Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Detecting Foreign Bodies in a Head Laceration Sat, 31 Jan 2015 07:17:38 +0000 Open wounds represent a potential area of medicolegal risk if foreign bodies are not identified prior to wound closure. The importance of imaging of lacerations was underscored by a recent case where a 20-year-old male collided with a friend’s mouth on a trampoline sustaining a simple, superficial scalp laceration. The wound was evaluated in typical fashion including irrigation and local exploration and was prepared for closure. The friend was then evaluated and noted to have multiple extensive dental fractures. An increased index of suspicion generated further evaluation of the first patient’s wound. Plain radiography obtained of the first patient’s skull was noted to have bony foreign bodies consistent with teeth, which were then removed after further exploration. Superficial wounds are common and complications arising from retained foreign bodies are a potential source of substantial morbidity and consequently medical litigation. This case serves as a reminder to be vigilant and maintain a high index of suspicion regarding the potential for foreign body. Thomas R. Fowler, Steven J. Crellin, and Marna Rayl Greenberg Copyright © 2015 Thomas R. Fowler et al. All rights reserved. Profound Hypoglycemia with Ecstasy Intoxication Tue, 27 Jan 2015 06:34:26 +0000 Background. 3,4-Methylenedioxymethamphetamine (MDMA) or ecstasy is a synthetic drug that is commonly abused for its stimulant and euphoric effects. Adverse MDMA effects include hyperthermia, psychomotor agitation, hemodynamic compromise, renal failure, hyponatremia, and coma. However, endogenous hyperinsulinemia with severe persistent hypoglycemia has not been reported with MDMA use. Case Report. We report the case of a 29-year-old woman who remained severely hypoglycemic requiring continuous intravenous infusion of high-dose dextrose solutions for more than 24 hours after MDMA intoxication. Serum insulin and C-peptide levels confirmed marked endogenous hyperinsulinemia as the cause of the severe hypoglycemia. Why Should an Emergency Physician Be Aware of This? Immediate and frequent monitoring of blood glucose should be instituted in patients presenting with MDMA ingestion particularly if found to be initially hypoglycemic. Early recognition can help prevent the deleterious effects of untreated hypoglycemia that can add to the morbidity from MDMA use. Clinicians need to be aware of this side effect of MDMA so they can carefully monitor and treat it, especially in patients presenting with altered mental status. Perliveh Carrera and Vivek N. Iyer Copyright © 2015 Perliveh Carrera and Vivek N. Iyer. All rights reserved. Diagnosis of Mondor’s Disease in the Emergency Department with Bedside Ultrasound Sun, 18 Jan 2015 07:41:10 +0000 Mondor’s disease is a rare condition characterized by a superficial thrombophlebitis that can occur in the thoracoabdominal and genital areas. Findings with ultrasound in penile Mondor’s disease are readily measurable: a noncompressible penile vein without flow and absence of tears of the corpus cavernosum or tunica albuginea, hematoma, or evidence of fracture of the penis. We present a case of Mondor’s disease, diagnosed with bedside ultrasound, in the emergency department. Ultrasonography is readily available within the emergency department, and we suggest its use in aiding diagnosis of genitourinary disorders such as Mondor’s disease. J. Michael O’Neal, Erik Castleberg, and Vi Am Dinh Copyright © 2015 J. Michael O’Neal et al. All rights reserved. Methamphetamine Ingestion Misdiagnosed as Centruroides sculpturatus Envenomation Wed, 14 Jan 2015 09:26:04 +0000 The authors present a case report of a 17-month-old female child who ingested a large amount of methamphetamine that looked very similar clinically to a scorpion envenomation specific to the southwestern United States by the species Centruroides sculpturatus. The child was initially treated with 3 vials of antivenom specific for that scorpion species and showed a transient, though clinically relevant neurologic improvement. Her clinical course of sympathomimetic toxicity resumed and she was treated with intravenous fluids and benzodiazepines after blood analysis showed significant levels of d-methamphetamine. This case report is to specifically underline the clinical confusion in discerning between these two conditions and the realization of limited and/or expensive resources that may be used