C3-C4 cervical disc herniation producing Brown-Séquard syndrome: A case report and review of the literature.

Brown-Séquard Syndrome (BSS) is a rare form of incomplete spinal cord injury and is characterized by ipsilateral motor deficit and contralateral sensory loss. BSS is commonly associated with traumatic etiologies, but non-traumatic causes should be considered as well. A 38-year-old woman presented with a 3-week history of weakness in her right upper extremity, and she has developed numbness and tingling in her left upper and lower extremities over the past week and a half, along with some motor difficulty. Imaging showed a large right paracentral disc protrusion at the C3-C4 level causing severe spinal canal narrowing and resulting in abnormal cord signal. The patient subsequently underwent a C3-4 cervical total disk replacement. Hemovac placed during surgery was removed on post-op day one, and she was re-evaluated by PT/OT and recommended for outpatient therapies on post-op day two. Our case, along with a review of the literature, highlights those non-traumatic causes of BSS should be considered as a cause of BSS. BSS produced by a herniated cervical disc is extremely rare and is often misdiagnosed.

Prevalence of intra-abdominal injury among patients with seatbelt signs, a systematic review and meta-analysis.

INTRODUCTION: The advancement of seat belts have been essential to reducing morbidity and mortality related to motor vehicle collisions (MVCs). The "seat belt sign" (SBS) is an important physical exam finding that has guided management for decades. This study, comprising a systematic review and random-effects meta-analysis, asses the current literature for the likelihood of the SBS relating to intra-abdominal injury and surgical intervention. METHODS: PubMed and Scopus databases were searched from their beginnings through August 4, 2023 for eligible studies. Outcomes included the prevalence of intra-abdominal injury and need for surgical intervention. Cochrane's Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess for heterogeneity. RESULTS: The search yielded nine observational studies involving 3050 patients, 1937 (63.5%) of which had a positive SBS. The pooled prevalence of any intra-abdominal injury was 0.42, (95% CI 0.28-0.58, I2 = 96%) The presence of a SBS was significantly associated with increased odds of intra-abdominal injury (OR 3.62, 95% CI 1.12-11.6, P = 0.03; I2 = 89%), and an increased likelihood of surgical intervention (OR 7.34, 95% CI 2.03-26.54, P < 0.001; I2 = 29%). The measurement for any intra-abdominal injury was associated with high heterogeneity, I2 = 89%. CONCLUSION: This meta-analysis suggests that the presence of a SBS was associated with a statistically significant higher likelihood of intra-abdominal injury and need for surgical intervention. The study had high heterogeneity, likely due to the technological advancements over the course of this study, including seat belt design and diagnostic imaging sensitivity. Further studies with more recent data are needed to confirm these results.

Author Response.

How to cite this article: Rahmatinejad Z, Hoseini B, Pourmand A, Reihani H, Rahmatinejad F, Eslami S, et al. Author Response. Indian J Crit Care Med 2024;28(2):183-184.

Recurrent abdominal pain visits to the emergency department: A case report using the Central Sensitization Inventory.

Chronic pain conditions are among the most common complaints seen in the emergency department (ED). Exacerbations of these conditions are often approached as one would an acute painful condition, with liberal use of imaging, labs, and analgesics. This patient population is often prescribed short courses of opioids without a definite explanation for their painful episodes and often leave the ED dissatisfied with their experience. We describe a patient with a history of chronic abdominal pain who presented to the ED with an exacerbation of his pain. Upon further review of his previous records, we noted that this patient experienced many similar events, resulting in 46 imaging studies over the past year. At this point, the patient was given the Central Sensitization Inventory, and his score demonstrated severe underlying central sensitization. The patient was counseled about his condition and provided with appropriate follow-up care.

Approach to anisocoria in the emergency department.

