Subtle vaginal evisceration resulting in small bowel evisceration: a case report.

BACKGROUND: Evisceration of bowel contents through the vagina is a rare event that may be complicated by bowel obstruction. OBJECTIVE: We report a case of vaginal evisceration with small bowel obstruction which, in contrast to previous, more dramatic case reports in the literature, is a more subtle and, in fact, characteristic clinical presentation for this unusual occurrence. CASE REPORT: A 72-year-old woman with a previous history of pelvic surgery presented to the Emergency Department with lower abdominal discomfort and a prolapsing mass from her vagina. She was initially discharged home after bedside reduction of the mass, but returned 48 h later with worsening symptoms. A computed tomography scan on her repeat visit confirmed evisceration of bowel into the vaginal vault with obstruction of distal bowel loops. Surgical and gynecologic services were consulted and the patient underwent partial small bowel resection and vaginal cuff repair in the operating room. CONCLUSION: Early recognition of subtle presentations of vaginal evisceration is crucial for preserving bowel viability and preventing morbidity from bowel ischemia or infarction. Risk factors for this rare condition include postmenopausal status, previous pelvic surgery, and presence of an enterocele.

Ruptured abdominal aortic aneurysm presenting as painless testicular ecchymosis: the scrotal sign of Bryant revisited.

The diagnosis of ruptured abdominal aortic aneurysm (AAA) is often missed as a result of an atypical presentation, resulting in increased mortality. Here we present an unusual case of painless scrotal ecchymosis as a presentation of ruptured AAA. We review the origin of the scrotal sign of Bryant and emphasize the importance of this uncommon finding as a diagnostic aid in atypical cases of ruptured AAA.

Ultrasonography-guided peripheral intravenous catheter survival in ED patients with difficult access.

OBJECTIVES: We determined the survival and complications of ultrasonography-guided peripheral intravenous (IV) catheters in emergency department (ED) patients with difficult peripheral access. METHODS: This was a prospective, observational study conducted in an academic hospital from April to July of 2007. We included consecutive adult ED patients with difficult access who had ultrasonography-guided peripheral IVs placed. Operators completed data sheets and researchers examined admitted patients daily to assess outcomes. The primary outcome was IV survival >96 hours. As a secondary outcome, we recorded IV complications, including central line placement. We used descriptive statistics, univariate survival analysis with Kaplan Meier, and log-rank tests for data analysis. RESULTS: Seventy-five patients were enrolled. The average age was 52 years. Fifty-three percent were male, 21% obese, and 13% had a history of injection drug use. The overall IV survival rate was 56% (95% confidence interval, 44%-67%) with a median survival of 26 hours (interquartile range [IQR], 8-61). Forty-seven percent of IVs failed within 24 hours, most commonly due to infiltration. Although 47 (63%) operators reported that a central line would have been required if peripheral access was unobtainable, only 5 (7%; 95% confidence interval, 2%-15%) patients underwent central venous catheterization. Only 1 central line was placed as a result of ultrasonography-guided IV failure. We observed no infectious or thrombotic complications. CONCLUSION: Despite a high premature failure rate, ultrasonography-guided peripheral IVs appear to be an effective alternative to central line placement in ED patients with difficult access.

The painful eye.

Emergency physicians are required to diagnose and treat patients who have a painful eye on a regular basis. This article focuses on ophthalmologic emergencies that range in presentation from mild to severe symptomatology and include vision and eye-threatening ailments. The etiology, pathophysiology, physical examination, and treatment of the following conditions are discussed: acute angle closure glaucoma, scleritis, anterior uveitis, optic neuritis, keratitis, and corneal abrasion. This article should provide the necessary information to allow for rapid diagnosis and initiation of appropriate treatment of the painful eye.