in the process. Joshua Strommen and Farshad Shirazi Copyright © 2015 Joshua Strommen and Farshad Shirazi. All rights reserved. Recurrent Coagulopathy after Rattlesnake Bite Requiring Continuous Intravenous Dosing of Antivenom Mon, 12 Jan 2015 13:18:45 +0000 Context. Snakebite envenomation is common and may result in systemic coagulopathy. Antivenom can correct resulting laboratory abnormalities; however, despite antivenom use, coagulopathy may recur, persist, or result in death after a latency period. Case Details. A 50-year-old previously healthy man presented to the emergency department after a rattlesnake bite to his right upper extremity. His presentation was complicated by significant glossal and oropharyngeal edema requiring emergent cricothyrotomy. His clinical course rapidly improved with the administration of snake antivenom (FabAV); the oropharyngeal and upper extremity edema resolved within several days. However, over the subsequent two weeks, he continued to have refractory coagulopathy requiring multiple units of antivenom. The coagulopathy finally resolved after starting a continuous antivenom infusion. Discussion. Envenomation may result in latent venom release from soft tissue depots that can last for two weeks. This case report illustrates the importance of close hemodynamic and laboratory monitoring after snakebites and describes the administration of continuous antivenom infusion, instead of multidose bolus, to neutralize latent venom release and correct residual coagulopathy. Charles W. Hwang and F. Eike Flach Copyright © 2015 Charles W. Hwang and F. Eike Flach. All rights reserved. Development of ST Elevation Myocardial Infarction and Atrial Fibrillation after an Electrical Injury Thu, 08 Jan 2015 08:50:54 +0000 Electrical energy is a type of energy that is commonly used in daily life. Ventricular premature beats, ventricular tachycardia, ventricular fibrillation, atrial tachycardia, atrial fibrillation, bundle branch blocks, and AV block are arrhythmic complications that are encountered in case of electric shocks. Myocardial infarction is one of the rarely seen complications of electric shocks yet it has fatal outcomes. Coronary arteries were detected to be normal in most of the patients who had myocardial infarction following an electric shock. So, etiology of myocardial infarction is thought to be unrelated to coronary atherosclerosis in these cases. Coronary artery vasospasm is thought to be the primary etiological cause. In our case report, we presented a patient who developed ST elevation MI with atrial fibrillation after an electric shock. Erdal Gursul, Serdar Bayata, Ercan Aksit, and Basak Ugurlu Copyright © 2015 Erdal Gursul et al. All rights reserved. Atypical Presentation of Traumatic Aortic Injury Tue, 30 Dec 2014 07:11:52 +0000 Background. Blunt thoracic aorta injury (BAI) is second only to head injury as cause of mortality in blunt trauma. While most patients do not survive till arrival at the hospital, for the remainder, prompt diagnosis and treatment greatly improve outcomes. We report an atypical presentation of BAI, highlighting the diagnostic challenges of this condition in the emergency department. Case Presentation. A previously well 25-year-old male presented 15 hours after injury hemodynamically stable with delirium. There were no signs or symptoms suggestive of BAI. Sonography showed small bilateral pleural effusions. Chest radiograph showed a normal mediastinum. Eventually, CT demonstrated a contained distal aortic arch disruption. The patient underwent percutaneous endovascular thoracic aortic repair and recovered well. Conclusion. This catastrophic lesion may present with few reliable signs and symptoms; hence, a high index of suspicion is crucial for early diagnosis and definitive surgical management. This paper discusses the diagnostic utility of clinical features, injury mechanism, and radiographic modalities. Consideration of mechanism of injury, clinical features, and chest radiograph findings should prompt advanced chest imaging. Andrew Fu Wah Ho, Tallie Wei-Lin Chua, Puneet Seth, Kenneth Boon Kiat Tan, and Sohil Pothiawala Copyright © 2014 Andrew Fu Wah Ho et al. All rights reserved. Retrograde Gastrojejunostomy Tube Migration Mon, 29 Dec 2014 07:53:59 +0000 Percutaneous enteral feeding tubes are placed about 250,000 times each year in the United States. Although they are relatively safe, their placement may be complicated by perforation, infection, bleeding, vomiting, dislodgment, and obstruction. There