Retrobulbar hemorrhage with orbital compartment syndrome: A rare sight-threatening emergency during air medical evacuation

Traumatic retrobulbar hemorrhage may be rapidly progressive, converts to a sight-threatening emergency with potentially devastating complications. Assisted-escape systems in fast jet aircraft can lead to the pilot's facial/orbital injuries at any stage of the ejection sequences, which may result in retrobulbar hemorrhage. Orbital traumas are common and rarely result in retrobulbar hemorrhage and orbital compartment syndrome. However, early diagnosis and urgent out-of-the-hospital lateral canthotomy with cantholysis were recommended to save the patient's vision.

Recurrent unilateral pupillary dilation and transient visual blurring: A clinical challenge during hypoxia exposure in a male fighter pilot

Hypoxia is an operational concern in military aviation, and fighter pilots should undertake altitude hypoxia training. Anisocoria is a significant clinical dilemma and may remain a diagnostic challenge for specialists. We present a case of atraumatic unilateral mydriasis during hypobaric chamber training. Our diagnostic dilemma is novel and unique because the authors reported no similar presentation yet, it occurred in a fighter pilot whose occupational future depends on having normal vision, and second, the presence of hypoxia seems to trigger symptoms.

Diseases leading to permanent disqualification in Islamic Republic of Iran Air Force non-pilot crew

Background

Efficient personnel is the most important Armed Forces capital. Many studies have shown the relationship between health and performance. Understanding the factors leading to disability has preventive importance. This study was aimed to identify diseases leading to permanent disqualification of Islamic Republic of Iran Air Force (IRIAF) non-pilot crew (NPC) to identify existing deficiencies and prevent personnel disqualification.

Methods

The study was designed as descriptive, cross-sectional, retrospective research. Medical causes and diseases leading to early and permanent medical disqualification (EPMD) of IRIAF NPC from 1986 to 2016 were collected from their medical records and council files. Data were registered and sorted in predesigned electronic sheets for analysis by SPSS version 26.

Results

Of all the 155 cases with permanent disqualifications, 126 persons had medical disqualification, and others were killed or missed in actions. Flight engineers, navigators, and loadmasters had the most medical disqualification. The highest number of killed or missed persons in actions was for navigators, loadmasters, and crew chiefs. The main reasons for EPMD were psychiatric, cardiac, and neurologic, wherein common diseases included generalized anxiety disorder, myocardial infarction, and lumbar discopathy. The total lost service years were 1569 person-years. Its average was 12.45 person-years per individual with a standard deviation of ±2.4.

Conclusion

Due to the similarity in the work environment, we compared NPC results with similar studies in other flight crew. Nonetheless, the main causes and diseases leading to early EPMD of the flight crew were similar in different studies, but their orders and frequencies were different.

Association of thyroid dysfunction and COVID-19: A systematic review and meta-analysis

This systematic review and meta-analysis was conducted to evaluate the effect of COVID-19 on thyroid function and the role of thyroid hormones alterations in predicting the severity of COVID-19. Online databases, including Scopus, Medline/PubMed, EMBASE, Google Scholar, and Cochrane were searched up to August 2, 2022. After screening titles, abstracts, and full manuscripts, respectively, 30 reports were enrolled. The risk of bias (ROB) was evaluated using the QUADAS-2 tool. In addition, odds ratio (OR) and hazard ratio (HR) analysis for assessing the OR of abnormal thyroid function tests (TFT) in predicting the COVID-19 severity and poor outcomes. Among 30 enrolled studies, ROB of the current study is estimated low to moderate. The average number of patients in each study was 325 (range: 40-3,703), with an overall mean age of 57.6, and the female proportion of 40.4%. Overall, the pooled analysis showed that the prevalence of thyroid dysfunction among 9,707 COVID-19 cases was 15%. Among mild to moderate COVID-19 patients, 6.2% had abnormal TFT, and among patients who experienced severe to critical COVID-19, 20.8% had abnormal TFT. The pooled OR for abnormal TFT and the severity of COVID-19 obtained from 3,865 COVID-19 patients was 3.77 (2.03, 6.99). The pooled HR of TSH level of COVID-19 mortality was 1.57 (0.91, 2.72). Our results demonstrate a high prevalence of thyroid dysfunction in COVID-19, and that among patients severe cases had a 3.77-fold higher risk of abnormal TFT compared to mild to moderate COVID-19. Further studies are required to evaluate the longer-term prognostic role of thyroid dysfunction in severe COVID-19, and investigate potential therapeutic strategies.