Anisocoria describes asymmetric pupillary diameter, which can result from traumatic, pharmacologic, inflammatory, or ischemic effects on the eye. In many cases, anisocoria represents a normal physiologic variant. Morbidity associated with anisocoria is directly related to the inciting cause and can vary from benign to life-threatening. A thorough understanding by emergency physicians of normal ocular neuroanatomy, and of common causes of pathologic anisocoria, including medication-induced anisocoria, can facilitate appropriate resource utilization and timely subspecialty consultation, and can help prevent irreversible ocular injury and patient morbidity. We describe a patient who presented to the emergency department with acute onset of blurry vision with anisocoria.

Ventilation assisted feedback in out of hospital cardiac arrest.

Excessive ventilatory volumes and rates during cardiopulmonary resuscitation (CPR) can lead to adverse effects, such as elevated intrathoracic pressure and decreased coronary blood flow. The 2020 American Heart Association (AHA) guidelines acknowledge the value of real-time feedback devices in improving CPR performance. In this case series, three out-of-hospital cardiac arrest cases received ventilation feedback during prehospital resuscitation and the initial in-hospital care phase. In each case, a notable increase in ventilation rate and volume was observed following the transfer of care from emergency medical services to hospital staff. This deviation from established ventilation guidelines emphasizes the importance of monitoring and addressing ventilation strategy during the transition to hospital care. Existing evidence supports the importance of maintaining specific ventilation rates and tidal volumes during cardiac arrest to improve outcomes. We believe further research is essential to establish a definitive link between ventilation strategies and patient outcomes, ultimately enhancing resuscitation efforts and patient survival rates. Integrating real-time ventilation feedback devices both in and out of the hospital during cardiac arrest presents an opportunity for quality improvement and adherence to national standards.

Evaluation of phenobarbital based approach in treating patient with alcohol withdrawal syndrome: A systematic review and meta-analysis.

BACKGROUND: Alcohol Withdrawal Syndrome (AWS) among patients with chronic and heavy alcohol consumption can range from mild to severe and is associated with high morbidity and mortality. Currently, treating AWS with benzodiazepines is the standard of care, but phenobarbital has also been hypothesized to be an effective first-line treatment due to its pharmacological properties and mechanism of action. We conducted a meta-analysis to review relevant literature and compare the clinical outcomes for patients diagnosed with AWS in ED and ICU settings. METHODS: We performed a literature search in in the PubMed, Scopus, and Web of Science databases from inception to June 30, 2022. Randomized trials and observational (prospective or retrospective) studies were eligible if they included adult patients who presented in the ED and were treated in the ED and/or the intensive care unit (ICU) with a diagnosis of AWS. The primary outcome was the rate of intubation among patients who received phenobarbital, compared with benzodiazepines. Secondary outcomes such as rates of seizures, hospital, and ICU length of stay (LOS), also were included. The PROSPERO registration is CRD42022318862. RESULTS: We included twelve studies (1934 patients) in our analysis. Of the 1934 patients in these studies, 765 (41.7%) were treated with phenobarbital and 1169 (58.3%) were treated with other modalities for alcohol withdrawal. Treating AWS patients with phenobarbital did not affect their risk for intubation, as the risk for intubation was similar between the phenobarbital and the control group (RR 0.70, 95% CI 0.36-1.38, P = 0.31). In addition, patients who were treated with phenobarbital were found to have similar rates of seizures (RR 0.73, 95% CI 0.29-1.89) and length of stay in the hospital (Standardized Mean Difference -0.02, 95% CI -0.26, 0.21) or the ICU (SMD -0.02, 95% CI -0.21, 0.25) when compared with patients receiving benzodiazepines. CONCLUSIONS: Management of patients with AWS with phenobarbital is associated with similar rates of intubation, length of stay in the ICU, or length of stay in the hospital as treatment with benzodiazepines. However, due to the inclusion of mostly observational studies and a significant level of heterogeneity among the studies assessed in this review, additional trials with strong methodology are needed.

Cyclobenzaprine utilization for musculoskeletal back pain: Analysis of 2007-2019 National Hospital Ambulatory Medical Care Survey Data.

