High risk and low prevalence diseases: Blast injuries.

INTRODUCTION: Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries. OBJECTIVE: This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION: Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential. CONCLUSIONS: An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Commercial Airline In-Flight Emergency: Medical Student Response and Review of Medicolegal Issues.

BACKGROUND: As the prevalence of air travel increases, in-flight medical emergencies occur more frequently. A significant percentage of these emergencies occur when there is no certified physician, nurse, or paramedic onboard. During these situations, flight crews might enlist the help of noncertified passengers, such as medical students, dentists, or emergency medical technicians in training. Although Good Samaritan laws exist, many health care providers are unfamiliar with the limited legal protections and resources provided to them after responding to an in-flight emergency. CASE REPORT: A 78-year-old woman lost consciousness and became pulseless onboard a commercial aircraft. No physician was available. A medical student responded and coordinated care with the flight crew, ground support physician, and other passengers. After receiving a packet (4 g) of sublingual sucrose and 1 L i.v. crystalloid, the patient regained pulses and consciousness. The medical student made the decision not to divert the aircraft based on the patient's initial response to therapy and, 45 min later, the patient had normal vital signs. Upon landing, she was met and taken by paramedics to the nearest emergency department for evaluation of her collapse. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians are the most qualified to assist in-flight emergencies, but they might not be aware of the medicolegal risks involved with in-flight care, the resources available, and the role of the flight crew in liability and decision making. This case, which involved a medical student who was not given explicit protection under Good Samaritan laws, illustrates the authority of the flight crew during these events and highlights areas of uncertainty in the legislation for volunteer medical professionals.

Evaluation of levonorgestrel intrauterine system upon presumed nonintact removal.

A 51 year old woman presented for removal of her expired levonorgestrel intrauterine device (IUD). The IUD arms appeared absent upon IUD removal. Further examination of the device revealed that the arms were concealed inside the hormonal cylinder. Recognizing abnormal presentations of the levonorgestrel IUD upon removal can avoid unnecessary procedures.

Acute Water Intoxication With Resultant Hypo-Osmolar Hyponatremia Complicated by Hypotension Secondary to Diffuse Third-Spacing.

Hypotonic hyponatremia secondary to acute water intoxication is most commonly associated with primary polydipsia in the setting of psychiatric illness. However, in certain circumstances, otherwise healthy individuals can be compelled to consume large enough volumes of water to overwhelm the kidney's dilutional capacity of urine and cause a potentially life-threatening rapid decline in serum sodium. We present such a case of a 20-year-old basic military trainee with acute symptomatic hypotonic hyponatremia after drinking five to six liters of water prior to urine drug testing. The clinical manifestations of this disorder are non-specific and can be seen with many different pathologic processes, presenting a diagnostic challenge to the emergency clinician. This challenge can be further complicated by unclear or unobtainable history depending on clinical presentation. The authors will discuss key diagnostic and treatment elements of this potentially life-threatening disease to encourage clinicians to utilize social history when evaluating cases of acute water intoxication and resultant symptomatic hypotonic hyponatremia.