Two Rare Cases of Appendicitis: Amyand's Hernia and De Garengeot's Hernia.

An Amyand's hernia is an inguinal hernia that contains vermiform appendix. De Garengeot's hernias are similar; however, in this case the appendix is within a femoral hernia. Both types of hernia are rare, and those hernias associated with appendicitis, perforation, or abscess are even scarcer presentations. The treatment of Amyand's hernia and De Garengeot's hernia is not standardized. Generally, hernia repair is performed but disagreement remains regarding the use of mesh and performing appendectomy. This case series describes two individuals with appendicitis presenting to one emergency department within a 24-hour time frame. One case is of a patient with Amyand's hernia and another case is a patient with De Garengeot's hernia with an adjacent abscess. Both individuals were managed with appendectomy and hernia repair without the use of mesh.

A Rare Central Nervous System Fungal Infection Resulting from Brown Heroin Use.

BACKGROUND: Fungal nervous system infection can be a difficult diagnosis to make, due to the fact that there are no specific manifestations of the disease and laboratory confirmation is difficult to confirm. CASE REPORT: We report a young male who presented to our emergency department with a variety of unilateral visual field complaints. While he initially denied recent IV drug abuse, his physical examination was highly suggestive of a fungal infection known to result from brown heroin use. He was ultimately diagnosed with meningitis, ventriculitis, and endogenous endophthalmitis believed to result from a Candida species. The response to treatment with vitrectomy and broad-spectrum antimicrobials gave support to the presumed diagnosis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We provide a rarely described report of a possible complication from the use of IV brown heroin that led to a central nervous system infection involving vision loss by fungal infection.

Glasgow Coma Scale Motor Component ("Patient Does Not Follow Commands") Performs Similarly to Total Glasgow Coma Scale in Predicting Severe Injury in Trauma Patients.

STUDY OBJECTIVE: Trauma victims are frequently triaged to a trauma center according to the patient's calculated Glasgow Coma Scale (GCS) score despite its known inconsistencies. The substitution of a simpler binary assessment of GCS-motor (GCS-m) score less than 6 (ie, "patient does not follow commands") would simplify field triage. We compare total GCS score to this binary assessment for predicting trauma outcomes. METHODS: This retrospective analysis of a statewide trauma registry includes records from 393,877 patients from 1999 to 2013. Patients with initial GCS score less than or equal to 13 were compared with those with GCS-m score less than 6 for outcomes of Injury Severity Score (ISS) greater than 15, ISS greater than 24, death, ICU admission, need for surgery, or need for craniotomy. We judged a priori that differences less than 5% lack clinical importance. RESULTS: The relative differences between GCS and GCS-m scores less than 6 were less than 5% and thus clinically unimportant for all outcomes tested, even when statistically significant. For the 6 outcomes, the differences in areas under receiver operating characteristic curves ranged from 0.014 to 0.048. Total GCS score less than or equal to 13 was slightly more sensitive (difference 3.3%; 95% confidence interval 3.2% to 3.4%) and slightly less specific (difference -1.5%; 95% confidence interval -1.6% to -1.5%) than GCS-m score less than 6 for predicting ISS greater than 15, with similar overall accuracy (74.1% versus 74.2%). CONCLUSION: Replacement of the total GCS score with a simple binary decision point of GCS-m score less than 6, or a patient who "does not follow commands," predicts serious injury, as well as the total GCS score, and would simplify out-of-hospital trauma triage.

Resuscitation of a Pediatric Drowning in Hypothermic Cardiac Arrest.

The prognosis of pediatric patients who require prolonged resuscitation after ice water drowning and hypothermic cardiac arrest remains guarded. We report a case of successful prolonged resuscitation of a pediatric patient in hypothermic cardiac arrest who showed severe metabolic derangements and went on to make a rapid and full neurologic recovery without the use of extracoproreal rewarming or mechanical cardiac support. Many ground and air medical emergency medical service programs have policies against interfacility transfer of patients in hypothermic cardiac arrest, calling into question the need to revise current protocols.