Needle Decompression of Tension Pneumoperitoneum: A Case Report

Introduction: Tension pneumoperitoneum is rarely encountered in the emergency department but can have disastrous effects on the body when it is. However, an emergency physician has skills that can be readily applied to needle decompress the abdomen for rapid stabilization. Case Report: A 42-year-old male arrived via ambulance after a likely overdose with mental status improvement following naloxone administration. He was found to be in respiratory distress due to a rigid, distended abdomen that required intubation for stabilization. Computed tomography imaging showed significant pneumoperitoneum with tension physiology. Surgery consultation was unable to intervene immediately, and needle decompression with an angiocatheter was performed at the bedside with immediate ventilatory improvement. Conclusion: Tension pneumoperitoneum is a rare but potentially disastrous consequence of overdose secondary to emesis and rupture of the gastric wall. Needle decompression is a skillset already in the emergency physician’s toolbox and can be applied for emergency stabilization of a tension pneumoperitoneum with proper forethought and technique.

Legal, Regulatory, and Reimbursement Considerations

The expansion of health care services delivered through telehealth is impacted by numerous legal, regulatory, and reimbursement frameworks. Standard medical practices for consent, privacy, credentialing, and licensing apply to telehealth; however, the opportunity for cross-state practice complicates their application. Hospital-specific rules for credentialing and emergency stabilization must also be considered. Delivery of medical services is often driven by reimbursement, which for telehealth is governed by a complicated web of rules that vary by service, payer, and location. Temporary changes to these rules in association with the public health emergency (PHE) declared in response to the COVID-19 pandemic has rapidly reshaped the telemedicine regulatory landscape. Advocacy for smart legislation that improves and simplifies access to care is important to ensure equity of telehealth services.

Post-fire Soil Erosion Risk in Portugal– Prediction, Validation and Uncertainties of a Nation-wide MMF Application

Wildfires are a recurrent and increasing threat in mainland Portugal, where over 4,5 million hectares of forests and scrublands have burned over the last 38 years. These fire-affected landscapes have suffered an intensification of soil erosion processes, which can negatively affect soil carbon storage, reduce fertility, forest productivity, and become a source of pollutants. The main objective of the present study is to produce a post-fire soil erosion risk map for the forest and scrubland areas in Mainland Portugal and assess its reliability. To this end, the semi-empirical Morgan–Morgan–Finney erosion model was used to assess the potential post-fire soil erosion according to distinct scenarios (burn severity and climate), and the accuracy of the predictions was verified by an uncertainty analysis and validated against independent field datasets. The proposed approach successfully allowed mapping post-fire soil erosion in Portugal and identified the areas with higher post-fire erosion risk for past and future climate extremes. The outcomes of this study comprise a set of tools to help forest managers in their decision-making for post-fire emergency stabilization, ensuring the adequate selection and implementation of mitigation measures to minimize the economic and environmental losses caused by fire-enhanced soil erosion.

Mitigation of post-fire erosion from terraced micro-catchments using timber barriers

<p>Recently burnt areas across the world have been documented to produce strong to extreme erosion responses but these responses are much better quantified for (micro-)plots and planar hillslopes than for convergent hillslopes and catchments. The same applies, mutatis mutandis, for the effectiveness of so-called emergency stabilization measures to reduce the risks of such strong to extreme responses. The only prior study in Portugal on the mitigation of post-fire erosion beyond the planar slope scale (i.e. swales of 500-800 m2) tested mulching with eucalypt logging residues. It found the treatment to be highly effective during the first two post-fire hydrological years in the sense that soil losses were, average, 88 and 77% smaller at the three mulched swales than at the 3 untreated swales. This in spite the mulch had been applied at reduced rate (2.4 Mg ha-1) compared to preceding, plot-scale studies in the region (>8 Mg ha-1). Against this background, the present study decided to test the effectiveness of log barriers to reduce post-fire erosion beyond the planar slope scale, in particular to provide evidence supporting the post-fire land management strategy that is being developed by the INTERREG-SUDOE project EPyRIS (SOE2/P5/E0811). The study area is located in the Aveiro District of central Portugal and burnt during early  September 2020. In the part of the burnt area that is being managed by the Portuguese Nature Conservation and Forests Institute (ICNF), three pairs of neighbouring micro-catchments of 0.3-0.8 ha and, in one exceptional case (due to run-on from a forest track), 2.7 ha were instrumented with sediment fences at their outlets before the occurrence of the first significant rainfall event after the wildfire. The barriers, however, could not be installed until after the subtropical storm ALPHA that hit continental Portugal on 18-19 September, also due to some delay in the contracting of a company that would have prior experience in implementing post-fire emergency stabilization measures. The sediment yields produced by this first post-fire rainfall event were used to select which of each pair of micro-catchments to be treated, i.e. the one producing most erosion. Furthermore, the initial sediment yields of the three to-be-treated micro-catchments were used to decide the number of barriers per catchment, ranging from one to three. Both these aspects of the experimental design imply that the quantification of (cost-)effectiveness will less straightforward than in case of a randomized design. In compensation, the upslope part of each barrier was covered with geotextile immediately after construction to estimate the barrier’s capacity to induce sediment deposition and, at the scale of the entire micro-catchment, its effectiveness to reduce post-fire sediment yields, even if sediment deposition will only be measured at the end of each hydrological. This envisaged poster will present the differences in sediment yields between the paired, treated and untreated micro-catchments during the first post-fire autumn-winter period, and discuss them in function of terrain characteristics of the micro-catchments, RS-based fire severity, rainfall regime and changes in surface cover as derived from RGB imagery acquired with a low-cost drone.</p>

