Clinical Practice and Cases in Emergency Medicine

A 59-year-old female presented to the emergency department (ED) three days after accidental ingestion of an intact in-the-ear hearing aid. This is the first report of ingestion of a complete hearing aid traveling past the gastroesophageal junction. Of concern was the exposed battery attached to the hearing aid that had advanced minimally in the three days since last evaluation. This case report discusses her ED testing, including gastroenterology consultation, and ultimately retrieval from her distal stomach. The authors conclude that this removal was not medically necessary.

Laceration injuries comprise over 8% of all emergency department (ED) visits annually.1 Giventhat laceration injuries represent a significant volume of ED visits, emergency physicians (EP)should be comfortable treating these types of injuries. We present the case of a 34-year-old malewho presented to the ED as a trauma activation who suffered multiple injuries including complexfull-thickness lacerations to his face. While there are scenarios in which consulting a specialist isnecessary, knowledge and application of basic wound closure principles allows for many complexlacerations to be repaired by EPs. We provide a helpful systematic approach to evaluating andtreating complex facial lacerations in the ED.

Since marijuana legalization, pediatric exposures to cannabis have increased.1 To date, pediatric deathsfrom cannabis exposure have not been reported. The authors report an 11-month-old male who, followingcannabis exposure, presented with central nervous system depression after seizure, and progressed tocardiac arrest and died. Myocarditis was diagnosed post-mortem and cannabis exposure was confirmed.Given the temporal relationship of these two rare occurrences – cannabis exposure and sudden deathsecondary to myocarditis in an 11-month-old – as well as histological consistency with drug-inducedmyocarditis without confirmed alternate causes, and prior reported cases of cannabis-associatedmyocarditis, a possible relationship exists between cannabis exposure in this child and myocarditisleading to death. In areas where marijuana is commercially available or decriminalized, the authors urgeclinicians to preventively counsel parents and to include cannabis exposure in the differential diagnosis ofpatients presenting with myocarditis.

We present the case of a 33-year-old male with end stage renal disease presenting to theemergency department (ED) with headache, dizziness, and unilateral weakness. Initial concern wasfor ischemic or hemorrhagic stroke. Magnetic resonance imaging confirmed posterior reversibleencephalopathy syndrome (PRES). The patient was treated appropriately and made a fullneurologic recovery. PRES is an under-recognized diagnosis in the ED. As a stroke mimic, PREScan lead the clinician on an incorrect diagnostic pathway with potential for iatrogenic harm.

Takotsubo cardiomyopathy, also known as apical ballooning syndrome and stress cardiomyopathy, is a transient systolic and diastolic left ventricular dysfunction with a variety of cardiac wall-motion abnormalities that is increasingly being associated with significant morbidity and mortality.  Wellens’ syndrome is an electrocardiographic pattern in a pain-free patient that is indicative of critical occlusion of the left anterior descending coronary artery requiring immediate cardiac catheterization.  The authors report a case of a patient presenting with electrocardiographic findings consistent with Wellens’ syndrome that was later found to have Takotsubo cardiomyopathy with angiographically normal coronary arteries on cardiac catheterization after a seizure.

Acute myocardial infarction and perforated peptic ulcer disease with associated peritonitis are bothmedical emergencies requiring urgent intervention. This patient presented with both emergenciessimultaneously. Current literature is devoid of guidance as to which should be addressed initially. Amultidisciplinary discussion was conducted leading to a unanimous decision for initiating percutaneouscoronary intervention (PCI). After successful PCI, the patient was immediately taken to the operatingroom for laparoscopic repair of the perforated viscous. Subsequent to the operative repair, the patientbecame hemodynamically unstable and a repeat electrocardiogram demonstrated complete rightcoronary occlusion. Shock ensued and the patient died in the intensive care unit despite this plan ofcare. It is our opinion that this case reveals the need for expert panels to devise decision algorithms forconcomitant presentations of life-threatening diseases.

Isolated pelvic DVTs are rare and difficult to diagnose, but are more common in pregnant women and carry an increased risk of embolization.  Pulmonary embolism (PE) is the most common non-obstretric cause of death in pregnancy.  Compression ultrasound is the first-line imaging test for suspected lower extremity DVT, but it cannot usually directly visualize or easily diagnose isolated pelvic DVT.  Nonetheless, Point of Care Ultrasound (POCUS) may provide valuable clues to help rule in pelvic DVT and expedite initiation of anticoagulant therapy.  Such findings include increased venous diameter, increased resistance to compression, visible venous reflux, and blunted phasicity.  This case presents an example of how these findings on POCUS led the emergency physician to make the difficult diagnosis of pelvic DVT at the bedside within seconds.

