Emergency Medicine

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• Persistent cardioactive glycosides intoxication related to gastric phytobezoar of oleander leaves Michel Pescia, Marco Conti, Romina Contratto Views: 264 PDF: 331 HTML: 29

  Nerium oleander is a plant containing cardiac glycosides, and intoxication with its leaves is a medical emergency. We report the case of a 73-year-old man who took a decoction of oleander leaves for a reckless purpose. Upon arrival in the emergency room, he presented an altered state of consciousness, drooling and vomiting. He was bradycardic with intermittent third- degree atrioventricular block and typical downsloping ST-segment depression related to glycosides toxicity. Despite initial treatment with atropine, isoprenaline and repeated bolus of digoxin-specific antibody (Fab) fragments, symptoms were persistent 12 hours after admission. Suspecting that the patient not only drank the decoction but also ingested the leaves and had slow gastric emptying, we performed gastric lavage without benefit. We subsequently performed a gastroscopy that showed an oleander phytobezoar, and its removal permitted a rapid clinical improvement.

  Treatment with digoxin-specific antibodies for intoxication is well described and dosage should be adapted to the plasmatic level. Such an examination is useless in oleander intoxication because it does not represent the real quantity of toxin. The dosage of antibodies is empiric and should be guided by the clinical severity.
  In such intoxication, the presence of a phytobezoar from oleander leaves cannot be excluded so we believe that a gastroscopy for its mechanical removal should always be considered to avoid persistent release of toxin.

• Hiatal hernia: the great masquerade in the emergency department Angelina Borizanova, Elena Kinova, Dimitar Peichinov, Plamen Getsov, Assen Goudev Views: 367 HTML: 820 PDF: 375

  Chest pain and dyspnoea are among the most common complaints seen in the emergency room and each symptom calls for a broad differential diagnosis. Large hiatal hernias are infrequent, but they can lead to atypical symptoms mimicking different cardiovascular, pulmonary and neoplastic diseases. We present two cases of older patients with an apparent left atrial mass on transthoracic echocardiography, which was subsequently identified as hiatal hernia by other imaging modalities. A multidisciplinary team with multimodality imaging is necessary for diagnostic work-up of chest pain and dyspnoea of non-cardiac origin and especially for a suspected mass compressing the heart, causing chest discomfort.

• Multiple rib fractures, pleural effusion and right-sided diaphragmatic herniation of the colon into the chest associated with chronic cough after COVID-19 Sanjana Chetana Shanmukhappa, Muhammad Ahmed Malik, Navya Akula, Fahd Shaukat Views: 359 HTML: 67 PDF: 461

  Rib fractures are an infrequent consequence of severe cough. In some patients, undetected rib fractures can lead to life-threatening outcomes. The case of a 73-year-old man who presented with shortness of breath and a worsening dry cough from a SARS-CoV-2 infection for 4 weeks is described. In the emergency department, he was found to be hypoxic and hypotensive. Imaging studies revealed a large right pleural effusion, multiple rib fractures, and right-sided herniation of the colon into the chest. He was admitted to the cardiothoracic intensive care unit where he underwent a flexible bronchoscopy, right video-assisted thoracoscopic surgery, evacuation of a haemothorax, complete decortication, and repair of a diaphragmatic hernia. This case is an unusual presentation of an amalgamation of rare complications resulting from an unrelenting, poorly controlled SARS-CoV-2 infection cough that prompted rapid recognition and swift action.

• Spontaneous renal hemorrhage João Luís Cavaco, Francisco Capinha, Maria José Pires, Ana Furão Rodrigues, Ana Oliveira Pedro, António Pais de Lacerda Views: 406 HTML: 46 PDF: 320

  Introduction: Spontaneous renal haemorrhage is a rare condition with potentially serious complications.

  Case description: We describe a 76-year-old woman with a 3-day history of fever and malaise, with no associated trauma. She was admitted to our emergency room with signs of shock. A contrast-enhanced computed tomography scan revealed an extensive right kidney haematoma. Despite fast surgical management, the patient died less than 24 h after admission.

  Conclusion: Spontaneous renal haemorrhage should be quickly identified due to its fatal complications. Early diagnosis leads to a better prognosis.