Caffeine overdose resulting in severe rhabdomyolysis and acute renal failure.

Despite the fact that caffeine is the most commonly used stimulant in modern society, cases of caffeine overdose are relatively rare, with fatalities reported from doses of 10 g and higher (Nord J Psychiatry. 2006;60:97-106). Large doses produce symptoms associated with stimulation of the cardiovascular, central nervous, and gastrointestinal symptoms (Associates of the California Poison Control Center, Poisoning and Drug Overdose, pp. 142-143. 5th Ed). We present the first reported case of a man with delayed presentation to the emergency department after ingesting 24 g of caffeine in a suicide attempt who suffered complications of severe rhabdomyolysis and acute renal failure requiring subsequent hemodialysis.

Spontaneous septic arthritis in a patient without trauma, coinfection, or immunosuppression.

Septic arthritis is a rare infection, most often affecting the knee and hip [1]. Infections are often secondary to joint repair or replacement surgery, systemic infection, or intravenous recreational drug use [1,2].Diabetes, rheumatoid arthritis, hepatic dysfunction, and immunosuppression are common risk factors [1,2]. Although septic arthritis can occur spontaneously, such occurrences are rare. We report a case of a previously healthy 54-year-old woman with no known risk factors presenting to a freestanding emergency department with 5 days of shoulder pain.

The impact of two freestanding emergency departments on a tertiary care center.

BACKGROUND: Freestanding emergency departments (FEDs) have become increasingly popular as the need for emergency care continues to grow. OBJECTIVE: To analyze the impact of two FEDs on a local tertiary care center's patient volume and admission rates. METHODS: A retrospective analysis examined monthly volume and admission rates for the main ED and two FEDs located 9.6 and 12 miles away. Main ED census records were divided into three distinct time frames: period A (control) was January 2007 through June 2007. Period B was July 2007 through July 2009 when one FED was open. Period C was August 2009 through June 2010 when both FEDs were open. A two-factor analysis of variance was used to analyze admission rates while adjusting for monthly variation. RESULTS: The mean monthly patient volume for the main ED was 4709 for period A, but dropped significantly (p<0.01) to 4447 for period B, and again dropped significantly (p<0.01) to 4242 during period C. The volume for all facilities increased throughout the study period. A combined monthly volume increase to 5642 occurred in Period B, and increased to 6808 in Period C. The adjusted mean admission rate at the main ED for period A was 0.221, which dropped somewhat, though not significantly (p=0.3505) to 0.213 for period B, and then significantly (p<0.01) to 0.189 for period C. CONCLUSION: Opening two FEDs decreased the volume and admission rates for the main ED and increased the overall ED volume for the health care system.

The Use of Whole Blood in Rural Trauma Leads to Decreased Resource Utilization.

BACKGROUND: Nearly 40% of trauma deaths result from uncontrolled hemorrhage. Most of these deaths occur within 24 hours, highlighting the importance of early resuscitation. Balanced component resuscitation has been shown to improve outcomes in hemorrhagic shock. However, hemostatic properties may then be decreased, leading to inadequate coagulopathy treatment or higher transfusion requirements. Data comparing the efficacy of component vs. whole blood (WB) resuscitation in early trauma is poor, particularly in the rural population. This study investigates WB use and resource utilization at a rural Level 1 trauma center. METHODS: A prospective cohort study with historical controls (HC) was performed using patients over age 17 presenting as the highest priority trauma. Two units of WB were available to patients with signs of hemorrhagic shock, with subsequent transfusions via massive transfusion protocol or thromboelastography guidance. Component utilization, time to hemorrhage control, complications, and transfer times were examined. RESULTS: Forty patients received WB vs. 153 HC. WB patients had lower complication rates (35% vs. 55.6%; P = .02), and a significant reduction in pRBC utilization in the emergency department (0 vs. 2; P < .0001) and throughout admission (2.0 vs. 4.0; P = .0003). All patients had prolonged transport times given the rural setting (1.42 hours HC vs. 2.03 hours WB; P = .002). DISCUSSION: Unlike most urban WB studies, this study occurred in a rural area with extended transportation times, when WB is inaccessible for patients. Despite this delay, WB patients demonstrated lower component utilization and complication rates. Further research is needed to characterize the impact of early WB access.