Fatal fentanyl-associated cerebellitis in a young man.

A 22-year-old man was brought in by EMS for coma and respiratory failure. The initial diagnosis was an opioid overdose but the patient did not respond to naloxone. A head CT revealed findings consistent with cerebellitis. The patient developed obstructive hydrocephalus and herniation. Despite neurosurgical and ICU care, the patient did not recover. Cerebellitis is a seldom-discussed complication of opioid use which may become more common as the opioid and fentanyl epidemic evolves.

Small bowel obstruction caused by massive fibroids.

A 44-year-old woman presented to the Emergency Department with abdominal pain. She had a history of fibroids and no prior surgeries. Ultrasonography and CT imaging revealed a small bowel obstruction and massive uterine fibroids. The patient required laparotomy to relieve the intestinal obstruction after conservative therapy failed. Massive uterine fibroids is a rare cause of small bowel obstruction which requires the vigilance of Emergency Medicine physicians.

Treatment of caffeine toxicity with metoprolol.

A 27-year-old man presented with an intentional overdose of concentrated caffeine powder that he bought over the internet. The patient received benzodiazepines and ondansetron for symptomatic treatment when he arrived in the Emergency Department (ED). Subsequently, he developed recurrent supraventricular tachycardia in the ED. The SVT was successfully treated with metoprolol. The patient's caffeine level was >90 mg/L. This is the first known report of treatment of caffeine-induced supraventricular tachycardia with metoprolol.

Safety and efficacy of intravenous combination sedatives in the ED.

OBJECTIVE: The objective of the study is to determine the safety of intravenously administered combination sedatives in the emergency department (ED). METHODS: This was a retrospective study of alcohol-intoxicated patients in the ED. We examined the incidence of adverse events in agitated patients who received combination sedatives intravenously and compared the efficacy of combination sedatives and single-agent sedatives. RESULTS: Of 1300 patient visits, there was a single adverse event, a dystonic reaction, in the combination sedative group, for an adverse event rate of less than 1%. Patients who received combination sedatives were less likely to require a second dose of sedative medication than patients who received a single-agent sedative (21% vs 44%). CONCLUSIONS: Combination sedatives appear to be safe when administered intravenously in the ED. Combination sedatives may be more effective than single-agent sedatives in agitated alcohol-intoxicated patients.

A novel use of 2-octyl-cyanoacrylate: controlling post-hemodialysis site hemorrhage.

BACKGROUND: A common complication of hemodialysis is bleeding from the dialysis site. DISCUSSION: To demonstrate the use of 2-octyl-cyanoacrylate in controlling venous bleeding associated with hemodialysis access. CONCLUSION: 2-octyl-cyanoacrylate is effective in stopping venous bleeding from hemodialysis sites.

Laryngopyocoele: an unusual cause of a sore throat.

Laryngopyocoeles are rare entities that present as airway obstruction or as neck masses. We present a unique case of a laryngopyocoele in a young patient with a sore throat. A 22-year-old man presented to the emergency department with a sore throat of 1-week duration. He had no other upper respiratory symptoms. His vitals were as follows: heart rate, 91; respiratory rate, 16; blood pressure, 119/60; and temperature, 36.8 (98.3°F). There were no signs of respiratory distress or airway involvement. The findings from his physical examination were normal except for tenderness on palpation of his larynx. A soft tissue neck x-ray was suggestive of epiglottitis. Fiberoptic laryngoscopy revealed a nonerythematous, edematous epiglottis and edema of the left arytenoid and aryepiglottic fold with slight bulging into the airway. A contrast neck computed tomography revealed a nonenhancing fluid collection at the level of the left arytenoid cartilage. The diagnosis of a laryngopyocoele was made. The patient was admitted to the intensive care unit for airway monitoring and treated conservatively with intravenous antibiotics. The collection did not resolve by day 4, and the patient was taken to the operating room for incision and drainage of the laryngopyocoele. The patient made an uneventful recovery.

Are 2 smaller intravenous catheters as good as 1 larger intravenous catheter?

