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.

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.

Guanfacine toxic ingestion with subsequent cardiogenic pulmonary edema.

Guanfacine is a central alpha-2 agonist often prescribed for Attention-deficit hyperactive disorder as well as tic disorder, with a usual dose of 1-4 mg per day. Due to its sympatholytic mechanism of action, Guanfacine can cause autonomic instability and hypotension. It can additionally cause cardiac dysfunction to include symptomatic bradycardias and contractility suppression. The authors present a case of a 17 year-old male with an ingestion of 80 mg of extended release Guanfacine with delayed onset cardiogenic pulmonary edema requiring mechanical ventilation. Previous pediatric ingestions have generated bradycardia, hypotension, and decreased level of consciousness, responsive to intravenous fluids, vasopressors, and occasionally naloxone. However, cardiogenic pulmonary edema from reduced cardiac contractility is a novel consequence of extended release Guanfacine ingestion. With Guanfacine's extended half-life, this unique case underscores the importance of emergency providers' familiarity with this toxidrome as well the necessity for prolonged, close observation following Guanfacine ingestion.

Postpartum Bilateral Subdural Hematomas: A Case Report.

Postpartum headache is a common emergency department (ED) complaint in women following delivery. Though the majority of these headaches are due to primary headache disorders or postdural puncture headaches, life-threatening complications can occur. Both postpartum pre-eclampsia can occur as well as hypercoagulable and vascular disorders including stroke, venous sinus thrombosis (VST), and reversible cerebral vasoconstrictive syndrome. With the increasing use of epidurals for intrapartum analgesia, rare, dangerous complications can present in a similar fashion. The authors present a persistent postpartum headache secondary to bilateral subdural hematomas (SDH) from epidural induced intracranial hypotension.

Pediatric Cirrhotic Variceal Bleed Precipitating Diabetic Ketoacidosis.

Cirrhosis and its associated complications such, as variceal bleeding, are rare in children, carrying significant morbidity and mortality. Leading causes of cirrhosis in the pediatric population include infection, neoplasm, and metabolic and genetic disorders, which is in contrast to the adult population. Acute gastrointestinal bleeding, as seen with variceal bleeding, has been previously associated with diabetic ketoacidosis through a multifactorial relationship. The case was complicated by hypovolemic shock whose resuscitation and subsequent transfusion was associated with cardiac overload. We highlight the need for balanced, judicious resuscitation in these individuals as well as the need for heightened awareness of coexisting pathologies such as diabetic ketoacidosis.

Cardiomegaly Masquerading as a Pediatric Thymoma: A Case Report.

Thymoma is a very rare pediatric tumor, accounting for less than 1% of all childhood mediastinal tumors with scant literature, and only 23 pediatric cases were identified by a pediatric tumor surveillance registry between 1973 and 2008. In contrast to adult thymomas, pediatric thymomas have an aggressive tendency, though the majority is discovered as incidental findings. Patient presentations to the emergency department (ED) are often subtle and non-specific such as dyspnea, cough, and chest pain, requiring a broad differential on the part of the emergency clinician. Because of this presentation, diagnosis often occurs later in the disease process when compared with adults. Chest radiograph may demonstrate an enlarged thymic shadow or cardiomegaly, necessitating further cardiac workup, commonly routed through cardiology. Computed tomography and biopsy are required for definitive diagnosis, requiring a multidisciplinary approach to management. We present a case of a 16-year-old female complaining of progressive dyspnea and chest pain over the course of one to two months with radiographic cardiomegaly. She was found to have a Masaoka stage III World Health Organization (WHO) type B3 thymic endothelial neoplasm and underwent surgical resection.

Thyroid Storm, Rhabdomyolysis, and Pulmonary Embolism: An Unusual Triad Case Report.

INTRODUCTION: Thyroid storm is a medical emergency associated with significant mortality. Hyperthyroid states have been associated with hypercoagulability as well as rhabdomyolysis. However, the pathophysiology of this association remains under investigation. CASE REPORT: A 62-year-old male patient presented to the emergency department with weakness and was found to have thyroid storm with concurrent submassive pulmonary embolisms and rhabdomyolysis. To our knowledge, this is the first reported presentation of this triad. CONCLUSION: This case highlights the potentially difficult diagnosis and management of thyroid storm, as well as associated life-threatening complications, including venous thromboemboli and rhabdomyolysis.

Acute Mesenteric Ischemia With Secondary Thromboembolism: A Rare Complication.

