Unmet clinical laboratory need in patients hospitalized for acute poisoning from long-acting anticoagulant rodenticides.

The importance of real-time, quantitative toxicology data available for physicians treating poisoned patients was illustrated during the 2018 outbreak in Illinois of severe coagulopathy caused by inhaling illicit synthetic cannabinoids products contaminated with commercially-available brodifacoum, difenacoum, and bromadiolone, three potent, long-acting anticoagulant rodenticides (LAARs). Identification and quantification of these life-threatening toxins in blood samples of hospitalized patients required toxicology testing with liquid chromatography-tandem mass spectrometry (LC-MS/MS) that was not available in clinical laboratories of hospitals at the time of the outbreak. This highly-sensitive, quantitative assay can provide critical information to guide patient care during and after hospitalization, including identification of offending LAARs, estimates of the ingested dose, and dosage and discontinuation of oral vitamin K1 therapy after hospital discharge once plasma LAARs concentrations decreased to a safe level (<10 ng/mL). Accordingly, we propose an action plan to enable treating physicians to quantify plasma concentrations of several LAARs simultaneously in poisoned patients. It involves rapid (<15 min), sensitive, and validated LC-MS/MS methods developed, tested and validated in our laboratory. This will allow treating physicians to request quantitative plasma LAARs testing, report test results in the patient's hospital discharge summary, and recommend regular monitoring of plasma LAARs concentrations in the outpatient setting.

Severe Vitamin K-dependent Coagulopathy from Rodenticide-contaminated Synthetic Cannabinoids: Emergency Department Presentations.

INTRODUCTION: Synthetic cannabinoids are a rapidly expanding subset of designer drugs widely available in the United States since 2008. In Illinois during the spring of 2018, over 160 documented cases of bleeding and prolonged coagulopathy occurred secondary to contaminated synthetic cannabinoids. METHODS: We conducted a retrospective cohort study consisting of 38 patients to describe the initial emergency department (ED) presentation, diagnosis, and treatment. RESULTS: Through serum testing we found that three long-acting anticoagulant rodenticides (LAAR) were detected in patients who had inhaled these tainted products: brodifacoum, difenacoum, and bromodialone. DISCUSSION: This study encompasses the largest ED presentation of LAAR poisoning via the inhalational route known to date. CONCLUSION: The emergency physician should be aware of the potential for tainted coingestants as the cause of undifferentiated coagulopathy.

Recommendations for the Emergency Department Prevention of Sport-Related Concussion.

Sport-related concussion refers to the subset of concussive injuries occurring during sport activities. Similar to concussion from nonsport mechanisms, sport-related concussion is associated with significant morbidity, including migrainous headaches, disruption in normal daily activities, and long-term depression and cognitive deficits. Unlike nonsport concussions, sport-related concussion may be uniquely amenable to prevention efforts to mitigate these problems. The emergency department (ED) visit for sport-related concussion represents an opportunity to reduce morbidity by timely diagnosis and management using best practices, and through education and counseling to prevent a subsequent sport-related concussion. This article provides recommendations to reduce sport-related concussion disability through primary, secondary, and tertiary preventive strategies enacted during the ED visit. Although many recommendations have a solid evidence base, several research gaps remain. The overarching goal of improving sport-related concussion outcome through enactment of ED-based prevention strategies needs to be explicitly studied.

Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids.

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.

The effect of a community crash reenactment program on teen alcohol awareness and behavior.

Background: Motor vehicle crashes (MVCs) are the leading cause of death in US teens, encompassing greater than one in three deaths. Mock crash reenactments have been used to promote awareness in communities about the effects of drinking and driving.  The majority of these programs are for alcohol injury prevention, target high school students, and often involve a scenario of a student driving while under the influence (DUI) and sustaining a fatal car crash. Objective: The purpose of this study is to evaluate the effectiveness of a regional mock crash reenactment upon the students' drinking and driving knowledge and behaviors. Methods: An observational pre-post study was conducted.  The survey had seven five-point Likert-scale questions (1 being strongly disagree and 5 strongly agree) measuring outcomes. Students were surveyed before and after the crash reenactment concerning their knowledge and attitudes related to drinking and driving. The survey also included questions that queried participant's age, gender, alcohol consumption history, and seatbelt usage. Results: The final study population included 947 pre-surveys and 840 post-surveys.  Students demonstrated no significant increase in knowledge-based drinking and driving questions.  However, after the reenactment program, students were 1.39 times less likely to report drinking and driving in the future or that they would get into a car with someone who would drive drunk. Students were 1.7 times more likely to report thinking about the risks associated with drinking and driving after participating in the program. Conclusion: After viewing a mock crash reenactment, students reported they were less likely to drink and drive in the future or get into a car with someone who would drive drunk, and were more likely often think the risks associated with drinking and driving.

