Case Reports in Emergency Medicine The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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 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 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 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 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 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 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 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 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 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 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 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 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 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. Facing the Danger Zone: The Use of Ultrasound to Distinguish Cellulitis from Abscess in Facial Infections Thu, 16 Jan 2014 09:28:21 +0000 Physical exam alone is often insufficient to determine whether or not cellulitis is accompanied by an abscess. Bedside ultrasound can be a valuable tool in ruling out suspected abscess by allowing direct visualization of a fluid collection. The proximity of the infection to adjacent structures can also be determined, thus aiding clinical decision making. Patients with cellulitis near the eye and nose are of particular concern due to the adjacent facial structures and the anatomy of the venous drainage. Accurately determining the presence or absence of an associated abscess in these patients is a crucial step in treatment planning. The purpose of this report is to (1) emphasize the benefits of bedside ultrasound when used in conjunction with the physical exam to rule out abscess; (2) demonstrate the utility of bedside ultrasound in planning a treatment strategy for soft tissue infection; (3) depict an instance where ultrasound detected an abscess when computed tomography (CT) scan did not. Dywanda L. Lewis, Christine J. Butts, and Lisa Moreno-Walton Copyright © 2014 Dywanda L. Lewis et al. All rights reserved. Traumatic Implantation: A Novel Aetiology in the Development of Peritoneal Mesothelioma Thu, 26 Dec 2013 14:59:31 +0000 Peritoneal mesothelioma is a rare intra-abdominal malignancy. Its aetiology has been thought to be due to either inhalation or ingestion of asbestos particles. We present a case of peritoneal mesothelioma developing as a result of a novel third route and the inoculation of fibres into the peritoneal cavity by penetrating trauma and direct transport. This case report highlights the important long term consequences of penetrating abdominal trauma and the need for vigilance in undertaking peritoneal toilet. Nicola Humphrys, Amy Downing, Luke Evans, and Martin Sinclair Copyright © 2013 Nicola Humphrys et al. All rights reserved. Bedside Ultrasound in Workup of Self-Inserted Headset Cable into the Penile Urethra and Incidentally Discovered Intravesical Foreign Body Wed, 25 Dec 2013 08:58:56 +0000 There are multiple reports of foreign bodies inserted into the lower urinary tract. We report the case of an incidentally discovered foreign body identified within the bladder in a male patient presenting with a radio antenna protruding from the urethra attached to a head set. On workup patient was found to have an additional foreign body within the bladder and second radiolucent object within the urethra. This case demonstrates the importance of complete evaluation of the lower urinary tract during workup of inserted foreign bodies and the value of the bedside ultrasound as a diagnostic tool in distinguishing between rectal and genitourinary tract insertion. Ali Hajiran, Dana C. Point, and Stanley Zaslau Copyright © 2013 Ali Hajiran et al. All rights reserved. A Case Report of Spontaneous Closure of a Posttraumatic Arterioportal Fistula Wed, 18 Dec 2013 14:01:15 +0000 As the indications for the nonoperative management (NOM) of hepatic injury have expanded, the incidence of complications of NOM has increased. Among such complications, arterioportal fistula (APF) formation is rare, although dangerous, due to the potential for portal hypertension. Embolization is performed in APF patients with clinical signs suggestive of portal hypertension. Meanwhile, no indications for treatment have been established in APF patients without symptoms, as the natural history of posttraumatic APF is not well understood. We herein report the case of a 35-year-old female with severe hepatic injury (Grade IV on the Organ Injury Scale of the American Association for the Surgery of Trauma) due to a traffic accident. Her hemodynamic state remained stable, and an enhanced CT scan obtained on admission showed no extravasation of contrast medium, pseudoaneurysm formation, or APF; therefore, NOM was selected. Although the patient’s physical condition was stable, an enhanced CT scan obtained 13 days after the