Clinical Practice and Cases in Emergency Medicine

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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: 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: 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: 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.

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.