Death from cardiac glycoside "pong-pong" following use as weight-loss supplement purchased on Internet.

Cerbera odollam or "pong-pong" tree contains cardiac glycosides similar to digoxin, oleander and yellow oleander. Cerbera odollam is a common method of suicide in South East Asia and has also been used as a weight loss supplement. We present a case of a 33-year-old female presenting with lethargy, vomiting, bradycardia, severe hyperkalemia of 8.9 mEq/L, slow atrial fibrillation followed by cardiovascular collapse following the ingestion of "pong-pong", the kernel of Cerbera odollam, as a weight loss supplement. Despite the administration of a total of nine vials of digoxin-specific Fab the patient could not be resuscitated. Clinicians should be aware of natural cardiac glycosides being uses as weight-loss agents and consider acute cardiac glycoside poisoning in patients with hyperkalemia, abnormal cardiovascular signs, symptoms and abnormal ECG findings.

Does the Flipped Classroom Improve Learning in Graduate Medical Education?

BACKGROUND: The flipped classroom model for didactic education has recently gained popularity in medical education; however, there is a paucity of performance data showing its effectiveness for knowledge gain in graduate medical education. OBJECTIVE: We assessed whether a flipped classroom module improves knowledge gain compared with a standard lecture. METHODS: We conducted a randomized crossover study in 3 emergency medicine residency programs. Participants were randomized to receive a 50-minute lecture from an expert educator on one subject and a flipped classroom module on the other. The flipped classroom included a 20-minute at-home video and 30 minutes of in-class case discussion. The 2 subjects addressed were headache and acute low back pain. A pretest, immediate posttest, and 90-day retention test were given for each subject. RESULTS: Of 82 eligible residents, 73 completed both modules. For the low back pain module, mean test scores were not significantly different between the lecture and flipped classroom formats. For the headache module, there were significant differences in performance for a given test date between the flipped classroom and the lecture format. However, differences between groups were less than 1 of 10 examination items, making it difficult to assign educational importance to the differences. CONCLUSIONS: In this crossover study comparing a single flipped classroom module with a standard lecture, we found mixed statistical results for performance measured by multiple-choice questions. As the differences were small, the flipped classroom and lecture were essentially equivalent.

Headache in the Emergency Department: Avoiding Misdiagnosis of Dangerous Secondary Causes.

There are a number of dangerous secondary causes of headaches that are life, limb, brain, or vision threatening that emergency physicians must consider in patients presenting with acute headache. Careful history and physical examination targeted at these important secondary causes of headache will help to avoid misdiagnosis in these patients. Patients with acute thunderclap headache have a differential diagnosis beyond subarachnoid hemorrhage. Considering the "context" of headache "PLUS" some other symptom or sign is one strategy to help focus the differential diagnosis.

Medication Overdoses at a Public Emergency Department in Santiago, Chile.

INTRODUCTION: While a nationwide poison control registry exists in Chile, reporting to the center is sporadic and happens at the discretion of the treating physician or by patients' self-report. Moreover, individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The goal of this study was to identify all cases of intentional medication overdose (MO) that occurred over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile. METHODS: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and recreational drugs were included only when they were ingested with other medications. RESULTS: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases, corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks were identified, corresponding to the spring of each year sampled. The rate of hospital admission was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants (TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were involved in two of these deaths. CONCLUSION: Similar to other developed and developing nations, intentional MO accounts for a significant number of ED presentations in Chile. Chile is unique in the region, however, in that its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a relatively low rate of acetaminophen ingestion.

Importance of hospital entry: walk-in STEMI and primary percutaneous coronary intervention.

INTRODUCTION: Patients with ST elevation myocardial infarction (STEMI) require rapid identification and triage to initiate reperfusion therapy. Walk-in STEMI patients have longer treatment times compared to emergency medical service (EMS) transported patients. While effective triage of large numbers of critically ill patients in the emergency department is often cited as the reason for treatment delays, additional factors have not been explored. The purpose of this study was to evaluate baseline demographic and clinical differences between walk-in and EMS-transported STEMI patients and identify factors associated with prolonged door to balloon (D2B) time in walk-in STEMI patients. METHODS: We performed a retrospective review of 136 STEMI patients presenting to an urban academic teaching center from January 2009 through December 2010. Baseline demographics, mode of hospital entry (walk-in versus EMS transport), treatment times, angiographic findings, procedures performed and in-hospital clinical events were collected. We compared walk-in and EMS-transported STEMI patients and identified independent factors of prolonged D2B time for walk-in patients using stepwise logistic regression analysis. RESULTS: Walk-in patients (n=51) were more likely to be Latino and presented with a higher heart rate, higher systolic blood pressure, prior history of diabetes mellitus and were more likely to have an elevated initial troponin value, compared to EMS-transported patients. EMS-transported patients (n=64) were more likely to be white and had a higher prevalence of left main coronary artery disease, compared to walk-in patients. Door to electrocardiogram (ECG), ECG to catheterization laboratory (CL) activation and D2B times were significantly longer for walk-in patients. Walk-in patients were more likely to have D2B time >90 minutes, compared to EMS- transported patients; odds ratio 3.53 (95% CI 1.03, 12.07), p=0.04. Stepwise logistic regression identified hospital entry mode as the only independent predictor for prolonged D2B time. CONCLUSION: Baseline differences exist between walk-in and EMS-transported STEMI patients undergoing primary percutaneous coronary intervention (PCI). Hospital entry mode was the most important predictor for prolonged treatment times for primary PCI, independent of age, Latino ethnicity, heart rate, systolic blood pressure and initial troponin value. Prolonged door to ECG and ECG to CL activation times are modifiable factors associated with prolonged treatment times in walk-in STEMI patients. In addition to promoting the use of EMS transport, efforts are needed to rapidly identify and expedite the triage of walk-in STEMI patients.

