An unusual cause of neck pain: acquired Chiari malformation leading to brainstem herniation and death

Background

Chiari malformations are structural defects in which portions of the cerebellum are located below the foramen magnum. Of the four types of Chiari malformation, emergency physicians are most likely to encounter Type I (Chiari I). Chiari I malformations may be congenital or acquired. Congenital Chiari I malformations are most frequently encountered in the emergency department (ED) setting due to an exacerbation of subacute or chronic Chiari-related symptoms. However, acute Chiari-associated symptoms from an occult congenital or a secondary (acquired) Chiari malformation may occur.

Objective

To present a literature-guided approach to the identification and initial management of patients with Chiari I malformations in the ED setting.

Case Report

We present the case of a 30-year-old man who presented to the ED with isolated cervical region pain, and who subsequently died as a result of acute brainstem herniation from an acquired Chiari I malformation.

Conclusions

Although rare, acute Chiari I malformation may present to the ED. The new finding of a Chiari I malformation should be presumed acquired until proved otherwise, and should trigger an evaluation for central nervous system lesions or hydrocephalus. Brain imaging to exclude increased intracranial pressure and, in certain cases, specialty consultation, are important considerations.     

Fetal outcomes in first trimester pregnancies with an indeterminate ultrasound

Background

Pregnant women commonly present to the Emergency Department (ED) for evaluation during their first trimester. These women have many concerns, one of which is the viability of their pregnancy and the probability of miscarriage.

Study Objectives

We sought to determine fetal outcomes of women with an indeterminate ultrasound who present to the ED during the first trimester of pregnancy.

Methods

A retrospective analysis of consecutive ED patient encounters from December 2005 to September 2006 was performed to identify patients who were pregnant and who had an indeterminate transvaginal ultrasound performed by an emergency physician or through the Radiology Department during their ED visit. Demographic data, obstetric/gynecologic history, and presenting symptoms were recorded onto a standardized patient chart template designed to be used for any first trimester pregnancy. Outcomes (spontaneous abortion, ectopic pregnancy, and 20-week gestation) were determined via computerized medical records.

Results

During the study timeframe, a total of 1164 patients were evaluated in the ED during the first trimester of their pregnancy; 359 patients (30.8%) met inclusion criteria and had a diagnosis of indeterminate ultrasound. Outcome data were obtained for 293 patients. Carrying the pregnancy to ≥20 weeks occurred in 70 patients (23.9%). Spontaneous abortion occurred in 193 women (65.9%), and 30 women (10.2%) were treated for an ectopic pregnancy. Total fetal loss incidence was 89.2% in patients presenting with any vaginal bleeding, compared to 34.7% in patients with pain only.

Conclusion

Indeterminate ultrasounds in the setting of first trimester symptomatic pregnancy are indicative of poor fetal outcomes. Vaginal bleeding increased the risk of fetal loss. These data will assist emergency physicians in counseling women in the ED who are found to have an indeterminate ultrasound.     

Hypotension after medical termination of pregnancy: think outside of the uterus

Background

Under usual circumstances, an ectopic pregnancy would not be generally considered in the initial differential diagnosis of shock after voluntary termination of pregnancy.

Objective

To present a rare case of a young woman with shock after voluntary termination of pregnancy due to undiagnosed ectopic pregnancy with concealed hemorrhage.

Case Report

A 37-year-old woman presented to the Emergency Department (ED) 3 days after termination of pregnancy with clinical features of shock. The patient had some evidence of infection and was initially managed as a case of septic shock secondary to possible complication of recent termination of pregnancy. Subsequent work-up led to suspicion of internal bleeding, and ruptured ectopic pregnancy was confirmed and managed successfully.

Conclusion

Ruptured ectopic pregnancy can present with a wide range of symptoms and under variable circumstances. Recognition of subtle signs of hemorrhage and consideration of the diagnosis of ruptured pregnancy in the ED will lead to early diagnosis and appropriate management.     

