Indian Journal of Emergency Medicine

Background: Snakebite Envenomation is a time-limiting, acute medical emergency and a significant public health hazard in rural and suburban India. Neurotoxic Envenomation, predominantly caused by the Common Krait (Bungarus caeruleus), presents profound diagnostic dilemmas. Because Kraits are nocturnal and possess fine fangs, their bites are frequently painless, lack significant local signs, and can escape the patient’s awareness. When a patient presents with atypical soft tissue swelling or an alternative medical history, significant diagnostic delays and rapid clinical deterioration can occur.

Background: Thoracentesis is a commonly performed diagnostic and therapeutic procedure. Although generally safe, rare complications such as retained foreign bodies may occur. Case Presentation: We describe a case involving a 40-year-old female who presented with fever and progressive dyspnea. Imaging revealed a right-sided pleural effusion. During diagnostic pleural tap using a 16G intravenous (IV) cannula, the catheter fractured, with the proximal two-thirds retained in the chest wall. Immediate point-of-care ultrasound (POCUS) and high-resolution computed tomography (HRCT) localized the fragment. The retained segment was successfully retrieved surgically under ultrasound guidance, and the patient recovered uneventfully. Conclusion: This report highlights the importance of vigilance during pleural procedures and emphasizes the role of multimodal imaging, particularly POCUS and HRCT, in the safe localization and retrieval of retained foreign bodies

Pregnancy is a physiologic hypercoagulable state characterized by increased clotting factors, reduced fibrinolytic activity, and venous stasis, all of which contribute to an elevated risk of venous thromboembolism. Pregnancy is associated with a gradual increase in thrombotic risk that culminates during the third trimester and extends into the postpartum period owing to physiological changes in coagulation and venous circulation. Among these stages, the puerperium is the most vulnerable, with epidemiological studies demonstrating that women are at least five times more likely to experience VTE during the first two to six weeks after delivery than during pregnancy.Among the less common causes of iliofemoral deep vein thrombosis is May-Thurner syndrome, an anatomical venous compression disorder characterized by impaired iliac venous drainage due to chronic extrinsic compression. The resulting venous stasis predisposes patients to venous stenosis, obstruction, chronic venous insufficiency, and thrombosis. Recognition of this condition is particularly important in patients with unexplained left-sided iliofemoral DVT. I present you a case of a 30 years old,5 weeks’ post-partum lactating mother [P1L1] who came to ED with complaints of generalised weakness, pain in lower abdomen radiating towards lower back, and medial side of left thigh and ipsilateral groin since 7 to 10 days, associated with swelling of the thigh. After careful examination, an immediate bilateral lower limb DVT scan was ordered which suggested echogenic thrombus within CIV, EIV, CFV, left femoral vein and popliteal vein, which were distended and non-compressible. A vascular surgeon was approached and a plan to insert fluoroscopic guided IVC filter via right IJV percutaneous approach followed by a mechanical thrombus aspiration via left popliteal vein was made and performed. Most VTE can be treated with oral or injectable anticoagulants however, the case of limb or life threatening VTE requires consideration of thrombolysis and other reperfusion therapies. Early recognition of atypical symptoms, prompt diagnosis and timely intervention are crucial to prevent serious morbidity and mortality. This case highlights the importance of maintaining a high index of suspicion for VTE in post-partum women. While anticoagulants with LMWH remains the cornerstone of treatment, advanced intervention such as thrombus aspiration and IVC filer placement may be required in selected patient with extensive or limb threatening thrombosis.

Cholelithiasis typically presents with right upper quadrant abdominal pain, nausea, and vomiting. However, atypical presentations may occur due to autonomic reflexes. One such rare manifestation is bradycardia resulting from the cardio-biliary reflex, also known as Cope’s sign. We report the case of a 45-year-old male presenting with acute right hypochondrial and epigastrict pain associated with marked sinus bradycardia (heart rate 42/min). Initial cardiac evaluation was unremarkable. Further abdominal imaging revealed cholelithiasis with features of acute cholecystitis. Following definitive management, the patient’s heart rate normalized. This case highlights the importance of recognizing extra-cardiac causes of bradycardia and underscores the clinical relevance of the cardio-biliary reflex in gallbladder pathology.

