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Long-acting intrauterine contraceptives such as intrauterine devices (IUD) are popular due to their high rates of long-term efficacy, ease of use, and reversibility. Though rare, these devices can incur complications such as uterine perforation. Signs and symptoms are often vague abdominal and pelvic pain, and patients rarely present with a surgical emergency. This uterine perforation can happen immediately upon IUD placement or in a delayed manner. This case details an example of an IUD uterine perforation with abdominal migration two years after placement. The patient's history is complicated by the unique fact that she became pregnant and carried her pregnancy to a term vaginal delivery after the IUD had been placed. Her pregnancy led healthcare providers from previous encounters to believe that the IUD had been spontaneously expelled. The IUD was identified in the patient's left lower abdominal cavity via computed tomography (CT) and was surgically removed uneventfully.

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INTRODUCTION: Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. MATERIALS AND METHODS: We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. RESULTS: There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. CONCLUSIONS: We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.

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Ectopic pregnancy is a potentially life-threatening outcome of pregnancy that occurs with the implantation of an embryo outside of the endometrial cavity. Classically considered a "must not miss" diagnosis, ectopic pregnancy is a common emergency department presentation, associated with a symptom triad of amenorrhea, vaginal bleeding, and abdominal pain. However, varied presentations of ectopic pregnancy or lack of typical risk factors can complicate the evaluation and diagnosis of this condition. This case report describes an atypical presentation of ectopic pregnancy after a reported spontaneous abortion, in which the patient was initially discharged with a diagnosis of pelvic inflammatory disease. This case provides an illustration of ectopic pregnancy that presented without classically associated symptoms, and also highlights how anchoring bias and pre-emptive closure, among other cognitive biases, contributed to a missed diagnosis.

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Study objectives: This study investigated the interrater reliability of the history component of the HEART (history, electrocardiogram, age, risk, troponin) score between physicians in emergency medicine (EM) and internal medicine (IM) at 1 tertiary-care center. Methods: We conducted a retrospective, secondary analysis of 60 encounters selected randomly from a database of 417 patients with chest pain presenting from January to June 2016 to an urban tertiary-care center. A total of 4 raters (1 EM attending, 1 EM resident, 1 IM attending, and 1 IM resident) scored the previously abstracted history data from these encounters.The primary outcome was the interrater agreement of HEART score history components, as measured by kappa coefficient, between EM and IM attending physicians. Secondary outcomes included the agreement between attending and resident physicians, overall agreement, pairwise percent agreement, and differences in scores assigned. Results: The kappa value for the EM attending physician and IM attending physician was 0.33 with 55% agreement. Interrater agreement of the other pairs was substantial between EM attending and resident but was otherwise fair to moderate. Percent agreement between the other pairs ranged from 48.3% to 80%. There was a significant difference in scores assigned and the subgroup in which there was disagreement between the raters demonstrated significantly higher scores by the EM attending and resident when compared to the IM attending. Conclusion: This study demonstrates fair agreement between EM and IM attending physicians in the history component of the HEART score with significantly higher scores by the EM attending physician in cases of disagreement at 1 tertiary-care center.

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Lactation ketoacidosis is a very rare cause of metabolic acidosis in breastfeeding patients. We present a case of a 34-year-old female, 8-weeks postpartum, who was breastfeeding while also on the ketogenic diet. She developed dyspnea, chest pain, nausea, vomiting, and an inability to tolerate oral intake for several days. She presented with a metabolic acidosis with an anion gap of 33, HCO3 of 5.1 mmol/L, venous pH of 7.045, and serum b-hydroxybutyrate of 7.4 mmol/L. She was treated in the emergency department with intravenous normal saline and intravenous dextrose, with prompt transfer to the intensive care unit for treatment with an intravenous sodium bicarbonate drip and an intravenous insulin drip with dextrose. After normalization of laboratory values, she re-developed an elevated anion gap acidosis after breastfeeding in the ICU overnight. She was started on a carbohydrate-rich diet and made a full recovery without reported repeat incidences. We provide a summary of our case, discuss known causes of lactation ketoacidosis, and emphasize the importance of a thorough history and physical. In this case a dietary history was more helpful than a very expensive laboratory and imaging evaluation.