Emergency neurological life support: traumatic brain injury.

Traumatic brain injury (TBI) was chosen as an Emergency Neurological Life Support topic due to its frequency, the impact of early intervention on outcomes for patients with TBI, and the need for an organized approach to the care of such patients within the emergency setting. This protocol was designed to enumerate the practice steps that should be considered within the first critical hour of neurological injury.

Cutaneous conditions leading to dermatology consultations in the emergency department.

INTRODUCTION: We established the most common cutaneous diseases that received dermatology consultation in the adult emergency department (ED) and identified differentiating clinical characteristics of dermatoses that required hospital admission. METHODS: A retrospective chart review of 204 patients presenting to the ED who received dermatology consultations at Los Angeles County/University of Southern California Medical Center, an urban tertiary care teaching hospital. RESULTS: Of all patients, 18% were admitted to an inpatient unit primarily for their cutaneous disease, whereas 82% were not. Of nonadmitted patients, the most commonly diagnosed conditions were eczematous dermatitis not otherwise specified (8.9%), scabies (7.2%), contact dermatitis (6.6%), cutaneous drug eruption (6.0%), psoriasis vulgaris (4.2%), and basal cell carcinoma (3.6%). Of patients admitted for their dermatoses, the most highly prevalent conditions were erythema multiforme major/Stevens-Johnson syndrome (22%), pemphigus vulgaris (14%), and severe cutaneous drug eruption (11%). When compared with those of nonadmitted patients, admitted skin conditions were more likely to be generalized (92% vs 72%; P = 0.0104), acute in onset (<1 month duration) (81% vs 51%; P = 0.0005), painful (41% vs 15%; P = 0.0009), blistering (41% vs 7.8%; P < 0.0001), and ulcerated or eroded (46% vs 7.8%; P < 0.0001). They were more likely to involve the mucosa (54% vs 7.2%; P < 0.0001) and less likely to be pruritic (35% vs 58%; P = 0.0169). CONCLUSION: We have described a cohort of patients receiving dermatologic consultation in the ED of a large urban teaching hospital. These data identify high-risk features of more severe skin disease and may be used to refine curricula in both emergency and nonemergency cutaneous disorders for emergency physicians.

Pitfalls in the management of headache in the emergency department.

Headache is the fifth most common primary complaint of patients presenting to an emergency department (ED) in the United States. The emergency physician (EP) plays a unique role in the management of these patients, one that differs from that of the primary care physician, the neurologist, and other specialists. Diagnostic nomenclature used in the ED is necessarily less specific, as care is more appropriately focused on the relief of symptoms and the identification of life-threatening causes. By seeking a limited number of specific critical features on history and physical examination, the EP can minimize the risk of overlooking one of these dangerous causes of headache. When certain features are present, empirical therapies and diagnostic testing should be initiated in the ED. The most frequently encountered pitfalls in the management of patients with headache in emergency medicine practice, and those with the greatest likelihood to adversely affect patient outcomes, are discussed.

Evaluating the sensitivity of visual xanthochromia in patients with subarachnoid hemorrhage.

