High risk and low prevalence diseases: Toxic alcohol ingestion.

INTRODUCTION: Toxic alcohol ingestion is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of toxic alcohol ingestion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Toxic alcohols include ethylene glycol, methanol, isopropyl alcohol, propylene glycol, and diethylene glycol. These substances can be found in several settings including hospitals, hardware stores, and the household, and ingestion can be accidental or intentional. Toxic alcohol ingestion presents with various degrees of inebriation, acidemia, and end-organ damage depending on the substance. Timely diagnosis is critical to prevent irreversible organ damage or death and is based primarily on clinical history and consideration of this entity. Laboratory evidence of toxic alcohol ingestion includes worsening osmolar gap or anion-gap acidemia and end organ injury. Treatment depends on the ingestion and severity of illness but includes alcohol dehydrogenase blockade with fomepizole or ethanol and special considerations for the initiation of hemodialysis. CONCLUSIONS: An understanding of toxic alcohol ingestion can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Sigmoid volvulus after trauma, an uncommon twist.

Sigmoid volvulus occurs when a portion of sigmoid colon twists around its blood supply at the base of the mesentery, causing ischemia and necrosis. In developed nations, this is most commonly a condition of elderly, bed-bound, chronically constipated individuals. However, this condition may occur after blunt abdominal trauma, especially in individuals with underlying anatomic derangements from the aforementioned conditions. We present a unique case of sigmoid volvulus in a patient with no pre-existing abdominal complaints or surgical history, who sustained blunt traumatic injuries when she was struck by a motor vehicle. Prompt recognition of this deadly condition by emergency clinicians facilitated rapid surgical correction and mitigated further morbidity and mortality.

Mycobacterium marinum cellulitis: A fishy etiology.

Skin and soft tissue infections account for 2% of emergency department visits annually, though more unusual causative bacteria associated with saltwater exposure may result in morbidity. Mycobacterium marinum represents a rare but important cause of cellulitis, which if untreated or improperly managed, can progress to dactylitis or osteomyelitis. This unusual diagnosis is made more challenging due to the prolonged incubation period of approximately 21 days, temporally separating the inoculation from the disease. Patients will present with a nodular rash in a sporotrichoid pattern. While doxycycline is one antibiotic providing saltwater coverage, M. marinum has variable sensitivities to anti-mycobacterial antibiotics, and thus biopsy helps confirm the diagnosis as well as provide sensitivities for treatment. Emergency clinicians should inquire about environmental risk factors when caring for patients with cellulitis, especially with atypical skin presentations, and consider M. marinum as a rare but important cellulitis etiology.

Tattoo Associated Native Valve Infective Endocarditis.

Infective Endocarditis (IE) is an uncommon illness in the emergency department (ED) with significant associated morbidity. Patients with IE typically possess risk factors predisposing them to bacterial invasion. These risk factors include intravenous drug use, valvulopathies, valve replacement, poor oral hygiene, immunocompromised state, and recent invasive procedures. A rarer condition is tattoo-associated IE. Diagnosis of IE includes multiple blood cultures and echocardiography. Therapeutic interventions include prolonged intravenous antibiotics and potential surgery. Complications from IE can be severe, including organ injury from septic emboli, heart failure, valvular insufficiency, bacteremia, and fulminant septic shock. Prompt identification and treatment are necessary to reduce patient morbidity and mortality.

A coronavirus disease-2019 induced pancytopenia.

As the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2) pandemic progresses, various hematologic complications have emerged, often centered around the hypercoagulable state. However, pancytopenia represents a rare but serious complication from SARS-CoV2 infection. While lymphopenia is a common finding, concomitant acute anemia and thrombocytopenia are not commonly reported. We describe a novel case of SARS-CoV2 pancytopenia in a 40-year-old male without active risk factors for cell line derangements but subsequent critical illness.

Approach to nephrostomy tubes in the emergency department.

