One-Year Mortality and Associated Factors in Patients Receiving Out-of-Hospital Naloxone for Presumed Opioid Overdose.

STUDY OBJECTIVE: Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality. METHODS: This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors. RESULTS: Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not. CONCLUSION: Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.

Emergency Department Evaluation After Conducted Energy Weapon Use: Review of the Literature for the Clinician.

BACKGROUND: Conductive energy weapons (CEWs) are used daily by law enforcement, and patients are often brought to emergency departments (EDs) for medical clearance. OBJECTIVE: Our aim was to review the medical literature on the topic of CEWs and to offer evidence-based recommendations to emergency physicians for evaluation and treatment of patients who have received a CEW exposure. METHODS: A MEDLINE literature search from 1988 to 2018 was performed and limited to human studies published from January 1, 1988 to November 1, 2018 written in English with the following keywords: TASER, conductive energy device(s), electronic weapon(s), conductive energy weapon(s), non-lethal weapon(s), conducted energy device(s), conducted energy weapon(s), conductive electronic device(s), and electronic control device(s). Studies identified then underwent a structured review from which results could be evaluated. RESULTS: Two hundred and sixty-three articles on CEWs were screened and 37 appropriate articles were rigorously reviewed. Evaluation and treatment recommendations are presented. These studies did not report any evidence of dangerous laboratory abnormalities, physiologic changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to CEW electrical discharges of up to 15 s. CONCLUSIONS: The current medical literature does not support routine performance of laboratory studies, electrocardiography, or prolonged ED observation or hospitalization for ongoing cardiac monitoring after CEW exposure in an otherwise asymptomatic awake and alert patient.

Long QT syndrome unmasked in an adult subject presenting with excited delirium.

BACKGROUND: Excited delirium is increasingly recognized as a risk factor for sudden death, though the specific pathophysiology of these deaths is typically unclear. OBJECTIVES: We describe a survivor of excited delirium that displayed a transient severe prolongation of the QT interval, suggesting unmasking of long QT syndrome as a possible mechanism of sudden death. CASE REPORT: A 30-year-old man was arrested by police for violent assaultive behavior. Officers at the scene noted confusion, nonsensical speech, sweating, and bizarre agitated behavior; he was transported to the Emergency Department for medical evaluation of possible excited delirium. His initial electrocardiogram revealed a markedly prolonged corrected QT interval of over 600 ms. Intravenous hydration and sodium bicarbonate were administered, with normalization of the QT; he was admitted and recovered uneventfully. CONCLUSIONS: We discuss the possible association between long QT syndrome and unexplained sudden deaths seen with excited delirium. Sodium bicarbonate may be considered when long QT syndrome is identified during or after agitated delirium, though its routine use cannot be recommended based on a case report.

Tactical emergency medical support programs: a comprehensive statewide survey.

BACKGROUND: Specially trained tactical emergency medical support (TEMS) personnel provide support to law enforcement special weapons and tactics (SWAT) teams. These programs benefit law enforcement agencies, officers, suspects, and citizens. TEMS programs are increasingly popular, but there are wide variations in their organization and operation and no recent data on their prevalence. OBJECTIVE: We sought to measure the current prevalence and specific characteristics of TEMS programs in a comprehensive fashion in a single southeastern state. METHODS: North Carolina emergency medical services (EMS) systems have county-based central EMS oversight; each system was surveyed by phone and e-mail. The presence and selected characteristics of TEMS programs were recorded. U.S. Census data were used to measure the population impact of the programs. RESULTS: All of the 101 EMS systems statewide were successfully contacted. Thirty-three counties (33%) have TEMS programs providing medical support to 56 local law enforcement agencies as well as state and federal agencies. TEMS programs tend to be located in more populated urban and suburban areas, serving a population base of 5.9 million people, or 64% of the state's population. Tactical medics in the majority of these programs (29/33; 88%) are not sworn law enforcement officers. CONCLUSIONS: Approximately one-third of county-based EMS systems in North Carolina have TEMS programs. These programs serve almost two-thirds of the state's population base, using primarily nonsworn tactical medics. Comparison with other regions of the country will be useful to demonstrate differences in prevalence and program characteristics. Serial surveillance will help track trends and measure the growth and impact of this growing subspecialty field.

Transcardiac conducted electrical weapon (TASER) probe deployments: incidence and outcomes.