Comparison of pelvic C-clamp and pelvic binder for emergency stabilization and bleeding control in type-C pelvic ring fractures

Severe bleeding is the major cause of death in unstable pelvic ring fractures. Therefore, a quick and efficient emergency stabilization and bleeding control is inevitable. C-clamp and pelvic binder are efficient tools for temporary bleeding control, especially from the posterior pelvic ring. Yet the C-clamp requires more user knowledge, training and equipment. However, whether this makes up for a more efficient bleeding control, is still under debate. Patients with a type-C pelvic ring fracture were identified from the German Pelvic Registry (GPR) and divided into three groups of 40 patients (1. no emergency stabilization, 2. pelvic binder, 3. C-clamp). The matching occurred according to the parameters age, gender, initial RR and initial HB. Complication—and mortality rates were compared especially regarding bleeding control. Regarding ISS and fracture dislocation there was no difference. The use of the C-clamp resulted in more complications, a higher mortality rate due to severe bleeding and more blood transfusions were admitted. Moreover the pelvic binder was established noticeably faster. However, the C-clamp was more often rated as effective. There is no evidence of advantage comparing the C-clamp to the pelvic binder, regarding bleeding control in type-C pelvic ring fractures. In fact, using the pelvic binder even showed better results, as the time until established bleeding control was significantly shorter. Therefore, the pelvic binder should be the first choice. The C-clamp should remain a measure for selected cases only, if an adequate bleeding control cannot be achieved by the pelvic binder.

Endosurgery Approach in a Dog with Thoracoabdominal Injury

Background: Chest trauma is one of the main thoracic injuries in dogs and cats, reaching a high morbidity and mortality. The tissue damage, in thoracic trauma, can be underappreciated by visual exam and traditional radiography. The thoracoscopy can provide information for a precise definitive diagnosis, by this technique bleeding or air leakage can be identified and corrected immediately and the diaphragm can be completely evaluated. The aim of this work was to describe the thoracoscopic approach in a case of diaphragmatic perforation caused by penetrating trauma in a dog.Case:A 6-year-old male dog mixed-breed dog, weighing 14 kg with thorax perforation was presented to the Veterinary Hospital. Clinical examination of the animal revealed the following: pale mucous membranes, moderate dyspnea, open pneumothorax, abdominal distension, heart rate of 108 beats per minute and respiratory rate of 64 breaths per minute. Physical examination confirmed a 3 cm perforation hemorrhagic lesion in the left ninth intercostal space. As an emergency treatment, oxygen therapy, tramadol hydrochloride [Cronidor® 2%, 4 mg/kg, i.v, TID], tranexamic acid [Transamin® 25 mg/kg, i.v, TID], ceftriaxone [Rocefin® 50 mg/kg, i.v, BID] and fluid therapy with lactated Ringer’s solution were administered. The hair was removed, and then, wound cleaning and obliteration of the wall injury with sterile gauze was performed. After the emergency stabilization, the animal was anesthetized, followed by preventive thoracocentesis by an approach close to thoracic perforation and thoracoscopy without pneumoperitonea through this thoracic perforation with 0-degree rigid endoscope. About 100 mL of blood and air was drained and diagnosed perforation in the diaphragm and pulmonary atelectasis in the caudal and left cranial lobes. the edges of the incisional wound were debrided, and the closure of thoracic incision was performed usual way. After that, the air was removed by a catheter and syringe system. A flexible plastic tube was inserted through the chest wall and into the pleural space for drainage every 2 h for 24 h. There were no intercurrences during the first 24 h after the surgical procedure. The patient was discharged 48 h after the surgery. Cephalexin [75 mg, 30 mg/kg, v.o, TID, during 5 days), Ketoprofen [20 mg, 2 mg/kg, v.o, SID, during 5 days], Tramadol Hydrochloride [50 mg, 4 mg/kg, v.o, SID, during 2 days] and Rifamycin spray at the wound site was prescribed. Ten days after surgery, the patient returned to the hospital for suture removal and reassessment.Discussion: The prognosis of chest perforation depends on the severity and number of internal and external thoracic lesions, as well as cardiovascular status at the time of initial patient care. In cases of penetrating chest trauma, it is essential to thoroughly examine the thoracic cavity for bleeding, tissue tears, and diaphragm perforation. The use of the endoscope allowed for a more detailed exploration of the chest without the need to increase the incision. When the diaphragm lesion was found, it was also possible to perform the abdominal examination by videoendoscopy, through this perforation. Laparotomy and thoracotomy cause postoperative pain and discomfort, in addition to increasing recovery time, however, even with trauma, not performing a larger incision favored the recovery of this patient, without any intercurrence in the first 24 h after the procedure. In conclusion, the endoscopic approach was efficient for diagnosis, avoiding greater trauma and contributing to a better clinical recovery of the patient.Keywords: dog, chest trauma, minimally invasive surgery, thoracocentesis, thoracoscopy.

Face Mask Policies in South Korea in Response to COVID-19

All over the world, the critical shortage of face masks has been evident during the COVID-19 outbreak. No specific policy to solve the shortage has been shared among public health scholars and practitioners. Recently, the Korean government implemented noteworthy policies to stabilize the face mask market. This article examines the three government initiatives (Emergency Stabilization Policies) using participant observation, and what the effects of the Emergency Stabilization Policies are.