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.

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.

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.

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.

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.

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.