Thalamic hemi-chorea: a rare complication after receiving the adenoviral vector-based COVID-19 vaccine: a case report

Lacunar strokes occur when a branch of a large cerebral artery is blocked. The thalamus is often affected, causing uncontrollable motions. A 72-year-old previously healthy man presented with involuntary motions in the right limbs, which were present at rest, and exacerbated during voluntary actions. He had received the first dose of the adenoviral vector-based coronavirus disease 2019 vaccine (ChAdOx1 nCoV-19) 9 days ago. Severe thrombocytopenia and elevated levels of lactate dehydrogenase, ferritin, C-reactive protein, and D-dimer were found, without any evidence of connective tissue disease. Electromyography demonstrated typical choreiform movements, and the brain magnetic resonance imaging indicated a small high signal lesion on the left side of the thalamus. Detection of the immunoglobulin G antibodies against platelet factor 4 in the blood, negative heparin-induced platelet activation (HIPA) test, and positive modified HIPA test confirmed the thalamic stroke due to the vaccine-induced prothrombotic immune thrombocytopenia (VIPIT). He was admitted to the intensive care unit and received nadroparin, sodium ozagrel, edaravone, methylprednisolone, and haloperidol. His hemi-chorea improved gradually over 2 weeks, and he was discharged after 21 days with rehabilitation advice. VIPIT due to the ChAdOx1 nCoV-19 is a novel immune-mediated response that needs clinicians' awareness and further investigations.

New-Onset Transient Global Amnesia: A Clinical Challenge in an Air Medical Transportation Pilot With a History of Coronavirus Disease 2019

A 43-year-old male Bell 214C helicopter pilot presented to the emergency ward with flu-like syndrome. His nasopharyngeal severe acute respiratory syndrome coronavirus 2 real-time polymerase chain reaction test was positive, and a chest computed tomographic scan confirmed coronavirus disease 2019 pneumonia. He was admitted, received treatment, was discharged, and returned to flying. During the mission debrief, copilots who had flown with him reported that he experienced episodes of in-flight dizziness and blacked out. They occurred briefly during the cruise and hovering flight, perhaps for a few seconds of disorientation and unconsciousness. Rapid identification of the copilot and control of the helicopter prevented any incident or accident. Afterward, he explained the sudden onset and unexpected brief periods of loss of consciousness after a headache. The flight safety office referred him to the aviation medical center for further investigations. The cardiovascular, neurologic, laboratory, and toxicologic assessments were inconclusive with the approach to sudden-onset transient loss of consciousness. The only abnormal finding was hippocampus lesions on brain magnetic resonance imaging (MRI). Because of the possible diagnosis of transient global amnesia, the aviation medical examiner suspended him from flight duties until complete recovery and the absence of any probable complications.

Clinical, Laboratory and Imaging Characteristics of Hospitalized COVID-19 Patients with Neurologic Involvement; a Cross-Sectional Study

Introduction

Although neurologic involvement and neuroimaging abnormalities have been frequently identified in COVID-19 patients, the underlying factors remain unclear. In this study, we assessed the association of the neurological manifestations and neuroimaging features of hospitalized COVID-19 patients with their clinical, laboratory, and imaging characteristics.

Methods

This multicenter cross-sectional study was conducted between September 2020 and March 2021 at two large academic hospitals in Tehran, Iran. We used census sampling from medical records to enroll hospitalized patients with a positive COVID-19 Polymerase chain reaction (PCR) test who underwent brain imaging due to presenting any acute neurologic symptom during hospital stay.