have been numerous reports of antegrade migration of gastrojejunostomy (G-J) tubes. We report a case of G-J tube regurgitation following protracted vomiting and discuss the management of this very rare entity. Adeleke Adesina, Guhan Rammohan, and Rebecca Jeanmonod Copyright © 2014 Adeleke Adesina et al. All rights reserved. Acute Renal Infarction Presenting with Acute Abdominal Pain Secondary to Newly Discovered Atrial Fibrillation: A Case Report and Literature Review Mon, 29 Dec 2014 07:25:04 +0000 We report an 85-year-old female with known history of recurrent diverticulitis presented with abdominal pain. It was believed that the patient again needed to be treated for another diverticulitis and was started on the routine treatment. The initial CT scan of abdomen showed renal infarcts bilaterally that were confirmed by a CT with and without intravenous contrast secondary to unknown cause. An ECG found accidentally that the patient was in atrial fibrillation, which was the attributed factor to the renal infarctions. Subsequently, the patient was started on the appropriate anticoagulation and discharged. Sherif Ali Eltawansy, Shil Patel, Mana Rao, Samaa Hassanien, and Mihir Maniar Copyright © 2014 Sherif Ali Eltawansy et al. All rights reserved. Acutely Onset Amiodarone-Induced Angioedema in a Patient with New Atrial Fibrillation Thu, 25 Dec 2014 10:07:23 +0000 A 50-year-old man was admitted to our emergency department due to new episode of palpitation. He had history of angioplasty of right coronary artery (RCA) with drug eluting stent 2 years ago. His electrocardiogram revealed atrial fibrillation (AF). Intravenous amiodarone 150 mg during 10 minutes and then 1 mg/min infusion were started to achieve rate control and pharmacologic conversion to sinus rhythm. After 60 minutes of starting amiodarone infusion, he developed swelling of the skin around his mouth and eyes, and also mucosa of the mouth, eyes and tongue. To conclude, angioedema should be considered a rare side effect of amiodarone which is used broadly in cardiovascular field. Hossein Vakili, Isa Khaheshi, Mehdi Memaryan, Habib Haybar, and Shooka Esmaeeli Copyright © 2014 Hossein Vakili et al. All rights reserved. A Vertebral Artery Dissection with Basilar Artery Occlusion in a Child Tue, 23 Dec 2014 00:10:10 +0000 This paper presents the case report of an 11-year-old boy with an acute dissection with thrombosis of the left vertebral artery and thrombosis of the basilar artery. The patient was treated with acute systemic thrombolysis, followed by intra-arterial thrombolysis, without any clinical improvement, showing left hemiplegia, bilateral clonus, hyperreflexia, and impaired consciousness. MRI indicated persistent thrombosis of the arteria basilaris with edema and ischemia of the right brainstem. Heparinization for 72 hours, followed by a two-week LMWH treatment and subsequent oral warfarin therapy, resulted in a lasting improvement of the symptoms. Vertebral artery dissection after minor trauma is rare in children. While acute basilar artery occlusion as a complication is even more infrequent, it is potentially fatal, which means that prompt diagnosis and treatment are imperative. The lack of class I recommendation guidelines for children regarding treatment of vertebral artery dissection and basilar artery occlusion means that initial and follow-up management both require a multidisciplinary approach to coordinate emergency, critical care, interventional radiology, and child neurology services. Katleen Devue, Annemie Van Ingelgem, Katrien De Keukeleire, and Marc De Leeuw Copyright © 2014 Katleen Devue et al. All rights reserved. Pediatric Stroke Presenting as a Seizure Mon, 22 Dec 2014 00:10:10 +0000 Background. Childhood arterial ischemic stroke (AIS) is rare and may be difficult to diagnose. Management of acute stroke in any age group is time sensitive, so awareness of the manifestations and appropriate diagnostic procedures for pediatric AIS is vital to establishing care. We present a pediatric case of arterial ischemic stroke that presented to the emergency department (ED) after two seizures. Case Report. A five-year-old female with an existing seizure disorder presented to a pediatric ED after having two seizures. Postictal upon arrival, she underwent a computed tomography (CT) scan of her head. Family reported that she had complained of a severe headache and vomited; her seizures were described as different from those she had experienced in the past. Loss of grey white matter