BACKGROUND: Nephrostomy tubes are commonly placed for urinary obstruction, urinary diversion, or future endourologic procedures. While the technical success of nephrostomy tube placement is high, nephrostomy tube complications may occur. OBJECTIVE OF REVIEW: Limited literature exists regarding the complication of nephrostomy tubes and their approach in the emergency department. This review summarizes the existing literature and provides a framework for emergency providers regarding the evaluation and management of nephrostomy tube complications. DISCUSSION: Nephrostomy tube failure, caused by kinking, dislodgment, or migration can manifest with obstructive signs and symptoms. In well appearing patients, asymptomatic bacteriuria is common and should not be treated. However, in the presence of infectious symptoms, patients should be treated similarly to complicated cystitis or pyelonephritis. While gross hematuria is common following catheter placement, prolonged hematuria, or the return of hematuria after previous resolution should trigger investigation for hematoma formation or a delayed presentation of an intraoperative vascular injury. Finally, clinicians should obtain laboratory testing, advanced imaging, and specialty consultation if serious complications are suspected. CONCLUSION: This narrative review highlights general nephrostomy tube care, minor complications, and troubleshooting in the emergency department. The majority of these minor complications can be managed at the bedside without specialty consultation. However, in patients with more serious complications including dislodgement, obstruction, infection, bleeding, and pleural injury, laboratory assessment and advanced imaging to include ultrasound and computed tomography with specialty consultation are essential in the patient's evaluation and management, particularly in cases of immune compromise and worsening renal function.

STEMI Mimic: Focal Myocarditis in an Adolescent Patient After mRNA COVID-19 Vaccine.

BACKGROUND: In May 2021, the U.S. Food and Drug Administration expanded the Emergency Use Authorization for the Pfizer-BioNTech mRNA Coronavirus disease 2019 (COVID-19) Vaccine (BNT162b2) to include adolescents 12-15 years of age. As vaccine administration continues to increase, potential adverse outcomes, to include myocarditis, are being reported to the Vaccine Adverse Event Reporting System. CASE REPORT: This case report describes a 17-year-old male patient who developed focal myocarditis mimicking an ST-segment elevation myocardial infarction (STEMI) 3 days after administration of an mRNA COVID-19 vaccine. Why Should an Emergency Physician Be Aware of This? Myocarditis is a rare complication in adolescents receiving mRNA COVID-19 vaccines. Focal myocarditis may demonstrate localizing electrocardiographic changes consistent with a STEMI. Overall, complications of the mRNA COVID-19 vaccines are extremely rare. The vaccine continues to be recommended by public health experts, as the benefits of vaccinations greatly outweigh the rare side effects.

Incidence of Coagulopathy After Resuscitation at a Role 1 Facility: The Prehospital Trauma Registry Experience.

BACKGROUND: The development of acute traumatic coagulopathy is associated with increased mortality and morbidity in patients with battlefield traumatic injuries. Currently, the incidence of acute traumatic coagulopathy in the Role 1 setting is unclear. METHODS: We queried the Prehospital Trauma Registry (PHTR) module of the Department of Defense Trauma Registry (DoDTR) for all encounters from inception through May 2019. The PHTR captures data on Role 1 prehospital care. Data from the PHTR was linked to the DoDTR to analyze laboratory data and patient outcomes using descriptive statistics. We defined coagulopathy as an international normalized ratio (INR) of ≥1.5 or platelet count ≤150×109/L. RESULTS: A total of 595 patients met the inclusion criteria; 36% (212) met our definition for coagulopathy, with 31% (185) carrying low platelet numbers, 11% (68) showing an elevated INR, and 7% (41) with both. The baseline (no coagulopathy) cohort had a mean INR of 1.10 (95% CI 1.09-1.12) versus 1.38 (95% CI 1.33-1.43) in the coagulopathic cohort. The mean platelet count was 218 (95% CI 213-223) ×109/L in the baseline cohort versus 117 (95% CI 110-125) ×109/L in the coagulopathic cohort. CONCLUSIONS: Our findings indicate a high incidence of coagulopathy in trauma patients. Approximately one-third of wounded patients had laboratory evidence of coagulopathy upon presentation to a forward medical care facility. Advanced diagnostic facilities are therefore needed to facilitate early diagnosis of acute traumatic coagulopathy. Blood products with a long shelf life can aid in early correction.

Efficacy of a Single Day Extracorporeal Membrane Oxygenation Training Course for Critical Care Air Transport Team Eligible Personnel.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel. OBJECTIVES: To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams. METHODS: Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired. RESULTS: Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%). CONCLUSIONS: An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.

Thyrotoxicosis.

Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.

