Erector spinae plane block (ESPB) for intractable, non-surgical abdominal pain: a scoping review.

Abdominal pain is one of the most common presenting chief complaints in the emergency department (ED). Erector spinae plane block (ESPB) is an ultrasound-guided nerve block with proven effectiveness in treating visceral and somatic abdominal pain. Despite the increasing popularity of ESPB, its role in the management of non-surgical abdominal pain has not yet been characterized. Our scoping review aims to review the current literature on the safety and efficacy of ESPB in the management of patients experiencing intractable, non-surgical abdominal pain. We searched PubMed and Scopus to evaluate the existing literature on ESPB for non-surgical abdominal pain. Reviewers screened 30 titles and abstracts that met the predefined inclusion and exclusion criteria. Following initial screening, 24 articles underwent full-text review. Two reviewers also screened references included in each study. A total of 14 journal articles were reviewed, including 12 case-based studies, one systematic review, and one narrative review of ESPB in the treatment of non-surgical abdominal pain. All cases described the successful use of ESPB in treating abdominal pain refractory to oral or intravenous analgesic medications, and each case reported no complications. This scoping review provides support for ESPB in the management of intractable, non-surgical abdominal pain. ESPB demonstrates efficacy in alleviating various conditions such as functional abdominal pain, renal colic, pancreatitis, herpetic pain, and cancer-related pain. Theoretical risks such as pneumothorax, bleeding, and infection are possible, although the studies reviewed did not report such complications.

Case Report of Herpes Zoster Ophthalmicus with Concurrent Parotitis.

A 36-year-old immunocompetent female presented to the emergency department (ED) with five days of headache and left-sided facial pain. Physical exam showed conjunctival injection of the left eye with multiple vesicular lesions distributed along the V1 dermatome. Labs were remarkable for mild elevation in erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) with no elevation in white blood cell (WBC) count. Computed tomography (CT) with contrast of the neck revealed soft tissue stranding around the parotid gland. The patient was diagnosed with herpes zoster ophthalmicus (HZO) with concurrent ipsilateral parotitis and subsequently treated with valacyclovir, ofloxacin eye drops, topical erythromycin ointment and amoxicillin/clavulanic acid. Upon follow-up ten days after discharge, the patient noted marked improvement in her symptoms and reduction in pain. To our knowledge, this is the first case described in medical literature of a female patient with HZO and ipsilateral parotitis. Topics: Herpes zoster opthalmicus, varicella-zoster virus, parotitis.

Bullous Pemphigoid Causing Successive Emergency Department Visits.

Case Presentation: In this case presentation, an 84-year-old male with Fitzpatrick type IV skin tone experienced blistering due to bullous pemphigoid (BP), first on the distal upper left extremity and then on the distal lower extremities, chest, and back. These symptoms resulted in three visits to the emergency department within a month, as well as an episode of hospitalization. Despite treatment, the blistering did not resolve until future outpatient care with dermatology. Discussion: Bullous pemphigoid is a rare autoimmune disease where autoantibodies target hemidesmosomal proteins causing basement membrane destruction and tense subepithelial bullae with pruritus. While uncommon, the incidence of BP is increasing. Bullous pemphigoid tends to affect older adults, appearing as a rash prior to bullae formation on the abdomen, extremities, groin, axillae, or mucosa. Bullous pemphigoid may also be drug-related with atypical symptoms. Diagnosis of BP should be based on immunopathology, and initial treatment of BP is through corticosteroid or doxycycline.

A Case Report of May-Thurner Syndrome Identified on Abdominal Ultrasound.

May-Thurner syndrome (MTS) is most commonly caused by the compression of the left iliac vein by the right iliac artery against the lumbar spine, which leads to the development of a partial or occlusive deep venous thrombosis (DVT).1 Diagnosis begins with a duplex ultrasound of the lower extremities to evaluate for a femoropopliteal thrombus, and in high-risk patients where a more proximal DVT is suspected and the DVT ultrasound is negative, a computed tomography venogram (CTV) or magnetic resonance venogram (MRV) is performed.1,3 In this case report, a patient presented to the emergency department (ED) with two days of left lower extremity pain and swelling. Initial lower extremity DVT ultrasound was negative, so a CTV was ordered and revealed a thrombus in the left common iliac vein with overlying compression by the right common iliac artery, suggesting the diagnosis of May-Thurner syndrome (Figure 1). Afterwards, a point-of-care ultrasound (POCUS) was performed at bedside to evaluate the caval and iliac arteries and the findings were consistent with the CTV (Figure 2, 3, 4). If the POCUS was performed prior to the CTV, the patient may have been spared the radiation exposure from CT, as well as the risks of intravenous (IV) contrast required for a venogram. Therefore, in high risk patients in whom a negative DVT ultrasound will prompt advanced imaging with CTV or MRV, I propose the addition of a lower abdominal ultrasound using a curvilinear probe to assess the caval and iliac arteries prior to obtaining a CTV or MRV. Topics: May-Thurner Syndrome, leg swelling, POCUS, ultrasound, deep venous thrombosis.