OBJECTIVE: Using Poiseuille's law and standardized gauge sizes, an 18-gauge (g) intravenous catheter (IV) should be 2.5 times faster than a 20-g IV, but this is not borne out by observation, in vitro testing, and manufacturer's data. Our objective was to determine if the infusion rate of a single 18-g IV was equivalent to the infusion rate of two 20-g IVs. METHODS: This was a prospective study in healthy adult volunteers. Subjects simultaneously received 500 mL of normal saline via an 18-g IV in one arm and 500 mL of normal saline via two 20-g IVs in the other arm. We measured the rates of fluid administration. Paired Student's t test was used for comparison of the 2 arms of the study. We estimated that 18 trials were needed in sample size analysis. RESULTS: Eighteen trials were completed. The mean infusion rate for a single 18-g 500-mL IV administration was 35.6 mL/min (95% confidence interval [CI], 30.3-40.8), with manufacturer's rating being 105 mL/min. The mean infusion rate for two 20-g IVs was 41.3 mL/min (95% CI, 36.1-46.4), with manufacturer's rating being 120 mL/min. The rate of infusion via two 20-g IVs were statistically significantly faster than the single 18-g IV, with a mean difference in flow rate of 5.7 mL/min (95% CI, 1.3-10; P = .026). CONCLUSION: In healthy volunteers, administration of intravenous fluids through two 20-g IVs is faster than a single 18-g IV, although both approaches are markedly slower than the manufacturer's estimates.

Resident experience of abuse and harassment in emergency medicine: ten years later.

BACKGROUND: In 1995, a Society for Academic Emergency Medicine in-service survey reported high rates of verbal and physical abuse experienced by Emergency Medicine (EM) residents. We sought to determine the prevalence of abuse and harassment 10 years later to bring attention to these issues and determine if there has been a change in the prevalence of abuse over this time period. OBJECTIVES: To determine the prevalence of abuse and harassment in a sample of EM residencies. METHODS: We conducted a cross-section survey of EM residents from 10 residencies. EM residents were asked about their experience with verbal abuse, verbal threats, physical threats, physical attacks, sexual harassment, and racial harassment; and by whom. The primary outcome of the study was the prevalence of abuse and harassment as reported by EM residents. RESULTS: There were 196 of 380 residents (52%) who completed the survey. The prevalence of any type of abuse experienced was 91%; 86% of residents experienced verbal abuse, 65% verbal threats, 50% physical threats, 26% physical attacks, 23% sexual harassment, and 26% racial harassment. Women were more likely than men to encounter sexual harassment (37% [38/102] vs. 8% [7/92]; p < 0.001). Racial harassment was not limited to minorities (23% [16/60] for Caucasians vs. 26% [29/126] for non-Caucasians; p = 0.59). Senior residents were more likely to have encountered verbal and physical abuse. Only 12% of residents formally reported the abuse they experienced. CONCLUSION: Abuse and harassment during EM residency continues to be commonplace and is underreported.

Exercise tolerance as a predictor of acute myocardial infarction in emergency department patients with potential acute coronary syndromes.

There is mounting evidence that exercise tolerance is an important predictor of heart disease. Our objective was to determine if decreased exercise tolerance, as estimated by physicians, may be useful in stratifying risk in Emergency Department (ED) patients with potential acute coronary syndromes. We conducted a prospective cohort study on a convenience sample of ED patients at an urban teaching hospital. Patients with chest pain, dyspnea, syncope, or epigastric pain who were evaluated for acute coronary syndromes were included. Clinical and laboratory data were recorded. In addition, the Emergency Physicians were asked to estimate the exercise tolerance of the patient as excellent, good, bad, or very poor. The primary outcome of the study was myocardial infarction (MI) or death in patients stratified by physician-perceived exercise tolerance (excellent or good vs. bad or very poor). There were 166 patients enrolled in the study. Nine patients (5%) had an MI; there were no deaths. Physicians reported exercise tolerance as excellent in 33 patients, good in 63, bad in 50, and very poor in 20. The unadjusted risk of MI was significantly elevated in patients with physician-perceived decreased exercise tolerance (relative risk = 4.8, 95% confidence interval 1.03-22). After adjustment for age, sex, and major cardiovascular risk factors, decreased exercise tolerance remained a significant predictor of MI (adjusted odds ratio = 7.3, 95% confidence interval 1.2-46). Exercise tolerance, as estimated by clinical impression, may be an important predictor of complications in ED patients presenting with potential acute coronary syndromes.