Isolated Uvulitis in a Patient After Smoking Fentanyl.

Isolated uvulitis is a rare but potentially devastating condition that can result in airway compromise. Etiologies include infection, trauma, allergy, primary angioedema, immunologic disorders, and inhalation injury. Uvulitis has been previously reported as a reaction to inhalation of cannabis, crack cocaine, and mephedrone. We present a case of isolated uvulitis with concerns for impending airway obstruction in a patient after smoking fentanyl. While a sore throat is a common chief complaint among ED patients, emergency providers should consider uvulitis within this deadly differential.

Treatment of Massive Hemoptysis with Repeated Doses of Nebulized Tranexamic Acid.

When life-threatening hemoptysis occurs, it can be challenging to treat. We present a case of a 61-year-old female with massive hemoptysis treated with multiple doses of nebulized tranexamic acid (TXA). This treatment led to the resolution of respiratory distress and the improvement of hemoptysis. Ultimately, in cases of massive hemoptysis, repeated treatments with nebulized TXA may be a safe short-term option for symptom management prior to a more definitive therapy via bronchoscopy or bronchial arterial embolization.

Electroconvulsive Therapy-Induced Paroxysmal Atrial Fibrillation in Healthy Young Male.

Electroconvulsive therapy (ECT) is a widely used and highly effective treatment for psychiatric disorders. This is an overall safe option for the management of antidepressant-resistant depression; however, there are known possibilities of cardiac complications. The majority of documented cardiac-related complications due to ECT are found in patients who are middle-aged or older and generally have comorbidities, including prior myocardial infarction, known arrhythmias, hypertension, obesity, diabetes mellitus, family history of cardiac disease, alcohol abuse, and smoking. We present a case of an overall healthy, 21-year-old male with no prior cardiac disease who developed paroxysmal atrial fibrillation (AF) after a routine ECT treatment, his evaluation in the emergency department, treatment, and follow-up.

Facial Natural Killer/T-Cell Lymphoma: A Deadly Sinusitis Mimic.

Sinusitis and pre-septal cellulitis are common emergency department (ED) conditions, though rare and lethal mimics can present in a similar manner. We present a case of natural killer (NK)/T-cell lymphoma mimicking sinusitis and pre-septal cellulitis. Diagnosis of this condition may include imaging modalities such as CT and MRI, though definitive diagnosis requires tissue biopsy. Therapeutic interventions involve chemotherapy and radiation, with little role for surgical debridement. Complications in treatment can occur including hemophagocytic lymphohistiocytosis. Despite standard treatments, mortality remains high for cases of facial lymphoma.

Shallow Water Diving-Associated Alveolar Hemorrhage in an Active Duty Sailor: A Case Report.

Breath-hold diving is a common practice as a part of military dive training. An association between prior lung injury and a propensity for lung barotrauma may have the potential to impact mission readiness for combat divers, Pararescue, Combat Controllers, Army Engineer divers, and various units in Naval Special Warfare and Special Operations. Barotrauma is a common complication of diving, typically occurring at depths greater than 30 m (98.4 ft). Individuals with abnormal lung anatomy or function may be at increased risk of barotrauma at shallower depths than those with healthy lungs, rendering these service members unfit for certain missions. We describe the case of a 25-year-old male, with a remote history of polytrauma and resultant pulmonary pleural adhesions, whose dive training was complicated by lung barotrauma at shallow depths. In missions or training utilizing breath-hold diving, the association with secondary alterations in lung or thoracic anatomy and function may limit which service members can safely participate.

Retropharyngeal Abscess With Severe Airway Compromise Following Anterior Cervical Spine Surgery: A Case Report.

Anterior cervical corpectomy, discectomy, and fusion are common surgical management options for symptomatic cervical radiculopathy and myelopathy. While these procedures are common and well-tolerated, postoperative complications span from mild dysphasia to airway compromise secondary to retropharyngeal or peri-cervical space abscess. These critical patients require robust airway management, which may entail a multidisciplinary approach or airway management in the operating room. We describe a patient who developed airway compromise 10 days following anterior cervical discectomy and fusion with a pre-platysmal abscess and a large retropharyngeal abscess. These abscesses were large enough to cause a mass effect with tracheal deviation. This deviation was severe enough that the patient required awake incision and drainage prior to rapid sequence intubation.