Child Passenger Restraint System Misuse in Rural Versus Urban Children: A Multisite Case-Control Study.

OBJECTIVES: Motor vehicle crashes are the leading cause of childhood fatality, making use of properly installed child passenger restraint system (CRS) a public health priority. Motor vehicle crashes in rural environments are associated with increased injuries and fatalities, and overall CRS use tends to be lower compared with urban populations. However, it remains unclear if proper installation of car seats is lower in a rural population compared with a similar matched urban population. METHODS: A multisite (Alabama, Arkansas, Illinois), observational, case-control study was performed using data from community child passenger safety checkup events in rural (economically and population-controlled) and urban locations. Data were matched to the primary child assessed in a vehicle, and stratified by age, site, and year with urban unscheduled CRS check data. All CRS checks were performed using nationally certified CRS technicians who used the best practice standards of the American Academy of Pediatrics and collected subject demographics, car seat misuse patterns, and interventions using identical definitions. RESULTS: Four hundred eighty-four CRS checks (242 rural and 242 urban) involving 603 total children from 3 states (Alabama, 43 [7%]; Arkansas, 442 [73%]; Illinois, 118 [20%]) were examined; of which, 86% had at least 1 documented CRS misuse. Child passenger restraint system misuse was more common in rural than urban locations (90.5% vs 82.6%; P = 0.01). Child passenger restraint system misuse was more common in rural children aged 4 to 8 years (90.3% vs 80.6%; P = 0.02). CONCLUSIONS: In this multisite study, rural location was associated with higher CRS misuse. Child passenger restraint system education and resources that target rural populations specifically appear to be justified.

Intubation Performance of Advanced Airway Devices in a Helicopter Emergency Medical Service Setting.

OBJECTIVE: This study attempts to determine if newer indirect laryngoscopes or intubating devices are superior to a standard laryngoscope for intubation success among helicopter emergency medical service (HEMS) personnel. METHODS: Flight nurses and paramedics intubated standardized mannequins with a normal airway, a trauma airway, and a difficult airway using a standard laryngoscope, a gum elastic bougie, the Airtraq laryngoscope (King System Corp, Noblesville, IN), the Glidescope Ranger laryngoscope (Verathon Inc, Bothell, WA), and the S.A.L.T. device (Microtek Medical, Inc, Lehmberg, IN) in grounded helicopters wearing helmets and flight gear. Participant demographics, time to glottic view, the modified Cormack-Lehane score, total intubation time, number of attempts, and overall successful intubation were recorded for each type of airway. RESULTS: Two-hundred thirty-six subjects were initially enrolled across 107 bases in 15 states, and 177 completed the study. First-attempt success rates did not vary by device for the normal airway (P = .203), but the Airtraq laryngoscope and the S.A.L.T. device were highest in the difficult airway (82.0% and 85.0%, respectively; P < .0001). The time to first-attempt success in the difficult airway was lowest for the S.A.L.T. device and the Airtraq laryngoscope (mean = 9.72 seconds and 19.70 seconds, respectively; P < .0001). CONCLUSION: Using HEMS providers, the Airtraq laryngoscope and the S.A.L.T. device showed the fastest and highest intubation success on the first attempt in difficult simulated HEMS airway scenarios.

Pediatric Extracorporeal Membrane Oxygenation: An Introduction for Emergency Medicine Physicians.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) therapy has supported critically ill pediatric patients in the intensive care unit setting with cardiac and respiratory failure. This therapy is beginning to transition to the emergency department setting. OBJECTIVE OF REVIEW: This article describes the fundamentals of ECMO and familiarizes the emergency medicine physician with its use in critically ill pediatric patients. DISCUSSION: ECMO can be utilized as either venoarterial (VA) or venovenous (VV), to support oxygenation and perfusion in respiratory failure, sepsis, cardiac arrest, and environmental hypothermia.

Death before disco: the effectiveness of a musical metronome in layperson cardiopulmonary resuscitation training.

