Mohammed Naveeth Imran

Case Presentation: A 30-year-old man presented to the emergency department with severe blunt facial trauma following a fall from height. Examination revealed extensive floor-of-mouth ecchymosis and a large tense sublingual hematoma causing tongue elevation, dysarthria, and swelling mimicking Ludwig’s angina, producing a traumatic pseudo-Ludwig appearance with marked airway crowding. Three-dimensional computed tomography demonstrated severely displaced bilateral mandibular fractures. Owing to pronounced segmental instability with mobile dentoalveolar fragments, temporary interdental bridle wire stabilization was performed in the emergency department. Despite the dramatic anatomical findings, serial airway reassessments confirmed sustained airway stability, permitting delayed definitive open reduction and internal fixation. Discussion: Traumatic pseudo-Ludwig angina secondary to bilateral mandibular fractures is an uncommon presentation that may closely mimic life-threatening infectious floor-of-mouth swelling. Hemorrhage within the confined sublingual space can rapidly elevate and posteriorly displace the tongue, resulting in progressive airway compromise. This case highlights the importance of dynamic airway assessment, serial airway reassessment, and early multidisciplinary management, including temporary interdental bridle wire stabilization, in carefully selected patients with traumatic hemorrhagic floor-of-mouth emergencies.

Diffuse alveolar haemorrhage is an uncommon but life-threatening cause of acute hypoxaemic respiratory failure and may closely mimic pulmonary oedema in patients with advanced chronic kidney disease. A man in his 50s with stage 5 chronic kidney disease receiving maintenance haemodialysis and immune thrombocytopenia treated with a tapering dose of oral prednisolone (30 mg/day) presented with minor haemoptysis followed by rapidly progressive breathlessness. He was severely hypoxaemic on arrival. Laboratory evaluation revealed thrombocytopenia and a progressive decline in haemoglobin levels. The absence of elevated jugular venous pressure and peripheral oedema, together with preserved left ventricular systolic function on transthoracic echocardiography, argued against cardiogenic pulmonary oedema. High-resolution CT of the chest showed bilateral ground-glass opacities with patchy consolidation. In the absence of clinical evidence of infection and with negative autoimmune screening, a clinicoradiological diagnosis of diffuse alveolar haemorrhage secondary to bleeding diathesis was made. The patient improved with non-invasive ventilation, platelet transfusion and nebulised tranexamic acid without invasive procedures. This case highlights an important emergency diagnostic pitfall: bilateral infiltrates in chronic kidney disease are not always caused by fluid overload.

Background: Pain is the most common presentation in the Emergency Department (ED), yet its management is often suboptimal due to a busy environment, leading to oligoanalgesia. Traditional blind landmark-based nerve blocks and procedural sedation have notable disadvantages. Ultrasound-guided regional anesthesia (UGRA) offers a safe and effective alternative, addressing the complications of conventional methods. Methodology: This prospective observational study was conducted at the ED of a tertiary care center from October 2022 to March 2024. Patients meeting the inclusion and exclusion criteria were enrolled after informed consent. Pain scores were recorded before and after the procedure. Pain relief was considered successful if there was at least a two-point reduction in pain score 30 minutes after the procedure. If the patient experienced discomfort during the procedure, it was considered an inadequate block, and additional analgesia was administered. If there was no pain reduction within 20 minutes, the block was deemed a failure. Results: A total of 101 UGRA procedures were performed. Overall, 94.1% of patients had successful blocks, while 5.9% experienced block failure. The mean pain score at baseline was 7.4, which significantly dropped to 1.4 after 30 minutes of UGRA. Physicians reported high satisfaction with the ease of procedure, anatomical visibility, and local anesthetic spread. Conclusion: The study demonstrates that UGRA is a highly effective and safe technique for pain management in the ED, with a high success rate and minimal complications when performed by emergency physicians.