Clinical Practice and Cases in Emergency Medicine

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Introduction: Pneumothoraces are frequently treated by emergency physicians. Tube thoracostomy, the definitive treatment for a spontaneous pneumothorax, is associated with significant pain. Analgesia prior to tube thoracostomy often involves the administration of opioids and local infiltration of anesthetics. Thus far, regional anesthesia prior to pigtail tube thoracostomy in the emergency department (ED) has not been well described; it offers promise in alleviating pain associated with this procedure. Due to its ability to anesthetize all or most of the structures associated with tube thoracostomy—skin, serratus anterior muscles, intercostal muscles, and the parietal pleura—the serratus anterior plane block (SAPB) is a potentially promising fascial plane block prior to pigtail tube thoracostomy.

Case Series: We present three cases of patients in the ED who received a SAPB and had nearly complete or complete anesthesia during pigtail tube thoracostomy.

Conclusion: Pigtail tube thoracostomies are commonly performed in the ED and can be associated with significant pain despite a multimodal approach to pain management. The SAPB offers a safe and effective approach to anesthesia for patients in the ED undergoing a pigtail tube thoracostomy.

Introduction: Lower extremity injuries are commonly evaluated and treated in the emergency department (ED). Pain management for these injuries often consists of acetaminophen, non-steroidal anti-inflammatories, and opioids. Despite this treatment regimen, adequate analgesia is not always achieved.

Case Report: A 38-year-old man presented to the ED with a non-displaced tibia-fibula fracture. The patient did not attain analgesia with intravenous medications but did get complete anesthesia of his lower leg with a combination saphenous and popliteal sciatic nerve block.

Conclusion: Emergency physicians possess the skill set required to effectively perform a saphenous and popliteal sciatic nerve block and should consider adding this procedure to their armamentarium of pain management techniques in treating injuries distal to the knee.

Introduction: Emergency physicians frequently manage anterior shoulder dislocations (ASD). While there are many effective methods to reduce an ASD, adequate analgesia is imperative.

Case Series: We used the supraclavicular brachial plexus (SBP) block to reduce ASD in three patients.

Conclusion: The SBP block reliably anesthetizes the entire upper extremity, including the shoulder, by targeting all trunks and divisions of the brachial plexus. Complications are rare. Considering its ease of implementation and paucity of complications, the SBP block may be an effective means for reducing ASD.

Introduction: A pericapsular nerve group (PENG) block is unique compared to other regional anesthetic techniques (femoral nerve and fascia iliaca blocks) because it is a motor-sparing block. It also provides anesthesia to more nerves that innervate the anterior capsule of the femoroacetabular joint when compared to the femoral nerve and fascia iliaca blocks. Additionally, regional anesthesia carries fewer risks and requires less resources when compared with procedural sedation, which is the typical method for reducing a dislocated femoroacetabular joint.

Case Report: We describe a novel case in which a PENG block was used in the emergency department (ED) to reduce a prosthetic hip dislocation.

Conclusion: The PENG block is a safe and effective method of achieving sufficient analgesia to reduce prosthetic hips in the ED.

Introduction: Takotsubo syndrome (TTS) expresses transient wall motion abnormality of the left ventricle, reportedly induced by sympathetic overstimulation. Takotsubo syndrome is unlikely to be included in the differential diagnosis of heart transplant patients with sudden cardiac dysfunction given the complete denervation occurring during the transplantation.  

Case Report: In this case report we describe the case of a female heart transplant recipient who showed apical ballooning on an echocardiogram following status epilepticus. Detailed clinical examinations and her clinical course confirmed the diagnosis of TTS. An iodine-123 meta iodobenzylguanidine myocardial scintigraphy revealed partial cardiac sympathetic reinnervation in the transplanted heart.  

Conclusion: This case demonstrates that TTS can manifest itself even in a transplanted heart with partial sympathetic reinnervation.

Introduction: Hereditary angioedema (HAE) is a genetic disorder associated with recurrent episodes of angioedema in the absence of urticaria and pruritus. Hereditary angioedema is inherited in an autosomal dominant pattern and results in a quantitative deficiency (HAE type I) or dysfunction (HAE type II) of the C1-esterase inhibitor (C1-INH) protein. A very rare third type of HAE which is associated with normal quantitative and functional levels of C1-INH (HAE-nl-C1-INH) has been described.

