Pneumomediastinum occurs as a result of traumatic or iatrogenic causes or in patients with preexisting lung conditions such as interstitial lung disease, asthma, and chronic obstructive pulmonary disease. Spontaneous pneumomedi-astinum (SPM), however, is rarely seen in clinical practice. The authors report the case of a 14-year-old boy who presented to the emergency department with chest discomfort and shortness of breath after a 1600-m run as part of a physical education class. The patient was found to have SPM, was admitted to the pediatric service for monitoring and pain control, and made a full recovery within 24 hours. This case is notable because SPM occurred in the absence of identifable organic causes and as the result of sustained noncontact physical activity. A review of the literature provides background information and highlights pathophysiologic processes of SPM and suggested treatment. Physicians should consider pneu-momediastinum in young patients or runners presenting with chest pain even in the absence of any known inciting event.

We report the case of a 21-year-old active duty U.S. Army soldier with painful and nonresolving priapism following blunt pelvic and lower extremity trauma from military static-line parachute injury during training. The patient's condition was initially managed with corporal aspiration and intracavernosal injections of phenylephrine that provided temporary relief but recurrence soon after. Referral to Urology at the site of the patient's injury yielded a diagnosis of penile hematoma. On subsequent evaluation by Urology on return to the patient's home duty station (over 96 hours after injury, with symptoms persisting), the corpora cavernosa were rigid, the corpus spongiosum was soft, and corporal blood gas drawn by the emergency department consistent with arterial blood. Penile duplex ultrasound revealed an isolated arterial-cavernosal fistula within the proximal left corporal body. The patient underwent percutaneous embolization of the fistula with successful resolution of his condition and return of normal erectile function. We discuss this unique case of high-flow priapism occurring after blunt trauma from military parachute injury and review suggested management in a stepwise fashion. The case is significant in that extensive literature review yields no previously described case of priapism following trauma from military parachute injury.

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triage). The goal of this study is to determine factors associated with variability in the assessment and treatment of SCD patients presenting to the ED with acute pain.Methods: Design: We performed a cross-sectional analysis of SCD patients with pain crisis. Setting: ED of an urban, community university-affiliated teaching hospital. Participants: From 1/1/15 to 12/31/17, all SCD patients presenting to the adult ED with acute pain constant with vaso-occlusive crisis; excluding patients who presented for traumatic injuries or complaints where pain was not part of their reason for visit. Measures: Patient characteristic variables included age, sex, self-reported race, insurance, triage category, reason for visit, presenting pain score and disposition. Differences in pain management process outcomes included the following: 1) time in minutes from arrival to administration of first analgesic, and 2) triage to administration of first analgesic change in pain scores. Analgesic agents used and routes of administration were coded. Descriptive statistics are reported with standard deviations. We compare continuous data using 2-tailed Student's t-test; categorical data were analyzed with the chi-squared test.Results: A total of 218 patients with 896 unique visits were recorded during our study period. The mean age of the population was 33 yrs, 76% female, 92% black, 81% non-Hispanic, and 68% had public insurance or were self-pay.Using regression modeling, patients who met the NHLBI recommended time to first analgesia under 1 hr from time of arrival were 6.2 more likely (95% CI 3.9-9.7) to be determined to be ESI level 2. There were no other statistically significant differences in patient (demographics, reason for visit, presenting pain score) or treatment variables (type and route of administration of analgesic) identified. 119 of the 896 encounters were triaged as ESI level 2. This cohort was more likely to meet the goal of analgesia within 30 minutes of triage (OR 3.8, 95% CI 2.7-5.5). Patients identified as ESI level 2 were not more likely to be admitted (1.2, 95% CI 0.9-1.7).Conclusions: Pain management of SCD patients remains a challenge. Our review reveals wide variability in the quality of care provided based on the NHLBI recommendations. We uncovered a significant opportunity for improvement related to the triage assessment. The association between ESI triage level and time to first analgesia suggests the importance of incorporating the ESI guidelines for triage of SCD patients.