J Emerg Med
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Tension pneumoperitoneum (TPP) is a rare but life-threatening pathology in which significant accumulation of free air in the peritoneum pressurizes the abdominal cavity, creating conditions similar to abdominal compartment syndrome. Due to compression of intra-abdominal vasculature, TPP results in hemodynamic instability. While it most commonly occurs due to viscus perforation in the setting of recent endoscopy, gastric perforation from resuscitative efforts can also lead to TPP. ⋯ We present a case of a 58-year-old female who was intubated out-of-hospital for unresponsiveness, then subsequently developed abdominal distension, mottled lower extremities, and hemodynamic instability. In the emergency department, the patient self-extubated for a brief time before suffering cardiac arrest. During resuscitative efforts, imaging showed significant abdominal free air concerning for tension pneumoperitoneum. The likely etiology was positive pressure ventilation after esophageal intubation, resulting in gastric perforation and rapid accumulation of air in the peritoneal cavity. Despite emergent abdominal needle decompression and prompt exploratory surgery, the patient expired. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: TPP is a critical pathology that should be on the differential for any patient with recent unverified intubation presenting with hemodynamic instability and abdominal distension. Abdominal needle decompression is a key intervention for the patient with TPP and should be in the emergency physician's skillset. It is also a reminder that intubated patients require confirmation of correct endotracheal tube placement to prevent negative outcomes.
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Lung cancer is frequently detected during visits to the emergency department (ED). The ED is crucial for identifying likely cases of lung cancer and coordinating the subsequent care for these patients. ⋯ Despite methodological heterogeneity, our synthesis indicates that patients presenting acutely with undiagnosed lung cancer often present at advanced stages and experience high mortality rates. These findings underscore the need for further research to develop evidence-based interventions for improving outcomes among ED patients with suspected lung cancer.
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Rib fractures represent a common injury after blunt chest wall trauma with known complications including pneumothorax, hemothorax, pulmonary contusion, and pneumonia. This case report describes an emergency department patient with acute decompensation from aortic laceration as a rare complication of rib fractures. There are rare documented cases of this complication occurring in admitted patients with rib fractures, but this is one of the only cases that describes this complication occurring in a patient presenting to the emergency department. ⋯ This case describes a patient who was found down at her home and presented to the emergency department in acute distress. She was found to have three left-sided posterior rib fractures, which had lacerated her thoracic aorta causing a large left hemothorax and acute decompensation. The patient was resuscitated in the emergency department followed by thoracic endovascular aortic repair in the operating room. The patient did well after surgical repair and was discharged from the hospital at her baseline mental and functional status. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It remains important to resuscitate an acutely ill patient based on history, physical examination, and vital signs. The key takeaway from this case report is that, although rare, aortic laceration remains a possible complication of posterior rib fractures in a patient who acutely decompensates.
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Tetanus is a life-threatening disease caused by tetanus neurotoxin (TeNT) produced by Clostridium tetani. Early symptoms of tetanus are trismus and muscle stiffness, both caused by spasticity. TeNT mainly exerts its effect by impairment of inhibitory neurons in the spine and brainstem, resulting in the hyperactivity of motor neurons, which causes spasticity and muscle spasms. Apnea is not a symptom that is predicted to occur in the early stages. ⋯ We present a rare case of severe tetanus with an early manifestation of apnea but without trismus. We believe that apnea was caused by spasms of the intercostal muscles and its early manifestation was due to a high load of TeNT, considering that the speed of disease progression is related to disease severity. We hypothesize that the absence of trismus was also due to a high load of TeNT, exerting toxic effect at the neuromuscular junction and causing flaccid paralysis of the masseters. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Since there is no diagnostic laboratory test for tetanus, emergency physicians must be well aware of symptoms that may or may not appear in tetanus. Tetanus should be considered as a differential diagnosis for patients arriving at the emergency department with apnea as an early symptom. The absence of trismus should not rule out the possibility of tetanus.
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Anterior dislocation of the temporomandibular joint (TMJ) occurs when the condylar head slips out of the glenoid fossa and is locked anterior to the articular eminence. Dislocation typically occurs in the setting of wide mouth opening and increased ligament flexibility, but trauma or anatomical variations of the condyle and articular eminence may contribute as well. In cases of muscle spasm following dislocation, local anesthetic, or sedation can be used to relieve muscle tension and reduce pain, thus facilitating successful TMJ reduction. ⋯ Multiple reduction techniques are compared, discussing the advantages and disadvantages of each. A novel decision-making algorithm is offered, detailing positioning, approach selection, use of local anesthesia, sedation, and aftercare instructions.