Case Report: A 54-year-old female with past medical history significant for HAE-nl-C1-INH presented to the emergency department (ED) for an acute attack of HAE and seizures. The patient arrived postictal after experiencing a total of three witnessed seizures, each lasting approximately 30 seconds. After the initial seizure was witnessed in the ED, the patient received 4200 Units of recombinant C1-INH intravenously. The patient’s mental status did not return to baseline, and she experienced two additional seizures. She was given a dose of the kallikrein inhibitor, ecallantide, as well as standard dosing of lorazepam and levetiracetam. The patient returned to her baseline and had no subsequent seizures while in the ED. Inpatient work-up included continuous video electroencephalography monitoring and magnetic resonance imaging of the brain, both of which were normal. The remainder of the inpatient course was
uncomplicated, and the patient was discharged home neurologically intact.

Conclusion: We present a case of status epilepticus in a patient with HAE-nl-C1-INH. The focus of emergent medical management of status epilepticus includes airway protection, respiratory support, and administration of abortive and prophylactic antiepileptic drugs. The emergency medicine physician should also consider and treat possible underlying etiologies. The treatment of an acute attack of HAE should focus on replacing C1-INH and preventing the formation and limiting the action of bradykinin.

Introduction: Tics in children are commonly diagnosed and not usually a cause for concern. Rarely, they may present as a symptom of underlying intracranial pathology.

Case Report: We describe an adolescent with sudden-onset tics following a fall who presented to the emergency department and was diagnosed with an arteriovenous malformation with parenchymal hemorrhage. He underwent a successful embolization, after which his tics resolved.

Conclusion: When evaluating a patient with tics, an atypical history or abnormal physical exam findings should raise suspicion for possible secondary etiologies, including arteriovenous malformation and stroke.

Introduction: Calcium channel blocker (CCB) and beta blocker (BB) overdoses are life-threatening conditions that can lead to vasoplegic and cardiogenic shock. Treatment involves a combination of vasopressors, calcium, glucagon, and/or high-dose insulin euglycemia therapy. The most severe overdoses may require venoarterial extracorporeal membrane oxygenation (VA-ECMO), which often results in interfacility transfers. This report describes two successful VA-ECMO transfers for refractory CCB/BB overdose.

Case Reports: Case 1: A 56-year-old male developed severe hypotension after ingesting 40-45 tablets of 10 milligram (mg) amlodipine tablets. After initial treatment approaches were unsuccessful, an early interdisciplinary discussion facilitated timely cannulation at the initial facility and quick transfer for VA-ECMO initiation. The patient was discharged at his neurological baseline after 60 days. Case 2: A 19-year-old female presented to the emergency department after a polypharmacy ingestion including 60 tablets of 20 mg propranolol. An early interdisciplinary discussion between the medical intensive care unit, medical toxicology, and the ECMO team allowed for prompt transfer directly to the receiving hospital catheterization lab for VA-ECMO within three hours of the initial presentation. The patient was discharged to an inpatient psychiatric facility after nine days.

Conclusion: Venoarterial extracorporeal membrane oxygenation for refractory shock due to CCB and BB overdoses can be a life-saving intervention. Interfacility transfer of poisoned patients for VA-ECMO is logistically challenging, which can delay the appropriate care for patients with an otherwise morbid prognosis. A streamlined interfacility transfer protocol with multidisciplinary collaboration can help optimize outcomes.

Introduction: This case highlights the advances that have been made when skilled sonographers using point-of-care ultrasound (POCUS) are able to evaluate for more than free fluid on the focused assessment with sonography in trauma (FAST) exam. Specific solid organ injury including an active liver bleed can also be detected during FAST exam, as seen in this case of a unstable hypotensive patient.

Case Report:A 55-year-old male who had recently been admitted to trauma service due to multiple rib fractures presented back to the emergency department (ED) due to an episode of syncope and was found to have an acute, left segmental pulmonary embolism. The patient was started on anticoagulation, and the following day was found to be hypotensive, encephalopathic, and minimally responsive to verbal stimuli. During the resuscitative efforts, a FAST exam performed by the emergency physician showed grossly positive free fluid in various quadrants and active flow around the liver concerning for active bleeding. Computed tomography subsequently confirmed an active subcapsular bleed of the liver, and patient was taken emergently to surgery for hemostasis from a ruptured liver hemangioma. This was then followed by a right hepatic arterial embolization.