Prepubertal Girl with Vaginal Bleeding

Background

Prepubertal children with vaginal bleeding are frequently brought in to the Emergency Department (ED) for evaluation with the primary concern of sexual abuse. Appropriate history and physical examination can help recognize the specific cause and allay anxiety of parents and reduce unnecessary work-up.

Objective

The purpose of this report is to describe a frequently unrecognized cause of vaginal bleeding that is unrelated to sexual abuse.

Case Report

We report the case of a 6-year-old African-American girl referred to our ED as a case of vaginal bleeding with suspicion of sexual abuse. She was clinically diagnosed to have urethral prolapse.

Conclusion

In prepubertal girls with vaginal bleeding, urethral prolapse should be strongly considered as a diagnostic possibility. Increased physician awareness and early recognition of urethral prolapse avoids unnecessary examinations and patient anxiety and prevents misdiagnosis as sexual abuse.     

Transarterial Embolization for Traumatic Intractable Oronasal Hemorrhage

Background

Severe craniofacial injury may cause intractable oronasal bleeding, a rare but life-threatening surgical emergency that may occur in the Emergency Department (ED). Uncontrolled massive bleeding is the major cause of mortality. This kind of trauma is usually associated with the transfer of high kinetic energy such as a motor vehicle collision.

Objective

We report an unusual case of intractable oronasal bleeding diagnosed by angiography.

Case Report

A 43-year-old man was brought to the ED after being in a high-energy motor vehicle collision. He had suffered severe craniofacial trauma, including intracranial hemorrhage and intractable oronasal bleeding; he later developed a large pseudoaneurysm arising from the right internal maxillary artery. In the ED, the patient successfully underwent endovascular treatment (EVT) using angiography with transarterial embolization (TAE) therapy to control the bleeding.

Conclusion

EVT by TAE for intractable oronasal bleeding was an effective treatment in this life-threatening situation.     

A Case of Sudden,Painless, and Persistent Urinary Incontinence

Background

Urinary incontinence is not a common emergency department (ED) complaint, and it is hard to imagine that a case involving this complaint could turn out to be interesting. We report the case of a patient who presented with the complaint of sudden onset of painless urinary incontinence for 1 day, who had an unexpected diagnosis.

Objectives

To describe a case of incontinence with an unexpected diagnosis and to review the various causes of incontinence.

Case Report

A 52-year-old woman with a history of kidney stones recently treated with lithotripsy, nephrostomy tubes, and ureteral stents, presented to the ED complaining of new-onset incontinence. The patient had awakened on the morning of presentation with urinary incontinence that persisted throughout the day. On examination she had normal vital signs, and other than a functioning nephrostomy tube, she had a normal examination. In addition to a urinalysis, a KUB (kidney, ureter, and bladder) X-ray study was performed, which showed that her recently placed right ureteral stent had migrated from its original location into the urethra. The stent was found by the urologist protruding from the urethral meatus and removed without difficulty. The patient’s incontinence resolved immediately after the stent was removed.

Conclusion

Emergency physicians frequently see patients with ureteral stents, but may not be aware of how frequently those stents can migrate or malfunction. Our experience suggests that radiologic determination of stent location may be helpful in patients who present with new-onset stress or overflow incontinence.     

Narcotic bowel syndrome

Background

Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists.

Objectives

The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome.

Case Report

We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin.

Conclusions

It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.     

Altered and Unstable: Wet Beriberi,a Clinical Review

Background

Undifferentiated altered mental status and hemodynamic instability are common presenting complaints in the Emergency Department (ED). Emergency practitioners do not have the luxury of time to perform sequential examination, history, testing, diagnosis, and treatment. Rather, we do all of these things at once to save lives and decrease morbidity. An important diagnosis to consider and upon which we can easily intervene is that of thiamine deficiency.

Objectives

We present a case of an altered and unstable woman who presented to our busy ED and had rapid improvement after the administration of vitamin B1. We discuss the presentation, pathophysiology, consequences of missed diagnosis, and management of this disease process.

Case Report

A middle-aged woman presented to our ED with unstable vital signs and an alteration in her mental status. She was unable to provide a history. Empiric treatment with thiamine resulted in the resolution of her hemodynamic instability and improvement in her mental status.

