Acute Generalized Erythrodermic Pustular Psoriasis Associated with Bupropion/Naltrexone (Contrave®).

BACKGROUND: We report a case of erythrodermic pustular psoriasis associated with initiation of bupropion/naltrexone (Contrave®; Orexigen Therapeutics, La Jolla, CA) in a patient with no history of psoriasis. CASE REPORT: A 55-year-old woman was transferred to our tertiary medical center from a community hospital for possible Stevens-Johnson syndrome 3 weeks after initiation of bupropion/naltrexone. The patient was admitted to the burn unit for wound treatment and hydration. She received intravenous cyclosporine during the admission that resulted in acute kidney injury and the therapy was discontinued. The skin biopsy ruled out Stevens-Johnson syndrome and was more consistent with generalized pustular psoriasis. After discharge, the patient followed up with her dermatologist. She was diagnosed with acute generalized and erythrodermic psoriasis and the patient was restarted on cyclosporine 100 mg twice a day. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Few case reports of bupropion-induced generalized pustular psoriasis and erythrodermic psoriasis in patients with a history of psoriasis have been reported. To our knowledge, acute generalized erythrodermic pustular psoriasis associated with bupropion/naltrexone has not been reported in a patient without history of psoriasis. Due to increases in obesity and increases in prescribing of bupropion/naltrexone SR, health care providers should be aware of this possible severe adverse reaction.

Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study.

BACKGROUND: Abuse or unintended overdose (OD) of opiates and heroin may result in prehospital and emergency department (ED) care. Prehospital naloxone use has been suggested as a surrogate marker of community opiate ODs. The study objective was to verify externally whether prehospital naloxone use is a surrogate marker of community opiate ODs by comparing Emergency Medical Services (EMS) naloxone administration records to an independent database of ED visits for opiate and heroin ODs in the same community. METHODS: A retrospective chart review of prehospital and ED data from July 2009 through June 2013 was conducted. Prehospital naloxone administration data obtained from the electronic medical records (EMRs) of a large private EMS provider serving a metropolitan area were considered a surrogate marker for suspected opiate OD. Comparison data were obtained from the regional trauma/psychiatric ED that receives the majority of the OD patients. The ED maintains a de-identified database of narcotic-related visits for surveillance of narcotic use in the metropolitan area. The ED database was queried for ODs associated with opiates or heroin. Cross-correlation analysis was used to test if prehospital naloxone administration was independent of ED visits for opiate/heroin ODs. RESULTS: Naloxone was administered during 1,812 prehospital patient encounters, and 1,294 ED visits for opiate/heroin ODs were identified. The distribution of patients in the prehospital and ED datasets did not differ by gender, but it did differ by race and age. The frequency of naloxone administration by prehospital providers varied directly with the frequency of ED visits for opiate/heroin ODs. A monthly increase of two ED visits for opiate-related ODs was associated with an increase in one prehospital naloxone administration (cross-correlation coefficient [CCF]=0.44; P=.0021). A monthly increase of 100 ED visits for heroin-related ODs was associated with an increase in 94 prehospital naloxone administrations (CCF=0.46; P=.0012). CONCLUSIONS: Frequency of naloxone administration by EMS providers in the prehospital setting varied directly with frequency of opiate/heroin OD-related ED visits. The data correlated both for short-term frequency and longer term trends of use. However, there was a marked difference in demographic data suggesting neither data source alone should be relied upon to determine which populations are at risk within the community.

Classification accuracy of serum Apo A-I and S100B for the diagnosis of mild traumatic brain injury and prediction of abnormal initial head computed tomography scan.