Conclusion: While the FAST exam is well established in the setting of trauma, this case further highlights the use of POCUS in a patient with undifferentiated hypotension and shock. It serves as a reminder of how imperative it is to not anchor on the primary diagnosis and reinforces the importance of ultrasonographic competency in physicians of all specialties and not just those in the realm of emergency medicine and critical care.

Introduction: Coinfection with human immunodeficiency virus (HIV) and Treponema pallidum represents a unique challenge in management, with increased risk of neurological complications. Haiti is well-known for being disproportionately impacted by the HIV epidemic, with rates of infection ~6 times higher than in the United States (US). Rates of coinfection in Haiti are incompletely characterized but likely high. The US has seen a marked increase in migration from Haiti, with implications for public health and migrant health management.   

Case Report: A 69-year-old male, recent Haitian migrant presented for subacute altered mental status and visual and auditory hallucinations for approximately four weeks. The patient’s neurological exam was non-focal, but laboratory evaluation showed an elevated paraprotein gap (6.7 grams per deciliter). This prompted concern for infectious etiology. The patient was diagnosed with HIV/AIDS with a CD4+ count of 154 cells per cubic millimeter and a positive rapid plasma reagin test (titer 1:128), with cerebrospinal fluid demonstrating elevated white blood cell count and protein concentration, consistent with neurosyphilis. The patient completed 14 days of intravenous benzathine penicillin G, with hospitalization complicated by hyponatremia and vomiting, which resolved after antibiotics.  

Conclusion: This case highlights the risk of coinfection with HIV and neurosyphilis in the Haitian migrant population and suggests possible benefit in routine screening for HIV and syphilis in the emergency department, particularly for at-risk populations. Neurosyphilis can be difficult to diagnose, requiring a high index of suspicion. Migrant patients can have difficulty accessing healthcare services, and the emergency department may have a role in screening and initiation of treatment in this population.

Introduction: Cullen sign is an area of periumbilical ecchymosis that results from blood tracking along the round ligament. Any source of retroperitoneal or abdominal hemorrhage can cause Cullen sign, but it is often described in association with acute pancreatitis.

Case Report: Here we report a case of a chronically ill male who presented with a bulging sensation in his lower abdomen and lower abdominal pain. On physical examination this patient was noted to have a large area of periumbilical ecchymosis predominantly on the left aspect of the umbilicus, consistent with Cullen sign. Computed tomography abdomen and pelvis were remarkable for an enlarging left external iliac artery aneurysm with adjacent hematoma and multifocal intraperitoneal hematoma tracking into the right side of the abdomen, concerning for aneurysmal rupture. The patient was taken to the operating room for a left iliac artery arteriogram and stent placement.

Conclusion: Isolated iliac artery aneurysms are rare and represent less than 2% of all abdominal aneurysmal disease; furthermore, external iliac artery aneurysms are exceedingly rare and account for the least common abdominal aneurysmal pathology. This case demonstrates the importance of considering other etiologies of Cullen sign beyond pancreatitis, including aneurysmal ruptures.

Introduction: Hydrocephalus presents a diagnostic and therapeutic challenge due to its diverse clinical manifestations and underlying causes. Symptoms can vary from feelings of unsteadiness to focal symptoms such as weakness, difficulty ambulating, or urinary incontinence. Due to the wide variety of symptoms, hydrocephalus can present a difficult diagnosis for any physician and may require different interventions depending on the underlying cause.

Case Report: This case report highlights a 69-year-old female with altered mental status, initially diagnosed with communicating hydrocephalus and sepsis. The patient’s symptoms, including confusion, urinary dysfunction, and gait ataxia, initially masked the hydrocephalus, emphasizing the importance of considering this condition in patients with prolonged progression of neurological deficits. Brain imaging, including magnetic resonance imaging (MRI) and computed tomography (CT), facilitated the diagnosis, suggesting hydrocephalus with downward tonsillar herniation. The acute management involved empirical antibiotic therapy for associated sepsis, followed by the placement of an external ventricular drain for cerebrospinal fluid diversion and sampling, including cytology and cell counts, given the concern for tonsillar herniation with a lumbar puncture. Cine MRI and CT cisternogram demonstrated a cyst filling the volume of the fourth ventricle. Subsequent surgical fenestration of the cyst using a suboccipital craniotomy for cyst resection alleviated symptoms and stabilized ventricular size.

