SCUBA and Diving Injuries

Image Credit: Flickr

Author: Daniel F. Leiva, MS OMSIV
Nova Southeastern University
Originally Published: Modern Resident, December/January 2015-2016

SCUBA, an acronym for self-contained underwater breathing apparatus, is a system for recreational diving practiced by hundreds of thousands of people across the world, but is not without its risks. In 2012, the incidence of SCUBA-related injuries ranged from seven to 35 per 10,000 divers and from five to 152 injuries per 100,000 dives. Insufficient training and preexisting medical conditions were common factors that played a role in injury, and drowning was the most common cause of death.[1] While risks of trauma, hypothermia and submersion injury also exist, those more specific to diving including barotrauma, decompression sickness and nitrogen narcosis will be discussed in this piece and the next.

Boyle’s law describes the relationship between pressure and volume of a system: as pressure increases (for example: descent), the volume of gas decreases. The opposite occurs during ascent. An example of this mechanism is the discomfort felt by divers and swimmers within their ears when descending and ascending in water. During descent, the increase in external water pressure causes a decrease in middle ear volume, a space enclosed by the tympanic membrane and the Eustachian tube. This causes pain in the form of middle ear squeeze or otic barotrauma, and is why divers and swimmers must frequently perform maneuvers to open their Eustachian tube. This is done by yawning, swallowing, jaw thrusting, head tilting and performing the Valsalva maneuver. For people who have trouble achieving equilibrium, advanced techniques employing a combination of moves may be necessary. Without equalization divers run the risk of tympanic membrane rupture or inner ear barotrauma leading to a perilymph fistula, which requires a referral to an otolaryngologist.

The Dying Gut: Identifying Patients with Intestinal Ischemia

Image Credit: Flickr

Author: Ashley Grigsby, DO PGY-1M
Indiana University
Originally Published: Modern Resident, February/March 2015

Intestinal ischemia is a serious illness with severe and life threatening complications. The likelihood of developing complications improves with earlier diagnosis. However, early diagnosis can be difficult, especially in the setting of no known risk factors.

Acute mesenteric ischemia is any process that causes hypoperfusion to the small intestine. The large intestine can also become ischemic from hypoperfusion, usually referred to as ischemic colitis.[1] Intestinal hypoperfusion can be due to arterial or venous obstruction from acute embolism, thrombosis or low-flow states.

We all learned in medical school, “abdominal pain out-of-proportion to physical exam” means acute mesenteric ischemia. However, in real-life situations, many emergency department patients presenting with abdominal pain would fit into this category. The question becomes, who gets a workup and who does not? First, a careful history should be performed; about one third of patients with acute intestinal ischemia will have a previous history of embolic event.[1] Patients with peripheral vascular disease, cardiac disease, atrial fibrillation, hypercoaguable states and hypovolemic states are all at increased risk of developing intestinal ischemia.[1]

Shiitake Mushroom Dermatitis: A Case Report

Image Credit: Wikimedia Commons

This post was peer reviewed.
Click to learn more.

Author:
Megan Litzau, MD
Emergency Medicine Resident
Indiana University
AAEM/RSA Social Media Committee


Overview:
A 31-year-old African American male presented with an erythematous rash of 8 days duration. The patient had been seen in the emergency department one week prior for the rash. At that time, he was given Eucerin cream, prednisone taper, and diphenhydramine. The patient returned one week later as the rash had not improved. Upon examination, the patient had a violaceous, linear rash across his torso and all of his extremities. The linear lesions appeared as though the patient had been scratching. However, he adamantly denied scratching and was unable to reach several of the lesions on examination. Upon further questioning, the only recent change in the patient’s habits was consuming a large amount of uncooked shiitake mushrooms 9 days prior. Approximately 12 hours after consuming the mushrooms, the rash appeared. Since that time, the rash had persisted. The rash was initially erythematous and had faded to a violaceous color during the course of the rash. The patient noted the rash to be constantly pruritic, which prompted his return visit to the emergency department. The patient also noticed that the rash and itching got worse when he was working outdoors. 

When Back Pain is More Than Musculoskeletal: The Red Flags of Spinal Epidural Abscesses

Image Credit: Flickr

Author: Kaitlin M. Fries, OMSIV
Ohio University Heritage College of Osteopathic Medicine

Originally Published: Modern Resident April/May 2015

As an emergency medicine physician it is important to always think about the worst-case scenario. What is the worst thing that could explain this patient’s symptoms? What could potentially kill this patient if not quickly identified and appropriately managed? For common complaints such as back pain, this mindset can easily be over looked. No matter how simple and straightforward a case of back pain may seem, it is still important to ensure there are no red flags. One of the most concerning worst-case scenarios of low back pain is that of a spinal epidural abscess.

Recent studies have shown that the number of cases of spinal epidural abscesses is rising due to an increase in IV drug abuse and spinal surgeries.[2,3] If overlooked, this infection can cause a rapid decline and lead to sepsis, meningitis and permanent paralysis.[3] With a mortality rate as high as 20%, it is vital to catch this infection on the patient’s first presentation.[2,3] Diagnostic delays are far too common in these patients. In 2003, a retrospective study looked at 63 cases of spinal epidural abscesses. It was found that 75% of these cases had multiple ED visits or were admitted without a clear diagnosis.[1]

More Than Meets the Eye: The Subtle Presentation of Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) in the Emergency Setting

Image Credit: Wikimedia Commons

This post was peer reviewed.
Click to learn more.

Authors: Taraneh Matin, OMS-IV MA; Victoria Comeau, DO; Daniel F. Leiva, DO, MS
Nova Southeastern University

Rashes in the emergency department can often be overlooked as benign skin conditions. Being able to differentiate between life-threatening and non-life-threatening rashes is vital for the emergency physician. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) comprise a spectrum of the same subset of vesiculobullous diseases with an incidence that ranges from 0.4 to 7 per million per year, with a mortality that ranges from 1-5% for SJS and 25-40% for TEN.[1,2] The majority of cases are caused by medications while a lesser extent are caused by infections.[1] Typical causative agents include allopurinol, antibiotics, nonsteroidal anti-inflammatory drugs, and anticonvulsants.

Although it is a fatal condition with serious systemic complications, SJS presents with very subtle and often times overlooked or misdiagnosed prodromal symptoms including fever, painful eyes, or pain with swallowing. These are often mistaken for a benign viral illness. When evaluating a patient with these findings, obtaining a thorough history is important due to the high correlation of these symptoms with the onset of a new medication. The cutaneous manifestations present within days of the initial symptoms as ill-defined, erythematous macules or purpura beginning on the trunk and spreading outward. The oral, genital, and/or ocular mucosa are involved in 90% of cases as well as frequent involvement of the palms and soles.[3] With progression, vesicles and bullae form and the skin begins to slough leading to a positive Nikolsky sign on examination.[5-7] Ocular involvement can present as erythema, conjunctivitis, keratitis, and endophthalmitis and has been seen in 50-80% of cases. One-third of these cases can lead to vision impairing ocular sequelae.[8] Other organ systems including the gastrointestinal or pulmonary systems may be involved. It is important when evaluating these patients to note the body surface area (BSA) involved. SJS has a BSA involvement of <10% while TEN has a BSA involvement of >30%. Risk factors include co-morbid HIV infection or an immunocompromised state.[6]