Case Reports in Emergency Medicine The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. Knee Dislocation: A Case Report, Diagnostic Vascular Work-Up, and Literature Review Wed, 22 Feb 2017 09:53:15 +0000 Knee dislocation is an uncommon, potentially limb-threatening, knee injury. Most often caused by high-velocity trauma, it can also result from low- or even ultra-low-velocity trauma. Rapid identification of the injury, reduction, and definitive management are necessary to minimize neurovascular damage. We present a case of rotatory anterolateral knee dislocation sustained during a twisting sports-related event. Special emphasis is placed on diagnosing vascular injuries associated with knee dislocations. Matthijs R. Douma, Michael D. Burg, and Björn L. Dijkstra Copyright © 2017 Matthijs R. Douma et al. All rights reserved. Atypical Neuroleptic Malignant Syndrome Associated with Use of Clozapine Mon, 20 Feb 2017 07:45:28 +0000 The Neuroleptic Malignant Syndrome (NMS) is a medical emergency of infrequent presentation in the emergency department, which is associated with the use of psychiatric drugs, such as typical and atypical antipsychotics. Our case addresses a 55-year-old patient diagnosed with undifferentiated schizophrenia for 10 years, who had been receiving clozapine and clonazepam as part of their treatment. This patient presents the symptoms of Neuroleptic Malignant Syndrome without fever, which improves with treatment especially with the withdrawal of clozapine. In the absence of fever and clinical improvement, the patient is considered to have an atypical presentation of this disease. Quevedo-Florez Leonardo, Granada-Romero Juliana, and Camargo-Arenas Juan Fernando Copyright © 2017 Quevedo-Florez Leonardo et al. All rights reserved. Epistaxis as a Common Presenting Symptom of Glanzmann’s Thrombasthenia, a Rare Qualitative Platelet Disorder: Illustrative Case Examples Sun, 19 Feb 2017 00:00:00 +0000 Children often present to emergency departments (EDs) with uncontrollable nose bleeding. Although usually due to benign etiologies, epistaxis may be the presenting symptom of an inherited bleeding disorder. Whereas most bleeding disorders are detected through standard hematologic assessments, diagnosing rare platelet function disorders may be challenging. Here we present two case reports and review diagnostic and management challenges of platelet function disorders with a focus on Glanzmann’s thrombasthenia (GT). Patient 1 was a 4-year-old boy with uncontrolled epistaxis. His medical history included frequent and easy bruising. Previous laboratory evaluation revealed only mild microcytic anemia. An otolaryngologist stopped the bleeding, and referral to a pediatric hematologist led to the definitive diagnosis of GT. Patient 2 was a 2.5-year-old girl with severe epistaxis and a history of milder recurrent epistaxis. She had a bruise on her abdomen with a palpable hematoma and many scattered petechiae. Previous assessments revealed no demonstrable hemostatic anomalies. Platelet aggregation studies were performed following referral to a pediatric hematologist, leading to the diagnosis of GT. As evidenced by these cases, the ED physician may often be the first to evaluate severe or recurrent epistaxis and should recognize indications for coagulation testing and hematology consultation/referral for advanced hematologic assessments. Michael Recht, Meera Chitlur, Derek Lam, Syana Sarnaik, Madhvi Rajpurkar, David L. Cooper, and Sriya Gunawardena Copyright © 2017 Michael Recht et al. All rights reserved. Delayed Stroke following Blunt Neck Trauma: A Case Illustration with Recommendations for Diagnosis and Treatment Thu, 09 Feb 2017 06:37:41 +0000 Blunt cerebrovascular injury (BCVI) to the carotid artery is a relatively rare injury that is difficult to identify even with imaging. Any symptoms or neurological deficits following blunt neck injury mandate evaluation and consideration of BCVI. In an effort to highlight this issue, we report the case of a 31-year-old male patient who presented with left-sided weakness consistent with transient ischemic attack (TIA) and concussion. The patient’s symptoms occurred within 24 hours of a blunt neck injury sustained by a knee strike during a basketball game. An initial computerized tomography (CT) scan of the brain was normal; a CT angiogram (CTA) of the neck and carotids did not reveal obstruction, dissection, stenosis, or abnormalities of the carotid or vertebral vessels and the patient was subsequently discharged. A magnetic resonance imaging (MRI) of the brain obtained four days after the initial injury demonstrated an acute infarct in the right middle cerebral artery (MCA) territory. Thus, despite initial negative imaging, neurological deficits must be aggressively pursued in order to prevent stroke in BCVI cases. Best Anyama, Daniela Treitl, Jeffery Wessell, Rachele Solomon, and Andrew A. Rosenthal Copyright © 2017 Best Anyama et al. All rights reserved. Intracerebral Bleeding and Massive Pericardial Effusion as Presenting Symptoms of Myxedema Crisis Wed, 01 Feb 2017 13:00:13 +0000 The endocrinological emergency of a fully blown myxedema crisis can present as a multicolored clinical picture. This can obscure the underlying pathology and easily lead to mistakes in clinical diagnosis, work-up, and treatment. We present a case of an unconscious 39-year-old patient with a medical history of weakness, lethargy, and findings of hyponatremia, intracerebral bleeding, and massive pericardial effusion. Finally, myxedema crisis was diagnosed as underlying cause. Replacement therapy of thyroid hormone and conservative management of the intracerebral bleeding resulted in patient’s survival without significant neurological impairment. However, diagnostic pericardiocentesis resulted in life-threatening pericardial tamponade. It is of tremendous importance to diagnose myxoedema crisis early to avoid adverse health outcomes. M. Kirsch, C. Rimpau, C. H. Nickel, and P. Baier Copyright © 2017 M. Kirsch et al. All rights reserved. Ultrasound Utility in the Diagnosis of a Morel-Lavallée Lesion Wed, 01 Feb 2017 00:00:00 +0000 Morel-Lavallée lesions are uncommon injuries that can be associated with significant comorbidities if not detected early. Rapid diagnosis in the Emergency Department could significantly improve patient outcomes. We describe the diagnosis of such a lesion through the use of ultrasound imaging in the Emergency Department to utilize a fast, cost-effective imaging technique that does not subject the patient to radiation exposure. Our patient received surgical consultation but improved with conservative management. Ultrasound findings associated with this lesion do not require specialized equipment and should be considered when evaluating soft tissue lesions using point of care ultrasound. Scott LaTulip, Rameshwar R. Rao, Alan Sielaff, Nik Theyyunni, and John Burkhardt Copyright © 2017 Scott LaTulip et al. All rights reserved. Pseudoaneurysm of the Profunda Femoris Artery following Blunt Trauma Treated by Endovascular Coil Embolization: Review of Two Cases and Relevant Literature Thu, 26 Jan 2017 13:34:58 +0000 Profunda femoris artery (PFA) pseudoaneurysm after blunt trauma without associated femur fracture is a rare occurrence. Most of the reported cases of PFA pseudoaneurysm in the English literature developed after penetrating trauma, surgical procedures, and femur fractures. We present two such cases following blunt trauma and without any associated long bone injury. After initial imaging failed to show any long bone fracture, CT angiography confirmed pseudoaneurysm of the branch of the PFA. Both patients were then treated with emergent coil embolization of the bleeding vessel. Pseudoaneurysms typically present late and signs of persistent hip pain, thigh swelling, presence of a pulsatile mass, and even unexplained anemia all may suggest the diagnosis. Recognition of PFA pseudoaneurysm requires high index of suspicion and is often difficult to diagnose clinically because of its location. Saptarshi Biswas, Patrick McNerney, and Paul Kiproff Copyright © 2017 Saptarshi Biswas et al. All rights reserved. Idiopathic Renal Infarction Mimicking Appendicitis Sun, 22 Jan 2017 