BACKGROUND: TASER (TASER International, Scottsdale, AZ) conducted electrical weapons (CEWs) are commonly used by law enforcement officers. Although animal studies have suggested that transcardiac CEW discharges may produce direct cardiac effects, this has not been demonstrated in human studies. OBJECTIVES: This study sought to determine the incidence and outcomes of transcardiac CEW probe impact locations in a large series of actual CEW deployments. METHODS: A multi-center database of consecutive CEW uses by law enforcement officers was retrospectively reviewed. Case report forms were independently reviewed by three investigators to identify cases with paired probe configurations potentially producing a transcardiac discharge vector. Descriptive analysis was performed and inter-rater reliability was assessed. RESULTS: Among 1201 total CEW uses, 813 included probe deployments and 178 cases had paired anterior probe impacts potentially capable of producing a transcardiac discharge vector. This represents 14.8% of all CEW uses (95% confidence interval [CI] 12.9-16.9%) and 21.9% of CEW uses in probe mode (95% CI 19.1-24.9%). Inter-rater agreement was very good, with kappa = 0.82. There were no immediate deaths in any cases (97.5% CI 0.0-0.3%) to suggest a cardiac dysrhythmia, including those with transcardiac discharge vector. CONCLUSION: CEW deployments with probe impact configurations capable of producing a transcardiac discharge occur in a minority of cases in field use conditions. None of these cases, transcardiac or otherwise, produced immediately fatal dysrhythmias. These data support the overall safety of CEWs and provide a benchmark estimate of the likelihood of transcardiac discharge vectors occurring in field use of CEWs.

Excited Delirium Syndrome (ExDS): defining based on a review of the literature.

BACKGROUND: Patients present to police, Emergency Medical Services, and the emergency department with aggressive behavior, altered sensorium, and a host of other signs that may include hyperthermia, "superhuman" strength, diaphoresis, and lack of willingness to yield to overwhelming force. A certain percentage of these individuals will go on to expire from a sudden cardiac arrest and death, despite optimal therapy. Traditionally, the forensic community would often classify these as "Excited Delirium" deaths. OBJECTIVES: This article will review selected examples of the literature on this topic to determine if it is definable as a discrete medical entity, has a recognizable history, epidemiology, clinical presentation, pathophysiology, and treatment recommendations. DISCUSSION: Excited delirium syndrome is characterized by delirium, agitation, acidosis, and hyperadrenergic autonomic dysfunction, typically in the setting of acute-on-chronic drug abuse or serious mental illness or a combination of both. CONCLUSIONS: Based upon available evidence, it is the consensus of an American College of Emergency Physicians Task Force that Excited Delirium Syndrome is a real syndrome with uncertain, likely multiple, etiologies.

Conducted electrical weapon (TASER) use against minors: a shocking analysis.

OBJECTIVE: Conducted electrical weapons (CEWs) such as the TASER are often used by law enforcement (LE) personnel during suspect apprehension. Previous studies have reported an excellent safety profile and few adverse outcomes with CEW use in adults. We analyzed the safety and injury profile of CEWs when used during LE apprehension of children and adolescents, a potentially vulnerable population. METHODS: Consecutive CEW uses by LE officers against criminal suspects were tracked at 10 LE agencies and entered into a database as part of an ongoing multicenter injury surveillance program. All CEW uses against minors younger than 18 years were retrieved for analysis. Primary outcomes included the incidence and type of mild, moderate, and severe CEW-related injury, as assessed by physician reviewers in each case. Ultimate outcomes, suspect demographics, and circumstances surrounding LE involvement are reported secondarily. RESULTS: Of 2026 consecutive CEW uses, 100 (4.9%) were uses against minor suspects. Suspects ranged from 13 to 17 years, with a mean age of 16.1 (SD, 0.99) years (median, 16 years). There were no significant (moderate or severe) injuries reported (0%; 97.5% confidence interval, 0.0%-3.6%). Twenty suspects (20%; 95% confidence interval, 12.7%-29.1%) were noted to sustain 34 mild injuries. The majority of these injuries (67.6%) were expected superficial punctures from CEW probes. Other mild injuries included superficial abrasions and contusions in 7 cases (7%). CONCLUSIONS: None of the minor suspects studied sustained significant injury, and only 20% reported minor injuries, mostly from the expected probe puncture sites. These data suggest that adolescents are not at a substantially higher risk than adults for serious injuries after CEW use.

Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician.