BACKGROUND: A novel musical memory aid has been proposed for aiding laypersons in complying with the American Heart Association (AHA) cardiopulmonary resuscitation (CPR) guidelines of 100 compressions per minute (cpm). OBJECTIVE: This study tested usefulness of such a memory aid to improve layperson long-term compliance with CPR compression rate guidelines. METHODS: A prospective randomized controlled trial was conducted using CPR-untrained laypersons. Subjects received either a standard CPR educational experience (AHA Heartsaver® CPR class) or an experimental CPR educational experience (AHA Heartsaver® CPR class augmented with a musical metronome). Experimental group subjects were taught to perform compressions to the cadence of a pop music song (The Bee Gees "Stayin' Alive"; Saturday Night Fever, The Original Movie Soundtrack; Polygram International Music, 1977) with a tempo of 100 beats/min. Compression rates, depth of compressions, and correct compressions were measured initially and upon retesting ≥6 weeks post-training. RESULTS: Control subjects had a higher mean compression rate both immediately (121 [standard deviation {SD} = 21] vs. 109 [SD = 15] cpm; 95% confidence interval [CI] of mean difference 4-19; p = 0.002) and at follow-up (120 [SD = 20] vs. 111 [SD = 13] cpm; 95% CI of mean difference 2-16; p = 0.014). Compression rates stratified to 100-120 cpm demonstrated no difference between groups initially (39% vs. 48%; p = 0.382), but more experimental subjects maintained these rates at follow-up (43% vs. 74%; p = 0.003). CONCLUSIONS: Subjects trained to use a musical metronome more often maintained a compression rate of 100-120 cpm at ≥6-week follow-up, suggesting the memory aid may improve long-term guideline adherence.

Promoting use of booster seats in rural areas through community sports programs.

BACKGROUND: Booster seats reduce mortality and morbidity for young children in car crashes, but use is low, particularly in rural areas. This study targeted rural communities in 4 states using a community sports-based approach. OBJECTIVE: The Strike Out Child Passenger Injury (Strike Out) intervention incorporated education about booster seat use in children ages 4-7 years within instructional baseball programs. We tested the effectiveness of Strike Out in increasing correct restraint use among participating children. METHODS: Twenty communities with similar demographics from 4 states participated in a nonrandomized, controlled trial. Surveys of restraint use were conducted before and after baseball season. Intervention communities received tailored education and parents had direct consultation on booster seat use. Control communities received only brochures. RESULTS: One thousand fourteen preintervention observation surveys for children ages 4-7 years (Intervention Group [I]: N = 511, Control [C]: N = 503) and 761 postintervention surveys (I: N = 409, C: N = 352) were obtained. For 3 of 4 states, the intervention resulted in increases in recommended child restraint use (Alabama +15.5%, Arkansas +16.1%, Illinois +11.0%). Communities in 1 state (Indiana) did not have a positive response (-9.2%). Overall, unadjusted restraint use increased 10.2% in intervention and 1.7% in control communities (P = .02). After adjustment for each state in the study, booster seat use was increased in intervention communities (Cochran-Mantel-Haenszel odds ratio 1.56, 95% confidence interval [1.16-2.10]). CONCLUSIONS: A tailored intervention using baseball programs increased appropriate restraint use among targeted rural children overall and in 3 of 4 states studied. Such interventions hold promise for expansion into other sports and populations.

Evaluation of a standardized all-terrain vehicle safety education intervention for youth in rural Central Illinois.

BACKGROUND: Although research investigating all-terrain vehicle (ATV) riders and ATV injury patterns has led to support for legislative and educational efforts to decrease injuries in users younger than 16 years, there is little published data regarding the utility of ATV safety education programs. This study investigates the effectiveness of a standardized adolescent ATV safety program in changing the safety knowledge and safe ATV riding practices reported by rural Central Illinois youths. METHODS: A convenience sample of 260 rural Central Illinois middle and high school students received an ATV safety presentation with both didactic and interactive features during the 2009-2010 school year. Preintervention and postintervention surveys were distributed and collected by teachers. Survey questions consisted of multiple-choice questions pertaining to demographics, ATV safety knowledge, and ATV riding practices. More than 200 surveys were collected prior to the intervention and 165 surveys were collected 12 to 24 weeks after the intervention. Percentages are reported, with differences in nominal variables tested by χ(2) test and interval variables by t test. RESULTS: Following the intervention, there was a significant increase in the correct response rate for ATV safety knowledge questions (45.2% vs 56.2%, P < .001). For adolescents who reported riding ATVs, both safety gear use (11.8% to 21.2%, P = .05) and helmet use (25.4% to 29.0%, P = .56) increased; changes were not significant. Adolescent ATV riders reporting 2 or more accidents showed a slight nonsignificant decrease (25.2% vs 23.4%, P = .77) between the time of the pretest and posttest. CONCLUSION: This safety program was effective at increasing ATV safety knowledge but demonstrates limited effect on safe riding practices.