Conclusion: Hydrocephalus can present with unique and varying symptoms, and it can have a variety of underlying causes. This case underscores the necessity for individualized treatment approaches tailored to the underlying etiology of hydrocephalus, including temporizing measures and more aggressive approaches once infection has improved.

Introduction: Point-of-care ultrasound (POCUS) is a rapid bedside tool, particularly in undifferentiated emergency department patients. Point-of-care ultrasound can investigate potential intra-abdominal infections in febrile patients, especially in the elderly, who often present atypically without abdominal pain or localizing symptoms.

Case Report: We highlight the important POCUS findings of cholecystoduodenal fistula and staghorn calculus in a febrile, elderly patient with dementia.

Conclusion: Early recognition of cholecystoduodenal fistula and staghorn calculus using POCUS can expedite appropriate antibiotic and interventional treatment for improved patient outcomes.

Introduction: Group A streptococcus (GAS) manifests as a spectrum of illnesses, ranging from mild to life-threatening. While relatively rare in infants, GAS infections can present with grave consequences.  

Case Report: An eight-month-old infant was found to have GAS bacteremia complicated by sepsis and disseminated intravascular coagulation, resulting in lower extremity myositis and tissue ischemia. Tissue ischemia progressed to dry gangrene requiring below-knee amputation followed by six weeks of antibiotics.  

Conclusion: This case serves as a reminder of the critical importance of vigilance, prompt recognition, and aggressive intervention in the management of invasive GAS infections in infants.

Introduction: Obstructive shock results from reduced cardiac output due to physical blockage of blood flow, such as cardiac tamponade. Cardiac tamponade compresses cardiac chambers, particularly the left atrium, causing decreased end-diastolic volume and cardiac output. Rapid fluid accumulation within the pericardial sac is the usual cause. Transesophageal echocardiography provides clearer visualization of these structures than transthoracic ultrasound. This case underlines the impact of esophageal pathology on cardiac output and highlights ultrasound’s dynamic diagnostic utility alongside computed tomography. 

Case Report: A 64-year-old female with a history of colon cancer and peritoneal metastases status post colostomy presented with altered mental status and urinary symptoms. Laboratory evaluation was notable for leukopenia, hypoglycemia, elevated ammonia, and an abnormal urinalysis that was positive for urinary tract infection. She was initially admitted to the internal medicine service for sepsis secondary to urine as the source of infection. During her hospital stay, she developed hypotension, tachypnea, tachycardia, and complained of chest pressure. Point-of-care echocardiogram revealed compression of the left atrium by distended gastric and esophageal contents. A nasogastric tube was placed and suctioned partially digested food and liquid with improvement of her condition. Follow-up ultrasound showed improvement of compression and cardiac function. 

Conclusion: In evaluation of acute shock, multiple etiologies must be considered. In this case, the cause of reduced cardiac output was direct compression of the left atrium from an adjacent structure. Even with direct visualization and imaging, immediate history and patient-centered approach are still useful to complete the clinical picture and treat the reversible cause of undifferentiated shock.

Introduction: While mild or moderate iron-deficiency anemia may not cause any symptoms, more severe deficiencies may present clinically as fatigue, shortness of breath, exertional dyspnea, lightheadedness, tachycardia, and presyncope or syncope, and, in rare instances, pica. Pica is defined as the developmentally inappropriate ingestion of non-nutritive, non-food substances for more than one month. We present the case of a duodenal obstruction secondary to a pica-associated bezoar in a patient with iron-deficiency anemia who presented to the emergency department (ED) with abdominal pain. 