Results

Of the 4372 hospitalized patients with COVID-19, only 211 met the inclusion criteria (35.5% with severe infection). Central nervous system and psychiatric manifestations were significantly more common in severe cases (p ≤ 0.044). Approximately, 30% had a new abnormality on their neuroimaging, with ischemic (38/63) and hemorrhagic (16/63) insults being the most common. The most frequent reasons that provoked cranial imaging were headache (27%), altered consciousness (25.6%), focal neurologic signs (19.9%), and delirium (18%). Analysis revealed a positive correlation for age, neutrophilia, lymphopenia, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) with the emergence of neuroimaging abnormalities (p ≤ 0.018). In addition, patients with new neuroimaging abnormalities had a significantly higher lung CT score than those without any pathologic findings (11.1 ± 4.8 vs. 5.9 ± 4.8, p < 0.001).

Conclusion

Approximately 30% of the study population had various acute neuroimaging findings. The lung CT score, neutrophil count, and age were strong predictors of acute neuroimaging abnormalities in hospitalized COVID-19 patients.

Acute vestibular neuritis: A rare complication after the adenoviral vector-based COVID-19 vaccine

Vestibular neuritis was first reported in 1952 by Dix and Hallpike, and 30% of patients reporting a flu-like symptom before acquiring the disorder. The most common causes are viral infections, often resulting from systemic viral infections or bacterial labyrinthitis. Here we presented a rare case of acute vestibular neuritis after the adenoviral vector-based COVID-19 vaccination. A 51-year-old male pilot awoke early in the morning with severe vertigo, nausea, and vomiting after receiving the first dose of the ChAdOx1 nCoV-19 vaccine 11 days ago. Nasopharyngeal SARS-CoV-2 RT-PCR test and chest CT scan were inconclusive for COVID-19 pneumonia. Significant findings were a severe spontaneous and constant true-whirling vertigo which worsened with head movement, horizontal-torsional spontaneous nystagmus, abnormal caloric test, positive bedside head impulse tests, and inability to tolerate head-thrust test. PTA, MRI of the brain and internal auditory canal, and cerebral CT arteriography were normal. According to the clinical, imaging, and laboratory findings, he was admitted to the neurology ward and received treatment for vestibular neuritis. His vertigo increased gradually over 6-8 h, peaking on the first day, and gradually subsided over 7 days. Ten days later, the symptoms became tolerable; the patient was discharged with advice for home-based vestibular rehabilitation exercises. Despite the proper treatment and rehabilitation, signs of dynamic vestibular imbalances persisted after 1 year. Based on the Federal Aviation Administration (FAA) regulations, the Air Medical Council (AMC) suspended him from flight duties until receiving full recovery. Several cases of vestibular neuritis have been reported in the COVID-19 patients and after the COVID-19 vaccination. This is the first case report of acute vestibular neuritis after the ChAdOx1 nCoV-19 vaccination in a healthy pilot without past medical history. However, the authors believe that this is a primary clinical suspicion that must be considered and confirmed after complete investigations.

Abdominal Compartment Syndrome: A Life-Threatening Condition in Air Medical Transportation of Multiple Trauma Patients

A 41-year-old male farmer was injured in a land mine explosion. After initial resuscitation, the emergency physician coordinated with the hospital and air medical crew for the patient's evacuation. The evacuation was started by a Bell 214C helicopter, and the patient's clinical condition deteriorated during flight with increased abdominal pain and distension, tachycardia, tachypnea, hypotension, and loss of consciousness. Intra-abdominal (vesical) pressure of 23 mm Hg, findings of in-flight bedside ultrasound, and echocardiography indicated intra-abdominal hypertension with abdominal compartment syndrome. The emergency physician started medical management quickly based on the World Society of Abdominal Compartment Syndrome, but after 15 minutes the intra-abdominal pressure was still > 20 mm Hg. Despite the in-flight difficult condition, the risk of vascular or neural damages, and infection, the emergency physician performed a midline decompression laparotomy and, when the intra-abdominal pressure reached about 11 mm Hg, temporarily covered the wound with a Bogota bag. After the patient's intra-abdominal pressure stabilized, permanent abdominal wound repair was performed by the surgeon, and he was discharged from the hospital.

