Acute aortic syndrome (AAS) is a potentially fatal vascular emergency in which prompt diagnosis and early intervention are critical to reducing morbidity and mortality. Computed tomography angiography (CTA) is the first-line imaging modality because of its rapid acquisition, wide availability, and high diagnostic accuracy. However, AAS may present with atypical clinical features and subtle imaging findings, creating significant diagnostic and therapeutic uncertainty. We report a challenging case of a 50-year-old woman who presented with chest pain, headache, and hypertensive crisis. CTA demonstrated a thin focal intimal abnormality along the lateral wall of the aortic arch without involvement of the ascending or descending aorta and no clearly defined true or false lumen. However, subsequent multidisciplinary review favored a penetrating atherosclerotic ulcer with associated localized intramural hematoma. The patient was managed conservatively with anti-impulse therapy and serial CTA surveillance, which demonstrated lesion stability followed by complete radiographic resolution on follow-up gated CTA. This case highlights the diagnostic and therapeutic challenges encountered by emergency physicians when evaluating AAS. Atypical clinical features, subtle CTA abnormalities, and uncertainty regarding lesion classification may complicate timely diagnosis and management decisions. The case also illustrates the potential for differing specialist interpretations when imaging findings are equivocal and the value of serial imaging in guiding diagnosis and treatment. Emergency physicians should maintain a high index of suspicion for AAS despite atypical clinical or imaging findings and initiate appropriate anti-impulse therapy and specialist consultation when clinically indicated to minimize missed or delayed diagnoses.

Lumboperitoneal (LP) shunts are increasingly used for cerebrospinal fluid diversion in idiopathic intracranial hypertension (IIH), but their complication profile may be unfamiliar to emergency physicians compared to those associated with ventriculoperitoneal shunt malfunction. We present a case of fatal cerebral and cerebellar herniation following a large programmable LP shunt valve adjustment in a patient with an intact cranium. Despite the initial CT scan that was read normal, patient rapidly deteriorated while boarding in the ED. Repeat CT was consistent with cerebral and cerebellar herniation, likely secondary to overdrainage-induced paradoxical intracranial hypertension. A high index of suspicion should be maintained for any neurologic complaints following valve reprogramming, even if initial imaging is reassuring; an expedient neurosurgery engagement may be warranted. Familiarity with LP shunt failure complication profiles will be of increasing importance for emergency physicians.

Acute traumatic shoulder injuries are often associated with severe pain that hinders examination, radiographic positioning, and timely orthopaedic management. Conventional systemic analgesia may be inadequate, while interscalene and superior trunk blocks can be limited by hemidiaphragmatic paresis. The ultrasound-guided infraspinatus teres minor (ITM) inter-fascial plane block is a recently described diaphragm-sparing technique that targets the suprascapular and axillary nerves through a single posterior injection and has shown promising anatomic and postoperative analgesic coverage in earlier reports. In this case series, four patients presenting to the emergency department with acute traumatic shoulder pain refractory to multimodal systemic analgesia, received ultrasound-guided ITM block using 20-25 mL of 0.375% ropivacaine with dexamethasone; three of them also received a continuous catheter infusion of 0.2% ropivacaine. Injuries included displaced proximal humeral fracture, glenoid fracture, humeral neck fracture, and humeral head dislocation. In all cases, pain scores fell rapidly from 8 to 10/10 to 0-1/10 within 30 min, facilitating examination, imaging, plaster application, immobilization, or closed reduction without rescue analgesia or procedural sedation. Analgesia remained satisfactory during observation, and no block-related complications were reported. These preliminary findings suggest that the ITM block may be an effective and practical diaphragm-sparing option for emergency department analgesia in acute shoulder injuries, with the added advantage of catheter-based prolongation when needed. Larger prospective comparative studies are required to confirm its efficacy, define safety, and clarify its role relative to other regional techniques.

Managing the neonatal and infant airway is challenging due to several anatomic and physiologic differences compared to adults. In 2024, the European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia published joint guidelines on airway management in neonates and infants (defined as <1 year). The guidelines recommend using history and physical examination to predict a difficult airway. They recommend using sedatives such as etomidate or ketamine to ensure appropriate anaesthesia combined with neuromuscular blocking agents. Videolaryngoscopy is the first choice for intubation, and apneic oxygenation should be used during the intubation attempt. A supraglottic device can be used for rescue oxygenation and ventilation if tracheal intubation is unsuccessful. The number of attempts should be limited, with consideration of changing to a different technique, provider, or both after each unsuccessful attempt. A stylet should be used for hyperangulated videolaryngoscopy blades and airways that are anatomically anterior. End-tidal capnography should be used to verify intubation. The guidelines also incorporate considering human factors to improve patient care and reduce harm. This review summarizes the 2024 guideline recommendations for management of the neonatal and infant airway with an emphasis on their impact on emergency medicine.