differentiation on the CT warranted magnetic resonance imaging (MRI), which demonstrated a right-sided stroke. After a complicated course in the hospital, the patient was discharged to a rehabilitation hospital. Why Should an Emergency Physician Be Aware of This? It is important that emergency physicians recognize that a seizure may be the initial symptom of a pediatric stroke regardless of an established seizure history. Pediatric seizures are relatively common; however consideration of the diagnosis of pediatric stroke may prevent unnecessary delays in treatment. Katie L. Ahmadzadeh, Vartika Bhardwaj, Steven A. Johnson, and Kathleen E. Kane Copyright © 2014 Katie L. Ahmadzadeh et al. All rights reserved. Emergency Open Incarcerated Hernia Repair with a Biological Mesh in a Patient with Colorectal Liver Metastasis Receiving Chemotherapy and Bevacizumab Uncomplicated Wound Healing Sun, 21 Dec 2014 00:10:16 +0000 Bevacizumab is a humanized monoclonal antibody targeting vascular endothelial growth factor (VEGF), often used in combinational chemotherapy regimens for the treatment of patients with colorectal liver metastases. However adverse events have been attributed to the use of bevacizumab including gastrointestinal perforations, thrombotic events, hypertension, bleeding, and wound healing complications. 53-year-old male, with a history of colorectal cancer with liver metastasis, receiving a combination of cytotoxic chemotherapy (FOLFIRI, irinotecan with fluorouracil and folinic acid) with bevacizumab presented as an emergency with an incarcerated incisional hernia. The last administration of chemotherapy and bevacizumab had taken place 2 weeks prior to this presentation. As the risk of strangulation of the bowel was increased, a decision was made to take the patient to theatre, although the hazard with respect to wound healing, haemorrhage, and infection risk was high due to the recent administration of chemotherapy with bevacizumab. The patient underwent an open repair of the incarcerated recurrent incisional hernia with placement of a biological mesh, and the postoperative recovery was uncomplicated with no wound healing or bleeding problems. Alexandros Giakoustidis, Dawn Morrison, Kyriakos Neofytou, Dimitrios Giakoustidis, and Satvinder Mudan Copyright © 2014 Alexandros Giakoustidis et al. All rights reserved. New Onset Refractory Status Epilepticus as an Unusual Presentation of a Suspected Organophosphate Poisoning Wed, 17 Dec 2014 11:26:10 +0000 New onset refractory status epilepticus (NORSE) is a new entity in medical literature. It has different infectious and noninfectious etiologies showing a devastating impact onto the clinical outcome of patients. Therapy with anaesthetic and antiepileptic agents often fails to improve the condition, unless the primary cause is rectified. Here is presented the case of a young female with a history of depression who after a recent bereavement came to the Emergency Department of Aga Khan University Hospital with complaints of drowsiness that lasted for few hours. Though she had no history of organophosphate poisoning, her physical examination and further investigations were suggestive of the diagnosis. During her hospital stay, she developed refractory status epilepticus. Her seizures did not respond to standard antiepileptic and intravenous anesthetic agents and subsided only after intravenous infusion of atropine for a few days. Organophosphate poisoning is a very common presentation in the developing world and the associated status epilepticus poses a devastating problem for emergency physicians. In patients with suspected organophosphate poisoning with favoring clinical exam findings, the continuation of atropine intravenous infusion can be a safe option to abate seizures. Shahan Waheed, Amber Sabeen, and Nadeem Ullah Khan Copyright © 2014 Shahan Waheed et al. All rights reserved. Histamine Poisoning from Ingestion of Fish or Scombroid Syndrome Sun, 07 Dec 2014 09:33:53 +0000 The scombroid poisoning is due to the ingestion of poorly preserved fish (especially tuna, sardines, and mackerel) out of the cold chain. Under the influence of the proliferation of gram negative bacteria that occurs for heating, the histidine content in the muscle of the fish is converted into histamine, by the action of the enzyme histidine decarboxylase. If the histamine is ingested in large quantities, it causes an anaphylactoid reaction with a variety of symptoms from moderate to severe to life-threating. We will describe two cases