BACKGROUND: With musculoskeletal back pain being one of the most common presentations in the emergency department, evidence-based management strategies are needed to address such complaints. Along with other medications, cyclobenzaprine is a muscle relaxant commonly prescribed for patients complaining of musculoskeletal pain, in particular, pain associated with muscle spasms. However, with recent literature questioning its efficacy, the role of cyclobenzaprine use in patients with musculoskeletal back pain remains unclear. OBJECTIVES: The objective of the study is to investigate trends of cyclobenzaprine utilization among patients presenting to the emergency department (ED) in the United States. METHODS: This is a retrospective cohort review of data obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 2007 and 2019. We analyzed ED visits of patients 18 years and older. Visits during which cyclobenzaprine was administered in the ED or prescribed at discharge were identified. Trends were described using a time series analysis of patients' visits who received administration and prescriptions of cyclobenzaprine. RESULTS: Between 2007 and 2019, we identified an estimated 1.35 billion ED visits, 57.2% (772.6 million) were female. From that sample, 2.4% (32.7 million) of all visits received cyclobenzaprine prescription in the ED only, and 0.5% (6.6 million) of total visits were both given the drug in the ED and were prescribed the drug at discharge). Overall trend analysis shows a slight decrease in annual percentages of cyclobenzaprine administration and prescriptions during the study period. Visits of certain subgroups: 26-44 years, white showed relatively higher percentages of administration and prescription of cyclobenzaprine. CONCLUSIONS: Although there was a slight decrease, our study still shows significant cyclobenzaprine utilization in the ED, despite conflicting evidence demonstrating efficacy for patients with musculoskeletal complaints and the concern for adverse effects. Additional studies are needed to examine its overall effectiveness and risk-benefit analysis in treating patients with such conditions.

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis.

BACKGROUND: Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway. METHODS: We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale. RESULTS: We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse. CONCLUSIONS: Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Rethinking Traditional Emergency Department Care Models in a Post-Coronavirus Disease-2019 World.

As the nursing shortage in United States emergency departments has drastically worsened since the coronavirus disease-2019 (COVID-19) pandemic, emergency departments have experienced increased rates of inpatient onboarding, higher rates of patients leaving without being seen, and declining patient satisfaction scores. This paper reviews the impacts of the coronavirus disease-2019 pandemic on the current nursing shortage and considers how various medical personnel (emergency nurse-extenders) can ameliorate operational challenges by redesigning emergency department systems. During the height of the coronavirus disease-2019 pandemic, the psychological effects of increased demand for emergency nurses coupled with the fear of coronavirus infection exacerbated nursing turnover rates. Health care workers who can be trained to augment the existing emergency department workforce include paramedics, Emergency Medical Technicians, emergency department technicians, ancillary staff, scribes, and motivated health sciences students. Utilizing non-nurse providers to fulfill tasks traditionally assigned to emergency nurses can improve emergency department flow and care delivery in a post-coronavirus disease-2019 world.

Comparison of Six Scoring Systems for Predicting In-hospital Mortality among Patients with SARS-COV2 Presenting to the Emergency Department.

Background: The study aimed to compare the prognostic accuracy of six different severity-of-illness scoring systems for predicting in-hospital mortality among patients with confirmed SARS-COV2 who presented to the emergency department (ED). The scoring systems assessed were worthing physiological score (WPS), early warning score (EWS), rapid acute physiology score (RAPS), rapid emergency medicine score (REMS), national early warning score (NEWS), and quick sequential organ failure assessment (qSOFA). Materials and methods: A cohort study was conducted using data obtained from electronic medical records of 6,429 confirmed SARS-COV2 patients presenting to the ED. Logistic regression models were fitted on the original severity-of-illness scores to assess the models' performance using the Area Under the Curve for ROC (AUC-ROC) and Precision-Recall curves (AUC-PR), Brier Score (BS), and calibration plots were used to assess the models' performance. Bootstrap samples with multiple imputations were used for internal validation. Results: The mean age of the patients was 64 years (IQR:50-76) and 57.5% were male. The WPS, REMS, and NEWS models had AUROC of 0.714, 0.705, and 0.701, respectively. The poorest performance was observed in the RAPS model, with an AUROC of 0.601. The BS for the NEWS, qSOFA, EWS, WPS, RAPS, and REMS was 0.18, 0.09, 0.03, 0.14, 0.15, and 0.11 respectively. Excellent calibration was obtained for the NEWS, while the other models had proper calibration. Conclusion: The WPS, REMS, and NEWS have a fair discriminatory performance and may assist in risk stratification for SARS-COV2 patients presenting to the ED. Generally, underlying diseases and most vital signs are positively associated with mortality and were different between the survivors and non-survivors. How to cite this article: Rahmatinejad Z, Hoseini B, Reihani H, Hanna AA, Pourmand A, Tabatabaei SM, et al. Comparison of Six Scoring Systems for Predicting In-hospital Mortality among Patients with SARS-COV2 Presenting to the Emergency Department. Indian J Crit Care Med 2023;27(6):416-425.

