Abstract Proceedings EROC 2011 - New York Osteopathic Medical ...

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EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: Elusive Hip Pain That May Take Your Life Away: A Case Report of a Necrotizing Fasciitis Authors: Melissa Keehn DO, Michelle Gebhard DO, Steven Zimmerman MD, John Tomasula MD Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: We report a case of a patient who presented to the emergency department with left hip pain. The cause was eventually determined to be an atypical presentation of localized necrotizing fasciitis, which rapidly progressed into profound sepsis and death within less than 24 hours. Case description: A 67 year-old female presented to the emergency department complaining of sharp left hip and thigh pain for twelve hours. The patient was evaluated 6 hours earlier in Emergency Department, had a normal left hip x-ray and was given a prescription for analgesia. The patient returned due to inability to sleep secondary to the pain. She was afebrile, normotensive but in moderate painful distress. Her left lower extremity had limited range of motion secondary to pain. Her left thigh had a dusky, 10cm patch of induration over the greater trochanter with slight crepitus on palpation. She was anemic, in metabolic acidosis with an elevated total CK. A left hip CT scan revealed no acute fracture or dislocation but extensive emphysema in the bone and soft tissues. The patient’s condition deteriorated rapidly during her ED stay. She became significantly hypotensive and was immediately started on intravenous fluids, antibiotics, sodium bicarbonate and vasopressors. She was intubated and taken to the operating room where a radical left hemipelvectomy was performed. The patient survived the surgery but very soon after passed away in the recovery room. Discussion: Necrotizing fasciitis is a very severe type of bacterial infection, which destroys skin, muscle and the underlying tissue and may do so at an alarming rate. The rate at which this case progressed makes it a compelling and certainly important differential for all medical practitioners to keep in the back of their minds when encountering any patient with vague or mysterious pain out of proportion to the physical findings. 34
EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: Sometimes You Don’t Have to Look for a Zebra in the Forest: A Case Report of a Celiac Artery Thrombosis, Splenic Infarct, and Pulmonary Embolism Authors: Steven Keehn DO, Robin Mackoff DO, David Levy DO, Lawrence Womack, MD, Manal Hegazy, MD. Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: We report a case of a patient who presented to the emergency department with abdominal pain. The cause was eventually determined to be the rare occurrence of a celiac artery thrombosis leading to splenic infarction. The patient concurrently developed a pulmonary embolism. The patient had no risk factors for these diagnoses or hypercoagulable disorders. Case description: A 41 year old male presented to the emergency department complaining of four hours of progressively worsening abdominal pain that began suddenly. He had nausea, diaphoresis, and constipation. Over-the-counter gastrointestinal preparations offered no relief. He was in mild distress and his exam was significant for lower abdomen tenderness. He had a mild leukocytosis. A CT scan of his abdomen and pelvis revealed a splenic infarction and a left common iliac artery aneurysm. A CT scan of his chest revealed a pulmonary embolism. An EKG and echocardiogram were normal. MRA of the mesentery revealed celiac access dissection with occlusion resulting in splenic infarction. The patient was anticoagulated and unfortunately developed heparin induced thrombocytopenia (HIT). After treatment the patient’s condition improved and he was eventually discharged with a therapeutic INR. Repeat evaluation for a disorder of coagulation after the patient’s condition improved revealed none. Discussion: Fewer than 180 cases of celiac artery aneurysms have been reported in the medical literature. To have a splenic infarction and simultaneously have a pulmonary embolism without a disorder of coagulation is quite unusual. Aneurysms of the celiac artery were first described in 1745. This anomaly accounts for 3.6% to 4% of splanchnic artery aneurysms, but have a high risk of mortality if they rupture. The annual incidence ranges from 0.005% to 0.01%. Twelve percent of these patients reported abdominal pain on presentation. It has been shown in patients with hypercoagulable states of which this patient did not have. 35
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