Post-COVID-19 rash: An atypical manifestation of guttate psoriasis.

Many complications are emerging from Coronavirus Disease 2019 (COVID-19), likely secondary to immune dysfunction and autoimmunity. While dermatologic changes have been reported, de novo guttate psoriasis, typically associated with streptococcal and other viral infections, secondary to COVID-19 infection has been minimally described. The authors report a case of a 34-year-old man who developed a diffuse rash 3 weeks following a COVID-19 infection found to have new onset guttate psoriasis who was responsive to topical corticosteroids and a vitamin D analog.

High risk and low prevalence diseases: Infected urolithiasis.

INTRODUCTION: Infected urolithiasis is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of infected urolithiasis, including presentation, diagnosis, and management in the emergency department based on current evidence. DISCUSSION: Although urolithiasis is common and the vast majority can be treated conservatively, the presence of a concomitant urinary tract infection significantly increases the risk of morbidity, to include sepsis and mortality. Identification of infected urolithiasis can be challenging as patients may have symptoms similar to uncomplicated urolithiasis and/or pyelonephritis. However, clinicians should consider infected urolithiasis in toxic-appearing patients with fever, chills, dysuria, and costovertebral angle tenderness, especially in those with a history of recurrent urinary tract infections. Positive urine leukocyte esterase, nitrites, and pyuria in conjunction with an elevated white blood cell count may be helpful to identify infected urolithiasis. Patients should be resuscitated with fluids and broad-spectrum antibiotics. Additionally, computed tomography and early urology consultation are recommended to facilitate definitive care. CONCLUSIONS: An understanding of infected urolithiasis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Oseltamivir induced oral-only erythema multiforme.

Severe dermatologic and mucosal adverse reactions to oseltamivir are rare. To date, only two other case reports have described mucosal changes secondary to oseltamivir, but both cases were associated with concomitant skin changes. We report a case of a previously healthy 18-year-old-male who developed oral-only erythema multiforme after being treated with oseltamivir for influenza B. Given the frequency of which oseltamivir is prescribed, we highlight the importance of recognizing this uncommon but serious adverse reaction.

Acute coronary syndrome in Dextrocardia.

Situs inversus with dextrocardia is both a clinical and diagnostic challenge for emergency physicians to properly identify acute coronary syndrome. While dextrocardia itself does not independently increase the risk of coronary artery disease, mirrored symptoms, including right-sided and rightward radiating chest pain in any patient with cardiac risk factors should raise suspicion for acute coronary syndrome. In patients with a reversed cardiac silhouette on a chest radiograph, a reversed electrocardiogram, to include both the precordial and limb leads, is necessary to evaluate for cardiac ischemia in presumed dextrocardia. The authors present a case of a 66-year-old man with dextrocardia who presented with shortness of breath and hypotension. Rapid application of a reversed electrocardiogram resulted in the timely diagnosis of ST-segment elevation myocardial infarction and activation of the cardiac catheterization laboratory resulting in the preservation of this patient's life.

Chimeric antigen receptor T-cell therapy: An emergency medicine focused review.

INTRODUCTION: Several novel cancer therapies have been recently introduced, each with complications that differ from chemotherapy and radiation. OBJECTIVE: This narrative review discusses complications associated with chimeric antigen receptor (CAR) T-cell therapy for emergency clinicians. DISCUSSION: Novel immune-based cancer therapies including CAR T-cell therapy have improved the care of patients with malignancy, primarily lymphoma and leukemia. However, severe complications may arise, including cytokine release syndrome (CRS) and immune effector cell-associated neurotoxicity syndrome (ICANS). CRS is associated with excessive cytokine release that results in severe end organ injury. Patients present with fever and a range of symptoms based on the affected organs. Grading is determined by the need for cardiopulmonary intervention, while management focuses on resuscitation, evaluation for other concomitant conditions, and treatment with tocilizumab or steroids. ICANS is also associated with cytokine release, causing patients to present with a variety of neurologic features. A grading system is available for ICANS based on feature severity. Management is supportive with steroids. Other complications of CAR T-cell therapy include infusion reactions, hypogammaglobulinemia, tumor lysis syndrome, cytopenias, cardiac toxicity, and graft-versus-host disease. CONCLUSIONS: Knowledge of this novel cancer therapy class and the potential complications can improve the care of these patients in the emergency department setting.

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.

Immune checkpoint inhibitors: An emergency medicine focused review.

INTRODUCTION: Several novel cancer therapies have been developed, many of which focused on immune system modulation. These include immune checkpoint inhibitors, modulators, T-cell therapy, monoclonal antibodies, cytokines, oncolytic viruses, and vaccines. Although many of these therapies are well tolerated, significant adverse reactions can occur as a result of these novel drugs. OBJECTIVE: This narrative review discusses complications associated with immune based cancer therapies, specifically immune checkpoint inhibitors, for emergency clinicians. DISCUSSION: Novel cancer therapies including immune checkpoint inhibitors can improve the care of patients with malignancy. However, these therapies have a number of potential complications, known as immune-related adverse events (irAEs). Complications can involve the neurologic, cardiac, pulmonary, dermatologic, renal, gastrointestinal, hepatic, and hematologic systems. IrAEs most commonly occur in the first several months following treatment initiation. These complications can be graded based on severity of clinical and laboratory findings. While most of these irAEs are mild, patients may present with critical illness. Treatment commonly includes immune checkpoint inhibitor discontinuation, steroids, and evaluation for other immunosuppressant medications. CONCLUSIONS: Knowledge of this novel cancer therapy class and its potential complications can improve the care of patients on immune checkpoint inhibitors in the emergency department setting.

