Prehospital Massive Transfusion for Resuscitation of an Entrapped Patient in a Rural Setting: A Case Report.

Resuscitation of injured patients suffering from hemorrhagic shock with blood products in the prehospital environment is becoming more commonplace. However, blood product utilization is typically restricted and can be exhausted in the event of a prolonged entrapment. Delivery of large amounts of blood products to a scene is rare, particularly in rural settings. We present the case of a 26-year-old male who was entrapped in a motor vehicle for 144 min. First responders assessed the entrapped patient to be in hemorrhagic shock from lower extremities injuries. The Helicopter Emergency Medical Services team exhausted their supply of blood products shortly after arrival on scene. The local trauma center's Surgical Emergency Response Team (SERT) was requested to the scene. The preplanned response included seven units of blood components to provide massive transfusion at the point of injury and released directly to field responders by the blood bank. During extrication, the patient was given two units of packed red blood cells by initial responders with three more units of blood components from the SERT supply. During transfer to the hospital, the patient received an additional three units, and four units were transfused on initial trauma resuscitation in the hospital. He was found to have severe lower extremities injuries as the cause of his hemorrhage. The patient survived to hospital discharge. Delivery of large volumes of blood products to an entrapped patient with prolonged extrication time may be a lifesaving intervention. We advocate for integration of blood bank services and on scene physician guided resuscitation for prolonged extrications.

Broadband radiometric measurements from GPS satellites reveal summertime Arctic Ocean Albedo decreases more rapidly than sea ice recedes.

New measurements from the Arctic ± 40 days around the summer solstice show reflected sunlight from north of 80°N decreases 20-35%. Arctic sea ice coverage decreases 7-9% over this same time period (as reported by the NSIDC) implying Arctic sea ice albedo decreases in addition to the sea ice receding. Similar Antarctic measurements provide a baseline to which Arctic measurements are compared. The Antarctic reflected sunlight south of 80°S is up to 30% larger than the Arctic reflectance and is symmetric around the solstice implying constant Antarctic reflectivity. Arctic reflected sunlight 20 days after solstice is > 100W/m2 less than Antarctic reflected sunlight. For perspective, this is enough heat to melt > 1 mm/hour of ice. This finding should be compared with climate models and in reanalysis data sets to further quantify sea ice albedo's role in Arctic Amplification. The measurements were made with previously unpublished pixelated radiometers on Global Positioning System satellites from 2014 to 2019. The GPS orbits give each radiometer instantaneous and continuous views of 37% of the Earth, two daily full views of the Arctic and Antarctic. Furthermore, the GPS constellation gives full-time full-Earth coverage that may provide data that complements existing limited field of view instruments that provide a less synoptic Earth view.

Contact chemical burn of the hand caused by xylene: A case report.

The use of household cleaners during non-commercial cleaning applications is a very common task, and the chemical makeup of the cleaning solutions vary as much as their applications do. Although most users of these products follow the written safety directions and are generally careful with their use, it is not uncommon for users to suffer toxicologic effects of these cleaners without proper protective equipment. In this case report, we describe an unusual chemical burn pattern to the hand of a young female patient after prolonged exposure to a xylene-containing product without proper chemical-resistant gloves. Fortunately, with prompt recognition, and urgent referral for burn treatment, the patient underwent a successful debridement of the burn and suffered minimal functional impairment.

A comparison of handheld ultrasound versus traditional ultrasound for acquisition of RUSH views in healthy volunteers.

Few studies evaluate the use of handheld ultrasound devices for point-of-care ultrasonography in the emergency department. We hypothesized that image acquisition time and image quality are similar between a handheld device and a traditional device. We compared these 2 types of devices in healthy, non-pregnant adults with using a crossover non-inferiority design while acquiring Rapid Ultrasound for Shock and Hypotension (RUSH) view. We excluded those with a history of surgical intervention or known abnormality to the lungs, abdomen, or pelvis. Images were compiled into a de-identified video clip reviewed for image quality by 2 blinded reviewers. Cohen's Kappa was used to determine interrater agreement. Disagreements were adjudicated by an independent physician. Imaging time was compared using a paired Student's t test. Of 59 screened participants, 9 were excluded. Most subjects (N = 30, 60%) were female with a mean age of 39 (Range: 19-67) years. The median time to complete the RUSH exam did not differ (handheld 249.4, interquartile range 33.5 seconds); traditional 251.4, interquartile range 66.3 seconds); [P = 0.81]). Agreement between ultrasound reviewers was good (agreement 83%; k = 0.69; 95% CI, 0.49-0.88). Images were determined to be of adequate quality for interpretation in 41/50 (82%) and 43/50 (86%) in the handheld and traditional devices, respectively (P = 0.786). Neither time to image acquisition nor image quality differed between the handheld and traditional devices. The handheld device may be an alternative for use in RUSH exams.

Avulsion fracture of the tibial eminence in an adult with a unique mechanism of injury.

Tibial eminence avulsion fractures are not infrequent in the pediatric population; however, they are rare in the adult population. These injuries typically occur in skeletally immature patients between the ages of 8 and 14 years. We report the unique clinical history, imaging findings, and operative results of a 48-year-old female who presented with severe knee pain. Imaging findings revealed an anterior tibial eminence fracture with an intact anterior cruciate ligament tendon attached to the avulsed fragment. The patient underwent knee arthroscopy, with direct repair of the tibial eminence fracture.