that came under our observation after consuming a meal of bluefin tuna. The diagnosis of scombroid syndrome was made on the basis of the anamnestic data and the clinical one. The rapid resolution of the signs and symptoms after treatment with histamines H1-H2 receptor blockers confirmed the suspected diagnosis. Vincenzo Tortorella, Peppino Masciari, Mario Pezzi, Assunta Mola, Simona Paola Tiburzi, Maria Concetta Zinzi, Annamaria Scozzafava, and Mario Verre Copyright © 2014 Vincenzo Tortorella et al. All rights reserved. What Lies behind the Ischemic Stroke: Aortic Dissection? Tue, 02 Dec 2014 11:01:41 +0000 Introduction. Some cases with aortic dissection (AD) could present with various complaints other than pain, especially neurological and cardiovascular manifestations. AD involving the carotid arteries could be associated with many clinical presentations, ranging from stroke to nonspecific headache. Case Report. A 71-year-old woman was admitted to emergency department with vertigo which started within the previous one hour and progressed with deterioration of consciousness following speech disorder. On arrival, she was disoriented and uncooperative. Diffusion magnetic resonance imaging (MRI) of brain was consistent with acute ischemia in the cerebral hemisphere. Fibrinolytic treatment has been planned since symptoms started within two hours. Echocardiography has shown the dilatation of ascending aorta with a suspicion of flap. Computed tomography (CT) angiography has been applied and intimal flap has been detected which was consistent with aortic dissection, intramural hematoma of which was reaching from aortic arch to bilateral common carotid artery. Thereafter, treatment strategy has completely changed and surgical invention has been done. Conclusion. In patients who are admitted to the emergency department with the loss of consciousness and stroke, inadequacy of anamnesis and carotid artery involvement of aortic dissection should be kept in mind. Turgut Deniz, Ersel Dag, Murat Tulmac, Burcu Azapoglu, and Caglar Alp Copyright © 2014 Turgut Deniz et al. All rights reserved. The Management of Gas-Filled Eyes in the Emergency Department Wed, 26 Nov 2014 11:53:55 +0000 Background. Intraocular gas bubbles are commonly used in retinal surgery. There are specific management guidelines that need to be followed to ensure surgical success, and there are also unique ophthalmic and systemic complications that can occur in such patients. Objective. To educate emergency department personnel about important issues in the management of patients who have a gas-filled eye following retinal surgery. Case Report. A patient with a gas-filled eye developed several complications including pain, severe vision loss, high-grade atrioventricular (AV) block, and pneumocephalus. Conclusion. Awareness of potential problems that may arise in patients with gas-filled eyes who present to the emergency department may help minimize morbidity for such patients. Lik Thai Lim, Elliott Y. Ah-kee, Beve P. House, and Jonathan D. Walker Copyright © 2014 Lik Thai Lim et al. All rights reserved. Lazy Lips: Hyperkalemia and Acute Tetraparesis—A Case Report from an Urban Emergency Department Tue, 25 Nov 2014 16:31:58 +0000 A 58-year-old male patient was admitted to our emergency department at a large university hospital due to acute onset of general weakness. It was reported that the patient was bradycardic at 30/min and felt an increasing weakness of the limbs. At admission to the emergency department, the patient was not feeling any discomfort and denied dyspnoea or pain. The primary examination of the nervous system showed the cerebral nerves II–XII intact, muscle strength of the lower extremities was 4/5, and a minimal sensory loss of the left hemisphere was found. In addition, the patient complained about lazy lips. During ongoing examinations, the patient developed again symptomatic bradycardia, accompanied by complete tetraplegia. The following blood test showed severe hyperkalemia probably induced by use of aldosterone antagonists as the cause of the patient’s neurologic symptoms. Hyperkalemia is a rare but treatable cause of acute paralysis that requires immediate treatment. Late diagnosis can delay appropriate treatment leading to cardiac arrhythmias and arrest. Christian T. Braun, David S. Srivastava, Bianca Maria Engelhardt, Gregor Lindner, and Aristomenis K. Exadaktylos Copyright © 2014 Christian T. Braun et al. All rights reserved. An Uncommon, Life-Threatening, Traumatic Hematoma