J Emerg Med
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Management of pain from traumatic rib injury is very challenging. Both acute and chronic pain caused by rib injury can cause significant morbidity (pain-induced hypoventilation, pneumonia, respiratory failure) and functional hindrance. Traditional pain management strategies in the emergency department (ED) that target acute traumatic rib pain are limited by the side effects of medications or the temporary half-life of anesthetics used for a nerve block. Both treatment modalities fall short of addressing subsequent chronic sequelae. ⋯ We present the first-time use of cryoneurolysis on an ED patient for the treatment of 10/10 severe traumatic intercostal neuralgia that resulted in the patient being discharged home pain free. The patient initially underwent a multilevel left-sided T5-T7 intercostal nerve block, followed by ultrasound-guided percutaneous cryoneurolysis of those intercostal nerves using two cycles of 2 min of cooling to a temperature of -70°C (nitrous oxide), with 30 s of thawing in between. The patient experienced 100% pain relief immediately post procedure that was sustained. He remained completely symptom free more than 6 months after the bedside procedure and returned to sports without restrictions. Why Should an Emergency Physician Be Aware of This? This case highlights the benefits of cross-departmental collaboration between the ED, Anesthesia, and Pain Management. We hope this model of multidisciplinary pain modulation can be replicated for other patients with similar pain and can herald a new paradigm of pain management in the ED.
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Symptomatic arsenic toxicity has not been associated with terracotta pottery despite thousands of years of use in food storage and preparation. We describe a case of chronic arsenic toxicity from undiagnosed pica involving the ingestion of terracotta pots. ⋯ A 49-year-old woman with a history of anemia and abnormal uterine bleeding presented to the Emergency Department complaining of lower extremity pain. She was also noted to have chronic lower extremity paresthesia, constipation, and fatigue. She admitted to ingesting glazed and unglazed terracotta pots for the past 5 years. This unusual craving was thought to be a manifestation of pica in the setting of chronic anemia. The patient was found to have an elevated urinary arsenic concentration of 116 µg/24 h. An abdominal radiograph showed opacifications throughout her bowel, and she received whole bowel irrigation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pica is a common behavior in certain populations. Practicing clinicians should be familiar with the complications of pica, including chronic arsenic toxicity and its associated array of nonspecific symptoms.
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Nonfatal strangulation has been identified as a common occurrence in intimate partner violence and can be associated with significant injuries and, at times, increased mortality. ⋯ Professionals providing legal and medical care to victims of nonfatal strangulation can be educated and forensic nurse examinations can be implemented successfully in an expeditious period of time with a county collaborative program approach.
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Delirium, poor performance status, and dyspnea predict short survival in the palliative care setting. ⋯ Patients with advanced cancers who present to the ED and have at least two triple threat conditions have a high probability of death within 30 days.
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Case Reports
Polyarticular Septic Arthritis Secondary to Septic Thrombophlebitis of the Brachiocephalic Vein: A Rare Case Report.
Polyarticular septic arthritis (PASA) accounts for approximately 15% of all septic arthritides and is rare in immunocompetent adults. Even with appropriate therapy PASA's mortality rate is nearly 50%. ⋯ We report a rare presentation of PASA caused by idiopathic septic thrombophlebitis of the brachiocephalic vein in an immunocompetent adult female patient who presented with symptoms of right clavicular, left wrist, and right hip pain associated with fevers. Methicillin-sensitive Staphylococcus aureus was isolated in blood cultures and joint aspiration of one of the affected hips. Transesophageal echocardiogram was negative for valvular vegetations and computed tomography chest with contrast revealed thrombi in the brachiocephalic and subclavian veins extending to the superior vena cava. It also showed bilateral pulmonary nodules consistent with septic pulmonary emboli. No clear precipitant for the underlying septic thrombophlebitis was identified. Management was conservative, with systemic anticoagulation and IV antibiotics. The patient's symptoms improved, and she was discharged to subacute rehabilitation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early diagnosis and treatment of PASA in the emergency department is imperative to reducing overall morbidity and mortality associated with this condition. To the best of our knowledge, this is the only case report of idiopathic septic thrombophlebitis of the subclavian vein causing PASA in an immunocompetent adult.