Conclusion

Our patient benefited from the swift administration of thiamine and illustrates the importance of thiamine administration in the altered or hemodynamically unstable emergency patient with an elevated lactate.     

Evaluation of mid-regional pro-atrial natriuretic peptide,procalcitonin, and mid-regional pro-adrenomedullin for the diagnosis and risk stratification of dyspneic ED patients

Objective

The aim of this study was to evaluate the diagnostic and the prognostic value of a laboratory panel consisting of mid-regional pro-atrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) for patients presenting to the emergency department (ED) with acute dyspnea.

Methods

We prospectively enrolled ED patients who presented with a chief complaint of dyspnea and who had an uncertain diagnosis after physician evaluation. Final primary diagnosis of the cause of shortness of breath was confirmed through additional testing per physician discretion. We recorded inpatient admission and 30-day mortality rates.

Results

One hundred fifty-four patients were enrolled in the study. Congestive heart failure exacerbation was the final primary diagnosis in 42.2% of patients, while infectious etiology was diagnosed in 33.1% of patients. For the diagnosis of congestive heart failure exacerbation, MR-proANP had a sensitivity of 92.7% and specificity of 36.8%, with a negative likelihood ratio (LR−) of 0.16 and a positive likelihood ratio (LR+) of 1.44 (cut-off value: 120 pmol/L). For the diagnosis of an infectious etiology, PCT had a 96.5% specificity and 48.8% sensitivity (LR−: 0.58, LR+: 13.8, cutoff value: 0.25 ng/mL). As a prognostic indicator, MR-proADM demonstrated similar values: odds ratio for 30-day mortality was 8.5 (95% CI, 2.5-28.5, cutoff value: 1.5 nmol/L) and the area under the receiver operating characteristic curve in predicting mortality was 0.81 (95% CI, 0.71-0.91).

Conclusion

The good negative LR− of MR-proANP and the good positive LR+ of PCT may suggest a role for these markers in the early diagnosis of ED patients with dyspnea. Furthermore, MR-proADM may assist in risk stratification and prognosis in these patients..     

Near-Miss in Focused Lower-Extremity Ultrasound for Deep Venous Thrombosis

Background

Focused, proximal compression ultrasound (FPCUS) is a commonly used point-of-care study in the Emergency Department (ED). Pelvic vein deep venous thrombosis (DVT) is a rare presentation, and Emergency Physicians need to be aware of the limitations and pitfalls of FPCUS.

Objective

A case of external iliac vein DVT diagnosed in the ED is presented, with a focus on subtle signs seen during FPCUS that led to the diagnosis and additional ultrasound techniques to aid in appropriate point-of-care diagnosis.

Case Report

We describe a patient who presented with lower-extremity pain and was subsequently diagnosed with external iliac DVT. A FPCUS study by Emergency Physicians was performed and demonstrated subtle findings that led to further investigation and appropriate diagnosis.

Conclusion

Emergency physicians using FPCUS in the evaluation of lower-extremity pain or swelling need to be aware of the pitfalls, limitations, and advanced techniques to avoid misdiagnosis while evaluating for DVT.     

Identification of intraluminal thrombus by ultrasonography in emergency department patients with acute deep venous thrombosis

Background

Traditionally, the diagnosis of deep venous thrombosis (DVT) using duplex ultrasonography (DU) has relied on the absence of venous compressibility. Visualization of an intraluminal thrombus is considered an uncommon finding.

Objectives

The purpose of this study is to determine the frequency of intraluminal thrombus in emergency department (ED) patients diagnosed with acute DVT.

Methods

Retrospective chart review of adult ED patients with DU examinations demonstrating acute DVT. Patients with chronic DVT or patients in whom DU did not demonstrate DVT were excluded from data analysis. Study reports and ultrasound images were reviewed and analyzed for the presence of intraluminal thrombus.

Results

There were 189 patients who met inclusion criteria, of which 160 (85%) were found to have intraluminal thrombus.