BACKGROUND: Conductive energy weapons (CEWs) are used daily by law enforcement, and patients are often brought to an emergency department (ED) for medical clearance. STUDY OBJECTIVES: To review the medical literature on the topic of CEWs and to offer evidence-based recommendations to Emergency Physicians for evaluation and treatment of patients who have received a CEW exposure. METHODS: A MEDLINE literature search from 1988 to 2010 was performed and limited to human studies published from January 1988 to January 20, 2010 for English language articles with the following keywords: TASER, conductive energy device(s), electronic weapon(s), conductive energy weapon(s), non-lethal weapon(s), conducted energy device(s), conducted energy weapon(s), conductive electronic device(s), and electronic control device(s). Studies identified then underwent a structured review from which results could be evaluated. RESULTS: There were 140 articles on CEWs screened, and 20 appropriate articles were rigorously reviewed and recommendations given. These studies did not report any evidence of dangerous laboratory abnormalities, physiologic changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to CEW electrical discharges of up to 15 s. CONCLUSIONS: The current medical literature does not support routine performance of laboratory studies, electrocardiograms, or prolonged ED observation or hospitalization for ongoing cardiac monitoring after CEW exposure in an otherwise asymptomatic awake and alert patient.

Safety and injury profile of conducted electrical weapons used by law enforcement officers against criminal suspects.

STUDY OBJECTIVE: Conducted electrical weapons such as the Taser are commonly used by law enforcement agencies. The safety of these weapons has been the subject of scrutiny and controversy; previous controlled studies in animals and healthy humans may not accurately reflect the risks of conducted electrical weapons used in actual conditions. We seek to determine the safety and injury profile of conducted electrical weapons used against criminal suspects in a field setting. METHODS: This prospective, multicenter, observational trial tracked a consecutive case series of all conducted electrical weapon uses against criminal suspects at 6 US law enforcement agencies. Mandatory review of each conducted electrical weapon use incorporated physician review of police and medical records. Injuries were classified as mild, moderate, or severe according to a priori definitions. The primary outcome was a composite of moderate and severe injuries, termed significant injuries. RESULTS: Conducted electrical weapons were used against 1,201 subjects during 36 months. One thousand one hundred twenty-five subjects (94%) were men; the median age was 30 years (range 13 to 80 years). Mild or no injuries were observed after conducted electrical weapon use in 1,198 subjects (99.75%; 95% confidence interval 99.3% to 99.9%). Of mild injuries, 83% were superficial puncture wounds from conducted electrical weapon probes. Significant injuries occurred in 3 subjects (0.25%; 95% confidence interval 0.07% to 0.7%), including 2 intracranial injuries from falls and 1 case of rhabdomyolysis. Two subjects died in police custody; medical examiners did not find conducted electrical weapon use to be causal or contributory in either case. CONCLUSION: To our knowledge, these findings represent the first large, independent, multicenter study of conducted electrical weapon injury epidemiology and suggest that more than 99% of subjects do not experience significant injuries after conducted electrical weapon use.

Resident Involvement in Tactical Medicine: 12 Years Later.

INTRODUCTION: Interest in tactical medicine, the provision of medical support to law enforcement and military special operations teams, continues to grow. The majority of tactical physicians are emergency physicians with additional training and experience in tactical operations. A 2005 survey found that 18% of responding Emergency Medicine (EM) residencies offered their resident physicians structured exposure to tactical medicine at that time. METHODS: This study sought to assess interval changes in tactical medicine exposure during EM residency and Emergency Medical Services (EMS) fellowship training. A secure online survey was distributed electronically to all 212 EM residency programs and 44 EMS fellowship programs in the United States. RESULTS: Responses were received from 99 (46%) EM residency and 40 (91%) EMS fellowship programs. Results showed that 52 (53%) of the responding residencies offered physician trainees formal exposure to tactical medicine as part of their training (P < .0001 compared to 18% in 2005). In addition, 32 (72%) of the 40 responding EMS fellowships (newly established since the initial survey) offered this opportunity. Experiences ranged from observation to active participation during tactical training and call-outs. The EM residents and EMS fellows provide support to local, state, and federal law enforcement agencies. A small number of programs (six residencies and four fellowships) allowed a subset of qualified trainees to be armed during tactical operations. CONCLUSION: Overall, training opportunities in tactical medicine have grown significantly over the last decade from 18% to 53% of responding EM residencies. In addition, 72% of responding EMS fellowships incorporate tactical medicine in their training program.Petit NP, Stopyra JP, Padilla RA, Bozeman WP. Resident involvement in tactical medicine: 12 years later. Prehosp Disaster Med. 2019;34(2):217-219.