Suprapubic catheter encasement by bladder stone.

Complications of suprapubic catheterization including acute urinary retention present often to the emergency department. Patients with chronic indwelling catheters are at increased risk of bladder calculi and recurrent infections, especially without appropriate follow up care. We describe a case of suprapubic catheter failure secondary to complete circumferential encrustation of the distal catheter tip by a bladder calculus. This case demonstrates the need for thorough evaluation of any case of catheter dysfunction and for careful consideration of bladder calculi in those patients at risk.

Outcomes of CMS-mandated fluid administration among fluid-overloaded patients with sepsis: A systematic review and meta-analysis.

INTRODUCTION: The outcomes of large-volume IVF administration to septic shock patients with comorbid congestive heart failure (CHF) and/or end-stage renal disease (ESRD) are uncertain and widely debated in the existing literature. Despite this uncertainty, CMS continues to recommend that 30 ml/kg of an intravenous crystalloid solution be administered to patients in septic shock starting within 3 h of presentation. We performed a systematic review and meta-analysis to assess the relationship between adherence to this guideline and outcomes among patients whose underlying comorbidities present a risk of fluid overload. METHODS: Our search was conducted on PubMed and Scopus through November 5, 2021 to identify studies that evaluated clinical outcomes among septic patients with CHF/ESRD based on volume of fluid administered. The primary outcome measured was mortality at 30 days post-hospital discharge. Other outcomes included the rates of vasopressor requirements, invasive mechanical ventilation during hospitalization, as well as length of stay in the intensive care unit and/or hospital. We used random effects meta-analysis when two or more studies reported the same outcome. RESULTS: We included five studies in the final meta-analysis, which comprised 5804 patients, 5260 (91%) of whom received non-aggressive fluid resuscitation, as defined by the studies' authors. Random-effects meta-analysis for all-cause mortality showed that aggressive fluid resuscitation was associated with statistically non-significant increased odds of mortality (OR 1.42, 95% CI 0.88-2.3, P = 0.15, I2 = 35%). There was no statistical association between volume of IVF administration and other outcomes evaluated. CONCLUSION: Among septic shock patients with CHF and/or ESRD, administration of greater than or equal to 30 ml/kg IVF was associated with a non-significant increase in odds of mortality. All other outcomes measured were found to be non-significant, although there was a trend toward better outcomes among patients in the restricted-volume compared to the standard-volume IVF groups. Since this meta-analysis only included five observational studies, more studies are needed to guide an optimal volume and rate of fluid administration in this patient population.

Pacemaker lead related myocardial perforation.

