Case Presentation: A 28-year-old woman was brought to the emergency department after being found collapsed at home. Because she was unable to provide a history, contextual bedside clues were important during the initial assessment. Bright yellow granular material with a medicinal odor was noted adherent to her hair. This unusual finding raised suspicion of overdose with an acetaminophen-containing over-the-counter (OTC) cold medication. Her serum acetaminophen concentration was elevated at 135 micrograms per milliliter, and N-acetylcysteine was promptly administered. She did not develop hepatic injury and was discharged after recovery. Discussion: This case highlights the diagnostic value of visible bedside clues when history is initially unavailable. The yellow residue was not pathognomonic, and no chemical analysis of the material was performed. However, in the context of the increasing incidence of overdoses involving OTC medications in Japan, especially among young women, the finding was clinically sufficient to raise suspicion for possible ingestion of an OTC combination cold medication containing acetaminophen. This mattered because it directly prompted serum acetaminophen measurement and timely antidotal treatment with N-acetylcysteine, which can prevent or mitigate acetaminophen-induced liver injury.
A seven-year-old girl presented to the pediatric emergency department with three days of nonbloody, nonbilious vomiting, nonbloody diarrhea, and decreased oral intake. She also had weight loss and fatigue over the preceding month. The examination showed persistent tachycardia despite antipyretics and fluids. This presentation addresses the many causes of persistent tachycardia in a child with a diagnostic test sent from the emergency department revealing the ultimate diagnosis.
Introduction: Agitation in the emergency department (ED) poses a significant safety concern for staff and patients. Multidisciplinary responses, such as Code Violet activations, are common but resource-intensive. Early identification and intervention may reduce escalation, but ED-specific data are limited. The objective of the study was to evaluate the implementation of a novel agitated behavior score (ABS) and assess whether higher ABS scores are associated with increased risk of Code Violet activation. Case Series: This prospective observational study included adult patients admitted to a behavioral health unit in a community teaching hospital ED. Trained staff administered a novel 25-point ABS incorporating altered mentation, verbal agitation, and motor agitation. The primary outcome was Code Violet activation; secondary outcomes included pharmacologic interventions and substance use. Among 83 patients, 27 (33%) experienced ≥ 1 Code Violet activation. And those patients with Code Violet activation had higher initial ABS scores (mean 10.9 [6.35] versus 4.6 [4.43]; P <.001). Overall rates of psychotropic medication use were similar between groups; however, time to first medication was longer in the Code Violet group (4.0 versus 2.7 hours). Patients with Code Violet activations more frequently received parenteral medications, whereas those without the code activation more commonly received oral agents. Conclusion: The agitated behavior score was associated with Code Violet activation and may help identify patients at greater risk of behavioral escalation. While it measures current agitation rather than predicting future agitation, its structured format may facilitate early recognition and management of agitation.
Introduction: The placement of central venous catheters (CVC) is a common procedure for the administration of chemotherapy. Adverse events include malposition or displacement; there are limited reports of misplaced implanted CVCs. Case Report: A 59-year-old female with a history of recently diagnosed metastatic small cell lung cancer, hypertension, former tobacco use of over 60 pack-years, and chronic obstructive pulmonary disease without chronic hypoxemic respiratory failure presented to the emergency department following the first outpatient infusion of chemotherapy. She developed acute onset dyspnea, moderate respiratory distress, and hypoxemia. She was found to have a malpositioned subclavian implanted (ie, “port”) CVC that was placed under fluoroscopy the week prior with placement confirmed by chest radiograph. The evaluation revealed a large right pleural effusion secondary to unintentional intrapleural infusion of chemotherapy. The patient was transferred to a tertiary-care center with successful clinical improvement after drainage of the effusion via tube thoracostomy. Conclusion: We present an uncommon diagnosis of a chemothorax from a malpositioned central venous catheter in the thorax, despite a radiograph suggesting correct placement, and infusion of chemotherapy causing a common complaint of shortness of breath. This case highlights the limitations of radiographic confirmation of CVCs and a resultant complication from malpositioning.
