Abiotrophia defectiva triple threat: A rare case of infective spondylodiscitis, endocarditis, and brain abscess.

Abiotrophia defectiva is a pathogen of the oral, gastrointestinal, and urinary tracts that can cause significant systemic disease with uniquely negative blood cultures depending on the growth medium. Prior cases note possible seeding from relatively common procedures such as routine dental work and prostate biopsies, however case literature describes prior infectious complications to include infective endocarditis, brain abscess formation, and spondylodiscitis. While prior cases describe some aspects of these presentations, we highlight a case of a 64-year-old male who presented to the emergency department (ED) f5or acute onset of low back pain with fever symptoms four days after an outpatient transrectal ultrasound-guided needle biopsy of the prostate, with a prior dental extraction described four weeks prior to arrival. Findings on initial ED presentation and subsequent hospitalization revealed infective spondylodiscitis, endocarditis, and brain abscess formation. This is the only cases noted in literature with all three infection locations with dual risk factors of dental and prostate procedures prior to symptom onset. This case highlights the multifocal illness that can complicate Abiotrophia defectiva infections, and the importance of thorough ED evaluation and multiservice approach for consultation and treatment.

Abdominal Extension of Fournier Gangrene From Undiagnosed Crohn's Disease: A Case Report.

Cellulitis and abscess are common skin infections in military populations. Although complications of necrotizing soft tissue infections (NSTIs) such as Fournier Gangrene (FG) are rare, they are associated with significant morbidity and mortality. Laboratory and radiological studies may aid in the evaluation of NSTI; however, focus should remain on physical examination and prompt surgical consultation, as these infections can spread rapidly with significant increases in mortality with delayed management. We present the case of a 37-year-old male soldier with reported history of two distant left inguinal hernia repairs, complaining of increasing buttock pain despite outpatient antibiotic therapy for perineal cellulitis from his primary clinician. Despite normal vital signs and low risk from established NSTI calculator scores, examination revealed crepitus and severe tenderness extending from the buttock through the perineum and scrotum characteristic of FG. Preoperative computed tomography found additional spread of subcutaneous air from these areas into the lower abdomen, likely facilitated by the previously repaired left inguinal hernia. Surgical management necessitated debridement, multiple washouts, and ileostomy. Follow-up evaluations revealed previously undiagnosed Crohn's disease with fistula-in-ano as the inciting factor.

Improvised Management of Polycythemia Vera Using Whole Blood Transfusion Kits.

Polycythemia vera (PV) is a frequent myeloproliferative disease resulting in excessive red blood cells, white blood cells, and platelets rarely identified in military populations. Increased blood viscosity and platelets can lead to fatal myocardial infarction and stroke. Historically, regimented phlebotomy managed this condition, but modern medicinal advances now are utilized. These immunosuppressive medications are generally incompatible with active-duty service and can lead to medical discharge. Phlebotomy therefore is critical for readiness and health; however, this can be challenging in resource-limited environments, necessitating effective improvisation. We describe an active-duty Soldier with PV symptoms consisting of substernal chest pressure, bilateral lower extremity paresthesias, and persistent pruritic neck rash. He had an elevated hematocrit (Hct) of 47%, necessitating phlebotomy and posing a challenge to his primary care team. The local emergency medicine team employed blood collection bags from whole blood (WB) transfusion kits, including proven volume estimation methods, to routinely draw one unit of blood and effectively manage this condition. This is the first reported case in military literature of PV managed with improvised field resources and techniques.

High risk and low prevalence diseases: Lemierre's syndrome.

INTRODUCTION: Lemierre's syndrome is a serious condition that carries with it a high rate of morbidity and even mortality. OBJECTIVE: This review highlights the pearls and pitfalls of Lemierre's syndrome, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Lemierre's syndrome is a condition marked by septic thrombophlebitis of the internal jugular vein (IJV), with the classic triad of pharyngotonsillitis, IJV thrombosis, and septic emboli resulting in metastatic abscess. It typically begins as pharyngitis, often caused by Fusobacterium necrophorum. Patients most commonly present with fever, recently diagnosed pharyngitis, and neck pain or swelling. Septic emboli may affect multiple organ systems, most commonly the pulmonary system. The disease should be considered in patients with prolonged symptoms of pharyngitis, pharyngitis that improves but then worsens, critically ill patients with pharyngitis, patients with pharyngitis and infection at a secondary site, and neck signs/symptoms. Diagnosis includes throat and blood cultures, as well as imaging to include computed tomography of the neck and chest with intravenous contrast. Additional imaging of other areas should be performed as clinically indicated. Initial management includes hemodynamic stabilization with intravenous fluids and vasopressors as needed, as well as broad-spectrum antibiotics. Anticoagulation for the primary thrombus and possible septic emboli is controversial and should be considered in a multidisciplinary approach with admission. CONCLUSIONS: An understanding of Lemierre's syndrome can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

A Case Report of Massive Intraperitoneal Hemorrhage from Rare Cornual Pregnancy.