Blunt Thoracic Aortic Injury: A Life-Threatening Emergency on Air Medical Transportation

A 54-year-old male driver was injured in a car crash in which his front-side passenger died at the scene. The initial assessment indicated that he was conscious and able to recall the accident. His vital signs included blood pressure of 155/95 mm Hg, heart rate of 112 beats/min, and respiratory rate of 21 breaths/min, and he complained of stabbing retrosternal pain. A palpable sternal fracture with a tender contusion, a discrepancy between the blood pressures between the arms, and diminished femoral pulses were other findings. With a thoracic aortic pseudoaneurysm suspicion, the emergency physician maintained the patient's systolic blood pressure around 100 mm Hg and his heart rate less than 100 beats/min. Because of the need for urgent medical interventions, the emergency physician decided to transport him by air to the nearest advanced trauma center. After accordance with the trauma center and the air medical crew, the air transportation began. The patient subsequently decompensated with bradycardia and hypotension to cardiac arrest, for which 30 minutes of cardiopulmonary resuscitation unfortunately proved unsuccessful. The forensic report indicated an aortic pseudoaneurysm rupture of the proximal descending aorta with a massive hematoma that was a possible cause of death.

Myocardial Contusion: A Case of Fatal Cardiac Dysrhythmias During Air Medical Transportation

A 34-year-old male worker suffered from blunt chest trauma after falling from a height of about 10 m. The initial assessment of the emergency physician (EP) indicated that he was confused but recalled the event and had a midthoracic superficial laceration, ecchymosis, tenderness, and severe substernal pain. Because of the urgent need for advanced medical management in a trauma center, the EP coordinated with the nearest trauma center and the air medical crew (AMC) for his evacuation. Blood pressure of 100/55 mm Hg, heart rate of 128 beats/min, respiratory rate of 24 breaths/min, pulse oximetry of 91%, and a capillary refill time of about 2 seconds were the bedside AMC findings. Despite the adverse weather conditions and darkness, the AMC performed the following preflight assessments and preparations for the patient: neck and body fixation, 2 saline locks, intravenous hydration, ketorolac 30 mg intravenously, oxygen mask, a 12-lead electrocardiogram with cardiac monitoring, and echocardiography. During the evacuation, the patient decompensated further from sudden cardiac dysrhythmias, hypotension, loss of consciousness, and apnea. However, despite the difficult and unusual in-flight conditions, the EP performed 30 minutes of cardiopulmonary resuscitation, which was unsuccessful. The forensic report indicated that the fatal cardiac dysrhythmias due to myocardial contusion were a possible cause of death.

Dynamic and static postural control among fighter pilots with spinal sagittal plane deformities

Background

Fighter pilots are at high risk for sagittal deformities because they are exposed to in-flight gravitational forces. These patients have reduced proprioception and are susceptible to imbalance. The present study was conducted to assess the dynamic and static postural control among fighter pilots with kyphosis and lordosis.

Methods

This is a causal-comparative study, which was conducted on 40 employed active fighter pilots during 2019. Our aim was to identify their sagittal plane deformity for complementary medical examinations, determine their flight status and reduce the possible related air accident. First, lordosis and kyphosis angles were measured in the standing position. Then, the static balance was measured using the one-leg standing test with the eyes open and closed. Dynamic balance was measured using the star excursion balance test in eight directions with a total of 16 unilateral squats.

Results

Dynamic balance in the hypo-kyphosis was significantly different in all directions, except for postero-lateral and lateral. No significant difference was obtained between the hyper- and hypo-lordosis in dynamic balance in all directions. The mean static balance scores in the hyper-kyphosis group were significantly more than that in the hypo-kyphosis group. There was no significant difference between the hyper- and hypo-lordosis participants with respect to static balance.

Conclusions

The hypo-kyphosis had a significantly higher dynamic balance in all directions, except for posterolateral and lateral, compared to the hyper-kyphosis group. No significant static and dynamic balance differences were observed between the patients with hyper- and hypo-lordosis. The static balance was higher in the hypo-kyphosis rather than hyper-kyphosis under the eyes open and closed. The patients with hyper-lordosis had a higher static balance, rather than hyper-kyphosis.

