Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers.

BACKGROUND: Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS: We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS: A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION: TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.

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.

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.

A clinical approach to an unidentified aerosolized bioterrorism agent: a narrative review for emergency providers.

The current heightened international political climate is accompanied by increased risk of chemical or biological agent weaponization. Historical accounts of biochemical warfare are extensive, and considering the recent use of such agents for targeted attacks, clinicians need to recognize and manage these cases. However, agent properties such as the color, odor, ability to be aerosolized, and long incubation period can introduce difficulties in the diagnostic and management approach. We searched PubMed and Scopus for a colorless, odorless, aerosolized substance with an incubation period of at least 4 hours. Data from articles were summarized and reported by agent. Based on data from the available literature, we included agents such as nerve agents, ricin, botulinum toxin, anthrax, tularemia, and psittacosis in this review. We also highlighted potential chemical and biological agents that could be weaponized and the optimal strategies for the diagnosis and treatment of patients exposed to an unknown aerosolized biological or chemical bioterrorism agent.

Forensic Analysis of Textile Synthetic Fibers Using a FT-IR Spectroscopy Approach.

Synthetic fibers are one of the most valuable trace lines of evidence that can be found in crime scenes. When textile fibers are analyzed properly, they can help in finding a linkage between suspect, victim, and the scene of the crime. Various analytical techniques are used in the examination of samples to determine relationships between different fabric fragments. In this exploratory study, multivariate statistical methods were investigated in combination with machine learning classification models as a method for classifying 138 synthetic textile fibers using Fourier transform infrared spectroscopy, FT-IR. The data were first subjected to preprocessing techniques including the Savitzky-Golay first derivative method and Standard Normal Variate (SNV) method to smooth the spectra and minimize the scattering effects. Principal Component Analysis (PCA) was built to observe unique patterns and to cluster the samples. The classification model in this study, Soft Independent Modeling by Class Analogy (SIMCA), showed correct classification and separation distances between the analyzed synthetic fiber types. At a significance level of 5%, 97.1% of test samples were correctly classified.

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.

Enantioseparation of Synthetic Cathinones Enantiomers with Tertiary Amine Structure in Urine and Plasma.

A sensitive and selective method for detection and quantitation of the enantiomers of 18 synthetic cathinones with tertiary amine structure using HPLC-UV-VIS has been developed. Two chiral columns, Astec Cellulose DMP and Amylose-based Chiralpak AS-H, have been examined separately. Mobile phase composed of hexane, isopropanol and triethylamine (99.0:1.0:0.1) was used under an isocratic elution mode. Three of these compounds were separated simultaneously after being spiked into urine and plasma samples. 2,3-Methylenedioxy pyrovalerone was used as an internal standard for the purpose of quantitation. The analytical method has been validated in terms of linearity, limits of detection (LOD), limits of quantitation (LOQ), recoveries and reproducibilities in urine and plasma matrices. The calibration curves exhibited correlation coefficients better than 0.99. It was found that the LODs of these cathinone derivatives in urine were in the range of 1.00-1.47 ppm; while in plasma, the LODs were in the range of 0.14-0.67 ppm. The LOQs in urine were in the range of 3.03-4.46 ppm and in plasma they were in the range of 0.42-2.04 ppm. The method recoveries in terms of percent error averaged 2.4% and 3.2% for the spiked plasma and urine samples, respectively; while interday and intraday reproducibilities reported at three different levels, 5, 100 and 200 ppm, in terms of coefficient of variance were in the range of (0.27-5.39)% in plasma and (0.47-3.12)% in urine which lies in the acceptable range.

Simultaneous Quantitative Determination of Synthetic Cathinone Enantiomers in Urine and Plasma Using GC-NCI-MS.

Development and validation of sensitive and selective method for enantioseparation and quantitation of synthetic cathinones is reported using GC-MS triple quadrupole mass spectrometry with negative chemical ionization (NCI) mode. Indirect chiral separation of thirty-six synthetic cathinone compounds has been achieved by using an optically pure chiral derivatizing agent (CDA) called (S)-(-)-N-(trifluoroacetyl)pyrrolidine-2-carbonyl chloride (L-TPC), which converts cathinone enantiomers into diastereoisomers that can be separated on achiral columns. As a result of using Ultra Inert 60 m column and performing slow heating rate (2°C/min) on the GC oven, an observed enhancement in enantiomer peak resolution has been achieved. An internal standard, (+)-cathinone, was used for quantitation of synthetic cathinones. Method validation in terms of linearities and sensitivity in terms of limits of detection (LODs), limits of quantitation (LOQs), recoveries, and reproducibilities has been obtained for fourteen selected compounds that examined simultaneously as a mixture after being spiked in urine and plasma. It was found that the LOD of the fourteen synthetic cathinones in urine was in the range of 0.26-0.76 µg/L, and in plasma, it was in the range of 0.26-0.34 µg/L. While the LOQ of the mixture in urine was in the range of 0.86-2.34 µg/L, and in plasma, it was in the range of 0.89-1.12 µg/L. Unlike the electron impact (EI) ion source, NCI showed better sensitivity by two orders of magnitude by comparing the obtained results with the recently published reports for quantitative analysis and enantioseparation of synthetic cathinones.