The causes of high anion gap metabolic acidosis (HAGMA) are well described in the literature. However, sometimes more frequent causes of HAGMA cannot explain its occurrence.

In the case of HAGMA and severe neurological depression in the absence of other causes of HAGMA, clinicians should consider an intoxication with gamma-hydroxybutyrate (GHB) as a possible cause.

GHB is endogenous to the mammalian central nervous system (CNS). Synthetic GHB was initially used as an anesthetic but is now only licensed for medical use in a limited number of indications such as the treatment of narcolepsy. Because of its euphoric effects, it became popular for recreational use under the street names: Liquid Ecstasy, Georgia Home Boy, and Liquid G.

We describe the clinical case of a patient who suffered from severe neurological depression and HAGMA.

A 60-year-old male presented to an emergency department (ED) with priapism following a sore throat illness. He did not have typical findings of sepsis. The patient then developed severe headache, mental status changes, and hypertension, then suffered a cardiopulmonary arrest. Autopsy showed group A streptococcal (GAS) sepsis, disseminated intravascular coagulation (DIC), and a septic thrombosis to the penile vein. This is the first known case of priapism being the presenting symptom of DIC.

Post-cardiac arrest hypotension is associated with worse outcomes. However, a significant proportion of patients may not be responsive to intravenous (IV) fluids, and vasopressor infusions require significant time to initiate. This case series describes the successful use of a bolus dose of epinephrine to rapidly treat IV fluid refractory hypotension among three patients in the post-arrest period. A bolus dose of epinephrine may be considered as a treatment for post-arrest hypotension that does not respond to IV fluids, but further studies should be performed prior to routine use.

Complications related to methamphetamine use and abuse are common presentations seen in the emergency department. Standard management focuses on addressing the central nervous system and cardiovascular effects with the use of sedation and hemodynamic support. We describe a case report of a patient with methamphetamine toxicity and subsequent severe cardiomyopathy refractory to conventional management that responded to cardiovascular support with extracorporeal membrane oxygenation therapy (ECMO). A 22-year-old female was admitted in severe cardiogenic shock following intravenous administration of methamphetamine and oral fentanyl use. Despite aggressive treatment with benzodiazepines, intravenous fluids, vasopressors, vasodilators, antibiotics and inotropes, the patient’s clinical status deteriorated, and she suffered a cardiac arrest. The patient was successfully resuscitated, and following the return of spontaneous circulation, ECMO was initiated. After 82 hours the patient was successfully weaned from ECMO with the recovery of her left ventricular function and no neurologic sequelae. The patient developed leg ischemia requiring embolectomy and open repair as a complication of ECMO cannulation. In our case, ECMO was used successfully in treating severe cardiac dysfunction from acute methamphetamine-induced cardiomyopathy and was used as a bridge to recovery. The complications seen in this patient emphasize the potential risks associated with this intervention and highlight the need for careful patient selection.

Electronic cigarettes, often referred to as e-cigarettes, have established a considerable market in North America over the last decade. In parallel to this trend, there has been a surge of e-cigarette battery explosions reported in the general media. Given the growing number of such events, acute care physicians should recognize the associated risks and injury patterns and initiate appropriate treatment. This report presents two cases of burn injuries from e-cigarette battery explosions requiring surgical management. The accompanying comprehensive literature review highlights the emerging importance of e-cigarettes as an aetiology of burn injury.

We describe the successful use and complications of bolus-dose alteplase to treat strongly suspected pulmonary embolism (PE) with cardiac arrest in a patient initially presenting as ST-elevation myocardial infarcation (MI). Case description is followed by a review of the indications, safety, and dosing of systemic thrombolytic therapy for high-risk PE in the emergency department (ED). Diagnostic and therapeutic approach to PE in critically ill patients is also considered, including the potential utility of point-of-care ultrasound (PoCUS) in the ED.

Acute tumor lysis syndrome in the absence of cytotoxic therapy is an uncommon event but has been reported with hematologic malignancies. The case described below illustrates spontaneous tumor lysis syndrome in the context of a rapidly proliferating metastatic colonic adenocarcinoma. Clinicians should consider ordering phosphate, uric acid, and calcium when assessing patients with recently diagnosed or suspected malignancy.

Eslicarbazepine is a novel anti-epileptic agent indicated for the treatment of partial-onset seizures. We present the case of an 18 year old female that presented to the Emergency Department four hours after a reported intentional ingestion of an estimated 5600 mg of eslicarbazepine. Although initially hemodynamically stable and neurologically normal, shortly after arrival she developed confusion, rigidity and clonus, followed by recurrent seizures, hypoxemia and cardiac arrest which responded to cardiopulmonary resuscitation and wide complex tachycardia requiring defibrillation. Treatment for refractory seizures included benzodiazepines and eventual intubation and sedation with propofol. Cardiac toxicity responded to sodium bicarbonate. In addition, empiric hemodialysis was performed. In this case report, we discuss the successful management of the first reported overdose of eslicarbazepine using supportive care and hemodialysis.