Vitamin deficiencies in acutely intoxicated patients in the ED.

OBJECTIVE: Physicians often administer intravenous multivitamins to intoxicated patients in the emergency department (ED); however, this practice is not supported by evidence from any prior study. We determined the prevalences of vitamin deficiencies in patients presenting to our ED with alcohol intoxication. METHODS: This study was a prospective, cross-section, observational study of a convenience sample of ED patients presenting with acute alcohol intoxication. Patients were tested for B(12), folate, and thiamine levels as add-ons to their blood samples. RESULTS: Seventy-seven patients were included in the final analysis. The mean age was 46 years, and 19% were female; the mean blood alcohol level was 280 mg/dL. Of 75 patients, no one (0%) had low B(12) or folate levels (95% confidence interval, 0-0.05); 6 (15%) of 39 patients had low thiamine levels (95% confidence interval, 0.06-0.31). Of these 6 patients, none exhibited clinical signs of thiamine deficiency. CONCLUSIONS: In our ED, patients with acute ethanol intoxication do not have B(12) or folate deficiencies. A significant minority (15%) of patients have thiamine deficiency; its clinical significance is unclear. Widespread administration of multivitamins is unwarranted by these findings, but thiamine may be considered.

An in vitro optimized injectable calcium phosphate cement for augmenting screw fixation in osteopenic goats.

This study reports the proportioning and standardized mixing procedures for preparing a hydroxylapatite cement (tetracalcium phosphate and dicalcium phosphate) of desired viscosity and mechanical strength reproducibly for application in trauma surgery. The behavior and the biomechanical properties of the resulting bone cement in screw augmentation were then evaluated in our osteopenic goat model. The use of a shaker standardized the mixing procedure. The optimal volume of Na2HPO4 used to prepare the injectable cement was 0.45 mL/g, with averaged in vitro compressive strength of 48.29 +/- 5.62 MPa. Histology showed increasing tightly-coupled bone apposition on the cement surface without fibrous encapsulation as observed in the screw-only controls with time in the osteopenic goat model. The cement increased the initial screw pull-out force (54.7%, p = 0.005) significantly and the energy required to failure (54.7%, p < 0.05) significantly, and remained higher than the screw-only controls after 3 months (9.8% and 20.2%, respectively) and 6 months (20.2% and 44.7%, respectively). These results imply potential in the prevention of interfacial micromotions and subsequent fibrous tissue formation at the implant-bone interface resulting in a decreased risk of implant failure. The optimized cement in this study may serve as a good candidate for augmenting fixation of osteoporotic bone.

Patient attitudes toward emergency physician attire.

Previous studies have suggested that Emergency Department (ED) patient satisfaction is unaffected by physician attire. We conducted a before-and-after trial to test this hypothesis. A convenience sample of ED patients was surveyed during a 2-week period. In the first week, emergency physicians wore white coats and formal attire. In the second week, the same physicians wore scrubs. Patients were asked to indicate on a 100-mm visual analog scale (VAS) their ratings of physician appearance, satisfaction, and professionalism. The primary outcome was the difference in VAS scores between the two dress styles. There were 111 patients surveyed. There were no significant differences between patients' evaluation of appearance (Delta=-.68 mm VAS, 95% confidence interval [CI] -5.5 to 4.1), satisfaction (Delta=.83 mm VAS, 95% CI -3.0 to 4.6), or professionalism (Delta=-.46 mm VAS, 95% CI -3.6 to 2.6) between the two dress styles. Emergency physician attire does not affect patient satisfaction.

Laboratory tests in adults with monoarticular arthritis: can they rule out a septic joint?