09:45:04 +0000 Renal infarction is a rare cause of referral to the emergency department, with very low estimated incidence (0.004%–0.007%). Usually, it manifests in patients aged 60–70 with risk factors for thromboembolism, mostly related to heart disease, atrial fibrillation in particular. We report a case of idiopathic segmental renal infarction in a 38-year-old patient, presenting with acute abdominal pain with no previous known history or risk factors for thromboembolic diseases. Because of its aspecific clinical presentation, this condition can mimic more frequent pathologies including pyelonephritis, nephrolithiasis, or as in our case appendicitis. Here we highlight the extremely ambiguous presentation of renal infarct and the importance for clinicians to be aware of this condition, particularly in patients without clear risk factors, as it usually has a good prognosis after appropriate anticoagulant therapy. Marco Di Serafino, Rosa Severino, Chiara Gullotto, Francesco Lisanti, and Enrico Scarano Copyright © 2017 Marco Di Serafino et al. All rights reserved. Cerebral Salt-Wasting Syndrome Caused by Minor Head Injury Tue, 17 Jan 2017 12:45:55 +0000 A 34-year-old woman was admitted to hospital after sustaining a head injury in a motor vehicle accident (day 1). No signs of neurological deficit, skull fracture, brain contusion, or intracranial bleeding were evident. She was discharged without symptoms on day 4. However, headache and nausea worsened on day 8, at which time serum sodium level was noted to be 121 mEq/L. Treatment with sodium chloride was initiated, but serum sodium decreased to 116 mEq/L on day 9. Body weight decreased in proportion to the decrease in serum sodium. Cerebral salt-wasting syndrome was diagnosed. This case represents the first illustration of severe hyponatremia related to cerebral salt-wasting syndrome caused by a minor head injury. Toshiki Fukuoka, Yuko Tsurumi, and Arihito Tsurumi Copyright © 2017 Toshiki Fukuoka et al. All rights reserved. Evaluating Complications of Chronic Sinusitis Mon, 09 Jan 2017 12:32:28 +0000 Chronic sinusitis is a relatively common diagnosis throughout the US. In patients with an otherwise unremarkable medical history the treatment is typically supportive, requiring only clinical evaluation. We present the case of a 25-year-old male with a history of chronic sinusitis that was brought to our emergency department with new-onset seizure. Three days before he had presented to his usual care facility with two days of headache and fever and was discharged stating headache, subjective fever, and neck stiffness. After further investigation he was diagnosed with a mixed anaerobic epidural abscess. The evaluation and management of chronic sinusitis are based on the presence of symptoms concerning for complication. Prompt investigation of complicated sinusitis is essential in preventing debilitating and fatal sequelae. Our case study underscores the importance of early diagnosis and appropriate management. Phillip Hong, Charles A. Pereyra, Uta Guo, Adam Breslin, and Laura Melville Copyright © 2017 Phillip Hong et al. All rights reserved. Congenital Diaphragmatic Hernia Presenting in a 7-Day-Old Infant Wed, 04 Jan 2017 11:38:09 +0000 A 7-day-old male infant presented to the emergency room after respiratory distress was noted at an outpatient well child check. On exam, he was observed to have tachypnea, increased work of breathing, and decreased breath sounds on the left side of the chest. On chest X-ray, he was found to have a left-sided congenital diaphragmatic hernia. The infant was transported to a tertiary care facility where the defect was repaired without complication. Interestingly, the mother had a history of a normal antenatal ultrasound, completed at 19 + 2 weeks of gestational age. This case report summarizes the challenges of diagnosing late-presenting congenital diaphragmatic hernia, associated malformations, possible etiologies, and prognosis. Christopher Rouse, Luke Schmidt, Lee Brock, and Angela Fagiana Copyright © 2017 Christopher Rouse et al. All rights reserved. Spontaneous Isolated Visceral