Educational Objective:

Discuss laboratory abnormalities associated with the syndrome of inappropriate anti-diuretic hormone (SIADH).

Key Point:

An elevated urine sodium in the face of hyponatremia suggests SIADH.

Explanation:

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) may be a complication of a malignancy such as carcinoma of the lung. Free water clearance by the kidney is blocked by the excess of the hormone with resultant expansion of the intravascular space and dilution of solutes. Thus, a high urine sodium, a low serum sodium, and low uric acid and blood urea nitrogen are typical of the syndrome. Progressive confusion and obtundation, sometimes accompanied by seizures, is characteristic of this level of hyponatremia. Mild hyponatremia and lack of neurologic findings may be simply treated with water restriction. In more severe presentations, such as the present case, saline or an inhibitor of vasopressin (e.g. conivaptan) should be administered. For patients  whose neurologic symptoms are thought to be due to inappropriate ADH activity, either 3% saline or conivaptan would be appropriate. The advantage of an inhibitor of vasopressin is that the risks of rapid volume overload with hypertonic saline would be eliminated.

References:

Ferri F, Syndrome of inappropriate ADH secretion. Ferri’s Clinical Advisor. 2018;

Sotki I, Skorecki K, Disorders of Sodium and Water Homeostasis. Goldman-Cecil Medicine 2016; 116: 741-755

Peters S, Kuhn R, Gardner B, Bernard,P. Use of conivaptan for refractory syndrome of inappropriate secretion of antidiuretic hormone in a Pediatric patient, Pediatr Emerg Care. 2013;29: 230-232

Educational Objective:

Recognize risk factors for postcoital UTIs in women.

Key Point:

Spermicide use may predispose for recurrent postcoital UTIs in females.

Explanation:

Spermicide use has been found to be an independent risk factor for recurrent UTI. Other risk factors include multiple sex partners, frequent intercourse and failure to clean the perineum following intercourse.

References:

Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic urinary tract infection in young women. N Engl J Med 1996; 335:468.

Arnold JJ, Hehn LE and Klein DA. Common Questions about Recurrent Urinary Tract Infections in Women. American Family Physician. 2016; 93: 560-569

This patient is presenting with 2 features of the metabolic syndrome, a grouping of abnormalities that reflect increased cardiovascular risk. Definitions of metabolic syndrome vary but all include central obesity, elevated triglycerides, low HDL, elevated blood pressure, and insulin resistance.

This patient is obese and has elevated blood pressure. She is at increased risk for having abnormalities of serum lipids and insulin.

References:

Hassink SG. Pediatric Obesity: Prevention, Intervention, and Treatment Strategies for Primary Care. 2nd ed., 2014.

Lee AM, Gurka MJ, DeBoer MD. Trends in metabolic syndrome severity and lifestyle factors among adolescents. Pediatrics. 2016;137(3):e20153177.

Patton HM, Yates K, Unalp-Arida A, et al. Association between metabolic syndrome and liver histology among children with nonalcoholic Fatty liver disease. Am J Gastroenterol. 2010;105(9):2093-2102.

Ten S, MacLaren N. Insulin resistance syndrome in children. J Clin Endocrinol Metab. 2004;89(6):2526-2539.

Somatoform disorders are marked by physical complaints out of proportion to physical findings. The lack of volitional control of behavior distinguishes somatoform disorder from factitious disorders.

Reference:

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision. 2013.

Educational Objective:

Discuss the management of abrasions caused by rough shark skin.

Key Point:

The skin of many sharks is rough, like sandpaper, and can cause a bad scrape. If this occurs, it should be managed similar to a second-degree burn.

Explanation:

Skin abrasions caused by shark skin are not known to have a complicated medical course. Debridement is not needed.

The below image depicts a shark invading a shark cage:

Figure.

References:

Auerbach PS, et al. Injuries from Aquatic Nonvenomous Aquatic Animals. Auerbach’s Wilderness Medicine7^thed. 2017. 1636 – 1678.e4.

