Pain and emergency department

AUDIENCE: The targeted audience for this simulation is Emergency Medicine (EM) residents. Medical students, advanced practice providers, and staff physicians could all also find educational merit in this scenario. BACKGROUND: Cardiovascular disease is the leading cause of death in the United States according to the CDC.1 Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a prior history of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encountered in the ED, with nearly 8 million visits annually occurring throughout the United States, with 10-20% of those patients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardial infarction (STEMI)...

An 87-year-old female with a history of total knee arthroplasty (TKA) presented to the emergency department (ED) for left knee pain in the setting of recent methicillin-sensitive Staphylococcus aureus (MSSA) sepsis of unknown origin. She was subsequently diagnosed with a complicated symptomatic periprosthetic joint infection of her left TKA hardware and was admitted for TKA revision following an orthopedic surgery consultation. Upon arrival at the operating room (OR), standard American Society of Anesthesiology (ASA) monitors were applied...

Uterine fibroid degeneration is a rare cause of abdominal pain during pregnancy. It can cause complications during pregnancy, including placental abruption, fetal growth restriction, and preterm delivery. Myxoid degeneration is an unusual form of fibroid degeneration. We present a case of a 38-year-old female, G1P0, who presented at 13 weeks gestation to the emergency department at the request of her obstetrician due to abdominal pain with concern about appendicitis. A diagnosis of myxoid degeneration was made...

Cryoglobulinemia is an uncommon condition characterized by the presence of cryoprecipitable immune complexes in circulation, leading to clinical symptoms like purpura, muscle weakness, and joint pain. Specifically, mixed cryoglobulinemia involves the formation of these complexes due to rheumatoid factors, mainly IgM, occasionally IgG or IgA. Previously, Hepatitis C (HCV) was a common cause of mixed cryoglobulinemia, as the chronic HCV infection triggered immune responses that resulted in cryoglobulin formation...

Acute median nerve neuropathy is most often due to trauma; acute carpal tunnel syndrome is considered a surgical emergency and must be ruled out. A right-hand dominant male presented to the emergency department with progressive unilateral pain and numbness in the median nerve distribution after experiencing a pop while doing pushups. The evaluation was limited to pain, but there was no gross deformity, and the distal right upper extremity was neurovascularly intact. All imaging was unremarkable. The patient received adequate pain control and complete resolution of symptoms...

We report a rare case of acute ischemic stroke from concurrent large vessel occlusions (LVOs) and subsequent successful mechanical thrombectomy revascularization in a patient with active coronavirus disease 2019 (COVID-19) pneumonia. A 59-year-old woman presented to the emergency department after one week of intermittent chest pain, dyspnea, and diarrhea found to have COVID-19 pneumonia. On hospital day three, the patient developed acute altered mental status and hemiparesis with a National Institutes of Health Stroke Scale (NIHSS) of 22...

We present the case of a 25-year-old African American female patient (G1P0) with a past medical history of brain arteriovenous malformation repair, pneumonia, and a urinary tract infection who was admitted to the labor and delivery floor at 39 weeks for a spontaneous vaginal delivery of a 4.025 kg female baby. In the immediate postpartum (PP) period, the patient presented with severe pelvic pain and trouble ambulating. Conservative management of oral non-narcotic analgesics was initiated until the diagnosis of PP pubic symphysis diastasis (PSD) was made...

BACKGROUND: Minor procedures in the emergency department (ED) can be distressing for patients. The emergence of virtual reality (VR) offers a promising new tool by immersing patients in an engaging three-dimensional world. Prior studies have shown VR's effectiveness during procedures in reducing pain, anxiety, and procedure duration but have not assessed its efficacy in the ED. This study aims to evaluate the efficacy of VR in managing pain and anxiety during ED minor hand procedures...

The number of approved immune checkpoint inhibitors (ICIs) and their indications have significantly increased over the past decade. Immune-related adverse effects (irAEs) of ICIs vary widely in presentation and symptoms and can present diagnostic challenges to emergency department (ED) physicians. Moreover, when ICIs are combined with radiotherapy, cytotoxic chemotherapy, or targeted therapy, the attribution of signs and symptoms to an immune-related cause is even more difficult. Here, we report a series of 5 ED cases of adrenal insufficiency in ICI-treated cancer patients...

INTRODUCTION: Tension headaches, as well as various scalp pathologies including lacerations and abscesses are commonly treated in the emergency department (ED). The occipital nerve block (ONB), previously described in anesthesia and neurology literature, offers analgesia of the posterior scalp on the side ipsilateral to the injection while maintaining a low adverse effect profile. CASE REPORT: We report three cases in which ONB was utilized for tension headache, scalp laceration repair, and incision and drainage of scalp abscess...