Introduction: The “lucky nut” is the seed of the yellow oleander plant, often sold as a medicinal supplement in unregulated markets and known to contain cardiac glycosides, which may cause life- threatening bradycardias and Digoxin-like toxicity upon ingestion. Diagnosis is typically clinical, with treatment including Digoxin immune Fab with supportive intensive cardiac care. Case Report: A 70-year-old male presented to the emergency department after ingesting one-fourth of a Peruvian nut he found at a local market to reduce his nocturnal polyuria. The patient brought a part of the Peruvian nut with him, which was identified as a seed of the yellow oleander. His clinical presentation was consistent with a digoxin-like toxicity, requiring multiple vials of Digoxin immune Fab and admission to the cardiac intensive care unit. Conclusion: Yellow oleander can cause a cardiac glycoside-related cardiotoxicity similar to a digoxin-like toxicity. Digoxin-like toxicity should be considered in the bradycardic patient with a recent ingestion of a plant or seed. It is important to obtain a thorough history including medication reconciliation and supplement use. Despite well-documented dangers, yellow oleander continues to appear as an unregulated ingredient or contaminant in dietary supplements. This case highlights the severity of oleander toxicity, the challenge of managing digoxin-like cardiac glycoside poisoning, and the public health risk posed by unintentional ingestion of supplements containing yellow oleander.
Introduction: The use of antipsychotic drugs can prolong the corrected QT (QTc) interval of the electrocardiogram and cause a life-threatening ventricular arrhythmia. There is no consensus as to what is considered normal or what cutoff indicates QTc prolongation. However, recent literature has described the biological variation of the QTc interval from healthy subjects, with researchers concluding that the best approach at establishing a normal range is to determine an individual baseline interval during health. Case Report: A baseline QTc interval (460 milliseconds) had been determined for a 42-year-old female with a history of schizophrenia and depression who was prescribed antipsychotic drugs including escitalopram, olanzapine, haloperidol, clonazepam and divalproex over the course of four years. Over that time frame, she was admitted on 20 occasions with chest pain, but her QTc interval was at or above her baseline level. Acute coronary syndrome was ruled out for each episode. Her medication history was not altered or discontinued until her QTc was greatly prolonged at 530 milliseconds several years later. Fortunately, she did not suffer torsades de pointes. Conclusion: This case illustrates how results from biological variation studies and a personalized reference level can be helpful to alert physicians earlier of the presence of a potentially toxic condition.
CASE PRESENTATION:A 60-year-old male from the country of Jordan presented to the emergency department with swelling, pain, black lesions on his fingertips and thumb, and a red streak up his arm. The patient had been trimming sheep wool and goat skin two weeks prior to onset of symptoms and cut his left thumb with trimming shears. DISCUSSION:Cutaneous anthrax is caused by Bacillus anthracis, a Gram-positive, spore-forming rod found naturally in the soil. Populations at greatest risk include those who consume undercooked meat with contaminated spores or who live and work in rural/agricultural areas. Occupations considered to be at a higher risk include farmers, wool sorters, and veterinarians. Although cutaneous anthrax is rare in the United States (U.S.), there have been cases reported since the bioterrorism attacks in 2001 when mail laced with anthrax was sent via the U.S. Postal Service. Human infection occurs in countries where the disease is endemic in livestock. Because there are no rapidly available diagnostic tests the diagnosis is primarily clinical. It is important to consider the possibility of cutaneous anthrax in the appropriate setting, despite the rarity of cases in the U.S. High clinical suspicion should be maintained in anyone presenting with the appropriate skin findings, especially in those traveling from endemic countries (South and Central Asia, Sub-Saharan Africa, Southern and Eastern Europe, Central America, South America, and the Caribbean).
