Interventions associated with survival after prehospital intubation in the deployed combat setting.

INTRODUCTION: Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. MATERIALS AND METHODS: We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. RESULTS: There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. CONCLUSIONS: We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.

Case Report: Recurrent Acute Macular Neuroretinopathy-Monitoring Recovery with Multimodal Imaging.

SIGNIFICANCE: Acute macular neuroretinopathy (AMN) is a rare, nonprogressive condition affecting the outer retina that can be diagnosed clinically using widely available multimodal imaging techniques. This case report presents an exceedingly rare same-eye recurrence of AMN and describes the characteristic imaging findings of this unique, not fully understood clinical entity. PURPOSE: The following report provides a detailed account of recurrent AMN from 4 hours of symptom onset to 4 months with repeat multimodal imaging captured at different visits. This report also devotes some discussion to the current understanding of its pathophysiology, associations, management, and imaging characteristics. CASE REPORT: A 32-year-old woman with unilateral recurrent AMN was monitored frequently with various multimodal imaging from 4 hours after onset of new scotoma to 4 months. The primary finding in the acute stage was a hyperreflective lesion of the outer nuclear and outer plexiform layers followed by disruption of underlying external limiting membrane, ellipsoid zone, and photoreceptors. This resolved into stable outer nuclear layer thinning and subtle disruption of the deeper layers after 1 week. Fundus photography revealed a red-brown petaloid lesion adjacent to the fovea, and optical coherence tomography angiography revealed subtle decreased perfusion of the choriocapillaris layer throughout follow-up. CONCLUSIONS: Acute macular neuroretinopathy is a rare nonprogressive condition of the outer retina most often affecting otherwise healthy young female individuals and is most associated with recent flu-like illness and oral contraceptives. The underlying mechanism of AMN remains unknown, but modern imaging techniques have elucidated the disease locus to be choroidal and/or deep capillary plexus. It is important for eye care providers to recognize AMN as a clinical entity distinct from other retinal conditions that require different management.

Lactation ketoacidosis induced by breastfeeding while on a ketogenic diet.

Lactation ketoacidosis is a very rare cause of metabolic acidosis in breastfeeding patients. We present a case of a 34-year-old female, 8-weeks postpartum, who was breastfeeding while also on the ketogenic diet. She developed dyspnea, chest pain, nausea, vomiting, and an inability to tolerate oral intake for several days. She presented with a metabolic acidosis with an anion gap of 33, HCO3 of 5.1 mmol/L, venous pH of 7.045, and serum b-hydroxybutyrate of 7.4 mmol/L. She was treated in the emergency department with intravenous normal saline and intravenous dextrose, with prompt transfer to the intensive care unit for treatment with an intravenous sodium bicarbonate drip and an intravenous insulin drip with dextrose. After normalization of laboratory values, she re-developed an elevated anion gap acidosis after breastfeeding in the ICU overnight. She was started on a carbohydrate-rich diet and made a full recovery without reported repeat incidences. We provide a summary of our case, discuss known causes of lactation ketoacidosis, and emphasize the importance of a thorough history and physical. In this case a dietary history was more helpful than a very expensive laboratory and imaging evaluation.

Development of ex situ normothermic reperfusion as an innovative method to assess pancreases after preservation.

Static cold storage (SCS) is the standard method for pancreas preservation prior to transplantation; however, it does not permit organ assessment. Normothermic reperfusion (NR) is utilized clinically for other organs to assess viability. Our aim was to develop NR using normothermic machine perfusion technique to simulate reperfusion at the time of transplantation, enabling evaluation of oxygenated hypothermic machine perfusion (HMPO2) as a newer strategy to optimize pancreas preservation. 13 porcine pancreases procured after circulatory death were divided into 3 groups: 4 pancreases preserved using SCS, and 2 groups preserved by HMPO2 (n = 4 and n = 5, differing by type of preservation solution). Duration of perfusion or cold storage was 6 hours before the 1-hour assessment using NR. Outcome measures were perfusion characteristics, biochemistry and change in tissue water mass as oedema assessment. During NR, the HMPO2 groups demonstrated better perfusion characteristics, normal macroscopic appearances, decreased water mass and one HMPO2 group demonstrated a response to glucose stimulation. Conversely, the SCS group showed an increased water mass and developed early macroscopic appearances of oedema, interstitial haemorrhage and minimal portal outflow. This study suggests that ex situ assessment of pancreases by NR is promising, and that HMPO2 may be better than SCS.

Acute coronary syndrome in Dextrocardia.

