Fournier's Gangrene Masking as Perineal and Scrotal Cellulitis.

Fournier's gangrene (FG) is a very serious and life threatening emergency. FG is a polymicrobial subset of necrotizing fasciitis affecting the genital region. Most cases have a perianal or colorectal focus; less often the gangrene originates from the urogenital tract or is preceded by trauma or a surgical procedure. FG is a surgical emergency that requires early intervention. Therefore, early recognition by emergency physicians is imperative. The diagnosis of FG during its early stages is often challenging and misdiagnosis is common. If FG is suspected, emergency department management should always include antimicrobial treatment with parenteral broad-spectrum antibiotics, aggressive hemodynamic stabilization and surgical consultation. We report a case of FG in an elderly male with no major risk factors, who presented with right groin and perineal pain that was initially diagnosed as scrotal cellulitis. He was later diagnosed with FG and subsequently developed multi-organ failure, required multiple surgical debridements, and was later transferred to a long-term care facility with poor prognosis. This case is important because it calls attention to the challenges of diagnosing this potentially fatal disease. Emergency physicians must recognize the symptoms of FG because early diagnosis can improve outcomes.

Variation in hospital admission rates between a tertiary care and two freestanding emergency departments.

BACKGROUND: Recently, freestanding emergency departments (FSEDs) have grown significantly in number. Critics have expressed concern that FSEDs may increase healthcare costs. OBJECTIVE: We determined whether admission rates for identical diagnoses varied among the same group of physicians according to clinical setting. METHODS: This was a retrospective comparison of adult admission rates (n=3230) for chest pain, chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF) between a hospital-based ED (HBED) and two FSEDs throughout 2015. Frequency distribution and proportions were reported for categorical variables stratified by facility type. For categories with cell frequency less or equal to 5, Fisher's Exact test was used to calculate a P value. Chi square tests were used to assess difference in proportions of potential predictor variables between the HBED and FSEDs. For continuous variables, the mean was reported and Student's t-test assessed the difference in means between HBED and FSED patients. Multivariate logistic regression analyses were performed to estimate the unadjusted and adjusted prevalence odds ratio with 95% confidence interval (CI) for patient disposition outcomes associated with type of ED facility visited. RESULTS: Of 3230 patients, 53% used the HBED and 47% used the FSED. Patients visiting the HBED and FSED varied significantly in gender, acuity levels, diagnosis, and number of visits. Age was not significantly different between facilities. Multivariable adjusted estimated prevalence odds ratio for patients admitted were 1.2 [95%CI: 1.0-1.4] in the HBED facility compared to patients using FSEDs. CONCLUSION: In our healthcare system, FSEDs showed a trend towards a 20% lower admission rate for chest pain, COPD, asthma and CHF.

Acute bilateral lower extremity arterial occlusion without risk factors or embolic source.

Acute arterial occlusion is an emergency condition that, if untreated, can lead to serious complications and potential limb amputation. Risk factors for acute arterial occlusion include aortic atherosclerosis, arterial trauma, recent myocardial infarction, and atrial fibrillation. We present a patient with no history of peripheral vascular disease who presented to the emergency department with severe bilateral leg pain. Computed tomography angiography was performed showing bilateral acute arterial occlusions. Emergent vascular surgery was performed to remove the thrombus and establish perfusion in order to prevent bilateral lower leg amputation.

Spontaneous septic arthritis of the pubic symphysis in an afebrile patient.

Septic arthritis is a rare infection usually involving the knee or hip but can infrequently affect less obvious joints such as the pubic symphysis.Risk factors for septic arthritis include joint repair or replacement surgery, systemic infection, intravenous recreational drug use, and alcoholism.We present the case of a 48-year-old man with a final diagnosis of septic arthritis of the pubic symphysis who had no risk factors besides alcoholism. The presentation was unusual in that the patient was afebrile,and the infection seemed to be spontaneous. The infecting pathogen was identified as Streptococcus anginosus or S constellatus, both being normal intestinal flora. Infection by either bacterium is rare in septic arthritis.

A comparison of acuity levels between 3 freestanding and a tertiary care ED.

INTRODUCTION: Freestanding emergency departments (FEDs) have grown in popularity. They often provide emergent care in areas distant from other EDs. Investigations and research to characterize the operation and dynamics of FEDs are needed. This study characterizes the severity of illness seen at FEDs and compares it with a hospital-based urban tertiary care ED using the emergency severity index (ESI), a quantification of patient acuity. METHODS: Patient ESI levels were analyzed retrospectively over 1 year for a single hospital system with 1 main urban hospital-based ED and 3 FEDs. Data analysis was completed using analysis of variance with and without time as a factor. RESULTS: The average ESI level at the main ED (3.04) was lower than the FEDs, respectively (3.42, 3.22, and 3.38) (P < .001). Patient ESI levels were significantly different between FEDs (P < .001). CONCLUSION: The main ED demonstrated lower ESI levels and thus higher acuity than the 3 affiliated FEDs. There were significantly different acuity levels between the main ED and 3 FEDs as well as between individual FEDs.