Artery Dissection in a Middle Aged Male Sun, 01 Jan 2017 13:25:46 +0000 Epigastric pain is a common complaint made by patients being evaluated in the emergency department. Spontaneous isolated visceral artery dissection is a rare cause with no reported prevalence. We present a case of a 37-year-old male evaluated in the emergency department for epigastric pain and subsequently diagnosed with a spontaneous isolated celiac artery dissection with involvement of the hepatic and splenic arteries. Recent case series suggest this disease may be managed medically in most cases. Surgical intervention may be considered for significant bleeding or signs of intestinal ischemia. Eric Melnychuk and Robert Strony Copyright © 2017 Eric Melnychuk and Robert Strony. All rights reserved. Death by Disimpaction: A Bradycardic Arrest Secondary to Rectal Manipulation Wed, 28 Dec 2016 12:04:15 +0000 Rectal examination and fecal disimpaction are common procedures performed in the Emergency Department on a daily basis. Here, we report a rare case of a patient suffering a cardiac arrest and ultimately death likely due to rectal manipulation. A 66-year-old male presented to the Emergency Department (ED) with a complaint of abdominal distention and constipation. A rectal exam was performed. During the examination the patient became apneic. On the cardiac monitor the patient was found to be in pulseless electrical activity with a bradycardic rate. Our recommendation would be to provide adequate analgesia and close patient monitoring of those undergoing this procedure especially patients with significant stool burdens. Christopher S. Sampson and Cory M. Shea Copyright © 2016 Christopher S. Sampson and Cory M. Shea. All rights reserved. Frontal Mucocele following Previous Facial Trauma with Hardware Reconstruction Mon, 28 Nov 2016 12:33:23 +0000 Mucoceles are cysts that can develop after facial bone fractures, especially those involving the frontal sinuses. Despite being rare, mucoceles can result in serious delayed sequelae. We present a case of a frontal mucocele that developed two years after extensive facial trauma following a motor vehicle crash (MVC) and review the emergency department (ED) evaluation and treatment of mucocele. Early recognition, appropriate imaging, and an interdisciplinary approach are essential for managing these rare sequelae of facial trauma. Megan EuDaly and Chadd K. Kraus Copyright © 2016 Megan EuDaly and Chadd K. Kraus. All rights reserved. Superior Mesenteric Artery Syndrome with Abdominal Compartment Syndrome Sun, 27 Nov 2016 12:07:51 +0000 Superior Mesenteric Artery (SMA) syndrome is a condition in which the duodenum becomes compressed between the SMA and the aorta, resulting in bowel obstruction which subsequently compresses surrounding structures. Pressure on the inferior vena cava (IVC) and aorta decreases cardiac output which compromises distal blood flow, resulting in abdominal compartment syndrome with ischemia and renal failure. A 15-year-old male with SMA syndrome presented with 12 hours of pain, a distended, rigid abdomen, mottled skin below the waist, and decreased motor and sensory function in the lower extremities. Exploratory laparotomy revealed ischemic small bowel and stomach with abdominal compartment syndrome. Despite decompression, the patient arrested from hyperkalemia following reperfusion. Kevin Reece, Rachel Day, and Janna Welch Copyright © 2016 Kevin Reece et al. All rights reserved. Tuberculosis and Migration: A Challenge for Medical Staff and Public Health Mon, 14 Nov 2016 11:06:53 +0000 A high number of asylum seekers enter Switzerland every year. They often originate from countries with a high TB prevalence. Our patient from Somalia presented with 2 lipoma-like tumors with pain on palpation on his left chest wall but no symptoms including coughing, fever, night-sweats, or loss of weight. CT scan then showed diffuse infiltrations of his lung and multiple abscesses on his left chest wall. Therefore contagious tuberculosis (TB) was suspected and the patient was put in isolation. In the follow-up the diagnosis of open TB was