J Emerg Med
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Cellulitis is a common clinical condition with low rates of morbidity and mortality if treated appropriately. Mimics of cellulitis presenting with erythema, edema, warmth, and pain can be associated with grave morbidity and mortality if misdiagnosed. ⋯ Cellulitis and its mimics present similarly due to the same physiologic responses to skin and soft tissue infections. A combination of history, physical examination, and diagnostic assessment will help the emergency physician differentiate cellulitis from mimics. Surgical intervention is frequently needed for high morbidity and mortality mimics.
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Case Reports
Postoperative Anticholinergic Poisoning: Concealed Complications of a Commonly Used Medication.
Scopolamine is a potent anticholinergic compound used commonly for the prevention of postoperative nausea and vomiting. Scopolamine can cause atypical anticholinergic syndromes due to its prominent central antimuscarinic effects. ⋯ A 47-year-old female presented to the emergency department (ED) 20 h after hospital discharge for a right-knee meniscectomy, with altered mental status (AMS) and dystonic extremity movements that began 12 h after her procedure. Her vital signs were normal and physical examination revealed mydriasis, visual hallucinations, hyperreflexia, and dystonic movements. Laboratory data, lumbar puncture, and computed tomography were unrevealing. The sustained AMS prompted a re-evaluation that revealed urinary overflow with 500 mL of retained urine discovered on ultrasound and a scopolamine patch hidden behind her ear. Her mental status improved shortly after patch removal and physostigmine, with complete resolution after 24 h with discharge diagnosis of scopolamine-induced anticholinergic toxicity. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although therapeutically dosed scopolamine transdermal patches rarely cause complications, incomplete toxidromes can be insidiously common in polypharmacy settings. Providers should thoroughly evaluate the skin of intoxicated patients for additional adherent medications that may result in a delay in ED diagnosis and curative therapies. Our case, as well as rare case reports of therapeutic scopolamine-induced anticholinergic toxicity, demonstrates that peripheral anticholinergic effects, such as tachycardia, dry mucous membranes, and hyperpyrexia are often not present, and incremental doses of physostigmine may be required to reverse scopolamine's long duration of action. This further complicates identification of the anticholinergic toxidrome and diagnosis.
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Case Reports
Successful Retrograde Intubation After Failed Fiberoptic Intubation and Percutaneous Cricothyrotomy.
An obstructive neck lesion presents an airway challenge for any emergency physician. Retrograde intubation is an infrequently used airway alternative that can be employed in the difficult airway algorithm that requires little training and is less invasive than surgical cricothyrotomy. ⋯ We report a case of a 31-year-old male patient who presented with respiratory distress progressing to respiratory failure from upper airway obstruction. The patient had significant tracheal thickening at the level of the thyroid gland based on a computed tomography report from 3 weeks prior to his presentation. Awake upright fiberoptic intubation and subsequent percutaneous cricothyrotomy were unsuccessful secondary to obstructive neck mass. We performed a retrograde intubation via tracheal approach and secured the airway via manipulation of a small-diameter endotracheal tube over the guidewire using visualization with video laryngoscopy. This case describes a combination of difficult airway techniques utilizing retrograde intubation with a Glidescope (Verathon Inc., Bothell, WA) as a rescue maneuver for a difficult airway secondary to a tracheal obstruction and supraglottic and subglottic stenosis. Follow-up confirmed the patient's diagnosis as granulomatosis with polyangiitis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In cases of supraglottic and subglottic narrowing or mass lesions, retrograde intubation can be a life-saving technique that is an important consideration in the difficult airway algorithm. This technique may be combined with other difficult airway techniques and is especially relevant and potentially life-saving for patients in whom an open cricothyrotomy is undesirable, such as patients with a potentially vascular neck mass, subglottic stenosis, localized neck trauma, or morbid obesity.
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Emergency Medical Services (EMS) providers, who perform initial assessments of ill and injured patients, often in a patient's home, are uniquely positioned to identify potential victims of elder abuse, neglect, or self-neglect. Despite this, few organized programs exist to ensure that EMS concerns are communicated to or further investigated by other health care providers, social workers, or the authorities. ⋯ EMS providers frequently identify potential victims of elder abuse, neglect, and self-neglect, but significant barriers to reporting exist. Strategies to empower EMS providers and improve reporting were identified.
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Case Reports
Delayed Detection of Spontaneous Bilateral Tubal Ectopic Pregnancies After Methotrexate Treatment.
Bilateral tubal ectopic pregnancies are a rare subset of ectopic pregnancy that can pose a diagnostic dilemma for clinicians. There is no distinct clinical presentation for bilateral tubal ectopic pregnancies, although they are typically associated with assistive reproductive techniques. In addition, there is no single diagnostic feature to help clinicians delineate bilateral tubal ectopic pregnancies from other types of ectopic pregnancy prior to passing the discriminatory zone (such as heterotopic pregnancy or twin ectopic [two gestational sacs in one tube]). Diagnosis is typically made via direct visualization intraoperatively and therefore treatment is usually surgical. ⋯ We present a case of spontaneous bilateral tubal ectopic pregnancies diagnosed 7 days apart via transvaginal ultrasound. The patient presented to the emergency department with pelvic pain on the contralateral side of her previously diagnosed ectopic pregnancy and vaginal spotting. Bilateral adnexal masses were visualized on ultrasound and her serum beta-human chorionic gonadotropin level had a 5.9% decline from day 4 to day 7 after methotrexate administration 7 days prior; gynecology was consulted. The patient was successfully treated with an additional dose of intramuscular methotrexate without any complications. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The implications of this case suggest that diagnosis of bilateral tubal ectopic pregnancies requires clinicians to have a high level of suspicion in any pregnant female with a suspected or known ectopic pregnancy who presents with pelvic pain regardless of prior diagnosis or treatment.