Gastric volvulus is a rare condition defined as an abnormal rotation of the stomach by more than180 degrees. Gastric volvulus could present atypically with simply nausea and vomiting. A highindex of suspicion is required for prompt diagnosis and treatment, especially when a patientpresents with subacute intermittent gastric volvulus. Here, we present the case of a 56-year-oldfemale with lung cancer status post left lower lobectomy undergoing chemotherapy who presentedwith intermittent nausea and upper abdominal pain for a few weeks. Barium study and computedtomography revealed acute mesenteroaxial gastric volvulus and she was treated with urgent surgicalintervention.

A 79-year-old female called 911 for abdominal pain in her left upper quadrant with radiationthrough to her back and left shoulder for three hours. Upon arrival to the emergency departmenther physical exam was positive only for tenderness in the left upper quadrant of her abdomen.The patient denied any history of trauma but reported she “did sneeze three times” just priorto the onset of her pain. Computed tomography angiography of the abdomen and pelvis wasobtained to evaluate for vascular pathology. The radiologist immediately called with concern forsplenic laceration. The general surgeon took the patient directly to the operating room whereshe underwent a splenectomy and recovered without sequelae. This is the first case report ofspontaneous splenic rupture that resulted after the act of sneezing. It is important to be aware ofthis rare clinical entity because early recognition can be life saving.

We report a case of a 52-year-old man who presented to the emergency department (ED) in extremis(hypotensive with an altered sensorium) with subsequent cardiac arrest after a motor vehicle collision.The initial trauma evaluation did not reveal a source of the hemodynamic compromise. A point-of-careultrasound revealed severe mitral regurgitation secondary to an anterolateral papillary muscle rupture.Patient underwent successful emergent mitral valve replacement after initial resuscitative efforts andintraaortic balloon pump placement.

Clenbuterol is a beta-agonist that has been abused by fitness-oriented individuals for muscle growthand weight loss. We report a case of a 46-year-old man who presented tachycardic, hypokalemic, andhyperglycemic after injecting testosterone obtained from Brazil. He developed refractory hypotensionand was started on an esmolol infusion for suspected beta-agonist toxicity. Laboratory analysisshowed a detectable clenbuterol serum concentration. Analysis of an unopened ampule containedboldenone undecylenate, clenbuterol, and vitamin E. This case illustrates a novel exposure thatcaused beta-agonist toxicity and was treated successfully with rapid-onset beta blocker.

Despite extensive review in the literature, compartment syndrome and crush syndrome remaindifficult to diagnose. Trauma, toxins and reperfusion have been associated with these syndromes.Cases involving alcohol and drug abuse have described patients “found down” compressing anextremity. We present a case of a registered nurse who developed compartment syndrome inmultiple limbs due to prolonged sleep after sleep deprivation and zolpidem use. To our knowledge,this is the first case of compartment syndrome or crush syndrome to have occurred in the settingof zolpidem use. Sleep disruption in healthcare workers represents a public health issue withdangerous sequelae, both acute and chronic.

Cyproheptadine is an H-1 antihistamine with anticholinergic and antiserotonergic effects.Cyproheptadine’s most common use has been in the management cold-induced urticaria. It is often usedin primary care for its side effect of appetite stimulation. Recently there has been increasing interest inits use in the treatment of drug-induced serotonin syndrome. Cyproheptadine overdose is uncommonlyreported in the medical literature. We report the rare case of a pediatric cyproheptadine overdose with aconfirmatory cyproheptadine level.

A 21-year-old pregnant female with no significant past medical history presented with acute onsetheadache and nausea as well as tonic-clonic seizures, then rapidly decompensated into a coma withcomplete absence of brainstem reflexes. The patient was ultimately diagnosed with hemolysis, elevatedliver enzymes, and low platelets (HELLP syndrome) and subsequent posterior reversible encephalopathysyndrome (PRES) with brainstem involvement. Emergent delivery and blood pressure control resulted inrapid and complete neurologic recovery.

The use of electronic nicotine delivery systems (ENDS) is increasing across the United States astobacco bans increase and more people use these devices in an attempt to quit smoking. They areunregulated by the Food and Drug Administration, and there is significant concern that ENDS couldproduce several toxic byproducts.

In this case a 35-year-old female presented to the emergency department with sudden-onsetdyspnea. She denied current tobacco smoking, but she was a user of ENDS. When bronchoscopywas performed, an extensive pattern of suspected chemical injury was noted in her airways. Sherequired transfer to a tertiary center where she required extracorporeal membranous oxygenation.

Despite public opinion that ENDS are generally safe, or at least safer than tobacco smoking,contrary evidence is mounting. We postulate that her injuries were likely suffered secondary to useof an ENDS.

