside ultrasound in their management, and introduce a new ultrasound protocol for use in reproductive age female patients with hemodynamic collapse. Hope T. Jackson, Silviu C. Diaconu, Patrick J. Maluso, Bruce Abell, and Juliet Lee Copyright © 2014 Hope T. Jackson et al. All rights reserved. Diagnosis of an Inguinal Hernia after a Blunt Inguinal Trauma with an Intestinal Perforation Sun, 09 Mar 2014 07:44:53 +0000 http://www.hindawi.com/journals/criem/2014/653847/ Introduction. Inguinal hernias are very common in men. A clinical exam can do the diagnosis easily. But bowel perforation inside an inguinal hernia caused by a directly blunt trauma is rare and can have important consequences. Up to now, there have been a few case reports that described blunt injury to the inguinal area causing traumatic perforation of the bowel in the inguinal hernia. Case Report. We present a case of a 45-year-old Eastern European man with a small perforation of ileal bowels and a peritonitis after direct blunt trauma to the inguinal hernia region, with no inguinal hernia known by the patient, and show how the diagnosis can be difficult. Conclusion. This case shows that external forces, that may seem too trivial to cause intraperitoneal injury, can cause significant injury when applied to a patient with a hernia and shows how a careful examination, with the help of an abdominal CT scan, is important even if the patient do not seem to have an inguinal hernia. Farès Moustafa, Julien Avouac, Marie-Aude Vaz, and Jeannot Schmidt Copyright © 2014 Farès Moustafa et al. All rights reserved. Severe Unexplained Relative Hypotension and Bradycardia in the Emergency Department Wed, 05 Mar 2014 08:29:16 +0000 http://www.hindawi.com/journals/criem/2014/969562/ A precipitous episode of hypotension with concomitant bradycardia is a true medical emergency especially in patients with chronic hypertension and often requires hospitalization for detailed interrogation of the underlying causes. We describe herein a case of a patient with chronic labile hypertension who presented to the ED with a sharp drop in blood pressure and heart rate which was not simply explained by an antihypertensive overdose but more so by an aggregate of the patient’s multiple chronic medical conditions. This report highlights the complexities of treating simultaneous hypotension and bradycardia and the importance of discerning the underpinnings of the causes including past medical issues, patient medications, and the timeline of key events leading to the issue at hand. Shivam Kharod, Candice Norman, Matthew Ryan, and Robyn M. Hoelle Copyright © 2014 Shivam Kharod et al. All rights reserved. Two Episodes of Ventriculoperitoneal Shunt Migration in a Patient with Idiopathic Intracranial Hypertension Wed, 19 Feb 2014 09:58:44 +0000 http://www.hindawi.com/journals/criem/2014/280793/ Introduction. Ventriculoperitoneal shunts are often placed as treatment for refractory idiopathic intracranial hypertension. Dislodgement and migration of the distal portion of the shunt are more common in obese patients and can be difficult to detect. We report the case of a woman with two separate episodes of shunt migration into her abdominal wall. Case Presentation. We report a case of a 37-year-old female with history of obesity eventually diagnosed with idiopathic intracranial hypertension (IIH) as the cause. She failed outpatient therapy and, through neurosurgery, had a VP shunt placed for symptom control. She had subsequent development of worsened symptoms that were found to be due to shunt migration. This happened not once but twice to the same patient. Conclusion. Shunt dislodgement, migration, and subsequent failure are common in obese patients who have shunts placed for IIH. The medical provider should maintain a high index of suspicion for shunt malfunction in these patients, particularly because clinical evaluation may be challenging due to habitus. V. Balakrishnan and R. Jeanmonod Copyright © 2014 V. Balakrishnan and R. Jeanmonod. All rights reserved. Perirectal Abscess Masquerading as Cauda Equina Syndrome in an Otherwise Healthy 12-Year-Old Child Thu, 13 Feb 2014 08:15:51 +0000 http://www.hindawi.com/journals/criem/2014/817124/ A 12-year-old boy was brought to an urgent care center for fever, back pain, and abnormal gait. In addition to back pain, the patient was found to be persistently febrile but also had decreased perianal sensation and bowel incontinence. He was therefore referred to the emergency department where his back pain improved without medication but he was still febrile with bowel incontinence and persistently decreased perianal sensation. An MRI was ordered to evaluate possible cauda equina syndrome and revealed a perirectal abscess. The child ultimately underwent an exam under anesthesia with pediatric surgery and had a drain placed. This case highlights a unique presentation of perirectal abscess masquerading as cauda equina syndrome. A discussion of important considerations in emergency room diagnosis and management is presented. Dylan Dean Copyright © 2014 Dylan Dean. All rights reserved. Dyspnea, Tachycardia, and New Onset Seizure as a Presentation of Wilms Tumor: A Case Report Wed, 05 Feb 2014 08:55:22 +0000 http://www.hindawi.com/journals/criem/2014/562672/ Wilms tumor is found in 1 in 10,000 children and most commonly presents in asymptomatic toddlers whose care givers notice a nontender abdominal mass in the right upper quadrant. This case of Wilms tumor presented as a critically ill eleven-year old with significant tachypnea, dyspnea, vague abdominal pain, intermittent emesis, new onset seizure, metabolic acidosis, and hypoxemia. This is the first case in the literature of Wilms Tumor with cavoatrial involvement and seizure and pulmonary embolism resulting in aggressive resuscitation and treatment. Treatment included anticoagulation, chemotherapy, nephrectomy, and surgical resection of thrombi, followed by adjunctive chemotherapy with pulmonary radiation. Linda Li, Jennifer Light, Michael Marchick, and Robyn Hoelle Copyright © 2014 Linda Li et al. All rights reserved. Acute Renal Failure after Consumption of Fish Gall Bladder Sun, 02 Feb 2014 09:47:14 +0000 http://www.hindawi.com/journals/criem/2014/194129/ A case of acute renal failure after consumption of fish gall bladder as traditional medical remedy is reported. The patient fully recovered with conservative treatment. The risk of acute kidney failure and even multiple organ dysfunction syndrome following ingestion of fish gall bladder is highlighted. Nishant Raj Pandey, Bian Yu Yao, and Sudha Khakurel Copyright © 2014 Nishant Raj Pandey et al. All rights reserved. Gunshot Wound Contamination with Squirrel Tissue: Wound Care Considerations Wed, 22 Jan 2014 00:00:00 +0000 http://www.hindawi.com/journals/criem/2014/342914/ While report of animal bites contaminating wounds is reported commonly, direct wound contamination with squirrel flesh has never been reported in the literature. The patient suffered an accidental self-inflicted gunshot wound that drove squirrel flesh and buck shot deep within his right buttock. This case outlines his hospital course and wound treatment. The patient was treated with ten days of broad spectrum antibiotics, extensive debridement of the wound in the operating room, and further treatment of the wound with a vacuum dressing system. While squirrel tissue and buckshot had to be removed from the wound on day six of the hospital stay, the patient remained afebrile without signs or symptoms of systemic illness. Porter W. Maerz, Tricia B. Falgiani, and Robyn M. Hoelle Copyright © 2014 Porter W. Maerz et al. All rights reserved.