J Emerg Med
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Posterior sternoclavicular dislocations can be challenging diagnostically, as traumatic force often happens to the lateral shoulder rather than directly to the sternoclavicular joint. Shoulder radiographs do not illustrate the sternoclavicular joint well, and can miss the diagnosis. This injury, however, has the potential for life-threatening complications due to proximity of mediastinal structures that might also be injured. ⋯ The following case illustrates a delayed diagnosis of posterior sternoclavicular dislocation. It also shows how point-of-care ultrasound can diagnose a dislocation, confirm persistence of a dislocation diagnosis when patients are transported from a referring facility, as well as educate the patient and family. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Point-of-care ultrasound can be used to rapidly diagnose posterior sternoclavicular dislocations and to provide patients education about their injury.
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Nasal septal abscess (NSA) is a rare condition most commonly seen as a complication of nasal trauma. The diagnosis of NSA requires emergent treatment, because delayed management can result in significant morbidity. Typically, NSA presents as a purulent collection that can be managed with drainage, either surgically or at bedside. ⋯ We report an unusual presentation of a spontaneous NSA in a 7-year-old boy as a solid nasal mass eroding the nasal septum. The solid, tumor-like nature of the mass necessitated intervention beyond drainage and was ultimately excised. Imaging initiated in the emergency department revealed a partially cystic mass and erosion of the septum, which was key to the diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the ease with which a diagnosis of NSA may be missed and the need for urgent management upon diagnosis of a NSA, we aim to highlight the clinical, radiologic, and histopathologic aspects that aid in diagnosis of NSA. Imaging, obtaining culture results, and initiation of antibiotics are paramount in management. In addition, NSAs may also necessitate bedside drainage given their emergent nature.
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Rash is a common complaint in the emergency department. Many causes of rash are benign; however, some patients may have a life-threatening diagnosis. ⋯ Rashes can be divided into petechial/purpuric, erythematous, maculopapular, and vesiculobullous. After this differentiation, the presence of fever and systemic signs of illness should be assessed. Through the breakdown of rashes into these classes, emergency providers can ensure deadly conditions are considered.
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Despite being an effective analgesic for children with fractures, some clinicians may avoid prescribing ibuprofen due to its potentially harmful effect on bone healing. ⋯ Children with extremity fractures who are exposed to ibuprofen do not seem to be at increased risk for clinically important bone healing complications.
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Although colonoscopy is generally a safe procedure, lethal complications can occur. Colonoscopic perforation is one of the most serious complications, and it can present with various clinical symptoms and signs. Aggravating abdominal pain and free air on simple radiography are representative clinical manifestations of colonoscopic perforation. However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis. We present two cases of pneumomediastinum, pneumothorax, and subcutaneous emphysema caused by colonoscopic perforation. ⋯ A 75-year-old woman and a 65-year-old man presented with dyspnea, and facial swelling and abdominal pain, respectively. In the first case, symptoms occurred during polypectomy, whereas they occurred after polypectomy in the second case. Chest radiograph and computed tomography scans revealed pneumomediastinum, pneumothorax, and subcutaneous emphysema in the neck. During both operations, an ascending colonic subserosa filled with air bubbles was observed, and laparoscopic right hemicolectomy was performed in the first case. In the second case, after mobilization of the right colon, retroperitoneal colonic perforation was identified and primary repair was performed. The postoperative course was uneventful. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: These cases show the unusual clinical manifestations of colonoscopic perforation, which depend on the mechanism of perforation. Awareness of these less typical manifestations is crucial for prompt diagnosis and management for an emergency physician.