injury showed APF in segment 8 of the liver. Although embolization was considered, the APF was not accompanied by portal dilatation suggestive of portal hypertension; hence, strict observation was selected. Consequently, follow-up CT performed on day 58 after the injury revealed spontaneous closure of the APF. Hirotada Kittaka, Hiroshi Akimoto, and Keitaro Tashiro Copyright © 2013 Hirotada Kittaka et al. All rights reserved. Gastric Lipoma Presenting with Massive Upper Gastrointestinal Bleeding Mon, 02 Dec 2013 09:42:09 +0000 A case of massive upper gastrointestinal bleeding in a 37-year-old female is presented showing a submucosal mass in the gastric body. At laparotomy a pedunculated submucosal mass was found located on the posterior wall at the junction of the body and antrum of the stomach, 8 cm from the pylorus. Pathology confirmed that it was a 4 cm benign gastric lipoma with a bleeding central ulcer. Gastric lipomas are rare, benign, typically submucosal tumors occurring in the gastric antrum. They are usually asymptomatic but can become symptomatic depending on size, location, and if there is ulceration of the lesion. These lesions may be mistaken as malignant tumors or present with upper GI bleeding or intussusception. The diagnosis can be made using a combination of upper endoscopy, endoscopic ultrasound, CT, and MRI with surgical excision being the definitive treatment of choice. We hope that this case highlights the fact that these lesions can present with massive upper GI haemorrhage and should be included in the diagnosis when appropriate. Michael J. Ramdass, Sanjana Mathur, Panduranga Seetahal-Maraj, and Shaheeba Barrow Copyright © 2013 Michael J. Ramdass et al. All rights reserved. Paediatric Orbital Fractures: The Importance of Regular Thorough Eye Assessment and Appropriate Referral Mon, 18 Nov 2013 16:08:59 +0000 The paediatric orbital fracture should always raise alarm bells to all clinicians working in an emergency department. A delay or failure in diagnosis and appropriate referral can result in rapidly developing and profound complications. We present a boy of childhood age who sustained trauma to his eye during a bicycle injury. Acceptance of the referral was based on no eye signs; however, on examination in our unit the eye had reduction in visual acuity, no pupillary reaction, and ophthalmoplegia. CT scan suggested bone impinging on the globe and the child was rushed to theatre for removal of the bony fragment. Postoperatively no improvement was noted and a diagnosis of traumatic optic neuropathy was made. An overview of factors complicating paediatric orbital injuries, their associated “red flags”, and appropriate referral are discussed in this short paper. Karim Kassam, Ishrat Rahim, and Caroline Mills Copyright © 2013 Karim Kassam et al. All rights reserved. Acute on Chronic Venous Thromboembolism on Therapeutic Anticoagulation Tue, 08 Oct 2013 18:20:16 +0000 A case of proximal venous thromboembolism in a patient who presented to the ED with lower extremity pain is presented. Making this diagnosis is very important as fifty percent of patients with symptomatic proximal DVTs will go on to develop PE without treatment. This report underscores the utility of bedside ultrasonography in the emergency department. Byron Bassi, L. Connor Nickels, F. Eike Flach, Guiliano DePortu, and Latha Ganti Copyright © 2013 Byron Bassi et al. All rights reserved. A Massive Posterior Neck Mass: Lipoma or Something More Sinister? Tue, 08 Oct 2013 10:49:39 +0000 Lipomas are slow-growing benign soft-tissue tumors which are typically asymptomatic and occur in approximately 1% of the population. A lipoma is considered to be of excessive size when it is greater than 10 cm in length (in any dimension) or weighs over 1000 g (Kransdorf (1995)). We describe a case of a man presenting with a giant posterior neck mass which greatly reduced the sagittal range of cervical spine. A discussion of the pathophysiology of lipomas and a literature review regarding giant lipomas versus malignancy follows. Matthew F. Ryan and Brandon Allen Copyright © 2013 Matthew F. Ryan and Brandon Allen. All rights reserved. Thrombogenic Catheter-Associated Superior Vena Cava Syndrome Tue, 01 Oct 2013 13:21:41 +0000 Superior vena cava syndrome has historically been associated with malignancy. With the increasing use of indwelling central lines, catheters, and pacemakers in the past decade, there have been an increasing number of cases associated with thrombosis rather than by direct external compression. Patients presenting to the ED with an acute process of SVC syndrome need to be assessed in a timely fashion. Computed tomography angiography (CTA) or magnetic resonance angiogram (MRA) are superb modalities for diagnosis and can quickly be used in the ED. Treatment is oriented towards the underlying cause of the syndrome. In cases of thrombogenic catheter-associated SVC syndrome, anticoagulation