Permanent pacemaker (PPM) insertion is widely used to treat cardiac rhythm disorders; approximately 600,000 pacemakers are implanted annually in the US. Almost 9% of patients who receive a permanent pacemaker, however, experience a variety of medical complications such as infections, battery problems, programming issues, lead migration, or lead fracture. Moreover 1-2% of these patients will encounter severe lead-related problems within 30 days of their pacemaker insertion. In this report, we focus on an uncommon but serious complication of PPM insertion: right ventricular lead perforation leading to a pericardial effusion. Although lead perforation is a relatively rare occurrence, this event can be life-threatening, and should be considered in the differential diagnosis when patients present to the emergency department (ED) with relevant symptoms and recent PPM insertion. Specifically, patients who experience complications from pacemaker insertion may present to the ED with a variety of symptoms such as chest pain, syncope, dyspnea, or even dizziness. Pacemaker complications include pneumothorax, pleural and/or pericardial effusions, and infection, placing the patient at serious risk for significant harm. The evaluation of a lead-related issue typically involves chest radiography to visualize abnormal lead placement and check for a pneumothorax or pleural effusion, and a 12­lead electrocardiogram (ECG) to detect pacing errors. We present the case of a patient who presented to the ED three days after his pacemaker insertion with chest pain and dyspnea; he was subsequently diagnosed with a lead perforation into the pericardial space resulting in a pericardial effusion.

Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis.

INTRODUCTION: Epistaxis is a very common presentation in the emergency department (ED), accounting for approximately 1 in 200 ED visits in the United States. Currently, standard practice includes the initial use of topical anesthetics and vasoconstrictors, followed by more invasive treatments such as nasal packing, cauterization or surgical ligation for refractory cases. Over the years several studies have investigated the potential use of topical Tranexamic Acid (TXA) in the management of epistaxis. We have conducted a meta-analysis to assess the efficacy of topical TXA versus other standard practices or placebo in the management of epistaxis. METHODS: PubMed and Scopus databases were searched from inception to April 2021. We included randomized controlled trials and observational studies investigating the efficacy of TXA in bleeding cessation in epistaxis in adults. The primary outcome measured was the prevalence of bleeding cessation after treatment at first assessment. Other outcomes were bleeding reoccurrence between 24 and 72 h and at 7-8 days. A random-effects model was used to estimate odds ratio (OR) for outcomes. RESULTS: A total of eight studies were included in the analysis, including seven randomized trials and one retrospective study. We included a total of 1299 patients, 596 (46%) received TXA while 703 (54%) received control treatment (placebo, lidocaine plus vasoconstrictors or local anesthetics). Patients who were treated with TXA were 3.5 times (OR 3.5, 95% CI 1.3-9.7) more likely to achieve bleeding cessation at the first assessment. Patients treated with TXA had 63% (OR 0.37, 95% CI 0.20-0.66) less likelihood of returning due to rebleeding at 24-72 h. CONCLUSION: Topical TXA is associated with better bleeding cessation rates after treatment compared to the standard practices.

Attitudes among healthcare professionals towards cardiopulmonary resuscitation during COVID-19.

BACKGROUND: Out-of-hospital cardiac arrests (OHCAs) are a leading cause of mortality in the United States. The ongoing COVID-19 pandemic has dramatically altered the landscape of response to OHCAs, particularly with regard to providing cardiopulmonary resuscitation (CPR). We aimed to describe, characterize, and address the attitudes and concerns of healthcare workers towards CPR of OHCA patients during the COVID-19 pandemic. METHODS: We performed a cross-sectional study of healthcare workers and trainees in the United States and Saudi Arabia via an online survey available between October 2020, and May 2021. The primary outcome of interest was willingness to perform CPR for OHCA, with confidence to handle CPR for OHCA as our secondary outcome. RESULTS: A total of 501 healthcare professionals, including 436 (87%) with background in emergency medicine, participated in our survey. 331 (66%) reported being willing to perform CPR for OHCA, while 170 (34%) were not willing. 311 (94%) willing participants stated that their medical oath and moral responsibility were the main motivators for willingness, while a fear of contracting COVID-19 was the primary demotivating factor for 126 (74%) unwilling participants. Time series analysis with simple exponential smoothing showed an increase in willingness to perform CPR from 30% to 50%, as well as an increase in mean confidence level to perform CPR from 60% to 70%, between October 2020 and May 2021. CONCLUSIONS: The ongoing COVID-19 pandemic significantly affected healthcare workers' attitudes towards performing CPR for OHCA. Confidence levels and willingness to perform CPR increased over time during the study period. Efforts should be directed towards the creation of standardized and evidence-based guidelines for CPR during COVID-19, as well as increasing knowledge regarding risks of infection and effective use of PPE during resuscitation.