proofed with bronchial secretion and EBUS-guided biopsy that showed acid-fast rods. This particular case shows how difficult the identification of patients with open TB can be, especially if there are no respiratory or systemic symptoms. Therefore awareness of possible infectious disease is paramount for ED Doctors treating patients from countries with high prevalence. Early and strict isolation measures can help to reduce risk of contagion among staff and patients. Ines Griesshammer, David Shiva Srivastava, Christophe von Garnier, Till Silvan Blaser, Aris Exadaktylos, and Moritz Steib Copyright © 2016 Ines Griesshammer et al. All rights reserved. Congenital Renal Fusion and Ectopia in the Trauma Patient Tue, 08 Nov 2016 08:38:35 +0000 We present two separate cases of young male patients with congenital kidney anomalies (horseshoe and crossed fused renal ectopia) identified following blunt abdominal trauma. Despite being rare, ectopic and fusion anomalies of the kidneys are occasionally noted in a trauma patient during imaging or upon exploration of the abdomen. Incidental renal findings may influence the management of traumatic injuries to preserve and protect the patient’s renal function. Renal anomalies may be asymptomatic or present with hematuria, flank or abdominal pain, hypotension, or shock, even following minor blunt trauma or low velocity impact. It is important for the trauma clinician to recognize that this group of congenital anomalies may contribute to unusual symptoms such as gross hematuria after minor trauma, are readily identifiable during CT imaging, and may affect operative management. These patients should be informed of their anatomical findings and encouraged to return for long-term follow-up. Andrew A. Rosenthal, Jordan J. Ditchek, Seong K. Lee, Rafael Sanchez, Chauniqua Kiffin, Dafney L. Davare, and Eddy H. Carrillo Copyright © 2016 Andrew A. Rosenthal et al. All rights reserved. Acute Paraplegia as a Presentation of Aortic Saddle Embolism Sun, 16 Oct 2016 15:45:16 +0000 Background. Acute onset paraplegia has a myriad of causes most often of a nonvascular origin. Vascular etiologies are infrequent causes and most often associated with postsurgical complications. Objective. To describe the occurrence and possible mechanism for aortic saddle embolism as a rare cause of acute paraplegia. Case Report. Described is a case of a 46-year-old female who presented with the sudden onset of nontraumatic low back pain with rapidly progressive paraplegia which was subsequently determined to be of vascular origin. Lisandro Irizarry, Anton Wray, and Kim Guishard Copyright © 2016 Lisandro Irizarry et al. All rights reserved. Tibiofibula Transposition in High-Energy Fractures Tue, 11 Oct 2016 06:32:00 +0000 We report two cases of failed attempts at closed reduction of high-energy tibial fractures with an associated fibula fracture. The first case was a 39-year-old male involved in high-speed motorbike collision, while the second was a 14-year-old male who injured his leg following a fall of three metres. Emergency medical services at the scenes of the accidents reported a 90-degree valgus deformity of the injured limb and both limbs were realigned on scene and stabilized. Adequate alignment of the tibia could not be achieved by manipulation under sedation or anaesthesia. Open reduction and exposure of the fracture sites revealed that the distal fibula fragment was “transposed” and entrapped in the medulla of the proximal tibial fragment. Reduction required simulation of the mechanism of injury in order to disengage the fragments and allow reduction. Tibiofibula transposition is a rare complication of high-energy lower limb fractures which has not previously been reported and may prevent adequate closed reduction. Impaction of the distal fibula within the tibial medulla occurs as the limb is realigned by paramedic staff before transfer to hospital. We recommend that when this complication is identified the patient is transferred to the operating room for open reduction and stabilization of the fracture. Peter R. Loughenbury, Rebecca A. Gledhill, and Nick