Fatal fentanyl-associated cerebellitis in a young man.

A 22-year-old man was brought in by EMS for coma and respiratory failure. The initial diagnosis was an opioid overdose but the patient did not respond to naloxone. A head CT revealed findings consistent with cerebellitis. The patient developed obstructive hydrocephalus and herniation. Despite neurosurgical and ICU care, the patient did not recover. Cerebellitis is a seldom-discussed complication of opioid use which may become more common as the opioid and fentanyl epidemic evolves.

Small bowel obstruction caused by massive fibroids.

A 44-year-old woman presented to the Emergency Department with abdominal pain. She had a history of fibroids and no prior surgeries. Ultrasonography and CT imaging revealed a small bowel obstruction and massive uterine fibroids. The patient required laparotomy to relieve the intestinal obstruction after conservative therapy failed. Massive uterine fibroids is a rare cause of small bowel obstruction which requires the vigilance of Emergency Medicine physicians.

Treatment of caffeine toxicity with metoprolol.

A 27-year-old man presented with an intentional overdose of concentrated caffeine powder that he bought over the internet. The patient received benzodiazepines and ondansetron for symptomatic treatment when he arrived in the Emergency Department (ED). Subsequently, he developed recurrent supraventricular tachycardia in the ED. The SVT was successfully treated with metoprolol. The patient's caffeine level was >90 mg/L. This is the first known report of treatment of caffeine-induced supraventricular tachycardia with metoprolol.

Safety and efficacy of intravenous combination sedatives in the ED.

OBJECTIVE: The objective of the study is to determine the safety of intravenously administered combination sedatives in the emergency department (ED). METHODS: This was a retrospective study of alcohol-intoxicated patients in the ED. We examined the incidence of adverse events in agitated patients who received combination sedatives intravenously and compared the efficacy of combination sedatives and single-agent sedatives. RESULTS: Of 1300 patient visits, there was a single adverse event, a dystonic reaction, in the combination sedative group, for an adverse event rate of less than 1%. Patients who received combination sedatives were less likely to require a second dose of sedative medication than patients who received a single-agent sedative (21% vs 44%). CONCLUSIONS: Combination sedatives appear to be safe when administered intravenously in the ED. Combination sedatives may be more effective than single-agent sedatives in agitated alcohol-intoxicated patients.

A novel use of 2-octyl-cyanoacrylate: controlling post-hemodialysis site hemorrhage.

BACKGROUND: A common complication of hemodialysis is bleeding from the dialysis site. DISCUSSION: To demonstrate the use of 2-octyl-cyanoacrylate in controlling venous bleeding associated with hemodialysis access. CONCLUSION: 2-octyl-cyanoacrylate is effective in stopping venous bleeding from hemodialysis sites.

Laryngopyocoele: an unusual cause of a sore throat.

Laryngopyocoeles are rare entities that present as airway obstruction or as neck masses. We present a unique case of a laryngopyocoele in a young patient with a sore throat. A 22-year-old man presented to the emergency department with a sore throat of 1-week duration. He had no other upper respiratory symptoms. His vitals were as follows: heart rate, 91; respiratory rate, 16; blood pressure, 119/60; and temperature, 36.8 (98.3°F). There were no signs of respiratory distress or airway involvement. The findings from his physical examination were normal except for tenderness on palpation of his larynx. A soft tissue neck x-ray was suggestive of epiglottitis. Fiberoptic laryngoscopy revealed a nonerythematous, edematous epiglottis and edema of the left arytenoid and aryepiglottic fold with slight bulging into the airway. A contrast neck computed tomography revealed a nonenhancing fluid collection at the level of the left arytenoid cartilage. The diagnosis of a laryngopyocoele was made. The patient was admitted to the intensive care unit for airway monitoring and treated conservatively with intravenous antibiotics. The collection did not resolve by day 4, and the patient was taken to the operating room for incision and drainage of the laryngopyocoele. The patient made an uneventful recovery.

Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

OBJECTIVE: Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. Our objective was to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs. METHODS: This was a prospective study in healthy adult volunteers. Subjects simultaneously received 500 mL of normal saline via an 18-g IV in one arm and 500 mL of normal saline via two 20-g IVs in the other arm. We measured the rates of fluid administration. Paired Student's t test was used for comparison of the 2 arms of the study. We estimated that 18 trials were needed in sample size analysis. RESULTS: Eighteen trials were completed. The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min (95% CI, 1.3-10; P = .026). CONCLUSION: In healthy volunteers, administration of intravenous fluids through two 20-g IVs is faster than a single 18-g IV, although both approaches are markedly slower than the manufacturer's estimates.

Resident experience of abuse and harassment in emergency medicine: ten years later.

BACKGROUND: In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. OBJECTIVES: To determine the prevalence of abuse and harassment in a sample of EM residencies. METHODS: We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. RESULTS: There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. CONCLUSION: Abuse and harassment during EM residency continues to be commonplace and is underreported.