Case Report: A 40-year-old female with past medical history of iron-deficiency anemia, asthma, and Von Willebrand disease and allergies to both oral and intravenous (IV) iron presented to the ED with one day of acute and severe abdominal pain associated with nausea and vomiting. The patient’s last bowel movement was one day prior to presentation. The abdominal exam revealed mild distention and generalized tenderness with no evidence of rebound or guarding. Computed tomography of the abdomen and pelvis with IV and oral contrast demonstrated gastric distention and a fecalized distal duodenum with wall thickening concerning for a duodenal obstruction. Given the patient’s known history of iron-deficiency anemia, the emergency physician inquired about ingestion of non-nutritive substances to which the patient replied that she had been consuming cotton foam. The patient was admitted to the hospital for gastroenterology consultation and esophagogastroduodenoscopy.  

Conclusion: Pica-associated gastrointestinal bezoars are a rare complication with a variety of reported substances being consumed. Patients presenting with small gastroduodenal bezoars may benefit from endoscopic removal, but large non-fragmentable bezoars can only be removed through surgical intervention.

Introduction: Ventricular ectopic beats and corrected QT interval (QTc) prolongation are both relatively common entities that are typically benign. It is difficult to predict subsequent dysrhythmias from either electrocardiogram (ECG) feature. The combination of both features may better predict the risk of torsades de pointes. We highlight a case of torsades preceded by a bizarre bigeminal rhythm with QTc prolongation likely caused by memantine use and hypokalemia. 

Case Report: An 84-year-old female presented to the emergency department with a fall. A syncope workup revealed an ECG demonstrating bigeminy with a prolonged QTc interval. Several minutes after obtaining the ECG, the patient went into torsades. She had multiple subsequent cardiac arrests during the rest of her hospital stay. This case report details the importance of recognizing ventricular bigeminy in the context of QTc prolongation as a harbinger of torsades. 

Conclusion: While premature ventricular contractions including bigeminy may be a benign finding, when accompanied by prolonged QTc intervals, they warrant immediate investigation and treatment of potential underlying pathology to prevent torsades and subsequent cardiac arrest. 

Introduction: Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis typically affecting dermal capillaries and venules. The condition is often idiopathic but can be associated with infections, neoplasms, autoimmune disorders, and certain drugs. 

Case Report: A 91-year-old female with past medical history of Alzheimer dementia and hypertension, being treated for lower extremity cellulitis, presented to the emergency department for an allergic reaction. Trimethoprim/sulfamethoxazole (TMP/SMX) had been initiated six days earlier. The patient was noted to have normal vital signs. Palpable purpura was discovered on the lower back, buttocks, lower extremities, ankles, and feet. Laboratory studies were within normal limits. Given the clinical presentation, physical exam findings, and normal eosinophil count, the diagnosis of LCV secondary to TMP/SMX was made. 

Conclusion: Most cases of LCV are limited to cutaneous symptoms and self-resolve with supportive care. 

Introduction: Penile pain in children and adolescents is an uncommon presenting symptom in the emergency department (ED). The differential diagnosis includes trauma, priapism, urethral stone, infection, Mondor disease, Peyronie disease, and thrombosis.  

Case Report: A 15-year-old male with a high-risk, B-cell acute lymphocytic leukemia and recent pegaspargase administration presented to the ED with new-onset penile pain. After the administration of opioid analgesics, he developed hypoxia prompting an urgent computed tomography pulmonary angiogram that revealed bilateral segmental acute pulmonary embolism (PE). Ultrasound of the penis revealed findings consistent with superficial dorsal vein thrombosis of the penis. 

Conclusion: To our knowledge, this is the first case report of an adolescent with superficial dorsal vein thrombosis of the penis and a coexisting PE. Doppler ultrasound can provide a prompt assessment of penile induration and differentiate venous thrombosis from other causes.

Introduction: Hydroxyapatite deposition disease (HADD) is caused by the presence of hydroxyapatite crystals in periarticular spaces oftentimes leading to inflammation, pain, and decreased range of motion.

Case Report: A 40-year-old right hand dominant female presented with three days of atraumatic right shoulder pain. Radiographs of the right shoulder were negative. Computed tomography
revealed a hydroxyapatite deposit adjacent to the acromioclavicular joint. The patient was managed with nonsteroidal anti-inflammatory drugs and a referral to orthopedic surgery.