The objective of the current study was to determine the classification accuracy of serum S100B and apolipoprotein (apoA-I) for mild traumatic brain injury (mTBI) and abnormal initial head computed tomography (CT) scan, and to identify ethnic, racial, age, and sex variation in classification accuracy. We performed a prospective, multi-centered study of 787 patients with mTBI who presented to the emergency department within 6 h of injury and 467 controls who presented to the outpatient laboratory for routine blood work. Serum was analyzed for S100B and apoA-I. The outcomes were disease status (mTBI or control) and initial head CT scan. At cutoff values defined by 90% of controls, the specificity for mTBI using S100B (0.899 [95% confidence interval (CI): 0.78-0.92]) was similar to that using apoA-I (0.902 [0.87-0.93]), and the sensitivity using S100B (0.252 [0.22-0.28]) was similar to that using apoA-I (0.249 [0.22-0.28]). The area under the receiver operating characteristic curve (AUC) for the combination of S100B and apoA-I (0.738, 95% CI: 0.71, 0.77), however, was significantly higher than the AUC for S100B alone (0.709, 95% CI: 0.68, 0.74, p=0.001) and higher than the AUC for apoA-I alone (0.645, 95% CI: 0.61, 0.68, p<0.0001). The AUC for prediction of abnormal initial head CT scan using S100B was 0.694 (95%CI: 0.62, 0.77) and not significant for apoA-I. At a S100B cutoff of <0.060 µg/L, the sensitivity for abnormal head CT was 98%, and 22.9% of CT scans could have been avoided. There was significant age and race-related variation in the accuracy of S100B for the diagnosis of mTBI. The combined use of serum S100B and apoA-I maximizes classification accuracy for mTBI, but only S100B is needed to classify abnormal head CT scan. Because of significant subgroup variation in classification accuracy, age and race need to be considered when using S100B to classify subjects for mTBI.

Evaluation of an emergency department educational campaign for recognition of suicidal patients.

INTRODUCTION: To evaluate the impact of a simple emergency department (ED)-based educational intervention designed to assist ED providers in detecting occult suicidal behavior in patients who present with complaints that are not related to behavioral health. METHODS: Staff from 5 ED sites participated in the study. Four ED staff members were exposed to a poster and clinical guide for the recognition and management of suicidal patients. Staff members in 1 ED were not exposed to training material and served as a comparator group. RESULTS: At baseline, only 36% of providers reported that they had sufficient training in how to assess level of suicide risk in patients. Greater than two thirds of providers agreed that additional training would be helpful in assessing the level of patient suicide risk. More than half of respondents who were exposed to the intervention (51.6%) endorsed increased knowledge of suicide risk during the study period, while 41% indicated that the intervention resulted in improved skills in managing suicidal patients. CONCLUSION: This brief, free intervention appeared to have a beneficial impact on providers' perceptions of how well suicidality was recognized and managed in the ED.

Absence of electrocardiographic change after prolonged application of a conducted electrical weapon in physically exhausted adults.

BACKGROUND: Conducted electrical weapons (CEWs) are used by law enforcement for control of subjects by causing neuromuscular incapacitation. There has been scrutiny of CEWs and their potential role in the occasional sudden death of subjects in custody. There is a hypothesized causal relationship due to induced cardiac dysrhythmia. Previous work has not shown dysrhythmia induction in resting humans. However, these devices are not often used on resting individuals in the field. OBJECTIVE: We sought to determine if exposure to a CEW in a physically exhausted human sample population caused detectable change in the 12-lead electrocardiogram (ECG). METHODS: Human volunteers were enrolled. All subjects had a baseline ECG obtained and then underwent an exercise regimen until exhaustion. The volunteers then received a continuous 15-s application from a TASER® X26 CEW (TASER International, Scottsdale, AZ). CEW electrodes were placed on random positions of their anterior thoraces. Electrode positions involved at least a 12-inch spread and always encompassed the normal anatomic position of the heart. An ECG was obtained immediately after CEW exposure. ECGs were interpreted by a blinded cardiologist. RESULTS: At baseline, 24/25 ECGs were normal. One baseline ECG was abnormal due to several monomorphic premature ventricular complexes. After CEW exposure, all 25 ECGs were interpreted as normal. CONCLUSIONS: Prolonged CEW application in an exhausted human sample did not cause a detectable change in their 12-lead ECGs. Theories of CEW-induced dysrhythmia in non-rested humans are not supported by our findings.

