J Emerg Med
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Case Reports
Another Disease Re-emerges Due to Parental Shot Refusal: Case Report of a Fussy Infant with Blood in Stool.
Infants may present to the emergency department (ED) with vague complaints worrisome to parents and may initially appear well, despite serious underlying pathology. Whereas sepsis and nonaccidental trauma are high on most providers' diagnostic considerations, we report a case representative of a worrisome trend secondary to the refusal of parenteral vitamin K at birth leading to significant neurologic sequelae. ⋯ A 10-week-old boy presented to the ED with gradual increase in fussiness for 2 weeks and new onset of blood flecks in the stool on the day of presentation. Careful physical examination revealed a pale-appearing infant, leading to diagnostic evaluation demonstrating profound anemia and intracranial bleeding. The patient was diagnosed with late-onset vitamin K-deficient bleeding (VKDB) secondary to parental refusal of the vitamin K shot at birth. Why Should Emergency Physicians be Aware of This? Emergency Medicine providers need to add this serious treatable disease into their diagnostic consideration for fussy infants, infants with unexplained bruising or bleeding, or infants with new-onset seizures. Rapid identification of VKDB can lead to prompt treatment and halt the rapid progression of symptoms. Emergency Medicine providers should ask all parents if their infant received parenteral vitamin K in the newborn period, especially if they are exclusively breastfed or born out of the hospital.
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Case Reports
Diagnosis and Management of Closed Internal Degloving Injuries: The Morel-Lavallée Lesion.
Morel-Lavallée (ML) lesions are closed degloving injuries described as posttraumatic subcutaneous fluid collections. They are most commonly seen in the proximal thigh. They can present several days to months after the inciting event. ⋯ A 55-year-old woman with a recent admission for trauma presented to the Emergency Department with increasing swelling and pain in the right thigh for the previous 3 days. Ultrasound of the thigh was negative. Magnetic resonance imaging performed to further evaluate for leg swelling revealed a "Morel-Lavallée lesion" of the thigh that required drainage. The patient recovered completely after the surgery. WHY SHOULD THE EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware of these rare lesions because they are often mistaken for tumors or hematomas. Early recognition may avoid subsequent complications and help in obtaining prompt specialist care.
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With improvements in endoscopic and interventional radiologic therapies, insertion of gastroesophageal balloon tamponade catheters, commonly known as Sengstaken-Blakemore or Minnesota tubes, is a rarely performed procedure for esophageal or gastric variceal bleeding. In small hospitals or freestanding emergency departments, endoscopic or interventional radiology (IR) therapies might not be available, so patients with exsanguinating variceal bleeding must be stabilized or temporized for transport to larger hospitals. Occasionally, tamponade devices are necessary as a rescue therapy for failed endoscopic or IR therapies or can be used as definitive therapy in select cases. In addition to being rarely performed, there are multiple technical complications associated with blind insertion of tamponade catheters. ⋯ Insertion of a Minnesota tube for bleeding esophageal or gastric varices is an uncommon, technically challenging procedure that can be lifesaving, and is something emergency physicians, intensivists, and gastroenterologists should be capable of performing. Addition of indirect laryngoscopy may help to improve rapid, safe, and successful placement of these devices.
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Chronic vitamin A intoxication is well known; however, there are few reports of acute vitamin A intoxication due to the ingestion of food rich in vitamin A, particularly in adults. ⋯ We report a case of a 27-year-old man presenting with chief complaints of flushing, headache, nausea, and joint pain. He had consumed 800 g of grilled ocean perch liver the day before and had experienced numbness shortly after. Although physical examination revealed only facial flushing, we suspected acute vitamin A intoxication due to his diet history. On day 2 after ingestion, his serum retinol levels were elevated at 1577 ng/mL, which confirmed vitamin A intoxication. He returned for follow-up on day 4 after ingestion, by which time his presenting symptoms had improved, but he had developed desquamation of his facial skin. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should consider acute vitamin A intoxication in the differential diagnosis of patients with headache, flushing, desquamation, nausea, and vomiting of unknown etiology. Complete diet histories and checking vitamin A levels are essential for diagnosis. This report highlights the diagnostic difficulties associated with vitamin A intoxication and the importance of an accurate diet history.