Facilitated Intubation: Time to Re-examine an Old Technique With Its Associated Risks Mitigated by New Technology.

BACKGROUND: Facilitated intubation (FI) refers to intubation performed using a sedative or anesthetic drug as an induction agent, without the use of a paralytic (neuromuscular blocking agent). In comparison, rapid sequence intubation (RSI) employs both an induction agent and a paralytic drug. RSI has been seen to outperform FI in terms of first-pass success when performing direct laryngoscopy and was quickly adopted as the gold standard in all situations. Recently, ketamine-only intubation has been used in situations where there is distorted anatomy or apnea intolerance (physically and physiologically difficult airways) resulting in an increased risk of a can't intubate/can't oxygenate scenario or significant hypoxemia. Frequent and recurring national ketamine shortages have resulted in renewed interest in whether or not other forms of FI are feasible in an era where other factors that mitigate complictions in achieving first-pass success (video laryngoscopy, bougie use, semi-Fowler positioning) are commonly used. We present a case series with outcomes for profoundly hypoxic patients with coronavirus disease 2019 (COVID-19) (physiologically difficult airways) undergoing FI during a time of national ketamine shortage, using modern techniques and technology to maximize first-pass success and minimize peri-intubation complication. METHODS: We included patients with COVID-19 pneumonia with pre-intubation oxygen saturations of less than 80% (significant hypoxemia) requiring intubation who presented to a tertiary care center in southern United States between August 25, 2021, and October 22, 2021. In this specific cohort, patients underwent endotracheal intubation with midazolam for induction without the use of paralytic agents. We used video-assisted laryngoscopy to increase the success of the first-pass attempt as well as placing the patients in a semi-Fowler position (head of bed elevation 30-45°) and bilevel positive pressure pre-oxygenation to minimize peri-intubation complications. RESULTS: Our case series included 29 consecutive patients that met the inclusion criteria. The mean ± standard deviation (SD) age of the patients was 49.5±15.0 years. The mean±SD pre-intubation oxygenation of our cohort was 73.1±5.9%. All 29 intubations were successful on the first-pass attempt. Only one patient (3.4%) required a rescue paralytic to facilitate oral opening. Of note, 27/29 (93%) of the patients did not receive any immunizations (including partial) for COVID-19. There were no incidents of peri-intubation arrest (cardiac arrest within 30 minutes of induction) or aspiration. CONCLUSIONS: In 29 physiologically difficult patients with acute respiratory failure, in whom the physician determined that RSI posed a higher than normal risk, FI assisted by VL, semi-Fowler positioning, and bilevel positive pressure pre-oxygenation resulted in excellent successful first-pass intubation rates without any incidences of peri-intubation arrest or aspiration. While this cohort was small, our study reveals that FI with midazolam does not likely pose a higher risk than ketamine-only intubation and warrants further study.

A Review of Acute Kidney Injury.

Acute kidney injury (AKI) is a serious, often silent, medical condition with diverse etiologies and complex pathophysiology. We discuss the case of a patient injured in a single vehicle rollover. Included is a discussion of prevention and supportive care, with a focus on electrolyte repletion, fluid correction, minimization of nephrotoxic exposures, and identification and treatment of the root cause.

Small Bowel in Vagina: A Case for Pelvic Exams.

Vaginal cuff dehiscence with small bowel evisceration is a serious but uncommon postoperative complication of total laparoscopic hysterectomies. The severity of surgical site dehiscence can range from small, partial to full-thickness wound dehiscence, manifesting with acute abdominal pain, vaginal bleeding, or discharge, and is often precipitated by sexual intercourse. While imaging, including a pelvic ultrasound and computed tomography (CT), may help in undifferentiated acute abdominal pain, vaginal cuff dehiscence remains a clinical diagnosis found on physical exam. Because vaginal cuff dehiscence is a clinical diagnosis, sparse data exist regarding radiographic sensitivities and specificities in the identification of vaginal cuff dehiscence. Despite the increasing literature suggesting that pelvic exams are invasive with often limited utility, the authors argue that pelvic exams remain essential in identifying complications of hysterectomies. The authors present a case of a 40-year-old woman with acute abdominal pain found to have loops of small bowel in the vaginal vault, discovered only on physical exam after negative CT and ultrasound imaging.

Interrater Agreement and Reliability of Burn Size Estimations Between Emergency Physicians and Burn Unit.