Bradycardia, Renal Failure, Atrioventricular Nodal Blockade, Shock, and Hyperkalemia (BRASH) Syndrome as a Presentation of Coronavirus Disease 2019.

The novel coronavirus disease 2019 (COVID-19) has led to a global pandemic. While acute respiratory failure has been the predominant concern, there have been reports of other end-organ damage such as renal failure. We report a case of an elderly woman who presented with BRASH syndrome, a constellation of bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH), which was likely triggered by COVID-19.

The Special K Constellation, a Rare Presentation of Ketamine Use: A Case Report.

Ketamine is commonly used in the emergency medicine setting, but also as a recreational drug. There have been many animal studies investigating ketamine, but little data on long-term clinical use of ketamine in humans. In this case presentation, a 22-year-old international male student presented with crepitus and cachexia and was found to have extensive subcutaneous emphysema, pneumorrhachis/intraspinal air, pneumomediastinum, and multiorgan failure. In this case report, we discuss how ketamine abuse is the likely cause of these findings.

Refractory Nonvariceal Upper Gastrointestinal Bleeding Requiring Surgical Intervention.

Nonvariceal upper gastrointestinal (GI) bleeds are a common emergency. Mortality in patients with an upper GI bleed has been reported to be as high as 30% for those who bleed inpatient. Definitive management after resuscitation can be done with endoscopy, transcatheter arterial embolization (TAE), and/or surgery. A 55-year-old female with multiple comorbidities presented with a refractory second episode of an acute nonvariceal upper GI bleed that required an interdisciplinary approach with the following interventions: endoscopy, embolization, and ultimately surgery. In this case report, the discussion is about the management algorithm of nonvariceal upper GI bleeds as well as the literature on prophylactic embolization and GI rebleeding. This unusual case presented with continued bleeding despite embolization, which led to the emergent rescue surgery that was necessary for this patient. Important take-home points are that patients with therapeutic hemostasis of upper GI bleeds may have rebleeding, a second attempt at therapeutic endoscopy after rebleeding may be limited due to a brisk bleed, the literature about prophylactic embolization is controversial, and one should involve both interventional radiology and surgery early on to assess a patient's clinical picture for further definitive interventions from both specialties.

Cost-Effectiveness of Fecal Microbiota Transplantation in the Treatment of Recurrent Clostridium Difficile Infection: A Literature Review.

Clostridium difficile (C. difficile) is a common cause of antibiotic--associated diarrhea (AAD), being responsible for 15--25% of all AAD cases. The purpose of this literature review is to determine the cost-effectiveness of fecal microbiota transplantation (FMT) and how it compares in this regard to the standard treatments of choice for recurrent C. difficile infection (CDI). The review of the literature along with the evaluation of three comparative cost effective analyses yielded findings consistent with the view that FMT is the most cost-effective option in treating recurrent CDI. There are some (but considerably less) data indicating that FMT may be a cost effective strategy in treating initial CDI, as well. The superior cost-effectiveness of FMT as compared to the preferred standards of treatment for recurrent CDI suggest FMT use should become more integrated in routine clinical practice. Increased utilization of FMTs would allow for better control of this increasingly problematic disease as well as lower costs associated with its management.

Anti-inflammatory and Antioxidant Effects of Sesame Oil on Atherosclerosis: A Descriptive Literature Review.

Sesame oil (SO) is a supplement that has been known to have anti-inflammatory and antioxidant properties, which makes it effective for reducing atherosclerosis and the risk of cardiovascular disease. Due to the side effects of statins, the current recommended treatment for atherosclerosis and cardiovascular diseases, the idea of using dietary and nutritional supplementation has been explored. The benefits of a dietary health regime have piqued curiosity because many different cultures have reaped health benefits through the ingredients in their cooking with negligible side effects. The purpose of this literary review is to provide a broad overview of the potential benefits and risks of SO on the development of atherosclerosis and its direction toward human clinical use. Current in vivo and in vitro research has shed light on the effects of SO and its research has shown that SO can decrease low-density lipoprotein (LDL) levels while maintaining high-density lipoprotein (HDL) levels. Current limitations in recent studies include no standardized doses of SO given to subjects and unknown specific mechanisms of the different components of SO. Future studies should explore possible synergistic and adverse effects of SO when combined with current recommended pharmaceutical therapies and other adjunct treatments.

Red blood cell transfusion in pediatric patients with severe chronic anemia: how slow is necessary?

Historic practice recommends slow transfusion for children with chronic anemia and hemoglobin less than 5.0 g/dl due to the theoretical risk of transfusion-associated circulatory overload (TACO). In our pediatric intensive care unit (PICU), we have been utilizing a more liberal transfusion practice in patients without underlying cardiopulmonary disease, and a faster transfusion rate appears safe in this population. Rate of transfusion must be based on multiple factors including convenience, timeliness of procedures and transport to an appropriate care facility, risk of alloimmunization and wastage of blood, stress for the family, and need for PICU monitoring.