Tuesday, January 8, 2013

Loss of consciousness subsequent to chronic nose-blowing

The case of a patient with OCD who blew his nose way too often: 

The case is described of a 50-year-old man, treated for 10 years in an outpatient psychiatric clinic for an obsessive compulsive disorder, who presented with acute loss of consciousness after forceful nose blowing. A CT scan revealed an intraparenchymal air collection with tension signs in the left frontal lobe and a bone defect in the roof of the ethmoid sinus. After emergency left frontal craniotomy and dura opening, the gaseous collection was evacuated by a ventricular catheter inserted into the brain and the bone defect was repaired with pericranium flap and muscle. The postoperative course was uneventful with neurocognitive improvement and regained motility. Spontaneous tension pneumocephalus is a rare life-threatening condition which is often caused by a bone defect near the tegmen tympani. This case illustrates both an unusual cause and a unique surgical treatment for spontaneous tension intraparenchymal pneumocephalus. It can be a dangerous entity with potential for early mortality and long-term morbidity if not promptly decompressed. The pathogenesis, diagnosis and surgical strategies for spontaneous tension pneumocephalus are briefly discussed. 

Mirone G, Rotondo M, Scuotto A, et al. Spontaneous intraparenchymal tension pneumocephalus triggered by compulsive forceful nose blowing. Emerg Med J. 2009;26(11):837-838

Beware of cheerleading

An article on the dangers of cheerleading and the critical height in which one can sustain a brain injury. And who said this sport was for wusses?

CONTEXT: Although playground surfaces have been investigated for fall impact attenuation, the surfaces that cheerleaders use have received little attention. 

OBJECTIVE: To determine (1) the critical height for selected surfaces used by cheerleaders at or below which a serious head impact injury from a fall is unlikely to occur, (2) the critical heights for non-impact-absorbing surfaces for comparison purposes, and (3) the effect of soil moisture and grass height on g(max) (which is defined as the multiple of g [acceleration due to gravity at the earth's surface at sea level: ie, 32.2 feet x s(-1) x s(-1)] that represents the maximum deceleration experienced during an impact) and the Head Injury Criterion (HIC) at the critical height for a dry grass surface. 

DESIGN: Observational study. SETTINGS: A local cheerleading gym, indoor locations within the authors' institution, and various outdoor locations. MAIN OUTCOME MEASURE(S): g(max), HIC, and critical height. 

RESULTS: Critical heights for the surfaces tested ranged from 0.5 ft (0.15 m) for concrete and vinyl tile installed over concrete to more than 11 ft (3.35 m) for a spring floor. Increases in grass height and soil moisture resulted in an increase in the critical height for grass surfaces. Only spring floors and 4-in (0.10-m)-thick landing mats placed on traditional foam floors had critical heights greater than 10.5 ft (3.20 m), thus providing enough impact-absorbing capacity for performance of 2-level stunts. 

CONCLUSIONS: The potential for serious head impact injuries can be minimized by increasing the shock-absorbing capacity of the surface, decreasing the height from which the person falls, or both. Cheerleaders and cheerleading coaches should use the critical heights reported in this study to compare the relative impact-absorbing capacities of the various surfaces tested, with critical height as an indicator of the impact-absorption capacity of the surface. The findings of this study can be used to select the most appropriate surface for the type of maneuver to be performed, based on the maximum height expected to be achieved by the cheerleader(s) during execution of the maneuver. Cheerleaders should not perform maneuvers at heights that exceed the critical height for the surface on which they are performing. 

Shields BJ, Smith GA. The potential for brain injury  on selected surfaces used by cheerleaders. J Athl Train. 2009;44(6):595-602

Monday, January 7, 2013

Weapon swallowing as a form of stress relief

Another fascinating case study. Patient with intellectual disability who swallowed sharp objects to reduce stress. If only this solution was a viable option to end world violence...

A 41-year-old male patient with intellectual disabilities presented after having swallowed approximately 20 sharp objects. While admitted to a psychiatric ward, surgeons removed a glove from his stomach endoscopically and pharmacologically facilitated the objects' complication-free bowel passage. The patient explained the swallowing as a means to release himself from tension induced by stress. His aberrant behavior also seemed to serve as a means to exert pressure on psychosocial workers. Other deviations included the pushing of sharp objects under the skin and multiple paraphiliae. As a child, the patient suffered from early psychological and physical traumatization. Both parents were allegedly physically abusive alcoholics.  Apart from possible alcohol embryopathy and traumatic brain damage, meningitis, which the patient had at the age of three, is discussed as the most likely reason for his oligophrenia, associated with left-sided, temporo-parietal atrophy and epilepsy. 

te Wildt BT, Tettenborn C, Schneider U, et al. Swallowing foreign bodies as an example of impulse control disorder in a patient with intellectual disabilities: A case report. Psychiatry (Edgemont). 2010;7(9):34-37