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Medically unexplained symptoms (MUS) are those with no identified organic aetiology. Our emergency department (ED) perceived an increase in MUS frequency during COVID-19. The primary aim was to compare MUS incidence in frequent attenders (FAs) during COVID-19 and a control period.A retrospective list of FA-MUS presenting to our ED from March to June 2019 (control) and March to June 2020 (during COVID-19) was compared. Fisher's exact test was used to compare binomial proportions; this presented as relative risk (RR) with 95% confidence intervals (95%CI).During COVID-19, ED attendances reduced by 32.7%, with a significant increase in the incidence of FA-MUS and FA-MUS ED visits compared to control; RR 1.5 (95%CI 1.1-1.8) p=0.0006, and RR 1.8 (95%CI 1.6-2.0), p<0.0001, respectively.Despite reduced ED attendances during COVID-19, there was a significant increase in the incidence of FA-MUS patients and corresponding ED visits by this cohort. This presents a challenge to ED clinicians who may feel underprepared to manage these patients effectively., (© Royal College of Physicians 2021. All rights reserved.)

Objective: To determine the effect of blood sampling through an intravenous catheter compared with a needle in Emergency Department blood sampling., Methods: We undertook a prospective, cross-sectional study in a UK university teaching hospital Emergency Department. A convenience sample of 985 patients who required blood sampling via venepuncture was collected. A total of 844 complete sets of data were analysed. The median age was 63 years, and 57% of patients were male. The primary outcome measure was the incidence of haemolysis in blood samples obtained via a needle compared with samples obtained via an intravenous catheter. Secondary outcome measures defined the effect on sample haemolysis of the side of the patient the sample was obtained from, the anatomical location of sampling, the perceived difficulty in obtaining the sample, the order of sample tubes collected, estimated tourniquet time and bench time. Data were analysed with logistic regression, and expressed as odds ratios (95% confidence intervals; P-values)., Results: Blood samples obtained through an intravenous catheter were more likely to be haemolysed than those obtained via a needle, odds ratio 5.63 (95% confidence interval 2.49-12.73; P<0.001)., Conclusion: Blood sampling via an intravenous catheter was significantly associated with an increase in the likelihood of sample haemolysis compared with sampling with a needle. Wherever practicable, blood samples should be obtained via a needle in preference to an intravenous catheter. Future research should include both an economic evaluation, and staff and patient satisfaction of separating blood sampling and intravenous catheter placement.

Spontaneous tumor lysis syndrome is a rare initial presentation of hematologic malignancy in children that typically presents with complications of electrolyte derangement, specifically hyperkalemia, hyperphosphatemia, and hyperuricemia. We report a case of a 5-year-old boy who presented to the emergency department with gross hematuria, abdominal pain, and vomiting and was ultimately diagnosed with uric acid nephrolithiasis and acute renal failure secondary to spontaneous tumor lysis syndrome in the setting of T-cell acute lymphoblastic leukemia. Tumor lysis syndrome is considered an oncologic emergency, and in this case, the child required urgent treatment with potassium-binding agents, rasburicase, and hemodialysis. This case demonstrates that occult hematologic malignancy should be suspected in cases of nephrolithiasis and acute renal failure when found in conjunction with hyperuricemia despite a normal complete blood count at the time of presentation., (Copyright © 2016 by the American Academy of Pediatrics.)

Introduction: Non-compressible torso haemorrhage (NCTH) carries a high mortality in trauma as many patients exsanguinate prior to definitive haemorrhage control. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct that has the potential to bridge patients to definitive haemostasis. However, the proportion of trauma patients in whom REBOA may be utilised is unknown., Methods: We conducted a population based analysis of 2012-2013 Trauma Audit and Research Network (TARN) data. We identified the number of patients in whom REBOA may have been utilised, defined by an Abbreviated Injury Scale score ≥3 to abdominal solid organs, abdominal or pelvic vasculature, pelvic fracture with ring disruption or proximal traumatic lower limb amputation, together with a systolic blood pressure <90 mm Hg. Patients with non-compressible haemorrhage in the mediastinum, axilla, face or neck were excluded., Results: During 2012-2013, 72 677 adult trauma patients admitted to hospitals in England and Wales were identified. 397 patients had an indication(s) and no contraindications for REBOA with evidence of haemorrhagic shock: 69% men, median age 43 years and median Injury Severity Score 32. Overall mortality was 32%. Major trauma centres (MTCs) received the highest concentration of potential REBOA patients, and would be anticipated to receive a patient in whom REBOA may be utilised every 95 days, increasing to every 46 days in the 10 MTCs with the highest attendance of this injury type., Conclusions: This TARN database analysis has identified a small group of severely injured, resource intensive patients with a highly lethal injury that is theoretically amenable to REBOA. The highest density of these patients is seen at MTCs, and as such a planned evaluation of REBOA should be further considered in these hospitals., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Intraosseous (IO) drug infusion has been reported to have similar pharmacokinetics to intravenous (IV) infusion. In military and civilian trauma, the IO route is often used to obtain rapid and reliable parenteral access for drug administration. Only a few case reports have described the use of IO infusion to administer drugs for rapid sequence induction of anaesthesia (RSI)., Objective: We aimed to assess the feasibility of the administration of RSI drugs via an IO catheter in a prospective observational study., Methods: A prospective observational study was undertaken at a combat hospital in Afghanistan. A validated data form was used to record the use of IO drugs for RSI by the prehospital, physician-led Medical Emergency Response Team (MERT), and by inhospital physicians. Data were captured between January and May 2012 by interview with MERT physicians and inhospital physicians directly after RSI. The primary outcome measure was the success rate of first-pass intubation with direct laryngoscopy., Results: 34 trauma patients (29 MERT and 5 inhospital) underwent RSI with IO drug administration. The median age was 24 years and median injury severity score 25; all were male. The predominant mechanism of injury was blast (n=24), followed by penetrating (n=6), blunt (n=3) and burn (n=1). First-pass intubation success rate was 97% (95% CI 91% to 100%). A Cormack-Lehane grade 1 view, by direct laryngoscopy, was obtained at first look in 91% (95% CI 81% to 100%) of patients., Conclusions: In this prospective, observational study, IO drug administration was successfully used for trauma RSI, with a comparable first pass intubation success than published studies describing the IV route., Trial Registration Number: RCDM/Res/Audit/1036/12/0162., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

We present a case of a 40-year-old soldier who was in close proximity to the detonation of an improvised explosive device (IED). Bubbles of gas were visible within the anterior chamber of his left eye. The authors propose that intraocular gas, present acutely after trauma, is diagnostic of open globe injury and is of particular importance in remote military environments.