Acute mesenteric ischemia presents a clinical challenge due to its subtle presentation and high mortality rate, which can mimic a variety of other conditions. Acute mesenteric ischemia requires a high index of suspicion, especially in those with comorbidities and risk factors such as hypertension, diabetes, atrial fibrillation, and peripheral arterial disease. The inciting thrombus commonly originates in the left atrial appendage or left atrium, embolizing to occlude mesenteric vessels, with resulting gut ischemia. Patients commonly present with post-prandial abdominal pain as mesenteric vascular demands increase, though diarrhea and gastrointestinal bleeding may be the presenting symptom. CT angiography of the abdomen and pelvis provides rapid confirmation of the diagnosis and visualization of the thrombus, aiding vascular surgical management. The authors present a novel case of a 69-year-old female with an acute mesenteric ischemia of her superior mesenteric artery and a second acute arterial thromboembolism to the right axillary artery visualized from her left atrial appendage.

Hide and Seek: Intermittent Preexcitation Wolff-Parkinson-White Syndrome Case Report and Management Overview.

Wolff-Parkinson-White (WPW) syndrome is an uncommon form of cardiac preexcitation due to an underlying structural accessory pathway, which may lead to potentially lethal arrhythmias. Classic electrocardiogram (ECG) findings of WPW include short PR interval, slurred upstroke of the QRS complex, and prolonged QRS duration. However, in intermittent preexcitation, a rare variant in contrast to continuous preexcitation, these findings are not always present, thus masking a diagnosis of WPW syndrome. Consequently, this may adversely affect or delay the appropriate treatment of short-term tachyarrhythmias and long-term definitive therapies for this syndrome. The emergency physician should promptly obtain an ECG after the termination of any tachyarrhythmia, and maintain a high index of suspicion for intermittent preexcitation with typical WPW ECG findings which were not present on prior studies. The authors present a case of a 17-year-old female diagnosed with an intermittent preexcitation variant of WPW syndrome after a case of successfully treated symptomatic supraventricular tachycardia (SVT).

A Case of Brodie's Abscess With Tibial Erosion and Extravasation Into Surrounding Soft Tissue.

Atraumatic limb pain and limp is a common pediatric presentation in the emergency department in the United States. In a majority of cases, these presentations are benign. However, in cases where pediatric patients are repeatedly presenting for atraumatic limb pain, further investigation is required. We present such the case of a 14-year-old female with acute worsening of progressive atraumatic knee pain who was found to have a Brodie's abscess, a subacute pyogenic form of osteomyelitis. This is a particularly challenging diagnosis, as it often presents with no associated symptoms such as fever or weight loss. The consequences of missing this diagnosis include permanent disability and potential amputation, but excellent outcomes can be expected for those who undergo timely surgical debridement and irrigation. We discuss the etiology, common presentations, and treatment of this rare but potentially limb-threatening disease in the hope that clinicians will consider this diagnosis in cases of persistent or progressive atraumatic limb pain.

Novel Application of Point-of-Care Ocular Ultrasound in a Left Central Retinal Artery Occlusion.

Central retinal artery occlusion represents a vision-threatening entity in those presenting with monocular painless vision loss, especially in the elderly and those with cardiovascular comorbidities. While confirmation of this diagnosis requires consultation with an ophthalmologist, prompt recognition is the crucial action of the emergency physician to help reverse retinal ischemia and save vision. Here we describe the case of a central retinal artery occlusion identified on point-of-care ocular ultrasound and confirmed by fluorescein angiography.

Multisystem organ failure secondary to Haemophilus parainfluenzae infective endocarditis on an ICD lead: A case report.

Infection of implanted cardiac devices (ICD) is an unusual but life threatening event, rarely caused by Haemophilus parainfluenzae. While clinical presentation varies widely, infective endocarditis (IE) involving an ICD lead requires aggressive resuscitation and a multidisciplinary approach. We present a case of a 33-year-old intravenous drug user who presented in multisystem organ failure secondary to infective endocarditis on an ICD lead. This patient had a complicated hospital course requiring removal of her ICD, highlighting the dramatic presentation of this clinical state.

Necrotic Fibroid Mimicking Ovarian Torsion in a Second Trimester of Pregnancy.

Uterine fibroids are incredibly common, benign smooth muscle tumors which range in severity of symptoms from asymptomatic to debilitating. While pain is frequently a symptom, degeneration and necrosis of uterine fibroids can rarely present as acute abdomen. The authors present the case of a pregnant female at 19 weeks' gestation, whose clinical and radiographic presentation mimicked that of ovarian torsion, ultimately requiring exploratory laparoscopy for definitive diagnosis.