Hematometrocolpos is a rare congenital abnormality of the female urogenital system that leadsto an imperforate hymen and subsequent retrograde menstruation. We present the case of a14-year-old female patient who presented to the emergency department with amenorrhea andabdominal pain, and was found to have an imperforate hymen and hematometrocolpos on transabdominalpoint-of-care ultrasound. It is important for emergency physicians to consider thisdiagnosis in pubescent female patients presenting with abdominal pain, as missed diagnosis canlead to infertility and other complications.

Blunt scrotal injury represents a diagnostic dilemma for emergency physicians (EP).Consequently, point-of-care ultrasound (POCUS) has emerged as a tool for early investigation ofthe acute scrotum in the emergency department. We describe a case where an EP used scrotalPOCUS to immediately visualize the loss of testicular contour and underlying heterogeneousparenchyma to rapidly make the diagnosis of testicular rupture in a young male presenting withscrotal trauma. The use of POCUS in this case expedited therapy, likely improving the patient’soutcome. To our knowledge, this is the first detailed description of testi cular rupture diagnosedwith POCUS by an EP.

Cervical artery dissection is a common cause of stroke in young adults. This may result from head andneck trauma; it can also occur spontaneously or secondary to genetic connective tissue or vasculardisorders. Neurologic symptoms arise as a result of thromboembolism and hypoperfusion causingcerebral ischemia. We present a case of a previously healthy male who was found to have a cervicalinternal carotid artery dissection and the decision to use antiplatelet therapy instead of anticoagulationto prevent stroke. Data is lacking regarding the efficacy of one therapy over the other.

Subacute endocarditis often presents with an indolent course. A potentially lethal form generated byinfection with Abiotrophia defectiva may be easily overlooked early in its presentation. This reportdiscusses the case of an 18-year-old male discovered to have severe endocarditis after presentingto the emergency department with the chief complaint of foot pain.

Minoxidil is a strong oral vasodilator that is used to treat patients with hypertension refractoryto first-line medications. We report a case of minoxidil-associated subacute cardiac tamponadediagnosed by point-of-care ultrasound (POCUS) in a hypertensive patient. A 30-year-old male witha past medical history of poorly controlled hypertension (treated with minoxidil) and chronic kidneydisease presented with 2-3 days of chest pain and shortness of breath with markedly elevated bloodpressures. A point-of-care transthoracic echocardiogram revealed a massive pericardial effusion withsonographic tamponade physiology. We review the risk factors for developing pericardial effusionsthat progress to cardiac tamponade, the utility of diagnosing these patients by POCUS, and theincidence of patients who present with sonographic signs of cardiac tamponade without hypotension.

We describe a case of wound botulism initially thought to represent Miller-Fisher variant Guillain-Barré syndrome (MFS). Botulism classically presents with the so-called “four D’s” (diplopia,dysarthria, dysphagia, dry mouth) with symmetric, descending weakness. MFS presents with a triadof limb-ataxia, areflexia, and ophthalmoplegia, with variable cranial nerve and extremity involvement.The distinction can be difficult but is important as early initiation of botulinum antitoxin is associatedwith improved patient outcomes in cases of botulism. Furthermore, it is important to recognizeintravenous drug use as a risk factor in the development of botulism, especially given an increase ininjection drug use.

We report a case of new-onset atrial fibrillation with rapid ventricular response in a 37-year-old malewho presented to the emergency department. This patient was not admitted to the hospital or placed onobservation, but rather placed on a cellular outpatient 12-lead telemetry (COTLT) device with emergencyresponse capabilities and discharged home. We define a new modality that allows these patients tobe managed via telemedicine and receive care similar to that which would be rendered in a hospital orobservation unit.

More people are struck and killed by lightning each year in Florida than any other state in the UnitedStates. This report discusses a couple that was simultaneously struck by lightning while walkingarm-in-arm. Both patients presented with characteristic lightning burns and were admitted forhemodynamic monitoring, serum labs, and observation and were subsequently discharged home.Despite the superficial appearance of lightning burns, serious internal electrical injuries are common.Therefore, lightning strike victims should be admitted and evaluated for cardiac arrhythmias, renalinjury, and neurological sequelae.

Erythema nodosum (EN) is associated with many systemic diseases and infections. This casereport provides an image of erythematous nodules, an overview of the various causes of EN, andthe laboratory tests and imaging that can be done in the emergency department to narrow its broaddifferential diagnosis.

Paratracheal cysts are a common finding on CT scan. In the setting of trauma, they can mimic pneumomediastinum. The nature of the paratracheal cyst is diverse, however they could be considered to be tracheal diverticula. We report a case of trauma with the incidental finding of a cyst in the thoracic outlet and how this may affect the work up for trauma. It is important that emergency physicians be mindful of this finding especially in the setting of trauma. The anatomic location of the cysts may complicate certain procedures such as central venous catheterization of the internal jugular vein.

This case highlights the rare complication of ischemic hand necrosis following peripheraladministration of epinephrine and norepinephrine.