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.

Efficacy of Noncontrast Computed Tomography of the Abdomen and Pelvis for Evaluating Nontraumatic Acute Abdominal Pain in the Emergency Department.

BACKGROUND: Computed tomography (CT) clarity has significantly improved since it became widely available in the early 1980s, making the utility and benefit of contrast material for image quality of the abdomen and pelvis uncertain, and so far, minimally studied. OBJECTIVES: This study sought to assess the efficacy of a noncontrast CT scan of the abdomen and pelvis by evaluating patients presenting to the emergency department (ED) with acute nontraumatic abdominal pain by following them for 7 days and observing for signs and symptoms of clinically significant acute emergent pathology. METHODS: We enrolled, and for 7 days followed, a prospective observational convenience sample of patients who received a noncontrast CT scan of the abdomen and pelvis in the ED for acute nontraumatic abdominal pain. The primary outcome, and defined as a failure, was abdominal surgery or death as the result of an intraabdominal process not found on the original noncontrast CT scan, or a subsequent contrasted CT scan with a finding that could explain the original complaint of abdominal pain that was also not seen on the initial noncontrast CT, during the 7-day observation. RESULTS: Seventy-two patients were enrolled in the study. The incidence of failure was 0% (0/72), 46% of patients (33/72) had a negative CT scan, 54% (39/72) had a positive CT scan, 57% (41/72) were admitted, 43% (31/72) discharged, 11% (8/72) had abdominal surgery, and a repeat contrasted CT scan was done on 4% (3/72). CONCLUSIONS: With certain inclusion and exclusion criteria, noncontrast CT of the abdomen and pelvis is likely a reliable diagnostic modality for the evaluation of acute nontraumatic abdominal pain in the ED.

Cholera Presenting With Hyperkalemia, Rhabdomyolysis, and Acute Renal Failure.

Cholera is a well known cause of significant disease, particularly in resource-poor nations, but it is very rare in developed countries. The morbidity and mortality of cholera is resultant from large-volume diarrhea, hypovolemia, and electrolyte derangement. In the following case, a 60-year-old man with no recent travel history presented to the emergency department with muscle cramping, abdominal pain, and gastrointestinal distress. It was later confirmed that he was suffering from cholera. On presentation, he was hyperkalemic with ECG changes and soon went into a hypovolemic shock. After a complicated hospital course, he fortunately made a complete recovery. This case demonstrates that common complaints may result in uncommon diagnoses. It is important to pay attention to the clinical situation and intervene accordingly.

Evaluation of commercially available traction splints for battlefield use.

BACKGROUND: Femoral fracture is a common battlefield injury with grave complications if not properly treated. Traction splinting has been proved to decrease morbidity and mortality in battlefield femur fractures. However, little standardization of equipment and training exists within the United States Armed Forces. Currently, four traction splints that have been awarded NATO Stock Numbers are in use: the CT-6 Leg Splint, the Kendrick Traction Device (KTD), the REEL Splint (RS), and the Slishman Traction Splint (STS). OBJECTIVE: The purpose of this study was to determine the differences between the four commercially available traction devices sold to the U.S. Government. METHODS: After standardized instruction, subjects were timed and evaluated in the application of each of the four listed splints. Participant confidence and preferences were assessed by using Likert-scaled surveys. Free response remarks were collected before and after timed application. RESULTS: Subjects had significantly different application times on the four devices tested (analysis of variance [ANOVA], p<.01). Application time for the STS was faster than that for both the CT-6 (t-test, p<.0028) and the RS (p<.0001). Subjects also rated the STS highest in all post-testing subjective survey categories and reported significantly higher confidence that the STS would best treat a femoral fracture (p<.00229). CONCLUSIONS: The STS had the best objective performance during testing and the highest subjective evaluation by participants. Along with its ability to be used in the setting of associated lower extremity amputation or trauma, this splint is the most suitable for battlefield use of the three devices tested.