Not Your Typical Thunderclap Headache.

We present the case of a young adult female who presented to the emergency department with headache and vomiting. After treatment with intravenous fluids, diphenhydramine and metoclopramide the headache completely resolved. Because of the patient's persistent symptoms and past medical history of systemic lupus erythematosus, a noncontrast head CT scan was done. In this case, the patient had a subarachnoid hemorrhage with edema and mass effect, detected on a noncontrast head CT scan. The patient required a nicardipine drip for blood pressure control. The patient recovered well and was discharged at her normal state of health. This case demonstrates the importance of maintaining high clinical suspicion for life-threatening emergencies even in patients with unremarkable physical exams who experience symptomatic improvement after treatment.

6-Year-Old Male Drowning Complicated by Cardiac Arrest and Ensuing Metabolic and Respiratory Acidosis: Should Presence of Pulses Lead Clinicians to Pursue Prolonged Cardiopulmonary Resuscitation?

BACKGROUND: Drowning is one of the leading causes of death in the pediatric population. Patients arriving to the emergency department (ED) with submersion injuries are often asymptomatic and well-appearing, but can sometimes present critically ill and require prolonged resuscitation. The question of how long to continue resuscitation of a pediatric patient with a submersion injury is a difficult question to answer. CASE REPORT: We present a case of 6-year-old boy was found by his friends submerged in sea water for 10-15 min. The patient was rescued by lifeguards and evaluated by emergency medical personnel, who found him breathing spontaneously but unresponsive. En route to hospital, the patient became apneic, cardiopulmonary resuscitation (CPR) was started, and the patient was intubated. The patient arrived to the ED in cardiopulmonary arrest, CPR was continued and epinephrine was administered. Return of spontaneous circulation was achieved after 42 min in the ED. Initial laboratory test results showed severe acidosis and chest x-ray study showed diffuse interstitial edema. Ventilator settings were adjusted in accordance with lung protective ventilation strategies and the acidosis began to improve. Over the next several days, the patient was weaned to noninvasive ventilation modalities and eventually made a complete neurologic recovery and continued to be a straight-A student. Why Should an Emergency Physician Be Aware of This?We make the case that, in select drowning patients, duration of CPR longer than 30 min can potentially result in favorable neurologic outcomes. Prolonged CPR should be especially strongly considered in patients with a pulse at any point during evaluation. With the combination of prolonged CPR and judicious use of lung protective mechanical ventilation strategies, we were able to successfully treat the patient in our case.

Finger Test for the Diagnosis of a Critically Ill Patient with Necrotizing Fasciitis.

BACKGROUND: Necrotizing fasciitis is a life-threatening soft-tissue infection, often characterized by soft-tissue destruction, systemic toxicity, and high mortality. No single laboratory value can diagnose necrotizing fasciitis; ultimately, necrotizing fasciitis is a clinical diagnosis and therefore presents a diagnostic dilemma for many physicians. The finger probe test is useful in confirming the diagnosis when imaging studies are unobtainable or nondiagnostic. CASE REPORT: We present the case of a 70-year-old woman presenting nonverbal and obtunded with a soft-tissue infection of the right lower extremity. The only pertinent positive vital sign was tachypnea with a respiratory rate of 22 breaths/min. Physical examination revealed nonpitting edema, cold-to-touch lower extremity, and Nikolsky-positive hemorrhagic bullae. Initial laboratory test results showed white blood cell count of 38 x 109/L and lactic acid of 8.2 mg/dL. Advanced imaging was unobtainable, given the patient's worsening clinical status, and the decision was made to perform the finger probe test, which revealed absence of bleeding and presence of friable tissue and "dishwater" discharge. Consequently, the general surgery team took the patient to the operating room and performed an above-the-knee amputation and surgical debridement. Postoperative report noted nonviable tissue consistent with necrotizing fasciitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Necrotizing fasciitis is a life-threatening emergency that can destroy soft-tissue at a rate of 1 inch/h. When imaging is unobtainable or nondiagnostic, the finger probe test can be used in select patients to aid with diagnosis.