J Emerg Med
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Case Reports
Spontaneous Cerebrospinal Fluid Leak in a Patient with Asymptomatic Idiopathic Intracranial Hypertension.
Spontaneous cerebrospinal fluid (CSF) leaks occur when there is a tear in the dura mater. Spontaneous CSF leaks are rare, and often associated with conditions like intracranial hypertension, connective tissue disorders, or congenital defects in the dura mater. ⋯ The patient was a 66-year-old woman who presented to the Emergency Department with clear, positional nasal discharge from her left nostril for 1 week. She had a history of chronic headaches, which seemed to have been relieved around the time of onset of her rhinorrhea. Diagnostic imaging, including computed tomography and magnetic resonance imaging scans, confirmed the presence of a CSF leak and a left temporal meningoencephalocele. The patient subsequently underwent surgical repair of the leak and ventriculoperitoneal shunt placement, and was discharged home in stable condition. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early detection of CSF leaks require a thorough history and physical examination, and is crucial in preventing potentially life-threatening complications such as meningitis and intracranial abscesses.
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Although common in pediatric airway equipment, positive-pressure relief ("pop-off") valves are also present on some adult resuscitator bags. These valves are designed to decrease barotrauma but, in doing so, limit the airway pressure provided during manual bag-assisted ventilation. In critically ill adult patients with high airway pressures, these valves can be detrimental and result in hypoventilation and subsequent hypoxemia. ⋯ In the 7 days after an unannounced introduction of new resuscitator bags with pop-off valves in the emergency department, there were 3 adult patients for whom an open pop-off valve resulted in hypoventilation and hypoxemia. These cases involved both medical and traumatic pathologies. In each case, there was a delay in discovering the change to a resuscitator bag equipped with a pop-off valve. Once the emergency physicians noticed the pop-off valve and closed them, there was significant improvement in ventilation and oxygenation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Hand-operated resuscitator bags are an essential tool for airway management. These cases represent two main lessons: changing airway equipment without notifying staff is dangerous, and an open pop-off valve will result in inadequate ventilation when patients have high airway pressures, without the tactile feedback of difficult bagging. Emergency physicians should be aware of equipment changes and know to disable the pop-off valve on resuscitator bags if they find them in their departments.
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A cervical radiofrequency ablation is a procedure that can be performed to treat arthritis-related pain in the neck and upper back. There have been no large studies reporting complications after this procedure. We report a case of a 55-year-old woman with iatrogenic vertebral artery dissection of C3-C4 with segmental occlusion leading to a posterior fossa stroke and lateral medullary stroke after a high-grade cervical nerve ablation. ⋯ A 55-year-old woman presented to the Emergency Department with vomiting, neck pain, temperature changes, dizziness, and dysarthria after undergoing C2-C3, C4-C5 nerve ablation 30 min prior to arrival. The patient was found to have a vertebral artery dissection with posterior fossa and lateral medullary stroke. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Vertebral artery dissection and subsequent stroke should be considered with recent cervical facet joint injections, such as intra-articular facet joint injections, medial branch blocks, or medial branch radiofrequency nerve ablation. The case we report shows devastating outcomes that can result from what many consider a relatively simple procedure.
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The estimated serum osmolality is a measurement of solutes in the blood, including sodium, glucose, and urea, but also includes ethanol and toxic alcohols (e.g., methanol, ethylene glycol, diethylene glycol, isopropyl alcohol, propylene glycol) when present. These rarely measured toxic alcohols can elevate the serum osmolality, giving the true measured osmolality. The difference between that and a calculated osmolality is the osmolal gap, which can be elevated in many clinical scenarios such as renal failure, ingestion of toxic alcohols, diabetic ketoacidosis, shock, and others. ⋯ We report a patient with a history of alcohol use disorder who came to the Emergency Department with an abnormally elevated osmolal gap in the setting of altered mental status. The patient's increased osmolal gap was further investigated while he was promptly treated with fomepizole, thiamine, and urgent hemodialysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss the differential diagnosis for substances that increase the osmolal gap with respective ranges of elevation. This case demonstrates that although osmolal gap elevation is often attributed to the presence of toxic alcohols, other common etiologies may account for the gap, including acute renal failure and multiple myeloma.