Thoracic aortic syndromes in the emergency department: recognition and management.

Acute aortic syndromes include aortic dissection, penetrating atherosclerotic ulcer, and intramural hematomas, but aortic dissection is the most common and the deadliest. This review summarizes the latest evidence on developing a differential for aortic dissection when common complaints, such as chest pain, abdominal pain, and syncope are also present. Recent evidence on the optimal uses of emergency department imaging studies and risk stratification tools are reviewed, along with special considerations in the management of penetrating atherosclerotic ulcer and intramural hematoma. Pharmacologic therapies for managing hemodynamic parameters and shock, and indications for operative intervention are also reviewed, along with cutting-edge diagnostic and treatment options on the horizon.

Infective endocarditis: identification and management in the emergency department.

Recognition of infective endocarditis in the emergency department continues to be a challenge, as its signs and symptoms can be subtle, laboratory results are limited, and it can involve or lead to many other serious conditions. With the increase in use of medical access devices, implantable cardiac devices, and the rise of intravenous drug use, the epidemiology of infective endocarditis is changing. Diagnostic imaging has evolved, and the use of point-of-care ultrasound and transthoracic echocardiography are critical in making an early diagnosis. This review provides a best-evidence approach to diagnostic strategies, antibiotic recommendations, and surgical treatment recommendations for infective endocarditis.

To tPA or Not to tPA: Two Medical-Legal Misadventures of Diagnosing a Cerebrovascular Accident as a Stroke Mimic.

We present two recent successfully litigated malpractice cases in which patients with cerebrovascular accidents were misdiagnosed as stroke mimics. The first was diagnosed as a hemiplegic migraine, which occurs in only 0.01% of the population. The second was diagnosed as a conversion disorder, which ultimately has a neurologic etiology in 4% of cases. In both cases, issues of poor patient communication and poor documentation were paramount in the legal outcome. We discuss caveats of stroke mimics, tissue plasminogen activator administration liability, and pitfalls in patient and family interactions.

Headache with Aura: A case report of ocular melanoma.

BACKGROUND: Headaches and visual complaints are common conditions encountered in the emergency department. While a patient's age, risk factors, and comorbidities often aid in risk stratification and guide emergency department evaluation, atypical presentations of serious disease may still occur in young otherwise healthy patients CASE: In this vignette we discuss a case of ocular (choroidal) melanoma in a 21 year-old female patient who presented with recurrent photopsia and headaches. DISCUSSION: Ocular melanoma is the most common non-skin melanoma and should be considered by the emergency physician for patients with visual deficits. Likely presentations and risk factors for ocular melanoma will be discussed as well as emergency department and specialty management.

Eruptive xanthoma in the setting of hypertriglyceridemia and pancreatitis.

BACKGROUND: Undifferentiated dermatologic complaints are often encountered in the emergency department. While a patient's exposures, risk factors, and comorbidities may help guide emergency department evaluation, the accurate diagnosis of dermatologic findings is critical to allowing rapid identification and treatment of disease. CASE: In this vignette we discuss a case of eruptive xanthoma in a 33-year-old male with diabetic ketoacidosis and pancreatitis. DISCUSSION: Dermatologic complaints pose a unique challenge to the emergency physician. Many dermatologic findings are benign; however, some may represent underlying serious disease even in young, otherwise healthy appearing patients. Eruptive xanthomas are cutaneous lesions often indicating severe hypertriglyceridemia and uncontrolled diabetes. Likely presentations and risk factors for eruptive xanthomas will be discussed as well as ED evaluation and management.

Injuries Sustained During Modern Army Combatives Tournaments.

INTRODUCTION: Injuries sustained during Modern Army Combatives (MAC) tournaments can result in variable recovery time for involved competitors and unpredictable loss of readiness for military units. A paucity of MAC data is available to guide military medical providers and unit commanders on expected injuries or loss of readiness. Literature reviewing mixed martial arts competitions offers some insight but demonstrates variation in fight outcomes resulting in injuries ranging from 8.5% to 70% and it is difficult to effectively extrapolate such data to predict MAC tournament injuries. MATERIALS AND METHODS: This study retrospectively reviews pre- and post-competition medical records from two MAC tournaments held at Fort Hood in 2014 and 2015 to provide descriptive clinical information on injury patterns to practitioners and military commanders. RESULTS: Records from a total of 195 competitors with a mean age of 24.4 yr were analyzed with a total of 67 injuries, 29 of which resulted in duty limitations (14.8% of participants). Competitors participating in less-restrictive mixed martial arts style fighting (Advanced MAC) were 4.3 times more likely to sustain an injury than those limited to upper body grappling events (95% confidence interval 2.30-8.16). Military Acute Concussion Evaluations were reliably recorded both pre- and post-competition in 44% of total participants with no significant statistical difference between pre- and post-tournament evaluations. Duty profile limitations of injured competitors averaged 1 mo in duration. CONCLUSIONS: MAC tournaments result in injury rates comparable with other combative sports and military training courses.

Sudden onset flank pain: Spontaneous renal rupture.

BACKGROUND: Undifferentiated abdominal pain is a common condition encountered in the emergency department. While a patient's age, risk factors, and comorbidities often aid in risk stratification and guide emergency department evaluation, atypical presentations of serious disease may still occur suddenly in young otherwise healthy patients. CASE REPORT: In this vignette we discuss a case of spontaneous, atraumatic renal rupture with large retroperitoneal hemorrhage (Wunderlich's Syndrome) in a 22year old male. DISCUSSION: Emergency physicians regularly encounter uncommon causes of abdominal pain. Wunderlich's syndrome is rare but proper understanding of the disease process will aid in decision making and improve disposition and outcomes for patients. Likely presentations and risk factors for atraumatic renal rupture will be discussed as well as ED management and definitive treatment options.