Introduction: Immunoglobulin A (IgA) vasculitis, formerly known as Henoch–Schönlein purpura, is a small-vessel leukocytoclastic vasculitis caused by IgA immune complex deposition. While it is the most common systemic vasculitis in children, adult cases can present with more severe systemic manifestations. The classic clinical tetrad includes palpable purpura, arthralgia, abdominal pain, and renal involvement. Gastrointestinal symptoms, occurring in approximately two-thirds of cases, result from inflammation of small bowel vessels resulting in bowel wall edema and hemorrhage, which may serve as lead points for intussusception. Case Report: A 21-year-old male presented with two days of severe periumbilical abdominal pain, bilateral knee pain, and a nonblanching palpable purpuric rash on his lower extremities. Physical examination revealed a soft but tender abdomen. Lab results were remarkable for leukocytosis. Computed tomography (CT) of the abdomen and pelvis demonstrated small bowel wall thickening and ileoileal intussusception. The patient was initially consented for a partial ileal resection; however, an exploratory laparotomy failed to localize the telescoping segment, suggesting spontaneous resolution. He was observed for 24 hours and discharged with outpatient follow-up. Conclusion: Intussusception is the most common surgical complication of IgA vasculitis. In adults, this condition requires high clinical suspicion and prompt diagnostic imaging with ultrasonography or CT, as small bowel involvement may be inaccessible by contrast enema. This case underscores the importance of recognizing IgA vasculitis-associated intussusception as a critical and potentially self-limiting complication in the adult population.
Introduction: Globe injuries constitute true ophthalmologic emergencies and require prompt surgical intervention. When direct physical examination is limited, due to trauma or swelling, point-of-care ultrasound (POCUS) can serve as a valuable adjunct in evaluating globe integrity. Case Report: We report the case of a 31-year-old male who presented to the emergency department with a barbed fishing hook embedded in his right eyelid. The patient reported pain localized to the eyelid but denied any visual disturbances or direct eye involvement. On examination, a large fishing hook embedded in the right upper eyelid was visualized. His eye was swollen, and he was unable to fully open it, limiting direct assessment of the globe. Given the limited exam, POCUS of the right eye revealed a foreign body traversing the anterior chamber toward the lens, raising concern for globe injury. Ophthalmology was consulted, and computed tomography of the orbits was obtained. The following morning, the patient underwent surgical removal of the barbed fishing hook and repair of the globe. Conclusion: Point-of-care ultrasonography is a valuable diagnostic adjunct in the evaluation of traumatic eye injuries and useful when physical examination is limited. In this case, POCUS was used to differentiate an intraocular foreign body and globe injury from eyelid foreign body. While POCUS is not routinely recommended in cases of suspected globe rupture, when physical exam is unclear it may be a useful adjunct.
INTRODUCTION:Infective endocarditis (IE) is associated with high mortality (30%). Patients with structural cardiac disease or implanted hardware have higher risk for IE (23-47%). Diagnosis per the 2023 Duke-International Society for Cardiovascular Infectious Diseases criteria is by pathological confirmation or the major/minor criteria. Major criteria include ≥ 2 positive blood culture sets, echocardiography or computed tomography vegetation visualization, and surgical visualization. Septic emboli symptoms (which complicate 25% of IE cases) include neurological deficits or shortness of breath. Early intravenous antimicrobial therapy within one hour for patients who meet sepsis criteria is recommended per Infectious Diseases Society of America guidelines. CASE REPORT:A middle-aged male with recent IE and aortic valve prosthesis presented to the emergency department with altered mental status and hypoglycemia. He had right basilar lung rales but no heart murmur, leg swelling, or jugular venous distension. He met sepsis criteria with leukocytosis and hypothermia. Computed tomography head was performed due to his altered mental status and revealed a right parietal-occipital hypodense lesion concerning for an abscess with edema and mass effect. Given his history of IE and ill appearance, three blood culture sets were drawn and intravenous antibiotics initiated. The patient was admitted to the hospital with magnetic resonance imaging confirming brain abscess; and neurosurgery performed a craniotomy with brain abscess evacuation. Intravenous antibiotics were continued for four weeks for septic brain emboli from recent IE. CONCLUSION:Clinicians should keep a broad differential for altered mental status patients. Sepsis patients should have antimicrobials initiated within one hour. Expedited diagnosis with three sets of blood cultures, echocardiography, and surgical consult should be completed in patients with suspected infective endocarditis for improved patient outcomes. Finally, clinicians should evaluate for septic emboli symptoms such as neurological deficits or respiratory symptoms.