Situs inversus with dextrocardia is both a clinical and diagnostic challenge for emergency physicians to properly identify acute coronary syndrome. While dextrocardia itself does not independently increase the risk of coronary artery disease, mirrored symptoms, including right-sided and rightward radiating chest pain in any patient with cardiac risk factors should raise suspicion for acute coronary syndrome. In patients with a reversed cardiac silhouette on a chest radiograph, a reversed electrocardiogram, to include both the precordial and limb leads, is necessary to evaluate for cardiac ischemia in presumed dextrocardia. The authors present a case of a 66-year-old man with dextrocardia who presented with shortness of breath and hypotension. Rapid application of a reversed electrocardiogram resulted in the timely diagnosis of ST-segment elevation myocardial infarction and activation of the cardiac catheterization laboratory resulting in the preservation of this patient's life.

A coronavirus disease 2019 (COVID-19) patient with bilateral orchitis.

During the development of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2), a myriad of complications has emerged and although rare, several genitourinary complications have been reported. The bulk of these complications have been secondary to hypercoagulable states, such as priapism. Previous SARS family infections have caused orchitis, though no adult cases of orchitis have been reported. We describe a novel case of SARS-CoV2 bilateral orchitis in a previously healthy 37-year-old male who presented for testicular pain with constitutional symptoms. Additionally, there was no epididymitis associated with the bilateral orchitis. Based on both data in SARS-CoV2 infected males and previous data from prior SARS infections, spermatocyte function may be compromised secondary to this infection. With the various symptoms associated with this virulent pathogen, we characterize the potential complications and importance of fertility follow up.

Pancreaticopleural fistula, a rare mediastinal emergency.

A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.

Guanfacine toxic ingestion with subsequent cardiogenic pulmonary edema.

Guanfacine is a central alpha-2 agonist often prescribed for Attention-deficit hyperactive disorder as well as tic disorder, with a usual dose of 1-4 mg per day. Due to its sympatholytic mechanism of action, Guanfacine can cause autonomic instability and hypotension. It can additionally cause cardiac dysfunction to include symptomatic bradycardias and contractility suppression. The authors present a case of a 17 year-old male with an ingestion of 80 mg of extended release Guanfacine with delayed onset cardiogenic pulmonary edema requiring mechanical ventilation. Previous pediatric ingestions have generated bradycardia, hypotension, and decreased level of consciousness, responsive to intravenous fluids, vasopressors, and occasionally naloxone. However, cardiogenic pulmonary edema from reduced cardiac contractility is a novel consequence of extended release Guanfacine ingestion. With Guanfacine's extended half-life, this unique case underscores the importance of emergency providers' familiarity with this toxidrome as well the necessity for prolonged, close observation following Guanfacine ingestion.

Precision glass molding of diffractive optical elements with high surface quality.

Diffractive optical surfaces have attractive properties for use in optical systems, like reducing weight and correcting for chromatic aberrations, but fabrication of high-quality glass diffractive optics is challenging, preventing it from being widely adopted in commercial applications. In this Letter, we report on a fabrication method to address molding challenges for high-surface-quality diffractive glass optics at molding temperatures up to 550°C, including selection of mold material, mold fabrication, precision glass molding, durability, and stability of the mold. To enable optimal mold machining and easy mold release, nickel phosphorous (NiP) is chosen as the plating material for its cutting performance and anti-adhesion properties, and copper-nickel C71500 (CuNi) is selected as the mold substrate because its coefficient of thermal expansion (CTE) is close to NiP. By the proposed method, diffractive glass optics with 2 nm Sa surface roughness is demonstrated.

Sialolithiasis with abscess: An uncommon presentation of a Ludwig's angina mimic.

Sialolithiasis represents the most common issue of the salivary gland, ranging from asymptomatic to airway compromising. In rapidly progressing, completely obstructive salivary stones, the presentation can mimic emergent oropharyngeal diseases, primarily Ludwig's angina. We present a case of a large and obstructive sialolith with abscess whose initial presentation was concerning for Ludwig's angina with impending airway compromise. While a common complaint, emergency providers should be aware of the nefarious presentation of an everyday complaint.

Pancreaticopleural fistula, a rare mediastinal emergency: A case report.