Evans Copyright © 2016 Peter R. Loughenbury et al. All rights reserved. Clinical Heterogeneity of Guillain-Barré Syndrome in the Emergency Department: Impact on Clinical Outcome Tue, 27 Sep 2016 08:37:51 +0000 Guillain-Barré syndrome (GBS) is mainly classified into acute inflammatory demyelinating polyneuropathy (AIDP) and acute motor axonal neuropathy (AMAN). Although diagnosis of GBS requires progressive weakness and universal areflexia or hyporeflexia, cases of GBS with preserved or increased deep tendon reflexes (DTRs) have been increasingly recognized. We report three cases of GBS, presenting at a single unit in six months. Our first case presented with pure sensory symptoms. The second case had nonspecific generalized weakness, while the third presented with typical ascending weakness. One of our patients had preserved DTRs, while the other two had increased DTRs. Our two cases with hyperreflexia were found to have a preceding Campylobacter jejuni infection and anti-ganglioside antibodies, and their electrophysiological studies revealed AMAN. The other case had an AIDP. Only one case was offered a diagnosis and treatment from the first emergency department (ED) visit and had a better clinical outcome. Clinical diagnosis of GBS in the ED can be challenging. Delay in diagnosis of GBS in the ED is common due to cases with intact or increased DTRs, atypical pattern of weakness, or pure sensory symptoms. Emergency physicians should be aware of GBS clinical heterogeneity, because early diagnosis and treatment improve clinical outcome. Athanasios Papathanasiou and Ioannis Markakis Copyright © 2016 Athanasios Papathanasiou and Ioannis Markakis. All rights reserved. Conservative Treatment of Carpometacarpal Dislocation of the Three Last Fingers Wed, 14 Sep 2016 14:02:12 +0000 Posterior carpometacarpal (CMC) dislocation is a rare condition. Treatment is usually surgical though no strict consensus can be found upon literature review. If diagnosed early and no associated fractures are found, CMC dislocation could benefit from conservative treatment comprising closed reduction and splint immobilisation. We report the case of a 26-year-old man diagnosed with a posterior dislocation of the third, fourth, and fifth CMC joints after a fall of 1.5 meters, treated by external reduction under procedural sedation and immobilisation with a cast for 6 weeks. Evolution was excellent with no relapse observed during follow-up. Our aim is to increase physician awareness of CMC dislocation so that they seek this injury in the emergency department. Unrecognised CMC dislocation can lead to neurovascular injuries as well as chronic instability and early articular degeneration. Hélène Jumeau, Philippe Lechien, and Florence Dupriez Copyright © 2016 Hélène Jumeau et al. All rights reserved. A Ruptured Ectopic Pregnancy Presenting with a Negative Urine Pregnancy Test Wed, 07 Sep 2016 10:08:51 +0000 A negative urine pregnancy test in the emergency department traditionally excludes the diagnosis of pregnancy. We report a rare case of ruptured ectopic pregnancy in a patient with a negative urine pregnancy test but with a serum beta-human chorionic gonadotropin (β-hCG) of 10 mIU/mL. The patient developed hemoperitoneum and required laparoscopy by Obstetrics and Gynecology (OB/Gyn). This case highlights the fallibility of the urine pregnancy test in diagnosing early pregnancy. Johnathan Michael Sheele, Rachel Bernstein, and Francis L. Counselman Copyright © 2016 Johnathan Michael Sheele et al. All rights reserved. Spider Bite: A Rare Case of Acute Necrotic Arachnidism with Rapid and Fatal Evolution Mon, 29 Aug 2016 13:11:28 +0000 The spider bites are quite frequent and often resolve quickly without leaving outcomes; only some species are capable of causing necrotic and systematic lesions in humans. Among them, we should mention the genus Loxosceles. The venom released from the spider bite of Loxosceles species is composed of proteins, enzymes, and nonenzymatic polypeptides. The phospholipase D family was identified as the active component of the venom. This family of enzymes is responsible