Introduction: Blunt thoracic aortic injury is a rare but potentially fatal consequence of motor vehicle collisions. While commonly associated with hemodynamic instability, some cases present with normal vital signs, delaying diagnosis and treatment. We present the case of a 42-year-old unrestrained backseat passenger who sustained a blunt thoracic aortic injury following a motor vehicle collision and underwent emergent endovascular repair. This case emphasizes the critical role of early imaging and multidisciplinary coordination in the management of high-risk trauma patients. Case Report: A 42-year-old female presented to the emergency department (ED) following a high-risk motor vehicle collision. She was an unbelted passenger in a vehicle traveling at approximately 35 miles per hour that collided with a telephone pole. The patient was unconscious at the scene but regained consciousness en route. Upon arrival at the ED she was alert, oriented, and hemodynamically stable. Her vital signs were as follows: blood pressure, 107/58 millimeters of mercury; heart rate, 62 beats per minute; respiratory rate, 18 breaths per minute; and oxygen saturation, 100% on room air. Physical examination revealed anterior chest wall tenderness but no signs of respiratory distress. Imaging revealed a high-grade blunt thoracic aortic injury with a left-sided hemothorax. The patient underwent emergent thoracic endovascular aortic repair and remained hemodynamically stable throughout hospitalization. Conclusion: Blunt thoracic aortic injury can present with hemodynamic stability despite its life-threatening nature. This case highlights the necessity of early imaging and multidisciplinary coordination in optimizing outcomes for high-risk trauma patients.
Introduction: Acute abdomen is a common emergency presentation, and gastrointestinal perforation can be rapidly fatal if not promptly identified. Point-of-care ultrasound (POCUS) offers a rapid bedside alternative when advanced imaging is delayed or unavailable. Case Report: We report a 40-year-old man presenting in cardiac arrest, resuscitated after ten minutes, with subsequent findings of abdominal distension and prior epigastric pain. Point-of-care ultrasound demonstrated classic signs of pneumoperitoneum, and intestinal perforation was confirmed by the drainage of feculent fluid. Despite intervention, the patient expired. Conclusion: This case underscores the value of POCUS in diagnosing perforation in unstable patients, guiding emergent decisions when transfer or definitive imaging is not feasible.
Introduction: Natural supplements are readily available without a prescription and are not regulated by the United States Food and Drug Administration. The popularity of berberine, a bioactive compound used for centuries in traditional Chinese medicine, has surged due to its proposed benefits in glycemic control and cardiovascular health. However, use of berberine may lead to possible negative electrophysiologic changes. Case Report: A 92-year-old male presented to the emergency department (ED) with chief complaints of tremors, urinary incontinence, and brief syncopal episodes that began approximately two weeks after starting berberine. In the ED he had multiple episodes of polymorphic ventricular tachycardia with pulselessness requiring immediate cardioversion, with a rapid return of spontaneous circulation between episodes. Amiodarone was started; however, despite this, he continued to have persistent episodes. Finally, the episodes resolved after starting lidocaine and isoproterenol in the intensive care unit. The patient’s workup was notable for heart rate-corrected QT interval (QTc) prolongation (QTc 616 milliseconds (ms) [male reference range, QTc < 430 ms]) confirming the polymorphic ventricular tachycardia as torsades de pointes. His cardiac evaluation was otherwise normal, including a normal ejection fraction on a transthoracic echocardiogram. Withholding berberine and supportive management resulted in an improved QTc. On hospital day 3, the QTc was 454 ms. The patient had a short inpatient admission and was discharged without any further episodes. Conclusion: Berberine has numerous effects and is purported to have beneficial effects and cardioprotective properties. Due to induced bradycardia and QT prolongation, patients who take berberine can be vulnerable to life-threatening arrhythmias, such as the R-on-T phenomenon in our patient’s case. Additional research on berberine is needed to better inform clinician–patient discussions about its use.
