Alcohol Withdrawal with Delirium Tremens.

Audience: Emergency medicine (EM) residents (1st year and 2nd year levels), 4th year medical students and advanced practice providers. Introduction: Alcohol use has played a major role in causing significant morbidity and mortality for patients. In 2016, it was the 7th leading risk factor for deaths and disability-adjusted life years globally.1 Among heavy alcohol users admitted for hospital management, the incidence of alcohol withdrawal syndrome is estimated to be 1.9 to 6.7%.1 Alcohol withdrawal (AW) in the ED has been associated with increased use of critical care resources, and frequent ED visits for alcohol-related presentations have been associated with mortality rates that are about 1-4% when withdrawal progresses to delirium tremens (DTs).1 Patients with alcohol withdrawal can present in many different ways to the ED including anxiety, tachycardia, delirium tremens (DTs), seizures and severe autonomic dysfunction leading to severe sickness and death.2 Therefore, it is extremely important for an EM physician to recognize the signs of AW in patients and to manage the critically ill patients. In addition, Clinical Institute Withdrawal Assessment (CIWA) of alcohol was developed to assess severity of alcohol withdrawal in 1989.3 EM physicians should utilize CIWA to help determine the severity of AW. Educational Objectives: By the end of the session, learner will be able to 1) discuss the causes of altered mental status, 2) utilize CIWA scoring system to quantify AW severity, 3) formulate appropriate treatment plan for AW by treating with benzodiazepine and escalating treatment appropriately, 4) treat electrolyte abnormalities by giving appropriate medications for hypokalemia and hypomagnesemia, and 5) discuss clinical progression and timing to AW. Educational Methods: This session was conducted using high-fidelity simulation, which was immediately followed by an in-depth debriefing session. The session was run during first year EM resident intern orientation, and it was run during two consecutive years. There was a total of 32 EM residents who participated. There was a total of 16 residents who actively managed the patient while the other 16 were observers. Each session had four learners and was run twice in two separate rooms. There was one simulation instructor running the session and one simulation technician who acted as a nurse. Research Methods: After the simulation and debriefing session was complete, an online survey was sent via surveymonkey.com to all the participants. The survey collected responses to the following questions: (1) the case was believable, (2) the case had right the amount of complexity (based on their Gestalt), (3) the case helped in improving medical knowledge and patient care, (4) the simulation environment gave me a real-life experience and, (5) the debriefing session after simulation helped improve my knowledge. The responses were collected using a Likert scale of 1 to 5 with 1 being "Strongly disagree" and 5 being "Strongly agree." Results: There was a total of 15 respondents from both years. One hundred percent of them either agreed or strongly agreed that the case was beneficial in learning, in improving medical knowledge and in patient care. All of them found the post-session debrief to be very helpful. Two of them felt neutral about the case being realistic. The median response for questions 1, 3 and 5 is 5. The median response for questions 2 and 4 was 4. The range of responses for questions 1, 2, 3 and 5 was 4-5 while the range for question 4 was 3-5. Discussion: This high-fidelity simulation was a cost-effective and realistic way of educating learners on how to manage AW with DTs. Learners are forced to start with a broad differential for the patient who presents with AMS. As they recognize the cause of mental status, the patient quickly decompensates into developing severe agitation and autonomic dysfunction requiring learners to manage the patient and establish an airway. Learners found the case to be beneficial in learning the management of AW. Topics: Alcohol withdrawal, delirium tremens, agitation, altered mental status.

Toxicokinetics of metformin overdose treated with CVVHDF.

A 53-year-old man died following a reported ingestion of 80 g of his metformin tablets resulting in severe, refractory shock and metformin-associated lactic acidosis. His peak serum metformin concentration was 53 µg/mL (therapeutic range 1-2 µg/mL), peak lactic acid concentration was 49.7 mmol/L, and arterial pH nadir was 7.06. He died despite vasopressors and renal replacement therapy [RRT; both intermittent hemodialysis (IHD) and continuous venovenous hemodiafiltration (CVVHDF)]. Serial metformin concentrations during CVVHDF suggested a half-life of 33-h. Similar to previous reports of RRT for metformin toxicity, CVVHDF appears to provide first-order elimination of metformin.

Integration of motion energy from overlapping random background noise increases perceived speed of coherently moving stimuli.

The perception of visual motion can be profoundly influenced by visual context. To gain insight into how the visual system represents motion speed, we investigated how a background stimulus that did not move in a net direction influenced the perceived speed of a center stimulus. Visual stimuli were two overlapping random-dot patterns. The center stimulus moved coherently in a fixed direction, whereas the background stimulus moved randomly. We found that human subjects perceived the speed of the center stimulus to be significantly faster than its veridical speed when the background contained motion noise. Interestingly, the perceived speed was tuned to the noise level of the background. When the speed of the center stimulus was low, the highest perceived speed was reached when the background had a low level of motion noise. As the center speed increased, the peak perceived speed was reached at a progressively higher background noise level. The effect of speed overestimation required the center stimulus to overlap with the background. Increasing the background size within a certain range enhanced the effect, suggesting spatial integration. The speed overestimation was significantly reduced or abolished when the center stimulus and the background stimulus had different colors, or when they were placed at different depths. When the center- and background-stimuli were perceptually separable, speed overestimation was correlated with perceptual similarity between the center- and background-stimuli. These results suggest that integration of motion energy from random motion noise has a significant impact on speed perception. Our findings put new constraints on models regarding the neural basis of speed perception.