Can emergency medicine residents reliably use the internet to answer clinical questions?

INTRODUCTION: The study objective was to determine the accuracy of answers to clinical questions by emergency medicine (EM) residents conducting Internet searches by using Google. Emergency physicians commonly turn to outside resources to answer clinical questions that arise in the emergency department (ED). Internet access in the ED has supplanted textbooks for references because it is perceived as being more up to date. Although Google is the most widely used general Internet search engine, it is not medically oriented and merely provides links to other sources. Users must judge the reliability of the information obtained on the links. We frequently observed EM faculty and residents using Google rather than medicine-specific databases to seek answers to clinical questions. METHODS: Two EM faculties developed a clinically oriented test for residents to take without the use of any outside aid. They were instructed to answer each question only if they were confident enough of their answer to implement it in a patient-care situation. Questions marked as unsure or answered incorrectly were used to construct a second test for each subject. On the second test, they were instructed to use Google as a resource to find links that contained answers. RESULTS: Thirty-three residents participated. The means for the initial test were 32% correct, 28% incorrect, and 40% unsure. On the Google test, the mean for correct answers was 59%; 33% of answers were incorrect and 8% were unsure. CONCLUSION: EM residents' ability to answer clinical questions correctly by using Web sites from Google searches was poor. More concerning was that unsure answers decreased, whereas incorrect answers increased. The Internet appears to have given the residents a false sense of security in their answers. Innovations, such as Internet access in the ED, should be studied carefully before being accepted as reliable tools for teaching clinical decision making.

Sonographic scoring for operating room triage in trauma.

OBJECTIVE: The focused assessment with sonography for trauma (FAST) exam is a routine diagnostic adjunct in the initial assessment of blunt trauma victims but lacks the ability to reliably predict which patients require laparotomy. Physiologic data play a major role in decision making regarding the need for emergent laparotomy versus further diagnostic testing or observation. The need for laparotomy often influences the decision to transfer the patient to a trauma center. We set out to derive a simple scoring system using both ultrasound findings and immediately available physiologic data that would predict which patients require laparotomy. METHODS: We conducted a prospective observational study of victims of blunt trauma who presented to a Level 1 Trauma Center. We collected FAST findings, physiologic data, and lab values. A previously-developed ultrasound scoring system was applied to the FAST findings. Patients were followed to determine if they underwent laparotomy. We used logistic regression analysis to determine which variables correlated with laparotomy and developed a new scoring system. RESULTS: We enrolled a convenience sample of 1,393 patients. A simple scoring system (range 0-6) was developed that included both FAST findings and vital signs (heart rate and blood pressure). Patients with a score of 0 or 1 had a less than 1% chance of requiring laparotomy. CONCLUSION: The combination of FAST findings with vital signs in our scoring system predicted which victims of blunt trauma did not undergo laparotomy. Applying this to trauma patients who present to non-trauma centers could help prevent unnecessary patient transfers. This derivation set must be validated prior to use in patient care.

Physiologic effects of prolonged conducted electrical weapon discharge in ethanol-intoxicated adults.