Introduction: Aortoesophageal fistula is a rare but life-threatening hemorrhagic complication of thoracic endovascular aortic repair. Without intervention, mortality approaches 100%. Our case highlights the utility of using an esophageal-gastric balloon tamponade device for hemostasis. Case Report: We report the case of a 70-year-old man who presented after a sentinel episode of hematemesis six days after thoracic endovascular aortic repair. Shortly after admission, the patient developed massive hematemesis and hemorrhagic shock from an aortoesophageal fistula. Hemorrhage was temporarily controlled via bedside placement of a Minnesota tube, a type of balloon tamponade device, by two emergency medicine and critical care physicians, allowing for hemostasis, resuscitation, and definitive diagnosis with esophagogastroduodenoscopy. The device successfully bridged the patient to the operating room, where he underwent definitive endovascular control of the hemorrhage and repair of the aortoesophageal fistula. Conclusion: Our case highlights the utility and pragmatism of using a balloon tamponade device for massive hematemesis in nonvariceal hemorrhage. It also supports the placement of the device for non-variceal hemorrhage by nonspecialists, including critical care and emergency physicians.
Introduction: Entrectinib is a kinase inhibitor used in ROS1-positive non-small cell lung carcinoma. Cardiovascular toxicity is rare, with only one prior report of myocarditis related to entrectinib use. The triangular QRS-ST-T waveform electrocardiographic pattern is a ST-elevated myocardial infarction equivalent and is rarely associated with myocarditis. Case Report: A 42-year-old male with metastatic non-small cell lung carcinoma presented with presyncope, palpitations, and dyspnea three days after initiating entrectinib. Electrocardiograph (ECG) revealed a “shark-fin” T-wave morphology with diffuse ST elevation, QTc prolongation, and elevated troponin. ST-elevated myocardial infarction protocol was initiated with tenecteplase, heparin, clopidogrel, and aspirin. Left heart catheterization was normal. The ECG showed an ejection fraction of 20–25% with global hypokinesis. Myocarditis with heart failure associated with entrectinib use was suspected. Cardiac magnetic resonance imaging confirmed myopericarditis with subsequent recovery of ejection fraction to 57%. The patient was discharged after five days with complete recovery. Conclusion: This is the second reported case of myocarditis associated with entrectinib use and the second documented case of myocarditis presenting with a T-wave ECG pattern. Clinicians should be aware that entrectinib is associated with early-onset myocarditis and that the T-wave pattern, while strongly correlated to occlusive myocardial infarction, may rarely occur in myocarditis. Prompt recognition is critical to avoid mismanagement.
Introduction: Retrograde intubation is a seldom used but valuable technique in managing difficult airways, especially in resource-limited settings when advanced equipment is unavailable or ineffective. Case Report: We report the case of a 64-year-old male with advanced ankylosing spondylitis and severe cervicothoracolumbar kyphosis who presented with altered mental status and respiratory distress. Extreme fixed cervical flexion, markedly restricted mouth opening, and an inaccessible anterior neck rendered direct laryngoscopy, video laryngoscopy, fiberoptic intubation, and surgical airway approaches unfeasible. Retrograde nasotracheal intubation was successfully performed, resulting in airway stabilization and hemodynamic improvement. Conclusion: This case highlights retrograde intubation as a lifesaving low-technology technique in complex anatomic and physiologic airways, demonstrating its continued relevance under the updated Difficult Airway Society 2025 guidelines.