Background: Referred shoulder pain is a well-recognized clinical symptom that may originate from thoracic, abdominal, diaphragmatic, or musculoskeletal pathology. In elderly patients with underlying spinal disease, atypical presentations can create diagnostic uncertainty and delay definitive management. Pleural-based lesions associated with pleural irritation may occasionally manifest predominantly as shoulder pain due to diaphragmatic and phrenic nerve involvement. Distinguishing infectious or inflammatory aetiologies from malignancy is especially important in such cases.

Deep vein thrombosis (DVT) in young individuals without classical risk factors is uncommon and warrants evaluation for underlying causes. We report a case of a 19-year-old male presenting with acute left lower limb swelling and pain, later diagnosed with extensive lower limb DVT associated with enteric fever and carbapenem-resistant E. coli urinary tract infection. The patient was managed with catheter-directed thrombectomy and anticoagulation, showing favorable recovery.

Background: The ATAK complex is a rare yet clinically significant overlap of allergic and cardiac pathology. It represents a clinical continuum involving Adrenaline, Takotsubo, Anaphylaxis, and Kounis syndrome, resulting in coronary vasomotor dysfunction and transient myocardial impairment. Such presentations often resemble acute coronary syndrome (ACS), creating a diagnostic challenge in an emergency setting. Case Presentation: We present the case of a 71-year-old male with hypertension, chronic kidney disease, and a permanent pacemaker who developed acute chest tightness, dyspnea, diaphoresis and generalised urticaria immediately following intravenous meropenem administration. Initial evaluation suggested ACS and 2D-echocardiography demonstrated an acute reduction in left ventricular systolic function; however, coronary angiography revealed non-obstructive coronary arteries. Serial echocardiography demonstrated partial recovery of left ventricular systolic function. The combination of an allergic trigger, systemic hypersensitivity, and reversible myocardial dysfunction led to the diagnosis of ATAK complex. Conclusion: This case highlights the importance of considering allergic myocardial involvement in patients presenting with ACS-like features following drug exposure. Recognition of ATAK complex is essential when hypersensitivity reactions coexist with reversible cardiac dysfunction, as it prompts a broader diagnostic approach and helps avoid misclassification as obstructive coronary artery disease, ensuring timely and appropriate management.

Introduction: Pulmonary embolism (PE) is a life-threatening manifestation of venous thromboembolism (VTE) and remains one of the leading causes of maternal morbidity and mortality worldwide. The post-partum period is associated with a heightened hypercoagulable state, which may be further amplified by inherited thrombophilia such as protein S deficiency. Early recognition is challenging due to the non-specific clinical presentation and the overlap of symptoms with physiological post-partum changes. Case Report: We report the case of a 28-year-old female who presented to the emergency department in an unconscious state following sudden collapse, 15 days after an uncomplicated lower segment caesarean section. The patient had a preceding history of unilateral leg pain. Initial resuscitation was successful, and subsequent investigations revealed massive pulmonary embolism with right ventricular strain. Laboratory evaluation demonstrated markedly elevated D-dimer levels and significantly reduced free protein S levels, consistent with protein S deficiency. The patient was managed with systemic thrombolysis followed by intensive care support and long-term anticoagulation. Conclusion: Pulmonary embolism should be considered in all post-partum patients presenting with sudden collapse or unexplained hemodynamic instability. Early diagnosis, prompt thrombolytic therapy in appropriate cases, and evaluation for underlying thrombophilia are essential to reduce mortality and guide longterm management strategies. Key Message: • Pulmonary embolism is a catastrophic yet potentially reversible cause of sudden collapse in post-partum patients. • In young individuals with massive PE, inherited thrombophilia such as protein S deficiency should be actively investigated, as identification significantly influences acute management, duration of anticoagulation, and future pregnancy counselling