OBJECTIVES: This study examines the physiologic effects of prolonged conducted electrical weapon (CEW) exposure on alcohol-intoxicated adult subjects. METHODS: Adult volunteers were recruited at a TASER International training conference. All subjects ingested mixed drinks until clinical intoxication or until a minimum breath alcohol level of 0.08 mg/dL was achieved. Blood samples for venous pH, Pco(2), bicarbonate, and lactate were measured in all subjects at baseline, immediately after alcohol ingestion, immediately after exposure to a 15-second TASER X26 discharge (Taser International Inc, Scottsdale, AZ), and 24 hours post-alcohol ingestion. Laboratory values were compared at sampling times using repeated-measure analysis of variance. A focused analysis comparing time points within groups was then performed using paired t tests. RESULTS: Twenty-two subjects were enrolled into the study. There was a decrease in pH and bicarbonate and an increase in lactate after alcohol ingestion. There was a further increase in lactate and drop in pH after CEW exposure. No subject experienced a significant adverse event. All values had returned to baseline levels at 24 hours except lactate, which demonstrated a small but clinically insignificant increase. CONCLUSIONS: Prolonged continuous CEW exposure in the setting of acute alcohol intoxication has no clinically significant effect on subjects in terms of markers of metabolic acidosis. The acidosis seen is consistent with what occurs with ethanol intoxication or moderate exertion.

Scholarly tracks in emergency medicine.

Over the past decade, some residency programs in emergency medicine (EM) have implemented scholarly tracks into their curricula. The goal of the scholarly track is to identify a niche in which each trainee focuses his or her scholarly work during residency. The object of this paper is to discuss the current use, structure, and success of resident scholarly tracks. A working group of residency program leaders who had implemented scholarly tracks into their residency programs collated their approaches, implementation, and early outcomes through a survey disseminated through the Council of Emergency Medicine Residency Directors (CORD) list-serve. At the 2009 CORD Academic Assembly, a session was held and attended by approximately 80 CORD members where the results were disseminated and discussed. The group examined the literature, discussed the successes and challenges faced during implementation and maintenance of the tracks, and developed a list of recommendations for successful incorporation of the scholarly track structure into a residency program. Our information comes from the experience at eight training programs (five 3-year and three 4-year programs), ranging from 8 to 14 residents per year. Two programs have been working with academic tracks for 8 years. Recommendations included creating clear goals and objectives for each track, matching track topics with faculty expertise, protecting time for both faculty and residents, and providing adequate mentorship for the residents. In summary, scholarly tracks encourage the trainee to develop an academic or clinical niche within EM during residency training. The benefits include increased overall resident satisfaction, increased success at obtaining faculty and fellowship positions after residency, and increased production of scholarly work. We believe that this model will also encourage increased numbers of trainees to choose careers in academic medicine.

Prolonged TASER use on exhausted humans does not worsen markers of acidosis.

OBJECTIVE: There are safety concerns about TASER conducted electrical weapon (CEW) use on humans, and there have been media reports of adverse human outcomes after CEW exposure. Conducted electrical weapons are often used on physically exhausted subjects. A single CEW application of a CEW is generally accepted to be 5 seconds of exposure. Some exposures in reality involve more than 5 seconds. We sought to determine if a prolonged (15 seconds) CEW exposure on exhausted humans caused acidosis, hyperkalemia, serum lactate change, or troponin change. METHODS: This was a prospective study of generally healthy human volunteers. Medical histories and baseline serum values were obtained, and several of the volunteers did have acute or chronic medical problems. Subjects underwent an exercise protocol until subjective exhaustion. Exhaustion was defined by the volunteer no longer being able to perform the exercise at a given pace. Blood was drawn immediately (defined as within 20 seconds) after exercise and was immediately followed by a 15-second CEW exposure. Blood was drawn immediately after exposure and again at 16 to 24 hours after exposure. Blood was analyzed for pH, pco(2), potassium, lactate, and troponin. Data were compared using Wilcoxon signed rank tests. RESULTS: There were 38 subjects enrolled with an average age of 39 years. The following health conditions were reported among the volunteers: hypertension (2), gastritis/reflux (2), active respiratory tract infections (3), asthma (2), chronic muscular pain conditions (4), pituitary adenoma (1) and glaucoma (1). Sixteen volunteers reported use of prescription medication at the time of their participation. The median initial pH of 7.38 (interquartile range [IQR], 7.35-7.40) decreased to 7.23 (IQR, 7.19-7.31) immediately after exercise. Immediately after exposure, median pH was 7.22 (IQR, 7.18-7.25). It was 7.39 (IQR, 7.37-7.43) at 24 hours. The pCO2 increased from 46.3 (IQR, 43.0-54.5) to 57.4 (IQR, 49.9-67.7) immediately after exercise, decreased to 51.3 (IQR, 44.4-65.0) immediately after exposure, and was 46.3 (IQR, 42.7-51.7) at 24 hours. Lactate increased from a median of 1.65 (IQR, 1.14-2.55) to 8.39 (IQR, 6.98-11.66) immediately after exercise, increased to 9.85 (IQR, 7.70-12.87) immediately after exposure, and was 1.02 (IQR, 0.91-1.57) at 24 hours. Serum potassium increased from 3.9 (IQR, 3.8-4.4) to 4.2 (IQR, 4.0-4.9) immediately after exercise, decreased to 3.8 (IQR, 3.7-4.4) immediately after exposure, and was 4.1 (IQR, 3.9-4.6) at 24 hours. No troponin elevations were detected. CONCLUSION: Prolonged CEW application on exhausted humans was not associated with worsening change in pH or troponin. Decreases in pCO2 and potassium and a small increase in lactate were found. Worsening acidosis theories due to CEW use in this population are not supported by these data.

