Submersion in Industrial Powders That Lead to Tracheal Impaction and an Unusual Intubation.

BACKGROUND: Silica, also known as quartz, is a naturally occurring compound that has many common uses, such as for glass, pottery, and concrete. Similarly, bentonite, another natural compound found in many clays, has been used for a variety of purposes from cat litter to bulk laxatives. Both are known for their fluid-absorptive properties. The long-term effects of exposure such as developing silica pneumoconiosis are well studied; acute inhalational injuries of similar substances are also documented. CASE REPORT: We discuss the difficult airway case of a 32-year-old man who presented to the emergency department (ED) in cardiac arrest after he was buried in a mound of powdered silica and bentonite due to an industrial accident. The combination of the naturally fluid-absorptive properties of silica and bentonite, and the moist environment of the oropharynx, led to a unique circumstance. Most foreign bodies in the airway can be remedied, at least in part, by standard irrigation for decontamination. However, irrigation of dry bentonite and silica would produce a clay-like substance that could occlude the trachea, leading to an avoidably more difficult airway presentation. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The difficulties experienced with his intubation can serve as a learning point to other providers who encounter a similar presentation. In the event that the inhaled substance is known to be fluid-absorptive, deviation from standard irrigation for decontamination may permit avoidance of a tracheal impaction, and facilitate establishment of a definitive airway. When there is suspicion for the potential of tracheal impaction, proceeding with bronchoscopy either in the ED or operating room as quickly as possible rather than continuing attempts at intubation may deliver the patient a definitive airway in a more timely fashion.

Acute Optic Neuritis Diagnosed by Bedside Ultrasound in an Emergency Department.

BACKGROUND: Transorbital ultrasound was used to diagnose acute optic neuritis (AON) at bedside in an emergency department (ED). CASE REPORT: A 59-year-old female patient presented to an ED after 7 days of progressive unilateral visual loss while she was receiving outpatient treatment for relapsing-remitting multiple sclerosis. Transorbital ultrasound revealed a disparity between the optic nerve sheath diameters of the affected and nonaffected eyes and striking optic nerve edema in the affected eye. These findings led to a diagnosis of AON and early definitive treatment. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given an absence of reliable diagnostic criteria for AON, comorbidity with multiple sclerosis, and limitations inherent to magnetic resonance imaging, transorbital sonography may facilitate diagnosis of this condition in emergent presentations.