UNLABELLED: It is difficult to differentiate septic arthritis from other causes of monoarticular arthritis solely with a history and physical examination. The clinician must rely on ancillary tests to make a diagnosis, such as the white blood cell count of peripheral blood (WBC), the erythrocyte sedimentation rate (ESR), and the white blood cell count of the joint fluid (jWBC) obtained from arthrocentesis. Although it is known that septic arthritis is associated with abnormalities in these tests, the majority of the data are based on studies in the pediatric population. In addition, although several emergency medicine texts indicate that a jWBC greater than 50,000 cells/mm(3) is "positive," it is known that septic arthritis can occur in patients with low jWBCs. OBJECTIVES: To determine whether specific ancillary tests have sufficiently high sensitivities to rule out septic arthritis in adults. METHODS: This was a retrospective consecutive case series of patients from an urban emergency department (ED). Patients at least 18 years old who had septic arthritis confirmed by positive arthrocentesis culture or operative findings were included in the study. WBC greater than 11,000 cells/mm(3), ESR greater than 30 mm/hr, and jWBC greater than 50,000 cells/mm(3) were considered elevated. RESULTS: Seventy-three patients met the inclusion criteria. The sensitivities of an elevated WBC, ESR, or jWBC in adults who had septic arthritis were 48%, 96%, and 64%, respectively. There were broad ranges of WBC, ESR, or jWBC among the patients. More than one third of adult patients with septic arthritis had jWBCs less than 50,000 cells/mm(3). All patients had an abnormality in at least one of these tests. CONCLUSIONS: The WBC, ESR, and jWBC are extremely variable in adults with septic arthritis. Laboratory tests do not rule out septic arthritis with accuracy.

SAEM abstracts to articles: 1997 and 1999-2001.

OBJECTIVES: The Society for Academic Emergency Medicine (SAEM) annual meeting is the primary research conference in emergency medicine. An abstract presented at the 2000 SAEM meeting found a trend of decreasing publication rates of articles based on SAEM abstracts from 47% in 1995 to 33% in 1997. The authors wished to determine whether the publication rates of articles based on SAEM abstracts continued to decline since 1997. METHODS: A MEDLINE search of all SAEM abstracts from 1997 and 1999-2001 was conducted. The primary outcome was the publication rates of articles based on abstracts presented each year. Secondary outcomes included comparison of publication rates by oral versus poster presentation and category of research. RESULTS: Thirty-eight percent of 2,054 SAEM abstracts were published as articles by fall 2003, with 40% in 1997, 40% in 1999, 38% in 2000, and 35% in 2001. The publication rate was higher for oral presentations (50%) than poster presentations (34%). Publication rates ranged from 32% to 53% by category of research; the highest rates were in wound (53%) and cardiopulmonary resuscitation/resuscitation (51%), and the lowest rates were in administration (32%) and cardiovascular (33%). Twenty-six percent of articles were published in emergency medicine journals. The times to publication were similar across the years: 4%-7% were published in the same year of the meeting, 15%-17% one year later, 10%-11% two years later, 5% three years later, and 3%-5% after three years. CONCLUSIONS: The publication rate of articles based on SAEM abstracts has held steady at 40% in recent years when the time delay to publication is taken into account.

Toothpick injury mimicking renal colic: case report and systematic review.

We describe a case of a patient with left flank pain that was caused by a perforation in the splenic flexure of the colon by a toothpick. We conducted a systematic review of the literature to examine the nature of injuries caused by ingested toothpicks. Articles were analyzed for the following outcome variables: presenting complaint, site of injury, recollection of toothpick ingestion, time to presentation, findings from imaging studies, and mortality. Most patients (70%) presented with abdominal pain. Few patients (12%) remember swallowing a toothpick. The onset of symptoms ranged from <1 day to 15 years. Toothpicks caused perforation most frequently at the duodenum and the sigmoid. In some cases, toothpicks migrated outside the gastrointestinal tract and were found in the pleura, pericardium, ureter, or bladder. Toothpicks were apparent on imaging studies in 14% of the cases. The definitive diagnosis was most commonly made at laparotomy (53%), followed by endoscopy (19%). Overall mortality was 18%. Ingested toothpicks may cause significant gastrointestinal injuries, and must be treated with caution.