A multicenter comparison of tap water versus sterile saline for wound irrigation.

OBJECTIVES: To compare wound infection rates for irrigation with tap water versus sterile saline before closure of wounds in the emergency department. METHODS: The study was a multicenter, prospective, randomized trial conducted at two Level 1 urban hospitals and a suburban community hospital. Subjects were a convenience sample of adults presenting with acute simple lacerations requiring sutures or staples. Subjects were randomized to irrigation in a sink with tap water or with normal saline using a sterile syringe. Wounds were closed in the standard fashion. Subjects were asked to return to the emergency department for suture removal. Those who did not return were contacted by telephone. Wounds were considered infected if there was early removal of sutures or staples, if there was irrigation and drainage of the wound, or if the subject needed to be placed on antibiotics. Equivalence of the groups was met if there was less than a doubling of the infection rate. RESULTS: A total of 715 subjects were enrolled in the study. Follow-up data were obtained on 634 (88%) of enrolled subjects. Twelve (4%) of the 300 subjects in the tap water group had wound infections, compared with 11 (3.3%) of the 334 subjects in the saline group. The relative risk was 1.21 (95% confidence interval = 0.5 to 2.7). CONCLUSIONS: Equivalent rates of wound infection were found using either irrigant. The results of this multicenter trial evaluating tap water as an irrigant agree with those from previous single institution trials.

Application of clinical criteria for ordering radiographs to detect cervical spine fractures.

OBJECTIVE: The aim of the study was to determine if spinal-immobilized patients met clinical criteria for x-rays and which clinical criteria were associated with cervical fractures. METHODS: This was a prospective, observational analysis of clinical findings and radiograph results for patients transported to the emergency department in spinal immobilization by emergency medical services. The presence of altered mentation, distracting injury, cervical spine tenderness, neck pain, neurologic deficit, and palpable deformity was recorded for each subject. RESULTS: Of the 2044 subjects enrolled in the study, 1367 subjects received radiographs and 50 had cervical spine fractures. Sixty percent of subjects met some clinical criteria for radiograph ordering. Cervical spine tenderness and neurologic deficit were the only clinical criteria statistically associated with fractures. All subjects with fractures met 1 or more of the clinical criteria for radiographs. CONCLUSION: Cervical spine radiographs were ordered for a significant number of patients who did not meet the clinical criteria. However, omission of any one of the criterion other than palpable deformity would have potentially resulted in a missed fracture. Strictly following the criteria would have significantly reduced the number of cervical spine radiographs taken.

The time first-response fire fighters have to initiate care in a midsize city.