How effective is extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest? A systematic review and meta-analysis.

BACKGROUND: Extracorporeal cardiopulmonary resuscitation (ECPR) has gained increasing as a promising but resource-intensive intervention for out-of-hospital cardiac arrest (OHCA). There is little data to quantify the impact of this intervention and the patients likely to benefit from its use. We conducted a meta-analysis of the literature to assess the survival benefit associated with ECPR for OHCA. METHODS: We searched PubMed, Embase, and Scopus databases to identify relevant observational studies and randomized control trials. We used the Newcastle-Ottawa Scale and Cochrane risk-of-bias tool to assess studies' quality. We performed random-effects meta-analysis for the primary outcome of survival to hospital discharge and used meta-regressions to assess heterogeneity. RESULTS: We identified 1287 articles, reviewed the full text of 209 and included 44 in our meta-analysis. Our analysis included 3097 patients with OHCA. Patients' mean age was 52, 79% were male, and 60% had primary ventricular fibrillation/ventricular tachycardia arrest. We identified a survival-to-discharge rate of 24%; 18% survived with favorable neurologic function. 30- and 90-days survival rates were both around 18%. The majority of included articles were high quality studies. CONCLUSIONS: Extracorporeal cardiopulmonary resuscitation is a promising but resource-intensive intervention that may increase rates of survival to hospital discharge among patients who experience OHCA.

African biomass burning is a substantial source of phosphorus deposition to the Amazon, Tropical Atlantic Ocean, and Southern Ocean.

The deposition of phosphorus (P) from African dust is believed to play an important role in bolstering primary productivity in the Amazon Basin and Tropical Atlantic Ocean (TAO), leading to sequestration of carbon dioxide. However, there are few measurements of African dust in South America that can robustly test this hypothesis and even fewer measurements of soluble P, which is readily available for stimulating primary production in the ocean. To test this hypothesis, we measured total and soluble P in long-range transported aerosols collected in Cayenne, French Guiana, a TAO coastal site located at the northeastern edge of the Amazon. Our measurements confirm that in boreal spring when African dust transport is greatest, dust supplies the majority of P, of which 5% is soluble. In boreal fall, when dust transport is at an annual minimum, we measured unexpectedly high concentrations of soluble P, which we show is associated with the transport of biomass burning (BB) from southern Africa. Integrating our results into a chemical transport model, we show that African BB supplies up to half of the P deposited annually to the Amazon from transported African aerosol. This observational study links P-rich BB aerosols from Africa to enhanced P deposition in the Amazon. Contrary to current thought, we also show that African BB is a more important source of soluble P than dust to the TAO and oceans in the Southern Hemisphere and may be more important for marine productivity, particularly in boreal summer and fall.

Tramadol Use in United States Emergency Departments 2007-2018.

BACKGROUND: Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids. OBJECTIVE: Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates. RESULTS: Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018. CONCLUSIONS: Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.

Valproic Acid Overdose: Case Report and Literature Review.

BACKGROUND: Valproic acid (VPA) is a common antiepileptic drug that is also used routinely for various psychiatric disorders. VPA toxicity typically manifests as central nervous system depression, while hyperammonemic encephalopathy and hepatotoxicity are potentially life-threatening complications. CASE REPORT: We describe the case of a 56-year-old man who presented to the emergency department after an intentional VPA overdose, was found to have hyperammonemia, and was treated with L-carnitine exclusively. He was subsequently admitted to the hospital for monitoring and serial laboratory testing. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although VPA toxicity has conventionally been managed by gastric decontamination, L-carnitine, and, in severe and refractory cases, extracorporeal removal, recent literature supports the use of carbapenem antibiotics, particularly meropenem. Thus, we report the details of current treatment modalities for VPA toxicity by reviewing current literature.