The initial approach to burn injuries has remained relatively unchanged over the past several decades and revolves around trauma assessment and fluid resuscitation, frequently initiated in the emergency department (ED). While previous research suggests that emergency physicians (EP) are poor estimators at total body surface area (TBSA) affected, we believe that estimation differences are improving, specifically at academic centers with co-located burn units that emphasize burn injury education. This study investigated the interrater agreement and reliability of burn size estimations at an academic ED and its co-located burn unit. This single-center, retrospective study was conducted at a large academic ED with a co-located burn unit. The study included adult patients admitted to the burn unit after receiving paired burn size estimations from EPs and the burn unit. The primary endpoint was the interrater agreement, measured by the kappa coefficient, κ, of 10% TBSA estimation intervals. The secondary endpoint was the intraclass correlation coefficient (ICC), evaluating the reliability of exact, nonranged, and TBSA estimations. A chart review was performed for patients evaluated from November 1, 2016 to July 31, 2019. One thousand one hundred and eighty-four patients were admitted to the burn unit, 1176 of which met inclusion criteria for the primary endpoint. The κ of TBSA between EPs and the burn unit was 0.586, while the weighted κ was 0.775. These values correlate with moderate and substantial agreements, respectively. Additionally, 971 patients had exact TBSA estimations from paired EPs and the burn unit which were used for the secondary endpoint. The ICC between EPs and the burn unit was 0.966, demonstrating an excellent reliability. Further sub-analysis was performed, revealing mean over- and underestimation differences of exact TBSA estimations of 3.93 and 2.93, respectively. EPs at academic institutions with co-located burn units are accurate estimators of TBSA in the assessment of burn injuries. We believe that burn education, to include core rotations within the burn unit, plays a major role in improved burn size estimations.

Seizure-Associated Takotsubo Cardiomyopathy.

Takotsubo cardiomyopathy (TCOM) is a syndrome characterized by acute systolic dysfunction that can mimic acute coronary syndrome (ACS), usually incited by physical or emotional stress. However, acute neurological dysfunction, including seizures, has been recently described as an additional risk factor for the development of TCOM. This specific case report reviews the pathophysiology of TCOM and its management. We emphasize that providers should maintain a high index of suspicion for TCOM after acute neurologic dysfunction in patients with chest pain or hemodynamic instability, while also initiating proper investigation for ACS. Although classically thought of as a transient process, recent data show that both in-hospital and post-hospital morbidity and mortality related to this condition remain concerning.

A Tale From the Early Stone Age: Pediatric Ureterolithiasis as Appendicitis Mimic - A Case Report and Management Overview.

Ureterolithiasis in the pediatric population is uncommon and may mimic acute abdomen. While the majority of small stones pass spontaneously, complications may ultimately warrant surgical intervention. As the majority of affected patients have a predisposing condition, targeted therapy with close and consistent follow-up may prevent recurrence, emphasizing timely diagnosis. The authors present the case of a previously healthy 13-year-old boy with eight days of right lower quadrant abdominal pain and emesis, who was found to have a distal ureteral stone necessitating surgical intervention.

Man with Penile Pain.

CASE PRESENTATION: We describe a case of spontaneous partial segmental thrombosis of the corpus cavernosum (PSTCC). DISCUSSION: PSTCC is a rare condition in which thrombus formation occurs in the corpus cavernosum. This condition is managed in conjunction with a urologist, and management typically includes anticoagulation and pain control.

ST-Segment Elevation in the Setting of Diabetic Ketoacidosis: Is It Acute Coronary Syndrome?

Diabetic ketoacidosis (DKA) with resulting hyperkalemia can lead to ST-segment elevations on electrocardiogram (ECG). Previous publications theorize that significant improvements in patient potassium levels lead to the resolution of this rare phenomenon, also known as "pseudo-infarct" pattern. The authors provide a unique case along with a literature review of DKA-associated ST-segment elevations. This specific case distinctively demonstrates the resolution of the pseudo-infarct pattern in the setting of minor improvements in serum potassium and continued acidosis.

Subdural Empyema in an Immunocompetent Active Duty Soldier: A Case Report.

Intracranial subdural empyema is a rare clinical entity with incidence estimates of 0.1 per 100,000 people. The condition is most often the sequela of a primary infection elsewhere and carries a high morbidity and mortality. The authors present the case of a 22-year-old active duty soldier on mission on the southern border of the United States. The patient had been complaining of headaches that became progressively worse over 2 weeks and presented to a civilian hospital where he was diagnosed with intracranial abscess versus sinus thrombosis on radiographic imaging. The patient was promptly transferred to a military tertiary care center where further workup including pivotal imaging confirmed subdural empyema and right transverse sinus thrombosis. Given the rapid patient deterioration associated with subdural empyema, the emergent intravenous antibiotics, neurosurgical consultation, and subsequent collection evacuation performed are likely to credit for saving this soldier's life. This case highlighted an atypical and time-sensitive etiology for a common complaint in the active duty population, which underscores the requirement for evacuation to higher roles of care in those soldiers with a similar diagnosis.