Conclusion: Many instances of HADD will not be diagnosed on plain radiographs, and heightened awareness will provide confidence when ordering confirmatory imaging. Management is typically conservative, however, referral to orthopedic surgery is recommended to ensure improvement and to assess the need for more invasive procedures.

Introduction: Prevalence of serious infections from Haemophilus influenzae has diminished over the last few decades because of immunizations against the most virulent serotype. However, over the last few years a handful of septic arthritis cases secondary to H influenzae have been documented. Most of the cases documented are in the pediatric and unimmunized population. This is a case of polyarticular septic arthritis in a 69-year-old male who presented with syncope and ankle pain.

Case report: A 69-year-old male presented to the emergency department after a syncopal event at home and complaining of right ankle pain. He was tachycardic and tachypneic on presentation and had an erythematous painful right ankle and right elbow. Aspiration of both joints produced purulent aspirate that grew H influenzae. Antibiotics were started, and the patient was taken to the operating room for emergent joint lavage. The patient made a full recovery and was discharged home with a peripherally inserted central catheter line for continued intravenous (IV) antibiotics.

Conclusion: Our case highlights an atypical presentation for a case of polyarticular septic arthritis caused by H influenzae. We were unable to rule out endocarditis as a source of the bacterial seeding, and the patient improved with IV antibiotics and surgical lavage of the affected joints.

Introduction: Salicylate poisoning remains one of the most common global accidental overdoses and poses a considerable health threat. Typical presentations for salicylate overdoses include nausea, vomiting, and abdominal pain as well as tinnitus, tachypnea, fever, and dehydration resulting in a concomitant metabolic acidosis and respiratory alkalosis. This may progress to a predominance of neurological symptoms such as mental status changes, confusion, delirium, and hallucinations.

Case Report: We describe the case of an accidental, sub-chronic overdose (up to 7.5 grams/day for multiple weeks; ~75 milligrams/kilogram/day) that resulted in predominantly neurological symptoms (ie, tinnitus and hallucinations, including the patient reporting “seeing dead people”) but without the more typical findings classically associated with salicylate toxicity. The patient was started on a sodium bicarbonate drip; after two days, symptoms completely resolved, and she was safely discharged home.

Conclusion: This case serves as a reminder for physicians to have a high index of suspicion for chronic toxicities including salicylates in patients who present as acute psychosis or altered mental status of unknown etiology.

Introduction: Methemoglobinemia is a rare hematologic disorder of hemoglobin, in which iron contained within the heme moiety becomes oxidized from ferrous iron to ferric iron at a concentration greater than 1% in the blood. This biochemical change reduces binding affinity for oxygen, leading to impaired oxygen deposition in tissues and subsequent hypoxia and hypoxemia. The etiology of methemoglobinemia is often acquired from exposure to oxidizing agents, commonly antibiotics such as dapsone or local anesthetics such as benzocaine. A rare cause results from congenital deficiency of cytochrome b5 reductase, a nicotinamide adenine dinucleotide dependent enzyme within red blood cells that donates electrons to reduce ferric to ferrous iron.

Case Report: A 22-year-old previously healthy female was referred to the emergency department (ED) by her dentist one week after a dental procedure where she was noted to have low oxygen saturation and dark blood upon reported exposure to benzocaine. Upon arrival to the ED one week after exposure, her vitals were notable for oxygen saturation of 89% on room air. She was placed on 6 liters supplemental nasal cannula oxygen with subsequent improvement of oxygen saturation to 92%. Her exam was concerning with pale appearance, perioral cyanosis, and dusky fingertips. Her laboratory studies were most notable for serum methemoglobin level critically elevated to 31.6% one week after exposure, and she received 1 milligram per kilogram methylene blue in the ED with subsequent reduction of methemoglobin to 0.7%. The patient’s inpatient workup revealed a congenital deficiency in cytochrome b5 reductase.

Conclusion: Methemoglobinemia arises when there is a mismatch between the formation of oxidized ferric iron and the subsequent reduction to ferrous iron. Classically, methemoglobinemia is an acquired pathologic process from acute exposure to any number of oxidative stressors; in rare cases, methemoglobinemia is caused by congenital deficiency in red blood cell reducing enzymes. We report a case of an acquired methemoglobinemia with prolonged methemoglobinemia in a patient with undiagnosed congenital methemoglobinemia from cytochrome b5 reductase deficiency.

