Emergency Medicine Journal Emergency casebook

Cannabinoid hyperemesis

Wild, K., Wilson, H. — 2011-12-20T16:23:52-08:00

A 21-year-old woman presented with a 4-week history of sudden onset vomiting, nausea and anorexia. Questioning revealed that she had a 7-year history of heavy cannabis use (smoking). She did not describe abdominal pain, change in bowel habit, antibiotic use, foreign travel or contact with gastroenteritis. Biochemistry results demonstrated mild metabolic derangement with a low potassium and a low bicarbonate, and urine toxicology was positive for cannabinoids. Other investigations, including a full blood count, renal function tests, liver function tests, a coagulation sample, an ECG, urinary β-hCG and a CT head scan, were all normal. A diagnosis of cannabinoid hyperemesis was made and her symptoms resolved after treatment with intravenous fluids, antiemetics and abstinence from cannabis. Since her discharge and abstinence she has had several relapses, each related to cannabis use and each resolving with abstinence. The patient is now seeking cognitive behavioural therapy to achieve permanent abstinence.

A fatal case of severe methaemoglobinemia due to nitrobenzene poisoning

Gupta, A., Jain, N., Agrawal, A., Khanna, A., Gutch, M. — 2011-12-20T16:23:52-08:00

An acute poisoning with nitrobenzene presenting as methaemoglobinemia is an uncommon medical emergency. A young girl with nitrobenzene induced methaemoglobinaemia died despite use of mechanical ventilator, administration of oral methylene blue and parenteral ascorbic acid. Here author highlights the rare occurrence of such cases, methaemoglobin induced severe oxidative stress, unexplained splenomegaly and leucocytosis and the ineffectivity of oral methylene blue and other supportive measures in evading death due to nitrobenzene poisoning.

Acute pulmonary embolus with visible right heart thrombus in transit

Debney, M. T. — 2011-12-20T16:23:52-08:00

Description

A 29-year-old woman presented to our emergency department with syncope, acute chest pain and circulatory collapse. She had a tachycardia of 135 bpm, blood pressure of 77/55 mm Hg and a profound metabolic acidosis (pH 7.07, lactate 10, base excess-20). A 12-lead ECG (figure 1) showed sinus tachycardia with right axis deviation, large p waves and poor R wave progression across the chest leads, suggestive of acute right heart strain. A D-dimer was elevated at 15984 μg/l (reference range 0–200 μg/l); a plain anteroposterior chest radiograph was unremarkable. Bedside transthoracic echocardiography showed a dilated, poorly functioning right ventricle with visible thrombus prolapsing across the tricuspid valve as demonstrated in figure 2 and video 1. These findings confirmed the clinical suspicion of acute massive pulmonary embolus causing circulatory collapse and intravenous thrombolysis was successfully administered. Once haemodynamic stability had been restored, CT pulmonary angiography confirmed...

Severe hypoxaemia due to methaemoglobinaemia and aspiration pneumonia

Mizutani, T., Hojo, M. — 2011-12-20T16:23:52-08:00

The authors report a case of a previously healthy 40-year-old man who was admitted to the emergency department due to severe hypoxaemia after emesis. He vomited after a cup of coffee with the milk at his office. On admission, he showed cyanosis and oxygen saturation measured by pulse oximetry was extremely low (86%) in spite of the administration of 10 litres of oxygen. The authors suspected pneumonia, but oxygen saturation was disproportionately low to pneumonia severity. Oxygen saturation measured by pulse oximetry was significantly different from oxygen saturation calculated from arterial blood gas analysis, suggesting the existence of haemoglobin abnormality. The level of methaemoglobin was 9.3% (reference range, 1–2%). The patient was treated by antibiotics for pneumonia, and his methaemoglobinaemia was spontaneously ameliorated. The authors later found that the patient drank bleach containing hypochlorous acid instead of milk by mistake. To conclude, the patient's hypoxaemia was due to pneumonia and drug-induced acquired methaemoglobinaemia.