for the local and systemic effects observed in loxoscelism. Phospholipases D interact with cell membranes triggering alterations which involve the complement system and activation of neutrophils and they cause the dermonecrotic skin lesions and systemic effects. We describe a fatal case of acute intoxication caused by a spider bite probably belonging to the species Loxosceles. The initial lesion was localized to a finger of a hand. Clinical course was worsening with deep necrotic lesions on limb, shock, hemolysis, acute kidney failure, and disseminated intravascular coagulation. All therapies were ineffective. This is the first fatal case described in Europe. Mario Pezzi, Anna Maria Giglio, Annamaria Scozzafava, Orazio Filippelli, Giuseppe Serafino, and Mario Verre Copyright © 2016 Mario Pezzi et al. All rights reserved. Pulmonary Embolism Presenting as Abdominal Pain: An Atypical Presentation of a Common Diagnosis Wed, 24 Aug 2016 17:58:10 +0000 Pulmonary embolism (PE) is a frequent diagnosis made in the emergency department and can present in many different ways. Abdominal pain is an unusual presenting symptom for PE. It is essential to maintain a high degree of suspicion in these patients, as a delay in diagnosis can be devastating for the patient and confers a high risk of mortality if left untreated. Here, we report the case of a 53-year-old male who presented to the emergency department with worsening right upper quadrant abdominal pain with fevers. Initial imaging was benign, although lab work showed worsening leukocytosis and bilirubin. Abdominal pathology seemed most likely, but the team kept PE on the differential. Further imaging revealed acute pulmonary embolus in the segmental branch of the right lower lobe extending distally into subsegmental branches. The patient was started on anticoagulation and improved drastically. This case highlights the necessity of keeping a broad differential and maintaining a systematic approach when dealing with nonspecific complaints. Furthermore, a discussion on the pathophysiology on why PE can present atypically as abdominal pain, as well as fevers, is reviewed. Using this information can hopefully lead to a subtle diagnosis of PE in the future and lead to a life-saving diagnosis. Hasan Rehman, Elizabeth John, and Payal Parikh Copyright © 2016 Hasan Rehman et al. All rights reserved. Lyme Disease Presenting with Multiple Cranial Nerve Deficits: Report of a Case Sun, 21 Aug 2016 14:05:18 +0000 Lyme disease is a tick-transmitted multisystem inflammatory disease caused by the spirochete Borrelia burgdorferi. With more than 25,000 CDC reported cases annually, it has become the most common vector-borne disease in the United States. We report a case of 38-year-old man with Lyme disease presenting with simultaneous palsy of 3rd, 5th, 7th, 9th, and 10th cranial nerves. Abhishek Chaturvedi, Keith Baker, Donald Jeanmonod, and Rebecca Jeanmonod Copyright © 2016 Abhishek Chaturvedi et al. All rights reserved. Necrotizing Fasciitis Presenting as an Itchy Thigh Thu, 04 Aug 2016 13:27:45 +0000 We present a case of necrotizing fasciitis diagnosed in the emergency department. The clinical presentation and diagnostic findings of necrotizing fasciitis are discussed. Thor Shiva Stead and V. Shushrutha Hedna Copyright © 2016 Thor Shiva Stead and V. Shushrutha Hedna. All rights reserved. Severe Methemoglobinemia due to Sodium Nitrite Poisoning Wed, 03 Aug 2016 08:14:24 +0000 Case. We report a case of severe methemoglobinemia due to sodium nitrite poisoning. A 28-year-old man was brought to our emergency department because of transient loss of consciousness and cyanosis. He was immediately intubated and ventilated with 100% oxygen. A blood test revealed a methemoglobin level of 92.5%. Outcome. We treated the patient with gastric lavage, activated charcoal, and methylene blue (2 mg/kg) administered intravenously. Soon after receiving methylene blue, his cyanosis resolved and the methemoglobin level began to decrease. After relocation to the intensive care unit, his consciousness improved and he could recall ingesting approximately 