Unstable bradycardia induced by posterior nasal packing: a rare activation of the Trigeminocardiacreflex.

A woman in her 40s presented to the emergency department with epistaxis. Anterior nasal packing was unsuccessful in achieving haemostasis. After the exchange of devices and insertion of a posterior nasal pack, the patient developed a junctional rhythm and progressively unstable bradycardia. The rhythm and bradycardia immediately improved following the removal of the posterior nasal pack. This case describes a rare occurrence of Trigeminocardiac reflex (TCR), following an insertion of a posterior nasal pack. Only one other such case has been reported and published. This case highlights the importance of raising awareness of this rare reflex and the need for prompt removal of the triggering cause in such scenarios. TCR can induce a junctional rhythm, which progresses to unstable bradycardia and may lead to asystole in susceptible individuals. The removal of the stimulus resolves the reflex and can result in prompt resolution of the bradycardia and hypotension induced via the TCR.

Pneumomediastinum in a child with severe COVID-19.

The current global pandemic of the novel coronavirus SARS-CoV2 is a threat to the health and lives of millions of people worldwide. The latest statistics from the World Health Organisation show that there have been 6,515,796 confirmed cases worldwide with 387,298 confirmed deaths (last update 5 June 2020, 10:41 CEST). The majority of critically unwell patients with SARS-CoV2 are adults and the radiological findings associated with them are consistent throughout the literature. However, the reported paediatric cases are few, and as such, there is a limited body of evidence available. More international data is needed, not only on the clinical presentation, but also the radiological findings, so that health-care providers are better able to understand and diagnose this pandemic disease. We describe a case of a previously healthy 9-year-old female who presented to the Emergency Department with symptoms suggestive of raised intracranial pressure. Her CT revealed a medulloblastoma and post-operatively she tested positive for SARS-CoV2. She had a rapid deterioration in her clinical condition and required admission to the intensive care unit (ICU). We provide the supporting radiology along her clinical course in order to demonstrate important insights into this disease in children, including the unusual pnemomediastinum complications which occurred as part of her clinical course. This case is the first reported of its kind.

Quantifying the motion of Kager's fat pad.

Kager's fat pad is located in Kager's triangle between the Achilles tendon, the superior cortex of the calcaneus, and flexor hallucis longus (FHL) muscle and tendon. Its biomechanical functions are not yet established, but recent studies suggest it performs important biomechanical roles as it is lined by a synovial membrane and its retrocalcaneal protruding wedge can be observed moving into the bursal space during ankle plantarflexion. Such features have prompted hypotheses that the protruding wedge assists in the lubrication of the Achilles tendon subtendinous area, distributes stress at the Achilles enthesis, and removes debris from within the retrocalcaneal bursa. This study examined the influence of FHL activity and Achilles tendon load on the protruding wedge sliding distance, using both dynamic ultrasound imaging and surface electromyogram. Intervolunteer results showed sliding distance was independent of FHL activity. This study has shown the protruding wedge to slide on average 60% further into the retrocalcaneal bursa when comparing the Achilles tendon loaded versus unloaded, consistently reaching the distal extremity. Sliding distance was dependent on a change in the Achilles tendon insertion angle. Our results support a number of hypothesized biomechanical functions of the protruding wedge including: lubrication of the subtendinous region; reduction of pressure change within the Achilles tendon enthesis organ; and removal of debris from within the retrocalcaneal bursa.