Combined computed tomography and cerebrospinal fluid (CSF) analysis has been shown to be 100% sensitive for detecting subarachnoid hemorrhage (SAH) when CSF is obtained between 12 h and 2 weeks from time of headache onset and spectrophotometry is used to evaluate CSF for xanthochromia. Because most hospitals do not use spectrophotometry, we sought to evaluate the sensitivity of CSF analysis for xanthochromia by visual inspection. We retrospectively identified all patients seen in the Emergency Department (ED) with an ED discharge diagnosis of SAH from June 1993 to November 2005. A structured chart review was performed on all patients with the additional billed procedure charge for "lumbar puncture" or "spinal tap." Data collected included: CSF color, time from headache onset to CSF collection, and confirmation of SAH by advanced imaging. There were 1323 patients diagnosed with SAH, and 102 of these also had CSF collected. Of these, 81 charts were available for review. By predetermined protocol, 35 were excluded for lack of a report of CSF color, 1 was excluded because the time from headache onset to CSF collection was < 12 h, and 26 were excluded for lack of documentation of a definitive imaging study. Of the remaining 19, 9 were found to have xanthochromic CSF and 10 were found to have colorless CSF, resulting in a sensitivity for visual inspection of CSF of 47.3% (95% confidence interval 24.4-71.1%). Visual inspection of CSF supernatant for xanthochromia lacks the sensitivity necessary to reliably exclude the diagnosis of SAH.

The presence of an Emergency Airway Response Team and its effects on in-hospital Code Blue.

The survival rate from in-hospital cardiac arrest due to pulseless electrical activity (PEA)/asystole in our institution was higher than expected (70%). It was the impression of the Emergency Department-led Code Blue Team (CBT) that many of these patients were actually suffering respiratory arrests before their cardiac events. To address this, the facility developed an early intervention team focused on early airway intervention-the Emergency Airway Response Team (EART). The objective of this study was to assess the effect of early intervention in patients during the "pre-Code Blue" period, specifically with regard to airway stabilization. Our hypothesis was that there would be fewer CBT calls (cardiac arrests) due to PEA and asystole and that the survival from these events would decrease. This was a retrospective review of all cardiac arrests responded to by the CBT and EART for a period of 2 years. Charts were reviewed for the initial presenting rhythm (as defined by the Utstein Format) and event survival for the 12-month period immediately before and immediately after the establishment of the EART (Time Periods 1 and 2, respectively). The total number of CBT calls decreased by 15%, return of spontaneous circulation from any rhythm decreased by 9%, and survival to discharge decreased by 8% (p = non-significant). The number of CBT calls specifically for asystole/PEA decreased by 8%. Deaths in hospital were significantly associated with Period 2 (odds ratio 1.84; 95% confidence interval 1.03-3.28) after adjusting for age, gender, and presenting rhythms. The total number of CBT calls decreased slightly with the creation of the Emergency Airway Response Team. Return of spontaneous circulation and survival to hospital discharge after cardiac arrest due to asystole/PEA were significantly decreased, suggesting early intervention may have benefit.

Diagnosis of diverticulitis by bedside ultrasound in the Emergency Department.

This case report describes a potential novel indication for the use of bedside ultrasound in the Emergency Department. The patient in this case had some of the signs and symptoms of diverticulitis. The "pseudo-kidney" sign, which was thought to represent acute diverticulitis, was appreciated on a rapid, bedside ultrasound and confirmed by computed tomography. Knowledge of the sonographic appearance of diverticulitis may aid emergency physicians in making this diagnosis promptly, and facilitate the appropriate disposition.

Empiric acyclovir is infrequently initiated in the emergency department to patients ultimately diagnosed with encephalitis.

STUDY OBJECTIVE: We evaluate the frequency of empiric acyclovir administration to patients in the emergency department (ED) who are ultimately diagnosed with encephalitis. METHODS: We conducted an explicit retrospective medical record review of consecutive patients discharged with a final diagnosis of herpes simplex encephalitis or viral encephalitis not otherwise specified for the period 1993 to 2003. The frequency of ED administration of empiric acyclovir was measured for patients who met the inclusion criteria of fever, neuropsychiatric abnormality, and cerebrospinal fluid pleocytosis with a negative Gram's stain result in the ED. RESULTS: Of the 90 patients reviewed, 24 (27%) met the inclusion criteria of fever, neuropsychiatric abnormality, and cerebrospinal fluid pleocytosis with a negative Gram's stain result in the ED. Of these 24 patients, 7 (29%) received empiric acyclovir in the ED, 6 (86%) patients after cerebrospinal fluid results were available, with a median time to administration of 1.5 hours (95% confidence interval [CI] 0 to 3.1 hours). The remaining 17 (71%) patients did not receive acyclovir in the ED, with median times of 16 hours (95% CI 7.5 to 44 hours) before initiation of acyclovir in inpatient settings. CONCLUSION: The majority of patients in our institution who were ultimately diagnosed with encephalitis did not receive empiric acyclovir in the ED, despite clinical presentations consistent with encephalitis.

A comparison of phenytoin-loading techniques in the emergency department.