Conclusion

Intraluminal thrombi are present in the majority of patients in our ED in whom acute DVT is identified by DU.     

Fetal loss in symptomatic first-trimester pregnancy with documented yolk sac intrauterine pregnancy

Background

The possibility of spontaneous miscarriage is a common concern among pregnant women in the emergency department (ED).

Objective

This study sought to determine fetal outcomes for women following ED evaluation for first-trimester abdominopelvic pain or vaginal bleeding who had an intrauterine pregnancy (IUP) on ultrasound before a visible fetal pole (“yolk sac IUP”).

Methods

A retrospective chart review of consecutive ED charts from December 2005 to September 2006 identified patients with a yolk sac IUP. Demographic data, obstetric/gynecologic history, and presenting symptoms were obtained. Outcomes were determined via computerized records. Fetal loss was diagnosed by falling β-human chorionic gonadotropin or pathology specimen. Live birth was diagnosed by viable fetus at 20-week ultrasound or delivery.

Results

A total of 131 patients were enrolled in this study. Of these, 14 were lost to follow-up (12%), leaving 117 patient encounters. Of the 117 women, 82 carried their pregnancies to at least 20-week gestation. Thirty-five patients miscarried. Fetal loss rate by chief complaint were as follows: 8 of 46 patients presenting with pain only, 14 of 34 presenting with vaginal bleeding only, and 13 of 37 with both vaginal bleeding and pain.

Conclusion

Seventy percent of women diagnosed with a yolk sac IUP in the ED carried their pregnancy to at least 20 weeks. The remaining women (30%) experienced fetal loss. Vaginal bleeding (with or without pain) increased the rate of fetal loss compared with women with pain only. These data will assist the emergency physician in counseling women with symptomatic first-trimester pregnancies.     

Seizure as a Presentation of Pulmonary Embolism

Background

Seizure is estimated to be the presenting symptom of pulmonary embolism (PE) < 1% of the time. A review of the available literature on the subject indicates that many of the reported cases are postmortem findings, and invariably, are examples of delayed diagnosis and treatment.

Objectives

To heighten physician awareness of the possibility of a PE in patients initially presenting with seizures, and to bring to light some key aspects of the history and physical examination that may assist in the final diagnosis.

Case Report

A 76-year-old man presented to the Emergency Department (ED) after suffering from two tonic-clonic seizures at home. He had a history of one isolated seizure 4 years prior, for which he was not prescribed any medication after full evaluation, including a negative electroencephalogram. In the ED, he was noted to have a resting tachycardia and a room air oxygen saturation of 92%. This prompted further evaluation in the ED. Electrocardiography and D-dimer were ordered, and both were found to be abnormal. Computed tomography scan was positive for multiple large pulmonary emboli. The patient was given an appropriate dose of enoxaparin and admitted to the internal medicine service.

Conclusion

Despite an atypical presentation, the authors were able to diagnose the patient due to a high level of suspicion for the disease. Our goal is to make physicians more attuned to the possibility of a PE as a final diagnosis in patients who present with new-onset seizures.     

Torsion of an undescended testis located in the inguinal canal

Background

Torsion of undescended testis located within the inguinal canal is a rare finding in the emergency department (ED). This diagnosis can present as undifferentiated abdominal or groin pain, and a full genitourinary examination is essential to making this diagnosis.

Objectives

We present this case to increase awareness among emergency physicians regarding torsion of undescended testis.

Case Report

A 5-year-old boy presented to the ED with abdominal pain and a mass in his right groin. Physical examination and Doppler ultrasound were used to diagnose torsion of undescended testis.

Conclusions

In a patient with undescended testis, torsion must be considered as a cause of abdominal or groin pain. Full genitourinary examination is essential to making this diagnosis.     

Female Patient Self-diagnosis Compared With Emergency Physician Diagnosis of Urinary Tract Infection

Background

Urinary tract infection (UTI) is a common emergency department (ED) complaint and self-diagnosis may be possible.

Objective

The objective was to compare female patient self-diagnosis compared with emergency physician (EP) diagnosis of UTI.