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Breath-hold diving is a common practice as a part of military dive training. An association between prior lung injury and a propensity for lung barotrauma may have the potential to impact mission readiness for combat divers, Pararescue, Combat Controllers, Army Engineer divers, and various units in Naval Special Warfare and Special Operations. Barotrauma is a common complication of diving, typically occurring at depths greater than 30 m (98.4 ft). Individuals with abnormal lung anatomy or function may be at increased risk of barotrauma at shallower depths than those with healthy lungs, rendering these service members unfit for certain missions. We describe the case of a 25-year-old male, with a remote history of polytrauma and resultant pulmonary pleural adhesions, whose dive training was complicated by lung barotrauma at shallow depths. In missions or training utilizing breath-hold diving, the association with secondary alterations in lung or thoracic anatomy and function may limit which service members can safely participate.

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AIM: To determine the incidence of peri-intubation cardiac arrest through analysis of a multi-center Emergency Department (ED) airway registry and to report associated clinical characteristics. METHODS: This is a secondary analysis of prospectively collected data (National Emergency Airway Registry) comprising ED endotracheal intubations (ETIs) of subjects >14 years old from 2016 to 2018. We excluded those with cardiac arrest prior to intubation. The primary outcome was peri-intubation cardiac arrest. Multivariable logistic regression generated adjusted odds ratios (aOR) of variables associated with this outcome, controlling for clinical features, difficult airway characteristics, and ETI modality. RESULTS: Of 15,776 subjects who met selection criteria, 157 (1.0%, 95% CI 0.9-1.2%) experienced peri-intubation cardiac arrest. Pre-intubation systolic blood pressure <100 mm Hg (aOR 6.2, 95% CI 2.5-8.5), pre-intubation oxygen saturation <90% (aOR 3.1, 95% CI 2.0-4.8), and clinician-reported need for immediate intubation without time for full preparation (aOR 1.8, 95% CI, 1.2-2.7) were associated with higher likelihood of peri-intubation cardiac arrest. The association between pre-intubation shock and cardiac arrest persisted in additional modeling stratified by ETI indication, induction agent, and oxygenation status. CONCLUSIONS: Peri-intubation cardiac arrest for patients undergoing ETI in the ED is rare. Higher likelihood of arrest occurs in patients with pre-intubation shock or hypoxemia. Prospective trials are necessary to determine whether a protocol to optimize pre-intubation haemodynamics and oxygenation mitigates the risk of peri-intubation cardiac arrest.

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During the development of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2), a myriad of complications has emerged and although rare, several genitourinary complications have been reported. The bulk of these complications have been secondary to hypercoagulable states, such as priapism. Previous SARS family infections have caused orchitis, though no adult cases of orchitis have been reported. We describe a novel case of SARS-CoV2 bilateral orchitis in a previously healthy 37-year-old male who presented for testicular pain with constitutional symptoms. Additionally, there was no epididymitis associated with the bilateral orchitis. Based on both data in SARS-CoV2 infected males and previous data from prior SARS infections, spermatocyte function may be compromised secondary to this infection. With the various symptoms associated with this virulent pathogen, we characterize the potential complications and importance of fertility follow up.

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Situs inversus with dextrocardia is both a clinical and diagnostic challenge for emergency physicians to properly identify acute coronary syndrome. While dextrocardia itself does not independently increase the risk of coronary artery disease, mirrored symptoms, including right-sided and rightward radiating chest pain in any patient with cardiac risk factors should raise suspicion for acute coronary syndrome. In patients with a reversed cardiac silhouette on a chest radiograph, a reversed electrocardiogram, to include both the precordial and limb leads, is necessary to evaluate for cardiac ischemia in presumed dextrocardia. The authors present a case of a 66-year-old man with dextrocardia who presented with shortness of breath and hypotension. Rapid application of a reversed electrocardiogram resulted in the timely diagnosis of ST-segment elevation myocardial infarction and activation of the cardiac catheterization laboratory resulting in the preservation of this patient's life.