OBJECTIVES: To compare the effectivenesses of three phenytoin-loading techniques. METHODS: Patients with subtherapeutic phenytoin concentrations who presented within 48 hours of a seizure were randomized to receive either 20 mg/kg of oral phenytoin (PO), divided in maximum doses of 400 mg every two hours, 18 mg/kg of intravenous phenytoin (IVP) at an initial infusion rate of 50 mg/min, or 18 mg/kg (phenytoin equivalents) of intravenous fosphenytoin (IVF) at an initial infusion rate of 150 mg/min. RESULTS: A total of 45 patients were enrolled: 16 in the PO group, 14 in the IVP group, and 15 in the IVF group. The times required to reach therapeutic drug concentrations were (mean +/- standard deviation [SD]) 5.62 +/- 0.28 hours, 0.24 +/- 0.3 hours, and 0.21 +/- 0.28 hours, respectively. A total of 17, 27, and 32 adverse drug events were observed in the PO, IVP, and IVF groups, respectively, with significantly fewer events in the PO group (p = 0.02, p = 0.01). No significant difference was found between the numbers of necessary adjustments to the infusions in the two IV groups. The average time to safe emergency department discharge was significantly shorter for the IV groups compared with the PO group (p < 0.001). CONCLUSIONS: Oral loading has fewer adverse drug events than either IV loading method, but its use may be limited when therapeutic concentrations are required quickly. Although IVF loading is faster, from an adverse-drug event perspective, no advantage of IVF over IVP was apparent.

Cost-effectiveness of oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin in the emergency department.

STUDY OBJECTIVE: Oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin are all commonly used for loading phenytoin in the emergency department (ED). The cost-effectiveness of each was compared for patients presenting with seizures and subtherapeutic phenytoin concentrations. METHODS: A simple decision tree was developed to determine the treatment costs associated with each of 3 loading techniques. We determined effectiveness by comparing adverse event rates and by calculating the time to safe ED discharge. Time to safe ED discharge was defined as the time at which therapeutic concentrations of phenytoin (>or=10 mg/L) were achieved with an absence of any adverse events that precluded discharge. The comparative cost-effectiveness of alternatives to oral phenytoin was determined by combining net costs and number of adverse events, expressed as cost per adverse events avoided. Cost-effectiveness was also determined by comparing the net costs of each loading technique required to achieve the time to safe ED discharge, expressed as cost per hour of ED time saved. The outcomes and costs were primarily derived from a prospective, randomized controlled trial, augmented by time-motion studies and alternate-cost sources. Costs included the cost of drugs, supplies, and personnel. Analyses were also performed in scenarios incorporating labor costs and savings from using a lower-urgency area of the ED. RESULTS: The mean number of adverse events per patient for oral phenytoin, intravenous phenytoin, and intravenous fosphenytoin was 1.06, 1.93, and 2.13, respectively. Mean time to safe ED discharge in the 3 groups was 6.4 hours, 1.7 hours, and 1.3 hours. Cost per patient was 2.83 dollars, 21.16 dollars, and 175.19 dollars, respectively, and did not differ substantially in the Labor and Triage (lower-urgency area of ED) scenarios. When the measure of effectiveness was adverse events, oral phenytoin dominated intravenous phenytoin and intravenous fosphenytoin, with a lower cost and number of adverse events. With time to safe ED discharge as the outcome measure, the incremental cost-effectiveness ratios were 3.90 dollars and 387.27 dollars per hour of ED time saved for oral phenytoin versus intravenous phenytoin and for intravenous fosphenytoin versus intravenous phenytoin, respectively. CONCLUSION: Oral phenytoin is the most cost-effective loading method in most settings. Intravenous phenytoin is preferred if one is willing to pay an additional 20.65 dollars to 44.25 dollars per patient and willing to have more adverse events for a quicker average time to safe ED discharge. It is unlikely that intravenous fosphenytoin is justifiable in any setting.

The acute cerebrovascular event: surgical and other interventional therapies.

Over the next decade, more early and aggressive treatments will become available for acute stroke. As EPs have been forced to push their skills and knowledge significantly further with the advent of time-sensitive interventions for myocardial ischemia, a similar sophistication will undoubtedly emerge in the management of acute stroke. Certain components of the neurological examination will likely assume a new significance and, as with the renewed focus on the nature of ST segment change on the ECG in ACS, there will be new attention to early imaging findings in stroke. Although it is unclear whether the balance of future advances in treatment will come from the world of neurosurgery, neurology, or interventional radiology, the EP is relatively assured to play a central role in their implementation.

Occult trauma in high-risk populations.

Several groups of patients are at increased risk for traumatic injury that is "occult," or not apparent on initial presentation. Perhaps the most notorious are those who abuse alcohol, but other groups include the elderly, coagulopathic, those with neurological disease, and the mentally ill. Moreover, traumatic injury can coexist with (or be masked by) medical pathology, resulting in the disposition of injured patients to nonsurgical services where surveillance for traumatic injury diminishes. Because delays or failures in diagnosis might result in unnecessary pain, morbidity, and mortality, it is important for the emergency physician to identify occult presentations of trauma before disposition. This review highlights commonly missed traumatic injuries in adult patients.