A pancreaticopleural fistula (PPF) is a rare condition that causes thoracic symptoms such as dyspnea and chest pain secondary to exudative pleural effusions. While PPF is a very rare complication with only 52 cases reported between 1960 and 2007, they typically occur in patients who are male, middle aged, and have a history of chronic alcohol use and chronic pancreatitis (Aswani and Hira, 2015; Francisco et al., n.d.; Valeshabad et al., 2018; Ali et al., 2009). The fistula between the pancreas and pleural cavity causes large, rapidly accumulating, and recurrent pleural effusions which cause symptoms that can be difficult to differentiate from other acute thoracic pathologies (Francisco et al., n.d.). As a result, it is essential that providers have a high index of suspicion for PPF in these appropriate populations. We present a case study to review the typical presentation, pathophysiology, and current approach to treatment of PPF. This case is unique as the patient had no known risk factors. Due to limited data on this topic, there are no evidence-based guidelines on this topic, leaving a variety of case reports to inform clinical management in the emergency department.

Traumatic coronary artery dissection leading to ventricular tachycardia.

Traumatic coronary artery dissection is an unusual injury following trauma. It is potentially life threatening and requires prompt recognition on presentation. We present a case report of a 42-year-old male who presented with ventricular tachycardia following a high-speed motorcycle collision that was found to have a coronary artery dissection. The patient had multiple complications, highlighting the importance of early recognition of this disease process.

An analysis of casualties presenting to military emergency departments in Iraq and Afghanistan.

BACKGROUND: During the past 17 years of conflict the deployed US military health care system has found new and innovative ways to reduce combat mortality down to the lowest case fatality rate in US history. There is currently a data dearth of emergency department (ED) care delivered in this setting. We seek to describe ED interventions in this setting. METHODS: We used a series of ED procedure codes to identify subjects within the Department of Defense Trauma Registry from January 2007 to August 2016. RESULTS: During this time, 28,222 met inclusion criteria. The median age of causalities in this dataset was 25 years and most (96.9%) were male, US military (41.3%), and part of Operation Enduring Freedom (66.9%). The majority survived to hospital discharge (95.5%). Most subjects sustained injuries by explosives (55.3%) and gunshot wound (GSW). The majority of subjects had an injury severity score that was considered minor (74.1%), while the preponderance of critically injured casualties sustained injuries by explosive (0.7%). Based on AIS, the most frequently seriously injured body region was the extremities (23.9%). The bulk of administered blood products were packed red blood cells (PRBC, 26.4%). Endotracheal intubation was the most commonly performed critical procedure (11.9%). X-ray (79.9%) was the most frequently performed imaging study. CONCLUSIONS: US military personnel comprised the largest proportion of combat casualties and most were injured by explosive. Within this dataset, ED providers most frequently performed endotracheal intubation, administered blood products, and obtained diagnostic imaging studies.

A HEART Pathway pitfall in an admitted patient.

This paper discusses a possible weakness of the HEART Pathway specific to patients identified as high risk, requiring admission for inpatient risk stratification. Emergency Department (ED) crowding is at an all-time high and the possibility that many of these patients will board in the ED for a period of time before they are transported to an inpatient ward is becoming more likely. Given troponins peak at 6 h after the initial cardiac injury, it is plausible an initial troponin could still remain negative upon arrival. Extending the HEART Pathway to include a 3-hour delta troponin for admitted patients boarded in the emergency department may help alert the patient's inpatient team of those requiring more aggressive evaluations or more timely interventions. The case discussed herein highlights the course of a patient who was admitted to a medicine floor for chest pain along the HEART Pathway. After remaining in the ED for 3 h following admission a second troponin was drawn that resulted in the diagnosis of a non-ST segment myocardial infarction. The patient then received further management in the ED and a change in admission to the Cardiac Care Unit instead of the medicine floor. The patient ultimately received a Coronary Artery Bypass Graft during admission. If the patient had not had the second troponin while in the ED this care would have been delayed.

Aromatherapy Versus Oral Ondansetron for Antiemetic Therapy Among Adult Emergency Department Patients: A Randomized Controlled Trial.

STUDY OBJECTIVE: We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. METHODS: In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. RESULTS: We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. CONCLUSION: Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.

Impact of the HEART Pathway on Admission Rates for Emergency Department Patients with Chest Pain: An External Clinical Validation Study.

