Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . 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. Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest Tue, 17 Nov 2015 11:09:53 +0000 More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient’s cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect. Gerard O’Connor, Gareth Fitzpatrick, Ayman El-Gammal, and Peadar Gilligan Copyright © 2015 Gerard O’Connor et al. All rights reserved. Concurrent Spontaneous Sublingual and Intramural Small Bowel Hematoma due to Warfarin Use Mon, 16 Nov 2015 11:47:17 +0000 Introduction. We present a case of concurrent spontaneous sublingual and intramural small bowel hematoma due to warfarin anticoagulation. Case. A 71-year-old man presented to the emergency department complaining of a swollen, painful tongue. He was on warfarin therapy. Physical examination revealed sublingual hematoma. His international normalized ratio was 11.9. The computed tomography scan of the neck demonstrated sublingual hematoma. He was admitted to emergency department observation unit, monitored closely; anticoagulation was reversed with fresh frozen plasma and vitamin K. 26 hours after his arrival to the emergency department, his abdominal pain and melena started. His abdomen tomography demonstrated intestinal submucosal hemorrhage in the ileum. He was admitted to surgical floor, monitored closely, and discharged on day 4. Conclusion. Since the patient did not have airway compromise holding anticoagulant, reversing anticoagulation, close monitoring and observation were enough for management of both sublingual and spontaneous intramural small bowel hematoma. Gül Pamukçu Günaydın, Hatice Duygu Çiftçi Sivri, Serkan Sivri, Yavuz Otal, Ayhan Özhasenekler, and Gülhan Kurtoğlu Çelik Copyright © 2015 Gül Pamukçu Günaydın et al. All rights reserved. Incidental Finding of Inferior Vena Cava Atresia Presenting with Deep Venous Thrombosis following Physical Exertion Tue, 10 Nov 2015 11:10:29 +0000 Inferior vena cava atresia (IVCA) is a rare but well described vascular anomaly. It is a rare risk factor for deep venous thrombosis (DVT), found in approximately 5% of cases of unprovoked lower extremity (LE) DVT in patients <30 years of age. Affected population is in the early thirties, predominantly male, often with a history of major physical exertion and presents with extensive or bilateral DVTs. Patients with IVC anomalies usually develop compensatory circulation through the collateral veins with enlarged azygous/hemizygous veins. Despite the compensatory circulation, the venous drainage of the lower limbs is often insufficient leading to venous stasis and thrombosis. We describe a case of extensive and bilateral deep venous thrombosis following physical exertion in a thirty-six-year-old male patient with incidental finding of IVCA on imaging. Shalini Koppisetty, Alton G. Smith, and Ravneet K. Dhillon Copyright © 2015 Shalini Koppisetty et al. All rights reserved. Elevated Intracranial Pressure Diagnosis with Emergency Department Bedside Ocular Ultrasound Mon, 26 Oct 2015 11:36:36 +0000 Bedside sonographic measurement of optic nerve sheath diameter can aid in the diagnosis of elevated intracranial pressure in the emergency department. This case report describes a 21-year-old female presenting with 4 months of mild headache and 2 weeks of recurrent, transient binocular vision loss. Though limited by patient discomfort, fundoscopic examination suggested the presence of blurred optic disc margins. Bedside ocular ultrasound (BOUS) revealed wide optic nerve sheath diameters and bulging optic discs bilaterally. Lumbar puncture demonstrated a cerebrospinal fluid (CSF) opening pressure of 54 cm H2O supporting the suspected diagnosis of idiopathic intracranial hypertension. Accurate fundoscopy can be vital to the appropriate diagnosis and treatment of patients with suspected elevated intracranial pressure, but it is often technically difficult or poorly tolerated by the photophobic patient. BOUS is a quick and easily learned tool to supplement the emergency physician’s fundoscopic examination and help identify patients with elevated intracranial pressure. D. Amin, T. McCormick, and T. Mailhot Copyright © 2015 D. Amin et al. All rights reserved. Disabling Orthostatic Headache after Penetrating Stonemason Pencil Injury to the Sacral Region Mon, 26 Oct 2015 08:21:24 +0000 Penetrating injuries to the spine, although less common than motor vehicle accidents and falls, are important causes of injury to the spinal cord. They are essentially of two varieties: gunshot or stab wounds. Gunshot injuries to the spine are more commonly described. Stab wounds are usually inflicted by knife or other sharp objects. Rarer objects causing incidental spinal injuries include glass fragments, wood pieces, chopsticks, nailguns, and injection needles. Just few cases of penetrating vertebral injuries caused by pencil are described. The current case concerns a 42-year-old man with an accidental penetrating stonemason pencil injury into the vertebral canal without neurological deficit. After the self-removal of the foreign object the patient complained of a disabling orthostatic headache. The early identification and treatment of the intracranial hypotension due to the posttraumatic cerebrospinal fluid (CSF) sacral fistulae were mandatory to avoid further neurological complications. In the current literature acute pattern of intracranial hypotension immediately after a penetrating injury of the vertebral column has never been reported. Carlo Brembilla, Luigi Andrea Lanterna, Paolo Gritti, Emanuele Costi, Gianluigi Dorelli, Elena Moretti, and Claudio Bernucci Copyright © 2015 Carlo Brembilla et al. All rights reserved. A Case of Palytoxin Poisoning in a Home Aquarium Enthusiast and His Family Mon, 26 Oct 2015 06:34:38 +0000 Inhalational exposure to palytoxin is an extremely rare cause of respiratory distress. This little-known marine toxin has the potential to cause significant morbidity and mortality. Toxicity has been best documented in cases of ingestion but has also been seen in cases of dermal exposure and inhalation of vapors. Palytoxin has been found in several coral species, some of which are favored by home aquarium enthusiasts and are commercially available. We report a case of a family who were exposed to the aerosolized toxin following the cleaning of a coral in their home aquarium. It is important that clinicians be aware of this source of toxic exposure to provide necessary care to these patients. Christine Hall, David Levy, and Steven Sattler Copyright © 2015 Christine Hall et al. All rights reserved.