Auerbach PS. Hazardous Aquatic Life and Aquatic Infections. Medicine for the Outdoors 6^thed., 2016. 347-360.

Multiple-trauma blast-injury patients will still mostly present with trauma to the 3 most commonly blast-injured body systems: auditory, pulmonary, and abdominal. In addition, there may be musculoskeletal and cerebral injuries. However, in all blast-injury patients, the following 3 systems also need careful evaluation:

• Cardiac: Mostly, hypotension in blast-injury patients will be due to noncardiac injuries. Occasionally, blast-injury patients may present with cardiac contusions, myocardial-wall hemorrhage, and atrial rupture. These injuries may be difficult to detect in the hypotensive multitrauma blast-injury patient; therefore, they require a high index of suspicion.
• Ocular: Up to 10% of people injured by explosions sustain ocular trauma (ruptured globes, hyphemas, conjunctival hemorrhage, serous retinitis, and orbital fractures). Some of these ocular injuries are initially easily missed, but they are not the most commonly missed injury in blast-injury patients (unfortunately, these patients present with many, easily missed injuries due to the fact that blasts cause difficult-to-diagnose ischemic injuries in many different tissues).
• Skin: Blast-induced burns (quaternary injuries) are present in roughly 30% of this patient population. Hands and face are most commonly affected, but more extensive lower body burns can occur in people trapped in burning vehicles or structures. Burns greatly complicate the care of blast-injury patients. In general, the following rules apply:
  
  • Burns are associated with an increased risk for primary blast injuries and fatal injuries. Full crystalloid resuscitation (e.g., by the Parkland formula) is crucial in the blast victim with extensive burns, but may lead to abdominal compartment syndrome (requires a high index of suspicion to be diagnosed) and severe pulmonary edema in the patient with concomitant primary blast injuries to the lung and gastrointestinal tract. However, this greatly complicates the management of blast-injury patients with burns. It would not be prudent to categorically avoid full crystalloid resuscitation in all blast-injury patients with burns because some patients might mainly be burn victims without other primary blast injuries.
  • The combination of blast lung injury and the systemic inflammation that follows a large surface burns can lead to severe, delayed adult respiratory distress syndrome and hypoxia. (Patients will not present with adult respiratory syndrome, but they will develop it during their hospital course.)
  • Blast-related burns may have underlying crush injuries, which makes debridement and management of the burn difficult and poses an increased risk for severe infection in the crushed limb.
  • Blast-injury patients with burns should be cared for in a burn center because of the elevated rates of infection and multiorgan dysfunction.

Reference:
Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Blast injuries. Lancet. 2009;374:405-415.

Elevation of the affected limb with episodic applications of cold packs for the next 48 hours.

RICE treatment is a cornerstone for musculoskeletal injury. It consists of: Rest—reduce activity, the injury should be splinted and should bear no weight. Ice—apply ice packs to reduce pain and swelling. Ice should be applied for 15- to 20-minute periods and should be removed for intervals of 30 to 45 minutes before reapplying. Compression—apply lightly in the form of an elastic wrap so that it accommodates swelling. Elevation—elevating the injured part above the level of the heart is standard to reduce swelling.

Take one pill every 1 to 2 hours until relief is obtained or adverse gastrointestinal effects occur, such as abdominal pain, nausea, or diarrhea

Colchicine acts as an anti-inflammatory and helps to suppress gouty attacks. It is usually taken as one tablet (0.6 mg) every 1 to 2 hours until relief is obtained (or adverse gastrointestinal [GI] effects occur, such as abdominal pain, nausea, or diarrhea). The patient should be prescribed only 10 tablets at a time (do not refill) during a flare-up. The maximum dose is 6 mg/day. Many patients will develop adverse GI effects even before the pain is relieved. Colchicine can also be taken daily in small amounts for prophylaxis.

Through the inhibition of cyclooxygenase, NSAIDs reduce the production of prostaglandins, which are important in the pathogenesis of inflammation and pain production.