is the mainstay of treatment. We present a case report and discussion of a 56-year-old male with a history of metastatic colorectal cancer and an indwelling central venous port with acute signs and symptoms of superior vena cava syndrome. Imran Shaikh, Kenneth Berg, and Nicholas Kman Copyright © 2013 Imran Shaikh et al. All rights reserved. Acute Hemolysis in the Emergency Department: Think about Clostridium perfringens! Wed, 18 Sep 2013 15:28:48 +0000 Clostridium perfringens (CP) gives several clinical settings, from an asymptomatic to a massive intravascular hemolysis. We report a case of fatal intravascular hemolysis due to CP septicemia having a hepatic supposed starting point in the emergency department. Like in many cases, the diagnosis was made when patient had already gone into shock and died. The CP septicemia often complicated the course of the digestive or genital pathologies. The alpha toxin can damage the structural integrity of the red cell membrane by means of a phospholipase activity. Nevertheless, a massive intravascular hemolysis arises only rarely in this septicemia, only from 7 to 15% of the cases. The emergency physician has to think about this complication in case of hemoglobinuria and/or signs of hemolysis associated with a septic syndrome. An immediate antibiotic treatment adapted as well as the symptomatic treatment of the spread intravascular coagulation could improve the survival of these patients. Roustit Cécilia, Vallé Baptiste, Clouzeau Benjamin, Heydel Virginie, Valdenaire Guillaume, Revel Philippe, and Biais Matthieu Copyright © 2013 Roustit Cécilia et al. All rights reserved. The Use of Bedside Ultrasound in the Evaluation of Patients Presenting with Signs and Symptoms of Pulmonary Embolism Tue, 10 Sep 2013 15:36:56 +0000 Evaluation of patients that present to the emergency department with concerns for the diagnosis of pulmonary embolism can be difficult. Modalities including computerized tomography (CT) of the chest, pulmonary angiography, and ventilation perfusion scans can expose patients to large quantities of radiation especially if the study has to be repeated due to poor quality. This is particularly a concern in the pregnant population that has an increased incidence of pulmonary embolism and may not be able to undergo multiple radiographic studies due to fetal radiation exposure. This paper presents a case of a pregnant patient with signs and symptoms concerning pulmonary embolism. The paper discusses the use of bedside ultrasound in the evaluation of patients with pulmonary embolism. Adarsh N. Patel, L. Connor Nickels, F. Eike Flach, Giuliano De Portu, and Latha Ganti Copyright © 2013 Adarsh N. Patel et al. All rights reserved. Rapidly Developing Toxic Epidermal Necrolysis Tue, 27 Aug 2013 15:54:42 +0000 Severe cutaneous reactions with potentially fatal outcomes can have many different causes. The Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare. They are characterized by a low incidence but high mortality, and drugs are most commonly implicated. Urgent active therapy is required. Prompt recognition and withdrawal of suspect drug and rapid intervention can result in favourable outcome. No further international guidelines for treatment exist, and much of the treatment relies on old or experimental concepts with no scientific evidence. We report on a 54-year-old man experiencing rapidly developing drug-induced severe TEN and presented multiorgan failure involving the respiratory and circulatory system, coagulopathy, and renal insufficiency. Detachment counted 30% of total body surface area (TBSA). SCORTEN = 5, indicating a mortality rate >90%. The patient was sedated and mechanically ventilated, supported with fluids and inotropes to maintain a stable circulation. Component therapy was guided by thromboelastography (TEG). The patient received plasmapheresis, and shock reversal treatment was initiated. He was transferred to a specialized intensive care burn unit within 24 hours from admittance. The initial care was continued, and hemodialysis was started. Pulmonary, circulatory, and renal sequelae resolved with intensive care, and re-epithelialization progressed slowly. The patient was discharged home on hospital day 19. Viktoria Oline Barrios Poulsen, Jonas Nielsen, and Troels Dirch Poulsen Copyright © 2013 Viktoria Oline Barrios Poulsen et al. All rights reserved. Acute Liver Failure Associated with Levetiracetam and Lacosamide Combination Treatment for Unspecified Epileptic Disorder Tue, 20 Aug 2013 08:18:21 +0000 Background and Aim. Levetiracetam is a second-generation antiepileptic drug. It is approved as an adjunctive treatment of partial onset seizures with or without secondary generalization. It is considered safe with less than 1% of patients with transient elevations of liver enzymes. Methods. We report a case of acute liver failure secondary to Levetiracetam in combination with Lacosamide