Exercise tolerance as a predictor of acute myocardial infarction in emergency department patients with potential acute coronary syndromes.

There is mounting evidence that exercise tolerance is an important predictor of heart disease. Our objective was to determine if decreased exercise tolerance, as estimated by physicians, may be useful in stratifying risk in Emergency Department (ED) patients with potential acute coronary syndromes. We conducted a prospective cohort study on a convenience sample of ED patients at an urban teaching hospital. Patients with chest pain, dyspnea, syncope, or epigastric pain who were evaluated for acute coronary syndromes were included. Clinical and laboratory data were recorded. In addition, the Emergency Physicians were asked to estimate the exercise tolerance of the patient as excellent, good, bad, or very poor. The primary outcome of the study was myocardial infarction (MI) or death in patients stratified by physician-perceived exercise tolerance (excellent or good vs. bad or very poor). There were 166 patients enrolled in the study. Nine patients (5%) had an MI; there were no deaths. Physicians reported exercise tolerance as excellent in 33 patients, good in 63, bad in 50, and very poor in 20. The unadjusted risk of MI was significantly elevated in patients with physician-perceived decreased exercise tolerance (relative risk = 4.8, 95% confidence interval 1.03-22). After adjustment for age, sex, and major cardiovascular risk factors, decreased exercise tolerance remained a significant predictor of MI (adjusted odds ratio = 7.3, 95% confidence interval 1.2-46). Exercise tolerance, as estimated by clinical impression, may be an important predictor of complications in ED patients presenting with potential acute coronary syndromes.

Vitamin deficiencies in acutely intoxicated patients in the ED.

OBJECTIVE: Physicians often administer intravenous multivitamins to intoxicated patients in the emergency department (ED); however, this practice is not supported by evidence from any prior study. We determined the prevalences of vitamin deficiencies in patients presenting to our ED with alcohol intoxication. METHODS: This study was a prospective, cross-section, observational study of a convenience sample of ED patients presenting with acute alcohol intoxication. Patients were tested for B(12), folate, and thiamine levels as add-ons to their blood samples. RESULTS: Seventy-seven patients were included in the final analysis. The mean age was 46 years, and 19% were female; the mean blood alcohol level was 280 mg/dL. Of 75 patients, no one (0%) had low B(12) or folate levels (95% confidence interval, 0-0.05); 6 (15%) of 39 patients had low thiamine levels (95% confidence interval, 0.06-0.31). Of these 6 patients, none exhibited clinical signs of thiamine deficiency. CONCLUSIONS: In our ED, patients with acute ethanol intoxication do not have B(12) or folate deficiencies. A significant minority (15%) of patients have thiamine deficiency; its clinical significance is unclear. Widespread administration of multivitamins is unwarranted by these findings, but thiamine may be considered.

Gender trends in emergency medicine publications.

BACKGROUND: In recent years, the number of women entering the field of emergency medicine (EM) has increased. OBJECTIVES: To determine if authorship in EM publications has increased in parallel with this trend. METHODS: The gender of first and last authors of EM articles in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine were examined. The authors reviewed articles from 1985, 1995, and 2005 for American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine and from 1999 and 2005 for Academic Emergency Medicine. The primary outcomes were the proportions of female authors. RESULTS: A total of 2,016 articles were reviewed. Overall, 18% of first and last authors were female. Respectively, for 1985, 1995, 1999, and 2005, the proportions of female first authors were 9%, 15%, 19%, and 24%; the proportions of female last authors were 9%, 18%, 19%, and 22%. The trend of increases in female authorship was statistically significant. CONCLUSIONS: Although female authorship remains a minority in EM publications, it has increased significantly in parallel with increases in female participation in EM.

Discrepancies in interpretation of ED body computed tomographic scans by radiology residents.

OBJECTIVE: In academic institutions, radiology residents are often relied on for providing preliminary reports of imaging studies done in the ED. We examined the prevalence of discrepant interpretations of body computed tomographic (CT) scans in our institution. METHODS: We conducted a retrospective study on a consecutive series of body CT scans at an urban ED. We compared the preliminary interpretation by radiology residents with the final interpretation by radiology attending physicians. An interpretation was characterized as having no discrepancy, minor discrepancy, or major discrepancy. A major discrepancy was defined as a discrepancy that resulted in a change in diagnosis, treatment, or disposition. RESULTS: Two hundred three body CT scans were identified during the study period. Of these CT scans, 20 had major discrepancies (10%), 40 had minor discrepancies (20%), and 143 had no discrepancy (70%). Major discrepancies included missed appendicitis, normal appendix, missed bowel obstruction, and missed colon cancer. Computed tomographic scans with abnormal findings were more likely to contain major discrepancies (relative risk = 6.0; 95% confidence interval = 1.8-2.0). CONCLUSION: Discrepancies between radiology residents and radiology attending physicians were common at our institution. Emergency department physicians should exercise caution when relying on residents' interpretation of body CT scans.