INTRODUCTION: A cornual pregnancy describes a rare ectopic location positioned within the myometrium next to the fallopian tube, which can be difficult to find on traditional ultrasound imaging. Given its location and the stretch within the uterine wall, cornual pregnancies can progress for weeks prior to diagnosis. Ruptures can, therefore, be catastrophic with disproportionally high maternal mortality rates compared to other ectopic pregnancies. CASE REPORT: A 34-year-old female recently treated with methotrexate for ectopic pregnancy presented to the emergency department (ED) for acute onset of lower abdominal cramping without vaginal bleeding. She arrived clinically stable and quickly decompensated with witnessed syncope in the ED, prompting point-of-care ultrasound showing free fluid in the abdomen. The patient was taken for emergent surgery by obstetrics while receiving transfusion of blood products for suspected ruptured ectopic pregnancy. A fetus estimated to be 10 weeks of age was discovered in the left cornual region. Approximately two liters of intraperitoneal blood were drained without complication. CONCLUSION: Cornual pregnancy is a difficult to diagnose but potentially disastrous type of ectopic pregnancy due to massive hemorrhage. Emergency clinicians should be aware of this condition given its rare occurrence but potentially catastrophic outcomes.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department.

BACKGROUND: Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries. OBJECTIVE: This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician. DISCUSSION: SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification. CONCLUSIONS: SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.

National Stop the Bleed Day: The impact of a social media campaign on the Stop the Bleed program.

BACKGROUND: National Stop the Bleed Day (NSTBD) was created to increase public awareness of the official Stop-the-Bleed initiative and the Bleeding Control Basic course. The goal was to develop and employ an effective national social media strategy that would encourage and support efforts already in place to train the public in basic bleeding control techniques. METHODS: March 31, 2018, was designated as NSTBD. Analysis focused on a 2-week window centered on NSTBD. The number of courses offered, number of instructors registered and total number of students trained overall during this period was derived from the American College of Surgeons (ACS) website bleedingcontrol.org. Courses not registered with the ACS were not included. Data on overall website activity were also included for analysis. RESULTS: Forty-three states and 18 countries participated in NSTBD. During the study period, there were 1884 courses registered on bleedingcontrol.org. Comparatively, over a 4-month period from August to November 2017, the mean number of registered courses per month was 834. There were 34,699 students trained during the two-week study period as opposed to August to November 2017, the mean number of people trained per month was 9,626. In addition, 576 new B-Con instructors were certified during this time window. Additionally, the international coordinators reported 1500 students were trained during the study period. During this time, the ACS reported a significant increase in website activity. This included 10,530 new visitors, 12,772 visitors overall and 35,342 page views recorded during the study period. CONCLUSION: The NSTBD effort was successful in generating widespread interest for the Stop-the-Bleed initiative. The use of a targeted social media campaign in this context was successful in driving people to available training opportunities while also increasing awareness of the overall effort. While only in its early stages, the NSTBD concept is a good one and should be developed further in coming years. LEVEL OF EVIDENCE: Retrospective, Level V.

Conducting fresh whole blood transfusion training.

Fresh whole blood is the optimal resuscitation fluid for casualties in hemorrhagic shock according to the Committee on Tactical Combat Casualty Care and has demonstrated to improve outcomes in severely wounded patients. Like all medical interventions, fresh whole blood transfusions are not without risks, but similarly can be mitigated through increased training to develop provider knowledge and proficiency. To date, no literature has been published regarding the proper technique to conduct fresh whole blood transfusion training. This article provides a structured foundation to establish a standardized fresh whole blood transfusion training program to increase skill and preparedness for fresh whole blood protocol implementation. Using these techniques in a training environment, providers will be able to provide optimal resuscitation in hemorrhagic shock in austere environments.