BACKGROUND: Chest pain is a common emergency department (ED) chief complaint. Safe discharge mechanisms for low-risk chest pain patients would be useful. OBJECTIVE: To compare admission rates prior to and after implementation of an accelerated disposition pathway for ED patients with low-risk chest pain based upon the HEART (History, ECG, Age, Risk factors, Troponin) score (HEART pathway). METHODS: We conducted an impact analysis of the HEART pathway. Patients with a HEART score ≥ 4 underwent hospital admission for cardiac risk stratification and monitoring. Patients with a HEART score ≤ 3 could opt for discharge with 72-h follow-up in lieu of admission. We collected data on cohorts prior to and after implementation of the new disposition pathway. For each cohort, we screened the charts of 625 consecutive chest pain patients. We measured patient demographics, past medical history, vital signs, HEART score, disposition, and 6-week major adverse cardiac events (MACE) using chart review methodology. We compared our primary outcome of hospital admission between the two cohorts. RESULTS: The admission rate for the preintervention cohort was 63.5% (95% confidence interval [CI] 58.7-68.2%), vs. 48.3% (95% CI 43.7-53.0%) for the postintervention cohort. The absolute difference in admission rates was 15.3% (95% CI 8.7-21.8%). The odds ratio of admission for the postintervention cohort in a logistic regression model controlling for demographics, comorbidities, and vital signs was 0.48 (95% CI 0.33-0.66). One postintervention cohort patient leaving the ED against medical advice (HEART Score 4) experienced 6-week MACE. CONCLUSIONS: The HEART pathway may provide a safe mechanism to optimize resource allocation for risk-stratifying ED chest pain patients.

An end-user's guide to the HEART score and pathway.

BACKGROUND: Chest pain accounts for a significant percentage of emergency department (ED) presentations. The HEART score and pathway have demonstrated an ability to appropriately risk stratify and discharge from the ED a significant proportion of patients. OBJECTIVE: This review evaluates vital components of the HEART score and pathway, while discussing important considerations for current and future use. DISCUSSION: Chest pain is a common ED presentation, and several conditions associated with chest pain result in patient morbidity and mortality. One major disease is acute coronary syndrome (ACS). Despite the fear associated with this disease, it accounts for a minority of patients with chest pain in the ED. Emergency physicians rarely miss myocardial infarction (MI) or ACS, with miss rates<1%. Many have sought a score and pathway that allow physicians to safely and reliably risk stratify patients. The HEART score and pathway have revolutionized chest pain evaluation, as they can risk stratify a significant number of patients accurately into separate categories based on history, electrocardiogram (ECG), troponin, age, and risk factors while displaying high sensitivity for MACE. Several intricacies must be considered in the use of this score including risk factors, ECG, troponin, age, history, gestalt, follow up, borderline score, and shared decision making. The HEART pathway can supplement clinician decision making. CONCLUSIONS: Appropriate use of the HEART pathway reliably risk stratifies patients. Physicians must consider several key components when utilizing the HEART pathway, and future directions may incorporate other patient factors.

Carrying a Pregnancy to Term With an Intrauterine Device in Place: A Case of an Intraabdominal Intrauterine Device Migration.

Long-acting intrauterine contraceptives such as intrauterine devices (IUD) are popular due to their high rates of long-term efficacy, ease of use, and reversibility. Though rare, these devices can incur complications such as uterine perforation. Signs and symptoms are often vague abdominal and pelvic pain, and patients rarely present with a surgical emergency. This uterine perforation can happen immediately upon IUD placement or in a delayed manner. This case details an example of an IUD uterine perforation with abdominal migration two years after placement. The patient's history is complicated by the unique fact that she became pregnant and carried her pregnancy to a term vaginal delivery after the IUD had been placed. Her pregnancy led healthcare providers from previous encounters to believe that the IUD had been spontaneously expelled. The IUD was identified in the patient's left lower abdominal cavity via computed tomography (CT) and was surgically removed uneventfully.

Thermotolerance in S. cerevisiae as a model to study extracellular vesicle biology.

The budding yeast Saccharomyces cerevisiae is a proven model organism for elucidating conserved eukaryotic biology, but to date its extracellular vesicle (EV) biology is understudied. Here, we show yeast transmit information through the extracellular medium that increases survival when confronted with heat stress and demonstrate the EV-enriched samples mediate this thermotolerance transfer. These samples contain vesicle-like particles that are exosome-sized and disrupting exosome biogenesis by targeting endosomal sorting complexes required for transport (ESCRT) machinery inhibits thermotolerance transfer. We find that Bro1, the yeast ortholog of the human exosome biomarker ALIX, is present in EV samples, and use Bro1 tagged with green fluorescent protein (GFP) to track EV release and uptake by endocytosis. Proteomics analysis reveals that heat shock protein 70 (HSP70) family proteins are enriched in EV samples that provide thermotolerance. We confirm the presence of the HSP70 ortholog stress-seventy subunit A2 (Ssa2) in EV samples and find that mutant yeast cells lacking SSA2 produce EVs but they fail to transfer thermotolerance. We conclude that Ssa2 within exosomes shared between yeast cells contributes to thermotolerance. Through this work, we advance Saccharomyces cerevisiae as an emerging model organism for elucidating molecular details of eukaryotic EV biology and establish a role for exosomes in heat stress and proteostasis that seems to be evolutionarily conserved.