Case Reports in Emergency Medicine

Background. Tranexamic acid (TXA) is routinely administered intravenously (IV) and intraosseously (IO) in response to exsanguination. Case. This report describes a patient who sustained multiple high-powered rifle gunshot wounds that received battlefield-environment intramuscular (IM) administration of TXA due to inability to obtain IV / IO access. This case represents the unlikely positive outcome in the setting of multiple remarkable obstacles, which may have been ameliorated by novel administration of TXA. Conclusion. Cases of IM TXA administration as a primary intervention are not well represented in the current body of medical literature. This case report highlights a clinical scenario where IM TXA was utilized as part of first-line treatment that led to a positive clinical outcome. Although IM TXA is not yet endorsed by current trauma guidelines, this case suggests that IM route administration of TXA should be further investigated. If indeed IM administration of TXA proves just as efficacious as alternative routes, this would hold considerable advantageous implications for austere situations were sterility and IV / IO placement are impractical. This would also represent another avenue by which to decrease the time-to-TXA for patients, allowing sooner correction of hemorrhage and trauma-associated coagulopathy.

The violent nature of generalized tonic-clonic seizures puts individuals at risk of a large number of potential injuries. These can occur due both to the profound muscular contractions that accompany these episodes as well as falls and other traumatic events that occur due to the period of loss of consciousness that occurs during generalized seizures. While injuries such as soft tissue contusions, tongue biting, dental injuries, and facial lacerations resulting from falls from standing predominate, bony injuries are not uncommon. We present a case of bilateral scapular fractures that occurred in an otherwise healthy 32-year male who presented with shoulder and back pain and inability to perform any significant movement of his upper arms secondary to pain after experiencing an apparent first-time generalized tonic-clonic seizure. The presence of unilateral and bilateral scapular fractures, while uncommonly described, should be considered as an additional potential orthopedic injury that may occur secondary to a generalized tonic-clonic seizure. In the absence of observed significant forceful traumatic injury, this injury is unusual, and its presence noted in a patient experiencing sudden loss of consciousness should raise heightened concern of seizures as the potential etiology.

Ectopic pregnancies develop outside of the uterus and lead to significant maternal morbidity and mortality if they rupture. As the primary diagnostic tool for these presentations, ultrasound has a growing list of signs and measurements that help distinguish between intrauterine and ectopic pregnancies, the latter being exceedingly rare once a woman has entered her second trimester. The present case reports a series of Emergency Department visits by a woman carrying a second-trimester pregnancy—deemed intrauterine on transabdominal ultrasound due to gestational age and location—who developed massive hemoperitoneum and was diagnosed with a ruptured 15-week tubo-ovarian pregnancy on laparotomy. The discussion describes the sonographic findings that could have helped make the proper diagnosis, most notably mantle distance—the thickness of the myometrium surrounding the gestational sac—which would have correctly identified this pregnancy as ectopic.

Acute aortic occlusion (AAO) is a rare and life-threatening condition that is rarely described in limited case series over the past several decades. The etiology and management are diverse across documented accounts, but prompt recognition facilitated by performing a thorough vascular and neurologic exam is critical to prevent delayed diagnosis and adverse outcomes. We report a patient who presented to the emergency department with the complaint of acute-onset lower extremity paralysis due to acute aortic occlusion. Her condition was rapidly diagnosed with a CT angiogram protocolized for aortic dissection and managed with anticoagulation and thrombectomy with eventual near complete recovery of her lower extremity function.

Cerebral arterial gas embolism (CAGE) is a rare but serious cause for acute neurologic deficit that occurs most often in divers who breathe compressed gas at depth or iatrogenically from a variety of invasive medical procedures. We present a rare case of CAGE caused by inhaling helium from an unregulated, high-pressure gas cylinder. Following inhalation, the patient experienced loss of consciousness, neurologic deficits, pneumomediastinum, and pneumothorax requiring transfer and treatment at a hyperbaric facility with resulting resolution of neurologic symptoms. This case highlights the importance of rapid diagnosis and hyperbaric oxygen treatment (HBO), facilitated by close coordination among community emergency departments, pediatric tertiary care centers, hyperbaric facilities, and poison control.

Transvaginal small bowel evisceration is a rare surgical emergency that requires urgent surgery to prevent bowel necrosis, sepsis, and death. It was first reported in 1864 by Hyernaux with less than 100 cases reported since the original publication. The overall mortality rate is reported as 5.6 percent. We present the case of a 49-year-old woman who presented to the emergency department with a chief complaint of moderate abdominal pain and vaginal bleeding for 1 hour. The patient reported that she underwent a robotic-assisted laparoscopic hysterectomy 11 weeks prior for uterine fibroids. Visual examination revealed a loop of the small bowel coming from the superior aspect of her vagina. Literature reviews have noted a higher incidence of dehiscence following robotic-assisted total laparoscopic hysterectomy. It is important for the emergency physician to make the diagnosis, initiate prompt consultation with departments of obstetrics and gynecology and general surgery, and treat for potential infection.