Management of an Entrapped Patient with a Field Amputation.

BACKGROUND: Emergency surgical amputations are rare and resource-intensive lifesaving interventions. Most emergency medical services (EMS) lack a formal protocol to manage these high-risk but low-occurrence events. There has been limited attention in the EMS community to address this issue. Without a literature-based approach, the EMS community has been offered little guidance on managing surgical field amputations. CASE REPORT: A 38-year-old man was terminally entrapped below the waist in an industrial auger. As a last resort, the decision to initiate a field amputation was made. We outline an adaptive strategy to address the circumstances surrounding this entrapment scenario. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: A carefully preplanned protocol may lead to increased overall survivability for entrapped patients requiring emergent field amputation. Based on the lessons learned from the outcome of this case, previous cases, and a literature review, we have devised a simplified planning tool in the form of a "LIMB" mnemonic to aid EMS services in developing their own traumatic amputation protocol (TAP). "LIMB" is an acronym for: Lists of resources and equipment, Initiate TAP checklist, Manage the extrication, and Bring the patient in. The LIMB mnemonic may also be used as a checklist to assist EMS personnel in performing a field amputation. We offer rescuers a starting point to develop their own TAP capable of being executed in their own rescue environment.

Compartment syndrome of the deltoid: a case report of a common presentation in a rare location.

Compartment syndrome presents with a slow onset of pain. Anything that causes an increased intra-compartmental pressure can lead to surgical emergency. A 45-year-old male presents to the emergency department with prolonged syncope. The patient is unable to recall the previous night except for using oxycodone. Patient medical history is significant for ischemic cardiomyopathy and myocardial infarction. Physical exam showed left arm pain and swelling, decreased sensation to light touch, and decreased range of motion. The left forearm was cool to touch with decreased pulses. Blood urea nitrogen/creatinine ratio was 47/4.0, white blood cell was 15.1, troponin was 34.2, and creatine kinase was immeasurable. Electrocardiogram showed non-specific T-wave abnormalities. Computed tomography showed left hemithoracic musculature enlargement. The patient's symptoms continued to worsen. The patient underwent emergency fasciotomy to relieve intra-compartmental pressure. Compartment syndrome of the deltoid is rare and yielded less than ten cases in our literature review. Although compartment syndrome usually affects the forearm, one must consider its possibility in any anatomical location.

Hereditary hyperferritinemia-cataract syndrome.

Hereditary hyperferritinemia-cataract syndrome (HHCS) is a recently recognized syndrome characterized by dominantly inherited, early-onset cataracts and elevated serum ferritin. The opacities are caused by elevated ferritin protein within the crystalline lens and usually become symptomatic in the second to fourth decade of life. Routine laboratory tests can establish this diagnosis. We report two unrelated cases that presented in the United States.

Mechanism of ocular hypotensive action of bimatoprost (Lumigan) in patients with ocular hypertension or glaucoma.

PURPOSE: To determine the mechanism of ocular hypotensive action of bimatoprost in patients with ocular hypertension or glaucoma. DESIGN: Double-masked, placebo-controlled, randomized, paired comparison crossover study of the effect of bimatoprost on aqueous humor dynamics. PARTICIPANTS AND CONTROLS: Twenty-nine patients with ocular hypertension or glaucoma. METHODS: Bimatoprost and a placebo were administered once a day, in the evening, for 7 days before assessment of aqueous dynamics using tonometry, Schiötz tonography, and fluorophotometry. Intraocular pressure (IOP) response to water drinking was measured. MAIN OUTCOME MEASURES: Aqueous humor flow rate, outflow facility, and IOP. RESULTS: Intraocular pressure was lowered 29% in the morning and 33% at noon by bimatoprost. Aqueous humor flow was unchanged. Tonographic facility of outflow was increased 47% by bimatoprost relative to the placebo. Assuming an extraocular pressure of 8 mmHg and that extraocular pressure is not altered by bimatoprost, the calculated rate of pressure-insensitive outflow was increased 95% by bimatoprost. During the first hour after water drinking, bimatoprost dampened the IOP rise. CONCLUSION: As was seen in healthy normal eyes, bimatoprost increased both the pressure-sensitive and the pressure-insensitive outflows of aqueous humor in patients with ocular hypertension or glaucoma. Bimatoprost had no significant effect on aqueous humor formation.

Botulinum toxin for the treatment of congenital entropion.

PURPOSE: To describe a case of congenital entropion presenting with ulcerative keratitis that was successfully treated with a single injection of botulinum toxin. DESIGN: Interventional case report. METHODS: A 3-week-old female infant with a corneal ulcer of the left eye since birth presented for evaluation. She was found to have entropion of the left lower lid. The pretarsal orbicularis muscle was injected with 5 units of botulinum toxin. RESULTS: Four days after treatment, the entropion had resolved and the corneal epithelial defect had healed. There was no recurrence of the entropion 7 months after botulinum toxin injection. CONCLUSIONS: Injection of botulinum toxin can effectively treat certain cases of congenital entropion.