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Guanfacine is a central alpha-2 agonist often prescribed for Attention-deficit hyperactive disorder as well as tic disorder, with a usual dose of 1-4 mg per day. Due to its sympatholytic mechanism of action, Guanfacine can cause autonomic instability and hypotension. It can additionally cause cardiac dysfunction to include symptomatic bradycardias and contractility suppression. The authors present a case of a 17 year-old male with an ingestion of 80 mg of extended release Guanfacine with delayed onset cardiogenic pulmonary edema requiring mechanical ventilation. Previous pediatric ingestions have generated bradycardia, hypotension, and decreased level of consciousness, responsive to intravenous fluids, vasopressors, and occasionally naloxone. However, cardiogenic pulmonary edema from reduced cardiac contractility is a novel consequence of extended release Guanfacine ingestion. With Guanfacine's extended half-life, this unique case underscores the importance of emergency providers' familiarity with this toxidrome as well the necessity for prolonged, close observation following Guanfacine ingestion.

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A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.

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Chest pain is a frequent chief complaint in the ED. Identifying acute coronary syndrome (ACS) and establishing proper disposition for further risk assessment for major adverse cardiac events are paramount. The HEART Score is a key decision-making tool used to determine patient risk and disposition. One scenario with a potential drawback of the HEART Score is found in patients with a score of four based solely on age and risk factors. The HEART Score categorizes a score of three or less as low risk, and patients with scores above this threshold are typically admitted. We present six cases of chest pain presenting to a military emergency department with a score of four based solely on age and risk factors. They represent every such case found in a previously created database used to validate the HEART Score. We followed each case forward one year in electronic medical records to identify major adverse cardiac events. With the exception of one case that was placed on hospice for non-cardiac reasons and subsequently lost to follow up, there were no adverse events. There is a rising concern for increasing hospital admission rates, overuse of resources, and cost. We highlight that this subset of HEART Score patients requires a more nuanced risk stratification in the ED. It may be worth the time and effort to risk stratify this subset with coronary computed tomography angiography. This additional effort may help reduce admission at such a patient's current and future presentations to the ED for chest pain.

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CASE PRESENTATION: We describe a case of spontaneous partial segmental thrombosis of the corpus cavernosum (PSTCC). DISCUSSION: PSTCC is a rare condition in which thrombus formation occurs in the corpus cavernosum. This condition is managed in conjunction with a urologist, and management typically includes anticoagulation and pain control.

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INTRODUCTION: The HEART (history, electrocardiogram [ECG], age, risk factors, troponin) pathway is a useful tool in the emergency department to identify patients that are safe for outpatient evaluation of chest pain. A dedicated HEART Clinic to follow-up versus primary care remains a topic that requires further delineation. We sought to identify how many patients discharged on the HEART pathway specifically followed up with the established HEART Clinic. MATERIALS AND METHODS: This is a secondary analysis of a previously published dataset. In an initial validation study of the HEART Pathway, 625 consecutive subjects were identified via chart review, 449 of which were included. We identified subjects for inclusion in this study if they were found to have a HEART score of 3 or less. Subjects were excluded if they were admitted or if their follow-up was beyond 6 weeks. RESULTS: Of the 449 subjects, 185 met criteria for study inclusion. 125 (67.6%) had follow-up with an average time of 7.94 days (95% CI: 6.54-9.34). Of those, half had additional testing such as ECG, cardiac computed tomography angiography, and treadmill stress testing. The most common clinics for follow-up were the Family Medicine, Internal Medicine, and HEART Clinic representing 35.8, 29, and 18% of the follow-ups, respectively. No subject died, had a myocardial infarction, or required reperfusion. CONCLUSIONS: Of the subjects discharged on the HEART Pathway, 67.6% followed up. Of those subjects that followed up, 18% did so at the HEART Clinic.