in the Neck Area Mon, 24 Nov 2014 08:31:07 +0000 It is well known that blunt neck trauma, when compared to a penetrating injury in the same anatomical area, is very rare. We report a case of an 81-year-old Caucasian woman with a blunt life-threatening neck trauma due to a bully goat. Although rare, direct evaluation should always be done in these cases because any misinterpretation may result in unfavorable outcomes. We have to highlight that close medical attention and prompt surgical treatment should be always considered in order to avoid dramatic consequences. Michalis Peroulis, Georgios D. Lianos, Vasilios Nousias, Zoi Anastasiadi, Aikaterini Lianou, Christos Katsios, and Miltiadis Matsagkas Copyright © 2014 Michalis Peroulis et al. All rights reserved. “Don Juan-Fracture” as a Hint to Aortic Isthmus Rupture Tue, 18 Nov 2014 06:45:08 +0000 We report a case of thoracic aortic rupture after blunt trauma in a 23-year-old male patient. The initial investigation found no external injury or bleeding, only a slightly widened mediastinum and a broken left calcaneus. Abdominal lavage was negative, biochemistry was normal, and breathing and oxygenation were not compromised. When changing his position during diagnostics, the patient all of a sudden developed cardiac arrest and typical signs of hypovolemic shock. An immediate sternotomy was done without any further diagnostics on suspicion of aortic isthmus injury. A circular avulsion at the ligamentum arteriosum was found as assumed and repaired under cardiopulmonary bypass. The patient left the hospital for rehabilitation after 12 days in adequate health status. Biodynamics of blunt trauma after high-speed frontal impact and the relationship between calcaneus fracture, called “Don-Juan fracture,” and aortic rupture at the site of ligamentum arteriosum are discussed. Sirilak Suksompong and Benno von Bormann Copyright © 2014 Sirilak Suksompong and Benno von Bormann. All rights reserved. Microcirculation Approach in HELLP Syndrome Complicated by Posterior Reversible Encephalopathy Syndrome and Massive Hepatic Infarction Tue, 18 Nov 2014 00:00:00 +0000 HELLP syndrome is a complication of severe forms of preeclampsia and occurs mainly in the third trimester of pregnancy. In extreme cases, it may evolve unfavorably and substantially increase maternal mortality. We present the case of an 18-year-old pregnant woman who was admitted to our emergency service in her 31st week, presenting with headache, visual disturbances, and epigastralgia, with progression to a severe condition of HELLP syndrome followed by posterior reversible encephalopathy syndrome (PRES) and hepatic infarction. We highlight the approach taken towards this patient and the case management, in which, in addition to the imaging examinations routinely available, we also used the sidestream dark field (SDF) technique to evaluate the systemic microcirculation. Stephanno Gomes Pereira Sarmento, Eduardo Feliz Martins Santana, Felipe Favorette Campanharo, Edward Araujo Júnior, Flavia Ribeiro Machado, Nelson Sass, and Antonio Fernandes Moron Copyright © 2014 Stephanno Gomes Pereira Sarmento et al. All rights reserved. Self-Administered Ethanol Enema Causing Accidental Death Tue, 11 Nov 2014 07:46:50 +0000 Excessive ethanol consumption is a leading preventable cause of death in the United States. Much of the harm from ethanol comes from those who engage in excessive or hazardous drinking. Rectal absorption of ethanol bypasses the first pass metabolic effect, allowing for a higher concentration of blood ethanol to occur for a given volume of solution and, consequently, greater potential for central nervous system depression. However, accidental death is extremely rare with rectal administration. This case report describes an individual with klismaphilia whose death resulted from acute ethanol intoxication by rectal absorption of a wine enema. Thomas Peterson, Landen Rentmeester, Bryan S. Judge, Stephen D. Cohle, and Jeffrey S. Jones Copyright © 2014 Thomas Peterson et al. All rights reserved. A Case of Lemierre Syndrome Secondary to Otitis Media and Mastoiditis Thu, 06 Nov 2014 11:18:13 +0000 Lemierre’s syndrome is a rare clinical condition that generally develops secondary to oropharyngeal infection caused by Fusobacterium necrophorum, which is an anaerobic bacteria. A 62-year-old patient with diabetes mellitus presented with internal jugular vein and sigmoid sinus-transverse sinus thrombophlebitis, accompanying otitis media and mastoiditis that developed