Postobstructive pulmonary edema in a 40-year-old man after suffocation by a swimming pool cover.

BACKGROUND: Postobstructive pulmonary edema (POPE) is a form of sudden onset, noncardiogenic pulmonary edema that can occur after the relief of an upper airway obstruction. OBJECTIVE: Since POPE is an uncommon diagnosis made in the emergency department (ED), this case is presented to increase emergency physicians' awareness of the etiology, pathophysiology, and management of this type of edema. CASE REPORT: This is a case of bilateral POPE in a 40-year-old man with no history of cardiac or pulmonary disease who experienced near suffocation due to the vacuum effect of a swimming pool cover. On presentation to the ED, the patient's symptoms included bilateral pleuritic pain over the anterior chest, shortness of breath, and inspiratory cough. He was tachycardic and tachypneic, with an oxygen saturation of 92% on room air. Pertinent physical examination findings included shallow breathing and right-sided rhonchi. The initial arterial blood gas on room air demonstrated a PaO2/FiO2 ratio of 304 mm Hg. Cardiac enzymes and the electrocardiogram result were normal. The patient's chest radiograph was interpreted as having marked bilateral pulmonary edema. The patient was admitted to the Medicine Intensive Care Unit and placed on noninvasive positive pressure ventilation (NIPPV). The patient was clinically asymptomatic and was discharged after 72 h. CONCLUSIONS: Emergency physicians should consider the diagnosis of POPE in a symptomatic patient if there is evidence of pulmonary edema immediately after a history of hanging, suffocation, strangulation, choking, naloxone administration, or other forms of upper airway obstruction. Rapid initiation of NIPPV with or without diuretics, steroids, or fluid restriction can lead to symptom resolution within 24 to 48 h.

Risk and ROSC - Legal implications of bystander CPR.

BACKGROUND: Early bystander cardiopulmonary resuscitation (CPR) has been associated with better patient outcomes in cardiac arrest. Despite this, not all cases of cardiac arrest receive bystander intervention. Reasons for this gap include disparities in provision of bystander CPR between race, gender and age groups. Concern of legal liability for responders has also been described. We propose that bystanders are more likely to face litigation for lack of intervention compared to providing bystander CPR due to the presence of 'Good Samaritan' statutes in all 50 states. This review of the legal literature seeks to quantify the number of cases brought against bystanders in the US over the past 30 years and explore the reasons behind them. METHODS: The Westlaw legal research database was searched for jury verdicts, settlements, and appellate opinions from all 50 states from 1989 to 2019 for personal injury or wrongful death lawsuits involving CPR. Of 506 cases manually reviewed by the authors, 170 were directly related to CPR. Case details including jurisdiction, location, date, plaintiff and defendant demographics, level of training of CPR provider, relationship to patient, motivation for the lawsuit, and case outcomes were recorded. RESULTS: Our data show a significant difference in the number of cases of cases alleging battery versus negligence regarding provision of CPR. Of 170 cases, 167 were due to inadequate or untimely bystander CPR. Three cases alleging harm due to providing CPR were identified. CONCLUSIONS: This study represents the largest single study of legal cases involving bystander CPR in the medical literature. The likelihood of litigation is significantly higher in cases with bystander CPR absent or delayed. The authors propose the inclusion of this data and reiteration of 'Good Samaritan' statutes in all 50 states during CPR training to reassure and encourage public response to cardiac arrests.

Preparations for a Controversial Speaker and Anticipated Volatility in a College Town.

In summer of 2017 in Charlottesville, Virginia, white nationalists clashed with counterprotestors, ultimately leading to the death of three people and leaving 34 more injured. Soon after, the same group was granted permission to speak on the campus of the University of Florida in Gainesville, Florida. Despite our college town having limited resources and personnel, the comprehensive and extensive preparation preceding the event ensured a peaceful resolution for such a large and potentially volatile situation. The preparatory steps required joint efforts from local and state partners in law enforcement, emergency medical services, and emergency departments. We describe here the situation we faced, the pre-event preparations, the response in the field and in our emergency department, and the outcomes from an emergency and tactical medicine perspective. We hope our successful experience will impart knowledge for similar events.

Serum Levels of Prealbumin and Albumin for Preoperative Risk Stratification.