Guillain-Barré Syndrome Associated with SARS-CoV-2 Infection: A Case Report

A 56-year-old man was referred to the emergency department for the subacute onset of and weakness in the lower extremities, paraesthesia and pain. He was diagnosed with SARS-CoV-2 pneumonia and then, he received the necessary treatment according to national protocol. Radiographic, laboratory, and electroneurographic findings indicated an acute polyradiculoneuritis with prominent demyelination and suggesting the diagnosis of Guillain-Barr syndrome associated with COVID-19 infection.

Overt hematochezia : A rare gastrointestinal presentation in patients with corona virus disease 2019

World health care systems are affected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and its associated disease, coronavirus disease 2019 (COVID-19). This new human pathogen mostly affects the respiratory system, but various extrapulmonary pathologies have been reported in the literature. It seems that the gastrointestinal system is one of the target organs for SARS-CoV- 2. Diarrhea as a long-term bowel symptom is not rare, although its occurrence is not as high as that of fever and cough.

Acute transverse myelitis after SARS-CoV-2 infection: a rare complicated case of rapid onset paraplegia

A 63-year-old Caucasian male, known case of controlled type 2 diabetes, chronic renal failure, and ischemic heart disease, was presented with weakness and loss of movement in lower limbs, an absent sensation from the chest below, constipation, and urinary retention. About 4 days before these symptoms, he experienced a flu-like syndrome. Suspicious for COVID-19, his nasopharyngeal specimen’s reverse transcription-polymerase chain reaction (RT-PCR) resulted positive. Chest X-ray and HRCT demonstrated severe pulmonary involvement. Immediately, he was admitted to the emergency ward, and the treatment was started according to the national COVID-19 treatment protocol. Subsequently, diagnostic measures were taken to investigate the patient’s non-heterogeneous peripheral (spinal) neuromuscular manifestations. Brain CT scan and MRI were normal, but spinal MRI with gadolinium contrast showed extensive increased T2 signal involving central gray matter and dorsal columns, extended from C7 to T12 with linear enhancement in the sagittal plane, posteriorly within the mid and lower thoracic cord. The CSF specimen demonstrated pleocytosis, positive RT-PCR for SARS-CoV-2, and elevated IgG index. Clinical presentation, MRI, CSF, and laboratory findings prioritized the acute transverse myelitis (ATM) as a probable complication of COVID-19 infection over other differential diagnoses. Intravenous methylprednisolone and, subsequently, IV human immunoglobulin were added to the treatment regimen. In the end, the complete resolution of dysesthesia, urinary retention, and constipation were achieved. After continuous and extended respiratory and motor rehabilitation programs, he was discharged asymptomatic.

Coronavirus Disease 2019 Suspicion: A Case Report Regarding a Male Emergency Medical Service Pilot With Newly Diagnosed Sarcoidosis

A 38-year-old emergency medical service Bell 214 male pilot with a dry cough, fever, anorexia, fatigue, and sweating for the past 3 days; an oral temperature of 38°C; blood pressure of 105/65 mm Hg; heart rate of 94 beats/min; respiratory rate of 21 breaths/min; and pulse oximetry of 93% on room air was suspicious for coronavirus disease 2019. Surprisingly, reverse transcription polymerase chain reaction was negative, but bilateral hilar adenopathy was reported in his chest radiography as a new challenge. The pathologic report of the adenopathy biopsy was noncaseating sarcoid-type granulomas. Serologic tests showed a serum angiotensin-converting enzyme level of 58 nmol/mL/min. The bronchoalveolar lavage fluid CD4/CD8 ratio was 3.68. The bronchoalveolar lavage findings provided an accurate sarcoidosis diagnosis, and a high-resolution computed tomographic scan revealed stage 1 pulmonary involvement. Because of the pulmonary involvement, clinical manifestations, use of inhaled fluticasone, and need for longer and accurate follow-up and to protect against coronavirus disease 2019, he has been temporarily suspended until the final assignment.