Introduction: Ludwig angina is a potentially fatal condition characterized by soft tissue infection of the submandibular, sublingual, and submental compartments. Pseudo-Ludwig angina is a rare condition characterized by sublingual swelling of non-infectious etiology, typically in the setting of supratherapeutic anticoagulation.

However, other etiologies, such as angioedema and trauma, have been described.

Case Report: We present the case of a 59-year-old female with pseudo-Ludwig angina that developed in the setting of warfarin therapy and supratherapeutic international normalized ratio. She presented with sublingual swelling and dysphagia. She was successfully treated with dexamethasone, vitamin K, and fresh frozen plasma. The most appropriate imaging modalities in these cases are contrast-enhanced computed tomography (CT) and CT angiogram. If a hematoma is present, antibiotics for anaerobic coverage are also appropriate.

Conclusion: We hope this case sheds light upon this rare pathology and ultimately hastens recognition and proper intervention.

Introduction: Gastroduodenal artery embolization is an increasingly common treatment method in patients with upper gastrointestinal (GI) bleeding who fail endoscopy or as a prophylactic procedure to help prevent further episodes. However, this new technique includes new risks including GI tract ischemia and risks associated with endovascular access such as hematoma formation, pseudoaneurysm development, and arterial dissection.

Case Report: We discuss a case of 51-year-old male with recurrent upper GI bleeding who presented to the emergency department for scrotal swelling following the prophylactic embolization of his gastroduodenal artery. He was subsequently found to have a ruptured testicular artery pseudoaneurysm resulting in hemorrhagic shock, which required massive transfusion protocol and vascular repair.

Conclusion: While endovascular access is relatively safe, patients can develop severe complications such as pseudoaneurysm development and subsequent rupture that may not be obviously apparent on physical exam. Because of this, clinicians must have a high index of suspicion for arterial injury, and risk stratification should be used when selecting appropriate candidates for prophylactic procedures.

Case presentation: A 21-year-old woman with a history of eczema presented to the emergency department with a painful rash over the previous three days spreading from her left axilla to her
left arm, left chest and left abdominal wall. The rash consisted of clusters of small, erythematous vesicles on hyperpigmented patches of skin. The patient was treated empirically with intravenous cyclovir for eczema herpeticum with improvement. Polymerase chain reaction testing of the fluid obtained from the rash vesicles later confirmed the presence of herpes simplex virus-1.

Discussion: Eczema herpeticum is a cutaneous superinfection with herpes simplex virus on pre- existing sites of eczema. Left untreated, it can have a mortality rate over 50%. Early identification and treatment of this high morbidity condition with antiviral agents is key to improving outcome.

Case Presentation: A 33 year old female with a history of antiphospholipid syndrome presented with exertional chest pain and ST-elevation in aVR with diffuse ST-depression. An emergent catheterization was performed which showed an isolated 99% stenosis in the left main coronary artery. The remaining coronary arteries were without any stenosis. Successful stent placement was performed, and the patient was discharged without complications.

Discussion: Previous guidelines suggested that ST-elevation with diffuse ST-depression should be treated as a STEMI-equivalent involving the left-main or proximal left anterior descending coronary artery. However recent data suggests that the majority of these cases may not involve that territory. Regardless, this ECG finding should still be concern for acute coronary syndrome with the need for urgent catheterization.

Case Presentation: We describe a case of persistent odynophagia due to a retained foreign body 27 days after emergent intubation.

Discussion: Dentures constitute a potential esophageal foreign body and warrant special consideration during airway management. Odynophagia, dysphagia, and changes in phonation should prompt consideration of retained esophageal foreign bodies, especially in the post-intubation setting.

Case Presentation: A male patient in his thirties with a history of polysubstance use presented to the emergency department (ED) due to an abrasion on his left forehead caused by banging his head against a wall in self-injurious behavior. A non-contrast computed tomography of the head obtained to rule out intracranial injury incidentally demonstrated a radiodense foreign body in the left external ear canal. A round metallic foreign body was subsequently visualized on otoscopic examination. The aural foreign body (AFB) was identified as a metallic bead that the patient had placed into his own ear; however, he reported no associated discomfort, hearing changes, or discharge. Traditional approaches for removing AFBs were considered; however, due to the position and smooth surface of the bead, there was concern they would be unsuccessful. Recognizing the metallic nature of the AFB, the clinician held a ceramic donut magnet adjacent to the patient’s ear and subsequently extracted the AFB without complication or patient discomfort.