15 g sodium nitrite about 1 hour before he was brought to our hospital. The patient was discharged on day 7 without neurologic impairment. Conclusion. Severe methemoglobinemia may be fatal. Therefore, accurate diagnosis of methemoglobinemia is very important so that treatment can be started as soon as possible. Kenichi Katabami, Mineji Hayakawa, and Satoshi Gando Copyright © 2016 Kenichi Katabami et al. All rights reserved. Ultrasound-Guided Forearm Nerve Blocks: A Novel Application for Pain Control in Adult Patients with Digit Injuries Sun, 31 Jul 2016 06:39:20 +0000 Phalanx fractures and interphalangeal joint dislocations commonly present to the emergency department. Although these orthopedic injuries are not complex, the four-point digital block used for anesthesia during the reduction can be painful. Additionally, cases requiring prolonged manipulation or consultation for adequate reduction may require repeat blockade. This case series reports four patients presenting after mechanical injuries resulting in phalanx fracture or interphalangeal joint dislocations. These patients received an ultrasound-guided peripheral nerve block of the forearm with successful subsequent reduction. To our knowledge, use of ultrasound-guided peripheral nerve blocks of the forearm for anesthesia in reduction of upper extremity digit injuries in adult patients in the emergency department setting has not been described before. Richard Amini, Parisa Patricia Javedani, Albert Amini, and Srikar Adhikari Copyright © 2016 Richard Amini et al. All rights reserved. Posttraumatic Haematuria with Pseudorenal Failure: A Diagnostic Lead for Intraperitoneal Bladder Rupture Thu, 28 Jul 2016 10:57:58 +0000 Bladder rupture is a very morbid injury following blunt or penetrating lower abdominal trauma. Prompt diagnosis is crucial to initiate optimal treatment. Intraperitoneal bladder rupture is associated with haematuria and biochemical features of renal failure. Cystogram is diagnostic. Immediate open surgical repair is the main stay of treatment. A case of intraperitoneal rupture diagnosed preoperatively by the presence of haematuria and pseudorenal failure is presented to highlight the association of posttraumatic haematuria and pseudorenal failure in such injuries. Ketan Vagholkar and Suvarna Vagholkar Copyright © 2016 Ketan Vagholkar and Suvarna Vagholkar. All rights reserved. Reversal of Dabigatran Using Idarucizumab in a Septic Patient with Impaired Kidney Function in Real-Life Practice Wed, 27 Jul 2016 12:01:47 +0000 Background. Immediate reversal of anticoagulation is essential when facing severe bleeding or emergency surgery. Although idarucizumab is approved for the reversal of dabigatran in many countries, clinical experiences are lacking, particularly in special patient-populations such as sepsis and impaired renal function. Case Presentation. We present the case of a 67-year-old male septic patient with a multilocular facial abscess and chronic kidney disease (GFR 36.5 mL/min). Thrombin time (TT) and activated partial thromboplastin time (aPTT) 15 hours after the last intake of 150 mg dabigatran were both prolonged (>120 sec, resp., 61 sec), as well as unbound dabigatran concentration (119.05 ng/mL). Before immediate emergency surgery dabigatran was antagonised using idarucizumab 2 × 2.5 g. Dabigatran concentration was not detectable 10 min after idarucizumab administration (<30 ng/mL). TT and aPTT time were normalised (16.2 sec, resp., 30.2 sec). Sepsis was controlled after surgery and kidney function remained stable. In the absence of postoperative bleeding, dabigatran was restarted 36 hours after admission. Conclusion. Idarucizumab successfully reversed the effect of dabigatran in real-life practice in a patient with sepsis and renal impairment and allowed emergency surgery with normal haemostasis. Efficacy and safety in real-life practice will nevertheless require prospective registries monitoring. Thomas C. Sauter, Sina Blum, Michael Nagler, Fabian L. Schlittler, Meret E. Ricklin, and Aristomenis K. Exadaktylos Copyright © 2016 Thomas C. Sauter et al. All rights reserved.