documented with a liver biopsy. Results. Liver biopsy demonstrated acute liver injury with a predominant submassive necrosis pattern and features of a drug-induced hepatitis. Conclusions. This is the first published case of acute liver failure due to antiepileptic therapy with Levetiracetam in combination with Lacosamide. Ylse Gutiérrez-Grobe, Jose Antonio Bahena-Gonzalez, Magali Herrera-Gomar, Pedro Mendoza-Diaz, Sandra García-López, and Octavio González-Chon Copyright © 2013 Ylse Gutiérrez-Grobe et al. All rights reserved. Chronic Neck Pain Associated with an Old Odontoid Fracture: A Rare Presentation Tue, 13 Aug 2013 11:10:41 +0000 Cervical spine injuries represent a minority of injury cases in motor vehicles accidents but are a real threat to a patient’s life. In the wide range of cervical spine injuries, odontoid (dens) fractures represent the most common findings. These fractures are more usually found in the elderly population due to the changes associated with age. Neurological deficit is not frequently found in these injuries. The following is a case presentation of a chronic odontoid fracture with neurological deficit in a young man that was discovered 23 years after he sustained a motor vehicle accident. Mauricio Avila-Guerra Copyright © 2013 Mauricio Avila-Guerra. All rights reserved. Two Cases of Accidental Injection of Epinephrine into a Digit Treated with Subcutaneous Phentolamine Injections Mon, 05 Aug 2013 11:38:44 +0000 Accidental injection into the digit from an epinephrine autoinjection device can cause discoloration, pain, and paresthesias. Although loss of digit is rare, treatment in the emergency department is commonly aimed at vasodilation of the affected tissue. We report two cases of accidental injection of epinephrine into the digits that were successfully treated with subcutaneous phentolamine injection with no adverse events. Ryan P. Bodkin, Nicole M. Acquisto, Holly Gunyan, and Timothy J. Wiegand Copyright © 2013 Ryan P. Bodkin et al. All rights reserved. Isolated Jejunal Perforation Following Bicycle Handlebar Injury in Adults: A Case Report Mon, 05 Aug 2013 08:59:57 +0000 The small intestine is the third in frequency intraperitoneal organ which is injured after blunt trauma of the abdomen. In most of the cases, this type of injuries is accompanied by other injuries, which make it more difficult to diagnose. Failure of diagnosis and delay in treating these injuries significantly increase the morbidity and mortality of these patients. Abdominal visceral injuries after flipping the handlebar of the bike are common in children. Such injuries can cause injury to both solid and hollow abdominal viscera. Unlike children, adults’ abdominal visceral injuries after flipping the bike’s handlebar are extremely rare. A 25-year-old man was admitted to our department due to progressively abdominal pain after an accident with the handlebar of his bike. The subsequent CT scan after per os administration of contrast medium revealed the presence of free intraperitoneal contrast. It is a rare case of jejunal perforation after flipping the handlebar of the bicycle which was treated by partial removal of the injured part of jejunum and end-to-end anastomosis. To the best of our knowledge this is the first time we describe such an injury with this mechanism to an adult. Kyriakos Neofytou, Maria Michailidou, Athanasios Petrou, Sakis Loizou, Charalampos Andreou, and Marios Pedonomou Copyright © 2013 Kyriakos Neofytou et al. All rights reserved. Lyme Carditis in an Immunocompromised Patient Thu, 01 Aug 2013 11:34:45 +0000 We present a case of a 68-year-old man with a history of liver transplant and of chronic immunosuppression therapy who presented to the emergency department (ED) for fevers and worsening fatigue for two days. On further investigation, the patient was found to have a new first-degree heart block on his electrocardiograph. Coupled with the history of a recent tick bite, the patient was diagnosed with vector-borne carditis. Although the patient’s titers for various vectors remained negative, due to a long history of immunosuppression, he was treated for Lyme disease and his heart block completely resolved with antibiotic treatment. We describe details of the case as well as discuss the impacts of immunosuppression on vector-borne disease. Immunosuppressed patients represent a special population and can present with chief complaints made even more complicated by their medical history, and this case illustrates the importance of being mindful of how immunosuppression can affect a patient’s presentation. As the efficacy of antirejection medications improved, the ED may see an increasing number of patients with solid organ transplants. A greater understanding of this special patient population is key to formulating optimal treatment plans. Matthew F. Ryan and Coben Thorn Copyright © 2013 Matthew F. Ryan and Cobin Thorn. All rights reserved.