Discussion: Aural foreign bodies account for a significant number of visits to EDs annually. Removal of AFBs can be challenging, often requiring specialized equipment or specialty referral for management. Using magnetism over short distances for the purpose of extracting metallic AFBs presents a low-cost, low-risk intervention. When used in applicable scenarios, this technique can decrease the need for specialty referral and can especially benefit patients seeking care in less-resourced settings.

Case Presentation: We present an image and discussion of spontaneous evisceration, or “burst abdomen,” from an anterior abdominal wall hernia. A 61-year-old female with prior history of
alcoholic cirrhosis and ascites presented to our emergency department with frank evisceration of multiple loops of small bowel from an open anterior abdominal wall dehiscence. Approximately one year prior to this visit she had also been seen in our department for spontaneous rupture of the skin overlying an umbilical hernia and large-volume external leakage of ascites (Flood syndrome). She required surgery to repair the abdominal wall at that time but had subsequently developed a new ventral hernia extending from the umbilicus across a large portion of her left lower abdomen as well as several other postoperative complications. On the day of presentation, she suffered dehiscence of that one-year-old surgical site resulting in spontaneous evisceration of her small bowel. She was transferred to a facility with acute care surgical capabilities where she remained in critical condition.

Discussion: Spontaneous evisceration from abdominal wall dehiscence is a devastating surgical complication. It tends to occur in the immediate postoperative period but has been reported to occur years later. This patient likely suffered from delayed burst abdomen due to multiple comorbidities and postoperative complications.

Case Presentation: An 83-year-old male with a history of prostate cancer and prior prostatectomy presented with lower abdominal pain, urethral leakage, and hematuria after a routine suprapubic catheter exchange, which was found to be incorrectly positioned in the bulbar urethra, leading obstructive nephropathy with mild hydronephrosis. 

Discussion: This case highlights the increased risk of suprapubic catheter misplacement and complications in elderly patients with neurogenic bladder and altered urinary anatomy, particularly after prostatectomy and artificial urethral sphincter placement. It emphasizes the importance of careful management during catheter exchanges in such patients to prevent complications of misplacement.

Case Presentation: We present a case of a 79-year-old male with gastric outlet obstruction resulting from a stomach herniation through a large left inguinal hernia.

Discussion: Stomach-containing inguinal hernias are a rare cause of gastric outlet obstruction. Treatment options range from conservative to surgical management. Once identified with imaging, prompt treatment should be initiated to prevent incarceration, strangulation, and gastric necrosis.

Case Presentation: An 18-year-old male presented with severe left ankle pain and inability to bear weight after jumping from a three-foot platform. Physical examination revealed decreased range of motion of the left ankle without visible deformity or neurovascular deficits. Imaging studies showed a vertical fracture of the distal tibia—a pilon fracture without fibular involvement.

Discussion: Pilon fractures involve the distal tibial articular surface and are rare. They typically result from high-energy trauma and often involve the fibula. This case illustrates a low-energy mechanism resulting in a pilon fracture without fibular involvement in a young patient without typical risk factors. It highlights the importance of considering pilon fractures in low-energy ankle injuries and the need for appropriate management even in less-complex cases.

Case Presentation: A 78-year-old male was admitted to the hospital due to acute-on-chronic liver failure with spontaneous bacterial peritonitis. About six liters of a yellow, turbid fluid were collected via indwelling urinary catheter (UC) overnight. He subsequently developed neurological and cardiac dysfunctions. Imaging confirmed bladder perforation and intraperitoneal placement of the UC, establishing the diagnosis of paracentesis-induced circulatory dysfunction due to unintended ascitic fluid drainage. He was stabilized with albumin replacement. The UC was removed, and the bladder injury resolved spontaneously.

Discussion: This case depicts a rare complication of urinary catheterization, which underscores the need for careful monitoring and prompt intervention to effectively manage unexpected catheter-related issues.