Methods

This was a prospective cohort study in a single urban ED. Women aged 18–64 years with a chief complaint of UTI, urinary frequency, or dysuria who presented to an urban academic ED were enrolled in a convenience sample fashion. Patients completed a written four-question survey by an ED greeter before triage. Charts of respondents were reviewed for demographic, laboratory, and EP diagnosis.

Results

Fifty women were enrolled; 100% of patients who were approached participated in the study. Mean age was 33.7 years (standard deviation 13.8). Forty-three patients (86%) had a history of UTI. Forty-one patients (82%) thought they had a UTI on the index visit. Thirty patients (60%) preferred to buy over-the-counter antibiotics for their symptoms instead of seeing a doctor. Fifteen patients (30%) identified a specific antibiotic they would take. Of the 41 patients who thought they had a UTI, 25 (61%) were given that diagnosis. Of the 30 patients who would have preferred over-the-counter antibiotics, 20 (67%) were actually prescribed them. Agreement between EP and women's final impressions was low (κ = 0.11).

Conclusions

There was poor agreement between EP diagnosis and self-diagnosis of UTI. In our ED population, women should be encouraged to seek medical attention to confirm the diagnosis.     

Emergency ultrasound diagnosis of ovarian hyperstimulation syndrome: case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an exaggerated response to ovulation induction therapy. It is a known complication of ovarian stimulation in patients undergoing treatment for infertility. As assisted reproductive technology and the use of ovulation induction agents expands, it is likely that there will be more cases of OHSS presenting to the Emergency Department (ED).

Objectives

OHSS has a broad spectrum of clinical manifestations, from mild abdominal pain to severe cases where there is increased vascular permeability leading to significant fluid accumulation in body cavities and interstitial space. Severe cases may present to the ED with ascites, pericardial effusions, pleural effusions, and lower extremity edema. Through a case report, we review OHSS with an emphasis on early diagnosis by Emergency Physician (EP)-performed bedside ultrasonography.

Case Report

We present a case of a patient undergoing treatment for infertility who presented to the ED with shortness of breath and abdominal pain. The diagnosis of severe OHSS was made, largely based on EP-performed bedside ultrasonography showing peritoneal free fluid and bilateral pleural effusions, as well as multiple ovarian follicles.

Conclusions

This report reviews the pathophysiology of OHSS, its clinical features, and pertinent diagnostic and management issues. This report emphasizes the importance of early EP-performed bedside ultrasonography.     

Patient Factors Associated with Failure to Diagnose Tuberculosis in the Emergency Department

Background

Emergency department (ED) presentation of pulmonary tuberculosis (TB) can be highly atypical and an ED visit might be the only health care interaction for high-risk patients.

Objective

Our objective was to identify patient factors associated with discharge without a diagnosis of TB during an infectious ED visit.

Methods

The study population consisted of 150 patients from 2000 to 2009 with 190 infectious ED visits. Patients were initially identified from the state registry of confirmed TB cases and epidemiological characteristics were identified prospectively during case investigation. A retrospective review was performed for clinical characteristics of visits dichotomized according to whether the diagnosis of TB was made during the ED visit.

Results

Analysis revealed that 77% of all infectious-patient visits ended with a diagnosis of TB. A TB diagnosis was more likely when patients presented with pulmonary or infectious chief complaints, endorsed cough, subjective fever, chills, dyspnea, previous TB infection, or had an abnormal lung examination or chest x-ray study. Patients were significantly less likely to be diagnosed with TB when they were unresponsive during clinical evaluation or when they reported a history of both homelessness and any substance abuse during the last year. In addition, these characteristics were independent predictors of nondiagnosis when traditional TB risk factors or abnormal vital signs were considered.

Conclusions

Patients with atypical presentations, as well as those who were unresponsive or reported a history of homelessness and substance abuse, were at greater risk for nondiagnosis of TB during an infectious ED visit.     

