J Emerg Med
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Case Reports
Point-of-Care Ultrasound Assists Diagnosis of Spontaneously Passed Common Bile Duct Stone.
Choledocholithiasis complicates approximately 10% of gallstone disease. Spontaneous stone migration out of the common bile duct (CBD) may occur in as many as 20% of choledocholithiasis cases. A decrease in CBD caliber occurs in the setting of spontaneous stone passage, but to our knowledge, this finding has not been appreciated using point-of-care ultrasound (POCUS) in the emergency medicine setting. ⋯ A 49-year-old woman presented to our Emergency Department (ED) with a complaint of epigastric pain radiating to the left shoulder. On examination she was found to have epigastric tenderness to palpation, but no guarding or rebound. POCUS demonstrated a dilated common bile duct, and her liver function tests were abnormally high. She was admitted to Medicine with concern for choledocholithiasis and plan for endoscopic retrograde cholangiopancreatography (ERCP), but her pain had resolved shortly after ED arrival. A repeat ultrasound examination demonstrated a normal-caliber common bile duct approximately 3 h after the initial scan. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Choledocholithiasis often requires admission and invasive testing. Using POCUS in conjunction with liver function tests and patient assessments may obviate a need for ERCP.
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Adequate analgesia is difficult to achieve in patients with an abscess requiring incision and drainage (I&D). There has been a recent increase in regional anesthesia use in the emergency department (ED) to aid in acute musculoskeletal pain relief. Specifically, transgluteal sciatic nerve (TGSN) block has been used as an adjunct treatment for certain chronic lumbar and lower extremity pain syndromes in the ED. ⋯ A 21-year-old woman presented to the ED with a painful gluteal abscess. The pain was so severe that the patient barely tolerated light palpation to the abscess area. Using dynamic ultrasound guidance, a TGSN block was performed with significant pain reduction. Ultrasonographic confirmation of abscess was obtained followed by definitive I&D. She was discharged from the ED and her incision site was healing well at the time of follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Abscess I&D is a common procedure in the ED. Procedural analgesia for I&D can be difficult to obtain. We describe the TGSN block as an additional analgesic option to be used for procedural analgesia. The use of regional anesthesia has the potential to decrease unwanted and at times dangerous side effects of opiate use and resource utilization of procedural sedation while optimizing patient comfort.
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Case Reports
Accelerated Idioventricular Rhythm: A Rare Case of Wide-Complex Dysrhythmia in a Teenager.
Accelerated idioventricular rhythm (AIVR) is an uncommon and typically benign dysrhythmia with similarities to more malignant forms of ventricular tachycardia (VT). It is often seen in adults after myocardial infarctions, although it also arises in the newborn period, as well as in children with and without congenital heart disease. ⋯ We describe a presentation of AIVR in an otherwise healthy 13-year-old girl, discovered on arrival to the pediatric emergency department in the setting of post-tonsillectomy bleeding. The case reviews the diagnostic criteria of AIVR, associated symptoms, the pathophysiologic origin of AIVR, and potential treatment strategies. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given its morphologic similarities to life-threatening forms of VT, AIVR can be misdiagnosed in the emergency department or primary care settings. With an understanding of the dysrhythmia's unique features, emergency physicians can avoid unnecessary interventions and provide the correct diagnosis, workup, and management of AIVR for pediatric patients.
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Review Case Reports
A Posttraumatic Dilated, Proptotic Eye Does Not Always Need a Lateral Canthotomy! A Review of Superior Orbital Fissure Syndrome for Emergency Physicians.
Superior orbital fissure syndrome (SOFS) is a rare constellation of findings consisting of ophthalmoplegia, ptosis, a fixed dilated pupil, forehead anesthesia, and loss of the corneal reflex. This syndrome, though rare, is most often encountered in trauma with individuals sustaining a facial fracture. ⋯ We present a case of a young woman who was diagnosed with SOFS after a fall in her house, hitting her face on a nightstand. Treatment consisted of high-dose i.v. steroids followed by a taper with close follow-up in the Ophthalmology clinic. We provide a brief review of SOFS, including treatment considerations and follow-up. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: SOFS can be easily overlooked in an individual presenting to the emergency department after facial trauma with proptosis. However, a thorough examination of the eye, visual acuity, and intraocular pressure will focus the physician on SOFS rather than the need for immediate decompression via lateral canthotomy. This report describes a traumatic cause of SOFS, the pathophysiology and treatment, and summarizes existing literature.