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BACKGROUND: The hemodynamic impact of induction agents is a critically important consideration in emergency intubations. We assessed the relationship between peri-intubation hypotension and the use of ketamine versus etomidate as an induction agent for emergency department (ED) intubation. METHODS: We analyzed ED intubation data for patients aged >14 years from the National Emergency Airway Registry performed in 25 EDs during 2016 through 2018. We excluded patients with preintubation hypotension (systolic blood pressure <100 mm Hg) or cardiac arrest prior to intubation. The primary outcome was peri-intubation hypotension. Secondary outcomes included interventions for hypotension (e.g., intravenous fluids or vasopressors). We report adjusted odds ratios (aOR) from multivariable logistic regression models controlling for patient demographics, difficult airway characteristics, and intubation modality. RESULTS: There were 738 encounters with ketamine and 6,068 with etomidate. Patients receiving ketamine were more likely to have difficult airway characteristics (effect size difference = 8.8%, 95% confidence interval [CI] = 5.3% to 12.4%) and to undergo intubation with video laryngoscopy (8.1%, 95% CI = 4.4% to 12.0%). Peri-intubation hypotension incidence was 18.3% among patients receiving ketamine and 12.4% among patients receiving etomidate (effect size difference = 5.9%, 95% CI = 2.9% to 8.8%). Patients receiving ketamine were more likely to receive treatment for peri-intubation hypotension (effect size difference = 6.5%, 95% CI = 3.9% to 9.3%). In logistic regression analyses, patients receiving ketamine remained at higher risk for peri-intubation hypotension (aOR = 1.4, 95% CI = 1.2 to 1.7) and treatment for hypotension (aOR = 1.8, 95% CI = 1.4 to 2.0). There was no difference in the aOR of hypotension between patients receiving ketamine at doses ≤1.0 mg/kg versus >1.0 mg/kg or patients receiving etomidate at doses ≤0.3 mg/kg versus >0.3 mg/kg. CONCLUSIONS: Pending additional data, our results suggest that clinicians should not necessarily prioritize ketamine over etomidate based on concern for hemodynamic compromise among ED patients undergoing intubation.

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Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

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Military free fall or high-altitude low-opening parachute jumps play a key role in special operations tactics, though injury patterns in these operators are not well characterized. In contrast to lower-altitude static line paratroopers, free fall operators require precise parachute deployment after a prolonged descent, with the potential for high-velocity trauma. This report describes a 33-year-old Marine Corps Reconnaissance operator who sustained left comminuted basicervical femoral neck fracture requiring cephalomedullary nail internal fixation with a full recovery. This femoral neck fracture highlights the high-energy injuries experienced by these invaluable operators, especially when conducting combat or night jumps.

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Intracranial subdural empyema is a rare clinical entity with incidence estimates of 0.1 per 100,000 people. The condition is most often the sequela of a primary infection elsewhere and carries a high morbidity and mortality. The authors present the case of a 22-year-old active duty soldier on mission on the southern border of the United States. The patient had been complaining of headaches that became progressively worse over 2 weeks and presented to a civilian hospital where he was diagnosed with intracranial abscess versus sinus thrombosis on radiographic imaging. The patient was promptly transferred to a military tertiary care center where further workup including pivotal imaging confirmed subdural empyema and right transverse sinus thrombosis. Given the rapid patient deterioration associated with subdural empyema, the emergent intravenous antibiotics, neurosurgical consultation, and subsequent collection evacuation performed are likely to credit for saving this soldier's life. This case highlighted an atypical and time-sensitive etiology for a common complaint in the active duty population, which underscores the requirement for evacuation to higher roles of care in those soldiers with a similar diagnosis.

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Osteitis Pubis (OP) is groin pain caused by overloading stresses on the pubic symphysis. This is often caused by the repetitive stress seen in competitive sports, but can also be caused by rapid acceleration or deceleration. It is a diagnosis of exclusion made after other entities such as fracture or infection are ruled out. It is often treated conservatively with rest, Non-Steroidal Anti-inflammatories (NSAIDS), and Physical Therapy (PT). After these treatment modalities have failed, intra-articular injection with local anesthetics and steroids can be considered. We report a case of a 22-year-old Male Active Duty Army Soldier who presented with OP immediately after landing during a routine Airborne Jump exercise. The Soldier reported landing in such a way that his feet did not impact the ground at the same time, creating a sheering force on his pelvis. Following two months of failed treatment involving NSAIDS and PT, the patient was referred to Sports Medicine where he received an injection of 1 mL of 1% lidocaine and 40 mg of triamcinolone into the pubic symphysis joint space. Shortly afterward the patient endorses complete resolution of his symptoms without return of symptoms at 1-month follow-up. Although injection of the pubic symphysis with local anesthetic and steroids has been previously described, this is the first time it has been described in a jump injury.

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A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.