Effectiveness of a pediatric verbal lead exposure screening protocol in emergency department patients.

PURPOSE: The population demographics found in many urban emergency departments (EDs) often mirrors those of children at risk for elevated serum lead levels. We evaluated the effectiveness of a verbal lead screening program for screening high-risk children presenting to the ED. METHODS: A prospective observational cohort study was conducted of children aged 9 months to 6 years, living in 2 target counties and presenting to an urban, academic, Midwestern ED. Those with a prior lead level, enrolled in a program requiring lead testing, or with an unstable medical condition were excluded. A 6-question validated verbal survey was administered to all parents of eligible children, and the results recorded in the patient's electronic medical record. Children who screened positive were referred to their local health department for blood lead testing. Health department records were reviewed for follow-up visits and blood lead levels. RESULTS: During the study period, 3513 children were eligible (mean age, 2.6 years; 53.3% male), with 815 patients screened and 209 (25.6%) screening positive. Most positively screened patients (71.8%) documented only 1 affirmative question, most often indicating they lived in a home built before 1978. Of those children who screened positive, 14.8% (31/209) had a blood lead level performed within 6 months. Of those tested, 4 children had an elevated lead level (>10 µg/dL). CONCLUSIONS: Use of an ED verbal lead exposure screening tool identified children requiring additional follow-up testing. However, health department-referred children had poor follow-up, and few children were ultimately documented with elevated lead levels.

Effectiveness of a Drill-assisted Intraosseous Catheter versus Manual Intraosseous Catheter by Resident Physicians in a Swine Model.

INTRODUCTION: Our objective was to compare the effectiveness, speed, and complication rate of the traditional manually placed intraosseous (IO) catheter to a mechanical drill-assisted IO catheter by emergency medicine (EM) resident physicians in a training environment. METHODS: Twenty-one EM residents participated in a randomized prospective crossover experiment placing 2 intraosseous needles (Cook® Intraosseous Needle, Cook Medical, Bloomington, IN; and EZ-IO® Infusion System, Vidacare, San Antonio, TX). IO needles were placed in anesthetized mixed breed swine (mass range: 25 kg to 27.2 kg). The order of IO placement and puncture location (proximal tibia or distal femur) were randomly assigned. IO placement time was recorded from skin puncture until the operator felt they had achieved successful placement. We used 3 verification criteria: aspiration of marrow blood, easy infusion of 10 mL saline mixed with methylene blue, and lack of stained soft tissue extravasation. Successful placement was defined as meeting 2 out of the 3 predetermined criteria. We surveyed participants regarding previous IO experience, device preferences, and comfort levels using multiple choice, Likert scale, and visual analog scale (VAS) questions. IO completion times, VAS, and mean Likert scales were compared using Student's t-test and success rates were compared using Fisher's exact test with p<0.05 considered significant. RESULTS: Drill-assisted IO needle placement was faster than manually placed IO needle placement (3.66 versus 33.57 seconds; p=0.01). Success rates were 100% with the drill-assisted IO needle and 76.2% with the manual IO needle (p=0.04). The most common complication of the manual IO insertion was a bent needle (33.3% of attempts). Participants surveyed preferred the drill-assisted IO insertion more than the manual IO insertion (p<0.0001) and felt the drill-assisted IO was easier to place (p<0.0001). CONCLUSION: In an experimental swine model, drill-assisted IO needle placement was faster and had less failures than manual IO needle placement by inexperienced resident physicians. EM resident physician participants preferred the drill-assisted IO needle.

Populations at risk: conservation genetics of kangaroo mice (Microdipodops) of the Great Basin Desert.