Introduction: Shoulder pain is a common emergency department (ED) presentation. Scapular winging is a rare condition often associated with long thoracic nerve injury. This case report describes an even rarer case of dorsal scapular nerve injury caused by a nontraumatic first rib fracture in a young weightlifter, an injury mechanism not previously reported in the literature. Case Report: A 17-year-old male presented to the ED with left shoulder pain following weightlifting. Physical examination demonstrated scapular winging, and a clinical diagnosis of dorsal scapular neuropraxia was made. Imaging revealed a nontraumatic first rib fracture. The patient was treated conservatively with nonsteroidal anti-inflammatory drugs and rest, resulting in complete resolution of symptoms within two weeks at clinic follow-up. Conclusion: To our knowledge, this is the first case in the emergency medicine literature of a nontraumatic rib fracture with associated dorsal scapular nerve injury and scapular winging. This case highlights the importance of thorough visual inspection and movement assessment by emergency physicians in patients presenting with shoulder pain, as key findings such as scapular asymmetry and neurologic injuries may otherwise be missed. Recognizing rare injuries like nontraumatic first rib fractures with associated neurologic deficits is critical for timely diagnosis and management, which can lead to excellent outcomes.
Introduction: Many emergency physicians will never perform a lateral canthotomy and cantholysis, and one-third of those who try will be unsuccessful at relieving the pressure that threatens permanent vision loss. This procedure is notoriously difficult and rare, but a recently proposed alternative—the vertical lid split—may be simpler and more effective. Case Report: We report the case of a 35-year-old woman with motor vehicle collision-related orbital trauma who presented to a community emergency department. Initially, she had intact vision and extraocular movements. Imaging showed a comminuted inferior orbital blowout fracture with retrobulbar hemorrhage, and the transfer process was initiated. However, after coughing she developed vision loss and elevated intraocular pressure. Lateral canthotomy and cantholysis was performed for suspected orbital compartment syndrome but did not fully address the elevated pressures or restore vision. The emergency physician then performed a vertical lid split procedure, which fully restored vision and normalized pressures. Conclusion: To the best of our knowledge, this is the first case report of orbital compartment syndrome to be treated with vertical lid split, and the first case report of any full-thickness eyelid incision technique being used for salvage of an unsuccessful lateral canthotomy and cantholysis; the result was excellent.
Introduction: Hyperkalemia is a common and potentially life-threatening complication of end- stage renal disease, often producing nonspecific symptoms but profound cardiac effects. While nonadherence and dietary indiscretion are typical precipitants, clinicians must also consider the adequacy and effectiveness of dialysis. Case Report: We report a patient with end-stage renal disease on thrice-weekly hemodialysis who presented with significant bradycardia and altered mental status. Initial prehospital electrocardiogram (ECG) was suspicious for acute coronary syndrome after automated ECG interpretation suggested anterior ST-segment elevation. In the emergency department, the patient was in a junctional escape rhythm with diffuse peaked T-waves. Serum potassium was 7.8 millimoles per liter with concomitant uremia. Despite administration of potassium-shifting therapies bradycardia persisted, and temporary pacing attempts failed. An epinephrine infusion was initiated while arranging for emergent hemodialysis. Following dialysis, the potassium normalized, cardiac conduction returned to sinus rhythm, and the patient’s mental status improved. In the absence of missed dialysis sessions, increased potassium intake, or access site dysfunction, nephrology determined the likely etiology to be dialysis access recirculation from improper cannulation. Conclusion: Dialysis recirculation is an uncommon but important cause of inadequate clearance leading to life-threatening hyperkalemia. Clinicians should consider this mechanism when confronted with otherwise unexplained electrolyte derangements in compliant dialysis patients.