Preoperative risk stratification has long been developed as a strategy to predict postoperative outcomes and potentially alter or optimize comorbidities and modifiable risk. Malnutrition is among the most common potentially modifiable risk factors and the strongest predictor of poor postsurgical outcomes. Historically, malnutrition has been difficult to address for healthcare providers because of the lack of a cohesive definition. Adding to the confusion has been the use of serum levels of albumin and prealbumin as biomarkers for malnutrition; many fail to understand that these visceral proteins are only valid as markers of nutrition status while at homeostasis. Surgical need is often driven by both sterile and non-sterile inflammation, but during this pathologic mechanism, hepatic reprioritization shunts visceral protein synthesis, rendering albumin and prealbumin invalid as biomarkers for malnutrition. Ultimately, understanding these limitations and embracing better indicators of malnutrition will improve preoperative risk stratification.

An outbreak of acute delirium from exposure to the synthetic cannabinoid AB-CHMINACA.

BACKGROUND: Synthetic cannabinoid containing products are a public health threat as reflected by a number of outbreaks of serious adverse health effects over the past 4 years. The designer drug epidemic is characterized by the rapid turnover of synthetic cannabinoid compounds on the market which creates a challenge in identifying the particular etiology of an outbreak, confirming exposure in cases, and providing current information to law enforcement. RESULTS: Between 28 May 2014 and 8 June 2014, 35 patients were evaluated and treated at the University of Florida Health Medical Center in Gainesville following reported exposure to a synthetic cannabinoid containing product obtained from a common source. Patients demonstrated acute delirium (24) and seizures (14), and five required ventilator support and ICU-level care; none died. The presence of N-[(1S)-1-(aminocarbonyl)-2-methylpropyl]-1-(cyclohexylmethyl)-1H-indazole-3-carboxamide (AB-CHMINACA), or one of its predicted metabolites was confirmed in 15 of 21 cases. A rapid public health response and aggressive public messaging prevented further morbidity, identified the source, and led to law enforcement seizure of the implicated product. DISCUSSION: The significance of this outbreak lies as much in the rapid occurrence of unpredictable, life-threatening adverse health effects from a newly identified synthetic cannabinoid compound as it does in the multidisciplinary investigation and novel partnership between local public health, the laboratory, and the chemical industry, resulting in termination of the outbreak. CONCLUSION: A coordinated response and collaboration between law enforcement, the local public health, emergency medical services and Health Center staff, were all key interventions in preventing a more substantial public health outbreak resulting from use of a novel synthetic cannabinoid compound. Real time collaborations between toxicology laboratories, suppliers of analytical standards and the public health system may be useful in the face of future novel chemical exposures.

TBI surveillance using the common data elements for traumatic brain injury: a population study.

BACKGROUND: To characterize the patterns of presentation of adults with head injury to the Emergency Department. METHODS: This is a cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of traumatic brain injury in adults. This IRB-approved project was conducted in collaboration with our Institution's Center for Translational Science Institute. Data were entered in REDCap, a secure database. Statistical analyses were performed using JMP 10.0 pro for Windows. RESULTS: The cohort consisted of 2,394 adults, with 40% being women and 79% Caucasian. The most common mechanism was fall (47%) followed by motor vehicle collision (MVC) (36%). Patients sustaining an MVC were significantly younger than those whose head injury was secondary to a fall (P < 0.0001). Ninety-one percent had CT imaging; hemorrhage was significantly more likely with worse severity as measured by the Glasgow Coma Score (chi-square, P < 0.0001). Forty-four percent were admitted to the hospital, with half requiring ICU admission. In-hospital death was observed in 5.4%, while neurosurgical intervention was required in 8%. For all outcomes, worse TBI severity per GCS was significantly associated with worse outcomes (logistic regression, P < 0.0001, adjusted for age). CONCLUSION: These cohort data highlight the burden of TBI in the Emergency Department and provide important demographic trends for further research.

A case of dens fracture: a pictorial review and discussion.

Dens fractures are more common in the elderly and may present after minimal trauma and with minimal neck pain. The case reports a case of a significant fracture after minimal trauma, presenting with neurologic symptoms and minimal neck pain.

Bilateral and Simultaneous Rupture of the Triceps Tendon in a Patient without Predisposing Factors.

Tendon rupture is typically associated with predisposing features including renal failure, hyperparathyroidism, and connective tissue elastosis. We present a case in which none of these risk factors is present and in a completely healthy patient. To our knowledge, this has never been reported in the literature.