after an upper airway infection. Interestingly, there were air bubbles in both the internal jugular vein and transverse sinus. Vancomycin and meropenem were started and a right radical mastoidectomy was performed. The patient’s clinical picture completely resolved in 14 days. High mortality and morbidity may be prevented with a prompt diagnosis of Lemierre’s syndrome. Aynur Turan, Harun Cam, Yeliz Dadali, Serdar Korkmaz, Ali Özdek, and Baki Hekimoğlu Copyright © 2014 Aynur Turan et al. All rights reserved. Out-of-Hospital Perimortem Cesarean Section as Resuscitative Hysterotomy in Maternal Posttraumatic Cardiac Arrest Thu, 30 Oct 2014 06:48:16 +0000 The optimal treatment of a severe hemodynamic instability from shock to cardiac arrest in late term pregnant women is subject to ongoing studies. However, there is an increasing evidence that early “separation” between the mother and the foetus may increase the restoration of the hemodynamic status and, in the cardiac arrest setting, it may raise the likelihood of a return of spontaneous circulation (ROSC) in the mother. This treatment, called Perimortem Cesarean Section (PMCS), is now termed as Resuscitative Hysterotomy (RH) to better address the issue of an early Cesarean section (C-section). This strategy is in contrast with the traditional treatment of cardiac arrest characterized by the maintenance of cardiopulmonary resuscitation (CPR) maneuvers without any emergent surgical intervention. We report the case of a prehospital perimortem delivery by Caesarean (C) section of a foetus at 36 weeks of gestation after the mother’s traumatic cardiac arrest. Despite the negative outcome of the mother, the choice of performing a RH seems to represent up to date the most appropriate intervention to improve the outcome in both mother and foetus. Francesca Gatti, Marco Spagnoli, Simone Maria Zerbi, Dario Colombo, Mario Landriscina, and Fulvio Kette Copyright © 2014 Francesca Gatti et al. All rights reserved. Intermittent Brugada Syndrome Presenting with Syncope in an Adult Female Tue, 14 Oct 2014 00:00:00 +0000 Background. Brugada syndrome accounts for 4–12% of all sudden deaths worldwide and at least 20% of sudden deaths in patients with structurally normal hearts. Case Report. A 48-year-old female presented to the emergency department after two witnessed syncopal episodes. While awaiting discharge had a third collapse followed by cardiac arrest with shockable rhythm. Initial electrocardiogram showed wide QRS complex with left axis deviation, ST-segment elevation of <1 mm in V1 and V2, and flattening of T waves in V1. The angiogram did not demonstrate obstructive coronary disease. The electrocardiogram obtained two days after these events showed a right bundle branch block with ST-segment elevation of >2 mm followed by a negative T wave with no isoelectric separation, suggestive of spontaneous intermittent Brugada type 1 pattern. Cardiac magnetic resonance imaging demonstrated neither structural heart disease nor abnormal myocardium. After placement of an implantable cardioverter defibrillator the patient was discharged. Why should an emergency physician be aware of this? Brugada syndrome is an infrequently encountered clinical entity which may have a fatal outcome. This syndrome primarily presents with syncope. It should be considered as a component of differential diagnosis in patients with family history of syncope and sudden cardiac death. Patricia Chavez, Daniel Bamira, Abel Casso Dominguez, Akshai Bhandary, and Eyal Herzog Copyright © 2014 Patricia Chavez et al. All rights reserved. Spontaneous Cervical Epidural Hematoma with Hemiparesis Mimicking Cerebral Stroke Thu, 02 Oct 2014 09:30:06 +0000 Aim. Spontaneous cervical epidural hematoma (SCEH) is defined as an epidural hematoma that does not have an etiological explanation. The most common site for SCEH is cervicothoracic area. Early diagnosis and treatment are important for prognosis and good results. In this paper, we aimed to present a case who complains of sudden weakness on right extremities imitating cerebral stroke and that neuroimaging reveals spontaneous cervical epidural hematoma. Case. A 72-year-old woman was admitted to our hospital with acute neck pain and loss of strength on right extremities. On neurological examination, the patient had right hemiparesis. PT, aPTT, and INR results were 50.5, 42.8, and 4.8, respectively. Cranial MRI was in normal limits. Spinal MRI revealed a lesion that extends from C4 to C7 located on the right side and compatible