Crayfish or Procambarus clarkii is a freshwater crustacean with worldwide distribution. Tons of crayfish are consumed each year. In this report, four adult patients with rhabdomyolysis after consuming crayfish were described. All of them presented to the emergency department with myalgia. The diagnosis of rhabdomyolysis was supported by an elevated creatine kinase level. All recovered with supportive treatment. The clinical picture of these 4 patients was compatible with Haff disease. Haff disease is a syndrome in which rhabdomyolysis develops subsequent to consumption of certain cooked seafood. Crayfish is a common culprit. Diagnosis depends on obtaining a diet history and creatine kinase level. Most patients recover uneventfully with supportive treatment for rhabdomyolysis.

Electrocardiographic changes resulting from apical hypertrophic cardiomyopathy may mimic an acute coronary syndrome. A 67-year-old Sudanese male without cardiac risk factors presented to hospital with chest pain and electrocardiographic findings of septal ST-segment elevation, ST-segment depression in V4-V6, and diffuse T-wave inversion. He was treated as an acute ST-elevation myocardial infarction with thrombolytics. There was no cardiac biomarker rise and coronary angiography did not reveal evidence of significant coronary arterial disease. Ventriculography, transthoracic echocardiography, and cardiac magnetic resonance imaging were consistent with apical hypertrophic cardiomyopathy. The patient was discharged three days later with outpatient cardiology follow-up. We highlight the clinical and electrocardiographic findings of apical hypertrophic cardiomyopathy, with an emphasis on distinguishing this from acute myocardial infarction.

Sustained monomorphic ventricular tachycardia (VT) can result in hypoperfusion or devolve into more dangerous rhythms such as ventricular fibrillation. In an unstable patient with VT and a pulse, synchronized cardioversion is the first-line treatment. When the VT is refractory to standard cardioversion, the next step is to add an antiarrhythmic, such as amiodarone, that carries with it the risk of lowering blood pressure in the already hypotensive patient. Here we describe a case of double sequential synchronized cardioversion of a patient with unstable VT refractory to standard direct current cardioversion, resulting in a rapid conversion to sinus rhythm and return to hemodynamic stability. The benefit of this technique is that it may obviate the need for rapid infusion of medications, such as amiodarone, in the acute setting that may worsen hypotension in the already unstable patient.

Cases of liraglutide overdose are rare in the literature. Prior reports have not found hypoglycemia related to the medication overdose. We describe a case of a non-diabetic patient who intentionally overdosed on liraglutide leading to severe hypoglycemia. The patient required admission to the intensive care unit for a dextrose infusion and close monitoring. Glucagon-like protein-1 agonists are recognized for their safety and rarely causing hypoglycemia in diabetic patients. However, in this case the patient’s non-diabetic status may have put him at risk for hypoglycemia in contrast to prior cases showing no hypoglycemia in diabetic patients. The case highlights the possible dangers of liraglutide overdose and need for blood glucose monitoring in the acute presentation.

Cardiac emergencies in pregnancy and the postpartum period are rare but often life-threatening. An emergency physician’s differential diagnosis for chest pain in the peripartum patient often includes serious etiologies such as pulmonary embolism or myocardial infarction (MI). A lesser-known but important consideration on the differential for MI is that of a spontaneous coronary artery dissection (SCAD). SCAD is defined as an intramural hematoma within the coronary artery that compresses the true lumen. Expansion by increased pressures may lead to subsequent myocardial ischemia and infarction. This condition is the most common cause of pregnancy-associated MI and is reported as the cause of MI in 24% to 35% of all women younger than 50 years. This condition is predominately seen in young healthy females with no traditional risk factors for coronary artery or cardiac disease, and typically in the postpartum period. SCAD in the peripartum period is defined as pregnancy-associated spontaneous coronary artery dissection (PASCAD). Abnormal ECG changes, elevated troponins, and regional wall motional abnormalities on echocardiography are all diagnostic findings of SCAD, which can be ultimately confirmed with coronary angiography. Failure to immediately address this condition can lead to acute heart failure, cardiogenic shock, and death. Thrombolytic treatment may be harmful and is not recommended, and percutaneous coronary intervention can result in the iatrogenic propagation of further coronary dissection. As a result, the management for suspected SCAD involves emphasis on urgent transfer and urgent coronary artery angiography to determine appropriate treatment modalities.

The eligibility criteria for applying extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest are currently unclear. For those patients with hypothermic cardiac arrest, the European Resuscitation Council (ERC) Guidelines recommend considering ECPR only for patients with potassium <8 mmol/L and a body temperature below 32°C, whereas the American Heart Association Guidelines (AHA) do not express this in a specific manner.

We report the case of an urban unwitnessed out-of-hospital cardiac arrest patient found with her head immersed in water at a temperature of 23°C. The patient presented an unclear history and a dire combination of clinical and laboratory parameters (asystole, arterial blood gas: pH 6.8, potassium 8.3 mmol/L, lactate 16.0 mmol/L). Despite these poor prognostic indicators, ECPR was initiated after 95 minutes of CPR and the patient survived with a good neurological outcome.

This case highlights the uncertainty in ECPR eligibility and prognostication, especially in those with hypothermia and water immersion for whom aggressive therapies may be warranted. Further data and improved strategies are required to delineate candidacy for this resource-intensive procedure better.