The objective of this study was to determine whether simultaneously dispatched first-response firefighters (fire) arrive before transporting EMS providers (ambulance) and the amount of time fire has on scene to initiate care. Fire and ambulance dispatch records were obtained for all 9-1-1 responses from four 1-month intervals. Only incidents to which both agencies had been simultaneously dispatched were included. Response time for each agency was determined by subtracting the time of dispatch from the time of arrival. The difference between fire and ambulance response time was the time fire had to initiate care. Both agencies were simultaneously dispatched to 4752 incidents. Average response time for all incidents was 4.0 +/- 2.6 min for fire and 5.3 +/- 2.0 min for ambulance. Fire had 1.3 +/- 3.2 min on average to initiate care. Fire arrived before ambulance for 69% (3262) of requests and for these calls had 2.8 +/- 1.7 min on average to initiate care. Utilization of densely staged first-response fire apparatus in a midsize city may be appropriate because firefighters frequently arrive before ambulances and may have adequate time to initiate lifesaving interventions.

Paramedic use of the endotracheal tube introducer in a difficult airway model.

OBJECTIVES: To determine whether advanced life support (ALS)-level prehospital providers can be taught to effectively use the Flex-Guide (FG) Endotracheal Tube (ETT) introducer in a difficult airway model by comparing success of styleted ETT intubation with Flex-Guide-assisted intubation. METHODS: Intermediate and advanced providers, who brought patients to a Level 1 emergency department, were given a handout and viewed an instructional video describing the bougie and its use. A difficult airway was simulated using the CPR 5000 model mannequin from Medical Plastics Laboratory, Inc. The tongue was inflated to a pressure of 180 mm Hg to partially obscure the view of the airway and a cervical collar was placed to limit flexion and extension. Participants were then asked to intubate the mannequin using both the ETT with a stylet and the bougie-assisted method. Whether the providers used the FG or stylet method first was randomized. Success or failure was recorded and the McNemar test was used to evaluate the paired nonparametric data. RESULTS: A total of 96 providers (66% advanced, 34% intermediate) were enrolled, 69 successfully intubated using the FG, while 64 successfully intubated with the stylet. Comparing successful bougie intubations with successful stylet intubations using the McNemar test, no significant difference was found between the groups (p = 0.486). CONCLUSION: Prehospital care providers were as successful intubating a difficult airway model using the newly learned bougie technique as they were using the more familiar styleted ETT technique.

Domestic violence screening and referral can be effective.

STUDY OBJECTIVE: We provide a targeted intervention in the emergency department for intimate partner violence (IPV) victims and to facilitate follow-up care from a professional case manager. METHODS: This observational case study was conducted in an urban ED from July 1, 1997, through December 31, 1999. The targeted population consisted of all English-speaking women between the ages of 18 and 65 years presenting 24 hours a day, 7 days a week. There were 3 components to the study. The first consisted of an effort to improve the screening for IPV of female patients seen in the ED. The primary outcome for this component was the correlation of increased screening rates with increased violence detection. Universal screening of all women for IPV regardless of their chief complaint was encouraged through an IPV script and a new reporting area on the nursing note. The second component was an on-site IPV advocacy intervention. Once IPV was identified by means of screening or self-disclosure, the nurse notified a volunteer advocate from a local human service agency, who came to the ED within 30 minutes, conducted a crisis intervention, and encouraged the patient to follow-up with the case manager. The outcomes were patient cooperation with the ED intervention and subsequent follow-up with the community-based agency. The third phase was telephone-based counseling by an IPV case manager to help the client reduce her exposure to additional violence. The outcome was the client's self-report of a life free of violence. RESULTS: Of the 528 women identified as IPV victims, 475 (84%) agreed to speak to the advocate, and 258 (54% of those seen by the advocate) accepted case management follow-up. After the case management process, lasting 3 to 6 weeks, 127 women reported that they no longer believed they were at risk for violence from their abuser. CONCLUSION: Through a coordinated effort by the medical staff and the volunteer advocates, 258 of 528 IPV victims seen in the ED received ongoing community-based services to address their experience of IPV.