with epidural hematoma. The patient was operated after normalization of INR values. Conclusion. Even though SCEH is a rare condition, it can cause severe morbidity and mortality. Early diagnosis and treatment are quiet important for prognosis. SCEH can easily be mistaken for stroke as with other pathologies and this diagnosis should come to mind especially in patients who have diathesis of bleeding. Mehmet Tiryaki, Recep Basaran, Serdar Onur Aydin, Mustafa Efendioglu, Ece Balkuv, and Naci Balak Copyright © 2014 Mehmet Tiryaki et al. All rights reserved. Treatment of Acute Flares of Chronic Pancreatitis Pain with Ultrasound Guided Transversus Abdominis Plane Block: A Novel Application of a Pain Management Technique in the Acute Care Setting Thu, 25 Sep 2014 00:00:00 +0000 The use of transversus abdominis plane (TAP) block to provide either analgesia or anesthesia to the anterior abdominal wall is well described. The technique yields high analgesic effectiveness and is opioid sparing and potentially of long duration with reported analgesia lasting up to 36 hours. When compared to neuraxial analgesia, TAP blocks are associated with a lower incidence of hypotension and motor blockade. TAP blocks are typically described as providing somatic analgesia only without any effect on visceral pain. There may be, however, certain conditions in which TAP blocks can provide effective analgesia in pain of visceral or mixed somatic and visceral origin. We describe two cases in which TAP blockade provided complete control of pain considered to be of visceral origin. Daryl I. Smith, Kim Hoang, and Wendy Gelbard Copyright © 2014 Daryl I. Smith et al. All rights reserved. Pleuritic Chest Pain in a Young Female: A Reminder for Acute Health Care Providers Wed, 27 Aug 2014 11:58:40 +0000 Chest pain is one of the most common reasons for emergency department visits. Emergency medicine doctors should focus their initial assessment on patients’ stability. History, physical examination, and ancillary testing should exclude serious causes such as acute coronary syndrome, acute aortic syndromes, pulmonary embolism, pneumothorax, esophageal perforation, and rupture as well as pericardial tamponade. Young age should not be used alone as a predictor of a benign condition. Below we present a case of a 24-year-old female who was found to have ascending aortic dissection and was sent for emergent surgery. Aibek E. Mirrakhimov, Alaa M. Ali, and Carolyn Stroncek Copyright © 2014 Aibek E. Mirrakhimov et al. All rights reserved. Postpartum Spontaneous Subcapsular Hepatic Hematoma Related to Preeclampsia Sun, 17 Aug 2014 00:00:00 +0000 Subcapsular hematoma of the liver represents an unusual clinical phenomenon in the pregnancy and postpartum period with serious complications in terms of fetal and maternal mortality. Here we report a case of a 32-year-old primiparous female at 36 weeks of gestation, admitted to a maternity ward of a private clinic for preeclampsia. The woman underwent an emergency caesarean section with the extraction of an alive foetus. A few hours after delivery, she was transferred to the emergency department of our institution complaining of severe epigastric pain. Diagnostic work-up was suggestive of a subcapsular right lob hepatic hematoma which was successfully managed conservatively. Timely diagnosis is necessary for the prevention of life-threatening events in mother and fetus. For this reason acute care physicians have to be vigilant of the condition and consider this in the differential diagnosis of epigastric pain during pregnancy and postpartum. Dimitrios Anyfantakis, Miltiades Kastanakis, Georgios Fragiadakis, Paraskevi Karona, Nikolaos Katsougris, and Emmanouil Bobolakis Copyright © 2014 Dimitrios Anyfantakis et al. All rights reserved. The Tin Whistle: A Rare and Serious Cause of Penetrating Oropharyngeal Trauma in Children Wed, 13 Aug 2014 12:12:07 +0000 Impalement injuries of the oral cavity are common in children and the potential for serious complications including internal carotid artery thrombosis can be unnoticed. We present a patient who sustained a penetrating injury in which a “tin whistle” caused herniation of the parotid gland which was not detected on clinical examination. We discuss the challenging clinical examination, the role of investigations, and consequences of these injuries aiming at increasing awareness and optimizing patient management. E. C. Francis, K. M. Browne, and P. A. Eadie Copyright © 2014 E. C. Francis et al. All rights reserved.