Quantitative assessment of diagnostic radiation doses in adult blunt trauma patients.

STUDY OBJECTIVE: Many emergency departments and trauma centers utilize extensive radiologic studies during the assessment of trauma patients. A point of concern arises about the possible biological effects of these cumulative radiation doses. The objective of this study is to determine the amount of ionizing radiation received by adult blunt trauma patients at a Level I trauma center during the first 24 hours of their care. METHODS: This nonconcurrent case series reviewed the first 100 consecutive adult blunt trauma patients who presented to a Level I trauma center in 2006. All patients met hospital standards for the less acute major triage criteria. Individual radiation dose reports calculated by the computed tomography (CT) scanner were used to determine the radiation doses from each CT procedure. Standardized tables were used to determine radiation dose for plain radiographs. The median effective dose of radiation (millisieverts) was calculated for the first 24 hours of hospitalization. RESULTS: A total of 100 eligible patients presented between January 1, 2006, and March 20, 2006. Eighty-six patients had complete radiologic records available. The median age was 32 years, with an intraquartile range of 23 to 46 years; the median Injury Severity Score was 14, with an intraquartile range of 9 to 29; and the median number of CT scans was 3, with an intraquartile range of 3 to 4. The median effective total dose of ionized radiation was 40.2 mSv, with an intraquartile range of 30.5 to 47.2 mSv. A dose of 40.2 mSv is the equivalent of approximately 1,005 chest radiographs. CONCLUSION: Trauma patients meeting the less acute major triage criteria are exposed to clinically important radiation doses from diagnostic radiographic imaging during the first 24 hours of their care.

Baby Shampoo to Relieve the Discomfort of Tear Gas and Pepper Spray Exposure: A Randomized Controlled Trial.

INTRODUCTION: Oleoresin capsicum (OC) or pepper spray, and tear gas (CS) are used by police and the military and produce severe discomfort. Some have proposed that washing with baby shampoo helps reduce this discomfort. METHODS: We conducted a prospective, randomized, controlled study to determine if baby shampoo is effective in reducing the severity and duration of these effects. Study subjects included volunteers undergoing OC or CS exposure as part of their police or military training. After standardized exposure to OC or CS all subjects were allowed to irrigate their eyes and skin ad lib with water. Those randomized to the intervention group were provided with baby shampoo for application to their head, neck, and face. Participants rated their subjective discomfort in two domains on a scale of 0-10 at 0, 3, 5, 10, and 15 minutes. We performed statistical analysis using a two-tailed Mann-Whitney Test. RESULTS: There were 58 participants. Of 40 subjects in the OC arm of the study, there were no significant differences in the ocular or respiratory discomfort at any of the time points between control (n=19) and intervention (n=21) groups. Of 18 subjects in the CS arm, there were no significant differences in the ocular or skin discomfort at any of the time points between control (n=8) and intervention (n=10) groups. CONCLUSION: Irrigation with water and baby shampoo provides no better relief from OC- or CS-induced discomfort than irrigation with water alone.

Injuries associated with police use of force.

BACKGROUND: Use of force [UOF] by police can result in serious injuries and fatalities. The risk of significant injuries associated with different force modalities is poorly defined. We sought to determine the incidence of police UOF and compare the likelihood of significant injury with different force modalities. METHODS: A prospective multicenter observational study of all UOF incidents was conducted via mandatory UOF investigations at three mid-sized police agencies over a two year period. Expert physicians reviewed police and medical records to determine injury severity using a priori injury severity stratification criteria. RESULTS: There were 893 UOF incidents, representing a UOF rate of 0.086% of 1,041,737 calls for service (1 in 1167) and 0.78% of 114,064 criminal arrests(1 in 128). Suspects were primarily young (mean age, 31 years; range, 12-86 years) males (89%). The 1,399 force utilizations included unarmed physical force (n = 710, 51%), CEWs (504, 30%), chemical (88, 6.3%), canines (47, 3.4%), impact weapons (9, 0.6%), kinetic impact munitions (8, 0.6%), firearms (6, 0.4%), and other (27, 1.9%). Among 914 suspects, 898 (98%) sustained no or mild injury after police UOF. Significant (moderate or severe) injuries occurred in 16 (1.8%) subjects. Logistic regression analysis shows these are most associated with firearm and canine use. There was one fatality (0.1%) due to gunshots. No significant injuries occurred among 504 CEW uses (0%; 95% confidence interval, 0.0-0.9%). Of the 355 suspects transported to a medical facility, 78 (22%) were hospitalized. The majority of hospitalizations were unrelated to UOF (n = 59, 76%), whereas a minority (n = 19, 24%) were due to injuries related to police UOF. CONCLUSION: Police UOF is rare. When force is used officers most commonly rely on unarmed physical force and CEWs. Significant injuries are rare. Transport for medical evaluation is a poor surrogate for significant injury due to UOF. LEVEL OF EVIDENCE: Epidemiological, level II.