The Great Basin Desert of western North America has experienced frequent habitat alterations due to a complex biogeographic history and recent anthropogenic impacts, with the more recent alterations likely resulting in the decline of native fauna and flora. Dark (Microdipodops megacephalus) and pallid (M. pallidus) kangaroo mice are ecological specialists found within the Great Basin Desert and are potentially ideal organisms for assessing ecosystem health and inferring the biogeographic history of this vulnerable region. Herein, newly acquired nuclear-encoded microsatellite loci were utilized to assess patterns of variation within and among spatially discrete groups of kangaroo mice and to evaluate gene flow, demographic trends, and genetic integrity. Results confirm that there are at least three genetically distinct units within M. megacephalus and two such units within M. pallidus. The three units of M. megacephalus appear to have different demographic histories, with effectively no gene flow among them since their divergence. Similarly, the two units of M. pallidus also appear to have experienced different demographic histories, with effectively no gene exchange. Contemporary effective population sizes of all groups within Microdipodops appear to be low (<500), suggesting that each genetic lineage may have difficulty coping with changing environmental pressures and hence may be at risk of extirpation. Results of this study indicate that each Microdipodops group should be recognized, and therefore managed, as a separate unit in an effort to conserve these highly specialized taxa that contribute to the diversity of the Great Basin Desert ecosystem. The Great Basin Desert of western North America has experienced frequent habitat alterations due to a complex biogeographic history and recent anthropogenic impacts, with the more recent alterations likely resulting in the decline of native fauna and flora. Herein, newly acquired nuclear-encoded microsatellite loci were utilized to assess patterns of variation within and among spatially discrete groups of the dark (Microdipodops megacephalus) and pallid (M. pallidus) kangaroo mouse, and to evaluate gene flow, demographic trends, and genetic integrity. Results of this study indicate that each Microdipodops group should be recognized, and therefore managed, as a separate unit in an effort to conserve these highly specialized taxa that contribute to the diversity of the Great Basin Desert ecosystem (photo credit J. C. Hafner).

All-terrain vehicle dealership point-of-sale child safety compliance in Illinois.

OBJECTIVES: In 2008, an estimated 37,700 children younger than 16 were treated in US emergency departments for nonfatal all-terrain vehicle (ATV) injuries. This study identifies safety guidelines and recommendations dealers convey to consumers at the point of sale. METHODS: A telephone survey of all 2004 licensed motorcycle dealers in Illinois was conducted. Trained investigators, using aliases and posing as a parent of a 13-year-old teenager, spoke with dealership personnel. Investigators indicated they wished to purchase an ATV with the dealership, but had no knowledge of ATV use or safety issues. The telephone call's true purpose was concealed during the survey. Specific responses from the salesperson, models and brands of ATVs, price quotes, engine sizes, and safety information/recommendations were recorded in a written survey instrument. RESULTS: One hundred twenty-seven ATV dealers completed the survey. A salesperson most often fielded the telephone interview (124/127). Telephone interviews by male investigators were longer than those by female interviewers (5 minutes 37 seconds vs 3 minutes 51 seconds; P = 0.001). Dealers recommended Consumer Product Safety Commission-based child-size ATVs (<90 mL engine size) during 75% of the calls. Nearly all dealers recommended helmet use (108/127), and few (3/127) labeled the vehicles as "safe." Most dealers (83.5%) recommended some form of rider training, with half (49.6%) offered point-of-purchase training. CONCLUSIONS: All-terrain vehicle dealers in Illinois recommend child-size vehicles, safety training, and helmet use for the majority of telephone inquiries. Injury prevention efforts targeting ATV dealers may be less needed than those using other populations.

Inappropriate helicopter emergency medical services transports: results of a national cohort utilization review.

BACKGROUND: Medical transport using helicopter emergency medical services (HEMS) has rapidly proliferated over the past decade. Because of issues of cost and safety, appropriate utilization is of increasing concern. OBJECTIVE: This study sought to describe the medical appropriateness of HEMS transports, using established guidelines, in a large national patient cohort. METHODS: A review was performed of all flights designated as inappropriate by a large national air medical company, Air Evac EMS Inc. (which operates Air Evac Lifeteam [AEL]), for the period from January 1, 2009, through December 31, 2009. Every flight was reviewed initially through a resource utilization process as well as a utilization review process. Medical appropriateness review criteria were derived from the Medicare Benefit Policy Manual and industry guidelines outlined by the Commission on Accreditation of Medical Transport Systems (CAMTS), Air Medical Physicians Association (AMPA) position papers, the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) Guidelines for Field Triage, and published clinical peer-reviewed articles, as well as previous interactions with Medicare contractors and reimbursement appeal decisions. Higher scrutiny was given to flights of <30 or >100 miles. Records indicating a possible inappropriate flight (i.e., review criteria were not satisfied, but special circumstances existed) were further reviewed by a senior quality assurance/quality improvement (QA/QI) nurse and/or senior medical director and were categorized. RESULTS: During the study period, 27,697 flights were completed and reviewed, with 582 (2.1%) flights identified for further review by a senior QA/QI nurse and/or senior medical director. Of those, 367 (1.3%) were determined to be medically inappropriate flights. Inappropriate flights were most often on-scene flights (59.9%), were most often for adult patients (92.9%; median age 56.9 years; 25-75% interquartile range 42-75 years), and most often represented medical diagnoses (57.8%). CONCLUSIONS: Based on established criteria, only 1.3% of total flights were determined to be inappropriate. This large national cohort demonstrated compliance with current industry standards.