Ability of Emergency Ultrasonography to Detect Pediatric Skull Fractures: A Prospective,Observational Study

Background

Blunt head trauma is a common reason for medical evaluation in the pediatric Emergency Department (ED). The diagnostic work-up for skull fracture, as well as for traumatic brain injury, often involves computed tomography (CT) scanning, which may require sedation and exposes children to often-unnecessary ionizing radiation.

Objectives

Our objective was to determine if bedside ED ultrasound is an accurate diagnostic tool for identifying skull fractures when compared to head CT.

Methods

We present a prospective study of bedside ultrasound for diagnosing skull fractures in head-injured pediatric patients. A consecutive series of children presenting with head trauma requiring CT scan was enrolled. Cranial bedside ultrasound imaging was performed by an emergency physician and compared to the results of the CT scan. The primary outcome was to identify the sensitivity, specificity, and predictive values of ultrasound for skull fractures when compared to head CT.

Results

Bedside emergency ultrasound performs with 100% sensitivity (95% confidence interval [CI] 88.2–100%) and 95% specificity (95% CI 75.0–99.9%) when compared to CT scan for the diagnosis of skull fractures. Positive and negative predictive values were 97.2% (95% CI 84.6–99.9%) and 100% (95% CI 80.2–100%), respectively.

Conclusions

Compared to CT scan, bedside ultrasound may accurately diagnose pediatric skull fractures. Considering the simplicity of this examination, the minimal experience needed for an Emergency Physician to provide an accurate diagnosis and the lack of ionizing radiation, Emergency Physicians should consider this modality in the evaluation of pediatric head trauma. We believe this may be a useful tool to incorporate in minor head injury prediction rules, and warrants further investigation.     

Behavioral Problems of Seniors in an Emergency Department

Background

Behavioral disorders are frequent in seniors with cognitive impairments. The ailment responsible for presentation to the Emergency Department (ED), in combination with preexisting conditions, can bring about a temporary cognitive disturbance or worsen an existing cognitive disturbance, thus increasing the frequency of behavioral disorders.

Study Objectives

The purpose of this research was to investigate whether there is any connection between pain, cognitive impairment, time in the ED, presence or absence of a supportive escort, and behavioral disorders exhibited by a senior.

Methods

The study sample consisted of 140 seniors aged 69 years and older who visited the ED. Data collected included personal data, presence or absence of an escort, length of stay in the ED, and formal reproducible evaluation of cognition, behavior, and pain.

Results

Behavioral disorders were found to be present in 18% of the total sample and in 25% of the group of seniors who suffered from cognitive impairment. The presence of cognitive impairment was found to increase by almost sevenfold the risk of a behavioral disorder. Presence of severe pain increased the risk of a behavioral disorder even more (odds ratio 63). Seniors with cognitive impairment who spent a longer-than-average time period in the ED exhibited behavioral disorders that were more severe than disorders in seniors without cognitive impairment. There was no moderating effect on behavioral disturbances by the presence of a supportive escort observed.

Conclusions

The findings of this study suggest that the risk of behavioral disorders in seniors attending the ED may be predicted by screening them for cognitive impairment and pain, and by monitoring the time period they are in the ED.     

Identification of Lipohemarthrosis With Point-of-Care Emergency Ultrasonography: Case Report and Brief Literature Review

Background

Traumatic knee pain is a common complaint in the emergency department (ED). Conventional radiographs are often ordered as the initial screening study, but might not be readily available or always identify significant fractures. Ultrasonography has been shown to be useful in the evaluation of knee fractures not identified by radiography.

Objectives

To discuss and briefly review the literature regarding the use of suprapatellar bursal ultrasonography to detect lipohemarthrosis (LH) as a surrogate marker for an intraarticular knee fracture.

Case Report

A 37-year-old man presented to the ED after a traumatic knee injury. Bedside ultrasonography demonstrated the characteristic triple layer sign of LH, raising the suspicion for an intraarticular fracture. The diagnosis was later confirmed with radiography and computed tomography (CT).

Conclusions

The sonographic finding of LH may be used as a sensitive surrogate marker for intraarticular knee fracture in the ED. Ultrasound can be considered as an adjunct modality in ED patients with suspicion for fracture and negative knee radiographs.