Thoracic compression fractures as a result of shock from a conducted energy weapon: a case report.

The Taser is an electrical conducted energy weapon used by law enforcement officers throughout the United States and the world. Though generally regarded as safe, conducted energy weapons can produce injuries. In this case report we describe for the first time thoracic spine compression fractures resulting from a conducted energy weapon discharge. Physicians who may care for patients who have been exposed to a conducted energy weapon discharge should be aware of this as a possible complication.

Intracardiac electrocardiographic assessment of precordial TASER shocks in human subjects: A pilot study.

BACKGROUND: Case reports of cardiac arrest in temporal proximity to Conducted Electrical Weapon(CEW) exposure raise legitimate concerns about this as a rare possibility. In this pilot study, we respectfully navigate the oversight and regulatory hurdles and demonstrate the intra-shock electrocardiographic effects of an intentional transcardiac CEW discharge using subcutaneous probes placed directly across the precordium of patients with a previously implanted intracardiac EKG sensing lead. METHODS: Adults scheduled to undergo diagnostic EP studies or replacement of an implanted cardiac device were enrolled. Sterile subcutaneous electrodes were placed at the right sternoclavicular junction and the left lower costal margin at the midclavicular line. A standard police issue TASER Model X26 CEW was attached to the subcutaneous electrodes and a 5 s discharge was delivered. Continuous surface and intracardiac EKG monitoring was performed. RESULTS: A total of 157 subjects were reviewed for possible inclusion and 21 were interviewed. Among these, 4 subjects agreed and completed the study protocol. All subjects tolerated the 5 s CEW discharge without clinical complications. There were no significant changes in mean heart rate or blood pressure. Interrogation of the devices after CEW discharge revealed no ventricular pacing, dysrhythmias, damage or interference with the implanted devices. CONCLUSIONS: In this pilot study, we have successfully navigated the regulatory hurdles and demonstrated the feasibility of performing intracardiac EKG recording during intentional precordial CEW discharges in humans. While no CEW-associated dysrhythmias were noted, the size of this preliminary dataset precludes making conclusions about the risk of such events. Larger studies are warranted and should consider exploring variations of the CEW electrode position in relation to the cardiac silhouette.

Empiric tenecteplase is associated with increased return of spontaneous circulation and short term survival in cardiac arrest patients unresponsive to standard interventions.

BACKGROUND: Prospective and retrospective studies have shown that empiric use of fibrinolytic agents in sudden cardiac arrest is safe and may improve outcomes in sudden cardiac arrest. Use of fibrinolytic agents for this indication is increasing in response to these data. METHODS: A prospective multicenter observational trial was performed in three emergency departments (EDs) to determine the proportion of patients that respond to empiric fibrinolysis with tenecteplase (TNK) after failing to respond to Advanced Cardiac Life Support (ACLS) measures. Cardiac arrest patients unresponsive to ACLS, who were given TNK by their treating physician, were enrolled in an outcome registry. Return of spontaneous circulation (ROSC), survival, complications, and neurological outcomes were recorded. RESULTS: Fifty patients received TNK after a mean of 30min of cardiac arrest and eight doses of ACLS medications. One hundred and thirteen concurrent control patients received standard ACLS measures. ROSC occurred in 26% of TNK patients (95% confidence interval (CI) 16-40%) compared to 12.4% (95% CI 6.9-20%) among ACLS controls (p=.04); 12% (4.5-24%) of TNK patients survived to admission compared to none in the control group (p=.0007); 4% (0.5-14%) survived to 24h (p=NS); and 4% (0.5-14%) survived to hospital discharge (p=NS). All survivors had a good neurological outcome (Cerebral Performance Category (CPC) 1-2). One intracranial hemorrhage (ICH) occurred. No other significant bleeding complications were observed. CONCLUSIONS: Empiric fibrinolysis with TNK in cardiac arrest is associated with increased ROSC and short term survival, and with survival to hospital discharge with good neurological function in patients who fail to respond to ACLS. Results may improve with earlier administration. Prospective controlled interventional trials are indicated to evaluate this promising new therapy.