STUDY OBJECTIVE: We aimed to assess and compare the analgesic efficacy and adverse effects of intravenous subdissociative-dose ketamine to nebulized ketamine in emergency department (ED) patients with acute painful conditions. METHODS: We conducted a prospective, randomized, double-blind, double-dummy clinical trial in adult patients (ages 18 and older) with a numerical rating scale pain score of ≥5. We randomized subjects to receive either a single dose of 0...

BACKGROUND: Diagnosis of ectopic pregnancy can be complicated by nonspecific laboratory and radiographic findings. The multiple alternative diagnoses must be weighed against each other based on the entire clinical presentation. CASE REPORT: We present a case of a 20-year-old woman who arrived to the Emergency Department (ED) with abdominal pain and ended up being transferred for an Obstetrics evaluation of a possible heterotopic pregnancy. Her radiology-performed ultrasound had revealed an "intrauterine gestational sac" along with an adnexal mass near the right ovary...

BACKGROUND: A minority of snake envenomations in the United States involve non-native snakes. In this report, we describe what we believe is the first documented human envenoming from an emerald horned pitviper, Ophryacus smaragdinus. CASE REPORT: A previously healthy 36-year-old woman was bitten on her left index finger by a captive emerald horned pitviper she was medicating at work. Swelling to the entire hand was present on emergency department arrival. She had no systemic symptoms and her initial laboratory studies were unremarkable...

BACKGROUND AND PURPOSE: Imaging stewardship in the emergency department (ED) is vital in ensuring patients receive optimized care. While suspected cord compression (CC) is a frequent indication for total spine MRI in the ED, the incidence of CC is low. Recently, our level-I trauma center introduced a survey spine MRI protocol to evaluate for suspected CC while reducing exam time to avoid imaging overutilization. This study aims to evaluate the time savings, frequency of ordering patterns of the survey, and the symptoms and outcomes of patients undergoing the survey...

INTRODUCTION AND IMPORTANCE: Diverticula are sac-shaped formations resulting from the inward folding of the intestinal wall's lining. While they predominantly occur in the colon, they can manifest in other parts of the gastrointestinal tract, with jejunal diverticulum being the most prevalent. Symptoms are infrequent in most cases, and when they do occur, intestinal perforation is the most severe complication. In such instances, prompt surgical intervention is imperative, typically entailing the excision of the affected intestinal segment, followed by a end-to-end anastomosis...

OBJECTIVE: Distal radius fractures (DRFs) are one of the most common orthopedic injuries, with most managed in the nonoperative ambulatory setting. The objectives of this study are to examine National Health Center Statistics (NHCS) data for DRF treated in the nonoperative ambulatory setting to identify opioid and nonopioid analgesic prescribing patterns and to determine demographic risk factors for prescription of these medications. Design, setting, patients, and measures: This study is a retrospective analysis of data collected by the NHCS from 2007 to 2016...

BACKGROUND: Many factors have been associated with the risk of toxigenic C. difficile diarrhea (TCdD). This study derived and internally validated a multivariate model for estimating the risk of TCdD in patients with diarrhea using readily available clinical factors. METHODS: A random sample of 3,050 symptomatic emergency department or hospitalized patients undergoing testing for toxigenic C. difficile at a single teaching hospital between 2014 and 2018 was created...

Mushroom poisoning, known as mycetism, represents a pressing health concern worldwide. Although the majority of mushroom ingestions are benign, select species like "Amanita phalloides" can induce catastrophic liver damage, culminating in acute liver failure. In this report, we detail a case involving a 35-year-old female who presented to the emergency department exhibiting symptoms of nausea, vomiting, abdominal pain, and palpitations merely six hours post-ingestion of "Amanita phalloides." Accurate identification of the specific mushroom species consumed proves challenging in over 90% of poisoning incidents, underscoring the necessity for clinical vigilance...

INTRODUCTION: Choricocarcinoma is a highly malignant tumor. It metastasize commonly to the lungs. Metastasis to the kidney is uncommon, and bilateral metastasis is described rarely. Initial presentation with spontaneous bleeding of the renal metastatic tumor is scarce in the literatures. Here we present a case report of a choriocarcinoma patient with bilateral renal metastasis, presenting with spontaneous renal hemorrhage. CASE PRESENTATION: A 22 years old female presented to our emergency department with sudden onset of left flank pain...

OBJECTIVE: To describe the patterns of health care utilization among patients with chronic pelvic pain. METHODS: Deidentified administrative claims data from the OptumLabs Data Warehouse were used. Adult female patients who had their first medical claim for chronic pelvic pain between January 1, 2016, and December 31, 2019, were included. Utilization was examined for 12 months after the index diagnosis. The greedy nearest neighbor matching method was used to identify a control group of individuals without chronic pelvic pain...