[Diving accident-induced arterial gas embolism]. / Arteriële gasembolieën na een duikongeval.

BACKGROUND: During scuba diving, nitrogen dissolves into the body tissues due to elevated pressure under water. During a sudden drop in pressure due to a rapid return to the water surface, arterial gas embolism can arise from pulmonary barotrauma. In a later phase, nitrogen bubbles can also arise in the venous circulation (decompression sickness). Arterial bubbles can incur vascular damage, obstruction, hypoxia and infarction. CASE DESCRIPTION: A 53-year-old healthy sport diver presented at the emergency department in a hypovolemic shock with progressive paresis of all the extremities. He had made an emergency ascent from a depth of 47 meter. During recompression therapy his condition deteriorated. It transpired that he had an patent foramen ovale. As a consequence of this, nitrogen bubbles due to decompression sickness entered the arterial circulation. Despite maximum therapeutic intervention the patient remained paretic. CONCLUSION: After an ill-fated dive, this patient with patent foramen ovale contracted arterial gas embolism due to pulmonary barotrauma and, at a later stage, decompression sickness. There was increasing damage to the spinal cord resulting in severe physiological disruption.

[National developments in Emergency Departments in the Netherlands: numbers and origins of patients in the period from 2012 to 2015]. / Landelijke ontwikkelingen in de Nederlandse SEH's.

OBJECTIVE: Gaining insight into key figures of emergency departments (EDs) in the Netherlands and developments in these figures. DESIGN: Longitudinal survey study. METHOD: Over the period from 2012 up to and including 2015, the following key data were surveyed: number of EDs, number of ED patients, ED patients' origin, number of hospital admissions from the ED and form of cooperation between ED and a general practitioner centre (GPC). RESULTS: An average of 96% of all EDs responded. The number of EDs decreased from 93 to 87. The percentage of EDs that maintained a form of cooperation with a GPC in the hospital rose from 49% to 79%. The total number of patients seen annually in an ED in the Netherlands decreased by 128,000 to 1.951 million. The proportion of patients presenting in the ED via ambulance, mobile medical team or 112 (emergency number) increased by 2.6% to 16.0%. The proportion of patients referred from their own GP or GPCs increased by 7.8% to an average of 50.3%. The proportion of self-referrals decreased by 12.6% to 17.4%. The proportion of patients who came up to the ED through a different route remained constant at around 14%. The nationwide variation in the origin of patients remained high. The average percentage of hospital admissions from the ED increased by 5.6% to 37.2%. CONCLUSION: The number of EDs is decreasing and the cooperation between EDs and GPCs has intensified. The number of patients seen in the ED has decreased. The percentage of self-referrals has decreased and the number of hospital admissions from the ED has increased significantly. For a successful and consistent policy, more substantive data on the nature and extent of emergency care in the ED are needed. This requires a national registry.

Diving accidents: a cohort study from the Netherlands.

BACKGROUND: Diving is, besides professional reasons, an increasingly popular leisure activity. Whilst statistically compared to other sports safe, diving accidents can result in serious complications. In order to treat this specific patient category adequately, early diagnosis is important. In this study, we explore various medical aspects of diving accidents. By sharing our experiences, we intend to create awareness and enhance urgent medical care for this specific category of patients. METHODS: We conducted a retrospective cohort study using anonymized patient records from the emergency department (ED) of the Admiraal De Ruyter Hospital (ADRZ) and affiliated Medical Centre Hyperbaric Oxygen Therapy (MCHZ1) both in Goes, Netherlands. We evaluated all patients that presented to our ED as a diving accident from 1 November 2011 to 30 August 2015. RESULTS: In the selected period, 43 patients presented to our ED with complaints after diving; 84 % were male and 49 % older than 40 years, and they came by ambulance or referred by a general practitioner or other medical centres in the area; 70 % presented the same date as their dive, 21 % 1 to 3 days and 9 % later than 3 days after having dived. Pain was the most frequently reported symptom (44 %), followed by constitutional symptoms (42 %). Numbness or paraesthesia was reported in 33 %. Respiratory symptoms, dizziness, a change in mental status (e.g. apathy, confused or restlessness) and problems with coordination were present in 10-21 % of the cases. Symptoms that were apparent in less than 10 % of the cases were cutis marmorata, visual or auditory complaints, muscle weakness, cardiovascular symptoms or a malfunction of the anal sphincter or urinary bladder. Most of our patients exhibited more than one symptom; 70 % of all patients received hyperbaric oxygen recompression therapy. CONCLUSIONS: The limited number of patients presenting with complaints after a diving incident, the difficulty of recognition and the (potential) huge impact if not recognized and treated adequately make us believe that every diving accident should be discussed with a centre of expertise.

Incidence and prognostic factors of chronic pain after isolated musculoskeletal extremity injury.

BACKGROUND: Chronic pain in patients is usually related to an episode of pain following acute injury, emphasizing the need to prevent progression from acute to chronic pain. Multiple factors in the acute phase might be responsible for perpetuating the pain. The presentation of patients at the emergency department (ED) presents a prime opportunity to identify patients at high risk for chronic pain and to start appropriate treatment. METHODS: The PROTACT study is a prospective follow-up study aiming to estimate the incidence and prognostic factors responsible for the development of chronic pain after musculoskeletal injury. Data including sociodemographic, pain, clinical, injury- or treatment-related and psychological factors of 435 patients were collected from registries and questionnaires at ED visit, 6-week, 3- and 6-month follow-up. RESULTS: At 6 months post-injury, 43.9% of the patients had some degree of pain (Numeric Rating Scale (NRS) ≥1) and 10.1% had chronic pain (NRS ≥4). Patients aged over 40 years, in poor physical health, with pre-injury chronic pain, pain catastrophizing, high urgency level and severe pain at discharge were found to be at high risk for chronic pain. CONCLUSIONS: Two prognostic factors, severe pain at discharge and pain catastrophizing, are potentially modifiable. The implementation of a pain protocol in the ED and the use of cognitive-behavioural techniques involving reducing catastrophizing might be useful.

[Diagnostic image (364). A boy with a painful inguinal mass]. / Diagnose in beeld (364). Een jongen met een pijnlijke zwelling in de lies.

A 9-year-old boy presented with right-sided abdominal pain and an inguinal mass due to torsion of an acquired ectopic testicle.