J Emerg Med
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Case Reports
Retroperitoneal and Cutaneous Necrotizing Fasciitis Secondary to Necrotizing Pancreatitis.
Retroperitoneal abscesses are rare complications of intraabdominal infectious processes and can progress to necrotizing infections. Necrotizing pancreatitis occurs in 10-25% of patients that require hospital admission for pancreatitis, is associated also with a 25% mortality rate, and may lead to formation of a retroperitoneal abscess. ⋯ We report a case of a 63-year-old woman with a recently resolved case of pancreatitis who presented to the Emergency Department (ED) with a painful nodule on her left flank for 3 weeks, rapidly progressing over the last 12 h. In the ED, examination revealed an expanding area of erythema over the left flank with sepsis. Computed tomography scan revealed necrotizing pancreatitis with retroperitoneal abscess tracking to the abdominal wall, resulting in necrotizing fasciitis. She was taken emergently to the operating room with a good outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Acute pancreatitis is common, with a minority of cases resulting in parenchymal necrosis, which can lead to retroperitoneal infections. Rarely, necrotizing fasciitis can present on the abdominal wall as a complication of intraabdominal or retroperitoneal infections. The emergency provider should be aware of these complications that may lead to necrotizing infections and a potentially indolent course.
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Femoral venous access is an essential part of patient care in the emergency department (ED). However, current medical literature and texts have not dealt with it much using actual patient anatomy. ⋯ Up to 95% of people have some degree of overlap of the femoral vein by the femoral artery. By positioning the leg in an abducted and externally rotated position, the amount of overlap is reduced and the diameter of the vein is increased, maximizing the percentage of the vein available for cannulation.
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Emergency physicians can utilize bedside ultrasound to aid in the diagnosis of abdominal wall hernias and in the reduction of incarcerated hernias. ⋯ A physician trained in bedside ultrasound can diagnose an abdominal wall hernia and facilitate the appropriate treatment of an incarcerated hernia.
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Pelvic injuries in young children are rare, and it has been difficult to establish clinical guidelines to assist providers in managing blunt pelvic trauma, especially in non-Level 1 trauma centers. ⋯ Patterns of injury, based on mechanism of injury, have been reported to assist the assessment and management of children with minor pelvic injuries.
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Traumatic coronary artery dissection (CAD) after blunt chest trauma (BCT) is extremely rare, particularly in children. Among coronary dissections, left main coronary artery (LMCA) dissection is the least common, with only two pediatric cases reported previously. Manifestations of coronary dissections can range from ST segment changes to sudden death. However, these manifestations are not specific and can be present with other cardiac injuries. To our knowledge we present the first pediatric case of traumatic LMCA dissection after sport-related BCT that was treated successfully with coronary stenting. ⋯ A 14-year-old child sustained BCT during a baseball game. Early in the clinical course, he had episodes of ventricular dysrhythmias, diffuse ST changes, rising troponin I, and hemodynamic instability. Emergent cardiac catheterization revealed an LMCA dissection with extension into the proximal left anterior descending artery (LADA). A bare metal stent was placed from the LMCA to the LADA, which improved blood flow through the area of dissection. He has had almost full recovery of myocardial function and has been managed as an outpatient with oral heart failure and antiplatelet medications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case highlights that CAD, although rare, can occur after pediatric BCT. Pediatric emergency responders must have a heightened awareness that evidence of ongoing myocardial ischemia, such as evolving and focal myocardial infarction on electrocardiogram, persistent elevation or rising troponin I, and worsening cardiogenic shock, can represent a coronary event and warrant further evaluation. Cardiac catheterization can be both a diagnostic and therapeutic modality in such cases. Early recognition and management is vital for myocardial recovery.